Specifications include, but are not limited to: EOHHS is soliciting competitive, responsive proposals from experienced and financially sound organizations to perform as its certifying actuary. EOHHS requires the services of an actuary to establish and certify rates paid to managed care providers contracted with the Medicaid program. These rates must be developed in accordance with all applicable federal and state regulations, sub regulatory guidance, and the generally accepted practices promulgated by the Actuarial Standards Board. This includes the requirements at 42 CFR 438.4 (4) , the Medicaid and CHIP Managed Care Final Rules from 2016 and 2020 (CMS-2390-F (5) and CMS-2408-F (6)), and the applicable version of CMS’s Medicaid Managed Care Rate Development Guide (7) . The selected vendor will be expected to have advanced financial analytics and systems capacity, with established processes for receiving, loading, transforming, analyzing, and reporting on Medicaid claims, enrollment, and eligibility data provided to the vendor by the State. In addition, the selected vendor will be required to develop standardized quarterly financial reporting templates to capture total revenues and expenses for each health plan, inclusive of non-benefit and nonencounterable medical expenses. Quarterly, the selected vendor will work with State staff to reconcile managed care encounter data to encounterable claims reported in this financial report to identify areas of corrective action. Additionally, the vendor will participate in regular cross functional meetings with EOHHS finance and analytics staff to discuss any issues related to the monthly claims extract.
