ODMR 2627-0005 Provider Reimbursement Technical Assistance.pdf

REQUEST FOR PROPOSALS

PROVIDER

REIMBURSEMENT

TECHNICAL ASSISTANCE

ODMR 2627-0005

RFP DUE DATE:

MARCH 19, 2026

4:00 PM EST

The Ohio Department of Medicaid Provider Reimbursement Technical Assistance

ODMR 2627-0005

TABLE OF CONTENTS

SECTION I. GENERAL PURPOSE

1.1 General Overview

1.2 Background

1.3

Objectives

SECTION II. PROCUREMENT PROCESS INFORMATION

2.1 Anticipated Procurement Timetable

2.2 Internet Question and Answer Period

2.3 Communication Prohibitions

2.4 Addenda to the RFP

SECTION III. OFFEROR QUALIFICATIONS AND EXPERIENCE

3.1 Minimum Mandatory Requirements

3.2 Organizational Experience and Capabilities

3.3 Key Personnel and Additional Staff – Experience and Capabilities

3.4 Replacement of Key Personnel

3.5 Subcontractor Identification and Participation Information

3.6 Sensitive Personal Information

SECTION IV. SCOPE OF WORK & SPECIFICATIONS OF DELIVERABLES

4.1 Introduction

4.2 4.2.1 4.2.2 4.2.3 4.2.4 4.2.5 4.2.6 4.2.7 4.3 4.4

Scope of Work & Deliverables Hospital Rebase, Rate Evaluation, CCA Report Monitoring Non-Institutional Service Examination and Analytics Available Grouping Products Fiscal Impact of Budget Initiatives and Rule Changes Coordination with the Federal Government and Various Stakeholders CMS Required Reporting General Assistance Performance Standards and Compliance (includes Appendix A) Transition Contract

SECTION V.

PROCESS INFORMATION

5.1 5.2

Project Management, Impact Analysis, and Reporting Project Updates

SECTION VI.

BUSINESS CONTINUITY PLAN

SECTION VII. PROPOSAL FORMAT AND STRUCTURE

7.1 Complete Proposal Content Requirements

7.2 Organizational Structure of the Technical Proposal

7.2.1 Attachment A: Required Offeror Information Requirements

7.2.2 Attachment E: Acknowledgements, Exceptions, and Assumptions

7.3 Cost Proposal Requirements (Attachment C)

7.4 7.5

Proposal Formatting Proposal Submission

SECTION VIII. CRITERIA FOR PROPOSAL EVALUATION AND SELECTION

8.1 Scoring of Proposals

8.2 Veteran-Friendly Business Enterprise Program

8.3 Clarifications, Exceptions, and Assumptions Review

8.4 8.5 8.6

Final Offeror Recommendation Contract Award No Obligation to Award

SECTION IX. PROTEST PROCEDURE

SECTION X. CONDITIONS AND OTHER REQUIREMENTS

10.1 Start Work Date

10.2 Trade Secrets Prohibition; Public Information Disclaimer

10.3 Contractual Requirements

10.4 Public Release of Evaluations and/or Reports

10.5 Ethical and Conflict of Interest Requirements

10.6 Americans with Disabilities Act (ADA)

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

Requirements

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

Debarments

10.9 Mandatory Contract Performance Disclosure

10.10 Mandatory Disclosures of Government Investigations.

10.11 MBE Subcontracting Requirements

SECTION XI. ATTACHMENTS A-G

A. Required Offeror Information (includes Attachments A1 through A6) B. Technical Proposal Score Sheet C. Cost Proposal Form D. ODM Contract Template E. Acknowledgements, Exceptions, and Assumptions F.

G.

Cost Point Calculation Data Security and Privacy Terms

END OF TABLE OF CONTENTS

SECTION I. PURPOSE

1.1 General Overview

This is a Request for Competitive Sealed Proposals (RFP) under Section 125.071 of the Ohio Revised Code (ORC) and Section 123:5-1-08 of the Ohio Administrative Code (OAC). The Ohio Department of Medicaid (ODM) is soliciting Proposals for the purpose of obtaining expert assistance and consultation, operational assistance, and liaison support for Provider Reimbursement Technical Assistance (PRTA) activities related to Medicaid healthcare business initiatives and work activities. The resulting contract (Contract) will assist ODM with implementing a variety of provider and, specifically, hospital, business transformational changes to support health, care, and cost savings through improvement initiatives and the modernization of hospital payment systems. The work ODM intends to have performed includes, but is not limited to:

1. Major hospital-related payment and modeling analytics, rebasing, and recalibration;

2. Impact analysis of hospital grouper changes on ODM and hospitals;

3. Cost coverage add-on performance tracking;

4. Hospital provider preventable analytics and reporting;

5. Hospital budget analytics;

6. Conducting the Access Monitoring and Reporting Program (AMRP), as may be required by the federal Centers for Medicare and Medicaid Services (CMS) and ODM;

7. Analysis of non-institutional provider payments as needed by ODM; and

8. Analysis regarding fee for service and managed care network adequacy.

For the purpose of this RFP, the term “Offeror” shall be defined as consulting or professional services firms that are interested in responding to this opportunity. The term “Proposal” is used to indicate materials submitted to ODM by an Offeror in order to be considered for award of a contract for services described in this RFP and consists of two components, the Technical Proposal and the Cost Proposal.

The term “Selected Offeror” means an Offeror selected by ODM through this RFP for contract award.

1.2 Background

ODM is the single state agency responsible for the implementation and administration of the Ohio Medical Assistance (Medicaid) Program and the State Children’s Health Insurance Program (SCHIP).

Medicaid and SCHIP are federal and state funded assistance programs that provide health care coverage to certain low-income and medically complex individuals. The State of Ohio purchases and delivers most health care services through a managed care model, although the traditional fee-for-service model is also used for a small portion of the Medicaid population.

In July 2013, ODM began overhauling some of its rates and methodologies related to managed care.

Inpatient (IP) reimbursement was transitioned to the 3M All-Patient Refined-Diagnosis Related Groups (APR-DRG) methodology from the Medicare Severity (MS) DRG methodology.

In August 2017, ODM overhauled its outpatient (OP) rates and methodology by transitioning to the 3M Enhanced Ambulatory Patient Groups (EAPG) reimbursement methodology. Ambulatory Surgical

Centers (ASCs) were also transitioned to EAPG from “flat” fee schedules. ODM had previously employed a state-designed fee schedule to reimburse outpatient and ASC services.

The EAPG grouper version has since been updated along with the hospital-specific rates to maintain payment neutrality. The cost-coverage add-on (CCA) program was also implemented. The CCA, which is case mix adjusted, is added to a hospital’s base rates for each inpatient discharge or outpatient service.

Most recently, an update to the cost-based inputs and the APR-DRG and EAPG groupers was completed, the first since the CCA implementation.

ODM has utilized external vendors to provide expertise and experience in financial and regulatory analysis and federal and stakeholder involvement and negotiations. ODM plans to continue using external consultants to further its work on health transformation and coordinated quality care to improve and maintain good health outcomes for all Medicaid recipients.

1.3 Objectives

ODM will implement a variety of healthcare business transformational changes to leverage resources and unify care. As part of those efforts, this project will support the following objectives:

A. Designing, developing, implementing, and providing subject matter expertise regarding reimbursement reform initiatives by providing accurate and insightful data, data-informed conclusions, and recommendations regarding program financing, funding strategies, and reimbursement and rate setting.

B. Assisting with and/or leading the design, development, and implementation of reimbursement reform initiatives which integrate revisions to some or all of Medicaid eligibility criteria benefit packages, delivery systems, and reimbursement methodologies.

C. Advising and assisting ODM in negotiations with key stakeholders including federal agencies.

D. Evaluating, planning, negotiating, and implementing a modernized, streamlined approach to Medicaid reimbursement, including opportunities afforded by state and federal regulatory changes.

SECTION II. PROCUREMENT PROCESS INFORMATION

2.1 Anticipated Procurement Timetable

DATE EVENT/ACTIVITY

February 17, 2026 ODM releases RFP on ODM and DAS websites; Question & Answer (Q&A) period opens.

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

4:00 PM EST

March 4, 2026

Q&A period for Offeror questions closes at 4:00 p.m. EST on this date.

- No further inquiries for RFP clarification will be accepted.

4:00 PM EST

March 19, 2026

Deadline for Offerors to submit Proposals to ODM (4:00 PM EST)

- This begins the ODM process of Proposal review.

LATE PROPOSALS WILL NOT BE CONSIDERED. NO EXCEPTIONS WILL BE

MADE.

June 1, 2026 (estimated)

ODM issues Contract award notification letter.

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

June 2026 (estimated)

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

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

Three total possible contract periods ending June 30, 2031

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

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

The initial Contract period is expected to run from Contract award through June 30, 2027, with the possibility for two (2) renewal Contracts, each for two-year periods, through June 30, 2031, contingent upon satisfactory performance, continued availability of funding, and all required approvals. Renewals may be subject to approval by the Controlling Board.

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

Learner Guide https://procure.ohio.gov/about/03_supplier-training/03_supplier-training

Viewing and Responding to Solicitations https://www.youtube.com/watch?v=K6iE32BUMJ0&feature=youtu.be

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

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

2.2 Internet Question and Answer Period

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

The purpose of the Q&A period is to provide the opportunity to seek clarity regarding the requirements and specifications of the RFP. Questions about this RFP must include:

1. A reference to the relevant part of the RFP,

2. The heading for the provision under question,

3. The page number where the provision can be found, and

4. The Offeror’s or interested party’s contact information, including the name of a representative of the Offeror or interested party, the company name, phone number, and e-mail address.

If Offerors have more than one question, Offerors must submit each question as a separate Inquiry, and Offerors are not to post Inquiries in any pre-formatted tables. ODM may, at its option, disregard any Inquiries that do not appropriately include the above elements or that do not seek clarification regarding the requirements or specifications of the RFP, in the opinion of ODM. Inquiries submitted after the date the Q&A period closes will not be answered.

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

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

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

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

mcdlegal@medicaid.ohio.gov.

If Offerors experience technical difficulties accessing the OhioBuys website, they may contact Ohio Shared Services at 877-644-6771 for assistance. If Offerors experience technical difficulties accessing documents related to this solicitation or are unable to get assistance from Ohio Shared Services, they may contact the ODM Bureau of Contracts and Acquisitions (BCA), RFP/RLB Unit, at ODM_Procurement@medicaid.ohio.gov for guidance. Substantive Inquiries related to this RFP submitted to Ohio Shared Services or to ODM as outlined in this paragraph will not be answered.

Offerors are encouraged to seek technical assistance early to avoid missing the Q&A Period.

2.3 Communication Prohibitions

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

The only exceptions to this prohibition are as follows:

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

Period;

2. As necessary in any pre-existing or on-going business relationship between ODM and any Offeror that could submit a Proposal in response to this RFP; and

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

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

If Offerors need to communicate regarding this RFP, they must contact ODM using one of the mechanisms above. Offerors are cautioned that communication attempts which do not comply with these instructions will not be answered. Any communication considered prohibited may disqualify Offerors from participation in this RFP.

2.4 Addenda to the RFP

If ODM revises this RFP before the Proposals are due, an amendment will be issued in OhioBuys as a new round of the RFP solicitation. If an Offeror has submitted a Proposal prior to an amendment being issued, the Offeror must resubmit its entire Proposal in response to the latest round of the RFP.

Proposals submitted in response to amended RFPs prior to the most recent amendment will not be mailto:mcdlegal@medicaid.ohio.gov opened or evaluated. ODM may issue amendments any time before Proposals are due, and it is each prospective Offeror’s responsibility to check for amendments and other current information regarding this RFP.

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

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

SECTION III. OFFEROR QUALIFICATIONS AND EXPERIENCE

3.1 Minimum Mandatory Requirements

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

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

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

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

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

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

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

7. The Offeror’s Proposal must include an attestation that the Offeror understands, accepts, and will comply with ODM’s right under Section 4.3(A) to impose corrective and/or remedial actions as provided in the RFP, including Appendix A.

8. The Offerors Proposal must include an affirmative statement that the Offeror, pursuant to Section 4.3(B), agrees that Contract performance specifications may be added or adjusted by mutual agreement during the term of an awarded Contract to align with ODM business needs, organizational objectives, and technological changes.

9. The Offeror’s Proposal must include an attestation that the Offeror, pursuant to Section

4.4, commits to assisting ODM with transitioning from its current vendor, if any, and/or to ODM and other vendors at the end of the Contract, if selected for a Contract.

10. The Offeror’s Proposal includes proper disclosure, pursuant to Section 9.9, of any formal claims of breach of contract against the Offeror or the Offeror’s proposed subcontractor(s); or the Offeror has provided an attestation that there are no such disclosures to make.

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

If the submitting organization is a State of Ohio Minority Business Enterprise (MBE), Encouraging Diversity, Growth and Equity (EDGE) Offeror, or Veteran-Friendly Business Enterprise (VFBE), provide copy of current certification from DAS.

3.2 Organizational Experience and Capabilities

Proposals should demonstrate significant organizational expertise of the Offeror. Proposals must include, at a minimum, the following demonstrated experience as detailed below. This information will be scored by ODM as part of the evaluation process.

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

B. Samples (excerpts and/or Executive Summaries acceptable) of at least two (2), but no more than four (4), similar sized projects completed or begun in the past five (5) years that demonstrate expertise and experience in providing expert assistance in the strategies and objectives listed in Section 1.3.

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

D. Names and contact information for at least three (3) entities for which the Offeror has performed similar large-scale projects in the past five (5) years.

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

3.3 Key Personnel and Additional Staff – Experience and Capabilities

Proposals should demonstrate significant expertise by assigning staff to key roles with the following requirements and capabilities. The positions listed in subsection A through G are considered “Key Personnel” under this RFP. Proposals must include, at a minimum, the following staff positions with demonstrated experience as detailed below (A-J). The staff may be located anywhere in the United States, but may be requested to attend in-person meetings at ODM offices from time to time. Proposals should also include a table of organization that outlines the hierarchy and relationship of the organization’s leadership (e.g. President, Chief Executive Officer, Chief Information Officer) to, and accountability for, each of the positions listed below.

A. Lead Medicaid Healthcare Business Expert: The Lead Medicaid Healthcare Business Expert

(Expert) will lead the work team in the design, development, analysis, evaluation, and implementation of various initiatives under the Contract resulting from this RFP. The Expert will provide advice on best practices; identify and quantify risks, challenges, and opportunities; and suggest ways to leverage specific opportunities and initiatives to accomplish larger Ohio, ODM, and administrative goals. The Expert will oversee and synthesize the work performed by other team members and be responsible for any final work products delivered by the Selected Offeror.

1. The Offeror’s Proposal must identify one (1) individual who will serve as the Expert. This individual must be a full-time employee of the Offeror and available to ODM as needed.

It is preferable (but not mandatory) for the individual to be exclusively assigned to ODM-related projects.

2. The Offeror must provide a curriculum vitae which demonstrates that the proposed

Expert has:

a. A minimum of seven (7) years of experience leading the design, development, and implementation of Medicaid delivery systems, programs, and waivers for state Medicaid agencies; and

b. Experience and skill in the ability to bring federal and state expertise to the project in the following areas:

i. Medicaid programs;

ii. Medicaid long term care services, both community and facility-based;

iii. Medicaid managed care delivery systems;

iv. Behavioral healthcare delivery;

v. Medicaid case management systems;

vi. Medicaid regulatory analysis;

vii. Medicaid reimbursement, rate setting, and other payer strategies; and

viii. Medicaid eligibility regulations, policies, and administrative operations.

B. Medicaid Healthcare Business Manager: The Medicaid Healthcare Business Manager

(Manager) will draft work plans, timelines, and impact analyses; coordinate work schedules and resources with ODM; report work progress and any problems to ODM's contract manager or other designated contact person; and ensure that projects under the Contract resulting from this RFP proceed efficiently.

1. The Offeror’s Proposal must identify one (1) individual who will serve as the Manager and one (1) individual who will provide back-up and assistance to the Manager. For clarity, the back up individual shall be considered staff and not Key Personnel. These individuals must be full-time employees of the Offeror and available to ODM as needed.

2. The Offeror must provide curricula vitae which demonstrate that the Manager and the Manager’s back-up each have:

A. A minimum of five (5) years of experience as the project manager of a large-scale, multi-year, complex project;

B. Experience as the project manager from initiation through post-implementation period on a minimum of two (2) projects, at least one (1) of which lasted a minimum of twelve (12) months; and

C. Experience following standard project management methodology and using various project management tools (e.g., MS Project Suite, Project Workbench), developing project plans, and defining tasks and tracking timelines and resources on a minimum of two (2) large-scale, multi-year, complex projects.

D. A Project Management Personnel Certification is preferred but not required.

C. Medicaid Regulatory Analysts: The Regulatory Analysts will review federal and state statutes, regulations, and guidance to analyze, evaluate, and identify the pros, cons, risks, and impacts of program changes (eligibility, benefit package, service delivery, or other); identify how program changes can legally be implemented; and provide analysis and recommendations on federal statutes and regulations from which to request waiver authority and which, if any, state regulations may require modification to effectuate the initiative.

1. The Offeror’s Proposal must identify at least two (2) Regulatory Analysts. These individuals must be full-time employees of the Offeror and available to ODM as needed.

2. The Offeror must provide curricula vitae which demonstrate that each proposed individual has at least five (5) years of experience in the analysis and evaluation of multiple initiatives as part of the implementation of at least one (1) 1115 and one (1) 1915 waiver.

D. Medicaid Financial and Budget Analysts: The Medicaid Financial and Budget Analysts will develop and synthesize complex, sophisticated models to assess the financial impact of proposed changes to Medicaid eligibility, benefits, service delivery, or reimbursement methodology at the federal and state levels.

1. The Offeror’s Proposal must identify at least two (2) Financial and Budget Analysts. These individual has at least five (5) years of experience in the analysis and evaluation of proposed Medicaid changes, including at least one (1) analysis and evaluation of Medicaid eligibility changes and at least one (1) evaluation of proposed changes to Medicaid service delivery or reimbursement methodology.

E. Medicaid Program Specialists: The Medicaid Program Specialists will develop initiatives for new or revised Medicaid eligibility, benefit package, service delivery, or reimbursement models (including possible 1115 or 1915 waivers or similar cooperative agreements), drawing on financial, regulatory, and program research to analyze and evaluate the Specialist-developed initiative’s cost effectiveness, impact on affected individuals, and feasibility (in terms of obtaining federal and state approval, implementing state regulations, and making necessary system changes) within specific time frames.

1. The Offeror’s Proposal must identify at least two (2) Medicaid Program Specialists. These individual has at least five (5) years of experience in the following:

a. Analysis, evaluation, and implementation of multiple types of proposals, including at least one (1) 1115 waiver and one (1) 1915 waiver; and

b. Revising State Plan Amendments (complete with financial impact statements), drafting implementation guidance, and designing training materials aimed at various impacted categories of stakeholders such as eligibility workers, case managers, providers, benefit recipients, potential applicants, etc.

F. Medicaid Program Evaluator(s): The Medicaid Program Evaluator will conduct assessments of

Medicaid populations, costs, programs and initiatives, and services on federal and state levels and submit recommendations about the program/service’s significance, value, worth, or quality.

1. The Offeror’s Proposal should identify at least one (1) Medicaid Program Evaluator. This individual must be a full-time employee of the Offeror and available to ODM as needed.

2. The Offeror must provide curricula vitae which demonstrates that the proposed individual has at least three (3) years of experience in:

a. Conducting analysis and evaluations of various programs and services, including

Medicaid-specific and government-related services.

b. Data collection methods, like survey distribution, interviews, and questionnaires;

outcome determination; customer satisfaction rates; and drawing appropriate conclusions.

G. Medicaid Program Researcher(s): The Medicaid Program Researcher will gather and analyze data, statutes, regulations, and best practices related to specific Medicaid, CHIP, waiver, or other public healthcare related programs and practices in Ohio and in other states to recommend best practices for eligibility policy; eligibility determination and verification processes; benefit design; service delivery; and reimbursement methodologies.

1. The Offeror’s Proposal must identify at least one (1) Medicaid Program Researcher.

2. The Offeror must provide sufficient curricula vitae which demonstrates:

a. The proposed individual has at least two (2) years of experience and expertise regarding Medicaid programs, statutes, and regulations, as well as a thorough understanding of how to source Medicaid-related information; and

b. At least three (3) examples of past healthcare-related research projects, the methods used to determine the appropriate resources in consideration of the purpose and the audience, and how the information was analyzed and presented.

H. Junior Financial and Budget Analyst(s): The Junior Financial and Budget Analyst will assist in developing and synthesizing complex, sophisticated models to assess the financial impact of proposed changes to Medicaid eligibility, benefits, service delivery, or reimbursement methodology on the federal and state levels.

1. The Offeror’s Proposal must identify at least one (1) Junior Financial and Budget Analyst.

individual has at least three (3) years of experience in the analysis and evaluation of proposed Medicaid changes, including at least one (1) analysis and evaluation of Medicaid eligibility changes and at least one (1) evaluation of proposed changes to Medicaid service delivery or reimbursement methodology.

I. Junior Medicaid Program Specialist(s): The Junior Medicaid Program Specialist will assist in developing initiatives for new or revised Medicaid eligibility, benefit package, service delivery, or reimbursement models (including possible 1115 or 1915 waivers or similar cooperative agreements), drawing on financial, regulatory, and program research to analyze and evaluate initiative’s cost effectiveness, impact on affected individuals, and feasibility (in terms of obtaining federal and state approval, implementing state regulations, and making necessary system changes) within specific time frames.

1. The Offeror’s Proposal must identify at least one (1) Junior Medicaid Program Specialist.

individual has at least three (3) years of experience in:

a. Analysis, evaluation, and implementation of various initiatives, including at least one (1) 1115 waiver and one (1) 1915 waiver; and

b. Revising State Plan Amendments (complete with financial impact statements), drafting implementation guidance, and designing training materials aimed at various impacted categories of stakeholders (such as eligibility workers, case managers, providers, benefit recipients, potential applicants, etc.).

J. Junior Medicaid Program Evaluator(s): The Medicaid Program Evaluator will assist in conducting assessments of Medicaid populations, costs, programs and initiatives, and services on federal and state levels and submit recommendations on the program/service’s significance, value, worth, or quality.

1. The Offeror’s Proposal must identify at least one (1) Junior Medicaid Program Evaluator.

individual has at least one and a half (1.5) years of experience in:

a. Conducting analysis and evaluations of various programs and services, including

Medicaid-specific and government-related services.

b. Data collection methods, like survey distribution, interviews, and questionnaires;

outcome determination; customer satisfaction rates; and drawing appropriate conclusions.

3.4 Replacement of Key Personnel

A. During each term of the Contract, the replacement of Key Personnel must first be approved by

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

B. If the Offeror removes Key Personnel from this project for any reason other than those specified above, ODM may assess liquidated damages in the amount of $1,500.00 for every day between the date on which the individual was removed and the date that the Contract is terminated, or the individual’s qualified replacement, selected in accordance with the process identified in this Section, starts performing on the project. ODM also may provide the Offeror with written notice of its default under this Section, which the Offeror must cure within 30 days.

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

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

3.5 Subcontractor Identification and Participation Information

A. Offerors must clearly identify the subcontractor(s) and their tasks in their Proposal. The

Proposal must include a letter from the proposed subcontractor(s), signed by a person authorized to legally bind the subcontractor, indicating the following:

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

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

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

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

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

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

B. Any additional or new subcontractors must be approved in writing by ODM in accordance with the terms and conditions of this Contract.

3.6 Sensitive Personal Information

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

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

SECTION IV. SCOPE OF WORK & SPECIFICATIONS OF DELIVERABLES

4.1 Introduction

The Selected Offeror will be responsible for the Scope of Work and Deliverables as described in Section 4.2, including all preparatory and intervening steps, whether or not ODM has explicitly specified or delineated them within the RFP. In developing their Proposals, all Offerors must fully and appropriately plan and cost out their proposed projects, including all necessary preparatory and intervening steps.

The Selected Offeror for this project will provide ODM with technical analytical expertise in developing reimbursement policies for ODM providers, including assistance in monitoring payments made for inpatient and outpatient hospital services, non-institutional services and other service areas as needed by ODM. Additionally, this project will continue the planned rebasing inpatient and outpatient hospital services payment rates as well as ambulatory surgical center rates scheduled to become effective in 2026. The type and amount of work being performed at any given time is expected to vary considerably depending on the timelines of specific initiatives. In particular, the Selected Offeror may be required to provide more intensive assistance during periods when state and federal budgets and/or policies are revised and when regulatory reporting requirements are due. The Selected Offeror should be prepared to adjust staffing levels as needed to address these cyclical changes in work levels. The Selected Offeror will assist ODM in determining how to optimize state and federal resources, including services available under this or another contract, for the best outcome for each initiative.

The Selected Offeror shall provide, at a minimum, the following services, as set forth in specific detail in Section 4.2:

1. Financial analysis, modeling, and reimbursement system development and modification, including designing, developing, and assisting with implementing alternative payment initiatives such as: program financing, funding, and payment innovation strategies, reimbursement approaches, billing guidance modifications, fee schedules revisions, and rate setting alternatives.

2. Regulatory analysis, including evaluating, planning, and analyzing proposed regulatory changes impacting provider payments or ODM payment systems, including identifying opportunities afforded by state and federal regulatory changes to health care coverage.

3. Assisting ODM with developing Upper Payment Limit (UPL) demonstration approaches and methods (or similar) and developing ODM’s access monitoring and review plans, including but not limited to existing and new regulations per Title XIX, Title XXI and Title XVIII of the Social Security Act;

4. Federal and stakeholder facilitation and negotiation, including advising ODM on anticipated federal or stakeholder strategies and potential responses, guiding and supporting negotiations with CMS, the Center for Medicare and Medicaid Innovation (CMMI), or other federal or state stakeholders, and having expertise on the Health Insurance Portability and Accountability Act

(HIPAA);

5. Other activities in support of successful, transformational provider payment program redesign and implementation, such as the development of tools, guidelines, curricula, training, audits, research and analytics, special reports and report cards, testing, rules development, and assessing outpatient, inpatient, or other services utilization.

4.2 Scope of Work & Deliverables

ODM requires the Selected Offeror to be responsible for, at minimum, the following services in the following categories:

4.2.1 Hospital Rebase, Rate Evaluation, CCA Report Monitoring

Selected Offeror will provide services related to inpatient services, outpatient services, and general hospital services, including rebasing, rate evaluation, and CCA report monitoring, as follows:

A. Inpatient Deliverables:

1. Track payments made to hospitals for inpatient hospital services, especially those related to add-on rates and payments.

2. Analyze multi-year inpatient hospital data sets for purposes of (1) costing inpatient claims, and (2) calculating inpatient hospital base rates and relative weights.

3. Calculate proposed rebased rates for inpatient hospital services under the APR-DRG grouper, with more recent information applied to ODM’s defined methodology and funding limitations.

4. Calculate per diem rates for free-standing psychiatric (FSP) hospitals.

5. Analyze and review FSP rates for future updates including proposals for case mix adjusted per diems.

6. Provide ODM assistance as requested in ODM’s ongoing management and implementation of inpatient rates, including assistance with claims classified with MS-

DRG.

7. Analyze cost report data to develop and model options for capital and Graduate Medical Education (GME)/Indirect Medical Education (IME) payments.

8. Determine base year(s) for claims and cost report data for projects and initiatives identified by ODM.

9. Support industry stakeholder negotiations with ODM.

10. Assist and support policy roll-out to ODM contracted managed care plans.

B. Outpatient Deliverables:

1. Calculate proposed rebased rates for outpatient hospital services under the EAPG grouper with more recent information applied to ODM’s defined methodology. ODM to review and finalize revised rates.

2. Provide ODM assistance as requested in ODM’s ongoing management and implementation of outpatient rates and payments.

3. Support industry stakeholder negotiations with ODM, and policy roll-out to ODM contracted managed care plans.

4. Provide technical assistance on ambulatory surgical center (ASC) rate setting and related activities, including monitoring expenditures, reviewing trends, building fiscal impact models, establishing fiscal model databases, pricing values, assessing and preparing policy changes, and systems requirements for billing changes.

C. General Hospital Deliverables:

1. Develop monthly inpatient and outpatient cost coverage add-on payment reports.

2. Create impact analyses at the statewide, hospital, and managed care entity (MCE) levels related to hospital rate setting.

3. Determine base year(s) for claims and cost report data for projects and initiatives identified by ODM.

4. Provide technical assistance on hospital inpatient and outpatient rate setting and related activities, including monitoring expenditures, reviewing trends, building fiscal impact models, establishing fiscal model databases, pricing values, assessing and preparing policy changes, and systems requirements for billing changes.

5. Calculate preliminary base rates for IP and OP services, and/or reimbursement based on initial decisions for peer groups.

6. Extract provider claims data from ODM’s payment system and evaluate extracted data for billing anomalies, payment and policy accuracy.

7. Use claim data, cost report data, and preliminary relative weights to analyze potential outlier cases and present options on outlier policies and other payment components.

8. Cost out the claims in created datasets, including mapping revenue codes to cost-to-charge ratios and identify anomalies.

9. Finalize fiscal impact model, statewide, by hospital, and by other categories as specified by ODM (e.g., maternity cases, neonate cases, Behavioral Health cases)

10. Analyze ODM’s plans for quality payments or indicators; assist ODM in determining the appropriate data and variables for use in fiscal modeling.

11. Finalize decisions on mapping revenue codes to cost reports (e.g., hospital-specific or standardized).

4.2.2 Non-Institutional Service Examination and Analytics

Selected Offeror will provide examination and analytics services, as follows:

A. Provide technical assistance for rate setting and evaluation and implementation of non-institutional service examination and analytics, including the CMS Access Rule Requirements (Documentation of Access to Care and Service Payment Rates) and other ad-hoc requests.

B. Submit data requests to ODM for claims and cost report data in accordance with an applicable data use agreement or business associate agreement entered by ODM and Selected Offeror, and/or other procedures set by ODM.

C. Assist in creating and publishing federally required data that demonstrates access to Medicaid services including fee-for-service reimbursement rates for various outpatient and non-institutional services.

D. Provide technical assistance on reimbursement to other community healthcare providers (non-institutional), including monitoring expenditures, reviewing trends, building fiscal impact models, establishing fiscal model databases, pricing values, assessing and preparing policy changes, and systems requirements for billing changes.

E. Create impact analyses at the statewide, hospital, and MCE levels related to ambulatory surgical center rate rebasing.

4.2.3 Available Grouping Products

Selected Offeror will provide services related to available grouping products, as follows:

A. Provide technical assistance using ODM-provided grouping software for reporting, including potentially preventable readmission (PPR) reports, as needed.

B. Complete PPR Reports/ dashboard reports in PDF format and provide native Excel source files.

C. Calculate the initial relative weights for each APR-DRG or EAPG and identify unstable APR-DRGs and EAPGs.

D. Develop options for collapsing unstable APR-DRGs and EAPGs.

E. Run claims through the APR-DRG and EAPG groupers and identify “ungroupables”.

4.2.4 Fiscal Impact of Budget Initiatives and Rule Changes

Selected Offeror will provide analysis of budget initiatives and rule changes, as follows:

A. Create the fiscal impact analysis, provided in Excel format.

B. Provide technical assistance regarding ODM’s budget development, as well as potential rate and reimbursement changes.

4.2.5 Coordination with the Federal Government and Various Stakeholders

Selected Offeror will assist with coordination with the Federal government and other relevant stakeholders, as follows:

A. Conduct regulatory analysis, including evaluating, planning, and analyzing proposed regulatory changes impacting provider payments or ODM payment systems, including identifying opportunities afforded by state and federal regulatory changes to health care coverage.

B. Facilitate relationships and support negotiations with federal government and other stakeholders.

C. Advise ODM on anticipated federal government or other stakeholder strategies and potential responses.

D. Guide and support negotiations with CMS, the Center for Medicare and Medicaid Innovation

(CMMI), or other federal or state stakeholders.

E. Meet with stakeholders to review methodology and impact.

F. Provide technical assistance on issues that arise with CMS on reimbursement initiatives as described in this RFP, or any other issue or question that may be raised by CMS, including obtaining data and conducting analyses as agreed upon with ODM, drafting responses to CMS under the guidance of ODM, and conducting other related activities at the direction of ODM.

4.2.6 CMS Required Reporting

Selected Offeror will assist with ODM’s required reporting to CMS, as follows:

A. Assist ODM with developing (1) UPL demonstration approaches and methods, and (2)

Documentation of Access to Care and Service Payment Rates (as needed), including existing and new regulations per Title XIX, Title XXI, and Title XVIII of the Social Security Act.

B. Update the Documentation of Access to Care and Service Payment Rates for CMS with final edits before submission to CMS.

C. Provide the final Documentation of Access to Care and…