Common use of Primary Care Physicians (PCPs) Clause in Contracts

Primary Care Physicians (PCPs). Primary Care Physicians (PCPs) may be individuals or group practices/clinics. Generally acceptable specialty types for PCPs are family/general practice, internal medicine, pediatrics and obstetrics/gynecology. (ODJFS reserves the right to request verification of a physician’s specialty type.) As part of their subcontract with an MCP, PCPs must stipulate the total Medicaid member capacity that they can ensure for that individual MCP. Each PCP must have the capacity and agree to serve at least 50 Medicaid members at each practice site in order to be approved by ODJFS as a PCP and included in the MCP's total PCP capacity calculation. The capacity by site requirement must be met for all ODJFS- approved PCPs. A PCP’s total capacity number may reflect the support the provider receives from residents, nurse practitioners, physician assistants, etc. For example, a PCP in private practice with no assistants might state that they have the capacity to serve 1000 members for an MCP. A PCP with assistants, however, might state that they are able to see up to 2500 members for an MCP. ODJFS reviews the capacity totals for each PCP to determine if they appear excessive. ODJFS reserves the right to request clarification from an MCP for any PCP whose total stated capacity for all MCP networks added together exceeds 2000 Medicaid members [i.e., 1 full-time equivalent (FTE)]. ODJFS may also compare a PCP’s capacity against the number of members assigned to that PCP, and/or the number of patient encounters attributed to that PCP to determine if the reported capacity number reasonably reflects a PCP’s expected caseload for a specific MCP. Where indicated, ODJFS may set a cap on the maximum amount of capacity that will be approved for a specific PCP. For PCPs contracting with more than one MCP, the MCP must ensure that the capacity figure stated by the PCP in their subcontract reflects only the capacity the PCP intends to provide for that one MCP. ODJFS utilizes each approved PCP’s capacity figure to determine if an MCP meets the minimum provider panel requirements and this stated capacity figure does not prohibit a PCP from actually having a caseload that exceeds the capacity figure indicated in their subcontract. ODJFS expects, however, that MCPs will need to utilize specialty physicians to serve as PCPs for some special needs members. Also, in some situations (e.g., continuity of care) a PCP may only want to serve a very small number of members for an MCP. In these situations it will not be necessary for the MCP to submit these PCPs to ODJFS for prior approval. These PCPs will not be included in the ODJFS PVS database and therefore may not appear as PCPs in the MCP’s provider directory. Also, no PCP capacity will be counted for these providers. These PCPs will, however, need to execute a subcontract with the MCP which includes the appropriate Model Medicaid Addendum. In order to determine if adequate PCP FTE capacity exists for each service area, ODJFS will total each MCP's approvable PCP FTEs for each service area (this would include both PCPs with practice sites located within that service area and PCP practice sites located in nearby counties which have been designated as alternate provider areas by ODJFS) and apply the following criteria: Number of Eligibles/County Minimum PCP Capacity (% Eligibles) >100,000 40%* <100,000 50%* * the minimum PCP capacity requirement is higher for Preferred Option counties (For example, WeCare MCP has a PCP FTE capacity of 19.5 for Service Area X. Service Area X has a population of 75,000 eligible recipients. 50% of 75,000 equals 37,500. 37,500 divided by 2000 equals 18.75. In that WeCare has a minimum PCP capacity of 19.5 FTEs for Service Area X and only is required to have a PCP capacity of 18.75 FTEs, ODJFS would find that WeCare MCP has sufficient PCP capacity to serve Service Area X.) At a minimum, each MCP must meet both the PCP minimum FTE requirement for that service area, as well as a minimum ratio of one PCP FTE for each 2,000 of their Medicaid members in that service area. When alternate provider areas are designated, there continues to be a minimum PCP capacity requirement which must be met by the MCP’s PCPs within the service area itself. The discretionary PCP FTE figure represents the maximum amount of PCP capacity that may be met in a designated alternate provider area. The minimum PCP provider panel requirements are specified in the charts in Section H of this appendix. Except in voluntary enrollment counties, all MCPs meeting the minimum PCP provider panel requirement must also satisfy a PCP geographic accessibility standard before they will receive a provider agreement for a specific service area. This standard must be maintained in each service area for the duration of the contract. ODJFS will match the PCP practice sites with the geographic location of the eligible population in that service area and perform analysis using Geographic Information Systems (GIS) software. The analysis will be used to determine if at least 40% of the eligible population are located within 10 miles of an MCP’s in-area or alternate provider area PCP provider site with PCP capacity taken into consideration. In addition to the PCP FTE capacity requirement, MCPs must also contract with the specified number of pediatric PCPs for each service area. These must be pediatricians who maintain a general pediatric practice (e.g., a pediatric neurologist would not meet this definition unless this physician also operated a practice as a general pediatrician) at a site(s) located within the service area or an alternate provider area, and be listed as a pediatrician with the Ohio State Medical Board. In addition, a designated number of these physicians must also be certified by the American Board of Pediatrics. The minimum provider panel requirements for pediatricians are included in specialty provider charts in Section H of this appendix.

Primary Care Physicians (PCPs). Primary Care Physicians (PCPs) may be individuals or group practices/clinicsclinics [Primary Care Clinics (PCCs)]. Generally acceptable Acceptable specialty types for PCPs are family/general practice, internal medicine, pediatrics and obstetrics/gynecologygynecology(OB/GYNs). (ODJFS reserves Acceptable PCCs include FQHCs, RHCs and the right to request verification of a physician’s specialty type.) acceptable group practices/clinics specified by ODJFS. As part of their subcontract with an MCP, PCPs must stipulate the total Medicaid member capacity that they can ensure for that individual MCP. Each PCP must have the capacity and agree to serve at least 50 Medicaid members at each practice site in order to be approved by ODJFS as a PCP PCP, and to be included in the MCP's total PCP capacity calculation. The capacity by capacity-by-site requirement must be met for all ODJFS- ODJFS-approved PCPs. A PCP’s total In determining whether an MCP has sufficient PCP capacity number may reflect the support the provider receives from residentsfor a region, nurse practitioners, ODJFS considers a physician assistants, etc. For example, who can serve as a PCP in private practice with no assistants might state that they have the capacity to serve 1000 for 2000 Medicaid MCP members for an MCP. A PCP with assistants, however, might state that they are able to see up to 2500 members for an MCPas one full-time equivalent (FTE). ODJFS reviews the capacity totals for each PCP to determine if they appear excessive. ODJFS reserves the right to request clarification from an MCP for any PCP whose total stated capacity for all MCP networks added together exceeds 2000 Medicaid members [(i.e., 1 full-time equivalent (FTE)]. ODJFS may also compare a PCP’s 's capacity against the number of members assigned to that PCP, and/or the number of patient encounters attributed to that PCP to determine if the reported capacity number reasonably reflects a PCP’s 's expected caseload for a specific MCP. Where indicated, ODJFS may set a cap on the maximum amount of capacity that we will be approved recognize for a specific PCP. ODJFS may allow up to an additional 750 member capacity for each nurse practitioner or physician's assistant that is used to provide clinical support for a PCP. For PCPs contracting with more than one MCP, the MCP must ensure that the capacity figure stated by the PCP in their subcontract reflects only the capacity the PCP intends to provide for that one MCP. ODJFS utilizes each approved PCP’s 's capacity figure to determine if an MCP meets the minimum provider panel requirements and this stated capacity figure does not prohibit a PCP from actually having a caseload that exceeds the capacity figure indicated in their subcontract. ODJFS expects, however, recognizes that MCPs will need to utilize specialty physicians to serve as PCPs for some special needs members. Also, . in some situations (e.g., e.g.. continuity of care) a PCP may only want to serve a very small number of members for an MCP. In these situations it will not be necessary for the MCP to submit these PCPs to ODJFS for prior approval. These PCPs will not be included in the ODJFS PVS database and therefore may not appear as PCPs in the MCP’s 's provider directory. Also, no PCP capacity will be counted for these providers. These PCPs will, however, need to execute a subcontract with the MCP which includes the appropriate Model Medicaid Addendum. In order to determine if adequate The PCP FTE capacity exists for each service area, ODJFS will total each MCP's approvable PCP FTEs for each service area (this would include both PCPs with practice sites located within that service area and PCP practice sites located in nearby counties which have been designated as alternate provider areas by ODJFS) and apply the following criteria: Number of Eligibles/County Minimum PCP Capacity (% Eligibles) >100,000 40%* <100,000 50%* * the minimum PCP capacity requirement is higher for Preferred Option counties (For example, WeCare based on an MCP has a PCP FTE capacity of 19.5 for Service Area X. Service Area X has a population of 75,000 eligible recipients. 50% of 75,000 equals 37,500. 37,500 divided by 2000 equals 18.75. In that WeCare has a minimum PCP capacity of 19.5 FTEs for Service Area X and only is required to have a PCP capacity of 18.75 FTEs, ODJFS would find that WeCare MCP has having sufficient PCP capacity to serve Service Area X.) 55% of the eligibles in the region. At a minimuma, each MCP must meet both the PCP minimum FTE requirement for that service arearegion, as well as and a minimum ratio of one PCP FTE for each 2,000 of their Medicaid members in that service arearegion. When alternate provider areas are designated, there continues to be a minimum PCP capacity requirement which must be met by the MCP’s PCPs within the service area itself. The discretionary PCP FTE figure represents the maximum amount of PCP capacity that may be met in a designated alternate provider area. The minimum PCP provider panel requirements are specified in the charts in Section H of this appendix. Except in voluntary enrollment counties, all MCPs meeting the minimum PCP provider panel requirement must also satisfy a PCP geographic accessibility standard before they will receive a provider agreement for a specific service area. This standard must be maintained in each service area for the duration of the contractstandard. ODJFS will match the PCP practice sites and the stated PCP capacity with the geographic location of the eligible population in that service area region (on a county-specific basis) and perform analysis using Geographic Information Systems (GIS) software. The analysis will be used to determine if at least 40% of the eligible population are is located within 10 miles of an MCP’s in-area or alternate provider area PCP provider site with available capacity in urban counties and 40% of the eligible population within 30 miles of a PCP with available capacity taken into considerationin rural counties. [Rural areas are defined pursuant to 42 CFR 412.62(f)(l)(iii).] In addition to the PCP FTE capacity requirement, . MCPs must also contract with the specified number of pediatric ofpediatric PCPs for each service arearegion. These pediatric PCPs will have their stated capacity counted toward the PCP FTE requirement. A pediatric PCP must be pediatricians who maintain a general pediatric practice (e.g., a pediatric neurologist would not meet this definition unless this physician also operated a practice as a general pediatrician) at a site(s) located within the service area or an alternate provider area, county/region and be listed as a pediatrician with the Ohio State Medical Board. In addition, a designated half of the required number of these physicians ofpediatric PCPs must also be certified Appendix H by the American Board of Pediatrics. The minimum provider panel requirements for pediatricians are included in specialty provider the practitioner charts in Section H of this appendix.

Primary Care Physicians (PCPs). Primary Care Physicians (PCPs) may be individuals or group practices/clinicsclinics [Primary Care Clinics (PCCs)]. Generally acceptable Acceptable specialty types for PCPs are family/general practice, and internal medicine. Acceptable PCCs include FQHCs, pediatrics RHCs and obstetricsthe acceptable group practices/gynecologyclinics specified by ODJFS. (ODJFS reserves the right to request verification of a physician’s specialty type.) As part of their subcontract with an MCP, PCPs must stipulate the total Medicaid member capacity that they can ensure for that individual MCP. Each PCP must have the capacity and agree to serve at least 50 Medicaid members at each practice site in order to be approved by ODJFS as a PCP and included in the MCP's total PCP capacity calculationPCP. The capacity by capacity-by-site requirement must be met for all ODJFS- ODJFS-approved PCPs. A PCP’s total capacity number may reflect the support the provider receives from residents, nurse practitioners, physician assistants, etc. For example, a PCP in private practice with no assistants might state that they have the capacity to serve 1000 members for an MCP. A PCP with assistants, however, might state that they are able to see up to 2500 members for an MCP. ODJFS reviews the capacity totals for each PCP to determine if they appear excessive. ODJFS reserves the right to request clarification from an MCP for any PCP whose total stated Appendix H Aged, Blind or Disabled (ABD) population Page 3 capacity for all MCP networks added together exceeds 2000 Medicaid members [(i.e., 1 full-time equivalent (FTE)]. ODJFS may also compare a PCPallow up to an additional 750 member capacity for each nurse practitioner or physician’s capacity against the number of members assigned assistant that is used to that PCP, and/or the number of patient encounters attributed to that PCP to determine if the reported capacity number reasonably reflects a PCP’s expected caseload provide clinical support for a specific MCP. Where indicated, ODJFS may set a cap on the maximum amount of capacity that will be approved for a specific PCP. For PCPs contracting with more than one MCP, the MCP must ensure that the capacity figure stated by the PCP in their subcontract reflects only the capacity the PCP intends to provide for that one MCP. ODJFS utilizes each approved PCP’s capacity figure to determine if an MCP meets the minimum provider panel requirements and this stated capacity figure does not prohibit a PCP from actually having a caseload that exceeds the capacity figure indicated in their subcontract. ODJFS expects, however, expects that MCPs will need to utilize specialty physicians to serve as PCPs for some special needs members. In these situations it will not be necessary for the MCP to submit these specialists to the PVS database as PCPs, however, they must be submitted to PVS as the appropriate required provider type. Also, in some situations (e.g., continuity of care) a PCP may only want to serve a very small number of members for an MCP. In these situations it will not be necessary for the MCP to submit these PCPs to ODJFS for prior approval. These PCPs will not be included in the ODJFS PVS database and therefore may not appear as PCPs in the MCP’s provider directory. Also, no PCP capacity will be counted for these providers. These PCPs will, however, need to execute a subcontract with the MCP which includes the appropriate Model Medicaid Addendum. In order to determine if adequate The PCP FTE capacity exists for each service area, ODJFS will total each MCP's approvable PCP FTEs for each service area (this would include both PCPs with practice sites located within that service area and PCP practice sites located in nearby counties which have been designated as alternate provider areas by ODJFS) and apply the following criteria: Number of Eligibles/County Minimum PCP Capacity (% Eligibles) >100,000 40%* <100,000 50%* * the minimum PCP capacity requirement is higher for Preferred Option counties (For example, WeCare based on an MCP has a PCP FTE capacity of 19.5 for Service Area X. Service Area X has a population of 75,000 eligible recipients. 50% of 75,000 equals 37,500. 37,500 divided by 2000 equals 18.75. In that WeCare has a minimum PCP capacity of 19.5 FTEs for Service Area X and only is required to have a PCP capacity of 18.75 FTEs, ODJFS would find that WeCare MCP has having sufficient PCP capacity to serve Service Area X.) At a minimum, each 40% of the eligibles in the region if three MCPs are serving the region and 55% of the eligibles in the region if two MCPs are serving the region. Each MCP must meet both the PCP minimum FTE requirement for that service area, as well as a minimum ratio of one PCP FTE for each 2,000 of their Medicaid members in that service arearegion. When alternate provider areas are designated, there continues to be a minimum PCP capacity requirement which must be met by the MCP’s PCPs within the service area itself. The discretionary PCP FTE figure represents the maximum amount of PCP capacity that may be met in a designated alternate provider area. The minimum PCP provider panel requirements are specified in the charts in Section H of this appendix. Except in voluntary enrollment counties, all MCPs meeting the minimum PCP provider panel requirement must also satisfy a PCP geographic accessibility standard before they will receive a provider agreement for a specific service area. This standard must be maintained in each service area for the duration of the contractstandard. ODJFS will match the PCP practice sites and the stated PCP capacity with the geographic location of the eligible population in that service area region (on a county-specific basis) and perform analysis using Geographic Information Systems (GIS) software. The analysis will be used to determine if at least 40% of the eligible population are is located within 10 miles of an MCP’s in-area or alternate provider area a PCP provider site with available capacity in urban counties and 40% of the eligible population within 30 miles of a PCP with available capacity taken into considerationin rural counties. In addition [Rural areas are defined pursuant to the PCP FTE capacity requirement, MCPs must also contract with the specified number of pediatric PCPs for each service area. These must be pediatricians who maintain a general pediatric practice (e.g., a pediatric neurologist would not meet this definition unless this physician also operated a practice as a general pediatrician) at a site(s) located within the service area or an alternate provider area, and be listed as a pediatrician with the Ohio State Medical Board. In addition, a designated number of these physicians must also be certified by the American Board of Pediatrics. The minimum provider panel requirements for pediatricians are included in specialty provider charts in Section H of this appendix42 CFR 412.62(f)(1)(iii).]

Primary Care Physicians (PCPs). Primary Care Physicians (PCPs) may be individuals or group practices/clinicsclinics [Primary Care Clinics (PCCs)]. Generally acceptable Acceptable specialty types for PCPs are family/general practice, internal medicine, pediatrics and obstetrics/gynecologygynecology(OB/GYMs). (ODJFS reserves the right to request verification of a physician’s specialty type.) As part of their subcontract with w'ith an MCP, PCPs must stipulate the total Medicaid member capacity that they can ensure for that individual MCP. Each PCP must have the capacity and agree to serve at least 50 Medicaid members at each practice site in order to be approved by ODJFS as a PCP PCP. and to be included in the MCP's total PCP capacity calculation. The capacity by capacity-by-site requirement must be met for all ODJFS- ODJFS-approved PCPs. A PCP’s total Appendix H In determining whether an MCP has sufficient PCP capacity number may reflect the support the provider receives from residentsfor a region, nurse practitioners, ODJFS considers a physician assistants, etc. For example, who can serve as a PCP in private practice with no assistants might state that they have the capacity to serve 1000 for 2000 Medicaid MCP members for an MCP. A PCP with assistants, however, might state that they are able to see up to 2500 members for an MCPas one full-time equivalent (FTE). ODJFS reviews the capacity totals for each PCP to determine if they appear excessive. ODJFS reserves the right to request clarification from an MCP for any PCP whose total stated capacity for all MCP networks added together exceeds 2000 Medicaid members [(i.e., 1 full-time equivalent (FTE)]. ODJFS may also compare a PCP’s 's capacity against the number of members assigned to that PCP, . and/or the number of patient encounters attributed to that PCP to determine if the reported capacity number reasonably reflects a PCP’s 's expected caseload for a specific MCP. Where indicated, ODJFS may set a cap on the maximum amount of capacity that we will be approved recognize for a specific PCP. ODJFS will allow up to an additional 750 member capacity for each nurse practitioner or physician's assistant that is used to provide clinical support for a PCP. For PCPs contracting with more than one MCP, . the MCP must ensure that the capacity figure stated by the PCP in their subcontract reflects only the capacity the PCP intends to provide for that one MCP. ODJFS utilizes each approved PCP’s 's capacity figure to determine if an MCP meets the minimum provider panel requirements and this stated capacity figure does not prohibit a PCP from actually having a caseload that exceeds the capacity figure indicated in their subcontract. ODJFS expects, however, expects that MCPs will need to utilize specialty physicians to serve as PCPs for some special needs members. Also, . in some situations (e.g., e.g.. continuity of care) a PCP may only want to serve a very small number of members for an MCP. In these situations it will not be necessary for the MCP to submit these PCPs to ODJFS for prior approval. These PCPs will not be included in the ODJFS PVS database and therefore may not appear as PCPs in the MCP’s 's provider directory. Also, no PCP capacity will be counted for these providers. These PCPs will, however, need to execute a subcontract with the MCP which includes the appropriate Model Medicaid Addendum. In order to determine if adequate PCP FTE capacity exists for each service area, ODJFS will total each MCP's approvable PCP FTEs for each service area (this would include both PCPs with practice sites located within that service area and PCP practice sites located in nearby counties which have been designated as alternate provider areas by ODJFS) and apply the following criteria: Number of Eligibles/County Minimum PCP Capacity (% Eligibles) >100,000 40%* <100,000 50%* * the The minimum PCP capacity requirement is higher for Preferred Option counties (For example, WeCare based on an MCP has a PCP FTE capacity of 19.5 for Service Area X. Service Area X has a population of 75,000 eligible recipients. 50% of 75,000 equals 37,500. 37,500 divided by 2000 equals 18.75. In that WeCare has a minimum PCP capacity of 19.5 FTEs for Service Area X and only is required to have a PCP capacity of 18.75 FTEs, ODJFS would find that WeCare MCP has having sufficient PCP capacity to serve Service Area X.) 55% of the eligibles in the region. At a minimum, each MCP must meet both the PCP minimum FTE requirement for that service arearegion, as well as and a minimum ratio of one PCP FTE for each 2,000 of their Medicaid members in that service arearegion. When alternate provider areas are designated, there continues to be a minimum PCP capacity requirement which must be met by the MCP’s PCPs within the service area itself. The discretionary PCP FTE figure represents the maximum amount of PCP capacity that may be met in a designated alternate provider area. The minimum PCP provider panel requirements are specified in the charts in Section H of this appendix. Except in voluntary enrollment counties, all MCPs meeting the minimum PCP provider panel requirement must also satisfy a PCP geographic accessibility standard before they will receive a provider agreement for a specific service area. This standard must be maintained in each service area for the duration of the contractstandard. ODJFS will match the PCP practice sites and the stated PCP capacity with the geographic location of the eligible population in that service area region (on a county-specific basis) and perform analysis using Geographic Information Systems (GIS) software. The analysis will be used to determine if at least 40% of the eligible population are is located within 10 miles of an MCP’s in-area or alternate provider area PCP provider site with available capacity in urban counties and 40% of the eligible population within 30 miles of a PCP with available capacity taken into considerationin rural counties. [Rural areas are defined pursuant to 42 CFR 412.62(t)(l)(iii).] In addition to the PCP FTE capacity requirement, . MCPs must also contract with the specified number of pediatric PCPs for each service arearegion. These pediatric PCPs will have their stated capacity counted toward the PCP FTE requirement. A pediatric PCP must be pediatricians who maintain a general pediatric practice (e.g., e.g.. a pediatric neurologist would not meet this definition unless this physician also operated a practice as a general pediatrician) at a site(s) located within the service area or an alternate provider area, county/region and be listed as a pediatrician with the Ohio State Medical Board. In addition, a designated half of the minimum required number of these physicians pediatric PCPs must also be certified by the American Board of Pediatrics. The minimum provider panel requirements for pediatricians are included in specialty provider the practitioner charts in Section H of this appendix.

Primary Care Physicians (PCPs). Primary Care Physicians (PCPs) may be individuals or group practices/clinics. Generally acceptable specialty types for PCPs are family/general practice, internal medicine, pediatrics and obstetrics/gynecology. (ODJFS reserves the right to request verification of a physician’s specialty type.) As part of their subcontract with an MCP, PCPs must stipulate the total Medicaid member capacity that they can ensure for that individual MCP. Each PCP must have the capacity and agree to serve at least 50 Medicaid members at each practice site in order to be approved by ODJFS as a PCP and included in the MCP's ’s total PCP capacity calculation. The capacity by site requirement must be met for all ODJFS- ODJFS-approved PCPs. A PCP’s total capacity number may reflect the support the provider receives from residents, nurse practitioners, physician assistants, etc. For example, a PCP in private practice with no assistants might state that they have the capacity to serve 1000 members for an MCP. A PCP with assistants, however, might state that they are able to see up to 2500 members for an MCP. ODJFS reviews the capacity totals for each PCP to determine if they appear excessive. ODJFS reserves the right to request clarification from an MCP for any PCP whose total stated capacity for all MCP networks added together exceeds 2000 Medicaid members [i.e., 1 full-time equivalent (FTE)]. ODJFS may also compare a PCP’s capacity against the number of members assigned to that PCP, and/or the number of patient encounters attributed to that PCP to determine if the reported capacity number reasonably reflects a PCP’s expected caseload for a specific MCP. Where indicated, ODJFS may set a cap on the maximum amount of capacity that will be approved for a specific PCP. For PCPs contracting with more than one MCP, the MCP must ensure that the capacity figure stated by the PCP in their subcontract reflects only the capacity the PCP intends to provide for that one MCP. ODJFS utilizes each approved PCP’s capacity figure to determine if an MCP meets the minimum provider panel requirements and this stated capacity figure does not prohibit a PCP from actually having a caseload that exceeds the capacity figure indicated in their subcontract. ODJFS expects, however, that MCPs will need to utilize specialty physicians to serve as PCPs for some special needs members. Also, in some situations (e.g., continuity of care) a PCP may only want to serve a very small number of members for an MCP. In these situations it will not be necessary for the MCP to submit these PCPs to ODJFS for prior approval. These PCPs will not be included in the ODJFS PVS database and therefore may not appear as PCPs in the MCP’s provider directory. Also, no PCP capacity will be counted for these providers. These PCPs will, however, need to execute a subcontract with the MCP which includes the appropriate Model Medicaid Addendum. Appendix H In order to determine if adequate PCP FTE capacity exists for each service area, ODJFS will total each MCP's ’s approvable PCP FTEs for each service area (this would include both PCPs with practice sites located within that service area and PCP practice sites located in nearby counties which have been designated as alternate provider areas by ODJFS) and apply the following criteria: Number of Eligibles/County Minimum PCP Capacity (% Eligibles) >100,000 4040 %* <100,000 5050 %* * the minimum PCP capacity requirement is higher for Preferred Option counties (For example, WeCare MCP has a PCP FTE capacity of 19.5 for Service Area X. Service Area X has a population of 75,000 eligible recipients. 50% of 75,000 equals 37,500. 37,500 divided by 2000 equals 18.75. In that WeCare has a minimum PCP capacity of 19.5 FTEs for Service Area X and only is required to have a PCP capacity of 18.75 FTEs, ODJFS would find that WeCare MCP has sufficient PCP capacity to serve Service Area X.) At a minimum, each MCP must meet both the PCP minimum FTE requirement for that service area, as well as a minimum ratio of one PCP FTE for each 2,000 of their Medicaid members in that service area. When alternate provider areas are designated, there continues to be a minimum PCP capacity requirement which must be met by the MCP’s PCPs within the service area itself. The discretionary PCP FTE figure represents the maximum amount of PCP capacity that may be met in a designated alternate provider area. The minimum PCP provider panel requirements are specified in the charts in Section H of this appendix. Except in voluntary enrollment counties, all MCPs meeting the minimum PCP provider panel requirement must also satisfy a PCP geographic accessibility standard before they will receive a provider agreement for a specific service area. This standard must be maintained in each service area for the duration of the contract. ODJFS will match the PCP practice sites with the geographic location of the eligible population in that service area and perform analysis using Geographic Information Systems (GIS) software. The analysis will be used to determine if at least 40% of the eligible population are located within 10 miles of an MCP’s in-area or alternate provider area PCP provider site with PCP capacity taken into consideration. In addition to the PCP FTE capacity requirement, MCPs must also contract with the specified number of pediatric PCPs for each service area. These must be pediatricians who maintain a general pediatric practice (e.g., a pediatric neurologist would not meet this definition unless this physician also operated a practice as a general pediatrician) at a site(s) located within the service area or an alternate provider area, and be listed as a pediatrician with the Ohio State Medical Board. In addition, a designated number of these physicians must also be certified by the American Board of Pediatrics. The minimum provider panel requirements for pediatricians are included in specialty provider charts in Section H of this appendix.

Primary Care Physicians (PCPs). Primary Care Physicians (PCPs) may be individuals or group practices/clinicsclinics [Primary Care Clinics (PCCs)]. Generally acceptable Acceptable specialty types for PCPs are family/general practice, internal medicine, pediatrics and obstetrics/gynecologygynecology(OB/GYNs). (ODJFS reserves Acceptable PCCs include FQHCs, RHCs and the right to request verification of a physician’s specialty type.) acceptable group practices/clinics specified by ODJFS. As part of their subcontract with an MCP, PCPs must stipulate the total Medicaid member capacity that they can ensure for that individual MCP. Each PCP must have the capacity and agree to serve at least 50 Medicaid members at each practice site in order to be approved by ODJFS as a PCP and included in the MCP's total PCP capacity calculationPCP. The capacity by capacity-by-site requirement must be met for all ODJFS- ODJFS-approved PCPs. A PCP’s total In determining whether an MCP has sufficient PCP capacity number may reflect the support the provider receives from residentsfor a region, nurse practitioners, ODJFS considers a physician assistants, etc. For example, who can serve as a PCP in private practice with no assistants might state that they have the capacity to serve 1000 for 2000 Medicaid MCP members for an MCP. A PCP with assistants, however, might state that they are able to see up to 2500 members for an MCPas one full-time equivalent (FTE). ODJFS reviews the capacity totals for each PCP to determine if they appear excessive. ODJFS reserves the right to request clarification from an MCP for any PCP whose total stated capacity for all MCP networks added together exceeds 2000 Medicaid members [(i.e., 1 full-time equivalent (FTE)]. ODJFS may also compare a PCP’s capacity against the number of members assigned to that PCP, and/or the number of patient encounters attributed to that PCP to determine if the reported capacity number reasonably reflects a PCP’s expected caseload for a specific MCP. Where indicated, ODJFS may set a cap on the maximum amount of capacity that we will be approved recognize for a specific PCP. ODJFS may allow up to an additional 750 member capacity for each nurse practitioner or physician’s assistant that is used to provide clinical support for a PCP. For PCPs contracting with more than one MCP, the MCP must ensure that the capacity figure stated by the PCP in their subcontract reflects only the capacity the PCP intends to provide for that one MCP. ODJFS utilizes each approved PCP’s capacity figure to determine if an MCP meets the minimum provider panel requirements and this stated capacity figure does not prohibit a PCP from actually having a caseload that exceeds the capacity figure indicated in their subcontract. ODJFS expects, however, recognizes that MCPs will need to utilize specialty physicians to serve as PCPs for some special needs members. Also, in some situations (e.g., continuity of care) a PCP may only want to serve a very small number of members for an MCP. In these situations it will not be necessary for the MCP to submit these PCPs to ODJFS for prior approval. These PCPs will not be included in the ODJFS PVS database and therefore may not appear as PCPs in the MCP’s provider directory. Also, no PCP capacity will be counted for these providers. These PCPs will, however, need to execute a subcontract with the MCP which includes the appropriate Model Medicaid Addendum. In order to determine if adequate The PCP FTE capacity exists for each service area, ODJFS will total each MCP's approvable PCP FTEs for each service area (this would include both PCPs with practice sites located within that service area and PCP practice sites located in nearby counties which have been designated as alternate provider areas by ODJFS) and apply the following criteria: Number of Eligibles/County Minimum PCP Capacity (% Eligibles) >100,000 40%* <100,000 50%* * the minimum PCP capacity requirement is higher for Preferred Option counties (For example, WeCare based on an MCP has a PCP FTE capacity of 19.5 for Service Area X. Service Area X has a population of 75,000 eligible recipients. 50% of 75,000 equals 37,500. 37,500 divided by 2000 equals 18.75. In that WeCare has a minimum PCP capacity of 19.5 FTEs for Service Area X and only is required to have a PCP capacity of 18.75 FTEs, ODJFS would find that WeCare MCP has having sufficient PCP capacity to serve Service Area X.) 40% of the eligibles in the region if three MCPs are serving the region and 55% of the eligibles in the region if two MCPs are serving the region. At a minimum, each MCP must meet both the PCP minimum FTE requirement for that service arearegion, as well as and a minimum ratio of one PCP FTE for each 2,000 of their Medicaid members in that service arearegion. When alternate provider areas are designated, there continues to be a minimum PCP capacity requirement which must be met by the MCP’s PCPs within the service area itself. The discretionary PCP FTE figure represents the maximum amount of PCP capacity that may be met in a designated alternate provider area. The minimum PCP provider panel requirements are specified in the charts in Section H of this appendix. Except in voluntary enrollment counties, all MCPs meeting the minimum PCP provider panel requirement must also satisfy a PCP geographic accessibility standard before they will receive a provider agreement for a specific service area. This standard must be maintained in each service area for the duration of the contractstandard. ODJFS will match the PCP practice sites and the stated PCP capacity with the geographic location of the eligible population in that service area region (on a county-specific basis) and perform analysis using Geographic Information Systems (GIS) software. The analysis will be used to determine if at least 40% of the eligible population are is located within 10 miles of an MCP’s in-area or alternate provider area PCP provider site with available capacity in urban counties and 40% of the eligible population within 30 miles of a PCP with available capacity taken into considerationin rural counties. [Rural areas are defined pursuant to 42 CFR 412.62(f)(1)(iii).] In addition to the PCP FTE capacity requirement, MCPs must also contract with the specified number of pediatric PCPs for each service arearegion. These pediatric PCPs will have their stated capacity counted toward the PCP FTE requirement. A pediatric PCP must be pediatricians who maintain a general pediatric practice (e.g., a pediatric neurologist would not meet this definition unless this physician also operated a practice as a general pediatrician) at a site(s) located within the service area or an alternate provider area, county/region and be listed as a pediatrician with the Ohio State Medical Board. In addition, a designated half of the required number of these physicians pediatric PCPs must also be certified by the American Board of Pediatrics. The minimum provider panel requirements for pediatricians are included in specialty provider the practitioner charts in Section H of this appendix.