QLV27007040 – Agency Solicitation Specifications Page 1 of 36

QLV27007040 - Fully Integrated Dual Eligible Special Needs Plan Program (FIDE-SNP)

SECTION A: BACKGROUND

The Rhode Island Department of Administration’s Division of Purchases (RIDOP), on behalf of the Rhode Island Executive Office of Health and Human Services (EOHHS), is soliciting proposals from qualified organizations to serve as Managed Care Organizations (MCOs) to provide Medicaid covered services through risk-based contracts under the Rhode Island Fully Integrated Dual

Eligible Special Needs Plan (FIDE-SNP) Program. This is a structured Solicitation to develop a

Qualified List of Vendors (QLV). Through this Solicitation, EOHHS intends to qualify at least one

(1), however no more than three (3) Bidders, during the evaluation process to deliver integrated

Medicare and Medicaid benefits under a State Medicaid Agency Contract (SMAC). More information regarding the evaluation process appears below.

FIDE-SNPs are Dual Eligible Special Needs Plans (D-SNPs) that provide dual eligible individuals access to Medicare and Medicaid benefits under a single entity that holds both a Medicare

Advantage contract with the Centers for Medicare & Medicaid Services (CMS) and a Medicaid

Health Plan contract with the State Medicaid Agency. CMS maintains primary authority for the regulation, oversight, and enforcement of all applicable Medicare requirements governing D-

SNPs. EOHHS is responsible for the administration and oversight of Medicaid services delivered through the FIDE-SNPs.

FIDE-SNPs awarded through this Solicitation must fully integrate care for full-benefit dually eligible (FBDE) individuals through exclusively aligned enrollment and provide coverage of primary, acute, behavioral health, durable medical equipment (DME), and long-term services and supports (LTSS) benefits. Successful Bidders may also offer a Coordination Only D-SNP (CO D-

SNP) to serve partial-benefit dually eligible individuals only. FBDE individuals must be served exclusively through the Bidder’s FIDE-SNP under an exclusively aligned enrollment model and may not be enrolled in a Bidder’s CO D-SNP. EOHHS reserves the right to not execute a SMAC for a CO D-SNP with an entity that is not successful under this Solicitation. Enrollment in the

FIDE-SNP’s Medicaid managed care plan is contingent upon enrollment in the same organization’s corresponding Medicare D-SNP. Accordingly, an individual's Medicare plan selection drives and determines enrollment into the aligned Medicaid managed care arrangement, creating a single, integrated delivery system for Medicare and Medicaid benefits.

Responses will be evaluated based on Bidder’s qualifications, including the submission of a business and technical proposal that demonstrates through substantial detail and evidence the

Bidder’s past and current experience and capability to fully meet all requirements to achieve

EOHHS’s priorities and goals outlined in the Solicitation.

EOHHS is seeking proposals from qualified and competent organizations to manage the delivery of the Rhode Island FIDE-SNP Program, as detailed in Appendix A, State Medicaid Agency

Contract.

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QLV27007040 – Agency Solicitation Specifications Page 2 of 36

1. Purpose of This Solicitation

The purpose of this Solicitation is to obtain proposals from qualified Bidders to provide high-quality health care services statewide to Medicaid beneficiaries enrolled in the Rhode Island FIDE-

SNP Program who are dually eligible for both Medicare and Medicaid (hereinafter referred to as dual-eligibles), utilizing the most cost-effective manner, and in accordance with the terms and conditions set forth herein.

EOHHS is seeking to partner with MCOs that will improve and build upon the success of the prior

Medicare-Medicaid Program (MMP) Financial Alignment Initiative (FAI) and further improve service delivery and quality of health care services dual-eligible beneficiaries receive in the managed care delivery system.

QLV27007040 – Agency Solicitation Specifications Page 3 of 36

2. Background on the Rhode Island Medicaid Program

2.1 Rhode Island EOHHS and Managed Care Overview

EOHHS serves as “the principal agency of the executive branch of state government” (RI

Gen. Laws § 42-7.2-21) responsible for managing the Departments of: Health (DOH);

Human Services (DHS); Children, Youth and Families (DCYF); and Behavioral

Healthcare, Developmental Disabilities and Hospitals (BHDDH). Last year, EOHHS agencies provided direct service to over 300,000 Rhode Islanders, as well as an array of regulatory, protective and health promotion services.2 In State Fiscal Year 2026 (SFY26), Health and Human Services benefits represented approximately $6.5 billion, or over 45% of the entire State budget.3

Rhode Island EOHHS is the single state agency (SSA) for Medicaid. EOHHS administers

Rhode Island’s $4.2 billion Medicaid Program, inclusive of federal funds, general revenues, and restricted receipts.4 The Rhode Island FIDE-SNP Program is one facet of the larger Rhode Island Medicaid Managed Care Program which provides health care coverage for over 290,000 eligible individuals representing more than a quarter (1/4) of

Rhode Islanders of all ages and from various ethnic and racial backgrounds.5

Rhode Island has adopted managed care as a crucial strategy for delivering Medicaid-covered services to eligible beneficiaries. The state initiated the Medicaid Managed Care

Program, RIte Care, in 1994, enrolling over 70,000 low-income children and families.

Since its inception, Rhode Island has progressively broadened managed care enrollment to encompass diverse populations with complex health care needs.

The Rhode Island Medicaid Managed Care Program is operated under the authority of a

Section 1115 Waiver and Section 1932(a) State Plan Amendment. EOHHS may pursue a change in federal authority or additional federal authorities at any time for the Rhode

Island Medicaid Managed Care Program.

For more information regarding Rhode Island Medicaid Managed Care Program enrollment data, interested parties are encouraged to review EOHHS reported enrollment data, State Medicaid and CHIP Applications, Eligibility Determinations, and Enrollment

Data’ on CMS’ website.6

2.2 FIDE-SNP Model and Dual-Eligible Population

Individuals who are dually eligible for Medicare and Medicaid often have complex medical, behavioral health, and LTSS needs. A FIDE-SNP is designed to integrate

Medicare and Medicaid benefits through a single health plan, helping members navigate care through one coordinated model, a unified care team, and an integrated care plan.

1 RI Gen. Laws § 42-7.2-2 - https://webserver.rilegislature.gov//Statutes/TITLE42/42-7.2/42-7.2-2.htm

2 https://eohhs.ri.gov/about-eohhs 3 https://www.rilegislature.gov/Special/comdoc/Senate%20Finance%205212020/FY26%20EOHHS%20Senate%

20Finance%20Slide%20Deck%20rev.pdf 4 Id.

5 https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/report-highlights 6 State Medicaid and CHIP Applications, Eligibility Determinations, and Enrollment Data-https://data.medicaid.gov/dataset/6165f45b-ca93-5bb5-9d06-db29c692a360 https://webserver.rilegislature.gov/Statutes/TITLE42/42-7.2/42-7.2-2.htm https://eohhs.ri.gov/about-eohhs https://www.rilegislature.gov/Special/comdoc/Senate%20Finance%205212020/FY26%20EOHHS%20Senate%25 https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/report-highlights https://data.medicaid.gov/dataset/6165f45b-ca93-5bb5-9d06-db29c692a360

QLV27007040 – Agency Solicitation Specifications Page 4 of 36

The model is intended to improve care coordination, reduce duplication and fragmentation across programs, and support a more seamless member experience.

Rhode Island previously participated in the CMS FAI through a MMP under the state’s

Integrated Care Initiative. As the MMP demonstration concluded, EOHHS transitioned the program to a FIDE-SNP model to preserve integrated coverage for full-benefit dual eligible members and continue building on the state’s experience coordinating Medicare and Medicaid services. The transition was intended to maintain continuity of care while positioning the program for a more sustainable integrated care structure.

EOHHS currently contracts with a single FIDE-SNP plan (Neighborhood Health Plan of

Rhode Island) to serve FBDE members. Through this Solicitation, EOHHS seeks to transition from a single-plan arrangement to a competitive, multi-plan program of no more than three (3) qualified plans. Expanding the number of participating plans is intended to support member choice, strengthen competition on quality and care management, and reduce reliance on a single contractor for the delivery of integrated care to the dual-eligible population.

With this Solicitation, all Bidders will be required to offer a FIDE-SNP and managed care plan to cover dual eligible beneficiaries. All FBDE beneficiaries will be offered choice to enroll with those Health Plans that are successful Bidders and selected by the

State. This population will include individuals who:

• Are age twenty-one (21) or older;

• Are entitled to or are enrolled in Medicare Part A;

• Are entitled to or enrolled in Medicare Part B; and

• Are eligible for full Medicaid benefits under the Rhode Island Medicaid State Plan.

FBDE members are served exclusively through the FIDE-SNP under exclusively aligned enrollment; a member's selection of a Bidder's FIDE-SNP for Medicare drives enrollment into that Bidder's Medicaid managed care coverage. Members that do not select a

Bidder’s FIDE-SNP for Medicare coverage will receive their Medicaid benefits through fee-for-service (FFS).

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2.3 Current Distribution of Dual Eligible Members

The table below provides information regarding the total number and distribution of full benefit dual eligible individuals in the state of Rhode Island as of May 2026.

Full Benefit Dual Eligible Enrollment Distribution as of August 2026 (by Population)

Population

FFS

Enrollment

NHPRI

FIDE-SNP

Enrollment

PACE

Enrollment

Total

LTSS

Nursing Home 4,208 483 - 4,691

HCBS Waiver 5,353 2,577 - 7,930

Developmentally Delayed

(DD)

1,520 1,162 - 2,682

Non-LTSS

Severe and Persistent Mental

Illness (SPMI) 946 1,228 - 2,174

Community Well 13,829 5,337 - 19,166

FBDE Total 25,856 10,787 416 37,060

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3. Goals and Strategies Under this Procurement

3.1 FIDE-SNP Program Goals

Rhode Island EOHHS’ mission is “to foster and strengthen a community-driven, equitable, comprehensive, responsive, and high-quality health and human services system in Rhode Island.” EOHHS’ vision for a more robust health and human services delivery system is to build a “resilient, equitable, and just communities nurturing the health, safety, wellbeing, and independence of all Rhode Islanders.”

EOHHS is committed to contracting with organizations that share these values and vision for ensuring that integrated Medicaid and Medicare services are delivered equitably and appropriately for all dual-eligible Rhode Islanders.

Access to quality and cost-effective healthcare services is integral to meeting the diverse health needs of the populations served in the Rhode Island Medicaid Managed Care

Program, including dual-eligible members. With this Solicitation, EOHHS intends to contract with qualified entities to coordinate and collaborate to achieve health care excellence by integrating the coordination, provision, and payment of Medicare and

Medicaid funded services for dual-eligible members, providers, and partners.

EOHHS is looking to further improve the fragmented dual-eligible Medicaid and

Medicare delivery system. This procurement advances EOHHS’s goals for the next phase of the FIDE-SNP Program which include the following six (6) strategic goals:

1. Healthier Communities*: Improve population health outcomes and advance equity by addressing social drivers of health.

2. Value & Affordability*: Control costs through value-based care and budgets that stay predictable.

3. Better Member Experience*: Help members make informed choices and navigate care in their preferred setting.

4. Coordinated Care: Integrate care across Medicare and Medicaid to reduce duplication and fragmentation.

5. Empowered Providers*: Reduce provider burden and equip the network with the tools, data, and support to deliver integrated care.

6. Accountability: Strengthen reporting and tie payments to person-centered, efficient care and member outcomes.

*Goals aligned with the National Institute of Health’s Quadruple Aim to optimize health system performance.

3.2 Alignment with the RI EOHHS Managed Care Quality Strategy

This procurement is consistent with the RI EOHHS Managed Care Quality Strategy for

2025–2028, which sets forth the state’s vision for continuously improving the quality of managed care services delivered across Rhode Island. In line with that strategy, EOHHS is committed to improving health outcomes, reducing health disparities, ensuring access to needed services, and engaging stakeholders in transparent quality improvement.

Qualified FIDE-SNP plans will be expected to advance these commitments—including health equity, screening for health-related social needs, and measurable quality performance across both Medicare and Medicaid domains.

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4. Contract Award Information

Through this Solicitation, EOHHS intends to qualify at least one (1), however no more than three

(3) Bidders, during the evaluation process to deliver integrated Medicare and Medicaid benefits under a SMAC. All qualified Bidders may not be selected through this Solicitation. Bidders will be evaluated based on their qualifications, experience, and ability to deliver fully integrated care as specified in this Solicitation as outlined in Section D: Evaluation and Selection. If more than three (3) Bidders meet the passing technical score of sixty (60) points, EOHHS will select the three

(3) Bidders with the highest scores. EOHHS may issue an award to only one (1) qualified Bidder if no other Bidders meet the passing technical score of sixty (60) points (not including the ISBE bonus points) required in Section D: Evaluation and Selection. Should no response be found satisfactory, RIDOP and EOHHS reserve the right to make no award and restart the Solicitation process.

The initial base contract period will be for one year, from January 1, 2028, to December 31, 2028.

Contracts may be renewed up to five (5) additional twelve (12) month periods based on Bidder’s performance and the availability of funds.

This Solicitation is to procure statewide services under a capitated, risk-bearing Contract. The

Rhode Island FIDE-SNP Program is a risk-bearing healthcare delivery system in which MCOs provide Medicaid covered services to enrollees in return for a per member, per month (PMPM) capitation payment. Awarded Contractors are responsible for ensuring adequate risk-based capital and capital reserve levels required under the rules and regulations of the Rhode Island Office of the Health Insurance Commissioner (OHIC) and other applicable fiscal-solvency requirements.

EOHHS shall establish an actuarially sound, risk-adjusted capitation rate to be paid to the awarded

Contractors in accordance with 42 CFR § 438.47 and all applicable CMS rules and regulations.

The rates shall not be subject to negotiation or dispute resolution and are intended to cover all benefits and management services outlined in this Solicitation. Each awarded Contractor will be paid based on the distribution of Members it has in each rate cell. Capitation rates are prepared annually by EOHHS' actuaries based on the rating period and may be amended during the year at the sole discretion of EOHHS.

7 42 CFR § 438.4- https://www.ecfr.gov/current/title-42/section-438.4 https://www.ecfr.gov/current/title-42/section-438.4

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5. Bidder Eligibility, Minimum Qualifications, and Attributes

EOHHS welcomes qualified Bidders, including new market entrants, with the capabilities to provide high-quality and cost-effective services to the dually eligible population in Rhode Island and that meet the eligibility, minimum qualifications, and organizational attributes required of

Bidders. As a condition of contracting with EOHHS, Bidders must be approved by CMS and execute an integrated D-SNP contract with CMS for plan year 2028 within the CMS established timeline. Under this Solicitation, awarded Bidders will be required to establish Medicare

Advantage contracts (H-contracts) that include only D-SNP plan types operating within a single state. Failure to meet this requirement may result in termination of the awarded contract to the successful Bidder(s).

5.1 Eligibility

Private organizations, defined as non-state entities that are either nonprofit, proprietary corporations, or partnerships that have a Rhode Island location or a proposed Rhode

Island location for its central business operations established within three (3) months of the resulting contract and is within a twenty-five (25) mile radius from the Virk’s

Building, 3 West Road, Cranston, Rhode Island, are eligible to submit proposals in response to this Solicitation.

If a qualified Bidder anticipates the use of additional resources through a partnership or subcontracting relationship with other entities, the requirements of this Solicitation will also apply to any entities that are engaged as partners or subcontractors of the Bidder(s) providing services directly to the state upon award of a contract.

Individuals who are not duly formed business entities are ineligible to participate in this procurement.

5.2 Minimum Qualifications

To ensure that only entities with the requisite federal, financial, and operational standing are evaluated, each Bidder must satisfy the following minimum qualifications, assessed on a pass/fail basis before any Technical Proposal is scored. Bidders that do not meet the minimum qualifications will be disqualified from having their proposal scored or evaluated.

To be considered for the right to have a proposal scored, Bidders must provide documentation for each of the following eight (8) minimum qualifications:

1. Meet the current federal definition of a managed care organization under 42 CFR §

438.28.

2. Currently operates as a health maintenance organization (HMO) that is either:

a. Licensed by the Rhode Island Department of Business Regulation (DBR);

or

b. Will receive HMO licensure or approval to conduct business in Rhode

Island no later than sixty (60) days after execution of SMAC. Bidders that

842 CFR § 438.2- https://www.ecfr.gov/current/title-42/section-438.2 https://www.ecfr.gov/current/title-42/section-438.2

QLV27007040 – Agency Solicitation Specifications Page 9 of 36 are not currently licensed with the state of Rhode Island will be required to provide a detailed timeline for obtaining licensure as outlined in this

Solicitation.

3. Not be an excluded individual or entity under 42 CFR § 438.808(b)9.

4. Have the capacity and willingness to perform all functions required by the SMAC, consistent with Medicaid managed care requirements and Medicare requirements under 42 CFR Parts 42210 and 42311.

5. Have at least three (3) consecutive years of experience managing an array of medical, behavioral, and long-term services and support services covered by

Medicaid and/or Medicare; and serve a minimum combined total of fifty thousand

(50,000) Medicaid, Medicare, or 12 members in one (1) or more U.S. states or territories.

6. Have its principal place of business located within the United States.

7. Be currently accredited by a nationally recognized agency, such as NCQA and/or

URAC, consistent with 42 CFR § 438.22413.

8. Be in compliance with all formatting requirements as outlined in this Solicitation.

5.3 Attributes

Qualified Bidders should have a proven track record and possess attributes in the following areas to be successful in managing the Rhode Island FIDE-SNP Program:

• Financial management, stability, and solvency to manage a risk-bearing contract, including full or partial risk Medicaid managed care contracts;

• Demonstrated experience providing Medicare managed care services including long-term services and supports;

• Ability to develop and maintain a sufficient provider network that meets the unique health care needs of the whole population, including services for vulnerable populations;

• Organizational capacity to manage the proposed services inclusive of administrative, managerial, and clinical staff to manage the unique care management needs of the population;

• Robust information systems that can manage and handle the complex member data to oversee and administer the program inclusive of encounter data requirements

9 42 CFR § 438.808(b) - https://www.ecfr.gov/current/title-42/section-438.808

10 42 CFR Part 422 - https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-422

11 42 CFR Part 423 - https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-423

12 Medicaid-like populations can broadly be defined as populations that have the following attributes: 1) Have low-income; 2) Must meet eligibility criteria that is determined by attributes or characteristics, such as family size, disability status, etc.; 3) Have complex health care needs or multiple comorbidities; or, 4) Includes vulnerable or underserved populations. A Bidder who is including Medicaid-like populations to qualify for Minimum Bidder

Qualifications must justify how their covered lives meets the definitions as defined in this solicitation.

13 42 CFR § 438.224 - https://www.ecfr.gov/current/title-42/section-438.224 https://www.ecfr.gov/current/title-42/section-438.808 https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-422 https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-423 https://www.ecfr.gov/current/title-42/section-438.224

QLV27007040 – Agency Solicitation Specifications Page 10 of 36 under 42 CFR § 438.24214, as well as new and emerging data types such as closed-loop referrals and health social needs related (HSRN) data;

• Knowledge of applicable laws and regulations, including those related to healthcare, privacy, security, and program integrity; and

• Operation of a high-performing program integrity unit with effective fraud, waste, and abuse prevention; data analytics; investigative oversight; compliance monitoring; and corrective action management.

14 42 CFR § 438.242 - https://www.ecfr.gov/current/title-42/section-438.242 https://www.ecfr.gov/current/title-42/section-438.242

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SECTION B: SCOPE OF WORK AND REQUIREMENTS

Proposals must follow all instructions, conditions, and requirements outlined within this

Solicitation. Appendix A- Addendum F to this Solicitation is the stand-alone SMAC, which details the scope of work for contracted Health Plans, as supplemented by the “Fully Integrated Dual

Special Needs Plan (FIDE-SNP) Manual.”15

The Solicitation, incorporating the SMAC, “FIDE-SNP Manual,” and the Bidder’s related proposal by reference, are considered the contracts to be executed between selected Bidders and the State as described in Addendum F, “Special Agency Requirements,” Attachment F-2, “EOHHS General

Terms and Conditions,” and Article 2, Section 2.2, “Agreement Order Precedence Hierarchy” of the SMAC.

Bidders are expected to read this Solicitation in its entirety before responding. Failure to follow any of the instructions, conditions, and requirements set forth in this Solicitation may result in a low score or disqualification.

Acceptable proposals must offer all required services identified in this Solicitation, including the

SMAC in Appendix A- Addendum F and the “FIDE-SNP Manual,” and agree to the contract conditions specified throughout the Solicitation and included in the Bidder’s Technical Proposal response to Section C of this Solicitation.

The Solicitation Appendix A- Addendum F, “SMAC” details the state’s requirements:

• Scope of Work (Attachment F-1);

• EOHHS General Terms and Conditions (Attachment F-2);

• Term of the Agreement (Attachment F-2, Section 1.5); and

• Terms and Conditions of Payment (Attachment F-2, Section 4).

The SMAC included in this Solicitation substantially represents the contract document that successful Bidders must agree to and sign as a condition precedent to being issued a Purchase

Order by the State of Rhode Island.

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15 https://eohhs.ri.gov/sites/g/files/xkgbur226/files/2026-05/RI%20Medicaid%20FIDE-SNP%20Manual%20-

%20CY2026%2C%20Version%201.2_FINAL.pdf https://eohhs.ri.gov/sites/g/files/xkgbur226/files/2026-05/RI%20Medicaid%20FIDE-SNP%20Manual%20-

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SECTION C: PROPOSAL MATERIALS

1. General Requirements for Proposal Submission

1.1. General Requirements

A Bidder’s proposal in response to this Solicitation shall consist of the following four (4) components:

1. Minimum Qualifications;

2. Executive Summary;

3. Business Proposal; and

4. Technical Proposal.

The proposal shall outline a Bidder’s strategies to achieve the specified goals and outcomes outlined in this Solicitation, backed by evidence of past or current experiences.

Proposal responses should not merely restate the expected outcomes but should elaborate on the unique qualifications of the Bidder. When possible, data should be provided to validate claims. Thoroughness and clarity are paramount.

1.2. Proposal Response Format

The Bidder’s proposal should respond to each item in the order in which it appears in

Section 1.3 below. The proposal should contain a Table of Contents, and each section should be separated by a tabbed page that includes headings and numbering to match the corresponding section of the Solicitation. Documents shall not be embedded within any document submitted as part of the proposal (e.g., pasting a PDF within a Word document).

1.2.1. Proposal Page Limits

Bidders must adhere to page limit requirements wherever specified. Appendices are exempt from page limits. Any proposal content beyond the specified page limits will not be evaluated by EOHHS. Any documentation not specifically requested will not be reviewed.

Attachments such as graphics, flowcharts, diagrams, and tables should follow the narrative response for each section or subsection under the specific proposal component. Bidders should ensure that the material within the counted pages is fully responsive to the questions.

Cover pages and Table of Contents pages will not count towards the page limit of the proposals.

1.2.2. Proposal Style Requirements

This is an electronic submission. Submitted proposals must adhere to and conform to the following style requirements:

a) Proposal Composition: Proposals shall be submitted as one PDF file clearly divided into four (4) sections: (1) Minimum Requirements; (2)

Executive Summary; (3) Business Proposal; and (4) Technical

Proposal.

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b) File Type and Page Size: Submitted proposals must be in a searchable

PDF format. Page size must be 8.5” X 11”, excluding pages with charts or graphics. Charts and/or graphs may be provided in a document size appropriate for electronic representation of the chart and/or graph. Optional key graphics, diagrams, and flow charts may use 11” X 17” in ‘landscape’ orientation.

c) Fonts and Margins: Proposals must be typewritten using black Times

New Roman, Arial or Tahoma fonts, font size no less than 12-point font, with standard one-inch margins. Appendices must comply with font restrictions, but do not have to comply with the margin restrictions. Font size and color do not apply to graphics or diagrams in the Proposal. Original documentation submitted in the appendices do not need to conform with font and margin restrictions (i.e., financial statements or original business process documentation).

d) Line Spacing: Proposals should be single-spaced.

e) Headers: The header of each page should indicate the corresponding element to which the page is responsive and include the Bidder’s name. For instance, if the page is part of the Bidder’s response to 5.1

Organizational Qualifications and Experience, the header should indicate “5.1 Organizational Qualifications and Experience, Bidder’s

Name.” Cover pages and Table of Contents do not need a header and footer label.

f) Pagination/Footers: Page numbers should appear in the footer of each page and centered. Cover pages and Table of Contents do not need a page number.

g) Table of Contents: The PDF file must contain a Table of Contents.

The Table of Contents must link to the beginning of each corresponding response section. A table of contents should accompany any attachments or an appendix with associated documentation.

h) Document File Naming Convention: The PDF File must include the following file name convention: Solicitation #, and Name of the

Bidder.

i) Confidential or Propriety Information: Bidder is responsible for marking and submitting proposal materials per Ocean State Procures

(OSP) requirements.

QLV27007040 – Agency Solicitation Specifications Page 14 of 36

1.3. Structure of Proposal

For each component of proposal, all elements must be addressed in the sequence as outlined in the table below. The Bidder shall structure its Minimum Qualifications, Executive Summary, Business Proposal, and Technical Proposal responses identifying each of the required elements separated by a section line header or page break with the following headings and numbering to match the corresponding Solicitation section below:

2. Minimum Qualifications Requirements

2.1 Managed Care Organization Status

2.2 Rhode Island Licensure

2.3 Exclusion Status

2.4 Capacity and Willingness to Perform

2.5 Relevant Operating Experience

2.6 Principal Place of Business

2.7 Accreditation

2.8 Formatting and Submission Requirements

3. Executive Summary Requirements

3.1 Summary of Proposal

4. Business Proposal Requirements

4.1 Bidder Profile

4.2 Attestations to Program Rules and Requirements

5. Technical Proposal Requirements

5.1 Organizational Qualifications and Experience

5.2 Covered Services and Proposed Benefits

5.3 Population Health and Care Management

5.4 Network Provider Access

5.5 Member Experience and Engagement

5.6 Quality Improvement and Outcomes

5.7 Operational Readiness

QLV27007040 – Agency Solicitation Specifications Page 15 of 36

2. Minimum Qualifications Requirements (No Page Limits) (Pass/Fail Scoring)

Proposals must meet all Minimum Qualifications to be considered for further review and possible award. There are no page limits for responses to Minimum Qualification requirements. The

Bidder’s responses to Minimum Qualification requirements will be assessed on a Pass/Fail basis.

No points will be awarded as a result of this review, but failure to meet one or more of the

Minimum Qualifications will eliminate a proposal from further consideration. EOHHS reserves the right to waive minor irregularities that would not provide one or more Bidders an advantage compared to other Bidders.

The Bidder must provide evidence of and/or acknowledge or attest to meeting the following

Minimum Qualifications:

2.1. Attestation that the Bidder’s submission complies with all formatting requirements outlined in this Solicitation.

2.2. Documentation verifying the Bidder meets the federal definition of a managed care organization (MCO) under 42 CFR 438.216, including:

2.2.1. Information to demonstrate that it is able to meet the solvency requirements set for through the Rhode Island Office of the Health Insurance Commissioner

(OHIC) and provide a description and/or evidence of financial solvency as a

Health Plan operating in Rhode Island or outside of Rhode Island; and

2.2.2. Attestation that the Bidder will adhere to all applicable statutory and regulatory provisions in 42 CFR Part 43817.

2.3. Provide either:

2.3.1. Documentation verifying Bidder operates as a health insurer licensed by the state of Rhode Island; or

2.3.2. For a Bidder that is not currently licensed in the state of Rhode Island, a detailed timeline for obtaining licensure no later than sixty (60) days after execution of the SMAC.

2.4. Documentation verifying that the Bidder is not an excluded individual or entity under 42

CFR 438.808(b)18.

2.5. Attestation that the Bidder has reviewed and comprehends the Solicitation objectives and affirms its capability and willingness to perform all functions in accordance with the

SMAC terms and conditions including meeting and exceeding performance standards and/or performance metrics, and consistent with Medicaid managed care requirements and Medicare requirements under 42 CFR 42219 and 42320.

2.6. Documentation verifying the Bidder (including a parent company, affiliate, or partner) has at least three (3) consecutive years of experience managing an array of medical, behavioral, and long-term services and support services covered by Medicaid and/or

16 42 CFR § 438.2 - https://www.ecfr.gov/current/title-42/section-438.2 17 42 CFR Part 438 - https://www.ecfr.gov/current/title-42/part-438 18 42 CFR § 438.808(b) - https://www.ecfr.gov/current/title-42/section-438.808 19 42 CFR Part 422 - https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-422 20 42 CFR Part 423 - https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-423 https://www.ecfr.gov/current/title-42/section-438.2 https://www.ecfr.gov/current/title-42/part-438 https://www.ecfr.gov/current/title-42/section-438.808 https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-422 https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-423

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Medicare; and served a minimum combined total of fifty thousand (50,000) Medicaid, Medicare, or Medicaid-like members in one (1) or more U.S. states or territories. For each, the Bidder must provide:

2.6.1. State/territory name;

2.6.2. Contract start date (and end date, if applicable);

2.6.3. Populations covered;

2.6.4. Enrollment;

2.6.5. Services covered;

2.6.6. Contact name, email address, and phone number; and

2.6.7. Source of experience (Bidder, parent company, affiliate, or partner).

2.7. Documentation verifying the Bidder’s principal place of business is located within the

United States.

2.8. Copies of all current Accreditation certifications to demonstrate Bidder is accredited by

NCQA as a Medicaid managed care organization in Rhode Island or, for a newly entering plan, is NCQA or URAC accredited in another state and an attestation that the Bidder will achieve full NCQA accreditation for Rhode Island Medicaid within twenty-four (24) months of the execution of the award under this Solicitation.

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3. Executive Summary Requirements (5 Page Limit) (Informational Only)

The Bidder’s response to the Executive Summary requirements will be reviewed for informational purposes only as specified in Section D: Evaluation and Selection. The Executive Summary is limited to five (5) pages total. Responses that exceed this page limit will not be reviewed.

The Bidder should provide a summary of the proposal that includes, at a minimum, the following information:

3.1. Bidder’s understanding of the services requested in the Solicitation and the problems presented;

3.2. Bidder’s familiarity with the program’s elements, population to be served, and the

Rhode Island healthcare, Medicaid, and Medicare systems at a national and state-level;

3.3. Bidder's capability to meet or exceed the requirements in the SMAC; and,

3.4. Areas the Bidder wishes to note as particularly innovative and demonstrative of the

Bidder's commitment to meaningfully participating in the Rhode Island FIDE-SNP

Program and in partnering with EOHHS to accomplish Program Goals in Section A.4 of this Solicitation.

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4. Business Proposal Requirements (5 Page Limit) (Pass/Fail Scoring)

The contents of the Bidder's Business Proposal are essential minimum business elements needed to ensure compliance with contract requirements. The Business Proposal response is limited to five

(5) pages; however, Bidders are encouraged to include relevant data, graphics, figures, tables etc.

as appropriate to supplement their response to the questions. Attachments, including graphics, flowcharts, diagrams, tables, sample materials, and any other items included as attachments, do not count toward the maximum page limit. The Business Proposal will be assessed on a Pass/Fail basis. Bidders failing to meet all requirements in this section will not be considered responsive, and their proposal will not progress to the Technical Proposal evaluation stage. Any proposal not satisfying all Business Proposal Requirements will be dismissed without undergoing the Technical

Proposal assessment by the Technical Evaluation Committee (TEC).

4.1. Bidder Profile

The Business Proposal shall include a Bidder Profile on the Bidder’s letterhead. The

Bidder Profile is exempt from style and branding requirements as specified in Section

1.2.2. The Bidder Profile should provide information that demonstrates how the Bidder meets minimum eligibility requirements and qualified Bidder attributes as outlined in this Solicitation and must include, at a minimum, the following information:

4.1.1. Bidder’s legal name and any doing business as (DBA)

4.1.2. Bidder’s corporate address

4.1.3. Bidder’s ownership status (e.g., publicly or privately held). If privately held, a statement listing name(s) and address(es) of the principal owners who hold more than five percent (5%) interest or more in the organization.

4.1.4. Bidder’s form of business (e.g., corporation, non-profit corporation, partnership, limited liability company)

4.1.5. Bidder’s federal and state taxpayer identification number

4.1.6. Individual authorized by Bidder to contractually obligate the Bidder (name, title, phone number, email address)

4.1.7. Whether Bidder proposes to use partners or subcontractors in the performance of the SMAC. If the Bidder proposes to use partners or subcontractors, provide: (1) name of each partner or subcontractor; (2) general scope of work; (3) approximate percent of total scope of work to be completed by the Bidder and each partner or subcontractor; and (4) geographical location where work will be performed (e.g., state) by the partner or subcontractor.

4.1.8. Bidder’s financial statements, including:

a) National Association of Insurance Commissioners (NAIC) Financial

Statements, including Risk Based Capital Reports;

b) Audited Financial Statements; and

c) Evidence that the parent company provides one hundred percent (100%) of subsidiary’s financial backing, where applicable.

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4.1.9. Description of how the Bidder satisfies Eligibility requirements contained in

Section A: Background (6.1) of this Solicitation.

4.1.10. Description of how the Bidder has met or will meet the attributes of a qualified

Bidder as described in Section A: Background (6.3) of this Solicitation.

4.1.11. A high-level description of the Bidder’s organization, including an organizational chart to reflect overall reporting structure for the delivery of services requested in this Solicitation and the SMAC as well as a description of the Bidder’s administrative capacity and capabilities and readiness to carry out all duties and responsibilities under this Solicitation, including the SMAC and “FIDE-SNP

Manual.” The Bidder’s description and/or organizational chart should indicate the personnel and functions that will operate within the state of Rhode Island as required in the SMAC.

4.1.12. Provide a provider network summary table for the FIDE-SNP service area with the following categories:

a) Primary Care Providers

b) Specialists (by key specialty)

c) Behavioral Health Providers (outpatient MH, SUD)

d) LTSS Providers (home health, personal care, adult day, nursing facility)

e) Pharmacy

f) DME

For each of the categories, provide: (a) count of contracted or letters of intent

(LOI) committed providers; (b) name(s) of provider(s); and (c) geographical location (city, state) of provider(s).

4.2. Attestations to Program Rules and Requirements

The Bidder shall submit an attestation signed by the owner, officer, or other authorized personnel of the Bidder or organization, including a statement that the Bidder has read, understands, acknowledges, and accepts the terms and conditions of this Solicitation. The attestation must include the following elements to be responsive to this section:

4.2.1. Bidder has thorough understanding of Rhode Island FIDE-SNP Program and the

Rhode Island health care environment;

4.2.2. Bidder has reviewed and comprehends the Solicitation objectives and affirms its capability to perform in accordance with the SMAC terms and conditions including meeting and exceeding performance standards and/or performance metrics;

4.2.3. Bidder acknowledges and understands the risks involved in the Rhode Island

FIDE-SNP Program as described in the Solicitation, including the risk of non-appropriation of funds;

4.2.4. Bidder attests to the accuracy and truthfulness of all information contained in the

Bidder’s responses to the Solicitation;

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4.2.5. Bidder is in good standing with, and has not been debarred from, participation in any Federal or Federal/State health care programs, including Medicare, CHIP, and any state Medicaid program;

4.2.6. Bidder agrees to enter into a Medicare Advantage agreement with CMS to provide a Medicare Advantage Special Needs Plan (SNP) that arranges for the provision of Medicare services for individuals who are dually eligible. The Bidder shall execute a statewide Medicaid managed care plan agreement to be eligible to obtain State authorization to operate a FIDE-SNP;

4.2.7. Bidder agrees to submit CY 2028 Notice of Intent to Apply (NOIA) documentation indicating the Bidder will offer a D-SNP only H-contract in the state of Rhode Island; and

4.2.8. Bidder has no moral or religious objections to providing any of the Covered

Benefits described in the Solicitation. If the Bidder does have any moral or religious objections under any of the benefits contained within the SMAC, the statement must describe, in as much detail as possible, all direct and related services that are objectionable. It must include a listing of the codes impacted including but not limited to CPT codes, HCPCS codes, diagnosis codes, revenue codes, modifier codes, etc. If there are none, it must so state.

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5. Technical Proposal Requirements (85 Page Limit) (Point Value)

The Bidder’s response to each of the following Technical Proposal requirements (Sections 5.1 –

5.7) will receive a numerical score as identified in Section D: Evaluation and Selection. The

Technical Proposal response is limited to 85 pages; however, Bidders are encouraged to include relevant data, graphics, figures, tables etc. as appropriate to supplement their response to the question. Attachments, including graphics, flowcharts, diagrams, tables, sample materials, and any other items included as attachments, do not count toward the maximum page limit.

5.1 Organizational Qualifications and Experience (5 Page Limit) (20 points)

5.1.1 Identify up to five (5) Medicaid contracts that the Bidder (or parent company, affiliate, or partner) has operated within the last five (5) years that are of similar size and scope to the requirements outlined in this Solicitation. For each, complete the table below and provide:

Contract Reference Number 1 2 3 4 5

State Name

Contract start date (and end date, if applicable)

Populations covered

Enrollment

Names of partner organizations supporting contracts (if applicable)

Contact name, email address, and phone number

5.1.2 Identify all States in which the Bidder (or parent company, affiliate, or partner) has operated a D-SNP within the past five (5) years. For each, provide:

a) State name;

b) Type (FIDE-SNP, HIDE-SNP, CO D-SNP);

c) Contract number (H-number);

d) Plan benefit package (PBP) number;

e) Dual-eligible enrollment;

f) Contract start date (and end date, if applicable); and

g) Most recent NCQA Model of Care score.

5.1.3 Provide a detailed description of the Bidder’s experience as a D-SNP in Rhode

Island and a workplan for how it will obtain CMS approval to operate a D-SNP only contract in Rhode Island by the timeline outlined in the SMAC.

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5.1.4 Identify and describe all instances of noncompliance issued to the Bidder, its parent company/organization, proposed partner(s), and affiliates under any

Medicaid managed care contracts within the past five (5) years. For each instance, provide:

a) Type of non-compliance

b) Date issued;

c) Reason issued;

d) Issuing agency; and

e) Sanction or enforcement action, including whether the matter is resolved.

A finding should be classified using the official action taken by the issuing agency, not the Bidder's characterization. For purposes of responding to this section, types of non-compliance include: compliance letters (Warning Letters, Notices of

Non-Compliance, Corrective Action Plans (CAPs) or similar state notices);

liquidated damages; enrollment suspensions; adverse performance audits

(contracts failing more than fifty-percent (50%) of audit elements; adverse financial audits (adverse opinions or disclaimed reports); failures to maintain fiscally sound operations (negative net worth or financial loss greater than half of the Bidder’s total net worth); exclusions enforcement actions (imposed by CMS as an intermediate sanction); and all other significant compliance concerns.

5.1.5 Disclose all CMS Medicare sanctions or enforcement actions against any of the

D-SNPs or MA plans offered by the Bidder, its parent company/organization, proposed partner(s), and affiliates within the past five (5) years. Response should disclose all CMS audit findings, notice of non-compliance letters, warning letters, corrective action plans (CAPs), civil monetary penalties (CMPs), enrollment sanctions, or other enforcement actions issued against any of the Bidder’s MA contracts. For each, provide: (a) contract number; (b) nature of finding/action; (c) date issued and resolved; (d) current status (resolved/unresolved).

5.1.6 Disclose all noncompliance of Material subcontractors to the Bidder’s Proposal in the past five (5) years. For each non-compliance issued, the Bidder shall indicate: (a) the type of non-compliance issued; (b) the date the non-compliance was issued and resolved; (c) the reason the non-compliance was issued; (d) the issuing agency in which the subcontractor was providing services for which the non-compliance was issued; and (e) any and all details of the sanctions applied against the subcontractor as a result of non-compliance.

5.1.7 Identify all instances of non-renewal or early termination of Medicaid or

Medicare contracts within the past ten (10) years. The Bidder shall specify: (a) the type of contract; (b) why the termination was initiated; and (c) by whom it was initiated (Bidder, state, mutual, or federally imposed). Where available, include the termination notice or other documentary evidence supporting the stated reason.

5.2 Covered Services and Proposed Benefits (12 Page Limit) (15 points)

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5.2.1 Describe the Bidder’s proposed approach and innovative strategies to meet or exceed the minimum SMAC requirements serving dual-eligible beneficiaries, specifically describing the Bidder’s experience with and/or approach to implementing and overseeing a comprehensive LTSS service array in accordance with the requirements outlined in the SMAC. Response should include:

a) Description of the Bidder’s experience administering nursing facility benefits and home and community-based services (HCBS), including waiver services;

b) Challenges/lessons learned from recent experience; and

c) Innovative strategies the Bidder has successfully implemented, the impact of those strategies, and how these would inform the Bidder's proposed approach.

5.2.2 Describe the Bidder’s commitment to offering Medicaid value-added services and any proposed value-added services the Bidder expects to offer under this program (e.g., covering Part D copays for enrollees). For each service proposed, provide:

a) Description of the service(s), including information on who would be eligible to receive the service, and the proposed timeframe for implementation.

b) Description of the expected impact in terms of cost savings, and perceived qualitative value of the service(s).

5.2.3 Describe the Bidder’s commitment to offering the pre-approved in-lieu of services (ILOS) currently listed in the SMAC, Exhibit F-4.4. If applicable, Bidder should provide:

a) Proposed timeline for implementation of pre-approved ILOS

b) Description of any additional ILOS(s) the Bidder proposes, including (a) information on what service each proposed additional ILOS is being offered in place of; (b) Bidder’s relevant experience providing this service in other states; (c) perceived qualitative and quantitative value of the service(s); (d)

Bidder’s proposed method(s) of education to providers regarding offering this service; and (e) proposed method(s) of outreach to increase member awareness and utilization of the service.

5.2.4 Describe the Bidder’s commitment to offering Medicare supplemental benefits.

For each service the Bidder proposes, provide a description of the service(s). The

Bidder must provide attestation that the Bidder understands the state may mandate the Bidder to offer Medicare supplemental benefits at a later date, and the

Bidder’s commitment to offer such additional Medicare supplemental benefits as directed by the state.

5.3 Population Health and Care Management (25 Page Limit) (20 points)

5.3.1 Describe the Bidder's approach…