12.10.24 ODMR 2425-0006 EQRO Base.pdf

External Quality Review Organization

ODMR 2425-0006

DUE:

January 22, 2025

2:00PM EST

The Ohio Department of Medicaid External Quality Review Organization

ODMR 2425-0006

TABLE OF CONTENTS

SECTION I. PURPOSE

1.1 Overview

1.2 Background

1.3 Overview of Project

1.4 Objectives

SECTION II. PROCUREMENT PROCESS INFORMATION

2.1 Anticipated Procurement Timetable

2.2 Internet Question and Answer Period

2.3 Communication Prohibitions

2.4 Addenda to the RFP

SECTION III. OFFEROR QUALIFICATIONS AND EXPERIENCE

3.1 Minimum Mandatory Requirements

3.2 Organizational Experience and Capabilities

3.3 Key Personnel and Additional Staff – Experience and Capabilities

3.4 Replacement of Key Personnel

3.5 Subcontractor Identification and Participation Information

3.6 Sensitive Personal Information

SECTION IV. SCOPE OF WORK & SPECIFICATIONS AND DELIVERABLES

4.1 4.2 4.3

Scope of Work & Deliverables Payments Structure, Performance Standards, and Compliance (includes Appendix A) Transition Contract

SECTION V. BUSINESS CONTINUITY PLAN

SECTION VI. PROPOSAL FORMAT AND STRUCTURE

6.1 Complete Proposal Content Requirements

6.2 Organizational Structure of the Technical Proposal

6.2.1 Attachment A: Required Offeror Information Requirements

6.2.2 Attachment E: Supplement A: State IT Policy, Standard, and Service Requirements

6.2.3 Attachment G: Acknowledgements, Exceptions, and Assumptions

6.3 Cost Proposal Requirements (Attachment C)

6.4 Proposal Formatting

6.5 Proposal Submission

SECTION VII. CRITERIA FOR PROPOSAL EVALUATION AND SELECTION

7.1 Scoring of Proposals

7.2 Veteran-Friendly Business Enterprise Program

7.3 Clarifications, Exceptions, and Assumptions Review

7.4 7.5 7.6

Final Offeror Recommendation Contract Award No Obligation to Award

SECTION VIII. PROTEST PROCEDURE

END OF TABLE OF CONTENTS

SECTION IX. CONDITIONS AND OTHER REQUIREMENTS

9.1 Start Work Date

9.2 Trade Secrets Prohibition; Public Information Disclaimer

9.3 Contractual Requirements

9.4 Public Release of Evaluations and/or Reports

9.5 Ethical and Conflict of Interest Requirements

9.6 Americans with Disabilities Act (ADA)

9.7 Confidentiality and Health Insurance Portability and Accessibility Act (HIPAA)

Requirements

9.8 Unresolved Findings for Recovery (ORC 9.24), Labor Practices, and Debarments

9.9 Mandatory Contract Performance Disclosure

9.10 Mandatory Disclosures of Government Investigations

9.11 MBE and EDGE Subcontracting Requirements

SECTION X. ATTACHMENTS A-H

A. Required Offeror Information (includes Attachments A1 through A6) B. Technical Proposal Score Sheet C. Cost Proposal Form D. ODM Contract Model E. Supplement A: State IT Policy, Standard, and Service Requirements F. Data Security and Privacy Terms G. Acknowledgements, Exceptions, and Assumptions H. Cost Point Calculation

SECTION I. PURPOSE

1.1 Overview

The Ohio Department of Medicaid (ODM) releases this Request for Proposals (RFP) to obtain a qualified Supplier to perform independent external quality review (EQR) services that consist of mandatory and optional activities (e.g., validation of performance improvement projects, encounter data validation studies, and consumer satisfaction surveys) required by the Centers for Medicare and Medicaid Services for Medicaid Managed Care Entities (MCEs) contracted with ODM. Information obtained from the EQR is used to assess the quality, accessibility, and timeliness of services that Medicaid MCEs provide to their enrolled members. The EQR results are also used to ensure ODM’s compliance with federal requirements to arrange for an external, independent evaluation of contracted MCEs and to fulfill reporting requirements specified in the Code of Federal Regulations (CFR) Title 42 § 438 Subpart E. The Selected Supplier will also provide ODM and its MCEs with technical assistance, national expertise, and other support to improve the overall performance of Ohio’s managed care delivery systems.

Supplier Proposals must clearly demonstrate the Supplier’s capability of providing services as described in this RFP. If the Supplier is proposing the use of subcontractor(s), the Supplier must identify the subcontractor(s) and provide evidence of the subcontractor(s)’ certification(s) and qualifications (See Section 4.2).

For the purpose of this RFP, the terms “Offeror” or “Supplier” shall be defined as consulting or professional services firms that are interested in responding to this opportunity. The terms “bid” and “proposal” may be used interchangeably to indicate materials submitted to ODM by a Supplier in order to be considered for award of a contract for services described in this RFP. The terms “Selected Offeror” or “Selected Supplier” may be used interchangeably in reference to a Supplier selected by ODM through this RFP for contract award.

1.2 Background

ODM is the single state agency responsible for the implementation and administration of the Ohio Medical Assistance (Medicaid) Program authorized under Title XIX of the Social Security Act (SSA) and for administering Title XXI of the SSA, the State Children’s Health Insurance Program (SCHIP), implemented in Ohio as a Medicaid expansion program.

Medicaid is jointly financed by federal and state government, providing healthcare coverage to approximately 3.0 million low-income children and adults, pregnant women, and children and adults with disabilities throughout the state of Ohio. While Ohio purchases and delivers most healthcare services through a managed care delivery system, the traditional fee-for-service system is also used to provide services to a small portion of the Medicaid population.

ODM has contracted with Medicaid managed care organizations (MCOs) since 1978.

Ohio’s risk-based comprehensive Medicaid Managed Care program was initially approved by the Centers for Medicare and Medicaid Services under a State Plan Amendment for the Aged, Blind, or Disabled (ABD) population and the Modified Adjusted Gross Income (MAGI) population, formerly known as the Covered Families and Children (CFC) population, with limited exceptions. The following population groups were added to Managed Care on the corresponding dates: ABD children (July 2013), Adult Extension (January 2014), MyCare dual eligible recipients (May 2014), and Adoption and Foster Kids (January 2017). Today, more than 90% of Ohioans served by Medicaid are in a managed care arrangement.

In 2019, ODM began reimagining the way the Ohio managed care program provided quality services to improve the health of the individual, their family and community. The resulting Next Generation Managed Care Program design was informed by more than 1,100 comments from providers, stakeholders, members and community partners; lessons learned from quality improvement initiatives; and identified gaps in previous models that were oriented towards managing risk as the sole mechanism for controlling costs.

The newly redesigned Ohio Medicaid managed care program includes three types of MCEs available statewide to focus on more effectively serving individual and population needs: seven (7) Managed Care Organizations; the OhioRISE prepaid inpatient health plan (PIHP), specifically designed to serve children and youth with complex behavioral health needs and involvement with multiple systems of care; and a single pharmacy benefit manager (SPBM) prepaid ambulatory health plan (PAHP). The new design also includes administrative simplification using a Fiscal Intermediary (FI) to centralize claims payment and prior authorization, and a streamlining of provider enrollment through the Centralized Credentialing component of the Provider Network Model (PNM) of the Ohio Medicaid Enterprise System (OMES).

Lastly, in SFY 2024, ODM released a request for application for Managed Care Organization (MCOs) to serve as the MyCare Ohio Plans (MCOPs) as Ohio moves toward a Fully Integrated Dual Eligible Special Needs Plan (FIDE SNP) model.

The Next Generation Ohio Medicaid program includes strong cross-agency coordination and partnership between ODM and MCEs, vendors, Suppliers partner state agencies, community-based organizations, colleges of medicine, and health systems to support specialization in addressing critical needs. ODM is working in collaboration with the Ohio Departments of Job and Family Services (ODJFS), Health (ODH), Mental Health and Addiction Services (OhioMHAS), Developmental Disabilities (DODD), Aging (ODA) and other state health and human services agencies to support a more seamless and personalized experience for individuals and providers.

The Next Generation Managed Care program integrated quality throughout the program by taking a population health management approach to improve the health of more than three million Ohioans served in the program. Aligned with the Institute for Healthcare Improvement’s Quintuple aim, ODM’s Managed Care Population Health and Quality Strategy (“Quality Strategy”) incorporates a population health management approach to improving healthcare quality, member and provider experience, health equity, and health outcomes while reducing cost. This includes the intelligent use of health data to identify individual and population needs in a timeline manner; the use of population health approaches such as quality improvement, care management, and cross-system collaboration; supporting innovation and sustaining improvements through supportive payment practices; and capturing actionable, accurate and timely data for effective decision making. Delivering healthcare through a person-centered lens is integral to the success of each approach and is interwoven throughout the fabric of ODM’s population health improvement efforts.

Working closely with stakeholders, advocates, medical professionals, and fellow state agencies, ODM continues to modernize the Medicaid program and improve Ohio’s healthcare landscape. ODM’s mission is to improve population health by pursuing the priorities of evidence-based care, engaging in person and family in care, promoting communication and coordination, promoting prevention and treatment, working with communities to enable health living, and making quality care affordable. Ohio’s managed care program is designed to achieve these priorities by focusing on targeted goals within the context of family and community while also keeping the individual at the forefront of all efforts. High-level priorities of ODM include:

• Improving wellness and health outcomes;

• emphasizing a personalized care experience;

• supporting providers in better patient care;

• improving the care of children and adults with complex needs; and

• increasing program transparency and accountability.

1.3 Overview of Project

States contracting with Managed Care Organizations, PIHPs, PAHPs (referred to collectively herein as MCEs) are federally required to conduct an annual independent review of the quality, accessibility, and timeliness of the healthcare services provided to Medicaid members by the MCEs. Relevant federal law can be found at 42 USC 1396u-2(c)(2) and 42 CFR 438 Subpart E.

Ohio’s external quality review (EQR) process will include mandatory and optional activities specified in 42 CFR 438.358. Information from Ohio’s EQR process will be used to produce the federally required annual detailed technical report that aggregates and analyzes data to draw conclusions about the timeliness, accessibility, and quality of services furnished by the MCEs; to provide an assessment of the MCEs’ performance with respect to timeliness, accessibility, and quality; to provide comparative information about MCEs when appropriate; to develop recommendations for improving the quality of healthcare furnished to Ohio’s Medicaid members; and to provide an assessment of the degree to which each MCE has effectively addressed the prior years’ EQR recommendations. Results from all EQR activities will be used to monitor plans’ compliance with state and federal regulations, to evaluate the effectiveness and impact of the Quality Strategy, and to enhance the administration of the Next Generation Managed Care Programs.

1.4 Objectives

There are two main objectives of this project: 1) to perform external quality review activities (mandatory and optional) and produce associated deliverables to assure Ohio Medicaid’s compliance with CMS requirements; and 2) to provide ODM and MCEs with technical assistance and national expertise to efficiently and effectively administer the Medicaid managed care programs.

SECTION II. PROCUREMENT PROCESS INFORMATION

2.1 Anticipated Procurement Timetable

DATE EVENT/ACTIVITY

December 10, ODM releases RFP on ODM and DAS websites; Question & Answer (Q&A) period opens.

- RFP becomes active; Offerors may submit inquiries for RFP clarification.

January 3, 2025 Q&A period for Offeror questions closes at 8:00 a.m. on this date.

- No further inquiries for RFP clarification will be accepted.

2:00 PM EST

January 22, 2025

Deadline for Offerors to submit Proposals to ODM (2:00 PM EST)

- This begins the ODM process of proposal review.

LATE BIDS WILL NOT BE CONSIDERED. NO EXCEPTIONS WILL BE MADE.

March 2025 ODM issues contract award notification letter (estimated).

- Offerors that submitted Proposals in response to this RFP will be sent letters stating whether their proposal was selected for award of the contract.

April 2025

Implementation (estimated - following notification of all contractual and funding approvals).

- ODM contracts are not valid and effective until the Ohio Office of Budget & Management approves the purchase order.

Three total possible biennial periods ending June 2031

One initial contract period plus two possible contract(s) renewal periods.

ODM reserves the right to revise this schedule if needed and/or to comply with the State of Ohio procurement procedures and regulations.

The contract period is expected to run from contract award through June 30, 2027, with the possibility for two (2) renewal contracts through June 30, 2031, contingent upon satisfactory performance, continued availability of funding, and all required approvals. Renewal may be subject to approval by the Controlling Board.

OhioBuys provides the primary platform to engage in procurement activities with the State of Ohio. For additional information on submitting Proposals see the “Viewing and Responding to Solicitations” Learner Guide or the “Viewing and Responding to Solicitations” Supplier Training Video linked below.

Learner Guide https://procure.ohio.gov/about/03_supplier-training/03_supplier-training Viewing and Responding to Solicitations https://www.youtube.com/watch?v=K6iE32BUMJ0&feature=youtu.be https://ohiobuys.ohio.gov/page.aspx/en/usr/login?ReturnUrl=%2Fpage.aspx%2Fen%2Fbuy%2Fhomepage https://procure.ohio.gov/about/03_supplier-training/03_supplier-training https://www.youtube.com/watch?v=K6iE32BUMJ0&feature=youtu.be

In accordance with Ohio Revised Code (ORC) Section 126.07, ODM contracts are not valid and enforceable until the Office of Budget and Management (OBM) certifies the availability of appropriate funding, as indicated by the approval of the Purchase Order (PO). The Selected Supplier may neither perform work nor submit an invoice for payment for work performed for this project for any time period prior to the PO approval date. ODM will notify the Selected Supplier when the requirements of ORC Section 126.07 have been met and send them a copy of the PO at that time.

2.2 Internet Question and Answer Period

Offerors or other interested parties may submit clarifying questions regarding this RFP during the Question and Answer (Q&A) Period as outlined in Section II, Anticipated Procurement Timetable. To submit their question, Offerors must login to OhioBuys, navigate to the solicitation, open the Inquiry tab, and submit their question (Inquiry).

The purpose of the Q&A period is to provide the opportunity to seek clarity regarding the requirements and specifications of the RFP. Questions about this RFP must reference the relevant part of the RFP, the heading for the provision under question, and the page number where the provision can be found. If Offerors have more than one (1) question, Offerors must submit each question as a separate Inquiry, and Offerors are not to post Inquiries in any pre-formatted tables. The name of a representative of the Offeror or other interested party, the company name, phone number, and e-mail address must be provided to submit an Inquiry. ODM may, at its option, disregard any Inquiries that do not appropriately reference an RFP provision or location within the RFP, that do not include identification of the originator of the Inquiry, or that do not seek clarification regarding the requirements or specifications of the RFP, in the opinion of ODM. Inquiries submitted after the Q&A period closes will not be answered.

ODM’s answers (Responses) to all Inquiries asked via the Internet will be posted in the OhioBuys website through the Inquiry tab for public reference. ODM will not provide Responses directly to the Offerors or any interested party that submitted Inquiries. ODM is under no obligation to acknowledge Inquiries submitted through the Q&A process if those Inquiries are not in accordance with these instructions.

Once posted, ODM’s Responses may be accessed on the OhioBuys Public Solicitations page by opening the Solicitation Overview and navigating to the Inquiries section of that page. ODM strongly encourages Offerors to submit Inquiries early in the Q&A period so that answers can be posted with sufficient time for follow-up Inquiries. ODM strives to answer all Inquiries within two business days; however, in the event of a high volume of Offeror Inquiries, the response time may exceed the two business-day timeframe. The Offeror will not receive a personalized response nor an automated response when ODM has answered the Inquiry.

Offeror Proposals in response to this RFP are to take into account any information communicated by ODM in the Q&A process for the RFP. It is the responsibility of all Offerors to check this site on a regular basis for Responses to Inquiries, as well as for any addenda, alerts, or other pertinent information regarding this RFP because these items become incorporated within the RFP. Once submitted Inquiries have been answered, Responses are clearly identified through the Inquiry tab located within the RFP in the OhioBuys website. ODM does not consider Inquiries asked during the inquiry period through the inquiry process as exceptions to the terms and conditions of this RFP.

https://ohiobuys.ohio.gov/page.aspx/en/usr/login?ReturnUrl=%2Fpage.aspx%2Fen%2Fbuy%2Fhomepage https://ohiobuys.ohio.gov/page.aspx/en/usr/login?ReturnUrl=%2Fpage.aspx%2Fen%2Fbuy%2Fhomepage

Requests for copies of any previous RFPs, Request for Letterhead Bids (RLBs), etc., or for past Offeror Proposals, score sheets or contracts for this or similar past projects are not clarification questions regarding the present RFP, but are Public Records Requests (PRRs), and should be submitted to:

mcdlegal@medicaid.ohio.gov.

If Offerors experience technical difficulties accessing the OhioBuys website, they may contact Ohio Shared Services at 877-644-6771 for assistance. If Offerors experience technical difficulties accessing documents related to this solicitation or are unable to get assistance from Ohio Shared Services, they may contact the ODM Office of Contracts and Procurement (OCP), RFP/RLB Unit, at ODM_Procurement@medicaid.ohio.gov for guidance. Substantive questions related to this RFP submitted in the manner outlined in this paragraph will not be answered. Offerors are encouraged to seek technical assistance early in the Q&A Period to avoid missing the Q&A Period.

2.3 Communication Prohibitions

From the date this RFP is issued until a contract is awarded, there must be no communications concerning the RFP between any Offeror and any employee, vendor, supplier, or subcontractor of ODM, who is in any way involved in the development of the RFP or the selection of the Offeror.

The only exceptions to this prohibition are as follows:

A. Communications conducted pursuant to Section 2.2, Internet Question & Answer (Q&A) Period;

B. As necessary in any pre-existing or on-going business relationship between ODM and any

Offeror that could submit a proposal in response to this RFP; and

C. As part of any Offeror interview process, proposal clarification, or negotiation process initiated by ODM, which ODM deems necessary in order to make a final selection.

ODM is not responsible for the accuracy of any information regarding this RFP that is obtained or gathered through a source other than the Q&A process described in this RFP. Any attempts at prohibited communications by Offerors may result in the disqualification of those Offerors’ Proposals.

If Offerors need to communicate regarding this RFP, they must contact ODM using one of the mechanisms above. Offerors are cautioned that communication attempts which do not comply with these instructions will not be answered, and that ODM will not consider any Proposals submitted to any address other than as provided in this RFP. Any communication considered prohibited, or Proposals not submitted to the proper address, may disqualify Offerors from participation in this RFP.

2.4 Addenda to the RFP

If ODM revises this RFP before the Proposals are due, an amendment will be issued in OhioBuys as a new round of the RFP solicitation. If an Offeror has submitted a Proposal prior to an amendment being issued and wishes to be considered, the Offeror must resubmit its entire Proposal in response to the latest round mailto:mcdlegal@medicaid.ohio.gov of the RFP. Proposals submitted in response to amended RFPs prior to the most recent amendment will not be opened or evaluated. ODM may issue amendments any time before Proposals are due, and it is each prospective Offeror’s responsibility to check for amendments and other current information regarding this RFP.

Offerors may view amendments by navigating to the OhioBuys Public Solicitations page and searching for the amendment.

After the proposal due date, ODM will distribute any additional addenda or other announcements only to those Offerors whose Proposals are under active consideration. If ODM issues an addendum to the RFP after the due date for Proposals, ODM will permit Offerors to withdraw their Proposals within five (5) business days, or as otherwise specified in the addendum, after the addendum is issued. Alternatively, if specified in the addendum, ODM may allow Offerors that have Proposals under active consideration to modify their Proposals in response to the addendum.

SECTION III. OFFEROR QUALIFICATIONS AND EXPERIENCE

3.1 Minimum Mandatory Requirements

Offerors MUST meet and provide proof of, at minimum, ALL the following qualifications. Suppliers who do not meet all of these minimum mandatory requirements will be disqualified from further consideration. Suppliers shall also refer to the Technical Proposal Score Sheet (Attachment B) for ALL mandatory requirements.

A. The Offeror’s Proposal must be received by the deadline as specified in Sections 2.1 and 6.5.

B. The Offeror’s submitted Proposal must be comprised of a Technical Proposal, and in a separate, appropriately labeled, sealed envelope, a Cost Proposal as specified in Sections 6.1, 6.2, and 6.3.

C. The Offeror’s submitted Proposal must include a fully completed Attachment A, including all required signatures, affirmative statements, and certifications, as specified in Section 6.2.1.

D. The Offeror is not prohibited from entering into a contract with ODM, due to restrictions related to the federal debarment list, unfair labor findings, or as established in ORC Section 9.24, as specified in Section 9.8.

E. An attestation the Offeror has at least 5-years’ experience in the following areas: Medicaid beneficiaries, policies, data systems and processes; managed care delivery systems, organizations, and financing; quality assessment and performance improvement methods;

quality improvement science methods; research design, methods and statistical analysis;

effective population health management strategies; and value-based payment strategies.

F. An attestation the Offeror has assigned, or proposed staff who are employed with, or have a subcontract with, a qualified organization that is designated as a National Committee for Quality Assurance (NCQA) – certified Healthcare Effectiveness Data and Information Set (HEDIS) Compliance Auditor. Suppliers must include a copy of their NCQA Recognition Certificate that provides the name of the certified Supplier/subcontractor/individual, an effective date, and an expiration date of the certification.

G. An attestation the Offeror has an IT system with the capacity capable of receiving, storing, transferring, protecting, organizing, managing, manipulating, and analyzing large data sets that cover a population of approximately 3.0 million individuals.

H. An attestation that Offeror’s Technical Proposal demonstrates the required knowledge of

X-12 standards and experience with electronic data interchange (EDI).

I. An attestation the Offeror’s Technical Proposal contains demonstrated experience with cloud-based Software-as-a-Service (SaaS) database management tools and advanced analytic capabilities using programming language (e.g. R, Python, SAS).

J. An attestation the Offeror’s Technical Proposal contains demonstrated experience with data visualization tools and dashboard server management.

K. An attestation Offeror’s Technical Proposal contains demonstrated information security and privacy compliance including implementation of the Health Insurance Portability and Accountability Act 0f 1996 (HIPAA) compliant administrative, technical, and physical safeguards.

L. An attestation Offeror’s Technical Proposal evidences demonstrated independence from the state Medicaid agency, MCEs, and providers (e.g., Medicaid-contracted hospitals and providers enrolled in the Comprehensive Primary Care Program) under review as part of this Contract and as required by 42 CFR 438.354(c). If a conflict does exist between the Offeror and providers under evaluation, the Offeror must be able to mitigate this conflict in a manner approved by ODM.

M. Complete and return all requirements and forms in Attachment A upon submission of

Proposal.

N. Submission with proposal of a selected Ohio certified Minority Business Enterprise (MBE) subcontractor assigned job duties that will equate to a minimum of 15 percent of the total dollar amount of the contract per state fiscal year (SFY). This requirement is further described in Minority Business Enterprise Subcontracting Requirements.

O. The Offeror’s Proposal must meet the requirements and prohibitions related to, including in the Proposal, personal confidential information as provided in Section 3.6 and trade secret/proprietary information as described in Section 9.2.

P. An attestation that the Offeror understands, accepts, and will comply with ODM’s payment structures based upon Statement of Work sets of key milestones and services credits as described in Section 4.2.A.

Q. An attestation that the Offeror understands, accepts, and will comply with ODM’s right under Section 4.2.B to impose corrective and/or remedial actions as provided in the RFP, including Appendix A.

R. Agreement that, pursuant to Section 4.2.C, Contract performance specifications may be added or adjusted by mutual agreement during the term of an awarded Contract to align with ODM business needs, organizational objectives, and technological changes.

S. An attestation that the Offeror, pursuant to Section 4.3, commits to assisting ODM with transitioning services from its current EQR vendor to the Offeror if selected for a Contract.

T. Pursuant to Section 9.9, the Offeror has either disclosed any formal claims of breach of contract against the Offeror or the Offeror’s proposed subcontractor(s), as well as any Corrective Action Plans (CAPs) or non-CAP service credits, liquidated damages, penalties or sanctions issued against the Offeror or the Offeror’s proposed subcontractor(s) in the three

(3) years leading up to the Proposal due date for this RFP, or the Offeror has provided an attestation that there are no disclosures to make.

U. The Offeror’s Technical Proposal must be well-organized and comply with the formatting instructions in Sections 4.1, 6.1, 6.2, and 6.4.

3.2 Organizational Experience and Capabilities

Proposals should demonstrate significant organizational expertise of the Offeror. As such, Proposals must include, at a minimum, the following demonstrated experience and abilities and commitment to engagement as detailed below. As part of the evaluation process, this information will be scored by ODM:

A. Demonstrated experience relevant to completing the work identified in the Scope of Work (SOW) Section of this RFP. Include information on the background of the Offeror, including any subcontractors who would perform work under any Contract resulting from this RFP.

B. Samples (excerpts and/or Executive Summaries acceptable) of at least two, but no more than four, similar sized projects completed or begun in the past five (5) years that demonstrate expertise and experience in providing expert assistance in the strategies and objectives listed in Sections 1.3 and 1.4.

C. Demonstrated knowledge of and experience in Medicaid and the practical application of the laws and regulations impacting its operations. Include Ohio-specific knowledge and experience.

D. Names and contact information for at least three entities for which the Offeror has performed similar large-scale projects in the past five (5) years.

E. Demonstrated commitment to ongoing engagement with ODM including but not limited to staying current on ODM’s policies and programs, and any relevant changes; participating in executive leadership meetings with ODM’s Director, Medical Director, and other key ODM personnel; attending meetings on-site as requested by ODM; collaborating with ODM’s Contracted Vendors/Suppliers as requested by ODM; and following ODM’s guidance as evidenced by the Supplier’s willingness to cooperate, be flexible, and timely respond to ODM’s feedback regarding performance concerns.

F. Demonstrated commitment with dedicated, appropriate resources to adopt and implement a comprehensive, integrated, and customized approach for all SOWs outlined in Section 4.1 that ensures: 1) development of project work plans and project management tools, including timelines, report templates, methodologies, analysis plans, etc.; 2) coordination with ODM on activities with project dependencies, overlapping goals, etc.; 3) cross pollination across the different SOWs (i.e., to share best practices and insights from one area of work with another); 4) regular meetings for the core team of key staff, including project leads, as specified in Section 3.3 and led by the Project Director; 5) the Project Director will take an active role in overseeing all aspects of the SOWs and deliverables; and

6) that at-risk activities will be escalated as soon as possible to ODM’s Agreement Manager.

G. Description of supplier’s method(s) for ensuring sufficient staffing capacity for providing the services and deliverables under the SOWs.

H. Description of a robust training plan that ensures staff will be sufficiently trained in Ohio Medicaid’s programs, policies, and requirements and all relevant federal requirements pertaining to the SOWs described in Section 4.1.

I. Description of the supplier’s robust quality assurance process for all deliverables; and

J. Description of the supplier’s process to ensure data integrity.

The Offeror’s information provided for all the above topics should include summary descriptions of all successfully completed projects, any notable accomplishments and outcomes, and contact information for an Offeror’s customers that received the services provided, if not already included as a reference. The Offeror’s experience and knowledge should be demonstrated by providing key samples, excerpts, or copies that represent the quality of relevant work.

3.3 Key Personnel and Additional Staff - Experience and Capabilities

Proposals should demonstrate significant expertise by assigning staff to key roles with the following requirements and capabilities. The positions listed in subsections A through F are considered “Key Personnel” under this RFP. Proposals must include, at a minimum, the following staff positions with demonstrated experience as detailed below (A-G). Proposals should also include a table of organization that outlines the hierarchy and relationship of the organization’s leadership (e.g. President, Chief Executive Officer, Chief Information Officer) to, and accountability for, each of the positions listed below.

A. Project Director: The Project Director must be fully dedicated to, and accountable for Ohio

Medicaid’s External Quality Review Contract. This position will be a full-time employee (FTE) of supplier and will be dedicated to the Ohio Contract. This individual may not be a subcontractor. The individual who fills this position must have:

1. Not less than a master’s degree (e.g., Business Administration, Public

Administration, Health Services Administration). Commensurate experience may be considered with approval by ODM.

2. Five years of healthcare related project/contract management experience with demonstrated successful implementation of multiple large-scale projects; and

3. Demonstrated knowledge and experience of working with Medicaid Managed Care Programs and federal managed care and external quality review regulations.

4. A Project Management Professional (PMP) Certification is preferred, but not required.

B. Medical Director/Chief Medical Officer: The Medical Director/Chief Medical Officer must be fully dedicated and available to Ohio Medicaid’s External Quality Review contract. This position will be an FTE of supplier dedicated to the Ohio Contract. This individual may not be a subcontractor. The individual who fills this position must:

1. Be a physician with a current, unencumbered license through the State Medical

Board, preferably in Ohio or the supplier’s primary business location; and

2. Have at least five years of experience with the following: Medicaid populations, direct clinical experience seeing patients and interacting with payors (contracting, utilization management, submitting claims, etc.), leading major clinical quality improvement initiatives (including relevant data analytics and use of rapid cycle quality improvement approaches and tools), health equity efforts, implementing meaningful population health management activities (i.e., activities that maintain and improve physical and psychosocial well-being and address health disparities through cost-effective, person-centered health solutions – e.g., care coordination and quality improvement – that address members’ health needs in multiple settings at all points along the continuum of care) and leading/guiding practice transformation efforts (i.e., refers to the process of change in the organization and delivery of care aimed at improving health outcomes, patient engagement, etc.).

C. Statistician: The individual who fills this position must be an FTE of supplier and must have the following. This individual may not be a subcontractor.

1. No less than a master’s degree in a related field (e.g., Statistics, Mathematics, Biostatistics), commensurate experience may be considered with approval by ODM;

2. Five years healthcare related experience; and

3. Five years of experience with complex statistical analysis, statistical programming, sampling methodologies, etc.

D. Information Technology Director: The individual who fills this position must be an FTE of supplier and must have the following. This individual may not be a subcontractor.

1. No less than a master's degree in a related field (e.g., Computer Science, Computer Programming), commensurate experience may be considered with approval by ODM; and

2. Five years of experience with the following:

a. Managing a healthcare data warehouse for a large data set covering a population of 3,000,000 or more individuals;

b. Providing role-based access to multiple users for the receipt and exchange of data, ensuring system security and performance consistent with industry standards;

c. Performing information systems reviews;

d. Providing technical assistance to users;

e. Designing building, and maintaining complex business intelligence solutions

(e.g., databases, scorecards, dashboards);

f. Electronic health record-derived measures and related application programming interfaces (APIs), health information exchanges, data validation, data quality and accuracy checks; and

g. The ability to provide privacy and protection of data provided by ODM.

E. Healthcare Data Analyst: The individual who fills this position must be an FTE of supplier and must have the following. This individual may not be a subcontractor.

1. No less than a master’s degree in a related field (e.g., Health Services

Administration, Public Health, Public Administration, or Business Administration), commensurate experience may be considered with approval by ODM; and

2. Five years of experience working with large data sets (enrollment and eligibility files, claims and encounter data), survey methods, HEDIS quality measures (or equivalent national measurement sets), and explaining performance variation, comparisons with performance benchmarks, and trends in metrics.

F. Technical Writer: The individual who fills this position must be an FTE of supplier and must have the following. This individual may not be a subcontractor.

1. No less than a bachelor’s degree in a related field (e.g., Communications, Technical

Writing, Business);

2. Three years of experience in writing external quality review reports; and

3. Demonstrated experience with synthesizing information with critical thinking related to key insights derived from the data.

G. Project Lead: The supplier must assign a Project Lead for each SOW. The Project Lead will interact directly with ODM’s assigned Project Lead and can be a lead for multiple SOWs.

The Project Lead cannot be filled by the individual serving as the Project Director. Each individual serving in a Project Lead role can be an FTE or subcontractor and must have the following.

1. A bachelor’s degree in a related field (e.g., Health Services Administration, Health

Policy, Public Health or Business Administrations);

2. At least one year of experience performing external quality review related activities.

3. Demonstrated knowledge of federal managed care and external quality review regulations.

4. Demonstrated experience with successful implementation of one large scale project.

3.4 Replacement of Key Personnel

A. During each Term of the Contract, the replacement of any Key Personnel must first be approved by ODM; the positions listed in Section 3.3, subsections A through F are Key Personnel. ODM reserves the right to disapprove a key staff member’s assignment if it determines the minimum education and experience requirements are not met. The Offeror shall use all commercially reasonable efforts to ensure the continued availability of those Key Personnel. Also, the Offeror may not remove Key Personnel from the project without the prior written consent of ODM, except if doing so is necessary for legal or disciplinary reasons. However, the Offeror must make a reasonable effort to give ODM 30 calendar days’ prior, written notice of the removal. Offeror’s notice to ODM to remove or replace Key Personnel must include two qualified replacement candidates’ resumes with detailed documentation of the proposed candidate’s experience with projects of similar size and scope to the subject of this RFP.

B. If the Offeror removes a key staff member from this project for any reason other than those specified above, ODM may assess liquidated damages in the amount of $1,500.00 for every day between the date on which the individual was removed and the date that the Contract is terminated, or the individual’s qualified replacement, selected in accordance with the process identified in this Section, starts performing on the project.

ODM also may provide the Offeror with written notice of its default under this section, which the Offeror must cure within 30 days. If the Offeror fails to cure its default within the 30-day cure period, the Contract may be terminated immediately for cause, and ODM will be entitled to damages in accordance with the Suspension and Termination Section of the executed Contract. If ODM assesses liquidated damages or is otherwise entitled to damages under this provision, it may offset these damages from any fees due under the Contract.

C. ODM has an interest in ensuring that its operations are carried out in an efficient, professional, legal, and secure manner. Therefore, ODM will have the right to require the Offeror to remove any individual involved in the project, if ODM determines that any such individual has or may interfere with ODM's interests including those identified above. In such a case, the request for removal will be treated as a case in which an individual providing services under the Contract has become unavailable, and the Offeror must follow the procedures identified above for replacing unavailable Key Personnel. This provision also applies in the event ODM permits Offeror to utilize subcontractors in any Key Personnel positions.

3.5 Subcontractor Identification and Participation Information

Offerors shall clearly identify the subcontractor(s) and their tasks in their Proposal. The Proposal must include a letter from the proposed subcontractor(s), signed by a person authorized to legally bind the subcontractor, indicating the following:

A. Subcontractor’s legal status, federal tax ID number, and principal business address;

B. Name, phone number, and email address of a person who is authorized to legally bind the subcontractor to contractual obligations;

C. A complete description of the work the subcontractor will do;

D. A commitment to do the work, if the Offeror is selected;

E. A statement that the subcontractor has read and understands the RFP, the nature of the work, and the requirements of the RFP; and

F. The MBE certification number, if applicable, and a copy of their current MBE Certification letter must be included.

3.6 Sensitive Personal Information

It is the sole responsibility of the Offeror submitting a proposal to remove all personal confidential information (such as home addresses and social security numbers) of Offeror staff and/or of any subcontractor and subcontractor staff from resumes or any other part of the proposal package.

Following submission to ODM, all Proposals submitted may become part of the public record. ODM reserves the right to disqualify any Offeror whose proposal is found to contain such prohibited personal information.

SECTION IV. SCOPE OF WORK & SPECIFICATIONS OF DELIVERABLES

4.1 Scope of Work & Deliverables

The Selected Supplier will be responsible for the Scopes of Work (SOW) and Deliverables in this Section, including all preparatory and intervening steps, whether ODM has explicitly specified or delineated them within the RFP. The Selected Supplier will be required to submit any reports required herein to meet the Deliverables pursuant to the specifications provided. In developing their Proposals, all Offerors shall fully and appropriately plan and cost. Offerors must provide a detailed technical approach that describes how it will define and perform each of the Scopes of Work, including references to CMS’ External Quality Review Protocols, February 2023 (known hereinafter as “CMS EQR Protocols”), and how they will develop and manage services performed under all subcontracting arrangements. Offerors must also provide a workplan and timeline for each SOW; Offeror’s responses should correspond to the appropriate SOW.

Note: The Proposal’s detailed technical approach provided for each Scope of Work shall not exceed 10 single-spaced pages for each SOW or SOW subsection. For example, SOW A1A may be 10 pages, SOW A1B may be 10 pages, SOW A2 may be 10 pages, SOW M may be 10 pages, and so on.

A. SOW A: PERFORMANCE MEASURE VALIDATION, CALCULATION, AND REPORTING

The following four SOWs under this SOW A are requirements for the Selected Supplier for reporting. The Selected Supplier must complete the SOW Tasks and provide the Deliverables at the frequencies specified below.

1. SOW A1 HEDIS Measures

A. SOW A1A: Performance Measure Validation

ODM uses health plan self-reported, audited HEDIS performance measures and/or state-calculated performance measures as a component of the Ohio Department of Medicaid’s Population Health and Quality Strategy to evaluate health plan performance, monitor health plan compliance with ODM’s performance standards, meet federal requirements for the mandatory activity of validation of performance measures as specified in 42 CFR § 438.358, and complete a comparative review of quality process and outcome measures based on HEDIS) (MCO), MyCare Ohio Plans, (MCOP,) and OhioRISE employ their own certified HEDIS auditor to complete the data collection and submission of the measures to NCQA and as required in the Managed Care Entity (e.g., MCO, OhioRISE and MCOP) Provider Agreements. The measures must have received a “report” designation from the HEDIS-certified auditor and must be specific to the Medicaid population under evaluation and as specified in the Provider Agreement. MCEs submit their data to ODM in an electronic format. For the SPBM program, ODM, or its designee, will calculate performance measures and the EQRO will validate the SPBM performance measures according to CMS EQR Protocols.

i. Tasks A1A

a. For MCOP, MCO and OhioRISE:

i. Review the health plans’ final audit reports (FARs) to identify any potential data collection or reporting issues that may impact the final audited rates.

ii. Evaluate the reason any self-reported measures received an audit designation of “Not Report” (NR).

iii. Provide a report based on the review of the FARs and any NR designations for reported measures. This report should summarize the FARs to include documented findings that impact ODM’s evaluation of plan performance, a determination of the plan’s compliance with minimum performance standards, an evaluation of performance related to the award of ODM’s quality withhold payouts, as applicable, and recommendations to ODM related to potential corrective actions or quality improvement;

iv. Develop, maintain, and update ODM’s documents for health plans’ self-reported and audited results.

v. Validate the HEDIS measures reported by the health plans to confirm they: 1) are consistent with the protocols established by CMS for performance measure validation; and 2) use the results from CMS for evaluation of the MyCare Program, and other lines of business as needed;

vi. Maintain a data repository for the health plans’ NCQA Interactive

Data Submission System (IDSS) self-reported and audited HEDIS results and FARs, facilitating access to the files for ODM, and an industry-standard data exchange mechanism (e.g., secure FTP).

b. For SPBM:

i. Develop and maintain a methodology in collaboration with ODM to validate the ODM-calculated performance measures according to CMS protocols.

ii. Assess the data sources and systems used to calculate the SPBM performance measures.

iii. Conduct a detailed review of the measures incorporating findings from the data and systems assessment.

iv. Analyze data and submit a validation report to ODM as described below in Deliverable A1A for SPBM.

ii. Deliverable A1A – Frequency: Annually

a. For MCO, MCOP, and OhioRISE

i. Produce one FAR review summary report for each applicable line of business (MCO, MCOP, and OhioRISE). Each report must contain plan-specific findings.

ii. Produce one specifications document per each applicable line of business (MCO, MCOP, and OhioRISE) that describes methods for the submission of the health plan self-reported HEDIS audited data to

ODM.

b. For SPBM

i. Produce one validation report with a list of measures validated by the EQRO, which includes a description of the validation activities, an analyses, conclusion based on the validation process for each performance measure, and a validation status for each performance measure. The validation report must also provide results of each performance measure and recommendation for improving the process for calculating and reporting performance measures.

B. SOW A1B: HEDIS Performance Measure Calculation and Reporting

i. Tasks A1B The Selected Supplier must produce reports using the health plans’ self-reported, audited HEDIS data that include health plan-specific and statewide results, national benchmarks per program, and health plan compliance with performance standards per ODM’s specifications and timelines.

ii. Deliverable A1B – Frequency: Annually, beginning with the HEDIS Measurement

Year 2026 data submission for each applicable line of business.

The Selected Supplier must produce one aggregate annual HEDIS results on an Excel workbook for each line of business, MCO, MCOP, OhioRISE, and SPBM, that contains plan-specific and statewide results, as specified by ODM.

2. SOW A2: Non-HEDIS and Ohio-specific Performance Measures Development, Calculation, and Reporting ODM uses nationally recognized non-HEDIS measures and Ohio-specific measures to evaluate plans participating in the Medicaid Managed Care Program, the OhioRISE program, the MyCare Ohio Program, and SPBM. Additional lines of business may be added in the future. The specific measures that are used align with ODM’s Quality Strategy. This activity includes researching, developing, implementing, collecting data, calculating, and validating new quality measures as specified by ODM.

The Selected Supplier must develop methodologies and calculate results to evaluate plan and program performance. For example, the two domains and measures of interest for Home and Community Based Services (HCBS) and Long-Term Care include but are not limited to the following:

i. Transition to Home and Community Based Settings:

a. Successful Transitions from Long-Term Care to…