New Member Selection Freezes. Notwithstanding any other penalty or point assessment that ODJFS may impose on the MCP under this Appendix, ODJFS may prohibit an MCP from receiving new membership through consumer initiated selection or the assignment process if: (1) the MCP has accumulated a total of 51 or more points during a rolling 12-month period; (2) or the MCP fails to fully implement a CAP within the designated time frame; or (3) circumstances exist which potentially jeopardize the MCP’s members’ access to care. [Examples of circumstances that ODJFS may consider as jeopardizing member access to care include: - the MCP has been found by ODJFS to be noncompliant with the prompt payment or the non-contracting provider payment requirements; - the MCP has been found by ODJFS to be noncompliant with the provider panel requirements specified in Appendix H of the Agreement; - the MCP’s refusal to comply with a program requirement after ODJFS has directed the MCP to comply with the specific program requirement; or - the MCP has received notice of proposed or implemented adverse action by the Ohio Department of Insurance.] Payments provided for under the Agreement will be denied for new enrollees, when and for so long as, payments for those enrollees are denied by CMS in accordance with the requirements in 42 CFR 438.730.
Appears in 5 contracts
Samples: Ohio Medical Assistance Provider Agreement for Managed Care Plan (Wellcare Health Plans, Inc.), Provider Agreement (Wellcare Health Plans, Inc.), Ohio Medical Assistance Provider Agreement for Managed Care Plan (Wellcare Health Plans, Inc.)
New Member Selection Freezes. Notwithstanding any other penalty or point assessment that ODJFS may impose on the MCP under this Appendix, ODJFS may prohibit an MCP from receiving new membership through consumer initiated selection or the assignment process if: (1) the MCP has accumulated a total of 51 or more points during a rolling 12-month period; (2) or the MCP fails to fully implement a CAP within the designated time frame; or (3) circumstances exist which potentially jeopardize the MCP’s members’ access to care. [Examples of circumstances that ODJFS may consider as jeopardizing member access to care include: - • the MCP has been found by ODJFS to be noncompliant with the prompt payment or the non-contracting provider payment requirements; - • the MCP has been found by ODJFS to be noncompliant with the provider panel requirements specified in Appendix H of the Agreement; - • the MCP’s refusal to comply with a program requirement after ODJFS has directed the MCP to comply with the specific program requirement; or - • the MCP has received notice of proposed or implemented adverse action by the Ohio Department of Insurance.] Payments provided for under the Agreement will be denied for new enrollees, when and Appendix N Page 6 for so long as, payments for those enrollees are denied by CMS in accordance with the requirements in 42 CFR 438.730.
Appears in 1 contract
Samples: Ohio Medical Assistance Provider Agreement for Managed Care Plan (Molina Healthcare Inc)
