REQUEST FOR PROPOSALS (RFP)

RFP NO. 2026HCA4

NOTE: If you download this RFP from any source other than the Washington Electronic Business Solution (WEBS), you are responsible for registering in WEBS for your organization to receive any RFP amendments, including Bidder questions/agency answers. HCA is not responsible for any failure of your organization to register in WEBS or any other repercussions that may result to your organization because of this failure.

PROJECT TITLE: External Quality Review

PROPOSAL DUE DATE: August 7, 2026 by 2:00 p.m. Pacific Time, Olympia, Washington, USA.

Only e-mailed bids will be accepted.

ESTIMATED TIME PERIOD FOR CONTRACT: January 1, 2027 to December 31, 2031

The Health Care Authority reserves the right to extend the contract for up to five (5) additional one (1) year periods at its sole discretion, dependent on mutual agreement of the contract terms by the parties.

BIDDER ELIGIBILITY: This solicitation is open to those Bidders that satisfy the minimum qualifications stated herein and that are available for work in Washington State.

HCA RFP No. 2026HCA4 Page 1 of 50

TABLE OF CONTENTS

1 INTRODUCTION

1.1 DEFINITIONS

1.2 ESTIMATED SCHEDULE OF SOLICITATION ACTIVITIES

1.3 PURPOSE AND OBJECTIVES

1.4 BACKGROUND

1.5. SCOPE OF WORK

1.6. MINIMUM QUALIFICATIONS

1.7. FUNDING

1.8. PERIOD OF PERFORMANCE

1.9. ADA

2. GENERAL INFORMATION FOR BIDDERS

2.1. RFP COORDINATOR

2.2. PRE-PROPOSAL CONFERENCE

2.3. LETTER OF INTENT TO PROPOSE

2.4. BIDDER QUESTIONS PERIOD

2.5. SUBMISSION OF PROPOSALS

2.6. PROPRIETARY INFORMATION / PUBLIC DISCLOSURE

2.7. REVISIONS TO THE RFP

2.8. COMPLAINT PROCESS

2.9. RESPONSIVENESS

2.10. MOST FAVORABLE TERMS

2.11. RECEIPT OF INSUFFICIENT NUMBER OF PROPOSALS

2.12. NO OBLIGATION TO CONTRACT

2.13. REJECTION OF PROPOSALS

2.14. SUBCONTRACTOR PARTICIPATION MONITORING AND REPORTING

3. PROPOSAL CONTENTS AND REQUIREMENTS

3.1. PROPOSAL CONTENTS OVERVIEW

3.2. PROPOSAL REQUIREMENTS AND GUIDELINES

3.3. BIDDER PROFILE & SUBMITTAL FORM (MANDATORY)

3.4. DIVERSE BUSINESS INCLUSION PLAN (MANDATORY)

3.5. EXECUTIVE ORDER 18-03 (SCORED)

3.6. REFERENCES (MANDATORY/SCORED)

3.7. DRAFT CONTRACT (MANDATORY)

3.8. WRITTEN PROPOSAL (SCORED)

3.9. COST PROPOSAL (SCORED)

3.10. DATA SECURITY REQUIREMENTS RESPONSE (MANDATORY)

3.11. COMPETENCY INDEPENDENCE REQUIREMENTS (MANDATORY)

3.12. DELIVERABLES TABLE

4. EVALUATION AND CONTRACT AWARD

4.1. EVALUATION PROCEDURE

4.2. EVALUATION WEIGHTING AND SCORING

4.3. BEST AND FINAL OFFER (BAFO)

4.4. SUBSTANTIALLY EQUIVALENT SCORES

4.5. NOTIFICATION TO BIDDERS

4.6. DEBRIEFING OF UNSUCCESSFUL BIDDERS

4.7. PROTEST PROCEDURE

HCA RFP No. 2026HCA4 Page 2 of 50

5. RFP EXHIBITS

EXHIBIT A – BIDDER FORMS AND CERTIFICATIONS

EXHIBIT B – DRAFT CONTRACT

EXHIBIT C – WRITTEN PROPOSAL

EXHIBIT D – COST PROPOSAL

EXHIBIT D IS INCLUDED AS A SEPARATE DOCUMENT

EXHIBIT E – DATA SECURITY ATTESTATION

EXHIBIT F – DATA SECURITY QUESTIONNAIRE

EXHIBIT G – COMPETENCY AND INDEPENDENCE REQUIREMENTS

EXHIBIT H – DELIVERABLES

HCA RFP No. 2026HCA4 Page 3 of 50

1 INTRODUCTION

1.1 DEFINITIONS

Definitions for the purposes of this RFP include:

Apparent Successful Bidder (ASB) – The Bidder selected as the entity to perform the anticipated services under this RFP, subject to completion of contract negotiations and execution of a written contract.

Apple Health (Medicaid) Integrated Managed Care (AH-IFC) – means Washington State's "whole-person" Medicaid program. It combines physical health, mental health, and substance use disorder treatments under a single, unified health plan

Apple Health Integrated Foster Care (AH-IFC) – means Washington’s Medicaid managed care program managed by the Washington State Health Care Authority (HCA) designed specifically for children and youth in the foster care system, adoption support, or extended foster care.

Behavioral Health Services Only (BHSO) – means a type of managed care program that provides specialty mental health and substance use disorder (SUD) treatment services for eligible Apple Health (Medicaid) enrollees.

Bidder – Individual or company interested in the RFP that submits a proposal to attain a contract with the Health Care Authority.

Business Day – Monday through Friday, 8:00 a.m. to 5:00 p.m., Pacific Time, except for holidays observed by the state of Washington, unless otherwise specified within the RFP.

Code of Federal Regulations (C.F.R.) means the codification of the general and permanent rules and regulations (sometimes called administrative law) published in the Federal Register.

Consumer Assessment of Healthcare Providers and Systems (CAHPS®) means a suite of commercial and Apple Health standardized survey instruments used to measure client experience of health care. Code of Federal Regulations

External Quality Review Organization means the review and evaluation by an External Quality Review Organization of information on quality, timeliness, and access to the health care and services that a Managed Care Organization (MCO) or their contractor(s) furnish to Apple Health recipients (42 C.F.R. § 438.320).

Fee-for-Service (FFS) means health care delivery program whereby Washington Apple Health clients are served by health care providers reimbursed on a per service or point of service basis.

Health Care Authority (HCA) – An executive agency of the state of Washington that is issuing this

RFP.

Healthcare Effectiveness Data and Information Set (HEDIS®) means a set of standardized Performance Measures designed to ensure that health care purchasers and consumers have the information they need to reliably compare the performance of managed health care plans. HEDIS® also includes a standardized survey of consumers' experiences that evaluates plan performance in areas such as customer service, access to care and claims processing. HEDIS® is sponsored, supported, and maintained by National Committee for Quality Assurance (NCQA). Indian Health Care Providers

HCA RFP No. 2026HCA4 Page 4 of 50

Managed Care Organization (MCO) means an organization having a certificate of authority or certificate of registration from the State of Washington Office of the Insurance Commissioner that contracts with HCA under a comprehensive risk contract to provide prepaid health care services to eligible HCA enrollees under HCA Managed Care program. Medicaid

Proposal – A formal offer submitted in response to this solicitation. To be responsive, a Proposal must include all items outlined in Section 3 (PROPOSAL CONTENTS AND REQUIREMENTS). Two such items that may be referred to throughout this document are:

1) Cost Proposal – Bidder’s cost as described in Section 3.9 and Exhibit D.

2) Written Proposal – Bidder’s written response as described in Section 3.8 and Exhibit C.

Request for Proposals (RFP) – Formal solicitation document in which a service or need is identified but no specific method to achieve it has been chosen. The purpose of an RFP is to permit the bidder community to suggest various approaches to meet the need at a given price.

Revised Code of Washington (RCW) – The laws of the state of Washington, as enacted by the Legislature. Any references to specific titles, chapters, or sections of the RCW includes any substitute, successor, or replacement title, chapter, or section. Pertinent RCW chapters can be accessed at: http://apps.leg.wa.gov/rcw/.

Subcontractor – A person, partnership, or entity not in the employment of or owned by the Bidder, who would be performing all or part of the services under this RFP under a separate contract with or on behalf of the Bidder. The term “Subcontractor” means Subcontractors in any tier.

TEAMonitor means an interagency team of reviewers responsible for monitoring Managed Care plans’ compliance with standards for healthcare quality management, provider access and availability, credentialing, utilization management, enrollee grievances and appeals, contractual requirements, and applicable state and federal laws. TEAMonitor conducts the monitoring review required in § 438.358(b)(1)(iii). Additionally, TEAMonitor staff conduct yearly performance improvement project validation as described in § 438.358(b)(1)(i).

Washington’s Electronic Business Solution or WEBS – An internet-based bid notification system HCA uses to post competitive solicitations. Individuals and firms interested in state contracting opportunities with the Department of Enterprise Services or any state agency should register for competitive solicitation notices on WEBS. Note: There is no cost to register on WEBS.

1.2 ESTIMATED SCHEDULE OF SOLICITATION ACTIVITIES

Issue Request for Proposals July 10, 2026

Pre-Proposal Conference July 14, 2026 – 11:00 am

Letter of Intent Due July 16, 2026 – 2:00 pm

Bidder Questions Due July 21, 2026 – 2:00 pm

HCA Answers Posted* July 24, 2026

Complaints Due (if applicable) July 31, 2026 http://apps.leg.wa.gov/rcw/ https://www.des.wa.gov/services/contracting-purchasing/doing-business-state/webs-registration-search-tips

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Proposals Due August 7, 2026 – 2:00 pm

Evaluate Proposals* August 10-21, 2026

Conduct Oral Presentations with Finalists, if required August 25-27, 2026

Announce “Apparent Successful Bidder” via WEBS* August 31, 2026

Debrief Request Deadline (3 Business Days after the ASB announcement)

September 4, 2026

Negotiate Contract September 8-30, 2026

Implementation Period/Readiness review October 1-December 31, 2026

Security Design Review Completed November 30, 2026

Begin Contract Work January 1, 2027

*Dates are anticipated and subject to change without an official amendment.

HCA reserves the right in its sole discretion to revise the above schedule at any time.

1.3 PURPOSE AND OBJECTIVES

The Washington State Health Care Authority, hereafter called “HCA,” is initiating this Request for Proposals (RFP) to invite qualified and experienced Bidders interested in serving as the External Quality Review Organization (EQRO) for the Washington Apple Health (Medicaid) Integrated Managed Care (AH- IMC) and Integrated Foster-Care (AH-IFC) programs. This RFP includes External Quality Review activities required or allowed under C.F.R.

The State is required by federal regulation, 42 C.F.R. Chapter IV, Part 438, to develop and implement a quality assessment and improvement strategy for services it furnishes to its managed care enrollees.

HCA approaches this quality assessment of our Managed Care Organizations (MCOs’) administration of the Medicaid benefit through various means, including validation of Healthcare Effectiveness Data and Information Set (HEDIS®) and non-HEDIS measures, CAHPS® survey, external quality review of quality, timeliness, and accessibility of health care services furnished to the state’s Medicaid enrollees. HCA intends to award one contract to provide the services described in this RFP. This RFP includes deliverables pertaining to physical and behavioral health through the following Medicaid contracts:

a) Apple Health – Integrated Managed Care (AH-IMC) program

b) Apple Health – Integrated Foster Care (AH-IFC) Managed Care program

The specifications for deliverables required under this RFP may evolve from year-to-year in response to program changes, legislative direction, MCO participation, new pilot projects, and managed care enrollment levels. Any future managed care entities contracted with HCA, which meet the C.F.R.

requirement for inclusion are assumed to be included within this RFP and associated deliverables.

During the contract period, additional work requests may be made of the Contractor(s) at the sole discretion of HCA. If state, federal, or grant funding becomes available for optional activities described in 42 C.F.R. § 438.358(c) or comparable activities that assess the quality of care of HCA’s managed care programs, HCA reserves the right to seek other qualified entities to conduct such work.

HCA RFP No. 2026HCA4 Page 6 of 50

HCA intends to award one contract to provide the services described in this RFP.

1.4 BACKGROUND

HCA purchases health care for more than 1.9 million Washington residents through Apple Health (Medicaid). Most of Washington’s Apple Health clients, are enrolled in a Managed Care Organization (MCO) with a smaller Fee-for-Service program serving select populations (primarily American Indian/Alaskan Native clients). Managed Care serves approximately 86% of Medicaid- and CHIP-eligible clients, covering 48% of children and 46% of deliveries in Washington State.

Washington State is committed to whole-person care, integrating physical health, mental health, and substance use disorder treatment for quality results and healthier residents. Currently HCA contracts with five MCOs to deliver care to Apple Health enrollees in a physical and behavioral health integrated program under two Medicaid contracts: Apple Health Integrated Managed Care (AH-IMC) and Apple Health Integrated Foster Care (AH-IFC). Each MCO is responsible for administering physical health, mental health, and substance use disorder treatment benefits, and coordinating all Apple Health care under one health plan.

Federal Medicaid managed care regulations require states to conduct compliance monitoring and oversight of Medicaid managed care, which may be delegated to the EQRO or performed by the state.

Washington State has performed the compliance review function for the MCO line of business since 2003 coordinating this work across various subject matter experts within HCA. This cross-agency function is called TEAMonitor. TEAMonitor includes annual compliance review and performance improvement project (PIP) validation.

Attachment 4, Apple Health – Integrated Managed Care Model Contract, is attached for reference.

Attachment 6, Apple Health Managed Care Service Area Matrix, and Attachment 7, Apple Health Regional Service Area, show which MCOs serve Enrollees in each Region and County.

1.4.1 Apple Health - Integrated Managed Care Behavioral Health Services Wraparound (IMC Wraparound)

All AH-IMC plans are required to hold a second contract to address state-funded services for Apple Health (Medicaid) enrollees, called “IMC Wraparound” or “Apple Health – Integrated Managed Care Behavioral Health Services Wrap-around” Contract. The services covered within the IMC Wraparound contract is not covered within the scope of this RFP as it is not funded by Medicaid services; however, the MCOs contracted for this service are the same MCOs referenced throughout this RFP.

1.4.2 Apple Health - Integrated Foster Care

The AH-IFC (or simply IFC) program provides integrated managed physical and behavioral health coverage to children and youth in foster care statewide, with benefits substantively equivalent to AH-IMC. HCA contracts with one MCO to provide this program; the AH-IFC MCO is required to also hold an IMC contract. The AH-IFC program administers benefits and provides care coordination specifically focused on supporting children and youth who are:

https://www.hca.wa.gov/assets/billers-and-providers/imc-medicaid.pdf https://www.hca.wa.gov/assets/free-or-low-cost/19-0038-apple-health-service-area-matrix.pdf https://www.hca.wa.gov/assets/free-or-low-cost/19-0036-apple-health-service-area-map.pdf

HCA RFP No. 2026HCA4 Page 7 of 50

1.4.2.1. Under the age of 21 in foster care (out-of-home placement) through Department of Child, Youth, and Family (DCYF) placement.

1.4.2.2. Under the age of 21 receiving adoption support.

1.4.2.3. Young adults in extended foster care (18–21-year-olds).

1.4.2.4. Young adults 18-26 who are aged out of foster care on or after their 18th birthday (alumni).

1.4.2.5. Children and youth reunified with their families (eligible for 12 months after foster care ends).

Attachment 5, Apple Health – Integrated Foster Care Model Contract, is attached for reference.

1.4.3. Apple Health – Integrated Foster Care Behavioral Health Services Wrap-around (IFC Wraparound)

The AH-IFC plan is required to hold a second AH-IFC-focused contract to address state-funded services for Apple Health (Medicaid) IFC enrollees, called “IFC Wraparound” or “Apple Health – Integrated Foster Care Behavioral Health Services Wrap-around” Contract.

The services covered within the IFC Wraparound contract are not covered within the scope of this RFP as it is not funded by Medicaid services; however, the MCO contracted for IFC Wraparound services is the same IFC MCO referenced throughout this RFP.

1.4.4. Behavioral Health Services Only (BHSO)

Apple Health offers Behavioral Health Services Only (BHSO) for Medicaid- and CHIP-eligible with full-scope benefits through Apple Health, but not enrolled in managed care for physical health benefits. Clients enrolled in the Fee-For-Service program may select an MCO to provide their Behavioral Health Services Only. HCA will automatically enroll clients, with exception of American Indian/Alaska Native (AI/AN) clients with the right of choice, in BHSO coverage when a person is eligible for behavioral health services under Apple Health but receives their physical health coverage outside the managed medical care program (Fee-For-Service). This includes:

1.4.4.1. Individuals with primary insurance through Medicare (traditional or Part C), referred to as dually-eligible.

1.4.4.2. Individuals in foster care who receive their medical care through the Fee-for-Service program (also referred to as coverage without a managed care plan).

1.4.4.3. Certain individuals who have private insurance coverage.

1.4.4.4. Clients who have met their Medicaid spenddown.

1.4.4.5. AI/AN clients may opt in or out of BHSO coverage at any time.

The BHSO services are offered by the same MCOs administering Integrated Managed Care with BHSO marked as an enrollee program code designation. Washington State operates BHSO services under a 1915b waiver and classifies these as Prepaid Inpatient Health Plan (PIHP) services; these enrollees and services provided to them are included in the scope of this RFP. All mandatory EQR activities are addressed: the Annual EQR Technical Report CFR § 438.364 (called MCO Evaluation report), PIP validation by HCA staff, compliance review by HCA staff, performance measure validation, and validation of network adequacy.

The Apple Health – Integrated Managed Care Contract covers both IMC and BHSO enrollees (Attachment 4).

https://www.hca.wa.gov/assets/billers-and-providers/ifc-medicaid.pdf

HCA RFP No. 2026HCA4 Page 8 of 50

1.4.5. Behavioral Health Administrative Service Organization (BH-ASO)

The crisis system is operated regionally by a Behavioral Health Administrative Service Organization (BH-ASO). BH-ASOs provide crisis services to any individual in the region, including MCO-enrolled individuals experiencing a behavioral health crisis. Crisis services are provided regardless of residence, income, insurance status, or ability to pay. These entities administer services such as:

1.4.5.1. 24/7 regional crisis hotline for mental health and substance use disorder crises.

1.4.5.2. Mobile crisis outreach teams.

1.4.5.3. Application of behavioral health involuntary commitment statutes, available 24/7 to conduct Involuntary Treatment Act (ITA) assessments and file detention petitions.

Within available funding, a BH-ASO entity also has the discretion to provide outpatient behavioral health services or voluntary psychiatric inpatient hospitalizations for non- Medicaid individuals (those who are not eligible for or enrolled in Apple Health). Services provided through the BH-ASO to individuals not eligible for Apple Health are not covered under the scope of this RFP. Services provided through the BH-ASO to Apple Health enrollees are covered under the scope of this RFP as they are provided through the MCO-focused EQR activities. BH-ASOs are formally MCO-delegated entities; no direct review by the EQRO of the BH-ASO is required. The BH-ASO may be included in quality improvement activities and education at the sole discretion of HCA to support the MCO-related scope of work.

1.4.6. Current Managed Care Organizations

The table below describes the current MCOs and the corresponding managed care contracts.

Managed Care Organization

Washington Headquarters

AH-IMC AH-IFC

Coordinated Care of Washington, Inc. (CCW)

Tacoma, Washington

X X

Community Health Plan of Washington (CHPW)

Seattle, Washington

X

Molina Healthcare of Washington, Inc.

(MHW)

Bothell, Washington

X

UnitedHealthcare Community Plan (UHC)

Seattle, Washington

X

Wellpoint Washington, Inc. (WLP)

Seattle, Washington

X

1.4.7. Eligibility and Enrollee Distribution

As of December 2025, there were 1,745,800 clients enrolled in managed care including BHSO. Eligibility category descriptions and the enrollee population distribution are provided below.

1.4.7.1. AH-IMC Eligibility Type by MCO: The following table provides a breakdown of AH- IMC member counts by Medicaid eligibility category for the managed care plans.

HCA RFP No. 2026HCA4 Page 9 of 50

Eligibility Category Descriptions

CHPW CCW MHW UHC WLP Dec 2025 Enrollment

Percent (Program/ Total)

Adult Expansion

(AHAC)

103,689 73,409 272,465 81,363 60,913 591,839 37.5%

Children’s Health Insurance Program (CHIP

8,997 7,380 33,479 6,268 4,587 60,711 3.9%

Women and Children Apple Health (HO)

142,066 101,727 444,872 83,928 68,080 840,673 53.3%

Blind/Disabled Children and Adults

(AHBD/HOBD)

13,404 10,749 36,712 11,095 10,866 82,826 5.3%

Total 268,156 193,265 787,528 182,654 144,446 1,576,049

1.4.7.2. Program Enrollment by MCO: The following table provides a breakdown of member counts by enrollment category and managed care plan:

Enrollment Category Descriptions

CHPW CCW MHW UHC WLP Dec 2025 Enrollment

Percent (Program/

Total)

AH-IMC

(FIMC)**

268,156 193,265 787,528 182,654 144,446 1,576,049 81.3%

AH-IFC 0 20,061 0 0 20,061 1.0%

BHSO 30,180 25,786 41,163 23,282 29,279 149,690 7.7%

FFS (no

BHSO)

0 0 0 0 0 191,639 9.9%

Total 298,336 239,112 828,691 205,936 173,725 1,937,439

**The AH-IMC eligibility category (programming code FIMC) = Integration of physical health, mental health and substance use disorder treatment services under one type of MCO contract (AH-IMC).

1.4.7.3. The AH-IMC program is further broken down into the following four Medicaid eligibility categories:

1.4.7.3.1. Apple Health Family & Children – includes lose-income programs for families, children, pregnant women and Temporary Assistance to Needy Families (TANF).

1.4.7.3.2. Apple Health Adult Low-income program for adults between 19 and 65 years old who are at or below the 138% federal poverty level (FPL). This expansion of coverage was introduced as part of the Affordable Care Act (ACA) in 2014.

1.4.7.3.3. Apple Health Blind/Disabled (AH-BD) – Program for Supplemental Security Income (SSI) – related eligible members, including those who are currently receiving SSI.

1.4.7.3.4. Apple Health for Kids – State Children’s Health Insurance Program

(CHIP).

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1.4.7.3.4.1. Provides coverage for eligible children in households that are up to 250% FPL

1.4.7.3.4.2. The state also utilizes Medicaid CHIP funding to provide coverage with a monthly premium for children in households up to 312% FPL Children enrolled in the CHIP program are not subject to separate performance measure requirements, as this population is included within the Healthcare Effectiveness Data and Information Set (HEDIS®) Compliance AuditTM.

Newly eligible Medicaid clients and renewing clients choose or are auto assigned into an MCO the day they become eligible. Their managed care enrollment is backdated to the beginning of the current month.

1.4.8. Fee-for-Service (FFS) Program

In addition to HCA covering services for the FFS population directly, the state also directly provides some services for MCO enrollees as carved out services. The following services are examples of the services covered FFS for MCO enrollees:

1.4.8.1. Dental care

1.4.8.2. Eyeglass and fitting services for children

1.4.8.3. Long-term services and supports

1.4.8.4. Certain services for individuals with intellectual or developmental disabilities

1.4.8.5. Certain pregnancy-related services, including maternity support services, prenatal genetic counseling, and pregnancy termination

1.4.8.6. Long-term inpatient psychiatric care

1.4.9. Washington Apple Health Primary Care Case Management (PCCM) and PCCM Entities

HCA contracts with PCCMs and PCCM Entities to provide services for American Indian/Alaska Native (AI/AN) clients. Indian Health Care Providers (IHCPs), including Tribal FQHC, Facilities of Indian Health Services (IHS) and Tribal 638 facilities, are contracted as PCCMs and both IHCPs and Urban Indian Health Organizations are contracted as PCCM Entities per 42 C.F.R. 438.310(c)(2). No currently contracted Apple Health PCCM Entity provides shared savings, incentive payments or other financial reward for the PCCM entity for improved quality outcomes; therefore, none meet C.F.R. requirements for EQR (42 C.F.R. 438.358 (b)(2)).

1.5. SCOPE OF WORK

In order to comply with federal regulations under Subpart E, External Quality Review, 42 C.F.R. §

438.310 through 42 C.F.R. § 438.370, this Request for Proposal (RFP) seeks responses from organizations to provide External Quality Review (EQR) activities that will enable HCA to comply with all existing federal EQR requirements as well as those issued as part of the final rule for the Balanced Budget Act (BBA) of 1997 for the full scope of EQR activities occurring within the state and subject to special requirements. HCA intends to include both managed care and FFS EQR activities with the scope of this RFP. Not all deliverables will have a FFS component; FFS activities are indicated by deliverable.

FFS deliverables to be provided upon HCA request. When requested, Contractor is required to perform

HCA RFP No. 2026HCA4 Page 11 of 50 within the scope of this RFP. The Apparent Successful Bidder (ASB) awarded by this RFP will serve as the State of Washington’s EQRO as required by 42 C.F.R. § 438.356.

ASB will be expected to successfully complete a readiness review prior to start of contract.

The EQRO is expected to perform the following work with associated deliverables detailed in the Contract (Draft Sample Contract is attached as Exhibit F):

1.5.1. MCO Evaluation: Apple Health External Quality Review (EQR) Annual Technical Report

(ATR) (42 C.F.R. § 438.364):

1.5.1.1. Annually produce a report describing the manner in which data from all activities conducted in accord with 42 C.F.R. § 438.358 are collected and aggregated. Data related to the quality, timeliness, and access to care furnished by Medicaid managed care will be analyzed and synthesized into an annual report.

1.5.1.2. Review literature, best practices, and recent ATRs from other state Medicaid agencies and include any Centers for Medicare and Medicaid Services (CMS) feedback in the production of the EQR report.

1.5.1.3. The MCO Evaluation Report will be written in accord with 42 C.F.R. § 438.364, External Quality Review Results. This report must include EQRO-contracted findings, as specified by C.F.R., as well as EQR activities conducted by the state, such as compliance reviews and PIP validation. HCA will provide annual TEAMonitor reports with findings from HCA compliance reviews and PIP validation activities.

1.5.1.4. The HCA currently contracts with five entities that meet the C.F.R. requirements to include in the MCO Evaluation Report. The five entities are MCOs that are contracted through AH-IMC and AH-IFC contracts for IMC, IFC, and BHSO enrollees. The MCO Evaluation Report shall include all EQR-activities conducted regarding the PIHP-contracted BHSO enrollees.

1.5.1.5. The report shall include:

1.5.1.5.1. An assessment of each MCO’s strengths and weaknesses with respect to the quality, timeliness, and access to health care services furnished to Apple Health recipients;

1.5.1.5.2. Recommendations for improving the quality of health care services furnished by each MCO.

1.5.1.5.3. Methodologically comparative information about all MCOs.

1.5.1.5.4. An assessment of quality of data collected and recommendations regarding improving data collection and usability to improve performance improvement both for the state and MCOs.

1.5.1.6. The report is publicly posted on HCA’s website and submitted to CMS in accordance with § 438.364.

Attachment 1, MCO Evaluation Report (previously labelled as the Annual EQR Technical Report), provides an example using the most recent publication.

https://www.hca.wa.gov/assets/billers-and-providers/eqr-technical-report-2026.pdf

HCA RFP No. 2026HCA4 Page 12 of 50

1.5.2. Managed Care Measures Analysis: Apple Health EQR comparative performance analysis (42 C.F.R. § 438.364):

1.5.2.1. Produce the Managed Care Measures Analysis Report annually. Conduct analyses of MCO performance measures and produce charts and tables displaying associated data.

1.5.2.2. Performance measure analysis will include a between-program comparison (e.g.

Blind/Disabled and CHIP) and demographic stratification sub-analysis (e.g., race, ethnicity, language). Narrative will include analysis and recommendations regarding stratification when data provides sufficient information to inform health equity efforts.

1.5.2.3. Performance measure data will be compared to Washington State peer MCOs, the calculated state average, and national Medicaid all plan HEDIS® performance or other benchmarks if there is regional or national benchmark data by which to compare performance.

1.5.2.4. Performance measure data will be analyzed regionally to identify differences in regional performance across all MCOs (e.g., rural and urban areas) using HCA RSA geographic boundaries. Narrative to include recommendations regarding regional variation when data informs health equity efforts. Additionally, when disparity is identified, further analysis provided to detail findings and recommendations by MCO, by region, race, ethnicity, language.

1.5.3. Tables and charts shall include plan-to-plan comparison, plan-to-state, all MCO average, and MCO to national or regional MCO benchmarks all depicted in graphs and charts. An appendix containing all data must be part of the Managed Care Measures Analysis report;

as in Appendix A in the attached sample report.

1.5.3.1. Any narratives accompanying charts and graphs should be based on the most current, peer-reviewed literature and national and regional trends for Apple Health (Medicaid) enrollees.

1.5.4. Produce annual appendix with an Apple Health Plan Report Card showing MCO performance on a subset of Performance Measures, Consumer survey data, and additional quality/outcomes indicators for the Washington State Health Benefit Exchange (HBE) website, called Healthplanfinder (HPF). This report will be used by Apple Health recipients to select an MCO for enrollment along with the information provided in the state’s Medicaid and CHIP Quality Rating System (MAC QRS). Attachment 1, MCO Evaluation Report (previously known as the Annual EQR Technical Report), provides a sample of the current Apple Health Plan Report Card report. (See PDF page 162 of the 2025 ATR for the most recent publication).

1.5.4.1. The target audience is HCA, MCOs, Washington State legislature, and other interested stakeholders. The report is publicly posted on HCA’s website and submitted by HCA to the legislature.

1.5.5. Attachment 2, Managed Care Measures Analysis (previously known as the Comparative and Regional analysis report), provides an example using the most recent publication. Note:

Attachment 2 does not include the regional analysis within the same document; rather, the regional analysis is provided within a separate report. Attachment 3, Regional Comparison results, is an example.

1.5.6. Validation of Performance Measures (438.358(b)(2)):

https://www.hca.wa.gov/assets/billers-and-providers/eqr-technical-report-2026.pdf https://wa-hca-wams-public.s3.us-west-2.amazonaws.com/2025+Comparative+Analysis+Report+Final+-+Rev+2-6-26.pdf https://wa-hca-wams-public.s3.us-west-2.amazonaws.com/Appendix+E+Comparative+Report+2025+Final+1.30.26.pdf https://wa-hca-wams-public.s3.us-west-2.amazonaws.com/Appendix+E+Comparative+Report+2025+Final+1.30.26.pdf

HCA RFP No. 2026HCA4 Page 13 of 50

1.5.6.1. Annual validation of MCO methods used to collect Healthcare Effectiveness Data and Information Set (HEDIS®) for measures identified for NCQA’s HEDIS® Medicaid line of business, ensuring ongoing compliance NCQA HEDIS® Technical specifications and supporting ongoing evolution of HEDIS® measures towards electronic clinical data systems (ECDS) measures and use of digital quality measurement.

https://www.ncqa.org/hedis/

1.5.6.1.1. The validation process for HEDIS® data will be accomplished through methods described in the most recent version of the National Committee for Quality Assurance (NCQA) HEDIS® Compliance Audit™.

Specifications shall be complemented by the Centers for Medicare and Medicaid Services (CMS) Validating Performance Measures. The External Quality Review Protocols can be found at Quality of Care External Quality Review | Medicaid.gov:

(https://www.medicaid.gov/medicaid/quality-of-care/medicaid-managed-care/external-quality-review/index.html).

1.5.6.1.2. A HEDIS® Compliance Audit™ will be conducted annually. All Apple Health MCOs are subject to these requirements, which are inclusive of all enrolled and HEDIS® eligible populations, including ACA Adults, TANF/Apple Health, Blind/Disabled, CHIP, and AH-IFC populations.

1.5.6.1.3. The following assumptions for conducting the audit include:

1.5.6.1.3.1. All current, contracted Apple Health MCOs are required to be accredited by NCQA as a Medicaid Health Plan (WAC 182-538-140). Plans entering the market will be required to become NCQA accredited within three (3) years of entering the Apple Health market. These MCOs will be required to produce the full set of Medicaid HEDIS® Performance Measures according to NCQA fully accredited plans and submit to a full accreditation audit following achievement of accreditation status.

1.5.6.1.3.2. All contracted MCOs will be required to submit Performance Measures according to NCQA specifications for reporting, unless otherwise defined by Apple Health Contracts.

1.5.6.1.3.3. All MCOs will be subject to an annual, full HEDIS® audit.

1.5.6.1.3.4. For the single MCO contracted for both AH-IMC and AH-IFC, both populations (AH-IFC and AH-IMC) will be included within the annual, full HEDIS® audit.

1.5.6.1.3.5. Children enrolled in the CHIP program are not subject to separate performance measure requirements, as this population is included within the HEDIS® audit.

1.5.6.1.4. A copy of the list of performance measures required in each contract is found in Attachment 4, Apple Health – Integrated Managed Care Model Contract, and Attachment 5, Apple Health – Integrated Foster Care Model Contract, Section 7, and the contracts’ Attachment 1.

https://www.ncqa.org/hedis/ https://www.medicaid.gov/medicaid/quality-of-care/medicaid-managed-care/external-quality-review/index.html https://www.medicaid.gov/medicaid/quality-of-care/medicaid-managed-care/external-quality-review/index.html

HCA RFP No. 2026HCA4 Page 14 of 50

1.5.6.1.5. The audit meets C.F.R. requirements for compliance monitoring of Health Information Systems (42 C.F.R. § 438.242) related to Performance Measure Validation and the Information Systems Capabilities Assessment (ISCA). HCA performs ISCA monitoring for elements that are not addressed within the HEDIS® Compliance Audit.

1.5.7. Annual reporting of state-validated Performance Measures included in the HCA’s MCO contracts. The state validates performance measures when existing, audited HEDIS performance measures do not meet the identified need and as directed. The measures validated by the state are identified in the MCO contracts annually. The Contractor is responsible to review and report on the validation performed within the MCO Evaluation Report.

1.5.7.1. Performance measure validation for BHSO enrollees is performed by the state to address the PIHP-contracted work. The assumptions for this work are:

1.5.7.1.1. BHSO enrollees receive care through the five MCOs within the AH-IMC contracts. Federal classification requires these services to operate as a PIHP, requiring performance measure validation.

1.5.7.1.2. Validation shall be per MCO at the statewide level, conducted annually, and includes state-validated, behavioral health performance measures.

The data is analyzed by Research and Data Administration (RDA) staff within the Department of Social of Health Services (DSHS). MCOs are responsible for understanding measure specifications and perform measure tracking and reporting.

1.5.8. Consumer Assessment of Healthcare Providers and Systems (CAHPS®) (42 C.F.R. § 438.358(c)(2)):

1.5.8.1. Analyze and report on the CAHPS® surveys, which may include administering Apple Health surveys, validating MCO survey samples for Apple Health contracts, and/or aggregating MCO CAHPS® data. Survey may be Medicaid CAHPS® Adult, Child, or Child with Chronic Conditions survey.

1.5.8.1.1. Collect raw data, aggregate MCO CAHPS® survey data, and produce a statewide report of the CAHPS data conducted by the MCO CAHPS vendors. The survey may be Medicaid CAHPS® Adult or Child with Chronic Conditions survey, as determined by the Apple Health contract.

1.5.8.1.2. Administer statewide Medicaid Child CAHPS® survey every year, specific to the CHIP population. The population meeting CAHPS® specifications will be drawn by HCA and provided to the Contactor. A statewide sample will be selected from the population by the Contractor.

The Contractor will conduct the survey and produce a survey report.

1.5.8.1.3. Review and report results for the IFC-specific CAHPS® survey annually.

Provide a summary of strengths and recommendations to the HCA.

Summary level results and reporting shall be included within the MCO Evaluation Report.

1.5.8.2. The following tasks will be performed by the Contractor when administering a CAHPS® survey:

HCA RFP No. 2026HCA4 Page 15 of 50

1.5.8.2.1. Conduct the MCO sample validation; or when the Contractor conducts the survey for HCA, verify clean, survey sample data.

1.5.8.2.2. Follow Mixed Mode Methodology of survey administration, consisting of a minimum of two (2) questionnaire mailings, two (2) reminder post cards, and up to six (6) phone attempts.

1.5.8.2.2.1. The Contractor may administer surveys using on-line survey capability if email contact information is available and known by survey vendor; and

1.5.8.2.2.2. Use enrollee incentives or similar approaches to increase survey response.

1.5.8.2.3. Administer the survey in English with the option to complete the survey in Spanish.

1.5.8.2.4. Complete administrative forms (e.g., survey introductory letter and postcard reminders to enrollees).

1.5.8.2.5. Submit weekly survey disposition reports to the HCA Contract Manager.

1.5.8.2.6. Prepare member level data files and dictionaries for each population surveyed.

1.5.8.2.7. Produce MCO reports that include each population surveyed.

1.5.8.2.8. Case-mix adjusted ratings (below average, average, and above average) for each Managed Care program. Average is the statewide mean;

1.5.8.2.9. CAHPS® Database report following the data submission requirements;

include a copy to HCA in appropriate format on all completed survey questions for adult and child samples;

1.5.8.2.10. Production of annual CAHPS® stakeholder report provided in electronic format only, in PDF and Word file formats.

1.5.9. Validation of Network Adequacy (42 C.F.R. § 438.358 (b)(iv)

1.5.9.1. HCA complies with network adequacy standards required by 42 C.F.R. 438.68. The EQRO is required to validate MCO network adequacy, per 42 C.F.R. § 438.358.

Validation includes an MCO network secret shopper survey conducted annually for all critical provider types in the MCO’s contract who meet the C.F.R. requirement for inclusion and any additional provider types HCA selects to inform MCO provider network validation. Any future provider types required to be contracted with MCOs as a network provider, which meet the C.F.R. requirement for inclusion, are assumed to be included within this RFP and deliverable.

HCA intends to issue an Apple Health-focused technical guide providing specifications to the contracted EQRO and MCOs that is substantively aligned with CMS’s Technical Guide for Qualified Health Plans (https://www.cms.gov/files/document/awt-sss-tech-guide-qhp-ffe- 508.pdf). This document will be evaluated annually to ensure compliance with the MCO contracts and as needed to ensure compliance with any future release from CMS regarding the Medicaid MCO line of business.

https://www.cms.gov/files/document/awt-sss-tech-guide-qhp-ffe-508.pdf https://www.cms.gov/files/document/awt-sss-tech-guide-qhp-ffe-508.pdf

HCA RFP No. 2026HCA4 Page 16 of 50

HCA intends to be in compliance with the federal timeframe for secret shopper surveys and implement the surveys with a phase in by provider type beforehand. HCA reserves the right to expand the surveys to additional provider types identified in the Apple Health contracts.

Attachment 3, Estimated Secret Shopper Surveys, provides the phase in schedule HCA intends to follow, adding each provider type resulting in an annual survey for each provider type by MCO. The number of providers that are applicable to be surveyed will vary each year and by MCO due to market dynamics. The attachment provides the current number of providers contracted within the entire Apple Health managed care networks as of April 2026.

1.5.10. Technical Assistance (42 C.F.R. 438.358(d))

1.5.10.1. Provide technical assistance to MCOs regarding EQR-related activities to support system-wide quality improvement. The Contractor will provide in-person, educational quality forums to keep MCOs informed and involved in quality initiatives.

1.5.10.2. In-person quality forums events held annually at HCA facilities in Olympia, WA.

1.5.10.3. Lead agenda preparation, topic selection, and speaker arrangement, with consultation and approval from HCA to inform this work.

1.5.10.4. Submit written materials intended for MCO communication or education activities to HCA for approval in advance of distribution to attendees.

1.6. MINIMUM QUALIFICATIONS

The following are the minimum qualifications for Bidders:

1.6.1. Licensed to do business in the state of Washington or provide a commitment that it will become licensed in Washington within thirty (30) calendar days of being selected as the Apparent Successful Bidder.

1.6.2. Be in compliance with HIPAA Security, Privacy, and Breach Notification Rules (45 C.F.R.

§ 164).

1.6.3. The Bidder must adhere to all WaTech IT Security Policies.

1.6.4. Agree to undergo and pass a Security Design Review conducted by HCA or Washington Technology Solutions (WaTech) prior to contract start date.

1.6.5. Organizations must have submitted a Letter of Intent to Propose by July 14, 2026, 2:00 p.m. in order to be eligible to submit a response to this RFP.

1.6.6. A minimum of five (5) years’ experience performing External Quality Review activities under federal regulations 42 C.F.R. Subpart E.

1.6.7. Have leadership staff, including CEO, CMO, Contract Manager, Analytical Lead and any Subcontractor lead staff, with skills, experience, and knowledge of the requirements in 42 C.F.R. 438.354(b) and the following:

1.6.7.1. Medicaid beneficiaries, policies, and processes;

1.6.7.2. Washington State populations and health care system;

1.6.7.3. Managed care regulations, program, and data systems;

https://watech.wa.gov/policies?combine=&field_categories_target_id=80&field_type_target_id=All

HCA RFP No. 2026HCA4 Page 17 of 50

1.6.7.4. Managed Care delivery systems, organizations, and financing;

1.6.7.5. Physical and behavioral health care services;

1.6.7.6. Quality assessment and performance improvement methods;

1.6.7.7. Survey methods;

1.6.7.8. Research design and methodology, including statistical analysis; and

1.6.7.9. Writing and publication skills.

1.6.8. Be independent from the State Medicaid agency and from the MCOs that are reviewed.

“Independence”, as defined in 42 CFR 438.354(c) means:

1.6.8.1. If a State agency, department, university or other State entity: may not have Medicaid purchasing or managed care licensing authority and, must be governed by a Board or similar body the majority of whose members are not government employees.

1.6.8.2. An EQRO may not:

1.6.8.2.1. Review any MCO, PIHP, PAHP, or PCCM entity, or a competitor operating in the State, over which the EQRO exerts control or which exerts control over the EQRO (“control” has the meaning given the term in 48 C.F.R. § 19.101) through: (A) stock ownership; (B) stock options or convertible debentures; (C) voting trusts; (D) common management, including interlocking management; and (E) contractual relationships.

1.6.8.2.2. Deliver any health care services to Medicaid beneficiaries.

1.6.8.2.3. Conduct, on the State’s behalf, ongoing Medicaid managed care program operations related to oversight of the quality of MCO, PIHP, PAHP, or PCCM entity services, except for the related activities specified in 42 C.F.R. § 438.358.

1.6.8.2.4. Review any MCO, PIHP, PAHP, or PCCM entity for which it is conducting or has conducted an accreditation review within the previous three (3) years.

1.6.8.2.5. Have a present, or known future, direct or indirect financial relationship with an MCO, PIHP, PAHP, or PCCM entity that it will review as an

EQRO.

1.6.9. The Bidder must have experience working with a governmental agency within the past five (5) years.

1.6.10. The Bidder must be a National Committee for Quality Assurance (NCQA)-certified Consumer Assessment of Health Plans Survey (CAHPS®) vendor, or subcontract with a vendor with this certification.

1.6.11. The Bidder must be an organization, or subcontract with a vendor, that is licensed by NCQA to conduct HEDIS® audits.

https://www.ecfr.gov/current/title-42/part-438/section-438.354#p-438.354(c)

HCA RFP No. 2026HCA4 Page 18 of 50

1.6.12. Have at least 70% of staff located in Washington State with dedicated office space and experienced with Washington health care, culture, and geography dedicated to this Contract. Minimum availability of day-to-day business operations must be Monday through Friday from 8:00 a.m. to 5:00 p.m.

1.7. FUNDING

HCA has budgeted an amount not to exceed Twelve Million, Seventy-One Thousand, Five Hundred and Five Dollars ($12,071,505.00) for this project over the five (5) year initial term. Proposals in excess of $12,071,505.00 will be considered non-responsive and will not be evaluated.

Each state fiscal year (SFY) funding is available as follows:

SFY 2027 (January 1, 2027 – June 30, 2027) $1,207,150.50

SFY 2028 (July 1, 2027 – June 30, 2028) $2,414,301.00

SFY 2029 (July 1, 2028 – June 30, 2029) $2,414,301.00

SFY 2030 (July 1, 2029 – June 30, 2030) $2,414,301.00

SFY 2031 (July 1, 2030 – June 30, 2031) $2,414,301.00

SFY 2032 (July 1, 2031 – December 31, 2031) $1,207,150.50

Each fiscal year funds will be limited to that specific year and will not carry over if not spent.

Any contract awarded as a result of this solicitation is contingent upon the availability of funding.

1.8. PERIOD OF PERFORMANCE

The period of performance of any contract resulting from this RFP is tentatively scheduled to begin on or about January 1, 2027 and to end on December 31, 2031. Amendments extending the period of performance, if any, will be at the sole discretion of HCA.

HCA reserves the right to extend the contract for up to five (5) additional one (1) year periods.

1.9. ADA

HCA complies with the Americans with Disabilities Act (ADA). Bidders may contact the RFP Coordinator to receive written information in another format (e.g., large print, audio, accessible electronic formats, and other formats).

HCA RFP No. 2026HCA4 Page 19 of 50

2. GENERAL INFORMATION FOR BIDDERS

2.1. RFP COORDINATOR

The RFP Coordinator is the sole point of contact in HCA for this solicitation. All communication between the Bidder and HCA upon release of this RFP must be with the RFP Coordinator, as follows:

Name Kimberly French

E-Mail Address HCAProcurements@hca.wa.gov

Any other communication will be considered unofficial and non-binding on HCA. Bidders are to rely on written statements issued by the RFP Coordinator. Communication directed to parties other than the RFP Coordinator may result in disqualification of the Bidder.

2.2. PRE-PROPOSAL CONFERENCE

A pre-proposal conference is scheduled to be held on July 14, 2026 at 11:00 a.m., Pacific Time via a video-conferencing tool at HCA’s discretion. All prospective Bidders should attend; however, attendance is not mandatory. An agenda containing meeting details will be posted as an amendment to this solicitation.

HCA will be bound only to HCA written answers to questions. Questions arising at the pre-proposal conference or in subsequent communication with the RFP Coordinator will be documented and answered in written form. A copy of the questions and answers will be posted on WEBS as an Amendment to this RFP.

2.3. LETTER OF INTENT TO PROPOSE

To be eligible to submit a Proposal, a Bidder must submit a Letter of Intent to Propose. The Letter of Intent to Propose must be emailed to the RFP Coordinator, listed in Section 2.1, and must be received by the RFP Coordinator no later than the date and time stated in the Solicitation Schedule, Section 1.2. The subject line of the email must include the following: [Solicitation #] – Letter of Intent to Propose – [Your entity’s name].

The Letter of Intent to Propose may be attached to the email as a separate document, in Word or PDF, or the information may be contained in the body of the email.

Information in the Letter of Intent to Propose should be placed in the following order:

A. Bidder’s Organization Name;

B. Bidder’s authorized representative for this RFP (who must be named the authorized representative identified in the Bidder’s Proposal);

C. Title of authorized representative;

D. Address, telephone number, and email address;

mailto:HCAProcurements@hca.wa.gov

HCA RFP No. 2026HCA4 Page 20 of 50

E. Statement of intent to propose; and

F. A statement of how the Bidder meets ALL the minimum requirements specified in Section 1.6 of this RFP.

HCA may use the Letters of Intent to Propose as a pre-screening to determine whether Minimum Qualifications are met.

2.4. BIDDER QUESTIONS PERIOD

Bidders are provided an…