Actuarial Services

2026-11-03

Scope of Work Summary of Scope The Idaho Department of Health and Welfare ( DHW ) is seeking the services of an Actuary to provide services for new and existing managed care organization ( MCO ) programs identified by the DHW , in accordance with the specifications in this Exhibit . Budgetary Expectations DHW current has a two point two million dollar ($ 2 . 2M ) appropriation for Actuarial Services within each State Fiscal Year ( SFY ). Schedule & Term Expectations The term of this Contract will be for one ( 1 ) year . Upon mutual , written agreement , the Contract may be renewed , extended or amended . The anticipated total Contract term is five ( 5 ) years . Idaho Department of Health and Welfare ( DHW ) Responsibilities DHW will provide the Contractor with monthly Medicaid utilization data in excel format or other extract methods mutually agreed upon by the Contractor and DHW . DHW will submit all rate certifications , waivers , State Plan Amendments ( SPAs ), or other federal deliverables to the Centers for Medicare & Medicaid Services ( CMS ). Contractor Requirements The Contractor must comply with all provisions of state and federal laws , rules , regulations , policies , and guidelines as amended or modified that govern performance of the services of this Contract . The Contractor must complete actuarial services for new and existing managed care organization ( MCO ) programs identified by DHW . The Contractor must : Complete annual actuarial soundness testing for an estimated population of three hundred forty - five thousand four hundred and twenty - eight ( 345 , 428 ) for the following managed care population : Medicare – Medicaid Coordinated Plan ; Idaho Medicaid Plus Plan ; Basic and Enhanced Benchmark dental plans ; Idaho Behavioral Health Plan ( IBHP ); Basic and Enhanced Benchmark plans group eligibility classes for future Medicaid managed care plan ; Non - emergency medical transportation plans ; Comprehensive managed care program as directed by Idaho Legislatures 2025 House Bill 345 ( H345 ) to include up to three ( 3 ) managed care providers ; and Other Medicaid capitation services as requested by DHW . Develop , set , and certify actuarially sound capitation rates for all MCO programs for each rate year . Rates must meet actuarial standards subject to the actuarial soundness requirements in the Code of Federal Regulations ( CFR ), specifically 42 CFR § 438 . Capitation rates must be developed based on factual data and may be developed by line of business . Rates must be certified by a date specified by DHW but no less than once annually . This work includes the following : Develop the managed care cohorts and capitation rates using a variety of parameters including recipients ’ age , gender , category of eligibility , level of care , and geographic locations . Identify medical service utilization patterns by category of service and medical and administrative cost profiles for all managed care cohorts and major lines of business . Calculate actuarially sound capitation rate cells in accordance with the CMS rate setting checklist guidance and Medicaid managed care rules . Analyze financial data of the managed care plan ( s ) with a focus on relevant issues affecting capitation rate development . Analyze programmatic changes effective for the rate year to inform adjustment factors to be applied to existing or pending rate cells . Analyze state or federal policy changes effective for the rate year to inform adjustment factors to be applied to existing or pending rate cells . Analyze applicability of risk mitigation factors and calculated related settlements where applicable and as approved . Analyze applicability of rate parity . Verify the accuracy of the health plan ’ s network adequacy reporting to inform rates . Complete and provide mid - year rate adjustments as directed by DHW . Participate in periodic meetings with DHW to discuss the parameters , priorities , methodology , and ongoing results of managed care capitation rate development in each rate cycle . Provide projected rates for three ( 3 ) MCOs for comprehensive managed care within six ( 6 ) months of execution of this Contract . The MCOs will be identified by DHW after Contract execution . Ensure that the methodology used to develop overall rate and rate components is clear and can be easily comprehended by DHW , MCOs , and other outside entities . State Directed Payments ( SDP ) Develop SDP programs for all MCO programs . This includes : The transition of existing value - based payment programs , non - risk - based payments , and supplemental payment programs into a new SDP for hospitals , nursing facilities , intermittent care facilities , ground emergency medical transportation providers , and graduate medical education . The development of new SDP programs including value - based payments , minimum fee schedules , maximum fee schedules , and uniform rate adjustments .

Idaho

2026-05-11