Pre-Proposal Conference 9.10.26.pdf

Welcome Medicaid Managed Care Orgs

Pre-Proposal Meeting September 10, 2026

State of Indiana Bidder Profile

• A bidder profile with IDOA is required to access the Indiana Supplier Portal and to submit bid responses.

• Scan the QR Code to access Supplier Portal Information.

• Before an award may be granted, the bidder must be registered with the Secretary of State

General Information

• Potential Respondents are typically given the opportunity to express interest in a solicitation and to have their company and contact information posted to the solicitation website by submitting the Pre-Proposal Network Opportunities Form (Attachment I).

• The form is optional but must be submitted to rfp@idoa.in.gov by the date and time specified in the documents for each solicitation.

• Potential Respondents are encouraged to submit any questions pertaining to a solicitation via the Question/Inquiry process, using Attachment G.

• Specific deadlines for each event are listed in the published solicitation document(s) (RFP Main Document).

mailto:rfp@idoa.in.gov

Submission Forms/Documents

• Additional forms may also be required depending on the event.

• Use the templates provided for all responses and do not alter any templates.

• Responses must be submitted per the RFP instructions. See RFP Sections 1.7 and 2.1 for additional details. Late submissions and emailed or hand-delivered submissions will not be accepted.

Please see the Key Dates section (RFP Section 1.24) of each solicitation to confirm due dates for these items.

Required Submission Forms/Documents

• Attachment A – IVOSB Participation Plan Form

• Letters of Commitment

• Certification Documentation

• Attachment E – Business Proposal Template

• Attachment F1 & F2 – Technical Proposal Templates

• Attachment H1 & H2 – Reference Check Forms

• Attachment J – Attestation Form

• Attachment L – AI Technical Proposal Questions

• Attachment M – Infrastructure Overview

• Executive Summary

Executive Summary The Executive Summary must be completed and submitted via the online submission process. At a minimum, your Executive Summary must address the following (also outlined in Section 2.2 of the RFP):

• Summarize your ability and desire to supply the required services;

• Make sure the Executive Summary is signed by an authorized representative;

• Include your primary contact

• State your understanding of the respondent notification.

• Must include an explicit acknowledgement of acceptance of the methodologies included in the Capitation Rate Certifications

You may include additional “cover letter” information within the Executive Summary if desired.

Attestation Form

The Attestation Form (Attachment J) must be completed.

• Mandatory Submission and Requirements

• Confirm Mutual Understanding and Submission

• Claim Clarification (Buy Indiana), if applicable

• Claim Clarification (Qualified Agency), if applicable

• Confidential / Redacted File Information

• Authorizing Document

• Secretary of State status indication

Confidential Information Confidential Information (RFP Main Document - Section 1.14)

• All materials contained in proposals are subject to the Access to Public Records Act (APRA) and can be accessed by any member of the public after contract award. The responses are deemed to be “public records” unless a specific provision of IC 5-14-3 protects parts of the response from disclosure.

• In order to request certain information be kept confidential, Respondents must claim a statutory exception to the APRA in their Attestation Form (Attachment J), including a description of which specific provision applies to any specific part of their response.

• Confidential information must also be clearly marked and kept separate from the proposal in the electronic copies. IDOA recommends sending a “public” file that has the confidential information redacted (may be in PDF format) and a “final” file that includes all required information (must be in format provided).

• A redacted version must be submitted along with the Confidential copy.

• DO NOT LABEL YOUR ENTIRE RESPONSE AS CONFIDENTIAL.

Business Proposal Company Financial Information (Section 3.0)

• This section must include the Respondent's and Respondent's ultimate controlling person's financial statement, including an income statement and balance sheet, for each of the two most recently completed fiscal years, plus unaudited monthly financial statements (balance sheet and income statement) through September 2026 (if available at time of submission) including RBC ratio for each month. The financial statements must demonstrate the Respondent's financial stability.

• If the documents are from a parent or holding company, Respondents must explain the business relationship between the entities and demonstrate the financial stability of the entity which is directly responding to this RFP.

• Contract Terms (Section 5.0)

• Respondents should review sample State contract and note exceptions to

State non-mandatory clauses in Business Proposal.

• The State may refuse to consider any redlines requested in negotiation of a contract that were not specifically identified and included in a vendor’s response.

• Mandatory clauses are non-negotiable.

References (Section 6.0)

• Often, Respondents must have at least five (5) references who:

• Can speak to the Respondent’s experience in providing products and/or services that are the same, or similar, to those products and/or services requested in this solicitation

• Can speak to the Respondent’s performance on contracts of similar scope for government clients

• Respondents must ask each reference to complete Attachment H1 (Reference

Check Form) and email it directly to IDOA (idoareferences@idoa.in.gov) by the date specified in the solicitation.

mailto:idoareferences@idoa.in.gov

Technical Proposal & Outcomes Measures

Attachment F1 & F2

• Every point made in each section must be addressed in the order given. The same outline numbers must be used in the response.

• Where appropriate, supporting documentation may be referenced by a page and paragraph number. However, when this is done, the body of the Technical

Proposal must contain a meaningful summary of the referenced material.

• The referenced document must be included as an appendix to the

Technical Proposal with referenced sections clearly marked.

• If there are multiple references or multiple documents, these must be listed and organized for ease of use by the State.

Optional Submission Forms/Documents

Submission of these documents is optional and does not impact your ability to submit a proposal.

• Attachment I - Pre-Proposal Networking Opportunity Form

• Attachment G - Questions and Answers Form

Please see the Key Dates section (RFP Main Document) of each solicitation to confirm due dates for these items.

Evaluation Criteria

Indiana Veteran Owned Small Business

• Contact Information

• Phone: 317-232-3061

• E-mail: Indianaveteranspreference@idoa.in.gov

• Web: https://www.in.gov/idoa/indiana-veteran-owned-small-business-program/

• Complete Attachment A, IVOSB Form

• Include subcontractor letters of commitment

• Goals for Proposal

• 3% Veteran Owned Small Business of Total Bid Amount mailto:Indianaveteranspreference@idoa.in.gov

Indiana Veteran Owned Small Business

• Process. IVOSB scoring is conducted based on 5 points plus a possible 1 bonus point scale.

• IVOSB: Possible 5 points + 1 bonus point

• Professional Services Scoring Methodology. The points will be awarded on the following schedule:

• Fractional points will be awarded based upon a graduated scale between whole points. (e.g., a 0.3% commitment will receive .5 points, and a 1.5% commitment will receive 2.5 points)

• Submissions of 0% participation will result in a deduction of 1 point in each category

• The highest submission which exceeds the goal will receive 6 points (5 points plus 1 bonus point). In case of a tie both firms will receive 6 points.

RFP Information

• Contract Term: The term of the contract shall be for a period of four years from the date of contract execution. There may be two 1-year renewals for a total of six years at the State’s option.

Activity Date

Issue of solicitation August 27, 2026

Pre-Proposal Conference

September 10, 2026, 1:30 ET

Indiana Government Center South Conference Center Conference Room C

Deadline to Submit Written Questions (Round 1) September 11, 2026, by 3:00 PM Eastern

Time

Response to Written Questions/Amendments (Round 1)

October 2, 2026

Deadline to Submit Written Questions (Round 2) October 9, 2026, by 3:00 PM Eastern Time

Response to Written Questions/Amendments (Round 2)

October 23, 2026

Submission Due Date/Time November 6, 2026, by 3:00 PM Eastern Time

General Program Overview o Indiana Medicaid continues to provide coverage and services across the four existing managed care programs, while planning to align and refine programs to best serve Hoosiers under a single set of contracts that will start January 1, 2029 o A focus on FSSA’s triple aim has been applied:

▪ Make Indiana Healthy Again

▪ Partner with plans dedicated to the State of Indiana

▪ Ensure fiscal integrity and responsibility of Medicaid programs o A single set of contracts with aligned requirements and structure will better allow members to move across programs and/or align with family members in different programs

▪ Programmatic updates have been made across programs

▪ Care Coordination requirements have been revised comprehensively

▪ Contract compliance standards have been updated significantly

▪ Carve-in of MRO, CCBHC, and 1915(i)

▪ References to potential future Contract changes

PathWays for Aging oProgram Overview

▪ Indiana’s PathWays program is a Statewide coordinated care program for Indiana’s Medicaid members who are sixty (60) years of age and older and are eligible for Medicaid on the basis of age, blindness, or disability and have limited income and resources. PathWays covers members who have a full Medicare benefit and those who are receiving long-term services and supports (LTSS) in a home or community-based setting.

oExample Programmatic Updates

▪ HEA 1277 compliance

Healthy Indiana Plan (HIP) oProgram Overview:

▪ Healthy Indiana Plan provides comprehensive, consumer-driven health insurance for eligible low-income adults oExample Programmatic Updates

▪ Structural shift to exclusively designate Healthy Indiana Plan for the eligible Medicaid expansion population

▪ Addition of work requirements and medically frail definitions

▪ Removal of POWER Account structure

▪ Removal of tiered HIP model oHIP 3.0 may have further edits after the State receives CMS approvals.

Please expect an updated Scope of Work prior to program implementation.

Hoosier Care Connect (HCC) oProgram Overview:

▪ Supporting complex, chronic conditions for aged, blind, and disabled Hoosiers under age sixty who are not Medicare-eligible

▪ Supporting children in foster care within the child welfare population oExample Programmatic Updates

▪ Carve-in of wards and foster populations for mandatory enrollment

▪ Child welfare leadership, staffing and partnership requirements

▪ Enhanced high-acuity crisis response expectations and requirements

Hoosier Healthwise (HHW) oProgram Overview

▪ Hoosier Healthwise serves low-income children up to age 19 and pregnant women

▪ Children who fall under the Children’s Health Insurance Program (CHIP) oExample Programmatic Updates:

▪ Integration of the Indiana Pregnancy Promise Program into Hoosier Healthwise’s complex case management and care coordination infrastructure to promote seamless coordination

▪ Additional populations to be included from HIP non-expansion members (low income caretaker, transitional medical assistance, and pregnant members)

Capitation Rate Development

September 10, 2026

Content Topic Slide

Overview of Programs 3

Overview of Rate Development Process 5

Rate Development Focus Areas: PathWays for Aging Program 7

Rate Development Focus Areas: HIP/HHW/HCC Programs 9

Rate Development Focus Areas: All Programs 13

Questions 16

Overview of Programs

Overview of Programs

Healthy Indiana Plan (“HIP”)

• Currently, non-disabled adults ages 19-64, including pregnant women and the expansion population, with incomes up to approximately 138% of the federal poverty level. In the future, intent is for HIP to cover Medicaid expansion adults only

Hoosier Healthwise (“HHW”)

• Low-income children under age 19 including CHIP members (Children’s Health Insurance Program); and pregnant women whose income levels are above the HIP program income limits. In the future, intent is for non-expansion adults to be served under HHW as well

Hoosier Care Connect (“HCC”)

• Members under the age of 60 who are aged, blind, or disabled and not eligible for Medicare, including eligible SSI (Supplementary

Security Income), MEDWorks (Medicaid for Employees with Disabilities), and certain foster-care populations

PathWays for Aging (“PathWays”)

• Members aged 60 and older, including individuals dually eligible for Medicare

• Integrated medical, behavioral health, and long-term services and supports, including care coordination and home-and community-based services

The below table gives an overview of the HIP, HHW, HCC, and PathWays for Aging Programs.

Overview of Rate Development Process

Rate Development Methodology Overview

• Encounter Data Review

• Financial Data Review

• Physician and ancillary

• Inpatient and Outpatient Hospital

• Physician Faculty Access to Care (PFAC)

• Hospice (PathWays)

• Mental Health Medication Prior Authorization

• Maternity Case Rate Count

• Apply trend to base data from midpoint of base period to the midpoint of rating period

• Normalized for acuity, completion, and program change adjustments

• Administrative and care management load

• Underwriting gain

• Third Party Liability (TPL) Recovery

• Pay for outcome (P40) withholds estimated to be not reasonably achievable

• Waiver Liability (PathWays)

• Removal of non-covered services

• Removal of Institution of Mental Disease (IMD) Long-Stays

• Completion adjustment

• Acuity adjustment

• Plan-level risk adjustment

Base Data Base Data

Adjustments Fee Schedule Adjustments

Trend Non-Benefit

Expenses

Other Program Change

Adjustments

Other Adjustments

Acuity Factor & Risk

Adjustment

The figure below illustrates examples of rate components that have been included in historical rate development.

Rate Development: PathWays Focus Areas

PathWays: Upcoming Items for Consideration

• 7/1/2027 Long-Term Nursing Facility Member Carve-Out

• Effective 7/1/2027, nursing facility members receiving >100 days of nursing facility care are carved out from managed care to the fee-for-service program

• Considerations for impacts in rate development include but are not limited to:

• Administrative cost impact

• Enrollment shifts

• Medical cost impact

• PathWays Risk Adjustment Development – Timing TBD

• HCBS Services: Currently exploring available data sources, potential model development

• Acute Services: CDPS + Rx model, similar to HCC Program

• FIDE-SNP (Fully Integrated Special Needs Plan)

• Effective 1/1/2026, FIDE-SNP plans were incorporated to increase care integration for PathWays dual members

Various items are being evaluated for potential impacts on the PathWays program.

Rate Development Focus Areas:

HIP/HHW/HCC Programs

Risk Adjustment: HIP/HHW/HCC

CY 2026 Rating Period CY 2027 Rating Period (Anticipated)

Initial Rates Risk Adjustment

• Cost Weight Data: Claims from September 2023 to August 2024 and paid through November 2024

• CDPS+Rx Grouping Data: Claims from September 2023 to August 2024 and paid through November

• Member Plan Assignment: July 2025 enrollment snapshot

• Cost Weight Data: Claims from January to December 2025 and paid through June 2026

• CDPS+Rx Grouping Data: Claims from January to December 2025 and paid through June 2026

• Member Plan Assignment: July 2026 enrollment snapshot

Rate Amendment Risk Adjustment (Anticipated)

• Cost Weight Data: Claims from January to December 2025 and paid through June 2026

• CDPS+Rx Grouping Data: Claims from January to December 2025 and paid through June 2026

• Member Plan Assignment: July 2026 enrollment snapshot

• Cost Weight Data: Anticipate using claims from CY 2026 with run-out through mid-2027

• CDPS+Rx Grouping Data: Anticipate using claims from CY 2026 with run-out through mid 2027

• Member Plan Assignment: Anticipate mid-2027 enrollment snapshot

The figure below illustrates the anticipated risk adjustment methodologies for CY 2026 and CY 2027 rating periods.

Acuity Considerations: HIP and HHW Programs

• Recent Declining Enrollment in HIP and HHW Programs

• Work Requirements

• Estimated to result in further enrollment declines for non-medically frail expansion members not meeting requirements beginning 1/1/2027 a n e b ar p r u l g ct o ec b ar r l edicaid nrollment HIP and HH

HIP HH

Various factors have contributed to declining enrollment in HIP/HHW programs and resulting impact on acuity.

Hospital and Physician State Directed Payments (SDPs)

CY 2026 Hospital SDP Design

• Uniform percentage increase on hospital inpatient and outpatient services

• Total payment level after SDP payments increase rates to between 120% and 158% of the current Medicare fee schedule based on hospital class and current average commercial rates (ACR)

• Payments currently made quarterly on a retrospective basis via a separate payment term outside of capitation rates with final payments to vary based on actual utilization of inpatient and outpatient services during the rating year

• Estimated CY 2026 amount of $1,866 million, approximately 22.0% of capitation rates

CY 2026 Physician SDP Design

• Uniform percentage increase on professional services for physician and non-physician practitioners

• ~46% increase per eligible claim

• Payments currently made quarterly on a retrospective basis via a separate payment term outside of capitation rates

• Estimated CY 2026 amount of $46 million, approximately 0.5% of capitation rates

Separate payment terms for hospital and physician payments were approved May 2026 for HIP, HHW, and HCC.

Rate Development Focus Areas: All Programs

Pay for Outcomes (P4O) Withhold Program

• A percentage of the capitation payments are currently withheld during the measurement year and can be earned back based on quality measure performance relative to targets established by FSSA

Outcomes Measured:

• To support continuous quality improvement, measures vary from year-to-year and may shift according to the needs of the program’s members

• Healthcare Effectiveness Data and Information Set (HEDIS) measures have historically accounted for the majority of the withhold measures. Examples of measures used in recent time periods include:

• Adult Preventative Care

• Well-Child Visits

• Child Immunization Status

• Follow-up After Emergency Department Visits

FSSA’s Pay for Outcomes Withhold Program incentivizes quality performance by MCOs in State priority areas.

Rate Development: Pharmacy High-Cost Drug Carve-Out

• The current list of drugs can be found here:

• https://provider.indianamedicaid.com/ihcp/Publications/providerCodes/Physician_Administered_Drugs_Ca rved_Out_and_Separately_Reimbursed.pdf

Certain high-cost drugs are carved out from the HIP, HHW, HCC, and Pathways for Aging Programs.

Top 10 Carve Out Drugs by CY 2025 Spend

Procedure Code Description Approximate

Spend

J1413 Elevidys $ 10,080,000

J3399 Zolgensma $ 7,223,577

J7170 Hemlibra $ 2,712,241

Q2042 Kymriah $ 2,492,840

Q2041 Yescarta $ 2,115,036

J7188 Hemophilia Blood Coagulation Factors and Hemophilia Hemostatic Agents $ 716,111

Q2056 Carvykti $ 583,076

J0791 Adakveo $ 457,097

J2326 Spinraza $ 451,894

J7192 Hemophilia Blood Coagulation Factors and Hemophilia Hemostatic Agents $ 289,566

1 Approximate spend is Fee for Service claims incurred January – December 2025 paid through July 2026 as reported in the tate’s encounter data warehouse.

Questions