40DHHS-S3339 - Scopes of Work.docx

Nevada State Purchasing Division Department of Administration 515 E Musser St Ste 300 Carson City, NV 89701 purchasing.nv.gov nevadaepro.com

Scope of Work 1: MCO & DBA Capitation Rate Setting (MCO-DBA)

Managed Care Organizations (MCOs) are reimbursed on a capitated basis with monthly capitation rates prepared in accordance with federal regulations at 42 CFR § 438.4. Capitation rates are required to be reviewed at least annually but may be modified more frequently based on existing actuarial factors and experience. The awarded vendor will be expected to complete annual rate development for the MCOs and Dental Benefit Administrator (DBA) beginning with Calendar Year 2027 in the initial year of the contract and identify fiscal impacts of policy recommendations and rate updates, on a calendar year basis, for future years of the managed care program’s operation. Monitoring and adjustment of the Calendar Year 2026 rates based on emerging experience will also be required of the selected vendor during the first year of the contract. The selected vendor will also be required to provide certification of the capitation rates and assistance with contract negotiations with the contracted MCOs and contracted DBA.

Capitation rates must comply with actuarial soundness requirements in 42 CFR § 438.4. The selected vendor will be expected to comply with the rate development and documentation standards outlined in 42 CFR Part 438, the most recent version available of the Medicaid Managed Care Rate Development Guide, and all relevant Actuarial Standards of Practice (ASOPs) as part of the obligation to develop rates and certain payment terms in accordance with generally accepted actuarial principles and practices. Relevant ASOPs include No. 1, 5, 12, 23, 25, 41,45, 49, and 56. ASOP 49 focuses on the development of Medicaid managed care rates and should be carefully reviewed by the selected vendor. The Centers for Medicare and Medicaid Services publishes rate development guides at https://www.medicaid.gov/medicaid/managed-care/guidance/rate-review-and-rate-guides The Actuarial Standards Board publishes the Actuarial Standards of Practice at: https://www.actuarialstandardsboard.org/standards-of-practice/

ACTUARIAL RATE SETTING

The selected vendor shall provide for the preparation and certification of actuarially-sound capitation rates subject to 42 CFR § 438.4 for contracted MCOs and DBA to provide services to Medicaid enrollees for both the Nevada Medicaid and Nevada Check-Up (CHIP) populations. In all cases where rates are developed for an enrollee population, fully benchmarked rates must be produced by the selected vendor for each year of the contract term. Capitation rates produced in the interim of a year in which benchmarked rates were produced may utilize actuarially-sound trends and indices. The selected vendor shall provide technical assistance to the State, MCOs, DBAs, and other stakeholders as identified by the State, as needed and as directed by the State, regarding the rate setting methodology and matters affecting program costs.

The selected vendor will be responsible for providing stakeholder management functions in consultation and partnership with the State. This shall include, but is not limited to:

Leading discussions with the State, and MCOs/DBA to address any concerns regarding emerging experience and capitation rate setting and methodology in support of the State negotiations for rate setting process;

Reviewing and assisting the State with responding to data and analysis submitted by MCOs/DBA regarding emerging experience that may affect the selected vendor’s capitation payment rate setting methodology and calculations;

Developing and discussing contract amendments or provisions related to rate setting and other risk mitigation strategies for the State’s managed care programs; and Communicating with MCOs/DBA regarding capitation rate methodology and process for developing capitation rate or other payment methods, rate cell questions, and other questions or inquiries as they arise.

Any stakeholder communication with MCOs/DBA and other stakeholders regarding services provided under this contract must be reviewed and approved in writing by the State prior to distribution.

No later than the end of the second week of September of each CY, the selected vendor agrees to provide the State with the preliminary rate estimates for each managed care product/program for the upcoming CY and a draft written summary describing key assumptions and experience supporting the preliminary rates for the State’s review and approval.

Capitation rate setting must consider and include the following:

New covered services as applicable;

Provider reimbursement rate changes as applicable;

Inflation and cost trends affecting program expenditures including changes in utilization; and Other items expressly noted for the methodology and outcomes of the final rate certification

Additionally, the selected vendor shall develop a slide deck presentation for each managed care product/program for the State to review and approve prior to a formal, virtual presentation to the State’s managed care vendors regarding the preliminary capitation rates for the upcoming CY as calculated by the selected vendor. The selected vendor shall present the slide deck to managed care vendors with State staff no later than October 15 of each CY. An extension of this timeline for preliminary rates and presentation is available if the State approves in writing.

The selected vendor will provide managed care assistance and certification of the capitation rates and assistance with contract negotiations with the contracted MCOs and DBA.

RATE ADJUSTMENTS & MODIFICATIONS

Risk adjustment is a methodology to account for the health status of enrollees through the use of relative risk factors when predicting or calculating costs of services covered under the contract for defined populations or for evaluating retrospectively the experience of MCOs contracted with the State.

The State utilizes Interim Prospective Risk Adjustment and Retrospective Risk Adjustment models for each rating year under its current Contract with MCOs. The State intends to continue this practice unless otherwise stated in future amendments to MCO contracts.

The selected vendor will be required to develop and calculate risk adjustment scores and related adjustments for each CY under the final awarded contract for the MCOs and DBA. As required by 42 CFR § 438.5(g), if risk adjustment is applied prospectively or retrospectively, states and their actuaries must select a risk adjustment methodology and must apply it in a budget neutral manner, consistent with generally accepted actuarial principles and practices, across all MCOs in the program to calculate adjustments to the payments as necessary.

Interim Prospective Risk Adjustments

The selected vendor shall be required to complete the interim prospective risk adjustment by applying a similar methodological process as the prior year’s interim prospective development, using the existing member-level risk scores to develop the interim prospective risk adjusted rates. The selected vendor shall propose for approval to the State, a methodological process to conduct the interim prospective risk adjustment no later than the end of the first week of October of each CY to ensure interim prospective results are completed as soon as practicable while ensuring accuracy.

Retrospective Risk Adjustments

The selected vendor shall be required to complete retrospective risk adjustments when applicable. This may include, but is not limited to, a risk scoring methodology, the development and documentation of the approved risk scoring methodology, calculation of individual risk scores and any related adjustments, and the reconciliation of total capitation amounts paid to the MCOs with the realigned results after the risk adjustments have been applied.

The model currently used is the most recent version of the Combined Chronic Illness and Pharmacy Payment System (CDPS+Rx) available at the time risk score calculations begin. This tool is used to forecast medical costs over a one-year period. CDPS+Rx leverages both diagnostic (ICD-10 codes) and pharmacy (NDC codes) data. Its primary objective is to predict the severity of costs, with higher predicted costs indicating greater severity.

The member-level risk scores from the completed retrospective process from two rating periods prior shall be used to develop the next interim prospective risk adjustment plan factors.

Risk Sharing Mechanisms

In accordance with 42 CFR § 438.6(b), the State utilizes risk-sharing mechanisms with its MCOs. Risk sharing mechanisms includes any and all mechanisms or arrangements that have the effect of sharing risk between the MCO and the State on an aggregate level, including risk mitigation strategies and other arrangements that protect the State or the MCO against the risk that the assumptions used in the initial development of capitation rates differ from actual experience.

The current risk mitigation strategies used by the State include:

Stop-Loss: The State assumes partial risk for inpatient hospital medical costs that exceed a predetermined amount. For CY 2025, the predetermined amount is set at $500,000. Costs that exceed this amount are reimbursed at 75%, provided all other conditions are met for the reimbursement request (i.e. associated claims detail).

Maternity Kick Payment (Sixth Omnibus Budget Reconciliation Act, aka SOBRA): the State makes a one-time payment to the MCO to mitigate the risk associated with the covered delivery of a child.

Very Low Birth Weight (VLBW) Risk Pool: The State has implemented this strategy to mitigate the risk of low-birth-weight babies. The Capitation Payment for the zero (0) to one (1) age group will be adjusted to allow funding for a low-birth-weight supplemental payment to managed care vendors. This amount will be determined by the State’s will remain budget neutral to the State.

Money drawn from the zero (0) to one (1) age group will be distributed in an actuarially-sound manner to offset expenses to any MCO that receives a disproportionately large number of low-birth-weight babies. It is not expected that the money will end up evenly distributed among the MCOs, nor is it expected that these supplemental payments will fully offset the actual medical costs of these low-birth-weight babies.

Once determined and agreed upon by the submitting MCO and the State as meeting the criteria for payment, any claims will be paid within thirty (30) Calendar Days of receipt by the State. The distribution will be incident based throughout the year and there will be no requirement for bundling of claims by the MCOs. Although incident based, it is not limited by birth episode criteria but will be paid out for each child delivered, for example, twice for twins, three times for triplets, etc. The weight to be considered low birth weight will be determined by the State with the mutual agreement of the State’s Actuary and the MCO, and with the understanding that the actual weight in grams may be considered very low birth weight, or worse, by some national standards. Claims requesting payments for births of low birth-weight babies (1500 grams or less) infants must be submitted to the State within ninety (90) Calendar Days from date of delivery, unless an Out-of-State Provider is utilized in which case the Contractor will have an additional forty-five (45) Calendar Days to submit the claim.

The low-birth-weight funds determined by the State’s actuary are drawn from what would otherwise be paid in the form of capitation payment to the MCO(s). Because the methodology applied must be neutral to the State, there exists the possibility that, should enrollment trend exceed expectations, a deficit or surplus may occur. The number of low-birth-weight payments made during a CY will be a function of caseload using a methodology determined by the State and its actuary and will adjudicate in accordance with birth date and time.

No supplemental payments will be made for deliveries beyond the contracted amount funded. Conversely, should deliveries fall short of the contracted amount funded, any surplus will be paid back to the MCO, as in a manner determined by the State’s actuary, and mutually agreed upon by the MCOs.

Risk Corridor – Specialty Pharmacy: If deemed necessary, the selected vendor shall work with the State to develop a risk mitigation strategy for high-cost specialty pharmacy treatments.

Risk Corridor – General Medical: If deemed necessary to establish, selected vendor shall work with the State to develop the target MLR and percentage band(s) to implement such risk corridor.

For all risk sharing mechanisms the awarded vendor shall update and complete the risk corridor data submission template for the current rating period, review the MCO’s risk corridor submissions for reasonableness, develop and submit questions to the State if needed regarding observed issues with each MCOs risk corridor submission, and perform settlement calculations of the risk corridor to determine any payment liabilities on the part of the MCO or Nevada Medicaid. Additional risk mitigation strategies shall be evaluated as the managed care program evolves and as new populations are included into the managed care program.

The selected vendor shall conduct additional analysis and provide capitation rate adjustments and reports as requested by the State if within approved funding.

OTHER RATING SERVICES

The selected vendor will assist the State with encounter data and encounter utilization monitoring. Encounter data will be provided to the awarded vendor by the State or its Fiscal Agent. The vendor shall analyze submitted encounter data to ensure data is complete and accurate and verify that data received from providers is accurate, complete, and timely in accordance with 42 CFR 438.242(b)(2) and validate the conversion process of the data.

As part of rate development, the selected vendor shall routinely produce reports comparing Health Plan submitted encounter data with the self-reported financial and utilization Health Plan data to ensure financial solvency and to verify adequacy of rate structures. This includes the development of documentation for distribution to the State and MCO and DBA plans (Health Plan) and conduct meetings to discuss methodology and specifications.

Vendor may provide reporting capabilities through alternative methods, including electronic tools developed by Vendor, provided that the State will have access to the reports and information through those tools.

Prepare reports estimating the financial impact and cost benefit of the managed care service delivery models compared to the fee for service delivery model.

Prepare comparative utilization reports of services furnished to recipients for the various State service delivery models based on encounter data, whether supplied by the State’s designated data processor or Fiscal Agent, or other methods as may be specified by the State, such as directly from the State contracted MCO vendor(s).

Obtain and monitor Encounter Data and periodically monitor Encounter Utilization to verify if any adjustments become necessary.

Make all collected data available to the State and upon request to Centers for Medicare and Medicaid Services (CMS), as required.

Provide strategic planning services to the State’s administrators and managers.

MEDICAL LOSS RATIO (MLR) REPORT REVIEW

Vendor shall leverage their actuarial expertise and other staff resources with applicable experience in financial reporting and accounting, along with other consultants and analysts to assess the reasonableness of the applicable MCO and/or DBA MLR inputs through a comparison to available data sources (e.g., the State’s managed care financial reports, Vendor’s supplemental data requests, or other), as well as Vendor’s professional opinion. Vendor’s review shall not constitute an audit of the 438.8 MLR reports.

MLR reports are due from the MCOs/DBA to the State within 12 months of the end of the rating period year. The awarded vendor shall review the MLR inputs to ensure: managed care plans appropriately allocate spending in the numerator or denominator of the MLR, managed care plans’ MLR reports appropriately include all State Directed Payments made to providers in the numerator and associated revenue in the denominator, certain administrative costs, such as indirect or overhead costs that do not directly improve quality are excluded in calculations of the numerator.

The selected vendor shall identify and communicate to the State anomalies or inconsistencies in the MLR reports, and in consultation with the State, develop an action plan communicate and resolve issues with MCOs.

The awarded vendor shall provide a detailed written summary of the MLR review outlining findings, observations, and suggestions to improve the MLR reporting process in future submission years. This report should be delivered no more than six months after the MLR reports have been submitted to the State.

FAMILY PLANNING SERVICES ENHANCED FEDERAL MEDICAID ASSISTANCE PERCENTAGE (FMAP) CLAIMING IDENTIFICATION

Each year, the awarded vendor shall provide a letter to the State that gives a Statewide percentage for applicable TANF/CHAP rate cells subject to the 90% enhanced FMAP for family planning services and supplies.

SCope of work 2: specialty mco for youth with complex behavioral health needs

The selected vendor shall provide for the preparation and certification of actuarially-sound capitation rates and sound rate structures subject to 42 (CFR) § 438.4 for the establishment of a new, Specialty MCO to provide services for the children’s behavioral health population and foster care children and the service continuum to serve these populations. The Children’s Behavioral Health populations will include, but are not limited to: Nevada Medicaid or Check-Up eligible youth ages 0-21 with a determination of Serious Emotional Disturbance (under the age of 18) or Serious Mental Illness (above the age of 18); all foster youth (up to age 26); youth with co-occurring SED/SMI and Intellectual or Developmental Disabilities; and youth “at risk” of developing complex behavioral health needs.

Services available to this population will include all State plan medical benefits and all behavioral health benefits available to eligible members of the focus population. Additionally, it will include comprehensive case management services (such as intensive care management or wraparound services), dependent on clinical need. Actuarial services are required to set actuarially-sound rates, perform rate specific analysis, and consult on the implementation of rates and programs for a Statewide Specialty MCO for Youth with Complex Behavioral Health Needs.

The awarded vendor will develop, document and support actuarially-sound rate setting methodologies for capitated rates for the eligible Specialized Managed Care population. In all cases where rates are developed for an enrollee population, the State requires that fully benchmarked rates be produced for each year of the contract term; rates produced in the interim of a year in which benchmarked rates were produced may utilize actuarially-sound trends and indices. Actuarially-sound rate structures will be applied to Specialized Managed Care populations projected to be approximately 20,000 currently, subject to change.

Preliminary rate estimates shall be delivered to the State no later than April 2026 for review, unless the State provides extends this timeline in writing.

The awarded vendor will also provide research and recommendations to the State on risk strategies to ensure State funds are maximized for clinical services and the program is sustainable for the Specialty MCO awarded a contract for this new program. These strategies may include but are not limited to: Minimum Loss Ratio target setting, profit caps, risk corridors, shared profit, and withholds. If strategies are selected by State personnel, the selected vendor will develop, document, and support sound targets.

The selected vendor will be expected to provide technical assistance concerning rate setting methodology and matters affecting program costs to State personnel, the Specialty MCO, and other stakeholders as identified by the State, as needed and as directed by the State. This includes the development of agendas and materials for specific sessions, delivery of technical assistance related to the use of rate setting methodologies, and statistical data analysis.

The selected vendor will be responsible for providing stakeholder management functions in consultation and partnership with the State. This shall include, but is not limited to, leading discussions between the vendor, the State, and the Specialty MCO to address concerns regarding emerging experience and capitation rates and to support the State in negotiations and finalizing the contract with the Specialty MCO, communication with the Specialty MCO regarding capitation rates, capitation rate development or payment methods, rate cell questions, and other questions or inquiries as they arise.

Any stakeholder communication provided under this contract must be reviewed and approved in writing by the State prior to distribution.

RISK SHARING MECHANISMS

In accordance with 42 CFR § 438.6(b) Nevada Medicaid utilizes risk-sharing mechanisms with its MCOs. Risk sharing mechanisms includes any and all mechanisms or arrangements that have the effect of sharing risk between the MCO and the State on an aggregate level, including risk mitigation strategies and other arrangements that protect the State or the MCO against the risk that the assumptions used in the initial development of capitation rates differ from actual experience.

The selected vendor will partner with the State to identify appropriate risk mitigation strategies specific to this specialized managed care population and provide implementation support and guidance. These may reflect current strategies used by the State or national best practices from States with similar models.

For all risk sharing mechanisms the awarded vendor shall update and complete the risk corridor data submission template for the current rating period, review the MCO’s risk corridor submissions for reasonableness, develop and submit questions to the State if needed regarding observed issues with each MCOs risk corridor submission, and perform settlement calculations of the risk corridor to determine any payment liabilities on the part of the MCO or Nevada Medicaid.

SCOPE OF WORK 3: NON-EMERGENCY MEDICAL TRANSPORTATION RATE SETTING

Actuarial services are required for the preparation and certification of actuarially-sound rates for Non-Emergency Medical Transportation (NEMT) services. Nevada Medicaid utilizes a single vendor model as its delivery system for NEMT services.

NEMT services are divided by geography between urban and rural counties beginning January 1, 2026. The NEMT Broker contracted by the State will be responsible for NEMT services for both MCO and FFS recipients in urban Clark County and Washoe County; however, in the remaining 15 rural counties in Nevada the NEMT broker is only responsible for approximately 46,000 FFS recipients in the rural areas.

The selected vendor shall provide for the preparation and documentation of actuarially-sound capitation rates and sound rate setting methodologies for non-emergency medical transportation services to be applied to NEMT eligible populations. In all cases where rates are developed for an enrollee population, the State requires that fully benchmarked rates be produced for each year of the contract term; rates produced in the interim of a year in which benchmarked rates were produced may utilize actuarially-sound trends and indices. The selected vendor will analyze and evaluate NEMT trip modes and NEMT Broker revenues, direct service expenditures as well as operating costs and net income levels by month to determine an appropriate PMPM. Preliminary rate estimates shall be delivered to the State early to mid-August for review.

The selected vendor will be responsible for providing stakeholder management functions in consultation and partnership with the State. This shall include, but is not limited to, leading discussions between the vendor, the State, and the NEMT broker to address concerns regarding emerging experience and capitation rates and to support the State in negotiations and finalizing the contract with the NEMT broker, communication with the NEMT broker regarding capitation rates, capitation rate development or payment methods, rate cell questions, and other questions or inquiries as they arise.

To strengthen the State’s delivery system and single vendor model for NEMT, the selected vendor shall review the current NEMT broker contract and make recommendations on how best to improve this contract so the State can hold future NEMT vendors accountable for these services. This will also include review of NEMT Broker provider agreements to determine payment terms for NEMT subcontractors. The review and subsequent recommendations will include, but are not limited to, pathways to improve coverage for NEMT services, potential rate methodology changes needed to achieve the State’s goals for access to these services, and financing strategies to maximize State funds.

The awarded vendor will be expected to provide technical assistance concerning rate setting methodology and matters affecting program costs to State personnel, the NEMT broker, and other stakeholders as identified by the State, as needed and as directed by the State. This includes the development of agendas and materials for specific sessions, delivery of technical assistance related to the use of rate setting methodologies, and statistical data analysis.

RISK MITIGATION

The selected vendor will partner with the State to identify appropriate risk mitigation strategies specific to NEMT services and provide implementation support and guidance. These may reflect current strategies used by the State or national best practices from States with similar models.

Risk Corridor - If deemed necessary by the State to establish, the selected vendor shall develop the target MLR and percentage band(s) to implement. The selected vendor shall review the NEMT Broker’s risk corridor submissions for reasonableness, develop and submit questions as needed regarding observed issues with the risk corridor submission, and perform settlement calculations of the risk corridor to determine amounts owed to or from the NEMT broker.

Other risk mitigation techniques shall be evaluated as the NEMT program evolves. The selected vendor will conduct additional analysis and provide rate adjustments and reports as requested by the State.

FOR SCOPES OF WORK 1, 2 AND 3, THE AWARDED VENDOR(S) SHALL:

Within 30 days of contract issuance, provide to the State for approval, a set of written project management plans to successfully guide the project team(s) through all project tasks. The vendor shall comply with the project management plan throughout the term of the contract.

At a minimum, plans shall clearly document the approach and processes used to successfully manage the following:

Scope of Work Deliverables schedule Quality Standards Change Process Risk and Issues management

Within 30 days of contract issuance, provide to the State for approval, a contract administration plan (CAP). The vendor shall comply with the CAP throughout the term of the contract. The CAP shall include at a minimum the following:

Key Personnel and points of contact Roles and Responsibilities Critical Contract Milestones with Timeframes Communications Plan Payment Procedure Issue Resolution Process

RESOURCE POOL AND AD HOC REQUIREMENTS

The awarded vendors under this solicitation will be included in the resource pool of contracted Actuarial Services providers to provide Ad Hoc reporting or services as requested by the State to support program and strategic policy decisions as needed. All State requests for Ad Hoc reporting or services will follow the work order process defined by the State.

Ad Hoc reports or services requested include, but are not limited to:

Assistance in preparing the Medicaid budget, including the Integration of managed care rate setting and identification of industry trends in price, utilization, and management of health care services delivery and developing rates for other special populations which may be integrated into managed care during the contract period.

Technical support and assistance with all necessary actuarial tasks including rate setting for other services, included but not limited to waiver service rates and professional service rates.

Assistance with managed care program policies and operations as related to new and continuing State and federal initiatives that benefit the Medicaid program, Financial analysis, modeling, designing, developing acute and long-term care initiatives, including program financing and funding strategies and reimbursement rate setting, Assisting with federal proposals and actuarial requirements for cooperative agreements with CMS to integrate and improve the delivery of health care services, Federal and Stakeholder negotiations, advising the State on federal or stakeholder meetings, guiding negotiations with CMS, or other federal or State stakeholders, and Other actuarial activities in support of new innovative or value-based financial initiatives.

For all Ad Hoc reports or services, the selected vendor will provide technical assistance for each project. All State requests for Ad Hoc reports or services will:

Follow the work order process defined by the State.

Be reviewed by the Contract Unit at the State prior to the request being sent to the vendor.

As described in the work order process, the business need for the Ad Hoc reports and services will be detailed on a work order form and approved by State administration.

The vendor will submit completed Ad Hoc reports and services to the State with an itemized work order as backup to support an associated invoice with listed tasks and the cost included.

The Ad Hoc report or service work will not commence until State administration approves the State work order form in writing.

The State will not authorize reimbursement for Ad Hoc reports or services without an approved work order in accordance with the work order process. Ad Hoc services as defined in this scope of work, shall be in accordance with the Work Order process as defined by the State (see RFP Attachment – Work Order Form) and adhered to by the following:

The State shall submit a Work Order form to Vendor to initiate Ad Hoc requests and seek proposed cost proposals from selected vendors.

Vendor selected for the Ad Hoc project shall complete and submit the Work Order form detailing and itemizing Ad Hoc services and their breakdown of costs to the State for review and approval.

Work Orders must be approved by State administration in writing.

Once Ad Hoc services are completed, Vendor shall submit invoices to the State detailing the tasks and costs for Ad Hoc services, along with their itemized Work Orders as backup to support the associated invoices.

OBLIGATIONS, REQUIREMENTS, TERMS AND CONDITIONS

Actuarial Soundness

Ensure the methodologies developed and the rates calculated under all tasks meet all federal and State requirements, including CMS guidance for actuarial soundness, and are approved by the State. Certify all applicable work products as actuarially-sound by a Member of the American Academy of Actuaries (MAAA). All deliverables submitted to the State shall be compliant with applicable Actuarial Standards of Practice (ASOP No. 49).

All deliverables submitted to the State in final form shall be free from material, statistical, mathematical, and reference error. Vendor may be liable for damages as per the executed contract, should errors be identified that financially affect or misrepresent, or damages the image or public standing of the State.

Project Management

Identify Vendor project managers for each task area as outlined in Key Personnel. Project managers shall maintain actuarial credentials, Fellow of the Society of Actuaries (FSA) or Associate of the Society of Actuaries (ASA), and Member of the American Academy of Actuaries (MAAA) designations throughout the life of the Contract, and copies of certificates of current designations shall be submitted to the State within ten (10) business days of Contract execution. The State reserves the right of prior approval for all named project managers. The State also reserves the right of prior approval for any replacement of Vendor project managers.

Project manager(s) or designee(s) shall be available within one (1) business day of the State’s request for unscheduled telephone conferences. Vendor shall respond within one (1) business day of receipt of email or other contact by the State or other representative to ensure prompt and accurate delivery and receipt of communications and/or data.

Performance

Vendor is expected to apply actuarially-sound principles to produce rates and related analyses. Actuarially-sound rates shall be:

Developed in accordance with generally accepted actuarial principles and practices.

Appropriate for the covered populations and the services to be furnished under the contract.

Certified by actuaries who meet the qualification standards established by the American Academy of Actuaries and follow the practice standards established by the Actuarial Standards Board.

In the case of errors found to be the fault of Vendor, Vendor shall provide corrected documents, calculations, rates, etc., to the State at no cost to the State. Selected vendor must provide quality assurance for all deliverables to be submitted to the State.

Appeals

Provide all necessary assistance in all stages of the appeal process or other litigation concerning rate settings and actuarial services, including but not limited to providing expert testimony where appropriate to defend the actuarial determinations made.

Data

Vendor shall maintain databases and systems, as necessary, to support Contract functions, including the ability to interface with data sources as determined by the State, as follows:

Accept and maintain accurate current and historical data.

Create sufficient audit trails for all activities or projects.

Deliver all interfaces, projects or reports as per an agreed timeline for each activity, or as defined by the State.

Render all reports in the media, format, timeframe and frequency that are appropriate to the business nature of the report, as specified by the State.

Vendor shall meet the State’s and the Office of the Chief Information Officer’s (OCIO) security standards for data collection, storage, and secured electronic transmissions. This includes, but is not limited to, a minimum 256-bit encryption for both authentication and data transmission. Vendor shall manage application security to ensure access is available and appropriate to the role description. Vendor shall ensure security safeguards are in place to assure the integrity of system hardware, software, records, and files, including but not limited to:

Orienting new employees to security policies and procedures.

Conducting annual review sessions on security procedures.

Developing lists of personnel to be contacted in the event of a potential or suspected security breach.

Maintaining entry logs for limited access areas.

Maintaining an inventory of State assets, not including any financial assets.

Limiting physical access to systems hardware, software, and libraries.

Maintaining confidential and critical materials in limited access, secured areas.

If Vendor’s systems or applications will host State data, Vendor shall provide Documentation of Service Organization Control 2 (SOC2) compliance or the following documentation prior to system implementation and annually thereafter:

Attestation of passed information security risk assessment.

Attestation of passed network penetration scan.

If Vendor utilizes a web application in performance of services under the resultant contract, submit an attestation of passed web application security scan.

If Vendor’s solution involves a Cloud Service Model (CSM), the CSM must be Federal Risk and Authorization Program (FedRAMP) Moderate-level Authorized.

Disaster Recovery and Business Continuity Plan

Vendor shall work with the State to establish and execute a Disaster Recovery and Business Continuity Plan (Plan) to be approved by the State no later than 30 calendar days from final execution of contract. Plan shall address recovery of business functions, business units, business processes, human resources, and the technology infrastructure, which Vendor shall comply with and maintain throughout the term of the contract. Vendor shall protect against hardware and software failures, human error, natural disasters, and other emergencies that could interrupt services and operations.

Meetings

Participate in and contribute to all State meetings related to the Contract. Meetings shall include reviewing Contract status, planning for future action, and other aspects as necessary.

Meet with MCOs, provider groups, and other concerned parties as determined necessary by the State. This includes developing presentation materials, as determined by the State. For unscheduled meetings, Vendor shall be available within five (5) business days of State’s request.

Assist the State in the presentation of materials for any legislative and/or advisory committees and subcommittees. This task shall require Vendor to inform the State of its findings, conclusions, and progress of items in development and to provide any additional information that may be requested. Vendor and the State shall present materials to the requesting entity, either in person or via teleconference, as determined by the State.

Prepare and be available to provide periodic progress reports and contract-related tasks, as necessary, to CMS and any other legislative and/or advisory or oversight entities on any aspect of actuarial services with which Vendor is involved.

Periodic Project Reviews

On a periodic basis, the State reserves the right to review the approved deliverables to assess the direction of the project and determine if changes are required.

Changes to the approved deliverables may result in a contract amendment. However, in the event changes do not include cost or significant schedule modifications, mutually agreed-to changes may be documented in memo form and signed by the State and Vendor.

Ownership of Information and Data

The State shall have unlimited rights to use, disclose or duplicate, for any purpose, all information, forms, templates, tools developed for and paid for by the State and data developed, derived, documented, installed, improved or furnished by Vendor related to work performed for an awarded contract.

All files containing any State information are the sole and exclusive property of the State. Vendor agrees not to use information obtained for any purposes not directly related to this contract without prior written permission from the State.

Vendor agrees to abide by all federal and State confidentiality requirements including, without limitation, providing at Vendor’s expense all notices or other corrective or mitigating measures required by law in the event of a breach of the security of the data for which Vendor is responsible.

Key Personnel

Vendor shall submit staff resumes with proposal and identify the key personnel and their roles for contract term. shall be incorporated into the contract. Replacement of key personnel may be accomplished in the following manner:

A representative of Vendor authorized to bind the company shall notify the State in writing of the change in key personnel within five (5) business days.

The State may accept the change of the key personnel by notifying Vendor in writing.

Signed acceptance shall be considered an update to the key personnel and will not require a contract amendment. Copy of the acceptance must be kept on file by Vendor and the State throughout the contract term.

Replacements to key personnel are bound by all terms and conditions of the contract and any subsequent issue resolutions and other project documentation agreed to by the previous personnel.

If key personnel are replaced, individuals with comparable skill and experience levels must replace them.

Vendor shall provide written notice of the permanent removal or resignation of any management, supervisory, or other key professional personnel prior to the permanent assignment of replacement staff to the contract, and Vendor shall provide a resume and references for individual/s qualified for and proposed to replace any vacancies in key personnel, supervisory, or management positions.

Upon request, the proposed individuals shall be made available within five (5) business days of such notice for an in-person or video conference interview with the State staff at no cost.

The State shall have the right to accept, reject, or request additional candidates within five (5) business days of receipt of resumes or interviews with the proposed individuals, whichever comes later.

A written transition plan shall be provided to the State prior to approval of any change in key personnel.

Invoicing

Invoices shall be submitted to the State upon completion of deliverables. Upon review of invoices and acceptance by the State, payments shall be made within 30 days of invoice receipt, providing that all required information, documents, and/or attachments have been received. Invoices shall be emailed to dhcfppcu@dhcfp.nv.gov.

Invoices shall include the following:

Vendor name, address, phone number (Name and Address must match Nevada Controller’s Vendor Registration) Invoice number Invoice date Contract number Amount due Deliverable(s) completed

Revised 2024-10 Page 2 of 2

Page 1 of 1 40DHHS-S3339 – Scopes of Work image1.png