PROVIDER AGREEMENT BETWEEN STATE OF OHIO DEPARTMENT OF JOB AND FAMILY SERVICES AND WELLCARE OF OHIO, INC. Amendment No. 1
Exhibit 10.1
PROVIDER
AGREEMENT
BETWEEN
STATE OF
OHIO
DEPARTMENT
OF JOB AND FAMILY SERVICES
AND
WELLCARE
OF OHIO, INC.
Amendment No.
1
Pursuant
to Article IX.A. the Provider Agreement between the State of Ohio. Department of
Job and Family Services, (hereinafter referred to as "ODJFS") and WELLCARE OF
OHIO, INC. (hereinafter referred to as "MCP") for the Covered Families and
Children (hereinafter referred to as "CFC") population dated July 1, 2008. is
hereby amended as follows:
1. Appendices
C, D, E, F, G, H, J, K, L, M, N, and O have been modified as
attached.
2. All
other terms of the provider agreement are hereby affirmed.
The amendment contained herein shall be effective January 1,
2009.
WELLCARE
OF OHIO, INC.
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BY:
/s/ Xxxxx
Xxxxxxxxx
XXXXX
XXXXXXXXX, CHIEF EXECUTIVE OFFICER AND PRESIDENT
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DATE: 12-19-08
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OHIO
DEPARTMENT OF JOB AND FAMILY SERVICES:
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BY:
/s/ Xxx Xxxxx,
Director
XXX XXXXX, DIRECTOR
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DATE:
12/30/08
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Appendix
C
Covered
Families and Children (CFC) population
Page
1
APPENDIX
C
MCP
RESPONSIBILITIES
CFC
ELIGIBLE POPULATION
The MCP
must meet on an ongoing basis, all program requirements specified in Chapter
5101:3-26 of the Ohio Administrative Code (OAC) and the Ohio Department of Job
and Family Services (ODJFS) - MCP Provider Agreement. The following are MCP
responsibilities that are not otherwise specifically stated in OAC rule
provisions or elsewhere in the MCP provider agreement, but are required by
ODJFS.
General
Provisions
1.
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The
MCP agrees to implement program modifications as soon as reasonably
possible or no later than the required effective date, in response to
changes in applicable state and federal laws and
regulations.
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2.
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The
MCP must submit a current copy of their Certificate of Authority (COA) to
ODJFS within 30 days of issuance by the Ohio Department of
Insurance.
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3
The MCP must designate the following:
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a.
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A
primary contact person (the Medicaid Coordinator) who will dedicate a
majority of their time to the Medicaid product line and coordinate overall
communication between ODJFS and the MCP. ODJFS may also require the MCP to
designate contact staff for specific program areas. The Medicaid
Coordinator will be responsible for ensuring the timeliness, accuracy,
completeness and responsiveness of all MCP submissions to
ODJFS.
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b.
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A
provider relations representative for each service area included in their
ODJFS provider agreement. This provider relations representative can serve
in this capacity for only one service area (as specified in Appendix
H).
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As
long as the MCP serves both the CFC and ABD populations, they are not
required to have separate provider relations representatives or Medicaid
coordinators.
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4.
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All
MCP employees are to direct all day-to-day submissions and communications
to their ODJFS-designated Contract Administrator unless otherwise notified
by ODJFS.
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5.
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The
MCP must be represented at all meetings and events designated by ODJFS as
requiring mandatory attendance.
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6. | The MCP must have an administrative office located in Ohio. |
Appendix
C
Covered
Families and Children (CFC) population
Page
2
7.
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Upon
request by ODJFS, the MCP must submit information on the current status of
their company’s operations not specifically covered under this provider
agreement (for example, other product lines, Medicaid contracts in other
states, NCQA accreditation, etc.) unless otherwise excluded by
law.
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8.
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The
MCP must have all new employees trained on applicable program
requirements, and represent, warrant and certify to ODJFS that such
training occurs, or has
occurred.
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9.
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If
an MCP determines that it does not wish to provide, reimburse, or cover a
counseling service or referral service due to an objection to the service
on moral or religious grounds, it must immediately notify ODJFS to
coordinate the implementation of this change. MCPs will be required to
notify their members of this change at least thirty (30) days prior to the
effective date. The MCP’s member handbook and provider directory, as well
as all marketing materials, will need to include information specifying
any such services that the MCP will not
provide.
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10.
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For
any data and/or documentation that MCPs are required to maintain, ODJFS
may request that MCPs provide analysis of this data and/or documentation
to ODJFS in an aggregate format, such format to be solely determined by
ODJFS.
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11.
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The
MCP is responsible for determining medical necessity for services and
supplies requested for their members as specified in OAC rule
5101:3-26-03. Notwithstanding such responsibility, ODJFS retains the right
to make the final determination on medical necessity in specific member
situations.
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12.
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In
addition to the timely submission of medical records at no cost for the
annual external quality review as specified in OAC rule 5101:3-26-07, the
MCP may be required for other purposes to submit medical records at no
cost to ODJFS and/or designee upon
request.
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13.
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The
MCP must notify the BMHC of the termination of an MCP panel provider that
is designated as the primary care provider for 500 or more of the MCP’s
CFC members. The MCP must provide notification within one working day of
the MCP becoming aware of the
termination.
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14.
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Upon
request by ODJFS, MCPs may be required to provide written notice to
members of any significant change(s) affecting contractual requirements,
member services or access to
providers.
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15.
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MCPs
may elect to provide services that are in addition to those covered under
the Ohio Medicaid fee-for-service program. Before MCPs notify potential or
current members of the availability of these services, they must first
notify ODJFS and advise ODJFS of such planned services availability. If an
MCP elects to provide additional services, the MCP must ensure to the
satisfaction of ODJFS that the services are readily available and
accessible to members who are eligible to receive them. Additional
benefits must be made available to members for at least six (6) calendar
months from date approved by
ODJFS.
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Appendix
C
Covered
Families and Children (CFC) population
Page
3
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a.
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MCPs
are required to
make transportation available to any member requesting transportation when
they must travel
(thirty) 30 miles or more from their home to receive a medically-necessary
Medicaid-covered service. If the MCP offers transportation to their
members as an additional benefit and this transportation benefit only
covers a limited number of trips, the required transportation listed above
may not be counted toward this trip
limit.
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b.
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Additional
benefits may not vary by county within a region except out of necessity
for transportation arrangements (e.g., bus versus cab). MCPs approved to
serve consumers in more than one region may vary additional benefits
between regions.
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c.
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MCPs
must give ODJFS and members (ninety) 90 days prior notice when decreasing
or ceasing any additional benefit(s). When it is beyond the control of the
MCP, as demonstrated to ODJFS’ satisfaction, ODJFS must be notified within
(one) 1 working day.
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16.
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MCPs
must comply with any applicable Federal and State laws that pertain to
member rights and ensure that its staff adheres to such laws when
furnishing services to its members. MCPs shall include a requirement in
its contracts with affiliated providers that such providers also adhere to
applicable Federal and State laws when providing services to
members.
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17.
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MCPs
must comply with any other applicable Federal and State laws (such as
Title VI of the Civil rights Act of 1964, etc.) and other laws regarding
privacy and confidentiality, as such may be applicable to this
Agreement.
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18.
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Upon
request, the MCP will provide members and potential members with a copy of
their practice guidelines.
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19.
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The
MCP is responsible for promoting the delivery of services in a culturally
competent manner, as solely determined by ODJFS, to all members, including
those with limited English proficiency (LEP) and diverse cultural and
ethnic backgrounds.
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All MCPs must comply with the requirements specified in OAC rules
5101:3-26-03.1, 5101:3-26-05(D), 5101:3-26-05.1(A), 5101:3-26-08 and
5101:3-26-08.2 for providing assistance
to LEP members and eligible individuals. In addition, MCPs must
provide written translations of certain MCP materials in the prevalent
non-English languages of members and
eligible individuals in accordance with the
following:
Appendix
C
Covered
Families and Children (CFC) population
Page
4
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a.
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When
10% or more of the CFC eligible individuals in the MCP’s service area have
a common primary language other than English, the MCP must translate all
ODJFS-approved marketing materials into the primary language of that
group. The MCP must monitor changes in the eligible population on an
ongoing basis and conduct an assessment no less often than annually to
determine which, if any, primary language groups meet the 10% threshold
for the eligible individuals in each service area. When the 10% threshold
is met, the MCP must report this information to ODJFS, in a format as
requested by ODJFS, translate their marketing materials, and make these
marketing materials available to eligible individuals. MCPs must submit to
ODJFS, upon request, their prevalent non-English language analysis of
eligible individuals and the results of this
analysis.
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b.
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When
10% or more of an MCP's CFC members in the MCP’s service area have a
common primary language other than English, the MCP must translate all
ODJFS-approved member materials into the primary language of that group.
The MCP must monitor their membership and conduct a quarterly assessment
to determine which, if any, primary language
groups meet the 10% threshold. When the 10% threshold is met, the MCP must
report this information to ODJFS, in a format as requested by ODJFS,
translate their member materials, and make these materials available to
their members. MCPs must submit to ODJFS, upon request, their prevalent
non-English language member analysis and the results of this
analysis.
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20.
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The
MCP must utilize a centralized database which records the special
communication needs of all MCP members (i.e., those with limited English
proficiency, limited reading proficiency, visual impairment, and hearing
impairment) and the provision of related services (i.e., MCP materials in
alternate format, oral interpretation, oral translation services, written
translations of MCP materials, and sign language services). This database
must include all MCP member primary language information (PLI) as well as
all other special communication needs information for MCP members, as
indicated above, when identified by any source including but not limited
to ODJFS, ODJFS selection services entity, MCP staff, providers, and
members. This centralized database must be readily available to MCP staff
and be used in coordinating communication and services to members,
including the selection of a PCP who speaks the primary language of an LEP
member, when such a provider is available. MCPs must share specific
communication needs information with their providers [e.g., PCPs, Pharmacy
Benefit Managers (PBMs), and Third Party Administrators (TPAs)], as
applicable. MCPs must submit to ODJFS, upon request, detailed information
regarding the MCP’s members with special communication needs, which could
include individual member names, their specific communication need, and
any provision of special services to members (i.e., those special services
arranged by the MCP as well as those services reported to the MCP which
were arranged by the
provider).
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Appendix
C
Covered
Families and Children (CFC) population
Page
5
Additional
requirements specific to providing assistance to hearing-impaired,
vision-impaired, limited reading proficient (LRP), and LEP members and eligible
individuals are found in OAC rules 5101:3-26-03.1, 5101:3-26-05(D),
5101:3-26-05.1(A), 5101:3-26-08, and 5101-3-26-08.2.
21.
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The
MCP is responsible for ensuring that all member materials use easily
understood language and format. The determination of what materials comply
with this requirement is in the sole discretion of
ODJFS.
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22.
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Pursuant
to OAC rules 5101:3-26-08 and 5101:3-26-08.2, the MCP is responsible for
ensuring that all MCP marketing and member materials are prior approved by
ODJFS before being used or shared with members. Member materials must be
available in written format, but can be provided to the member in
alternative formats (e.g., CD-rom) if specifically requested by the
member, except as specified in OAC rule 5101:3-26-08.4. Marketing and
member materials are defined as
follows:
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a. |
Marketing
materials are those items produced in any medium, by or on behalf of an
MCP, including gifts of nominal value (i.e., items worth no more than
$15.00),which can reasonably be interpreted as intended to market to
eligible individuals.
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b. |
Member
materials are those items developed, by or on behalf of an MCP, to fulfill
MCP program requirements or to communicate to all members or a group of
members. Member health education materials that are produced by a source
other than the MCP and which do not include any reference to the MCP are
not considered to be member
materials.
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c. |
All
MCP marketing and member materials must represent the MCP in an honest and
forthright manner and must not make statements which are inaccurate,
misleading, confusing, or otherwise misrepresentative, or which defraud
eligible individuals or
ODJFS.
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d. |
All
MCP marketing cannot contain any assertion or statement (whether written
or oral) that the MCP is endorsed by CMS, the Federal or State government
or similar entity.
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e. |
MCPs
must establish positive working relationships with the CDJFS offices and
must not aggressively solicit from local Directors, MCP County
Coordinators, or or other staff. Furthermore, MCPs are prohibited from
offering gifts of nominal value
(i.e. clipboards, pens, coffee mugs, etc.) to CDJFS offices or managed
care enrollment center (MCEC) staff, as these may influence an
individual’s decision to select a particular
MCP.
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Appendix
C
Covered
Families and Children (CFC) population
Page
6
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f.
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MCP
marketing representatives and other MCP staff are prohibited from offering
eligible individuals the use of a portable device (laptop computer,
cellular phone, etc.) to assist with the completion of an online
application to select and/or change MCPs, as all enrollment activities
must be completed by the
MCEC.
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23.
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Advance
Directives – All MCPs must comply with the requirements specified
in 42 CFR 422.128. At a minimum, the MCP
must:
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a.
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Maintain
written policies and procedures that meet the requirements for advance
directives, as set forth in 42 CFR Subpart I of part
489.
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b.
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Maintain
written policies and procedures concerning advance directives with respect
to all adult individuals receiving medical care by or through the MCP to
ensure that the MCP:
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i. Provides written information to all
adult members concerning:
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a. |
the
member’s rights under state law to make decisions concerning their medical
care, including the right to accept or refuse medical or surgical
treatment and the right to formulate advance directives. (In meeting this
requirement, MCPs must utilize form JFS 08095 entitled You Have the Right, or
include the text from JFS 08095 in their ODJFS-approved member
handbook).
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b. |
the
MCP’s policies concerning the implementation of those rights including a
clear and precise statement of any limitation regarding the implementation
of advance directives as a matter of
conscience;
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c. |
any
changes in state law regarding advance directives as soon as possible but
no later than (ninety) 90 days after the proposed effective date of the
change; and
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d. |
the
right to file complaints concerning noncompliance with the advance
directive requirements with the Ohio Department of
Health.
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Appendix
C
Covered
Families and Children (CFC) population
Page
7
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ii. |
Provides
for education of staff concerning the MCP’s policies and procedures on
advance directives;
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iii. |
Provides
for community education regarding advance directives directly or in
concert with other providers or
entities;
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iv. |
Requires
that the member’s medical record document whether or not the member has
executed an advance directive;
and
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v. |
Does
not condition the provision of care, or otherwise discriminate against a
member, based on whether the member has executed an advance
directive.
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24. New Member
Materials
Pursuant
to OAC rule 5101:3-26-08.2 (B)(3), MCPs must provide to each member or
assistance group, as applicable, an MCP identification (ID) card, a new member
letter, a
member handbook, a provider directory, and information on advance
directives.
a. MCPs must use the model language specified by ODJFS for the new member
letter.
b. The ID card and new member letter must be mailed together to the member
via a method that will ensure their receipt prior to the member’s effective date
of coverage.
c.
The member handbook, provider directory and advance directives information may
be mailed to the member separately from the ID card and new member letter. MCPs
will
meet the timely receipt requirement for these materials
if they are mailed to the member within (twenty-four) 24 hours of the MCP
receiving the ODJFS produced monthly
membership roster (MMR). This is provided the materials are mailed via a method
with an expected delivery date of no more than five (5) days. If the member
handbook,
provider directory and advance directives information are mailed separately from
the ID card and new member letter and the MCP is unable to mail the materials
within twenty-
four (24) hours, the member handbook, provider directory and advance directives
information must be mailed via a method that will ensure receipt by no later
than the effective
date of coverage. If the MCP mails the ID card and new member letter with the
other materials (e.g., member handbook, provider directory, and advance
directives), the MCP
must
ensure that all
materials are mailed via a method that will ensure their receipt prior to the member’s
effective date of coverage.
d. MCPs must designate two (2) MCP staff members to receive a copy of
the new member materials on a monthly basis in order to monitor the timely
receipt of these materials.
At least one of the staff members must receive the materials at their home
address.
Appendix
C
Covered
Families and Children (CFC) population
Page
8
25. Call Center
Standards
The MCP must provide assistance to members through a member services toll-free
call-in system pursuant to OAC rule 5101:3-26-08.2(A)(1). MCP member services
staff must
be available nationwide to provide assistance to members through the toll-free
call-in system every Monday through Friday, at all times during the hours of
7:00 am to 7:00 pm
Eastern Time, except for the following major holidays:
• New Year’s Day
• Xxxxxx
Xxxxxx Xxxx’x Birthday
• Memorial Day
• Independence Day
• Labor Day
• Thanksgiving Day
• Christmas
Day
• 2
optional closure days: These days can be used independently or in combination
with any of the major holiday closures but cannot both be used within the
same
closure period.
Before
announcing any optional closure dates to members and/or staff, MCPs must receive
ODJFS prior-approval which verifies that the optional closure days
meet the specified criteria.
If a
major holiday falls on a Saturday, the MCP member services line may be closed on
the preceding Friday. If a major holiday falls on a Sunday, the member services
line may be closed on the following Monday. MCP member services closure days
must be specified in the MCP’s member handbook, member newsletter, or other some
general issuance to the MCP’s members at least (thirty) 30 days in advance of
the closure.
The MCP
must also provide access to medical advice and direction through a centralized
twenty-four-hour, seven day (24/7) toll-free call-in system, available
nationwide, pursuant to OAC rule 5101:3-26-03.1(A)(6). The 24/7 call-in system
must be staffed by appropriately trained medical personnel. For the purposes of
meeting this requirement, trained medical professionals are defined as
physicians, physician assistants, licensed practical nurses, and registered
nurses.
MCPs must
meet the current American Accreditation HealthCare Commission/URAC-designed
Health Call Center Standards (HCC) for call center abandonment rate, blockage
rate and average speed of answer. By the 10th of each
month, MCPs must self-report their prior month performance in these three areas
for their member services and 24/7 toll-free call-in systems to ODJFS. ODJFS
will inform the MCPs of any changes/updates to these URAC call center
standards.
MCPs are
not permitted to delegate grievance/appeal functions [Ohio Administrative Code
(OAC) rule 5101:3-26-08.4(A)(9)]. Therefore, the member services call center
requirement may not be met through the execution of a Medicaid Delegation
Subcontract Addendum or Medicaid Combined Services Subcontract
Addendum.
Appendix
C
Covered
Families and Children (CFC) population
Page
9
26.
Notification of Optional MCP
Membership
In order to comply with the terms of the ODJFS State Plan Amendment for the
managed care program (i.e., 42 CFR 438.50), MCPs in mandatory membership service
areas must
inform new members that MCP membership is optional for certain
populations. Specifically, MCPs must inform any applicable pending member or
member that the following
CFC populations are not required to select an MCP in order to receive
their Medicaid healthcare benefit and what steps they need to take if they do
not wish to be a member of
an MCP:
- Indians who are members of
federally-recognized tribes.
- Children under 19 years of age who
are:
o Eligible for Supplemental Security Income under title
XVI;
o In xxxxxx care or other out-of-home placement;
o Receiving xxxxxx care of adoption assistance;
o Receiving services through the Ohio Department of Health’s Bureau
for Children with Medical Handicaps (BCMH) or any other family-centered,
community-based,
coordinated care system that receives grant funds under section 501(a)(1)(D) of
title V, and is defined by the State in terms of either program participation or
special
health care needs.
27.
HIPAA Privacy
Compliance Requirements
The Health Insurance Portability and Accountability Act (HIPAA) Privacy
Regulations at 45 CFR. § 164.502(e) and § 164.504(e) require ODJFS to have
agreements with MCPs
as a means of obtaining satisfactory assurance
that the MCPs will appropriately safeguard all personal identified health
information. Protected Health Information (PHI) is
information received from or on behalf of ODJFS that meets the definition
of PHI as defined by HIPAA and the regulations promulgated by the United States
Department of
Health and Human Services, specifically 45 CFR 164.501, and any amendments
thereto. MCPs must agree to the following:
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a.
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MCPs
shall not use or disclose PHI other than is permitted by this agreement or
required by law.
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b.
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MCPs
shall use appropriate safeguards to prevent unauthorized use or disclosure
of PHI.
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c.
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MCPs
shall report to ODJFS any unauthorized use or disclosure of PHI of which
it becomes aware. Any breach by the MCP or its representatives of
protected health information (PHI) standards shall be immediately reported
to the State HIPAA Compliance Officer through the Bureau of Managed Health
Care. MCPs must provide documentation of the breach and complete all
actions ordered by the HIPAA Compliance
Officer.
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Appendix
C
Covered
Families and Children (CFC) population
Page
10
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d.
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MCPs
shall ensure that all its agents and subcontractors agree to these same
PHI conditions and restrictions.
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e. | MCPs shall make PHI available for access as required by law. |
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f.
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MCP
shall make PHI available for amendment, and incorporate amendments as
appropriate as required by
law.
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g.
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MCPs
shall make PHI disclosure information available for accounting as required
by law.
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h.
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MCPs
shall make its internal PHI practices, books and records available to the
Secretary of Health and Human Services (HHS) to determine
compliance.
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i.
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Upon
termination of their agreement with ODJFS, the MCPs, at ODJFS’ option,
shall return to ODJFS, or destroy, all PHI in its possession, and keep no
copies of the information, except as requested by ODJFS or required by
law.
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j.
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ODJFS
will propose termination of the MCP’s provider agreement if ODJFS
determines that the MCP has violated a material breach under this section
of the agreement, unless inconsistent with statutory obligations of ODJFS
or the MCP.
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28.
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Electronic
Communications – MCPs are required to purchase/utilize Transport
Layer Security (TLS) for all e-mail communication between ODJFS and the
MCP. The MCP’s e-mail gateway must be able to support the sending and
receiving of e-mail using Transport Layer Security (TLS) and the MCP’s
gateway must be able to enforce the sending and receiving of email via
TLS.
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29. MCP Membership acceptance,
documentation and reconciliation
a.
Selection Services
Contractor: The MCP shall provide to the MCEC ODJFS
prior-approved
MCP materials and directories for distribution to eligible individuals who
request additional information about the MCP.
b.
Monthly Reconciliation of
Membership and Premiums: The MCP shall reconcile member
data as reported on the MCEC produced consumer contact record (CCR)
with the ODJFS-produced monthly member roster (MMR) and report to the ODJFS any
difficulties in interpreting
or reconciling information received. Membership
reconciliation questions must be identified and reported to the ODJFS prior to
the first of the month to assure that no member is left without coverage. The
MCP shall
reconcile membership with premium payments and delivery payments as reported on
the monthly remittance advice (RA).
Appendix
C
Covered
Families and Children (CFC) population
Page
11
The MCP shall work directly with the ODJFS, or other ODJFS-identified entity, to
resolve any difficulties in interpreting or reconciling premium information.
Premium
reconciliation questions must be identified within thirty (30) days of
receipt of the RA. Monthly reconciliation data must be submitted in the format
specified by
ODJFS.
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c.
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Monthly Premiums and
Delivery Payments: The MCP must be able to receive monthly premiums
and delivery payments in a method specified by ODJFS. (ODJFS monthly
prospective premium and delivery payment issue dates are provided in
advance to the MCPs.) Various retroactive premium payments (e.g.,
newborns), and recovery of premiums paid (e.g., retroactive terminations
of membership for children in custody, deferments, etc.,) may occur via
any ODJFS weekly remittance.
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d.
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Hospital/Inpatient
Facility Deferment: When an MCP learns of a currently hospitalized
member’s intent to disenroll through the CCR or the 834, the disenrolling
MCP must notify the hospital/inpatient facility and treating providers as
well as the enrolling MCP of the change in enrollment within five (5)
business days of receipt of the CCR or 834. The disenrolling MCP
must notify the inpatient facility that it will remain responsible for the
inpatient facility charges through the date of discharge; and must notify
the treating providers that it will remain responsible for provider
charges through the date of
disenrollment.
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When
the enrolling MCP learns through the disenrolling MCP, through ODJFS or
other means, that a new member who was previously enrolled with another
MCP was admitted prior to the effective date of enrollment and remains an
inpatient on the effective date of enrollment, the enrolling MCP shall
contact the hospital/inpatient facility within five (5) business days of
learning of the hospitalization. The enrolling MCP shall verify that it is
responsible for all medically necessary Medicaid covered services from the
effective date of MCP membership, including treating provider services
related to the inpatient stay; the enrolling MCP must reiterate that the
admitting/disenrolling MCP remains responsible for the hospital/inpatient
facility charges through the date of discharge. The enrolling MCP shall
work with the hospital/inpatient facility to facilitate discharge planning
and authorize services as
needed.
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Appendix C
Covered
Families and Children (CFC) population
Page
12
When an MCP learns that a new member who was previously on Medicaid fee for
service was admitted prior to the effective date of enrollment and remains
an
inpatient
on the effective date of enrollment, the enrolling MCP shall notify the
hospital/ inpatient facility and treating providers that the MCP may not
be the payer.
The MCP shall work with hospital/inpatient facility, treating providers
and the ODJFS to assure that discharge planning assures continuity of care and
accurate
payment. Notwithstanding the MCP’s right to request a hospital deferment up to
six (6) months following the member’s effective date, when the enrolling MCP
learns
of a deferment-eligible hospitalization, the MCP shall notify the ODJFS and request the deferment
within five (5) business days of learning of the potential
deferment.
|
e.
|
Just Cause
Requests: The MCP shall follow procedures as specified by ODJFS in
assisting the ODJFS in resolving member requests for member-initiated
requests affecting
membership.
|
|
f.
|
Newborn
Notifications: The MCP is required to submit newborn notifications
to ODJFS in accordance with the ODJFS Newborn Notification File and
Submissions Specifications.
|
|
g.
|
Eligible
Individuals: If an eligible individual contacts the MCP, the MCP
must provide any MCP-specific managed care program information requested.
The MCP must not attempt to assess the eligible individual’s health care
needs. However, if the eligible individual inquires about
continuing/transitioning health care services, MCPs shall provide an
assurance that all MCPs must cover all medically necessary
Medicaid-covered health care services and assist members with
transitioning their health care
services.
|
h.
Pending
Member
|
If
a pending member (i.e., an eligible individual subsequent to plan
selection or assignment, but prior to their membership effective date)
contacts the selected MCP, the MCP must provide any membership information
requested, including but not limited to, assistance in determining whether
the current medications require prior authorization. The MCP must also
ensure that any care coordination (e.g., PCP selection, prescheduled
services and transition of services) information provided by the pending
member is logged in the MCP’s system and forwarded to the appropriate MCP
staff for processing as required. MCPs may confirm any information
provided on the CCR at this time. Such communication does not constitute
confirmation of membership. MCPs are prohibited from initiating contact
with a pending member. Upon receipt of the 834, the MCP may contact a
pending member to confirm information provided on the CCR or the 834,
assist with care coordination and transition of care, and inquire if the
pending member has any membership
questions.
|
Appendix
C
Covered
Families and Children (CFC) population
Page
13
i.
Transition of
Fee-For-Service Members
(Does
not apply to regions where members are not required to enroll in an
MCP)
|
Providing
care coordination for prescheduled health services and existing care
treatment plans, is critical for members transitioning from Medicaid
fee-for service (FFS) to managed care. Therefore, MCPs
must:
|
i.
Allow their new members that are transitioning from Medicaid
fee-for-service
to receive services from out-of-panel providers if the member or provider
contacts the
MCP to discuss the scheduled health services in advance of the service date and
one of the following applies:
|
a.
|
The
member is in her third trimester of pregnancy and has an established
relationship with an obstetrician and/or delivery
hospital;
|
|
b.
|
The
member has been scheduled for an inpatient/outpatient surgery and has been
prior-approved and/or precertified pursuant to OAC rule 5101:3-2-40
(surgical procedures would also include follow-up care as
appropriate);
|
|
c.
|
The
member has appointments within the initial month of MCP membership with
specialty physicians that were scheduled prior tothe effective date of
membership; or
|
|
d.
|
The
member is receiving ongoing chemotherapy or radiation
treatment.
|
|
If
contacted by the member, the MCP must contact the provider’s office as
expeditiously as the situation warrants to confirm that the service(s)
meets the above criteria.
|
ii.
Allow their new members that are
transitioning from Medicaid fee-for-service
to continue receiving home care services (i.e., nursing, aide, and skilled
therapy
services) and private duty nursing (PDN) services if the member or provider
contacts the MCP to discuss the health services in advance of the service date.
These
services must be covered from the date of the member or provider contact at the
current service level, and with the current provider, whether a panel or
out-of-panel
provider, until the MCP conducts a medical necessity review and renders an
authorization decision pursuant to OAC rule 5101:3-26-03.1. As soon as the MCP
becomes aware of the member’s current home care services, the MCP must initiate
contact with the current provider and member as applicable to ensure
continuity of
care and coordinate a transfer of services to a panel provider,
if appropriate.
Appendix
C
Covered
Families and Children (CFC) population
Page
14
|
iii.
|
Honor
any current fee-for-service prior authorization to allow their new members
that are transitioning from Medicaid fee-for-service to receive services
from the authorized provider, whether a panel or out-of-panel provider,
for the following approved
services:
|
|
a.
|
an
organ, bone marrow, or hematapoietic stem cell transplant pursuant to OAC
rule 5101:3-2-07.1 and 2.b.v of Appendix G;
|
b. | dental services that have not yet been received; | |
c. | vision services that have not yet been received; |
|
d.
|
durable
medical equipment (DME) that has not yet been received. Ongoing
DME services and supplies are to be covered by the MCP as
previously-authorized until the MCP conducts a medical necessity review
and renders an authorization decision pursuant to OAC rule
5101:3-26-03.1.
|
e. |
private
duty nursing (PDN) services. PDN services must be covered
at the previously-authorized service level until the MCP conducts a
medical necessity
review
and renders an authorization decision pursuant to OAC rule
5101:3-26-03.1.
|
As soon as the MCP becomes aware of the member’s current fee-for-service
authorization approval, the MCP must initiate contact with the authorized
provider and
member as applicable to ensure continuity of care. The MCP must implement a plan
to meet the member’s immediate and ongoing medical needs and, coordinate the
transfer of services to a panel provider, if appropriate. For organ, bone marrow
or hematapoietic stem cell transplants, MCPs must receive prior approval from
ODJFS
to
transfer services to a panel provider.
When an MCP medical necessity review results in a decision to reduce, suspend,
or terminate services previously authorized by fee-for-service Medicaid, the
MCP
must notify the member of their state hearing rights no less than 15
calendar days prior to the effective date of the MCP’s proposed action, per rule
5101:3-26-08.4 of
the Administrative Code.
iv.
Reimburse out-of-panel providers that agree to provide the transition
services
at 100% of the current Medicaid fee-for-service provider rate for the service(s)
identified in Section 29.i. (i., ii., and iii.) of this
appendix.
Appendix
C
Covered
Families and Children (CFC) population
Page
15
|
v. |
Document
the provision of transition of services identified in Section 29.i. (i.,
ii., and iii.) of this appendix as
follows:
|
|
a. |
For
non-panel providers, notification to the provider confirming the
provider’s agreement/disagreement to provide the service and accept 100%
of the current Medicaid fee-for-service rate as payment. If the provider
agrees, the distribution of the MCP’s materials as outlined in Appendix
G.3.e.
|
|
b. |
Notification
to the member of the non-panel provider’s agreement /disagreement to
provide the service. If the provider disagrees, notification to the member
of the MCP’s availability to assist with locating a provider as
expeditiously as the member’s health condition
warrants.
|
|
c. |
For
panel providers, notification to the provider and member confirming the
MCP’s responsibility to cover the
service.
|
MCPs must use the ODJFS-specified model
language for the provider and member notices and maintain
documentation of all member and/or provider contacts
relating to such services.
30.
Health Information System
Requirements
The ability to develop and maintain information management systems capacity is
crucial to successful plan performance. ODJFS therefore requires MCPs to
demonstrate their
ongoing capacity in this area by meeting several related
specifications.
a.
Health
Information System
i. |
As
required by 42 CFR 438.242(a), each MCP must maintain a health information
system that collects, analyzes, integrates, and reports data. The system
must provide
information on areas including, but not limited to, utilization,
grievances and appeals, and MCP membership terminations for other than
loss of
Medicaid
eligibility.
|
|
|
ii. |
As
required by 42 CFR 438.242(b)(1), each MCP must collect data on member and
provider characteristics and on services furnished to its
members.
|
iii. |
As
required by 42 CFR 438.242(b)(2), each MCP must ensure that data received
from providers is accurate and complete by verifying the accuracy
and
timeliness
of reported data; screening the data for completeness, logic, and
consistency; and collecting service information in standardized formats to
the
extent
feasible and appropriate.
|
Appendix
C
Covered
Families and Children (CFC) population
Page
16
|
iv. |
As
required by 42 CFR 438.242(b)(3), each MCP must make all collected data
available upon request by ODJFS or the Center for Medicare and Medicaid
Services (CMS).
|
|
v. |
Acceptance
testing of any data that is electronically submitted to ODJFS is
required:
|
a. Before an
MCP may submit production files
b. Whenever
an MCP changes the method or preparer of the electronic media; and/or
c. When the
ODJFS determines an MCP’s data submissions have an unacceptably high error
rate.
MCPs that change or modify information systems that are involved in producing
any type of electronically submitted files, either internally or by changing
vendors, are required to submit to ODJFS for review and approval a transition
plan including the submission of test files in the ODJFS-specified formats.
Once an acceptable test file is submitted to ODJFS, as
determined solely by ODJFS, the MCP can return to submitting production files.
ODJFS will inform
MCPs
in writing when a test file is acceptable. Once an MCP’s new or modified
information system is operational, that
MCP will have up to ninety (90) days
to submit an acceptable test file and an acceptable production
file.
Submission of test files can start before the new or modified information system
is in
production. ODJFS reserves the right to verify any MCP’s capability
to
report elements in the minimum data set prior to executing the provider
agreement for the next contract period. Penalties for noncompliance with this
requirement are specified in Appendix N, Compliance Assessment System of the
Provider Agreement.
b.
Electronic Data Interchange and Claims
Adjudication Requirements
Claims Adjudication
|
The
MCP must have the capacity to electronically accept and adjudicate all
claims to final status (payment or denial). Information on claims
submission procedures
must
be provided to non-contracting providers within thirty (30) days of a
request. MCPs
must inform providers of its ability to electronically process and
adjudicate
claims
and the process for submission. Such information must be initiated by the
MCP
and not only in response to provider
requests.
|
Appendix
C
Covered
Families and Children (CFC) population
Page
17
|
The
MCP must notify providers who have submitted claims of claims status
[paid, denied, pended (suspended)] within one month of receipt. Such
notification may be in the form of a claim payment/remittance advice
produced on a routine monthly, or more frequent,
basis.
|
Electronic Data
Interchange
The MCP shall comply with all applicable provisions of HIPAA including
electronic
data interchange (EDI) standards for code sets and the following electronic
transactions:
Health care
claims;
Health care claim status request and response;
Health care claim status request and response;
Health
care payment and remittance status;
Standard
code sets; and
National
Provider Identifier (NPI).
Each EDI transaction processed by the MCP shall be implemented in conformance
with the appropriate version of the transaction implementation guide, as
specified
by applicable federal rule or regulation.
The MCP must have the capacity to accept the following transactions from the
Ohio Department of Job and Family services consistent with EDI
processing
specifications in the transaction implementation guides and in conformance
with the 820 and 834 Transaction Companion Guides issued by
ODJFS:
ASC X12 820 - Payroll Deducted and Other Group Premium Payment for Insurance
Products; and
ASC X12 834 - Benefit Enrollment and Maintenance.
The MCP shall comply with the HIPAA mandated EDI transaction standards and code
sets no later than the required compliance dates as set forth in the federal
regulations.
Documentation of Compliance with
Mandated EDI Standards
The capacity of the MCP and/or applicable trading partners and business
associates to electronically conduct claims processing and related transactions
in
compliance with standards and effective dates mandated by HIPAA must be
demonstrated, to the satisfaction of ODJFS, as outlined
below.
Appendix
C
Covered
Families and Children (CFC) population
Page
18
Verification of Compliance with HIPAA
(Health Insurance Portability and Accountability Act of
1995)
MCPs shall comply with the transaction standards and code sets for sending and
receiving applicable transactions as specified in 45 CFR Part 162 – Health
Insurance
Reform: Standards for Electronic Transactions (HIPAA regulations) In addition
the MCP must enter into the appropriate trading partner agreement and
implemented
standard code sets. If the MCP has obtained third-party certification of HIPAA
compliance for any of the items listed below, that certification may be
submitted in lieu
of the MCP’s written verification for the applicable item(s).
i. Trading
Partner Agreements
ii. Code
Sets
iii. Transactions
|
a.
|
Health Care Claims or Equivalent Encounter Information (ASC X12N 837 & NCPDP 5.1) |
b. | Eligibility for a Health Plan (ASC X12N 270/271) | |
c. | Referral Certification and Authorization (ASC X12N 278) | |
d. | Health Care Claim Status (ASC X12N 276/277) | |
e. | Enrollment and Disenrollment in a Health Plan (ASC X12N 834) | |
f. | Health Care Payment and Remittance Advice (ASC X12N 835) | |
g. | Health Plan Premium Payments (ASC X12N 820) | |
h. | Coordination of Benefits |
Trading Partner Agreement with
ODJFS
MCPs must complete and submit an EDI trading
partner agreement in a format specified by the ODJFS. Submission of the copy of
the trading partner agreement prior
to entering into this Agreement may be waived at the discretion of ODJFS; if
submission prior to entering into this Agreement is waived, the trading partner
agreement must be
submitted at a subsequent date determined by ODJFS.
Noncompliance with the EDI and claims adjudication requirements will result in
the imposition of penalties, as outlined in Appendix N, Compliance Assessment
System, of the Provider Agreement.
c. Encounter Data Submission
Requirements
General
Requirements
Each MCP must collect data on services
furnished to members through an encounter data system and must report encounter
data to the ODJFS. MCPs are required to
submit this data
electronically to ODJFS on a monthly basis in the following standard
formats:
Appendix
C
Covered
Families and Children (CFC) population
Page
19
• Institutional Claims - UB92 flat
file
• Noninstitutional Claims - National
standard format
• Prescription Drug Claims -
NCPDP
ODJFS relies heavily on encounter
data for monitoring MCP performance. The ODJFS uses encounter data to measure
clinical performance, conduct access and
utilization reviews,
reimburse MCPs for newborn deliveries and aid in setting MCP capitation rates.
For these reasons, it is important that encounter data is timely,
accurate, and complete. Data
quality, performance measures and standards are described in the
Agreement.
An encounter represents all of the services, including medical
supplies and medications, provided to a member of the MCP by a particular
provider, regardless of the
payment arrangement
between the MCP and the provider. For example, if a member had an emergency
department visit and was examined by a physician, this would
constitute two encounters,
one related to the hospital provider and one related to the physician provider.
However, for the purposes of calculating a utilization
measure, this would be counted
as a
single emergency department visit. If a member visits their PCP and the PCP
examines the member and has laboratory procedures
done within the office, then this is
one encounter
between the member and their PCP.
If the PCP sends the member to a lab to have procedures performed, then this is
two encounters; one with the PCP and another with the lab. For pharmacy
encounters,
each prescription
filled is a separate encounter.
Encounters include services paid for retrospectively through fee-for-service
payment arrangements, and prospectively through capitated arrangements.
Only
encounters with services
(line items) that are paid by the MCP, fully or in part, and for which no
further payment is anticipated, are acceptable encounter data
submissions, except for immunization
services. Immunization services submitted to the MCP must be submitted to ODJFS
if these services were paid for by another
entity (e.g., free vaccine program).
All other services that are unpaid or paid in part and for which the MCP
anticipates further payment (e.g., unpaid services rendered during a delivery of
a newborn)
may
not be submitted
to ODJFS until they are paid. Penalties for noncompliance with this requirement
are specified in Appendix N, Compliance Assessment System
of the Agreement.
Appendix
C
Covered
Families and Children (CFC) population
Page
20
Acceptance
Testing
The MCP must have the
capability to report all elements in the Minimum Data Set as set forth in the
ODJFS Encounter Data Specifications and must submit a test file
in
the ODJFS-specified
medium in the required formats prior to contracting or prior to an information
systems replacement or update.
Acceptance testing of encounter data is
required as specified in Section 29(a)(v) of this Appendix.
Encounter Data File Submission
Procedures
A certification letter must accompany the submission of an encounter data file
in the ODJFS-specified medium. The certification letter must be signed by the
MCP’s
Chief Executive
Officer (CEO), Chief Financial Officer (CFO), or an individual who has delegated
authority to sign for, and who reports directly to, the MCP’s CEO
or
CFO.
Timing
of Encounter Data Submissions
ODJFS recommends that MCPs submit encounters no more
than thirty-five (35) days after the end of the month in which they were paid.
For example, claims paid in
January are due March
5. ODJFS recommends that MCPs submit files in the ODJFS-specified medium by the
5th of each month. This will help to ensure that the
encounters are included in the ODJFS
master file in the same month in which they were submitted.
d. Information Systems
Review
ODJFS
or its designee may review the information system capabilities of each MCP,
before ODJFS enters into a provider agreement with a new MCP, when
a
participating
MCP undergoes
a major information system upgrade or change, when there is identification of
significant information system problems, or at ODJFS’
discretion. Each MCP must participate
in the review. The review will assess the extent to which MCPs are capable of
maintaining a health information system including
producing valid encounter data, performance
measures, and other data necessary to support quality assessment and
improvement, as well as managing the care
delivered to its members.
The
following activities, at a minimum, will be carried out during the review. ODJFS
or its designee will:
|
i. |
Review
the Information Systems Capabilities Assessment (ISCA) forms, as developed
by CMS; which the MCP will be required to
complete.
|
Appendix
C
Covered
Families and Children (CFC) population
Page
21
ii. Review the
completed ISCA and accompanying documents;
iii.
|
Conduct
interviews with MCP staff responsible for completing the ISCA, as well as
staff responsible for aspects of the MCP’s information systems
function;
|
iv.
|
Analyze
the information obtained through the ISCA, conduct follow-up interviews
with MCP staff, and write a statement of findings about the MCP’s
information system.
|
v. Assess the ability
of the MCP to link data from multiple sources;
vi. Examine MCP processes
for data transfers;
vii.
|
If
an MCP has a data warehouse, evaluate its structure and reporting
capabilities;
|
viii.
|
Review
MCP processes, documentation, and data files to ensure that they comply
with state specifications for encounter data submissions;
and
|
ix.
|
Assess
the claims adjudication process and capabilities of the
MCP.
|
31. Delivery
Payments
MCPs will be reimbursed for paid deliveries that are identified in the submitted
encounters using the methodology outlined in the ODJFS Delivery Payment and
Reporting
Procedures document. The delivery payment represents the facility
and professional service costs associated with the delivery event and postpartum
care that is rendered in
the hospital immediately following the delivery event; no prenatal or
neonatal experience is included in the delivery payment.
If a delivery occurred, but the MCP did not reimburse providers for any costs
associated with the delivery, then the MCP shall not submit the delivery
encounter to ODJFS and
is not entitled to receive payment for the delivery. Delivery encounters
submitted by MCPs must be received by ODJFS no later than 460 days after the
last date of service.
Delivery encounters which are received by ODJFS after this time will be
denied payment. MCPs will receive notice of the payment denial on the remittance
advice.
To capture deliveries outside of institutions (e.g., hospitals) and deliveries
in hospitals without an accompanying physician encounter, both the institutional
encounters (UB-
92) and the noninstitutional encounters (NSF) are searched for
deliveries.
Appendix
C
Covered
Families and Children (CFC) population
Page
22
If
a physician and a hospital encounter is found for the same delivery, only one
payment will be made. The same is true for multiple births; if multiple delivery
encounters are
submitted, only one payment will be made. The method for reimbursing for
deliveries includes the delivery of stillborns where the MCP incurred costs
related to the delivery.
Rejections
If
a delivery encounter is not submitted according to ODJFS specifications, it will
be rejected
and MCPs will receive this information on the exception report (or error
report)
that
accompanies every file in the ODJFS-specified format. Tracking, correcting and
resubmitting
all rejected encounters is the responsibility of the MCP and is required
by
ODJFS.
Timing of Delivery
Payments
MCPs will be paid monthly for deliveries. For example, payment for a delivery
encounter submitted with the required encounter data submission in March, will
be reimbursed in
March. The delivery payment will cover any encounters submitted with the monthly
encounter data submission regardless of the date of the encounter, but will not
cover
encounters that occurred over one year ago.
This payment will be a part of the weekly update (adjustment payment) that is in
place currently. The third weekly update of the month will include the delivery
payment. The
remittance advice is in the same format as the capitation remittance
advice.
Updating and Deleting Delivery
Encounters
The process for updating and deleting delivery encounters is handled
differently from all other encounters. See the ODJFS Encounter Data Specifications
for detailed
instructions
on updating and deleting delivery encounters.
The process for deleting delivery encounters can be found on page 35 of
the UB-92 technical specifications (record/field 20-7) and page III-47 of the
NSF technical
specifications (record/field CA0-31.0a).
Auditing of Delivery
Payments
A delivery payment audit will be conducted periodically. If medical records do
not substantiate that a delivery occurred related to the payment that was made,
then ODJFS will
recoup the delivery payment from the MCP. Also, if it is determined that
the encounter which triggered the delivery payment was not a paid encounter,
then ODJFS will recoup
the delivery payment.
32.
|
If
the MCP will be using the Internet functions that will allow approved
users to access member information (e.g., eligibility verification), the
MCP must ensure that the proper safeguards, firewalls, etc., are in place
to protect member data.
|
Appendix
C
Covered
Families and Children (CFC) population
Page
23
33.
|
MCPs
must receive prior written approval from ODJFS before adding any
information to their website that would require ODJFS prior approval in
hard copy form (e.g., provider listings, member handbook
information).
|
34.
|
Pursuant
to 42 CFR 438.106(b), the MCP acknowledges that it is prohibited from
holding a member liable for services provided to the member in the event
that the ODJFS fails to make payment to the
MCP.
|
35.
|
In
the event of an insolvency of an MCP, the MCP, as directed by ODJFS, must
cover the continued provision of services to members until the end of the
month in which insolvency has occurred, as well as the continued provision
of inpatient services until the date of discharge for a member who is
institutionalized when insolvency
occurs.
|
36. Franchise Fee Assessment
Requirements
a.
|
Each
MCP is required to pay a franchise permit fee to ODJFS for each calendar
quarter as required by ORC Section 5111.176. The current fee to be paid is
an amount equal to 5.5 percent of the managed care premiums, minus
Medicare premiums that the MCP received from any payer in the quarter to
which the fee applies. Any premiums the MCP returned or refunded to
members or premium payers during that quarter are excluded from the
fee.
|
b.
|
The
franchise fee is due to ODJFS in the ODJFS-specified format on or before
the 30th day following the end of the calendar quarter to which the fee
applies.
|
c.
|
At
the time the fee is submitted, the MCP must also submit to ODJFS a
completed form and any supporting documentation pursuant to ODJFS
specifications.
|
d.
|
Penalties
for noncompliance with this requirement are specified in Appendix N,
Compliance Assessment System of the Provider Agreement and in ORC Section
5111.176.
|
37. Information Required for MCP
Websites
a.
|
On-line Provider
Directory – MCPs must have an internet-based provider directory
available in the same format as their ODJFS-approved provider directory,
that allows members to electronically search for the MCP panel providers
based on name, provider type, geographic proximity, and population (as
specified in Appendix H). MCP provider directories must include all
MCP-contracted providers [except as specified by ODJFS] as well as certain
ODJFS non-contracted
providers.
|
Appendix
C
Covered
Families and Children (CFC) population
Page
24
b.
|
On-line Member
Website - MCPs must have a secure internet-based website which
provides members the ability to submit questions, comments, grievances,
and appeals, and receive a response (members must be given the option of a
return e-mail or phone call). MCP responses to questions or comments must
be made within one working day of receipt. MCP responses to grievances and
appeals must adhere to the timeframes specified in OAC rule
5101:3-26-08.4. The member website must be regularly updated to include
the most current ODJFS-approved materials, although this website must not
be the only means for notifying members of new and/or revised MCP
information (e.g., change in holiday closures, changes in additional
benefits, revisions to approved member
materials).
|
The MCP member website must also include, at a minimum, the following
information which must be accessible to members and the general public without
any log-in
restrictions:
(1) MCP contact information, including the MCP’s toll-free member services phone
number, service hours, and closure dates; (2) a list of counties
covered in the MCP’s service area; (3) the ODJFS-approved MCP member
handbook, recent newsletters and announcements; (4) the MCP’s on-line
provider
directory as referenced in section 36(a) of this appendix; (5) the MCP’s
current preferred drug list (PDL), including an explanation of the list, which
drugs require prior
authorization (PA), and how to initiate a PA; and (6) the MCP’s current list of
drugs covered only with PA, how to initiate a PA, and the MCP’s policy for
covering
name brand drugs. MCPs must ensure that all website member information and
materials are clearly labeled for CFC members and/or ABD members, as
applicable.
ODJFS may require MCPs to include additional information on the member
website as needed.
c.
|
On-line Provider
Website – MCPs must have a secure internet-based website for
contracting providers through which providers can confirm a consumer’s
enrollment and through which providers can submit and receive responses to
prior authorization requests (an e-mail process is an acceptable
substitute if the website includes the MCP’s e-mail address for such
submissions).
|
The MCP provider website must also include, at a minimum, the following
information which must be accessible to providers and the general public without
any log-
in restrictions:
(1) MCP contact information, including the MCP’s designated contact for provider
issues; (2) a list of counties covered in the MCP’s service area;
(3)
the MCP’s provider manual including the MCP's claims submission process,
as well as a list of services requiring prior authorization, recent newsletters
and
announcements; (4) the MCP’s on-line provider directory as
referenced in section 36(a) of this appendix; (5) the MCP’s current PDL,
including an explanation of the
list, which drugs require PA, and how to initiate a PA; and (6) the MCP’s
current list of drugs covered only with PA, how to initiate a PA, and the MCP’s
policy for
covering name brand drugs. MCPs must ensure that all website information and
materials are clearly labeled for CFC members and/or ABD members, as
applicable.
ODJFS may require MCPs to include additional information on the provider
website as needed.
Appendix
C
Covered
Families and Children (CFC) population
Page
25
38.
|
MCPs
must provide members with a printed version of their PDL and PA lists,
upon request.
|
39.
|
MCPs
must not use, or propose to use, any offshore programming or call center
services in fulfilling the program
requirements.
|
40. Coordination of
Benefits
When a claim is denied due to third party liability, the managed care plan must
timely share appropriate and available information regarding the third party to
the provider for
the purposes of coordination of benefits, including, but not limited to
third party liability information received from the Ohio Department of Job and
Family Services.
41.
|
MCP
submissions with due dates that fall on a weekend or holiday are due the
next business
day.
|
Appendix
D
Covered
Families and Children (CFC) population
Page
1
APPENDIX
D
ODJFS
RESPONSIBILITIES
CFC
ELIGIBLE POPULATION
The
following are ODJFS responsibilities or clarifications that are not otherwise
specifically stated in OAC Chapter 5101: 3-26 or elsewhere in the ODJFS-MCP
provider agreement.
General
Provisions
1.
|
ODJFS
will provide MCPs with an opportunity to review and comment on the
rate-setting time line and proposed rates, and proposed changes to the OAC
program rules or the provider
agreement.
|
2.
|
ODJFS
will notify MCPs of managed care program policy and procedural changes
and, whenever possible, offer sufficient time for comment and
implementation.
|
3.
|
ODJFS
will provide regular opportunities for MCPs to receive program updates and
discuss program issues with ODJFS
staff.
|
4.
|
ODJFS
will provide technical assistance sessions where MCP attendance and
participation is required. ODJFS will also provide optional technical
assistance sessions to MCPs, individually or as a
group.
|
5.
|
ODJFS
will provide MCPs with an annual MCP Calendar of Submissions outlining
major submissions and due
dates.
|
6.
|
ODJFS
will identify contact staff, including the Contract Administrator,
selected for each MCP.
|
7.
|
ODJFS
will recalculate the minimum provider panel specifications if ODJFS
determines that significant changes have occurred in the availability of
specific provider types and the number and composition of the eligible
population.
|
8.
|
ODJFS
will recalculate the geographic accessibility standards, using the
geographic information systems (GIS) software, if ODJFS determines that
significant changes have occurred in the availability of specific provider
types and the number and composition of the eligible population and/or the
ODJFS provider panel
specifications.
|
9.
|
On
a monthly basis, ODJFS will provide MCPs with an electronic file
containing their MCP’s provider panel as reflected in the ODJFS Provider
Verification System (PVS) database, or other designated
system.
|
Appendix D
Covered
Families and Children (CFC) population
Page
2
10.
|
On
a monthly basis, ODJFS will provide MCPs with an electronic Provider
Master File containing all the Ohio Medicaid fee-for-service providers,
which includes their Medicaid Provider Number, as well as all providers
who have been assigned a provider reporting number for current encounter
data purposes. This file also includes National Provider Identifier (NPI)
information where applicable.
|
11.
|
It
is the intent of ODJFS to utilize electronic commerce for many processes
and procedures that are now limited by HIPAA privacy concerns to FAX,
telephone, or hard copy. The use of TLS will mean that private health
information (PHI) and the identification of consumers as Medicaid
recipients can be shared between ODJFS and the contracting MCPs via e-mail
such as reports, copies of letters, forms, hospital claims, discharge
records, general discussions of member-specific information, etc. ODJFS
may revise data/information exchange policies and procedures for many
functions that are now restricted to FAX, telephone, and hard copy,
including, but not limited to, monthly membership and premium payment
reconciliation requests, newborn reporting, Just Cause disenrollment
requests, information requests etc. (as specified in Appendix
C).
|
12.
|
ODJFS
will immediately report to Center for Medicare and Medicaid Services (CMS)
any breach in privacy or security that compromises protected health
information (PHI), when reported by the MCP or ODJFS
staff.
|
13.
|
Service Area
Designation Membership in a service area is mandatory unless ODJFS
approves membership in the service area for consumer initiated selections
only. It is ODJFS’current intention to implement a mandatory managed
care program in service areas wherever choice and capacity
allow and the criteria in 42 CFR 438.50(a) are
met.
|
14. Consumer
information
a.
|
ODJFS
or its delegated entity will provide membership notices, informational
materials, and instructional materials relating to members and eligible
individuals in a manner and format that may be easily understood. At least
annually, ODJFS or designee will provide MCP eligible individuals,
including current MCP members, with a Consumer Guide. The Consumer Guide
will describe the managed care program and include information on the MCP
options in the service area and other information regarding the managed
care program as specified in 42 CFR
438.10.
|
b.
|
ODJFS
will notify members or ask MCPs to notify members about significant
changes affecting contractual requirements, member services or access to
providers.
|
c.
|
If
an MCP elects not to provide, reimburse, or cover a counseling service or
referral service due to an objection to the service on moral or religious
grounds, ODJFS will provide
coverage and reimbursement for these services for the MCP’s members.
ODJFS
will provide information on what services the MCP will not cover and how
and
where the MCP’s members may obtain these services in the applicable
Consumer
Guides.
|
Appendix
D
Covered
Families and Children (CFC) population
Page
3
15.
Membership Selection
and Premium Payment
a.
|
The
managed care enrollment center (MCEC): The ODJFS-contracted MCEC will
provide unbiased education, selection services, and community outreach for
the Medicaid managed care program. The MCEC shall operate a statewide
toll-free telephone center to assist eligible individuals in selecting an
MCP or choosing a health care delivery
option.
|
The MCEC shall distribute the most current Consumer Guide that includes the
managed care program information as specified in 42 CFR 438.10, as well as
ODJFS
prior-approved MCP materials, such as solicitation brochures and provider
directories, to consumers who request additional materials.
b.
|
Auto-Assignment
Limitations – In order to ensure market and program stability,
ODJFS may limit an MCP’s auto-assignments if they meet any of the
following enrollment
thresholds:
|
•
|
55% of the statewide Covered Families and Children (CFC) eligible population; and/or
|
• | 70% of the CFC eligibles in any region with two MCPs; and/or |
• | 55% of the CFC eligibles in any region with three MCPs |
Once an MCP meets one of these enrollment thresholds, the MCP will only be
permitted to receive the additional new membership (in the region or statewide,
as
applicable) through: (1) consumer-initiated enrollment; and (2) auto-assignments
which are based on previous enrollment in that MCP or based on an historical
provider relationship with a provider who is not on the panel of any other MCP
in that region. In the event that an MCP in a region meets one or more of these
enrollment thresholds, ODJFS, in their sole discretion, may not impose the
auto-assignment limitation and auto-assign members to the MCPs in that region as
ODJFS
deems appropriate.
c
.
|
Performance Based
Auto-Assignments – Consumers who do not voluntarily select an MCP
or are not auto-assigned to an MCP based on previous enrollment in that
MCP or an historical provider relationship with a provider who is not on
the panel of another MCP in that region, will be auto-assigned based on
the MCP performance using the following performance rating
system:
|
Appendix
D
Covered
Families and Children (CFC) population
Page
4
MCPs will be scored based on the following ten measures:
i. MCP
Consumer Call Center (see Appendix C)
– Average Speed of
Answer
– Abandonment
Rate
– Blockage
rate
ii. MCP
Provider Call Center (measurement and standards will match those set for the MCP
Consumer Call Center outlined in Appendix
C.
– Average Speed of
Answer
– Abandonment
Rate
– Blockage
rate
iii. MCP Prior
Authorization (see OAC 5101:3-26-03.1)
– Average Time to Process
Non-Pharmacy Requests
– Average
Time to Process Pharmacy Requests
iv. Prompt Payment
of Claims (see Appendix J)
– Percentage
of Claims Paid within 30days
– Percentage
of Claims Paid within 90 days
Each MCP will receive a point for meeting the established standard. If an MCP
meets the established standard for each measure, they will receive ten points.
For each region,
the MCP with the highest score will receive the performance-based
auto-assignments for the region. If there is a tie for the highest score, then
each tying MCP will be
considered equal in the auto-assignment process. Scoring will take place
quarterly and applied to the auto-assignment process once the results are
finalized.
On a regional basis, MCPs that have auto-assignment limitations in accordance
with 15(b) do not qualify for performance-based auto-assignments unless (1)
there are two
MCPs in the region, (2) the auto-assignment limited MCP received 10 points
and (3) the other MCP in the regional failed to receive 10 points. In this case,
the MCP with the
auto-assignment limitation shall receive auto-assignments in the amount of
10% of the performance based auto-assignments for every point the other MCP is
below 10 points
(i.e.
if the other MCP has 7 points then the MCP would receive 30% (3 points *
10%)).
If
ODJFS implements a new enrollment freeze on an MCP as outlined in Appendix N,
the MCP will not receive any auto-assignments. Should ODJFS remove the new
enrollment
freeze, the MCP will not be entitled to receive performance based
auto-assignments until the next quarterly review is performed and implemented as
outlined in this section.
Appendix
D
Covered
Families and Children (CFC) population
Page
5
d.
|
Consumer Contact
Record (CCR): ODJFS or their designated entity shall forward CCRs
to MCPs on no less than a weekly basis. The CCRs are a record of each
consumer-initiated MCP enrollment, change, or termination, and each MCEC
initiated MCP assignment processed through the MCEC. The CCR contains
information that is not included on the monthly member
roster.
|
e.
|
Monthly member roster
(MR): ODJFS verifies managed care plan enrollment on a monthly
basis via the monthly membership roster. ODJFS or its designated entity
provides a full member roster (F) and a change roster (C) via HIPAA 834
compliant transactions.
|
f.
|
Monthly Premiums and
Delivery Payments: ODJFS will remit payment to the MCPs via an
electronic funds transfer (EFT), or at the discretion of ODJFS, by paper
warrant.
|
g.
|
Remittance
Advice: ODJFS will confirm all premium payments and delivery
payments paid to the MCP during the month via a monthly remittance advice
(RA), which is sent to the MCP the week following state cut-off. ODJFS or
its designated entity provides a record of each payment via HIPAA 820
compliant transactions.
|
h.
|
MCP Reconciliation
Assistance: ODJFS will work with an MCP-designated contact(s) to
resolve the MCP’s member and newborn eligibility inquiries, premium and
delivery payment inquiries/discrepancies and to review/approve hospital
deferment requests.
|
16. ODJFS
will make available a website which includes current program
information.
17.
|
ODJFS
will regularly provide information to MCPs regarding different aspects of
MCP performance including, but not limited to, information on MCP-specific
and statewide external quality review organization surveys, focused
clinical quality of care studies, consumer satisfaction surveys and
provider profiles.
|
18.
|
ODJFS
will periodically review a random sample of online and printed directories
to assess whether MCP information is both accessible and
updated.
|
19. Communications
a.
ODJFS/BMHC:
|
The
Bureau of Managed Health Care (BMHC) is responsible for the oversight of
the MCPs’ provider agreements with ODJFS. Within the BMHC, a specific
Contract Administrator (CA) has been assigned to each MCP. Unless
expressly directed otherwise, MCPs shall first contact their designated CA
for questions/assistance related to Medicaid and/or the MCP’s program
requirements /responsibilities. If their CA is not available and the MCP
needs immediate assistance, MCP staff should request to speak to a
supervisor within the Contract Administration Section. MCPs should take
all necessary and appropriate steps to ensure all MCP staff are aware of,
and follow, this communication
process.
|
Appendix
D
Covered
Families and Children (CFC) population
Page
6
b.
ODJFS
contracting-entities: ODJFS-contracting entities should never be
contacted
by the MCPs unless the MCPs have been specifically instructed to contact the
ODJFS contracting entity directly.
c.
|
MCP delegated
entities: In that MCPs are ultimately responsible for meeting
program requirements, the BMHC will not discuss MCP issues with the MCPs’
delegated entities unless the applicable MCP is also participating in the
discussion. MCP delegated entities, with the applicable MCP participating,
should only communicate with the specific CA assigned to that
MCP.
|
APPENDIX
F
REGIONAL
RATES
1.
PREMIUM RATES WITHOUT THE AT-RISK PAYMENT AMOUNTS FOR 01/01/09 THROUGH 06/30/09
SHALL BE AS FOLLOWS: An
at-risk amount of 1% is applied to the MCP rates. The status of the at-risk
amount is determined in accordance with Appendix O, performance
incentives.
MCP:
WellCare of Ohio, Inc.
SERVICE
ENROLLMENT
AREA
|
REGIONAL
STATUS
|
HF/HST
Age
< 1
|
HF/HST
Age
1
|
HF/HST
Age
2-13
|
HF/HST
Age
14-18
Male
|
HF/HST
Age
14-18
Female
|
HF
Age
19-44
Male
|
HF
Age
19-44
Female
|
HF
Age
45
and
over
|
HST
Age
19-64
Female
|
Delivery
Payment
|
Northeast
|
Mandatory
|
$560.36
|
$138.09
|
$98.52
|
$127.48
|
$171.11
|
$214.01
|
$318.30
|
$490.82
|
$395.17
|
$4,482.86
|
List
of Eligible Assistance Groups (AGs)
Healthy
Families: - MA-C Categorically eligible due to TANF
cash
-
MA-T Children under 21
- MA-Y Transitional
Medicaid
Healthy
Start: - MA-P Pregnant Women and
Children
For the
SFY 2009 contract period, MCPs will be put at-risk for a portion of the premiums
received for members in regions they served as of January
1, 2006, provided the MCP has participated in the program for more than
twenty-four months.
MCPs will
be put at-risk for a portion of the premiums received for members in regions
they began serving after January 1, 2006, beginning with the
MCP's twenty-fifth month of membership in each region. The at-risk amount will
be determined separately for each region an MCP serves. WellCare's regions at
risk: Northeast.
Page 1 of
3
APPENDIX
F
REGIONAL
RATES
2. AT-RISK AMOUNTS FOR 01/01/09 THROUGH 06/30/09 SHALL BE AS FOLLOWS: An at-risk
amount of 1% is applied to the MCP rates. The status of the at-risk amount is
determined in accordance with Appendix O, performance
incentives.
MCP:
WellCare of Ohio, Inc.
SERVICE
ENROLLMENT
AREA
|
REGIONAL
STATUS
|
HF/HST
Age
< 1
|
HF/HST
Age
1
|
HF/HST
Age
2-13
|
HF/HST
Age
14-18
Male
|
HF/HST
Age
14-18
Female
|
HF
Age
19-44
Male
|
HF
Age
19-44
Female
|
HF
Age
45
and
over
|
HST
Age
19-64
Female
|
Delivery
Payment
|
Northeast
|
Mandatory
|
$5.35
|
$1.32
|
$0.94
|
$1.22
|
$1.63
|
$2.04
|
$3.04
|
$4.68
|
$3.77
|
$42.77
|
List
of Eligible Assistance Groups (AGs)
Healthy
Families: - MA-C Categorically eligible due to TANF
cash
- MA-T Children under 21
- MA-Y Transitional Medicaid
Healthy
Start: -
MA-P Pregnant Women and Children
For the
SFY 2009 contract period, MCPs will be put at-risk for a portion of the premiums
received for members in regions they served as of January
1, 2006, provided the MCP has participated in the program for more than
twenty-four months.
MCPs will
be put at-risk for a portion of the premiums received for members in regions
they began serving after January 1, 2006, beginning with the
MCP's twenty-fifth month of membership in each region. The at-risk amount will
be determined separately for each region an MCP serves. WellCare's regions at
risk: Northeast.
Page 2 of
3
APPENDIX
F
REGIONAL
RATES
3. PREMIUM RATES FOR 01/01/09 THROUGH 06/30/09 SHALL BE AS FOLLOWS: An at-risk
amount of 1% is applied to the MCP rates. The status of the at-risk amount is
determined in accordance with Appendix O, performance
incentives.
MCP:
WellCare of Ohio, Inc.
SERVICE
ENROLLMENT
AREA
|
REGIONAL
STATUS
|
HF/HST
Age
< 1
|
HF/HST
Age
1
|
HF/HST
Age
2-13
|
HF/HST
Age
14-18
Male
|
HF/HST
Age
14-18
Female
|
HF
Age
19-44
Male
|
HF
Age
19-44
Female
|
HF
Age
45
and
over
|
HST
Age
19-64
Female
|
Delivery
Payment
|
Northeast
|
Mandatory
|
$565.71
|
$139.41
|
$99.46
|
$128.70
|
$172.74
|
$216.05
|
$321.34
|
$495.50
|
$398.94
|
$4,525.63
|
List
of Eligible Assistance Groups (AGs)
Healthy
Families: - MA-C Categorically eligible due to TANF
cash
- MA-T Children
under 21
- MA-Y Transitional Medicaid
Healthy
Start: -
MA-P Pregnant Women and Children
For the
SFY 2009 contract period, MCPs will be put at-risk for a portion of the premiums
received for members in regions they served as of January 1,
2006, provided the MCP has participated in the program for more than twenty-four
months.
MCPs will
be put at-risk for a portion of the premiums received for members in regions
they began serving after January 1, 2006, beginning with the
MCP's twenty-fifth month of membership in each region. The at-risk amount will
be determined separately for each region an MCP serves. WellCare's regions at
risk: Northeast.
Page 3 of
3
Appendix
G
Covered
Families and Children (CFC) population
Page
1
APPENDIX
G
COVERAGE
AND SERVICES
CFC
ELIGIBLE POPULATION
1.
Basic
Benefit Package
Pursuant to OAC rule 5101:3-26-03(A), with limited exclusions (see section G.2
of this appendix), MCPs must ensure that members have access to
medically-necessary services
covered by the Ohio Medicaid fee-for-service (FFS) program, and any additional
services as specified in OAC rule 5101:3-26-03. For information on
Medicaid-covered services,
MCPs must refer to the ODJFS website. The following is a general list of
the benefits covered by the Ohio Medicaid fee-for-service
program:
• Inpatient hospital
services
• Outpatient hospital
services
• Rural health clinics (RHCs) and
Federally qualified health centers (FQHCs)
•
|
Physician
services whether furnished in the physician’s office, the covered person’s
home, a hospital, or
elsewhere
|
• Laboratory and x-ray
services
•
|
Screening,
diagnosis, and treatment services to children under the age of twenty-one
(21) under the HealthChek (EPSDT)
program
|
• Family planning
services and supplies
• Home health and private duty nursing
services
• Podiatry
• Chiropractic
services
•
|
Physical
therapy, occupational therapy, developmental therapy and speech
therapy
|
•
|
Nurse-midwife,
certified family nurse practitioner, and certified pediatric nurse
practitioner services
|
• Prescription
drugs
• Ambulance and ambulette
services
• Dental
services
Appendix
G
Covered
Families and Children (CFC) population
Page
2
• Durable medical equipment and
medical supplies
• Vision care services, including
eyeglasses
• Nursing facility stays as specified
in OAC rule 5101:3-26-03
• Hospice care
• Behavioral health services (see
section G.2.b.iii of this appendix)
2. Exclusions, Limitations and Clarifications
a. Exclusions
MCPs are not required to pay for Ohio Medicaid FFS program (Medicaid)
non-covered services, except as specified in OAC rule 5101:3-26-03. For
information
regarding Medicaid noncovered services, MCPs must refer to the ODJFS
website. The following is a general list of the services not covered by the
Ohio
Medicaid fee-for-service program:
• Services
or supplies that are not medically necessary
•
|
Experimental services and procedures, including drugs and
equipment, not covered by
Medicaid
|
•
|
Abortions,
except in the case of a reported rape, incest, or when medically necessary
to save the life of the
mother
|
• Infertility services for males or
females
•
|
Voluntary
sterilization if under 21 years of age or legally incapable of consenting
to the procedure
|
• Reversal of voluntary sterilization
procedures
• Plastic or cosmetic surgery that is
not medically necessary*
• Services
for the treatment of obesity unless medically necessary*
• Custodial or supportive care not
covered by Medicaid
• Sexual or marriage
counseling
• Acupuncture and biofeedback
services
Appendix
G
Covered
Families and Children (CFC) population
Page
3
• Services to find cause of death
(autopsy)
• Comfort items in the hospital (e.g.,
TV or phone)
•
Paternity testing
MCPs are also not required to pay for non-emergency services or supplies
received without members following the directions in their MCP member handbook,
unless
otherwise directed by ODJFS.
*These services could be deemed medically necessary if medical
complications/conditions in addition to the obesity or physical imperfection are
present.
b.
Limitations &
Clarifications
i.
Member
Cost-Sharing
As specified in OAC rules 5101:3-26-05(D) and 5101:3-26-12, MCPs are permitted
to impose the applicable member co-payment amount(s) for dental services,
vision services, non-emergency emergency department services, or prescription
drugs, other than generic drugs. MCPs must notify ODJFS if they intend
to
impose a co-payment. ODJFS must approve the notice to be sent to the MCP’s
members and the timing of when the co-payments will begin to be imposed. If
ODJFS determines that an MCP’s decision to impose a particular co-payment on
their members would constitute a significant change for those members,
ODJFS may require the effective date of the co-payment to coincide with the
“Open Enrollment” month.
Notwithstanding the preceding paragraph, MCPs must provide an ODJFS-approved
notice to all their members 90 days in advance of the date that the
MCP
will impose the co-payment. With the exception of member co-payments the
MCP has elected to implement in accordance with OAC rules 5101:3-26-05(D) and
5101:3-26-12, the MCP’s payment constitutes payment in full for any covered
services and their subcontractors must not charge members or ODJFS any
additional co-payment, cost sharing, down-payment, or similar charge, refundable
or otherwise.
ii. Abortion and
Sterilization
The use of federal funds to pay for abortion and sterilization services is
prohibited unless the specific criteria found in 42 CFR 441 and OAC rules
5101:3-17-01
and 5101:3-21-01 are met. MCPs must verify that all of the information on
the required forms (JFS 03197, 03198, and 03199) is provided and that the
service
meets the required criteria before
any such claim is paid.
Appendix
G
Covered
Families and Children (CFC) population
Page
4
Additionally, payment must not be made for associated services such as
anesthesia, laboratory tests, or hospital services if the abortion or
sterilization itself
does not qualify for payment. MCPs are responsible for educating their
providers on the requirements; implementing internal procedures including
systems
edits
to ensure that claims are only paid once the MCP has determined if the
applicable forms are completed and the required criteria are met, as confirmed
by
the appropriate certification/consent forms; and for maintaining
documentation to justify any such claim payments.
iii. Behavioral Health
Services
Coordination of
Services: MCPs must have a process to coordinate benefits
of and referrals to the publicly funded community behavioral health
system.
MCPs must
ensure that members have access to all medically-necessary behavioral health
services covered by the Ohio Medicaid FFS program and are
responsible
for coordinating those services with other medical and support services. MCPs
must notify members via the member handbook and provider
directory of where and how to access behavioral health
services, including the ability to self-refer to mental health services offered
through ODMH
community mental
health centers (CMHCs) as well as substance abuse services offered through Ohio
Department of Alcohol and Drug Addiction Services
(ODADAS)-certified
Medicaid providers. Pursuant to ORC Section 5111.16, alcohol, drug addiction and
mental health services covered by Medicaid are not to
be paid by the
managed care program when the nonfederal share of the cost of those services is
provided by a board of alcohol, drug addiction, and mental
health services
or a state agency other than ODJFS. MCPs are also not responsible for providing
mental health services to persons between 22 and 64 years of
age while
residing in an institution for mental disease (IMD) as defined in Section
1905(i) of the Social Security Act.
MCPs must provide Medicaid-covered behavioral health services for members who
are unable to timely access services or are unwilling to access
services
through community providers.
Mental Health
Services:
There are a number of Medicaid-covered mental health (MH) services available
through ODMH CMHCs.
Appendix
G
Covered
Families and Children (CFC) population
Page
5
Where an MCP is responsible for providing MH services
for their members, the MCP is responsible for ensuring access to counselingand
psychotherapy,
physician/psychologist/psychiatrist services, outpatient clinic services,
general hospital outpatient psychiatric services, pre-hospitalization
screening,
diagnostic
assessment (clinical evaluation), crisis intervention, psychiatric
hospitalization in general hospitals (for all ages), and
Medicaid-covered
prescription drugs and
laboratory services. MCPs are not required to cover partial hospitalization, or
inpatient psychiatric care in a private or public free-
standing psychiatric
hospital. However, MCPs are required to cover the payment of physician services
in a private or public free-standing psychiatric hospital
when such
services are billed independent of the hospital. The payment of physician
services in an IMD is also covered by the MCPs, as long as the
member
is 21 years of
age and under or 65 years of age and older.
Substance Abuse
Services: There are a number of
Medicaid-covered substance abuse services available through ODADAS-certified
Medicaid providers.
Where
an MCP is responsible for providing substance abuse services for their members,
the MCP is responsible for ensuring access to alcohol and other
drug
(AOD) urinalysis screening, assessment, counseling,
physician/psychologist/psychiatrist AOD treatment services, outpatient clinic
AOD treatment services,
general hospital outpatient AOD treatment
services, crisis intervention, inpatient detoxification services in a general
hospital, and Medicaid-covered
prescription drugs and laboratory services. MCPs are not required to
cover outpatient detoxification, intensive outpatient programs (IOP) or
methadone
maintenance.
Financial Responsibility for Behavioral
Health Services:
MCPs are responsible for the following:
•
|
payment
of Medicaid-covered prescription drugs prescribed by an ODMH CMHC or
ODADAS-certified provider when obtained through an MCP’s panel
pharmacy;
|
•
|
payment
of Medicaid-covered services provided by an MCP’s panel laboratory when
referred by an ODMH CMHC or ODADAS-certified
provider;
|
•
|
payment
of all other Medicaid-covered behavioral health services obtained through
providers other than those who are ODMH CMHCs or ODADAS-certified
providers when arranged/authorized by the
MCP.
|
Limitations:
•
|
Pursuant
to ORC Section 5111.16, alcohol, drug addiction and
mental health services covered by Medicaid are not to be paid by the
managed care program when the nonfederal share of the cost of those
services is provided by a board of alcohol, drug addiction, and mental
health services or a state agency other than ODJFS. As part of this
limitation:
|
Appendix
G
Covered
Families and Children (CFC) population
Page
6
•
|
MCPs
are not responsible for paying for behavioral health services provided
through ODMH CMHCs and ODADAS-certified Medicaid
providers;
|
•
|
MCPs
are not responsible for payment of partial hospitalization (mental
health), inpatient psychiatric care in a private or public free-standing
inpatient psychiatric hospital, outpatient detoxification, intensive
outpatient programs (IOP) (substance abuse) or methadone
maintenance;
|
•
|
MCPs
are
required to cover the payment of physician services in a private or public
freestanding psychiatric hospital when such services are billed
independent of the hospital.
|
|
iv.
Pharmacy
Benefit: In providing the Medicaid pharmacy benefit to their
members, MCPs must cover the same drugs covered by the Ohio Medicaid
fee-for-
service program, in accordance with OAC rule 5101:3-26-03(A) and
(B).
|
Pursuant to ORC Section 5111.172, MCPs may, subject to ODJFS approval, implement
strategies for the management of drug utilization. (see appendix
G.3.a).
v.
|
Organ
Transplants: MCPs must ensure coverage for organ transplants and
related services in accordance with OAC 5101-3-2-07.1 (B)(4)&(5).
Coverage for all organ transplant services, except kidney transplants, is
contingent upon review and recommendation by the “Ohio Solid Organ
Transplant Consortium” based on criteria established by Ohio organ
transplant surgeons and authorization from the ODJFS prior authorization
unit. Reimbursement for bone marrow transplant and hematapoietic stem cell
transplant services, as defined in OAC 3701:84-01, is contingent upon
review and recommendation by the “Ohio Hematapoietic Stem Cell Transplant
Consortium” again based on criteria established by Ohio experts in the
field of bone marrow transplant. While MCPs may require prior
authorization for these transplant services, the approval criteria would
be limited to confirming the consumer is being considered and/or has been
recommended for a transplant by either consortium and authorized by ODJFS.
Additionally, in accordance with OAC 5101:3-2-03 (A)(4) all services
related to organ donations are covered for the donor recipient when the
consumer is Medicaid
eligible.
|
Appendix
G
Covered
Families and Children (CFC) population
Page
7
3.
Health
Management Programs
In an effort to improve access, quality, and continuity of care for MCP members,
each MCP must:
i. Establish a primary care provider
(PCP) for each member and encourage the member to have an ongoing relationship
with the PCP. For this requirement, a primary care
provider as defined in OAC: 5101: 3-26-01 serves as the ongoing source of
primary and preventive care; assists with coordination of care as appropriate
for the member’s
health care needs; recommends referrals to specialists for the member;
triages the member appropriately; notifies the MCP of a member who may benefit
from care
management services; and participates in development of the Care
Management care treatment plan. The MCP must ensure the primary care provider
agrees to perform the
care coordination responsibilities as outlined in OAC: 5101:
3-26-03.1.
ii. Provide education and outreach to each member to emphasize the
importance of disease prevention and health/wellness promotion. The MCP must
encourage and
enable the member to make informed decisions about accessing and utilizing
health care services appropriately.
iii. Direct and monitor coordination of care efforts for each member for medical
services delivered across the continuum of care. The MCP should incorporate
the
requirements in Sections 3 c, d, and e in its overall strategy for care
coordination.
iv. Develop and implement a strategy to identify members who display risk
factors for developing a disease and/or who over-/under-utilize health care
services, and would
benefit from targeted outreach or education. For this requirement, the MCP
must implement mechanisms to identify such members and should include the
following
information sources: administrative data review (e.g., pharmacy claims,
emergency department claims, or inpatient hospital admissions), provider/self
referrals, telephone
interviews, home visits, referrals resulting from internal MCP operations, and
data as reported by the MCEC during membership selection. Should the MCP
identify
members characterized as having an increased risk for developing a disease
or who inappropriately utilize health care services, the MCP must offer
education and outreach
initiatives (e.g., educational mailing) designed to mitigate the risk factors,
and prevent the member from requiring more progressive interventions, such as
care management
services.
v. Implement Utilization Management Programs as outlined in Section 3.a to
maximize effectiveness of care provided to members.
vi. Each MCP must implement a Care Management Program as outlined in Section 3.b
which coordinates and monitors the care for members with special health care
needs.
The Care Management Program must be designed to ensure the intensity of
interventions provided by the MCP corresponds to the member’s level of
need.
Appendix
G
Covered
Families and Children (CFC) population
Page
8
a. Utilization Management
Programs
General Provisions
- Pursuant to OAC rule 5101:3-26-03.1(A)(7), MCPs must implement a
utilization management (UM) program to maximize the effectiveness
of the care provided to members and may develop other UM programs, subject
to prior approval by ODJFS. For the purposes of this requirement, the
specific
UM programs which require ODJFS prior-approval are an MCP’s general
pharmacy program, a controlled substances and member management program,
and
any other program designed by the MCP with the purpose of redirecting or
restricting access to a particular service or service
location.
i.
|
Pharmacy
Programs - Pursuant to ORC Sec. 5111.172, MCPs may, subject to ODJFS
prior-approval, implement strategies for the management of drug
utilization. Pharmacy utilization management strategies may include
developing preferred drug lists, requiring prior authorization for certain
drugs, placing limitations on the type of provider and locations where
certain medications may be administered, and developing and implementing a
specialized pharmacy program to address the utilization of controlled
substances, as defined in section 3719.01 of the Ohio Revised Code. MCPs
may also implement a retrospective drug utilization review program
designed to promote the appropriate clinical prescribing of covered
drugs.
|
Drug
Prior Authorizations: MCPs must receive prior approval from ODJFS for the
medications that they wish to cover through prior authorization.
MCPs
must establish their prior authorization system so that it does not
unnecessarily impede member access to medically-necessary
Medicaid-covered
services. MCPs must make their approved list of drugs covered only with
prior authorization available to members and providers, as outlined
in
paragraphs 37(b) and (c) of Appendix C.
While MCPs may, with ODJFS approval, require prior
authorization for the coverage of 2nd
generation antipsychotic drugs, MCPs must allow any
member to continue receiving a specific 2nd
generation antipsychotic drug if the member is stabilized on that particular
medication. The MCP must
continue to cover that specific antipsychotic for the stabilized member
for as long as that medication continues to be effective for the member.
MCPs
must also collaborate with ODJFS in the retrospective review of 2nd
generation antipsychotic utilization.
MCPs must comply with the provisions of 1927(d)(5) of the Social Security Act,
42 USC 1396r-8(k)(3), and OAC rule 5101:3-26-03.1 regarding the
timeframes for prior authorization of covered outpatient
drugs.
Appendix
G
Covered
Families and Children (CFC) population
Page
9
Controlled Substances and Member Management Programs: MCPs may also, with ODJFS
prior approval, develop and implement Controlled Substances
and Member Management (CSMM) programs designed to address use of
controlled substances. Utilization management strategies may include
prior
authorization as a condition of obtaining a controlled substance, as
defined in section 3719.01 of the Ohio Revised Code. CSMM strategies may
also
include processes for requiring MCP members at high risk for fraud or
abuse involving controlled substances to have their controlled substances
prescribed by a designated provider/providers and filled by a pharmacy, medical
provider, or health care facility designated by the program.
ii.
|
Emergency Department
Diversion (EDD) – MCPs must provide access to services in a way
that assures access to primary, specialist and urgent care in the most
appropriate settings and that minimizes frequent, preventable utilization
of emergency department (ED) services. OAC rule 5101:3-26-03.1(A)(7)(d)
requires MCPs to implement the ODJFS-required emergency department
diversion (EDD) program for frequent
utilizers.
|
Each MCP must establish an ED diversion (EDD) program with the goal of
minimizing frequent ED utilization. The MCP’s EDD program must include
the
monitoring of ED utilization,
identification of frequent ED utilizers, and targeted approaches designed to
reduce avoidable ED utilization. MCP EDD
programs must, at a minimum, address those ED visits which could have
been prevented through improved education, access, quality or care
management approaches.
Although there is often an assumption that frequent ED visits are solely the
result of a preference on the part of the member and education is
therefore
the standard remedy, it is also important to ensure that a member’s frequent ED
utilization is not due to problems such as their PCP’s lack of
accessibility or
failure to make appropriate specialist referrals. The MCP’s EDD program must
therefore also include the identification of providers who
serve as PCPs for a substantial number of frequent ED utilizers and the
implementation of corrective action with these providers as so
indicated.
This requirement does not replace the MCP’s responsibility to inform and educate
all members regarding the appropriate use of the ED.
Appendix
G
Covered
Families and Children (CFC) population
Page
10
b. Care Management
Programs
In accordance with 5101:3-26-03.1(A)(8), MCPs must offer and
provide care management services which coordinate and monitor the care of
members with special
health care needs.
i. Each MCP must inform all
members and contracting providers of the MCP’s care management
services.
ii. The
MCP’s care management program must include, at a minimum, the following
components:
a.
|
Identification
Strategies
|
|
The
MCP must implement mechanisms to identify members potentially eligible for
care management services. These mechanisms must include an administrative
data review of pharmacy claims, emergency department visits, and inpatient
hospital admissions (e.g., diagnosis, cost threshold, and/or service
utilization) and may include provider/self referrals, telephone
interviews, information as reported by MCEC during membership selection,
home visits, or referrals resulting from internal MCP operations (e.g.,
utilization management, 24/7 nurse advice line, member services,
etc.).
|
Each MCP must incorporate identification strategies (i.e., mechanisms and
criteria) as specified in ODJFS Care Management Program
Requirements.
b.
|
Risk Stratification
Levels
|
|
The
MCP must develop a strategy to assign members to low, medium, or high risk
stratification levels based on the results of the identification and/or
assessment processes. This will be a continual process and the risk levels
will be adjusted based on the completion of the health assessment and the
member’s demonstrated progress in meeting the goals of the care treatment
plan. Each MCP must incorporate risk stratification levels as specified in
ODJFS Care Management
Program Requirements.
|
c.
|
Health
Assessment
|
|
Once
a member has been identified by the MCP as being potentially eligible for
care management, the MCP must arrange for, or conduct, a health assessment
to determine the member’s need for care management services. The health
assessment completed by the MCP will depend on the member’s initial
assignment to a low-, medium-, or high-risk stratification level. ODJFS
recognizes that the completion of an assessment may result in the
assignment of the member to a different risk stratification level (i.e.,
than the level originally assigned) or that the member may not demonstrate
a need for care management
services.
|
Appendix
G
Covered
Families and Children (CFC) population
Page
11
For a member assigned to the low- or medium-risk stratification levels,
the MCP must, at a minimum, complete a health assessment based on a
review
of administrative claims
data. The health assessment must be able to identify the severity of the
member’s condition/disease state, and must be
reviewed by a qualified health professional
appropriate for the member’s health condition. If an MCP opts to use a disease
management
methodology/algorithm to assign members to a risk stratification
level as part of the assessment, there must be clinical input to the development
of the
algorithm.
For
members assigned to a high risk stratification level, the MCP must complete a
health assessment that is comprehensive and evaluates the
member’s medical condition(s),
including physical, behavioral, social, and psychological
needs. The health assessment must also evaluate if
the
member has co-morbidities, or multiple complex
health care conditions. The goals of the assessment are to identify the member’s
existing and/or
potential health care needs and assess the member’s need
for care
management services. The health assessment for members assigned to the high risk
stratification level must be completed by a physician, physician
assistant, RN, LPN,
licensed social worker, or a graduate of a two- or four-year allied
health program. If the assessment is completed by a physician assistant, LPN,
licensed social
worker, or a graduate of a two- or four-year allied health
program, there should be oversight and monitoring by either a registered
nurse or physician.
The MCP must address the health assessment components as specified in
ODJFS Care Management Program
Requirements.
d. Care Treatment
Plan
The care treatment plan is
defined by ODJFS as the one developed by the MCP for the member. The development
of the care treatment plan must be
based on the health
assessment, and reflect the member’s health care needs. The care treatment plan
must also include specific provisions for periodic
reviews of the member's health
care needs. Periodic reviews may include administrative data reviews or
screening questions to alert appropriately
qualified MCP staff to update the health assessment
and the care treatment plan. The frequency of contact with the member must
correspond to the
member’s risk stratification level, and must include a provision
for two-way communication or feedback between the member and the
MCP.
Appendix
G
Covered
Families and Children (CFC) population
Page
12
The member and the member's PCP must be actively involved in the
development of, and revisions to, the care treatment plan. The designated PCP
is
the provider, or specialist,
who will manage and coordinate the overall care for the member. Ongoing
communication regarding the status of the care
treatment
plan may be accomplished
between the MCP and the PCP's designee (i.e., qualified health professional).
Revisions to the clinical portion of
the care treatment plan should be completed
in consultation with the PCP.
The elements of a care treatment plan include:
(a) Goals and actions that
address health care conditions identified in the health
assessment;
(b) Member level
interventions (i.e., referrals and making appointments) that assist members in
obtaining services, providers and programs related
to the health
care conditions identified in the health assessment;
(c)
Continuous review, revision and contact follow-up,
as needed, with members to insure the care treatment plan is adequately
monitored
including the following:
•
|
Identification
of gaps between recommended care and actual care provided;
and
|
•
|
Re-evaluation
of a member's risk level with adjustment to the level of care management
services provided.
|
The
MCP must address care treatment plan components as specified in ODJFS Care Management Program
Requirements.
e.
Coordination of Care and
Communication
The
MCP must assign an accountable point of contact (i.e., care manager) who can
help obtain medically necessary care, assist with health-related
services and coordinate
care needs.
Appendix
G
Covered
Families and Children (CFC) population
Page
13
The MCP must arrange or provide for
professional care management services that are performed collaboratively by a
team of professionals appropriate
for the member’s
condition and health care needs. The MCP’s care manager must attempt to
coordinate with the member’s care manager from other
health systems. The MCP must have
a process to facilitate, maintain, and coordinate both care and communication
with the member, PCP, and other
service providers and care managers. The MCP must
also have a process to coordinate care for a member that is receiving services
from state sub-
recipient agencies as appropriate [e.g., the Ohio Department of Mental
Health (ODMH); the Ohio Department of Mental Retardation and
Developmental Disabilities (ODMR/DD); and the Ohio Department of Alcohol
and Drug Addiction
Services (ODADAS)]. The MCP must have a
provision to disseminate information to the member/caregiver concerning the
health condition, types of services
that may be available, and how to
access the services.
f.
Member
Enrollment in the Care Management Program
The MCP must assure and coordinate the placement of the member into the Care
Management Program–including the identification of the member’s need
for
care management
services, completion of the health assessment, and timely development of the
care treatment plan. This process must occur within the
following timeframes for:
a) newly
enrolled members: 90 days from the effective date of enrollment for those
members who are identified as meeting the criteria for care
management; and
b)
existing members: 90 days from identifying their need for care
management.
For members assigned to
the low or medium risk stratification levels, the MCP may choose to implement an
“opt out” process for members. MCPs that
implement an opt out
process must provide care management services to the member until the member
declines the initial offer to participate in the program. The
opt out process must be clearly
defined in all member materials, and the MCP must have a documented process for
honoring any opt out requests. For members
assigned to a low- or medium – level, the
MCP may obtain verbal or written confirmation of the member’s care management
status in the care management
records. For members assigned to the high risk stratification
levels, the MCP must obtain written or verbal confirmation of the member’s care
management status
in the care management record.
Appendix
G
Covered
Families and Children (CFC) population
Page
14
g.
Provider and Member
Notifications
The MCP must have a process to inform members and their PCPs that they have been
identified as meeting the criteria for care management, including
their
enrollment into the care
management program. The MCP must develop, at a minimum, the following
notifications for members enrolled in the Care Management
program:
1.
|
Member
Enrollment in the Care Management Program: This must include a description
of the opt-out process (if an MCP implements) for members in the low- and
medium- risk stratification levels; contact information for the member’s
care manager; and the care management services available to the
member.
|
2.
|
Member
Disenrollment from the Care Management Program: This notice must include
the rationale for disenrolling the member from the care management
program, (e.g., declines participation in the program, meets goals in care
treatment plan, etc.) and information for the member to contact the MCP if
future assistance is needed.
|
h. Access to
Specialists
The MCP must implement mechanisms to notify all Members with
Special Health Care Needs of their right to directly access a specialist. Such
access
may be assured through,
for example, a standing referral or an approved number of visits, and documented
in the care treatment plan.
i.
Care Management
Strategies
The MCP must follow best-practice and/or evidence based clinical
guidelines when developing interventions for the risk stratification levels, the
care
treatment plan and
coordinating the care management needs. The MCP must develop and implement
mechanisms to educate and equip providers and
care managers with evidence-based
clinical guidelines or best practice approaches to assist in providing a high
level of quality of care to members.
j.
Care Management
Program Staffing
The MCP must identify the staff that will be involved
in the operations of the care management program, including but not imited to:
care manager
supervisors,
care manager,
and administrative support staff. The MCP must identify the role and functions
of each care management staff member as
well as the educational requirements,
clinical licensure standards, certification and relevant experience with care
management standards and/or
activities. The MCP must provide care manager
staff/member ratios based on the member risk stratification and different levels
of care being provided
to members.
Appendix
G
Covered
Families and Children (CFC) population
Page
15
k.
Information Technology
System for the Care Management Program
The MCP’s information technology system for the Care Management Program must
maximize the opportunity for communication between the MCP, the PCP,
the
member, and other
service providers and care managers. The MCP must have an integrated database
that allows MCP staff who may be contacted by a member
in care management
to have immediate access to, and review of, the most recent information with the
MCP’s information systems relevant to the case. The
integrated database may
include the following: administrative data, call center communications, service
authorizations, care treatment plans, health assessments,
care management notes, and PCP
notes. The information technology system must also have the capability to share
relevant information with the member, the
PCP, and other service providers and care managers.
The goal is to integrate information from a variety of sources in an effort to
facilitate care management
needs for the member.
l.
Care Management Data
Submission
The MCP must submit a monthly electronic report to the Care Management System
(CAMS) for all members who are provided care management
services by the MCP
as outlined in the ODJFS Case
Management File and Submission Specifications. In
order for a member to be submitted as care
managed in CAMS, the
MCP must complete the steps as outlined in Section ii.f: Enrollment in the Care
Management program. ODJFS, or its
designated entity, the external quality
review vendor, will validate on an annual basis the accuracy of the information
contained in CAMS with the
member’s care management record.
The CAMS files are due the 15th
calendar day of each month.
Appendix
G
Covered
Families and Children (CFC) population
Page
16
The MCP must also have an ODJFS-approved care management program which
includes the items in this Section. Each MCP must implement an
evaluation process
to review, revise and/or update the care management program on an annual basis.
If the evaluation process results in a revision to
identification strategies,
health assessment(s), and risk stratification strategies, then the MCP must
notify ODJFS in writing of the change, which
may
be subject to review and approval by ODJFS.
be subject to review and approval by ODJFS.
c. Care Coordination with
ODJFS-Designated Providers
Per OAC rule 5101:3-26-03.1(A)(4), MCPs are required to share specific
information with certain ODJFS-designated non-contracting providers in order to
ensure that
these providers have been supplied with specific information needed to
coordinate care for the MCP’s members. Once an MCP has obtained a provider
agreement, but
within the first month of operation, the MCP must provide to
the ODJFS-designated providers (i.e., ODMH Community Mental Health Centers,
ODADAS-certified
Medicaid providers, FQHCs/RHCs, QFPPs, CNMs, CNPs [if applicable], and
hospitals) a quick reference information packet which includes the
following:
i. A brief cover letter
explaining the purpose of the mailing; and
ii.
|
A
brief summary document that includes the following
information:
|
•
|
Claims
submission information including the MCP’s Medicaid provider number for
each region;
|
•
|
The
MCP’s prior authorization and referral procedures or the MCP’s website
which includes this
information;
|
•
|
A
picture of the MCP’s member identification card (front and
back);
|
•
|
Contact
numbers and website location for obtaining information for eligibility
verification, claims processing, referrals/prior authorization, and
information regarding the MCP’s behavioral health
administrator;
|
•
|
A
listing of the MCP’s major pharmacy chains and the contact number for the
MCP’s pharmacy benefit administrator
(PBM);
|
Appendix G
Covered
Families and Children (CFC) population
Page
17
•
|
A
listing of the MCP’s laboratories and radiology providers;
and
|
•
|
A
listing of the MCP’s contracting behavioral health providers and how to
access services through them (this information is only to be provided to
non-contracting community mental health and substance abuse
providers).
|
d. Care coordination with
Non-Contracting Providers
Per OAC rule 5101:3-26-05(A)(9), MCPs authorizing the delivery of services from
a provider who does not have an executed subcontract must ensure that they have a
mutually agreed upon compensation amount for the authorized service and
notify the provider of the applicable provisions of paragraph D of OAC rule
5101:3-26-05.
This notice is provided when an MCP authorizes a non-contracting provider to
furnish services on a one-time or infrequent basis to an MCP member and must
include
required ODJFS-model language and information. This notice must also be
included with the transition of services form sent to providers as outlined in
paragraph 29.h
of Appendix C.
e. Integration of Member
Care
The MCP must ensure that a discharge plan is in place to meet a member’s health
care needs following discharge from a nursing facility, and integrated into
the
member’s continuum of care. The discharge plan must address the services
to be provided for the member and must be developed prior to the date of
discharge from
the nursing facility. The MCP must ensure follow-up contact occurs with
the member, or authorized representative, within thirty (30) days of the
member’s discharge
from the nursing facility to ensure that the member’s health care needs
are being met.
Appendix
H
Covered
Families and Children (CFC) population
Page
1
APPENDIX
H
PROVIDER
PANEL SPECIFICATIONS
CFC
ELIGIBLE POPULATION
1.
GENERAL
PROVISIONS
MCPs must provide or arrange for the delivery of all medically necessary, Medicaid-covered health services, as well as assure that they meet all applicable provider panel requirements for their entire designated service area. The ODJFS provider panel requirements are specified in the charts included with this appendix and must be met prior to the MCP receiving a provider agreement with ODJFS. The MCP must remain in compliance with these requirements for the duration of the provider agreement.
If an MCP
is unable to provide the medically necessary, Medicaid-covered services through
their contracted provider panel, the MCP must ensure access to these services on
an as needed basis. For example, if an MCP meets the pediatrician requirement
but a member is unable to obtain a timely appointment from a pediatrician on the
MCP’s provider panel, the MCP will be required to secure an appointment from a
panel pediatrician or arrange for an out-of-panel referral to a
pediatrician.
MCPs are
required to make
transportation available to any member requesting transportation when they must travel 30 miles or more
from their home to receive a medically-necessary Medicaid-covered service. If
the MCP offers transportation to their members as an additional benefit and this
transportation benefit only covers a limited number of trips, the required
transportation listed above may not be counted toward this
trip limit (as specified in Appendix C).
In
developing the provider panel requirements, ODJFS considered, on a
county-by-county basis, the population size and utilization patterns of the
Covered Families and Children (CFC) consumers, as well as the potential
availability of the designated provider types. ODJFS has integrated existing
utilization patterns into the provider network requirements to avoid disruption
of care. Most provider panel requirements are county-specific but in certain
circumstances, ODJFS requires providers to be located anywhere in the region.
Although all provider types listed in this appendix are required provider types,
only those listed on the attached charts must be submitted for ODJFS prior
approval.
2.
PROVIDER
SUBCONTRACTING
Unless
otherwise specified in this appendix or OAC rule 5101:3-26-05, all MCPs are
required to enter into fully-executed subcontracts with their providers. These
subcontracts must include a baseline contractual agreement, as well as the
appropriate ODJFS-approved Model Medicaid Addendum. The Model Medicaid Addendum
incorporates all applicable Ohio Administrative Code rule requirements specific
to provider subcontracting and therefore cannot be modified except to add
personalizing information such as the MCP’s name.
Appendix
H
Covered
Families and Children (CFC) population
Page
2
ODJFS
must prior approve all MCP providers in the ODJFS- required provider type
categories before they can begin to provide services to that MCP’s members. MCPs
may not employ or contract with providers excluded from participation in Federal
health care programs under either section 1128 or section 1128A of the Social
Security Act. As part of the prior approval process, MCPs must submit
documentation verifying that all necessary contract documents have been
appropriately completed. ODJFS will verify the approvability of the submission
and process this information using the ODJFS Managed Care Provider Network
(MCPN), maintained by the Managed Care Enrollment Center (MCEC), or other
designated process. The MCPN is a centralized database system that maintains
information on the status of all MCP-submitted providers.
Only
those providers who meet the applicable criteria specified in this document, as
determined by ODJFS, will be approved by ODJFS. MCPs must
credential/recredential providers in accordance with the standards specified by
the National Committee for Quality Assurance (or receive approval from ODJFS to
use an alternate industry standard) and must have completed the credentialing
review before submitting any provider to ODJFS for approval. Regardless of
whether ODJFS has approved a provider, the MCP must ensure that the provider has
met all applicable credentialing criteria before the provider can render
services to the MCP’s members.
MCPs must
notify ODJFS of the addition and deletion of their contracting providers as
specified in OAC rule 5101:3-26-05, and must notify ODJFS within one working day
in instances where the MCP has identified that they are not in compliance with
the provider panel requirements specified in this appendix.
3.
PROVIDER PANEL
REQUIREMENTS
The
provider network criteria that must be met by each MCP are as
follows:
a.
Primary Care Providers
(PCPs)
Primary
Care Provider (PCP) means an individual physician (M.D. or D.O.), certain
physician group practice/clinic (Primary Care Clinics [PCCs]), or an advanced
practice nurse (APN) as defined in ORC 4723.43 or advanced practice nurse group
practice within an acceptable specialty, contracting with an MCP to provide
services as specified in paragraph (B) of OAC rule 5101: 3-26-03.1. The APN
capacity can count up to 10% of the total requirement for the county. Acceptable
specialty types for PCPs include family/general practice, internal medicine,
pediatrics, and obstetrics/gynecology (OB/GYN). Acceptable PCCs include FQHCs,
RHCs and the 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.
Appendix
H
Covered
Families and Children (CFC) population
Page
3
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. The capacity-by-site
requirement must be met for all ODJFS-approved PCPs.
In
determining whether an MCP has sufficient PCP capacity for a region, ODJFS
considers a provider who can serve as a PCP for 2000 Medicaid MCP members as 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 FTE). Where indicated, ODJFS may set a cap on the maximum
amount of capacity that we will 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 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
recognizes that MCPs will need to utilize specialty providers 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 MCPN
database, or other designated process, and therefore may not appear as PCPs in
the MCP’s provider directory. These PCPs will, however, need to execute a
subcontract with the MCP which includes the appropriate Model Medicaid
Addendum.
The PCP
requirement is based on an MCP having sufficient PCP capacity to serve 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 FTE requirement for that region, and a ratio of one
PCP FTE for each 2,000 of their Medicaid members in that region. MCPs must also
satisfy a PCP geographic accessibility standard. ODJFS will match the PCP
practice sites and the stated PCP capacity with the geographic location of the
eligible population in that 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 is located
within 10 miles of PCP with available capacity in urban counties and 40% of the
eligible population within 30 miles of a PCP with available capacity in rural
counties. [Rural areas are defined pursuant to 42 CFR
412.62(f)(1)(iii).]
Appendix
H
Covered
Families and Children (CFC) population
Page
4
In
addition to the PCP FTE capacity requirement, MCPs must also contract with the
specified number of pediatric
PCPs for each region. These pediatric PCPs will have their stated capacity
counted toward the PCP FTE requirement.
A
pediatric PCP must 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
county/region and be listed as a pediatrician with the Ohio State Medical Board.
In addition, half of the required number of pediatric PCPs must also be
certified by the American Board of Pediatrics. The provider panel requirements
for pediatricians are included in the practitioner charts in this
appendix.
b.
Non-PCP Provider
Network
In
addition to the PCP capacity requirements, each MCP is also required to maintain
adequate capacity in the remainder of its provider network within the following
categories: hospitals, dentists, pharmacies, vision care providers,
obstetricians/gynecologists (OB/GYNs), allergists, general surgeons,
otolaryngologists, orthopedists, certified nurse midwives (CNMs), certified
nurse practitioners (CNPs), federally qualified health centers (FQHCs)/rural
health centers (RHCs) and qualified family planning providers (QFPPs). CNMs,
CNPs, FQHCs/RHCs and QFPPs are federally-required provider
types.
All
Medicaid-contracting MCPs must provide all medically-necessary Medicaid-covered
services to their members and therefore their complete provider
network will include many other additional specialists and provider types. MCPs
must ensure that all non-PCP network providers follow community standards in the
scheduling of routine appointments (i.e., the amount of time members must wait
from the time of their request to the first available time when the visit can
occur).
Although
there are currently no FTE capacity requirements of the non-PCP required
provider types, MCPs are required to ensure that adequate access is available to
members for all required provider types. Additionally, for certain non-PCP
required provider types, MCPs must ensure that these providers maintain a
full-time practice at a site(s) located in the specified county/region (i.e.,
the ODJFS-specified county within the region or anywhere within the region if no
particular county is specified). A full-time practice is defined as one where
the provider is available to patients at their practice site(s) in the specified
county/region for at least 25 hours a week. ODJFS will monitor access to
services through a variety of data sources, including: consumer satisfaction
surveys; member appeals/grievances/complaints and state hearing
notifications/requests; clinical quality studies; encounter data volume;
provider complaints, and clinical performance measures.
Hospitals - MCPs must
contract with the number and type of hospitals specified by ODJFS for each
county/region. In developing these hospital requirements, ODJFS considered, on a
county-by-county basis, the population size and utilization patterns of the
Covered Families and Children
(CFC) consumers and integrated the existing utilization patterns into the
hospital network requirements to avoid disruption of care. For this reason,
ODJFS may require that MCPs contract with out-of-state hospitals (i.e. Kentucky,
West Virginia, etc.).
Appendix
H
Covered
Families and Children (CFC) population
Page
5
For each
Ohio hospital, ODJFS utilizes the hospital’s most current Annual Hospital
Registration and Planning Report, as filed with the Ohio Department of Health,
in verifying types of services that hospital provides. Although ODJFS has the
authority, under certain situations, to obligate a non-contracting hospital to
provide non-emergency hospital services to an MCP’s members, MCPs must still
contract with the specified number and type of hospitals unless ODJFS approves a
provider panel exception (see Section 4 of this appendix – Provider Panel
Exceptions).
If an
MCP-contracted hospital elects not to provide specific Medicaid-covered hospital
services because of an objection on moral or religious grounds, the MCP must
ensure that these hospital services are available to its members through another
MCP-contracted hospital in the
specified county/region.
OB/GYNs - MCPs must contract
with the specified number of OB/GYNs for each county/region, all of whom must
maintain a full-time obstetrical practice at a site(s) located in the specified
county/region. Only MCP-contracting OB/GYNs with current hospital privileges at
a hospital under contract with the MCP in the region can be submitted to the
MCPN, or other system, count towards MCP minimum panel requirements, and be
listed in the MCPs’ provider directory.
Certified Nurse Midwives (CNMs) and
Certified Nurse Practitioners (CNPs) - MCPs must ensure access to CNM and
CNP services in the region if such provider types are present within the region.
The MCP may contract directly with the CNM or CNP providers, or with a physician
or other provider entity who is able to obligate the participation of a CNM or
CNP. If an MCP does not contract for CNM or CNP services and such providers are
present within the region, the MCP will be required to allow members to receive
CNM or CNP services outside of the MCP’s provider network.
Only CNMs
with hospital delivery privileges at a hospital under contract with the MCP in
the region can be submitted to the MCPN, or other system, count towards MCP
minimum panel requirements, and be listed in the MCPs’ provider directory.The
MCP must ensure a member’s access to CNM and CNP services if such providers are
practicing within the region.
Vision Care Providers - MCPs
must contract with the specified number of ophthalmologists/optometrists for
each specified county/region , all of whom must maintain a full-time practice at
a site(s) located in the specified county/region. All ODJFS-approved vision
providers must regularly perform routine eye exams. (MCPs will be expected to
contract with an adequate number of ophthalmologists as part of their overall
provider panel, but only ophthalmologists who regularly perform routine eye
exams can be used to meet the vision care provider panel requirement.) If
optical dispensing is not sufficiently available in a region through the MCP’s
contracting ophthalmologists/optometrists, the MCP must separately contract with
an adequate
number of optical dispensers located in the
region.
Appendix
H
Covered
Families and Children (CFC) population
Page
6
Dental Care Providers - MCPs
must contract with the specified number of dentists. In order to assure
sufficient access to adult MCP members, no more than two-thirds of the dentists
used to meet the provider panel requirement may be pediatric
dentists.
Federally Qualified Health
Centers/Rural Health Clinics (FQHCs/RHCs) - MCPs are required to ensure
member access to any federally qualified health center or rural health clinic
(FQHCs/RHCs), regardless of contracting status. Contracting FQHC/RHC providers
must be submitted for ODJFS approval via the MCPN process, or other designated
process. Even if no FQHC/RHC is available within the region, MCPs must have
mechanisms in place to ensure coverage for FQHC/RHC services in the event that a
member accesses these services outside of the region.
In order
to ensure that any FQHC/RHC has the ability to submit a claim to ODJFS for the
state’s supplemental payment, MCPs must offer FQHCs/RHCs reimbursement pursuant
to the following:
•
|
MCPs
must provide expedited reimbursement on a service-specific basis in an
amount no less than the payment made to other providers for the same or
similar service.
|
•
|
If
the MCP has no comparable service-specific rate structure, the MCP must
use the regular Medicaid fee-for-service payment schedule for non-FQHC/RHC
providers.
|
•
|
MCPs
must make all efforts to pay FQHCs/RHCs as quickly as possible and not
just attempt to pay these claims within the prompt pay time
frames.
|
MCPs are
required to educate their staff and providers on the need to assure member
access to FQHC/RHC services.
Qualified Family Planning Providers
(QFPPs) - All MCP members must be permitted to self-refer to family
planning services provided by a QFPP. A QFPP is defined as any public or
not-for-profit health care provider that complies with Title X
guidelines/standards, and receives either
Title X funding or family planning funding from the Ohio Department of Health.
MCPs must reimburse all medically-necessary Medicaid-covered family planning
services provided to eligible members by a QFPP provider (including on-site
pharmacy and diagnostic services) on a patient self-referral basis, regardless
of the provider’s status as a panel or non-panel provider.
MCPs will
be required to work with QFPPs in the region to develop mutually-agreeable HIPAA
compliant policies and procedures to preserve patient/provider confidentiality,
and convey pertinent information to the member’s PCP and/or
MCP.
Appendix
H
Covered
Families and Children (CFC) population
Page
7
Behavioral Health Providers –
MCPs must assure member access to all Medicaid-covered behavioral health
services for members as specified in Appendix G.b.ii. Although ODJFS is aware
that certain outpatient substance abuse services may only be available through
Medicaid providers certified by the Ohio Department of Drug and Alcohol
Addiction Services (ODADAS) in some areas, MCPs must maintain an adequate number
of contracted mental health providers in the region to assure access for members
who are unable to timely access services or unwilling to access services through
community mental health centers. MCPs are advised not to contract with community
mental health centers as all services they provide to MCP members are to be
billed to ODJFS.
Other Specialty Types (pediatricians, general surgeons,
otolaryngologists, allergists, and orthopedists) - MCPs must contract
with the specified number of all other ODJFS designated specialty provider
types. In order to be counted toward meeting the provider panel requirements,
these specialty providers must maintain a full-time practice at a site(s)
located within the specified county/region. Only contracting general surgeons,
orthopedists, and otolaryngologists with admitting privileges at a hospital
under contract with the MCP in the region can be submitted to the MCPN, or other
system, count towards MCP minimum panel requirements, and be listed in the MCPs’
provider directory.
4.
PROVIDER PANEL
EXCEPTIONS
ODJFS may
specify provider panel criteria for a service area that deviates from that
specified in this appendix if:
-
|
the
MCP presents sufficient documentation to ODJFS to verify that they have
been unable to meet or maintain certain provider panel requirements in a
particular service area despite all reasonable efforts on their part to
secure such a contract(s),
and
|
-
|
if
notified by ODJFS, the provider(s) in question fails to provide a
reasonable argument why they would not contract with the MCP,
and
|
-
|
the
MCP presents sufficient assurances to ODJFS that their members will have
adequate access to the services in
question.
|
If an MCP
is unable to contract with or maintain a sufficient number of providers to meet
the ODJFS-specified provider panel criteria, the MCP may request an exception to
these criteria by submitting a provider panel exception request as specified by
ODJFS. ODJFS will review the exception request and determine whether the MCP has
sufficiently demonstrated that all reasonable efforts were made to obtain
contracts with providers of the type in question and that they will be able to
provide access to the services in question.
Appendix
H
Covered
Families and Children (CFC) population
Page
8
A
provider panel exception request (PPE) may be approved for a period of not more
than one year. Approvals shall have an effective date of the 1st day of the
month in which the PPE is approved by ODJFS. ODJFS will not accept or review a
request to extend the effective date of a PPE that is submitted earlier than 15
calendar days prior to the date of expiration. Once the MCP has resolved the
deficiency, the PPE is no longer valid. If the MCP becomes deficient in the same
area a new PPE request will need to be submitted prior to the next compliance
review.
ODJFS
will aggressively monitor access to all services related to the approval of a
provider panel exception request through a variety of data sources, including:
consumer satisfaction surveys; member appeals/grievances/complaints and state
hearing notifications/requests; member just-cause for termination requests;
clinical quality studies; encounter data volume; provider complaints, and
clinical performance measures. ODJFS approval of a provider panel exception
request does not exempt the MCP from assuring access to the services in
question. If ODJFS determines that an MCP has not provided sufficient access to
these services, the MCP may be subject to sanctions.
5.
PROVIDER
DIRECTORIES
MCP
provider directories must include all MCP-contracted providers [except as
specified by ODJFS] as well as certain non-contracted providers. At the time of
ODJFS’ review, the information listed in the MCP’s provider directory for all
ODJFS-required provider types specified on the attached charts must exactly
match the data currently on file in the ODJFS MCPN, or other designated
process.
MCP
provider directories must utilize a format specified by ODJFS. Directories may
be region-specific or include multiple regions, however, the providers within
the directory must be divided by region, county, and provider type, in that
order.
The
directory must also specify:
• provider
address(es) and phone number(s);
• an
explanation of how to access providers (e.g. referral required vs.
self-referral);
•
an indication of which providers are available to
members on a self-referral basis
•
|
foreign-language
speaking PCPs and specialists and the specific foreign language(s)
spoken;
|
•
|
how
members may obtain directory information in alternate formats that takes
into consideration the special needs of eligible individuals including but
not limited to, visually-limited, LEP, and LRP eligible individuals;
and
|
•
any PCP or specialist practice limitations.
Printed Provider
Directory
Prior to
receiving a provider agreement, all MCPs must develop a printed provider
directory that shall be prior-approved by ODJFS for each covered population. For
example, an MCP who serves CFC and ABD in the Central Region would have two
provider directories, one for CFC and one for ABD. Once approved, this directory
may be regularly updated with provider additions or deletions by the MCP without
ODJFS prior-approval, however, copies of the revised directory (or inserts) must
be submitted to ODJFS prior to distribution to members.
Appendix
H
Covered
Families and Children (CFC) population
Page
9
On a
quarterly basis, MCPs must
create an insert to each printed directory that lists those providers
deleted from the MCP’s
provider panel during the previous three months. Although this insert does not
need to be prior approved by ODJFS, copies of the insert must be submitted to
ODJFS two weeks prior to distribution to members.
Internet Provider
Directory
MCPs are
required to have an internet-based provider directory available in the same
format as their ODJFS-approved printed directory. This internet directory must
allow members to electronically search for MCP panel providers based on name,
provider type, and geographic proximity, and population (e.g. CFC and/or ABD).
If an MCP has one internet-based directory for multiple populations, each
provider must include a description of which population they
serve.
The
internet directory may be updated at any time to include providers who are not one of the ODJFS-required
provider types listed on the charts included with this appendix. ODJFS-required
providers must be added
to the internet directory within one week of the MCP’s notification of
ODJFS-approval of the provider via the Provider Verification process. Providers
being deleted from the MCP’s panel must deleted from the internet directory
within one week of notification from the provider to the MCP. Providers being
deleted from the MCP’s panel must be posted to the internet directory within one
week of notification from the provider to the MCP of the deletion. These deleted
providers must be included in the inserts to the MCP’s provider directory
referenced above.
6
.. FEDERAL ACCESS
STANDARDS
MCPs must
demonstrate that they are in compliance with the following federally defined
provider panel access standards as required by 42 CFR
438.206:
In
establishing and maintaining their provider panel, MCPs must consider the
following:
• The
anticipated Medicaid membership.
•
|
The
expected utilization of services, taking into consideration the
characteristics and health care needs of specific Medicaid populations
represented in the MCP.
|
•
|
The
number and types (in terms of training, experience, and specialization) of
panel providers required to deliver the contracted Medicaid
services.
|
•
|
The
geographic location of panel providers and Medicaid members, considering
distance, travel time, the means of transportation ordinarily used by
Medicaid members, and whether the location provides physical access for
Medicaid members with
disabilities.
|
Appendix
H Page 10
•
MCPs must adequately and timely cover services
to an out-of-network provider if the MCP’s contracted provider panel is unable
to provide the services covered under the
MCP’s provider agreement. The MCP must cover the
out-of-network services for as long as the MCP network is unable to provide the
services. MCPs must coordinate with
the out-of-network provider with respect to payment and ensure that the
provider agrees with the applicable requirements.
Contracting
providers must offer hours of operation that are no less than the hours of
operation offered to commercial members or comparable to Medicaid
fee-for-service, if the provider serves only Medicaid members. MCPs must ensure
that services are available 24 hours a day, 7 days a week, when medically
necessary. MCPs must establish mechanisms to ensure that panel providers comply
with timely access requirements, and must take corrective action if there is
failure to comply.
In order
to demonstrate adequate provider panel capacity and services, 42 CFR 438.206 and
438.207 stipulates that the MCP must submit documentation to ODJFS, in a format
specified by ODJFS, that demonstrates it offers an appropriate range of
preventive, primary care and specialty services adequate for the anticipated
number of members in the service area, while maintaining a provider panel that
is sufficient in number, mix, and geographic distribution to meet the needs of
the number of members in the service area.
This
documentation of assurance of adequate capacity and services must be submitted
to ODJFS no less frequently than at the time the MCP enters into a contract with
ODJFS; at any time there is a significant change (as defined by ODJFS) in the
MCP’s operations that would affect adequate capacity and services (including
changes in services, benefits, geographic service or payments); and at any time
there is enrollment of a new population in the MCP.
North East Region - PCP
Capacity
Minimum
PCP Capacity Requirements
|
||||||||||
PCPs
|
Total
Required
|
Ashtabula
|
Cuyahoga
|
Erie
|
Geauga
|
Huron
|
Lake
|
Xxxxxx
|
Xxxxxx
|
Additional
Required:
In-Region
*
|
Capacity 1
|
98,212
|
5,256
|
66,564
|
2,873
|
1,111
|
2,612
|
5,210
|
11,431
|
3,155
|
|
FTEs
|
49.11
|
2.63
|
33.28
|
1.44
|
0.56
|
1.31
|
2.61
|
5.72
|
1.58
|
¹ Based on an FTE of 2000 members |
* Must be
located within the region.
North
East Central Region - PCP Capacity
Minimum PCP
Capacity Requirements
|
|||||
PCPs
|
Total
Required
|
Columbiana
|
Mahoning
|
Trumbull
|
Additional
Required:
In-Region
*
|
Capacity
1
|
31,367
|
5,281
|
12,039
|
9,047
|
5,000
|
FTEs
|
15.68
|
2.64
|
6.02
|
4.52
|
2.50
|
¹ Based on an FTE of 2000 members |
* Must be
located within the region.
Xxxx
Xxxxxxx Xxxxxx - XXX Xxxxxxxx
Minimum
PCP Capacity Requirements
|
|||||||||||
PCPs
|
Total
Required
|
Ashland
|
Xxxxxxx
|
Xxxxxx
|
Portage
|
Richland
|
Xxxxx
|
Summit
|
Tuscarawas |
Xxxxx
|
Additional
Required:
In-Region
*
|
Capacity
1
|
55,006
|
1,732
|
1,226
|
794
|
4,329
|
5,363
|
14,376
|
20,279
|
3,616
|
3,291
|
|
FTEs
|
27.50
|
0.87
|
0.61
|
0.40
|
2.16
|
2.68
|
7.19
|
10.14
|
1.81
|
1.65
|
¹ Based on an FTE of 2000 members |
* Must be
located within the region.
Central Region - PCP
Capacity
County
|
Capacity 1
|
FTEs
|
Total
Required
|
100,253
|
50.13|
|
Xxxxxxxx
|
2,016
|
1.01
|
Delaware
|
2,307
|
1.15
|
Fairfield
|
4,698
|
2.35
|
Fayette
|
1,341
|
0.67
|
Franklin
|
55,101
|
27.55
|
Hocking
|
1,672
|
0.84
|
Xxxx
|
2,236
|
1.12
|
Licking
|
5,897
|
2.95
|
Xxxxx
|
1,656
|
0.83
|
Madison
|
1,378
|
0.69
|
Xxxxxx
|
3,042
|
1.52
|
Xxxxxx
|
1,492
|
0.75
|
Perry
|
2,263
|
1.13
|
Pickaway
|
2,123
|
1.06
|
Pike
|
2,116
|
1.06
|
Xxxx
|
4,442
|
2.22
|
Scioto
|
5,204
|
2.60
|
Union
|
1,269
|
0.63
|
¹ Based on an FTE of 2000 members |
* Must be
located within the region.
Xxxxx Xxxx Xxxxxx - XXX
Xxxxxxxx
Xxxxxx
|
Capacity 1
|
FTEs
|
Total
Required
|
42,412
|
21.21 |
|
Athens
|
2,664
|
1.33
|
Belmont
|
3,178
|
1.59
|
Coshocton
|
1,840
|
0.92
|
Gallia
|
1,918
|
0.96
|
Guernsey
|
2,518
|
1.26
|
Xxxxxxxx
|
810
|
0.41
|
Xxxxxxx
|
2,107
|
1.05
|
Jefferson
|
3,418
|
1.71
|
Xxxxxxxx
|
4,021
|
2.01
|
Meigs
|
1,557
|
0.78
|
Monroe
|
750
|
0.38
|
Morgon
|
930
|
0.47
|
Muskingum
|
5,304
|
2.65
|
Noble
|
581
|
0.29
|
Vinton
|
1,061
|
0.53
|
Washington
|
2,755
|
1.38
|
Additional
Required:
In-Region
*
|
7,000
|
3.50
|
¹ Based on an FTE of 2000 members |
* Must be
located within the region.
South West Region - PCP
Capacity
Minimum
PCP Capacity Requirements
|
||||||||||
PCPs
|
Total
Required
|
Xxxxx
|
Xxxxx
|
Xxxxxx
|
Clermont
|
Xxxxxxx
|
Xxxxxxxx
|
Highland
|
Xxxxxx
|
Additional
Required:
In
Region
*
|
|
||||||||||
Capacity
1
|
58,754
|
2,063
|
2,122
|
12,296
|
5,787
|
1,705
|
29,787
|
2,240
|
2,754
|
|
FTEs
|
29.38
|
1.03
|
1.06
|
6.15
|
2.89
|
0.85
|
14.89
|
1.12
|
1.38
|
¹ Based on an FTE of 2000 members |
* Must be
located within the region.
Xxxx
Xxxxxxx Xxxxxx - XXX Xxxxxxxx
Minimum
PCP Capacity Requirements
|
||||||||||
PCPs
|
Total
Required
|
Champaign
|
Xxxxx
|
Xxxxx
|
Xxxxxx
|
Miami
|
Xxxxxxxxxx
|
Xxxxxx
|
Xxxxxx
|
Additional
Required:
In-Region
*
|
Capacity
1
|
42,784
|
1,472
|
7,225
|
1,476
|
4,347
|
2,550
|
22,751
|
1,541
|
1,422
|
|
FTEs
|
21.39
|
0.74
|
3.61
|
0.74
|
2.17
|
1.28
|
11.38
|
0.77
|
0.71
|
¹ Based on an FTE of 2000 members |
* Must be
located within the region.
Xxxxx Xxxx Xxxxxx - XXX
Xxxxxxxx
Xxxxxx
|
Capacity 1
|
FTEs
|
Total Required |
68,540
|
34.27
|
Xxxxx
|
4,262
|
2.13
|
Auglaize
|
1,228
|
0.61
|
Defiance
|
1,555
|
0.78
|
Xxxxxx
|
1,270
|
0.64
|
Xxxxxxx
|
2,038
|
1.02
|
Xxxxxx
|
1,096
|
0.55
|
Xxxxx
|
894
|
0.45
|
Xxxxx
|
24,752
|
12.38
|
Xxxxxx
|
821
|
0.41
|
Ottawa
|
1,271
|
0.64
|
Paulding
|
710
|
0.36
|
Xxxxxx
|
770
|
0.39
|
Sandusky
|
2,142
|
1.07
|
Seneca
|
2,128
|
1.06
|
Van
Xxxx
|
847
|
0.42
|
Xxxxxxxx
|
1,478
|
0.74
|
Wood
|
2,444
|
1.22
|
Wyandot
|
634
|
0.32
|
Additional
Required:
In-Region
*
|
18,200
|
9.10
|
¹ Based on an FTE of 2000 members |
* Must be
located within the region.
WellCare
APPENDIX
J
FINANCIAL
PERFORMANCE
CFC
ELIGIBLE POPULATION
1.
SUBMISSION OF FINANCIAL STATEMENTS AND
REPORTS
MCPs must submit the following financial reports to ODJFS:
a.
|
The
National Association of Insurance Commissioners (NAIC) quarterly and
annual Health Statements (hereafter referred to as the “Financial
Statements”), as outlined in Ohio Administrative Code (OAC) rule
5101:3-26-09(B). The Financial Statements must include all required Health
Statement filings, schedules and exhibits as stated in the NAIC Annual
Health Statement Instructions including, but not limited to, the following
sections: Assets, Liabilities, Capital and Surplus Account, Cash Flow,
Analysis of Operations by Lines of Business, Five-Year Historical Data,
and the Exhibit of Premiums, Enrollment and Utilization. The Financial
Statements must be submitted to BMHC even if the Ohio Department of
Insurance (ODI) does not require the MCP to submit these statements to
ODI. A signed hard copy and an electronic copy of the reports in the
NAIC-approved format must both be provided to
ODJFS;
|
b.
|
Hard
copies of annual financial statements for those entities who have an
ownership interest totaling five percent or more in the MCP or an indirect
interest of five percent or more, or a combination of direct and indirect
interest equal to five percent or more in the
MCP;
|
c.
|
Annual
audited Financial Statements prepared by a licensed independent external
auditor as submitted to the ODI, as outlined in OAC rule
5101:3-26-09(B);
|
d.
|
Medicaid
Managed Care Plan Annual Ohio Department of Job and Family Services
(ODJFS) Cost Report and the auditor’s certification of the cost report, as
outlined in OAC rule
5101:3-26-09(B);
|
e.
|
Medicaid
MCP Annual Restated Cost Report for the prior calendar year. The restated
cost report shall be audited upon BMHC
request;
|
f.
|
Annual
physician incentive plan disclosure statements and disclosure of and
changes to the MCP’s physician incentive plans, as outlined in OAC rule
5101:3-26-09(B);
|
g. Reinsurance
agreements, as outlined in OAC rule 5101:3-26-09(C);
Appendix
J
Covered
Families and Children (CFC) population
Page
2
h.
|
Prompt
Pay Reports, in accordance with OAC rule 5101:3-26-09(B). A hard copy and
an electronic copy of the reports in the ODJFS-specified format must be
provided to ODJFS;
|
i.
|
Notification
of requests for information and copies of information released pursuant to
a tort action (i.e., third party recovery), as outlined in OAC rule
5101:3-26-09.1;
|
j.
|
Financial,
utilization, and statistical reports, when ODJFS requests such reports,
based on a concern regarding the MCP’s quality of care, delivery of
services, fiscal operations or solvency, in accordance with OAC rule
5101:3-26-06(D);
|
k. In
accordance with ORC Section 5111.76 and Appendix C, MCP Responsibilities,
MCPs must submit ODJFS-specified franchise fee reports in hard copy and
electronic
formats pursuant to ODJFS specifications.
2.
FINANCIAL
PERFORMANCE MEASURES AND STANDARDS
This Appendix establishes specific expectations concerning the financial
performance of MCPs. In the interest of administrative simplicity and
nonduplication of areas of the
ODI authority, ODJFS’ emphasis is on the assurance of access to and quality of
care. ODJFS will focus only on a limited number of indicators and related
standards to monitor
plan performance. The three indicators and standards for this contract
period are identified below, along with the calculation methodologies. The
source for each indicator will
be the NAIC Quarterly and Annual Financial
Statements.
Report Period: Compliance will be determined based on the
annual Financial Statement.
a. Indicator: Net Worth as measured by Net Worth
Per Member
|
Definition:
Net Worth = Total Admitted Assets minus Total Liabilities divided
by Total Members across all lines of
business
|
|
Standard:
For the financial report that covers calendar year 2009, a minimum net
worth per member of $363.00, as determined from the annual Financial
Statement
submitted to ODI and the
ODJFS.
|
The Net Worth Per Member (NWPM) standard is the Medicaid Managed
Care Capitation amount paid to the MCP during the preceding calendar year,
including
delivery payments, but excluding the at-risk amount,
expressed as a per-member per-month figure, multiplied by the applicable
proportion below:
Appendix
J
Covered
Families and Children (CFC) population
Page
3
0.75 if the MCP had a total membership of 100,000 or more during that calendar
year
0.90 if the MCP had a total membership of less than 100,000 for that calendar
year
If the MCP did not receive Medicaid Managed Care Capitation payments during the
preceding calendar year, then the NWPM standard for the MCP is the
average
Medicaid Managed Care capitation amount paid to Medicaid-contracting MCPs
during the preceding calendar year, including delivery payments, but excluding
the at-
risk amount, multiplied by the applicable proportion above.
b. Indicator: Administrative Expense
Ratio
Definition:
|
Administrative
Expense Ratio = Administrative Expenses minus Franchise Fees divided by
Total Revenue minus Franchise
Fees.
|
Standard:
|
Administrative
Expense Ratio not to exceed 15%, as determined from the annual Financial
Statement submitted to ODI and
ODJFS.
|
c.
Indicator: Overall Expense
Ratio
Definition:
|
Overall
Expense Ratio = The sum of the Administrative Expense Ratio and the
Medical Expense Ratio.
|
Administrative Expense Ratio = Administrative Expenses minus Franchise Fees
divided by Total Revenue minus Franchise Fees.
Medical Expense Ratio = Medical Expenses divided by Total Revenue minus
Franchise Fees.
Standard:
|
Overall Expense
Ratio not to exceed 100% as determined from the annual Financial Statement
submitted to ODI and ODJFS.
|
Penalty for noncompliance: Failure to meet
any standard on 2.a., 2.b., or 2.c. above will result in ODJFS requiring the MCP
to complete a corrective action plan (CAP) and
specifying the date by which compliance must be
demonstrated. Failure to meet the standard or otherwise comply with the CAP by
the specified date will result in a new
enrollment freeze unless ODJFS determines that
the deficiency does not potentially jeopardize access to or quality of care or
affect the MCP’s ability to meet administrative
requirements (e.g., prompt pay requirements). Justifiable
reasons for noncompliance may include one-time events (e.g., MCP investment in
information system products).
Appendix
J
Covered
Families and Children (CFC) population
Page
4
If the financial statement is not submitted to ODI by the due date, the MCP
continues to be obligated to submit the report to ODJFS by ODI’s originally
specified due date
unless the MCP requests and is granted an extension by
ODJFS.
Failure to submit complete quarterly and annual Financial Statements on a
timely basis will be deemed a failure to meet the standards and will be subject
to the noncompliance
penalties listed for indicators
2.a., 2.b., and 2.c., including the imposition of a new enrollment freeze. The
new enrollment freeze will take effect at the first of the month
following
the month in which the
determination was made that the MCP was non-compliant for failing to submit
financial reports timely.
In addition, ODJFS will review two liquidity indicators if a plan demonstrates
potential problems in meeting related administrative requirements or the
standards listed above.
The two standards, 2.d and 2.e, reflect ODJFS’ expected level of
performance. At this time, ODJFS has not established penalties for noncompliance
with these standards;
however, ODJFS will consider the MCP’s performance
regarding the liquidity measures, in addition to indicators 2.a., 2.b., and
2.c., in determining whether to impose a new
enrollment
freeze, as outlined above, or to not issue or renew a contract with an MCP. The
source for each indicator will be the NAIC Quarterly and annual Financial
Statements.
Long-term investments that can be liquidated without significant penalty within
24 hours, which a plan would like to include in Cash and Short-Term Investments
in the next
two measurements, must be disclosed in footnotes on the NAIC Reports.
Descriptions and amounts should be disclosed. Please note that “significant
penalty” for this
purpose is any penalty greater than 20%. Also, enter the amortized cost of
the investment, the market value of the investment, and the amount of the
penalty.
d. Indicator: Days Cash on
Hand
Definition:
|
Days
Cash on Hand = Cash and Short-Term Investments divided by (Total Hospital
and Medical Expenses plus Total Administrative Expenses) divided by
365.
|
Standard:
|
Greater
than 25 days as determined from the annual Financial Statement submitted
to ODI and ODJFS.
|
e. Indicator: Ratio of Cash to Claims
Payable
Definition: Ratio of Cash to Claims
Payable = Cash and Short-Term Investments
divided by claims Payable (reported and unreported).
Standard: Greater
than 0.83 as determined from the annual Financial Statement submitted to ODI and
ODJFS.
Appendix
J
Covered
Families and Children (CFC) population
Page
5
3.
REINSURANCE
REQUIREMENTS
Pursuant to the provisions of OAC rule 5101:3-26-09
(C), each MCP must carry reinsurance coverage from a licensed commercial carrier
to protect against inpatient-related
medical expenses incurred by Medicaid
members.
The annual deductible or retention amount for such
insurance must be specified in the reinsurance agreement and must not exceed
$75,000.00, except as provided below. Except
for transplant services, and as provided below,
this reinsurance must cover, at a minimum, 80% of inpatient costs incurred by
one member in one year, in excess of $75,000.00.
For transplant services, the reinsurance must cover, at a minimum, 50% of
inpatient transplant related costs incurred by one member in one year, in excess
of $75,000.00.
An MCP may request a higher deductible amount
and/or that the reinsurance cover less than 80% of inpatient costs in excess of
the deductible amount. If the MCP does not
have more than 75,000 members in Ohio, but
does have more than 75,000 members between Ohio and other states, ODJFS may
consider alternate reinsurance arrangements.
However, depending on the corporate structures of the Medicaid MCP,
other forms of security may be required in addition to reinsurance. These other
security tools may
include parental guarantees, letters of credit, or
performance bonds. In determining whether or not the request will be approved,
the ODJFS may consider any or all of the
following:
a.
|
whether
the MCP has sufficient reserves available to pay unexpected
claims;
|
b.
|
the
MCP’s history in complying with financial indicators 2.a., 2.b., and 2.c.,
as specified in this
Appendix.
|
c. the number
of members covered by the MCP;
d.
|
how
long the MCP has been covering Medicaid or other members on a full risk
basis.
|
e.
|
risk
based capital ratio greater than 2.5 calculated from the last annual ODI
financial statement.
|
f.
|
scatter
diagram or bar graph from the last calendar year that shows the number of
reinsurance claims that exceeded the current reinsurance
deductible.
|
The MCP has been approved to have a reinsurance policy with a deductible amount
of $75,000 that covers 80% of inpatient costs in excess of the deductible amount
for non-
transplant
services.
Appendix
J
Covered
Families and Children (CFC) population
Page
6
Penalty for noncompliance: If it is determined
that an MCP failed to have reinsurance coverage, that an MCP’s deductible
exceeds $75,000.00 without approval from ODJFS, or
that the MCP’s reinsurance for non-transplant services
covers less than 80% of inpatient costs in excess of the deductible incurred by
one member for one year without
approval from ODJFS, then the MCP will be
required to pay a monetary penalty to ODJFS. The amount of the penalty will be
the difference between the estimated amount, as
determined by ODJFS, of what the MCP would have paid in premiums for the
reinsurance policy if it had been in compliance and what the MCP did actually
pay while it was
out of
compliance plus 5%. For example, if the MCP paid $3,000,000.00 in premiums
during the period of non-compliance and would have paid $5,000,000.00 if the
requirements
had been met, then the penalty would be $2,100,000.00.
If it is determined that an MCP’s reinsurance for transplant services covers
less than 50% of inpatient costs incurred by one member for one year, the MCP
will be required to
develop a corrective action plan (CAP).
4.
|
PROMPT
PAY REQUIREMENTS
|
In accordance with 42 CFR 447.46, MCPs must pay 90% of all submitted
clean claims within 30 days of the date of receipt and 99% of such claims within
90 days of the date of
receipt, unless the MCP and its contracted provider(s) have established an
alternative payment schedule that is mutually agreed upon and described in their
contract. The
clean pharmacy
and non-pharmacy claims will be separately measured against the 30 and 90 day
prompt pay standards. The prompt pay requirement applies to the
processing
of both electronic
and paper claims for contracting and non-contracting providers by the MCP and
delegated claims processing entities.
The date of receipt is the date the MCP receives the claim, as indicated
by its date stamp on the claim. The date of payment is the date of the check or
date of electronic
payment transmission. A claim means a xxxx from a provider for
health care services that is assigned a unique identifier. A claim does not
include an encounter form.
A “claim” can include any of the following: (1) a xxxx for
services; (2) a line item of services; or (3) all services for one recipient
within a xxxx. A “clean claim” is a claim that can be
processed without obtaining additional information from the
provider of a service or from a third party.
Clean claims do not include payments made to a provider of service or a third
party where the timing of the payment is not directly related to submission of a
completed claim
by the provider of service or third party (e.g., capitation). A clean
claim also does not include a claim from a provider who is under investigation
for fraud or abuse, or a claim
under review for medical necessity.
Appendix
J
Covered
Families and Children (CFC) population
Page
7
Penalty for noncompliance: Noncompliance with prompt pay
requirements will result in progressive penalties to be assessed on a quarterly
basis, as outlined in Appendix N of
the Provider Agreement.
5.
PHYSICIAN INCENTIVE PLAN DISCLOSURE
REQUIREMENTS
MCPs must comply with the physician incentive plan requirements
stipulated in 42 CFR 438.6(h).
If the MCP operates a physician incentive plan, no specific payment can
be
made directly or indirectly under this physician incentive
plan to a physician or physician group as an inducement to reduce or limit
medically necessary services furnished to
an individual.
If the physician incentive plan places a physician or physician group at
substantial financial risk [as determined under paragraph (d) of 42 CFR 422.208]
for services that the
physician or physician group does not furnish itself,
the MCP must assure that all physicians and physician groups at substantial
financial risk have either aggregate or per-
patient stop-loss protection in accordance with paragraph (f) of 42 CFR
422.208, and conduct periodic surveys in accordance with paragraph (h) of 42 CFR
422.208.
In accordance with 42 CFR 417.479 and 42 CFR 422.210, MCPs must maintain copies
of the following required documentation and submit to upon
request:
a.
|
A
description of the types of physician incentive arrangements the MCP has
in place which indicates whether they involve a withhold, bonus,
capitation, or other arrangement. If a physician incentive arrangement
involves a withhold or bonus, the percent of the withhold or bonus must be
specified.
|
b.
|
A
description of information/data feedback to a physician/group on their: 1)
adherence to evidence-based practice guidelines; and 2) positive and/or
negative care variances from standard clinical pathways that may impact
outcomes or costs. The feedback information may be used by the MCP for
activities such as physician performance improvement projects that include
incentive programs or the development of quality improvement
initiatives.
|
c.
|
A
description of the panel size for each physician incentive plan. If
patients are pooled, then the pooling method used to determine if
substantial financial risk exists must also be
specified.
|
d.
|
If
more than 25% of the total potential payment of a physician/group is at
risk for referral services, the MCP must maintain a copy of the results of
the required patient satisfaction survey and documentation verifying that
the physician or physician group has adequate stop-loss protection,
including the type of coverage (e.g., per member per year, aggregate), the
threshold amounts, and any coinsurance required for amounts over the
threshold.
|
Appendix
J
Covered
Families and Children (CFC) population
Page
8
6.
NOTIFICATION OF
REGULATORY ACTION
Any MCP notified by the ODI of proposed or implemented
regulatory action must report such notification and the nature of the action to
ODJFS no later than one working day
after receipt from ODI. The ODJFS may request,
and the MCP must provide, any additional information as necessary to assure
continued satisfaction of program requirements.
MCPs may request that information related to such
actions be considered proprietary in accordance with established ODJFS
procedures. Failure to comply with this provision
will result in an immediate enrollment
freeze.
Appendix
K
Covered
Families and Children (CFC) population
Page
1
APPENDIX
K
QUALITY
ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM
AND
EXTERNAL
QUALITY REVIEW
CFC
ELIGIBLE POPULATION
1.
As required by federal regulation, 42 CFR 438.240, each managed care plan (MCP)
must have an ongoing Quality Assessment and Performance Improvement Program
(QAPI) that is annually prior-approved by the Ohio Department of Job and Family
Services (ODJFS). The program must include the following
elements:
a. PERFORMANCE IMPROVEMENT
PROJECTS
Each MCP must conduct performance improvement projects
(PIPs), including those specified by ODJFS. PIPs must achieve, through periodic
measurements and intervention,
significant and sustained improvement in clinical and non-clinical areas which
are expected to have a favorable effect on health outcomes and satisfaction.
MCPs must adhere
to ODJFS PIP content and format specifications.
All ODJFS-specified PIPs must be prior-approved by ODJFS. As part of the
external quality review organization (EQRO) process, the EQRO will assist MCPs
with conducting
PIPs by providing technical assistance and will annually validate the
PIPs. In addition, the MCP must annually submit to ODJFS the status and results
of each PIP.
MCPs must initiate and complete the following PIPs:
i. Non-clinical
Topic: Identifying children/members with special health care
needs.
ii. Clinical Topic:
Well-child visits during the first 15 months of life.
iii. Clinical Topic: Percentage of members aged 2-21
years that access dental care services.
Initiation of PIPs will begin in the second year of participation in the
Medicaid managed care program.
The MCPs will be required to participate in
a PIP collaborative beginning in SFY 2009, and as specified by ODJFS. A PIP
Collaborative is defined as a cooperative quality
improvement effort by the MCP, ODJFS, and the EQRO to address a clinical or
non-clinical topic area relevant to the Medicaid managed care program, which is
designed to
identify, develop, and implement standardized measures and statewide
interventions to optimize health outcomes for MCP members and improve
efficiencies related to health
care service delivery.
Appendix
K
Covered
Families and Children (CFC) population
Page
2
b. HEALTH CARE SERVICE
UTILIZATION
Each MCP must have mechanisms
in place to detect under- and over-utilization of health care services. The MCP
must specify the mechanisms used to monitor utilization in its
annual
submission of the QAPI program to ODJFS.
It should also be noted
that pursuant to the program integrity provisions outlined in Appendix I, MCPs
must monitor for the potential under-utilization of services by
their
members in order to assure that all Medicaid-covered
services are being provided, as required. If any under-utilized services are
identified, the MCP must immediately
investigate and correct the problem(s) which
resulted in such under-utilization of services.
In addition the MCP must conduct an ongoing review of service
denials and must monitor utilization on an ongoing basis in order to identify
services which may be under
utilized.
c. SPECIAL HEALTH CARE
NEEDS
Each MCP must have mechanisms in place to
assess the quality and appropriateness of care furnished to members with special
health care needs. The MCP must specify the
mechanisms used in its annual
submission of the QAPI program to ODJFS.
d. SUBMISSION OF PERFORMANCE
MEASUREMENT DATA
Each MCP must submit clinical performance measurement data as
required by ODJFS that enables ODJFS to calculate standard measures. Refer to
Appendix M “Performance
Evaluation” for a more comprehensive description of the
clinical performance measures.
Each MCP must also submit clinical performance measurement data as required by
ODJFS that uses standard measures as specified by ODJFS. MCPs are required to
submit
Healthcare Effectiveness Data and Information Set (HEDIS) audited data for
the following measures:
i. Well Child
Visits in the First 15 Months of Life
ii.
Child Immunization Status
The measures must have received a “report” designation from the HEDIS certified
auditor and must be specific to the Medicaid population. Data must be submitted
annually
and in an electronic format as specified by ODJFS. Data will be used for
MCP clinical performance monitoring and will be incorporated into comparative
reports developed by
the EQRO.
Initiation of submission of performance data will begin in the second year of
participation in the Medicaid managed care program.
Appendix
K
Covered
Families and Children (CFC) population
Page
3
e. QAPI PROGRAM
SUBMISSION
Each MCP must implement an evaluation process to review, revise, and/or update
the QAPI program. The MCP must annually submit its QAPI program for review and
approval
by ODJFS.
2.
EXTERNAL QUALITY
REVIEW
In addition to the
following requirements, MCPs must participate in external quality review
activities as outlined in OAC 5101:3-26-07.
a. EQRO ADMINISTRATIVE
REVIEWS
The EQRO will conduct annual focused administrative compliance assessments for
each MCP which will include, but not be limited to, the following domains as
specified by
ODJFS: member rights and services, QAPI program, case management, provider
networks, grievance system, coordination and continuity of care, and utilization
management.
In
addition, the EQRO will complete a comprehensive administrative compliance
assessment every three (3) years as required by 42 CFR 438.358 and specified by
ODJFS.
In accordance with 42 CFR 438.360 and 438.362, MCPs with accreditation from a
national accrediting organization approved by the Centers for Medicare and
Medicaid Services
(CMS) may request a non-duplication exemption from
certain specified components of the administrative review. ODJFS will inform the
MCPs when a non-duplication
exemption may be requested.
b. EXTERNAL QUALITY REVIEW
PERFORMANCE
In accordance with OAC 5101: 3-26-07, each MCP must participate in an annual
external quality review survey. If the EQRO cites a deficiency in performance,
the MCP will be
required to complete a Corrective Action Plan (e.g., ODJFS technical assistance
session) or Quality Improvement Directives depending on the severity of the
deficiency. (An
example of a deficiency is if an MCP fails to meet certain clinical or
administrative standards as supported by national evidence-based guidelines or
best practices.) Serious
deficiencies may result in immediate termination or non-renewal of the
provider agreement. These quality improvement measures recognize the importance
of ongoing MCP
performance improvement related to clinical care and service
delivery.
Appendix
L
Covered
Families and Children
Page
1
APPENDIX
L
DATA
QUALITY
CFC
ELIGIBLE POPULATION
A high
level of performance on the data quality measures established in this appendix
is crucial in order for the Ohio Department of Job and Family Services (ODJFS)
to determine the value of the Medicaid Managed Health Care Program and to
evaluate Medicaid consumers’ access to and quality of services. Data collected
from MCPs are used in key performance assessments such as the external quality
review, clinical performance measures, utilization review, care coordination and
care management, and in determining incentives. The data will also be used in
conjunction with the cost reports in setting the premium payment rates. The
following measures, as specified in this appendix, will be calculated per MCP
and include all Ohio Medicaid members receiving services from the MCP (i.e.,
Covered Families and Children (CFC) and Aged, Blind, or Disabled (ABD)
membership, if applicable): Incomplete Outpatient Hospital Data, Rejected
Encounters, Acceptance Rate, Encounter Data Accuracy, and Generic Provider
Number Usage.
Data sets
collected from MCPs with data quality standards include: encounter data; care
management data; data used in the external quality review; members’ PCP data;
and appeal and grievance data.
1.
ENCOUNTER DATA
For
detailed descriptions of the encounter data quality measures below, see ODJFS Methods for Encounter Data
Quality Measures for CFC and ABD.
1.a.
Encounter Data Completeness
Each
MCP’s encounter data submissions will be assessed for completeness. The MCP is
responsible for collecting information from providers and reporting the data to
ODJFS in accordance with program requirements established in Appendix C, MCP Responsibilities. Failure
to do so jeopardizes the MCP’s ability to demonstrate compliance with other
performance standards.
1.a.i.
Encounter Data Volume
Measure: The volume measure
for each service category, as listed in Table 2 below, is the rate of
utilization (e.g., discharges, visits) per 1,000 member months
(MM).
Report Period: The report
periods for the SFY 2009 and SFY 2010 contract periods are listed in Table 1.
below.
Appendix
L
Covered
Families and Children (CFC) population
Page
2
Table
1. Report Periods for the SFY 2009 and 2010 Contract
Periods
Quarterly
Report Periods
|
Data
Source:
Estimated
Encounter
Data
File Update
|
Quarterly
Report
Estimated
Issue Date
|
Contract
Period
|
Qtr
2 thru Qtr 4 2005,
Qtr
1 thru Qtr 4: 2006, 2007
Qtr
1 2008
|
July
2008
|
August
2008*
|
SFY
2009
|
Qtr
3, Qtr 4: 2005,
Qtr
1 thru Qtr 4: 2006, 2007
Qtr
1, Qtr 2 2008
|
October
2008
|
November
2008*
|
|
Qtr
4: 2005,
Qtr
1 thru Qtr 4: 2006, 2007
Qtr
1 thru Qtr 3: 2008
|
January
2009
|
February
2009*
|
|
Qtr
1 thru Qtr 4: 2006, 2007, 2008
|
April
2009
|
May
2009
|
|
Qtr
2 thru Qtr 4: 2006, Qtr 1 thru Qtr 4: 2007, 2008 Qtr 1
2009
|
July
2009
|
August
2009
|
SFY
2010
|
Qtr
3, Qtr 4: 2006,
Qtr
1 thru Qtr 4: 2007, 2008
Qtr
1, Qtr 2: 2009
|
October
2009
|
November
2009
|
|
Qtr
4: 2006,
Qtr
1 thru Qtr 4: 2007, 2008
Qtr
1 thru Qtr 3: 2009
|
January
2010
|
February
2010
|
|
Qtr
1 thru Qtr 4: 2007, 2008, 2009
|
April
2010
|
May
2010
|
Qtr1 =
January to March Qtr2 = April to
June Qtr3 = July to
September Qtr4 = October to
December
*The
first three report periods for SFY 2009 will be consolidated into one report, to
be issued in February 2009. There will only be one compliance period associated
with this (combined) report period.
Appendix
L
Covered
Families and Children (CFC) population
Page
3
Table
2. Standards – Encounter Data Volume (County-Based Approach)
Data Quality Standard, County-Based
Approach: The standards in Table 2 apply to the MCP’s county-based
results (see County-Based
Approach below). The utilization rate for all service categories listed
in Table 2 must be equal to or greater than the standard established in Table 2
below.
Category
|
Measure
per 1,000/MM
|
Standard
for
Dates
of Service
7/1/2003
thru
6/30/2004
|
Standard
for
Dates
of Service
7/1/2004
thru
6/30/2006
|
Standard
for
Dates
of
Service
on
or after
7/1/2006
|
Description
|
Inpatient
Hospital
|
Discharges
|
5.4
|
5.0
|
5.4
|
General/acute
care, excluding newborns and mental health and chemical dependency
services
|
Emergency
Department
|
Visits
|
51.6
|
51.4
|
50.7
|
Includes
physician and hospital emergency department encounters
|
Dental
|
38.2
|
41.7
|
50.9
|
Non-institutional
and hospital dental visits
|
|
Vision
|
11.6
|
11.6
|
10.6
|
Non-institutional
and hospital outpatient optometry and ophthalmology
visits
|
|
Primary
and
Specialist
Care
|
220.1
|
225.7
|
233.2
|
Physician/practitioner
and hospital outpatient visits
|
|
Ancillary
Services
|
144.7
|
123.0
|
133.6
|
Ancillary
visits
|
|
Behavioral
Health
|
Service
|
7.6
|
8.6
|
10.5
|
Inpatient
and outpatient behavioral encounters
|
Pharmacy
|
Prescriptions
|
388.5
|
457.6
|
492.2
|
Prescribed
drugs
|
County-Based Approach: All
counties with managed care membership as of February 1, 2006, will be included
in a county-based encounter data volume measure until regional evaluation is
implemented for the county’s applicable region.. Upon implementation of
regional-based evaluation for a particular county’s region, the county will be
included in the MCP’s regional-based results and will no longer be included in
the MCP’s county-based results. County-based results will be determined by MCP
(i.e., one utilization rate per service category for all applicable counties)
and must be equal to or greater than the standards established in Table 2 above.
[Example: The county-based result for MCP AAA, which has contracts in the
Central and West Central regions, will include Franklin, Pickaway, Xxxxxxxxxx,
Xxxxxx and Xxxxx counties (i.e., counties with managed care membership as of
February 1, 2006). When the regional-based evaluation is implemented for the
Central region, Franklin and Pickaway counties, along with all other counties in
the region, will then be included in the Central region results for MCP AAA;
Montgomery, Greene, and Xxxxx counties will remain in the county-based results
for MCP AAA until the West Central regional measure is
implemented.]
Appendix
L
Covered
Families and Children (CFC) population
Page
4
Interim
Regional-Based Approach:
Prior to
the transition to the regional-based approach, encounter data volume will be
evaluated by MCP, by region, using an interim approach. All regions with managed
care membership will be included in results for an interim regional-based
encounter data volume measure until regional evaluation is implemented for the
applicable region (see Regional-Based Approach below). Encounter data volume
will be evaluated by MCP ( i.e., one utilization rate per service category for
all counties in the region). The utilization rate for all service categories
listed in Table 3 must be equal to or greater than the standard established in
Table 3 below. The standards listed in Table 3 below are based on utilization
data for counties with managed care membership as of February 1, 2006, and have
been adjusted to accommodate estimated differences in utilization for all
counties in a region, including counties that did not have membership as of
February 1, 2006.
Prior to
implementation of the regional-based approach, an MCP’s encounter data volume
will be evaluated using the county-based approach and the interim regional-based
approach. A county with managed care membership as of February 1, 2006, will be
included in both the County-Based approach and the Interim Regional-Based
approach until regional evaluation is implemented for the county’s applicable
region.
Data Quality Standard, Interim
Regional-Based Approach: The standards in Table 3 apply to the MCP’s
interim regional-based results. The utilization rate for all service categories
listed in Table 3 must be equal to or greater than the standard established in
Table 3 below.
Table
3. Standards – Encounter Data Volume (Interim Regional-Based
Approach)
Category
|
Measure
per 1,000/MM
|
Standard
for
Dates
of
Service
on
or after
7/1/2006
|
Description
|
Inpatient
Hospital
|
Discharges
|
2.7
|
General/acute
care, excluding newborns and mental health and chemical dependency
services
|
Emergency
Department
|
Visits
|
25.3
|
Includes
physician and hospital emergency department
encounters
|
Dental
|
25.5
|
Non-institutional
and hospital dental visits
|
|
Vision
|
5.3
|
Non-institutional
and hospital outpatient optometry and ophthalmology
visits
|
|
Primary
and Specialist Care
|
116.6
|
Physician/practitioner
and hospital outpatient visits
|
|
Ancillary
Services
|
66.8
|
Ancillary
visits
|
|
Behavioral
Health
|
Service
|
5.2
|
Inpatient
and outpatient behavioral encounters
|
Pharmacy
|
Prescriptions
|
246.1
|
Prescribed
drugs
|
Regional-Based
Approach:
Appendix
L
Covered
Families and Children (CFC) population
Page
5
Transition
to the regional-based approach will occur by region, after the first four
quarters (i.e., full calendar
year quarters) of regional membership, or after determination of the
regional-based data quality
standards, whichever is later. Encounter data volume will be evaluated by MCP,
by region (i.e.,
one utilization rate per service category for all counties in the region). ODJFS
will use the first four
quarters of data (i.e., full calendar year quarters) from all MCPs serving in an
active region to determine
minimum encounter volume data quality standards for that
region.
The
utilization rate for all service categories listed in Table 4 must be equal to
or greater than the standard established in Table 4 below. The standards listed
in Table 4 below are based on utilization data for regions and have been
adjusted to accommodate estimated differences in utilization for all counties in
a region, including counties that did not have membership as of February 1,
2006.
Appendix
L
Covered
Families and Children (CFC) population
Page
6
Table
4. Standards – Encounter Data Volume (Regional-Based Approach
Region
|
Category
|
Measure
per
1,000/MM
|
Standard
for
Dates
of Service on or after TBD (in Spring, 2009)
|
Description
|
Central
|
Inpatient
Hospital
|
Discharges
|
TBD
|
General/acute
care, excluding newborns and mental health and chemical dependency
services
|
Emergency
Department
|
Visits
|
TBD
|
Includes
physician and hospital emergency department
encounters
|
|
Dental
|
TBD
|
Non-institutional
and hospital dental visits
|
||
Vision
|
TBD
|
Non-institutional
and hospital outpatient optometry and ophthalmology
visits
|
||
Primary
& Specialist Care
|
TBD
|
Physician/practitioner
and hospital outpatient visits
|
||
Ancillary
Services
|
TBD
|
Ancillary
visits
|
||
Behavioral
Health
|
Service
|
TBD
|
Inpatient
and outpatient behavioral encounters
|
|
Pharmacy
|
Prescriptions
|
TBD
|
Prescribed
drugs
|
|
East
Central
|
Inpatient
Hospital
|
Discharges
|
TBD
|
General/acute
care, excluding newborns and mental health and chemical dependency
services
|
Emergency
Department
|
Visits
|
TBD
|
Includes
physician and hospital emergency department
encounters
|
|
Dental
|
TBD
|
Non-institutional
and hospital dental visits
|
||
Vision
|
TBD
|
Non-institutional
and hospital outpatient optometry and ophthalmology
visits
|
||
Primary
& Specialist Care
|
TBD
|
Physician/practitioner
and hospital outpatient visits
|
||
Ancillary
Services
|
TBD
|
Ancillary
visits
|
||
Behavioral
Health
|
Service
|
TBD
|
Inpatient
and outpatient behavioral encounters
|
|
Pharmacy
|
Prescriptions
|
TBD
|
Prescribed
drugs
|
|
Northeast
|
Inpatient
Hospital
|
Discharges
|
TBD
|
General/acute
care, excluding newborns and mental health and chemical dependency
services
|
Emergency
Department
|
Visits
|
TBD
|
Includes
physician and hospital emergency department
encounters
|
|
Dental
|
TBD
|
Non-institutional
and hospital dental visits
|
||
Vision
|
TBD
|
Non-institutional
and hospital outpatient optometry and ophthalmology
visits
|
||
Primary
& Specialist Care
|
TBD
|
Physician/practitioner
and hospital outpatient visits
|
||
Ancillary
Services
|
TBD
|
Ancillary
visits
|
||
Behavioral
Health
|
Service
|
TBD
|
Inpatient
and outpatient behavioral encounters
|
|
Pharmacy
|
Prescriptions
|
TBD
|
Prescribed
drugs
|
|
Northeast
Central
|
Inpatient
Hospital
|
Discharges
|
TBD
|
General/acute
care, excluding newborns and mental health and chemical dependency
services
|
Emergency
Department
|
Visits
|
TBD
|
Includes
physician and hospital emergency department
encounters
|
|
Dental
|
TBD
|
Non-institutional
and hospital dental visits
|
||
Vision
|
TBD
|
Non-institutional
and hospital outpatient optometry and ophthalmology
visits
|
||
Primary
& Specialist Care
|
TBD
|
Physician/practitioner
and hospital outpatient visits
|
||
Ancillary
Services
|
TBD
|
Ancillary
visits
|
||
Behavioral
Health
|
Service
|
TBD
|
Inpatient
and outpatient behavioral encounters
|
|
Pharmacy
|
Prescriptions
|
TBD
|
Prescribed
drugs
|
Appendix
L
Covered
Families and Children (CFC) population
Page 7
Region
|
Category
|
Measure
per
1,000/MM
|
Standard
for Dates of
Service
on or
after
TBD
(in
Spring,
2009)
|
Description
|
Northwest
|
Inpatient
Hospital
|
Discharges
|
TBD
|
General/acute
care, excluding newborns and mental health and chemical dependency
services
|
Emergency
Department
|
Visits
|
TBD
|
Includes
physician and hospital emergency department
encounters
|
|
Dental
|
TBD
|
Non-institutional
and hospital dental visits
|
||
Vision
|
TBD
|
Non-institutional
and hospital outpatient optometry and ophthalmology
visits
|
||
Primary
& Specialist Care
|
TBD
|
Physician/practitioner
and hospital outpatient visits
|
||
Ancillary
Services
|
TBD
|
Ancillary
visits
|
||
Behavioral
Health
|
Service
|
TBD
|
Inpatient
and outpatient behavioral encounters
|
|
Pharmacy
|
Prescriptions
|
TBD
|
Prescribed
drugs
|
|
Southeast
|
Inpatient
Hospital
|
Discharges
|
TBD
|
General/acute
care, excluding newborns and mental health and chemical dependency
services
|
Emergency
Department
|
Visits
|
TBD
|
Includes
physician and hospital emergency department
encounters
|
|
Dental
|
TBD
|
Non-institutional
and hospital dental visits
|
||
Vision
|
TBD
|
Non-institutional
and hospital outpatient optometry and ophthalmology
visits
|
||
Primary
& Specialist Care
|
TBD
|
Physician/practitioner
and hospital outpatient visits
|
||
Ancillary
Services
|
TBD
|
Ancillary
visits
|
||
Behavioral
Health
|
Service
|
TBD
|
Inpatient
and outpatient behavioral encounters
|
|
Pharmacy
|
Prescriptions
|
TBD
|
Prescribed
drugs
|
|
Southwest
|
Inpatient
Hospital
|
Discharges
|
TBD
|
General/acute
care, excluding newborns and mental health and chemical dependency
services
|
Emergency
Department
|
Visits
|
TBD
|
Includes
physician and hospital emergency department
encounters
|
|
Dental
|
TBD
|
Non-institutional
and hospital dental visits
|
||
Vision
|
TBD
|
Non-institutional
and hospital outpatient optometry and ophthalmology
visits
|
||
Primary
& Specialist Care
|
TBD
|
Physician/practitioner
and hospital outpatient visits
|
||
Ancillary
Services
|
TBD
|
Ancillary
visits
|
||
Behavioral
Health
|
Service
|
TBD
|
Inpatient
and outpatient behavioral encounters
|
|
Pharmacy
|
Prescriptions
|
TBD
|
Prescribed
drugs
|
|
West
Central
|
Inpatient
Hospital
|
Discharges
|
TBD
|
General/acute
care, excluding newborns and mental health and chemical dependency
services
|
Emergency
Department
|
Visits
|
TBD
|
Includes
physician and hospital emergency department
encounters
|
|
Dental
|
TBD
|
Non-institutional
and hospital dental visits
|
||
Vision
|
TBD
|
Non-institutional
and hospital outpatient optometry and ophthalmology
visits
|
||
Primary
& Specialist Care
|
TBD
|
Physician/practitioner
and hospital outpatient visits
|
||
Ancillary
Services
|
TBD
|
Ancillary
visits
|
||
Behavioral
Health
|
Service
|
TBD
|
Inpatient
and outpatient behavioral encounters
|
|
Pharmacy
|
Prescriptions
|
TBD
|
Prescribed
drugs
|
Appendix
L
Covered
Families and Children (CFC) population
Page
8
Determination of Compliance:
Performance is monitored once every quarter for the entire report
period.
If the standard is not met for every service category in all quarters of the
report period in either
the county-based, interim regional-based, or regional-based approach, then the
MCP will be determined
to be noncompliant for the report period.
Penalty for noncompliance:
The first time an MCP is noncompliant with a standard for this measure,
ODJFS will issue a Sanction Advisory informing the MCP that any future
noncompliance instances with the standard for this measure will result in ODJFS
imposing a monetary sanction. Upon all subsequent measurements of performance,
if an MCP is again determined to be noncompliant with the standard, ODJFS will
impose a monetary sanction (see Section 6.) of two percent of the current
month’s premium payment. Monetary sanctions will not be levied for consecutive
quarters that an MCP is determined to be noncompliant. If an MCP is noncompliant
for three consecutive quarters, membership will be frozen. Once the MCP is
determined to be compliant with the standard and the violations/deficiencies are
resolved to the satisfaction of ODJFS, the penalties will be lifted, if
applicable, and monetary sanctions will be returned.
1.a.ii.
Incomplete Outpatient Hospital Data
Since
July 1, 1997, MCPs have been required to provide both the revenue code and the
HCPCS code on applicable outpatient hospital encounters. ODJFS will be
monitoring, on a quarterly basis, the percentage of hospital encounters which
contain a revenue code and CPT/HCPCS code. A CPT/HCPCS code must accompany
certain revenue center codes. These codes are listed in Appendix B of Ohio
Administrative Code rule 5101:3-2-21 (fee-for-service outpatient hospital
policies) and in the methods for calculating the completeness
measures.
Measure: The percentage of
outpatient hospital line items with certain revenue center codes, as explained
above, which had an accompanying valid procedure (CPT/HCPCS) code. The measure
will be calculated per MCP.
Report Period: For the SFY
2009 and SFY 2010 contract periods, performance will be evaluated using the
report periods listed in 1.a.i., Table 1.
Data Quality Standard: The
data quality standard is a minimum rate of 95%.
Determination of Compliance:
Performance is monitored once every quarter for all report
periods.
For
quarterly reports that are issued on or after July 1, 2007, an MCP will be
determined to be noncompliant for the quarter if the standard is not met in any
report period and the initial instance of noncompliance in a report period is
determined on or after July 1, 2007. An initial instance of noncompliance means
that the result for the applicable report period was in compliance as determined
in the prior quarterly report, or the instance of noncompliance is the first
determination for an MCP’s first quarter of measurement.
Appendix
L
Covered
Families and Children (CFC) population
Page
9
Penalty for noncompliance:
The first time an MCP is noncompliant with a standard for this
measure,
ODJFS will issue a Sanction Advisory informing the MCP that any future
noncompliance instances
with the standard for this measure will result in ODJFS imposing a monetary
sanction. Upon all
subsequent quarterly measurements of performance, if an MCP is again determined
to be noncompliant
with the standard, ODJFS will impose a monetary sanction (see Section 6) of one
percent
of the current month’s premium payment. Once the MCP is performing at standard
levels and
violations/deficiencies are resolved to the satisfaction of ODJFS, the money
will be refunded.
1.a.iii.
Incomplete Data For Last Menstrual Period
As
outlined in ODJFS Encounter
Data Specifications, the last menstrual period (LMP) field is a required
encounter data field. It is discussed in Item 14 of the “HCFA 1500 Billing
Instructions.” The date of the LMP is essential for calculating the clinical
performance measures and allows the ODJFS to adjust performance expectations for
the length of a pregnancy.
The
occurrence code and date fields on the UB-92, which are “optional” fields, can
also be used to submit the date of the LMP. These fields are described in Items
32a & b, 33a & b, 34a & b, 35a & b of the “Inpatient Hospital”
and “Outpatient Hospital UB-92 Claim Form Instructions.”
An
occurrence code value of ‘10’ indicates that a LMP date was provided. The actual
date of the LMP would be given in the ‘Occurrence Date’
field.
Measure: The percentage of
recipients with a live birth during the report period where a “valid” LMP date
was given on one or more of the recipient’s perinatal claims. If the LMP date is
before the date of birth and there is a difference of between 119 and 315 days
between the date the recipient gave birth and the LMP date, then the LMP date
will be considered a valid date. The measure will be calculated per MCP (i.e.,
to include the MCP’s service area for the CFC.
Report Period: For the SFY
2009 contract period, performance will be evaluated using the January - December
2008 report period. For the SFY 2010 contract period, performance will be
evaluated using the January - December 2009 report period.
Data Quality Standard: The
data quality standard is a minimum rate of 80%.
Penalty for noncompliance:
The first time an MCP is noncompliant with a standard for this measure, ODJFS
will issue a Sanction Advisory informing the MCP that any future noncompliance
instances with the standard for this measure will result in ODJFS imposing a
monetary sanction. Upon all subsequent measurements of performance, if an MCP is
again determined to be noncompliant with the standard, ODJFS will impose a
monetary sanction (see Section 6.) of one percent of the current month’s premium
payment. Once the MCP is performing at standard levels and
violations/deficiencies are resolved to the satisfaction of ODJFS, the money
will be refunded.
Appendix
L
Covered
Families and Children (CFC) population
Page
10
1.a.iv.
Rejected Encounters
Encounters
submitted to ODJFS that are incomplete or inaccurate are rejected and reported
back to the MCPs on the Exception Report. If an MCP does not resubmit rejected
encounters, ODJFS’ encounter data set will be incomplete.
Measure 1
only applies to MCPs that have had Medicaid membership for more than one
year.
Measure 1: The percentage of
encounters submitted to ODJFS that are rejected. The measure will be calculated
per MCP.
Report Period: For the SFY
2009 contract period, performance will be evaluated using the following report
periods: July – September 2008; October - December 2008; January - March 2009;
and April – June 2009. For the SFY 2010 contract period, performance will be
evaluated using the following report periods: July - September 2009; October -
December 2009; January - March 2010; and April – June 2010.
Data Quality Standard for measure 1:
The data quality standard for measure 1 is a maximum encounter data
rejection rate of 10% for each file type in the ODJFS-specified medium per
format for encounters submitted in SFY 2004 and thereafter. The measure will be
calculated per MCP.
Determination of Compliance:
Performance is monitored once every quarter. Compliance determination with the
standard applies only to the quarter under consideration and does not include
performance in previous quarters.
Penalty for noncompliance with the
Data Quality Standard for measure 1: The first time an MCP is
noncompliant with a standard for this measure, ODJFS will issue a Sanction
Advisory informing the MCP that any future noncompliance instances with the
standard for this measure will result in ODJFS imposing a monetary sanction.
Upon all subsequent measurements of performance, if an MCP is again determined
to be noncompliant with the standard, ODJFS will impose a monetary sanction (see
Section 6.) of one percent of the current month’s premium payment. The monetary
sanction will be applied for each file type in the ODJFS-specified medium per
format that is determined to be out of compliance. Once the MCP is performing at
standard levels and violations/deficiencies are resolved to the satisfaction of
ODJFS, the money will be refunded.
Measure 2
only applies to MCPs that have had Medicaid membership for one year or
less.
Measure 2: The percentage of
encounters submitted to ODJFS that are rejected. The measure will be calculated
per MCP.
Report Period: The report
period for Measure 2 is monthly. Results are calculated and performance is
monitored monthly. The first reporting month begins with the third month of
enrollment.
Data Quality Standard for measure
2: The data quality standard for measure 2 is a maximum encounter data
rejection rate for each file type in the ODJFS-specified medium per format as
follows:
Appendix
L
Covered
Families and Children (CFC) population
Page
11
Third through sixth months with
membership: 50%
Seventh through twelfth month with
membership: 25%
Files in
the ODJFS-specified medium per format that are totally rejected will not be
considered in the determination of noncompliance.
Determination of Compliance:
Performance is monitored once every month. Compliance determination with the
standard applies only to the month under consideration and does not include
performance in previous quarters.
Penalty for Noncompliance with the
Data Quality Standard for measure 2: If the MCP is determined to be
noncompliant for either standard, ODJFS will impose a monetary sanction of one
percent of the MCP’s current month’s premium payment. The monetary sanction will
be applied for each file type in the ODJFS-specified medium per format that is
determined to be out of compliance. The monetary sanction will be applied only
once per file type per compliance determination period and will not exceed a
total of two percent of the MCP’s current month’s premium payment. Once the MCP
is performing at standard levels and violations/deficiencies are resolved to the
satisfaction of ODJFS, the money will be refunded. Special consideration will be
made for MCPs with less than 1,000 members.
1.a.v.
Acceptance Rate
This
measure only applies to MCPs that have had Medicaid membership for one year or
less.
Measure: The rate of
encounters that are submitted to ODJFS and accepted (accepted encounters per
1,000 member months). The measure will be calculated per MCP
Report Period: The report
period for this measure is monthly. Results are calculated and performance is
monitored monthly. The first reporting month begins with the third month of
enrollment.
Data Quality Standard: The
data quality standard is a monthly minimum accepted rate of encounters for each
file type in the ODJFS-specified medium per format as
follows:
Third through sixth month with membership: 50 encounters per 1,000 MM for NCPDP
65
encounters per 1,000 MM for NSF
20 encounters per 1,000 MM for UB-92
Seventh through twelfth month of membership: 250 encounters per 1,000 MM for
NCPDP
350 encounters per 1,000 MM for NSF
100 encounters per 1,000 MM
for UB-92
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Determination of
Compliance: Performance is monitored once every month.
Compliance determination
with the standard applies only to the month under consideration and does not
include performance
in previous months.
Penalty for Noncompliance: If
the MCP is determined to be noncompliant with the standard, ODJFS will impose a
monetary sanction of one percent of the MCP’s current month’s premium payment.
The monetary sanction will be applied for each file type in the ODJFS-specified
medium per format that is determined to be out of compliance. The monetary
sanction will be applied only once per file type per compliance determination
period and will not exceed a total of two percent of the MCP’s current month’s
premium payment. Once the MCP is performing at standard levels and
violations/deficiencies are resolved to the satisfaction of ODJFS, the money
will be refunded. Special consideration will be made for MCPs with less than
1,000 members.
1.b.
Encounter Data Accuracy
As with
data completeness, MCPs are responsible for assuring the collection and
submission of accurate data to ODJFS. Failure to do so jeopardizes MCPs’
performance, credibility and, if not corrected, will be assumed to indicate a
failure in actual performance.
1.b.i.
Encounter Data Accuracy Studies
Measure 1: The focus of this
accuracy study will be on delivery encounters. Its primary purpose will be to
verify that MCPs submit encounter data accurately and to ensure only one payment
is made per delivery. The rate of appropriate payments will be determined by
comparing a sample of delivery payments to the medical record. The measure will
be calculated per MCP (i.e., to include the MCP’s entire service area for the
CFC membership.
Report Period: In order to
provide timely feedback on the accuracy rate of encounters, the report period
will be the most recent from when the measure is initiated. This measure is
conducted annually.
Medical
records retrieval from the provider and submittal to ODJFS or its designee is an
integral component
of the validation process. ODJFS has optimized the sampling to minimize the
number of records
required. This methodology requires a high record submittal
rate. To aid MCPs in achieving
a high
submittal rate, ODJFS will give at least an 8 week period to retrieve and submit
medical records
as a part of the validation process. A record submittal rate will be calculated
as a percentage of all
records requested for the study.
Data Quality Standard 1 for Measure
1: For results that are finalized during the contract year, the accuracy
rate for encounters generating delivery payments is 100%.
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Penalty for noncompliance:
The MCP must participate in a detailed review of delivery payments
made for
deliveries during the report period. Any duplicate or unvalidated delivery
payments must be
returned to ODJFS
Data Quality Standard 2 for Measure
1: A minimum record submittal rate of 85%.
Penalty for noncompliance:
For all encounter data accuracy studies that are completed during this
contract period, if an MCP is noncompliant with the standard, ODJFS will impose
a non-refundable $10,000 monetary sanction.
Measure 2: This accuracy
study will compare the accuracy and completeness of payment data stored in MCPs’
claims systems during the study period to payment data submitted to and accepted
by ODJFS. The measure will be calculated per MCP. Two levels of analysis will be
conducted: one to evaluate encounter data completeness for which two rates will
be calculated and one to evaluate payment data accuracy. Payment completeness
and accuracy rates will be determined by aggregating data across claim types
(i.e., professional, institutional, and pharmacy) and stratifying data by file
type (i.e., header and detail).
Encounter
Data Completeness (Level 1):
Omission
Encounter Rate: The percentage of encounters in an MCP’s fully adjudicated
claims file not
present in the ODJFS encounter data files.
Surplus
Encounter Rate: The percentage of encounters in the ODJFS encounter data files
not present in an MCP’s fully adjudicated claims files.
Payment
Data Accuracy (Level 2):
Payment
Error Rate: The percentage of matched encounters between the ODJFS encounter
data files and an
MCP’s fully adjudicated claims files where a payment amount discrepancy was
identified.
Report Period: In order to
provide timely feedback on the omission rate of encounters, the report period
will be the most recent from when the study is initiated. This study is
conducted annually.
Data
Quality Standard for Measure 2:
For SFY
2009, this measure is reporting only. For SFY 2009, each MCP must implement a
Corrective Action Plan (CAP) which identifies interventions and a timeline for
resolving data quality issues related to payments per the direction of ODJFS
and/or the EQRO. Additional reports to ODJFS addressing targeted areas of
deficiencies and progress implementing data quality improvement activities may
be required.
For SFY
2010:
For Level
1: An omission encounter rate and a surplus encounter rate of no more than 11%
for both header
and detail records.
For Level
2: A payment error rate of no more than 4%.
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Penalty for Noncompliance:
Beginning SFY 2010, if an MCP is noncompliant with the standard for
either level 1 or level 2 for this measure, the MCP must implement a CAP which
identifies interventions and a timeline for resolving data quality issues
related to payments. Additional reports to ODJFS addressing targeted areas of
deficiencies and progress implementing data quality improvement activities may
be required. Upon all subsequent measurements of performance, if an MCP is again
determined to be noncompliant with the standard, ODJFS will impose a monetary
sanction (see Section 6) of one percent of the current month’s premium payment.
Once the MCP is performing at standard levels and violations/deficiencies are
resolved to the satisfaction of ODJFS, the money will be
refunded.
1.b.ii.
Generic Provider Number Usage
Measure 1: This measure is
the percentage of institutional (UB-92) and professional (NSF) encounters with
the generic provider number in the Medicaid Provider Number field. Providers
submitting claims which do not have an MMIS provider number in the Medicaid
Provider Number field must be submitted to ODJFS with the generic provider
number (i.e. 9111115). The measure will be calculated per MCP. The report period
for this measure is quarterly.
Report Period for Measure 1:
For the SFY 2009 and SFY 2010 contract periods, performance will be evaluated
using the report periods listed in 1.a.i., Table 1.
Data Quality Standard for Measure 1:
A maximum generic provider number usage rate of 10%.
Determination of Compliance for
Measure 1: Performance is monitored once every quarter for all report
periods. For quarterly reports that are issued on or after July 1, 2007, an MCP
will be determined to be noncompliant for the quarter if the standard is not met
in any report period and the initial instance of noncompliance in a report
period is determined on or after July 1, 2007. An initial instance of
noncompliance means that the result for the applicable report period was in
compliance as determined in the prior quarterly report, or the instance of
noncompliance is the first determination for an MCP’s first quarter of
measurement.
Penalty for noncompliance for
Measure 1: The first time an MCP is noncompliant with a standard for this
measure, ODJFS will issue a Sanction Advisory informing the MCP that any future
noncompliance instances with the standard for this measure will result in ODJFS
imposing a monetary sanction.
Upon all
subsequent measurements of performance, if an MCP is again determined to be
noncompliant with the standard, ODJFS will impose a monetary sanction (see
Section 6.) of three percent of the current month’s premium payment. Once the
MCP is performing at standard levels and violations/deficiencies are resolved to
the satisfaction of ODJFS, the money will be refunded.
Measure 2: This measure is
the percentage of pharmacy encounters with the generic provider number in the
“Prescribing Provider ID” field. Providers submitting claims which do not have
an MMIS provider number in the “Prescribing Provider ID” field must be submitted
to ODJFS with the generic
provider number (i.e. 9111115). The measure will be calculated per MCP. The
report period
for this measure is quarterly.
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Report Period for Measure 2:
For the SFY 2009 and SFY 2010 contract periods, performance will be evaluated
using the report periods listed in 1.a.i., Table 1. The Qtr. 3, CY 2008
reporting period (July – September, 2008) will be used to calculate the baseline
rate.
Data Quality Standard for Measure2:
For SFY 2009, this measure is reporting only. For SFY 2010, the data
quality standard for this measure is to be determined (in Fall,
2009).
Determination of Compliance for
Measure 2: Performance is monitored once every quarter for all report
periods on or after July 1, 2008. An initial instance of noncompliance means
that the result for the applicable report period was in compliance as determined
in the prior quarterly report,
or the instance of noncompliance is the first determination for an MCP’s
first quarter of measurement.
Penalty for noncompliance with
Measure 2: The first time an MCP is noncompliant with a standard for this
measure, ODJFS will issue a Sanction Advisory informing the MCP that any future
noncompliance instances with the standard for this measure will result in ODJFS
imposing a monetary sanction.
Upon all
subsequent measurements of performance, if an MCP is again determined to be
noncompliant with the standard, ODJFS will impose a monetary sanction (see
Section 6.) of three percent of the current month’s premium payment. Once the
MCP is performing at standard levels and violations/deficiencies are resolved to
the satisfaction of ODJFS, the money will be refunded.
1.c.
Timely Submission of Encounter Data
1.c.i.
Timeliness
ODJFS
recommends submitting encounters no later than thirty-five days after the end of
the month in which they were paid. ODJFS does not monitor standards specifically
for timeliness, but the minimum claims volume (Section 1.a.i.) and the rejected
encounter (Section 1.a.v.) standards are based on encounters being submitted
within this time frame.
1.c.ii.
Submission of Encounter Data Files in the ODJFS-specified medium per
format
Information
concerning the proper submission of encounter data may be obtained from the
ODJFS Encounter Data File and Submission
Specifications document. The MCP must submit a letter of certification,
using the form required by ODJFS, with each encounter data file in the
ODJFS-specified medium per format.
The
letter of certification must be signed by the MCP’s Chief Executive Officer
(CEO), Chief Financial Officer (CFO), or an individual who has delegated
authority to sign for, and who reports directly to, the MCP’s CEO or
CFO.
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2.
CARE MANAGEMENT
DATA
ODJFS
designed a care management system (CAMS) in order to monitor MCP compliance with
program requirements specified in Appendix G, Coverage and Services. Each
MCP’s care management data submissions will be assessed for completeness and
accuracy. The MCP is responsible for submitting a care management file every
month. Failure to do so jeopardizes the MCP’s ability to demonstrate compliance
with care management requirements
2.a.
Timely Submission of Care Management Files
Data Quality Submission Requirement:
The MCP must submit Care Management files on a monthly basis according to
the specifications established in ODJFS’ Care Management File and
Submission Specifications.
Penalty for noncompliance:
See Appendix N, Compliance Assessment System,
for the penalty for noncompliance with this
requirement.
3.
EXTERNAL QUALITY
REVIEW DATA
In
accordance with federal law and regulations, ODJFS is required to conduct an
independent quality review of contracting managed care plans. OAC rule
5101:3-26-07(C) requires MCPs to submit data and information as requested by
ODJFS or its designee for the annual external quality review.
Two
information sources are integral to these studies: encounter data and medical
records. Because encounter data is used to draw samples for these studies,
quality must be sufficient to ensure valid sampling.
An
adequate number of medical records must then be retrieved from providers and
submitted to ODJFS or its designee in order to generalize results to all
applicable members. To aid MCPs in achieving the required medical record
submittal rate, ODJFS will give at least an eight week period to retrieve and
submit medical records.
3.a.
Independent External Quality Review
Measure: The percentage of
requested records for a study conducted by the External Quality Review
Organization (EQRO) that are submitted by the managed care
plan.
Report Period: The report
period is one year. Results are calculated and performance is monitored
annually. Performance is measured with each review.
Data Quality Standard: A
minimum record submittal rate of 85% for each clinical
measure.
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Penalty for noncompliance for Data
Quality Standard: For each study that is completed during this
contract
period, if an MCP is noncompliant with the standard, ODJFS will impose a
non-refundable $10,000
monetary sanction.
4.
MEMBERS’ PCP DATA
The
designated PCP is the provider who will manage and coordinate the overall care
for CFC members, including those who have care management needs. The MCP must
submit a Members’ Designated PCP file every month. Specialists may and should be
identified as the PCP as appropriate for the member’s condition per the
specialty types specified for the CFC population in ODJFS Member’s PCP Data File and
Submission Specifications; however, no CFC member may have more than one
PCP identified for a given month.
4.a.
Timely submission of Member’s' PCP
Data
Data Quality Submission Requirement:
The MCP must submit a Members’ Designated PCP Data file on a monthly
basis according to the specifications established in ODJFS
Member’s
PCP Data File and Submission
Specifications.
Penalty for noncompliance:
See Appendix N, Compliance Assessment System, for the penalty for noncompliance
with this requirement.
4.b.
Designated PCP for newly enrolled members
Measure: The percentage of
MCP’s newly enrolled members who were designated a PCP by their effective date
of enrollment.
Statewide Approach: MCPs will
be evaluated using their statewide result, including all active regions and
counties (Mahoning and Trumbull) in which an MCP has CFC
membership.
Report Periods: For the SFY
2009 contract period, performance will be evaluated annually using CY 2008. For
the SFY 2010 contract period, performance will be evaluated annually using CY
2009.
Data Quality Targets: For SFY
2009, a target of 85% of new members with PCP designation by their effective
date of enrollment. For SFY 2010, a target rate of 85% of new members with PCP
designation by their effective date of enrollment.
Data Quality Standards: For
SFY 2009, the level of improvement must result in at least a 10% decrease in the
difference between the target and the previous report period’s results. For SFY
2010, the level of improvement must result in at least a 10% decrease in the
difference between the target and the previous report period’s
results.
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Penalty for noncompliance: If
an MCP is noncompliant with the standard, ODJFS will impose a monetary sanction
of one-half of one percent the current month’s premium payment. Once the
MCP is
performing at standard levels and violations/deficiencies are resolved to the
satisfaction of ODJFS,
the money will be refunded. As stipulated in OAC rule 5101:3-26-08.2, each new
member
must have a designated primary care provider (PCP) prior to their effective date
of coverage.
Therefore, MCPs are subject to additional corrective action measures under
Appendix N,
Compliance Assessment System, for failure to meet this
requirement.
5.
APPEALS AND
GRIEVANCES DATA
Pursuant
to OAC rule 5101:3-26-08.4, MCPs are required to submit information at least
monthly to ODJFS regarding appeal and grievance activity. ODJFS requires these
submissions to be in an electronic data file format pursuant to the Appeal File and Submission
Specifications and Grievance File and Submission
Specifications.
The
appeal data file and the grievance data file must include all appeal and
grievance activity, respectively,
for the previous month, and must be submitted by the ODJFS-specified due
date. These
data files
must be submitted in the ODJFS-specified format and with the ODJFS-specified
filename in order
to be successfully processed.
Penalty for noncompliance:
MCPs who fail to submit their monthly electronic data files to the ODJFS
by the specified due date or who fail to resubmit, by no later than the end of
that month, a file which meets the data quality requirements will be subject to
penalty as stipulated under the Compliance Assessment System (Appendix
N).
6.
NOTES
6.a. Penalties,
Including Monetary Sanctions, for Noncompliance
Penalties
for noncompliance with standards outlined in this appendix, including monetary
sanctions, will be imposed as the results are finalized. With the exception of
Sections 1.a.i., 1.a.iii., 1.a.v., 1.a.iv, and 1.b.ii, no monetary sanctions
described in this appendix will be imposed if the MCP is in its first contract
year of Medicaid program participation. Notwithstanding the penalties specified
in this Appendix, ODJFS reserves the right to apply the most appropriate penalty
to the area of deficiency identified when an MCP is determined to be
noncompliant with a standard. Monetary penalties for noncompliance with any
individual measure, as determined in this appendix, shall not exceed $300,000
during each evaluation period.
Refundable
monetary sanctions will be based on the
premium payment in the month of the cited deficiency and due within 30 days of
notification by ODJFS to the MCP of the amount.
Any
monies collected through the imposition of such a sanction will be returned to
the MCP (minus any applicable collection fees owed to the Attorney General’s
Office, if the MCP has been delinquent in submitting payment) after the MCP has
demonstrated full compliance with the particular
program requirement and the violations/deficiencies are resolved to the
satisfaction of ODJFS. If
an MCP does not
comply within two years of the date of notification of noncompliance, then the
monies will not be
refunded.
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6.b.
Combined Remedies
If ODJFS
determines that one systemic problem is responsible for multiple deficiencies,
ODJFS may impose a combined remedy which will address all areas of deficient
performance. The total fines assessed in any one month will not exceed 15% of
the MCP’s monthly premium payment.
6.c.
Enrollment Freezes
MCPs
found to have a pattern of repeated or ongoing noncompliance may be subject to
an enrollment freeze.
6.d.
Reconsideration
Requests
for reconsideration of monetary sanctions and enrollment freezes may be
submitted as provided in Appendix N, Compliance Assessment
System.
6.e.
Contract Termination, Nonrenewals, or Denials
Upon
termination either by the MCP or ODJFS, nonrenewal, or denial of an MCP provider
agreement, all previously collected refundable monetary sanctions will be
retained by ODJFS.
6.f.
Report and Compliance Periods
ODJFS
reserves the right to revise report periods (and corresponding compliance
periods), as needed, due to unforeseen circumstances.
Unless
otherwise noted, the most recent report or study finalized prior to the end of
the contract period may be used in determining the MCP’s performance level for
the current contract period.
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APPENDIX
M
PERFORMANCE
EVALUATION
CFC
ELIGIBLE POPULATION
This
appendix establishes performance measures and minimum performance standards for
managed care plans (MCPs) in key program areas. The intent is to maintain
accountability for contract requirements. Performance measures and standards are
subject to change based on the revision or update of applicable national
measures, standards, methods or benchmarks. Performance will be evaluated in the
categories of Quality of Care, Access, Consumer Satisfaction, and Administrative
Capacity. Each performance measure has an accompanying minimum performance
standard. MCPs with performance levels below the minimum performance standards
will be required to take corrective action. All performance measures, as
specified in this appendix, will be calculated per MCP and include only members
in the CFC Medicaid managed care program.
With the
statewide expansion of the Ohio Medicaid Managed Care Program for the Covered
Families and Children (CFC) population nearly complete, evaluation of
performance will transition to a statewide approach encompassing all members who
meet the criteria specified per the given methodology for each measure (i.e.,
measures will include members in any county who meet criteria per the given
methodology as opposed to only those members with managed care membership as of
February 1, 2006).
The
statewide approach was implemented beginning January 1, 2008. Unless otherwise
noted, performance measures and standards (see Sections 1, 2, 3 and 4 of this
appendix) will be applicable for all counties in which the MCP has membership as
of February 1, 2006, until statewide measurement is
implemented.
Selected
measures in this appendix will be used to determine pay-for-performance (P4P) as
specified in Appendix O, Pay
for Performance.
1.
QUALITY OF CARE
1.a.
Independent External Quality Review
In
accordance with federal law and regulations, state Medicaid agencies must
annually provide for an external quality review of the quality outcomes and
timeliness of, and access to, services provided by Medicaid-contracting MCPs
[(42 CFR 438.204(d)]. The external review assists the state in assuring MCP
compliance with program requirements and facilitates the collection of accurate
and reliable information concerning MCP performance.
Measure:
The independent external quality review covers a review of clinical and
non-clinical performance as outlined in Appendix K.
Report
Period: Performance will be evaluated using the reviews conducted during SFY
2009.
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Action
Required for Deficiencies: For all reviews conducted during the contract period,
if the EQRO cites a deficiency in performance, the MCP will be required to
complete a Corrective Action Plan or Quality Improvement Directive depending on
the severity of the deficiency. Serious deficiencies may result in immediate
termination or non-renewal of the provider agreement.
1.b.
Members with Special Health Care Needs (MSHCN)
In order
to ensure state compliance with the provisions of 42 CFR 438.208, the Bureau of
Managed Health Care established care management basic program requirements in
Appendix G, Coverage
and Services,
and corresponding performance measures and minimum performance standards as
described below. The purpose of these measures is to ensure appropriate care
management services are provided to MSHCN.
1.b.i. Care Management of Children
(applicable to P4P
through SFY 2008)
Measure: The average monthly
case management rate for children under 21 years of age.
Report Period: For the SFY
2008 contract period: April – June 2008 (for P4P).
County-Based Approach: The
last report period using the MCP’s county-based statewide result for the
counties in which the MCP had membership as of February 1, 2006 for P4P (Appendix O) is April-June
2008. A detailed description of the of excellent and superior standards
associated with this measure for P4P determination for SFY 2008 can be found in
Appendix O, Section 1.b.1.
1.b.ii. Care Management of High Risk
Members (applicable to
performance evaluation beginning January
2009)
Measure: The percent of high
risk members who have had at least three consecutive months of enrollment in one
MCP that are care managed.
Report Period: For the SFY
2009 contract period: January – March 2009 (informational only), and April –
June 2009 (baseline – reporting only) report periods. For the SFY 2010 contract
period: July – September 2009, October – December 2009, January – March 2010,
and April – June 2010 report periods.
Interim Regional-Based Statewide
Minimum Performance Standard: For SFY 2009, each MCP must submit a
quality improvement plan (QIP) which addresses the following: 1) strategies the
MCP will implement to identify members eligible for care management services,
including low, medium and high-risk stratification levels; and 2) strategies the
MCP will implement to ensure the MCP's information technology system is designed
to accept, integrate, and analyze data used to inform and support the MCP's Care
Management Program, including the MCP's process for submitting data to CAMS as
outlined in the file specifications. The MCP will be expected to incorporate the
QIP into the submission of its Care Management Program for ODJFS review and
approval as outlined in Appendix G.
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Regional-Based Statewide Approach:
Performance will be evaluated using a regional-based statewide approach
for all active regions in which the MCP has membership. ODJFS will use the April
– June 2009 report period as the baseline report period. July-September 2009
will be the first report period that MCPs will be held accountable to the
performance standard and penalties will be applied for
noncompliance.
Regional-Based Statewide Target:
For SFY 2010, the target is a care management rate of
70%.
Regional-Based Statewide Minimum
Performance Standard: For SFY 2010, the standard is a level of
improvement that is at least a 10% decrease in the difference between the target
and the previous report period’s results.
Penalty for Noncompliance with the
Regional-Based Statewide Standard: Beginning SFY 2010, the first time an
MCP is noncompliant with a standard for this measure, ODJFS will issue a
Sanction Advisory informing the MCP that any future noncompliance instances with
the standard for this measure will result in ODJFS imposing a monetary sanction.
Upon all subsequent measurements of performance, if an MCP is again determined
to be noncompliant with the standard, ODJFS will impose a monetary sanction (see
Section 5) of two percent of the current month’s premium payment. Monetary
sanctions will not be levied for consecutive quarters that an MCP is determined
to be noncompliant. If an MCP is noncompliant for a subsequent quarter, new
member selection freezes or a reduction of assignments will occur as outlined in
Appendix N of the Provider Agreement. Once the MCP is determined to be compliant
with the standard and the violations/deficiencies are resolved to the
satisfaction of ODJFS, the penalties will be lifted, if applicable, and monetary
sanctions will be returned.
0.x.xxx.Xxxx Management of Members
(applicable to
performance evaluation beginning January 2009)
Measure: The average monthly
care management rate for members who have had at least three consecutive months
of enrollment in one MCP (including members assigned to low, medium, and high
risk stratification levels).
Report Period: For the SFY
2009 contract period, January – March 2009 (informational only), and April –
June 2009 (baseline – reporting only) report periods. For the SFY 2010 contract
period, July – September 2009, October – December 2009, January – March 2010,
and April – June 2010 report periods.
Interim Regional-Based Statewide
Minimum Performance Standard: For SFY 2009, each MCP must submit a
quality improvement plan (QIP) which addresses the following: 1) strategies the
MCP will implement to identify members eligible for care management services,
including low, medium, and high-risk stratification levels; and 2) strategies
the MCP will implement to ensure the MCP's information technology system is
designed to accept, integrate, and analyze data used to inform and support the
MCP's Care Management Program, including the MCP's process for submitting data
to CAMS as outlined in the file specifications. The MCP will be expected to
incorporate the QIP into the submission of its Care Management Program for ODJFS
review and approval as outlined in Appendix G.
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Regional-Based Statewide Approach:
Performance will be evaluated using a regional-based statewide approach
for all active regions in which the MCP has membership. ODJFS will use the April
– June 2009 report period as the baseline report period to determine a minimum
performance standard and target. July-September 2009 will be the first report
period that MCPs will be held accountable to the performance standard and
penalties will be applied for noncompliance.
Regional-Based Statewide Target:
For SFY 2010, the target is to be determined (in Fall,
2009).
Regional-Based Statewide Minimum
Performance Standard: For SFY 2010, the standard is to be determined (in
Fall, 2009).
Penalty for Noncompliance with the
Regional-Based Statewide Standard: Beginning SFY 2010, the first time an
MCP is noncompliant with a standard for this measure, ODJFS will issue a
Sanction Advisory informing the MCP that any future noncompliance instances with
the standard for this measure will result in ODJFS imposing a monetary sanction.
Upon all subsequent measurements of performance, if an MCP is again determined
to be noncompliant with the standard, ODJFS will impose a monetary sanction (see
Section 5) of two percent of the current month’s premium payment. Monetary
sanctions will not be levied for consecutive quarters that an MCP is determined
to be noncompliant. If an MCP is noncompliant for a subsequent quarter, new
member selection freezes or a reduction of assignments will occur as outlined in
Appendix N of the Provider Agreement. Once the MCP is determined to be compliant
with the standard and the violations/deficiencies are resolved to the
satisfaction of ODJFS, the penalties will be lifted, if applicable, and monetary
sanctions will be returned.
1.c.
Clinical Performance Measures
MCP
performance will be assessed based on the analysis of submitted encounter data
for each year. For certain measures, standards are established; the
identification of these standards is not intended to limit the assessment of
other indicators for performance improvement activities. Performance on multiple
measures will be assessed and reported to the MCPs and others, including
Medicaid consumers.
The
clinical performance measures described below closely follow the National
Committee for Quality Assurance’s Healthcare Effectiveness Data and Information
Set (HEDIS). Minor adjustments to HEDIS measures are required to account for the
differences between the commercial population and the Medicaid population, such
as shorter and interrupted enrollment periods. NCQA may annually change its
method for calculating a measure. These changes can make it difficult to
evaluate whether improvement occurred from a prior year. For this reason, ODJFS
will use the same methods to calculate the baseline results and the results for
the period in which the MCP is being held accountable. For example, the same
methods were being used to calculate calendar year 2005 results (the baseline
period) and calendar year 2006 results. The methods will be updated and a new
baseline will be created during 2007 for calendar year 2006 results. These
results will then serve as the baseline to evaluate whether improvement occurred
from calendar year 2006 to calendar year 2007. Clinical
performance measure results will be calculated after a sufficient amount of time
has passed after the end of the report period in order to allow for claims
runout. For a comprehensive description of the clinical performance measures
below, see ODJFS Methods for
Clinical Performance
Measures for the CFC Managed Care Program. Performance measures and
standards are subject to change based on the revision or update of NCQA methods
or other national measures, standards, methods or
benchmarks.
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For an MCP which had membership as
of February 1, 2006: MCP performance will be evaluated using an MCP’s
county-based statewide result for the counties in which the MCP had membership
as of February 1, 2006. For reporting period CY 2008, the county-based statewide
targets and performance standards for the Clinical Performance Measures
in this Appendix (1.c.i
– 1.c.vii) will be applicable to all counties in which MCPs had
membership as of February 1, 2006. The final reporting year (for evaluation) for
the counties in which an MCP had membership as of February 1, 2006, for one year
measures, was CY 2007. The final reporting year (for evaluation) for the
counties in which an MCP had membership as of February 1, 2006, for two year
measures, will be CY 2008. The final reporting year (for P4P) for the counties
in which an MCP had membership as of February 1, 2006, for both one and two year
measures, will be CY 2008.
For any MCP which did not have
membership as of February 1, 2006: MCP Performance will
be evaluated using an MCP's regional-based statewide result for all active
regions and counties (Trumbull and Mahoning) in which the MCP has membership.
For reporting period CY 2008, ODJFS will evaluate MCP performance using interim
regional-based statewide minimum performance standards. ODJFS will evaluate MCP
performance using regional-based statewide targets and performance standards
beginning with reporting period CY 2009.
For
measures requiring one year of baseline data, ODJFS will use the first full
calendar year of data (CY 2007) from all MCPs serving CFC membership. CY 2008
will be the first reporting year that MCPs will be held accountable to the
statewide performance standards for one year measures.
For
measures requiring two years of baseline data, ODJFS will use the first two full
calendar years of data (CY 2007 and CY 2008) from all MCPs serving CFC
membership to determine statewide minimum performance standards. CY 2009 will be
the first reporting year that MCPs will be held accountable to the statewide
performance standards for two year measures, and penalties will be applied for
noncompliance.
Statewide
performance measure results will be calculated after a sufficient amount of time
has passed after the end of the report period in order to allow for claims
runout.
Report Period: For the SFY
2008 contract period, performance will be evaluated using the January -December
2007 report period. For the SFY 2009 contract period, performance will be
evaluated using the January - December 2008 report period. For the SFY 2010
contract period, performance will be evaluated using the January – December 2009
report period.
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1.c.i. Perinatal
Care – Frequency of Ongoing Prenatal Care
Measure: The percentage of
enrolled women with a live birth during the year who received the expected
number of prenatal visits. The number of observed versus expected visits will be
adjusted for length of enrollment.
County-Based Statewide Target:
At least 80.0% of the eligible population must receive 81.0% or more of
the expected number of prenatal visits.
County-Based Statewide Minimum
Performance Standard: The level of improvement must result in at least a
10.0% decrease in the difference between the target and the previous report
period’s results. (For example, if last year’s results were 20.0%, then the
difference between the target and last year’s results is 60.0%. In this example,
the standard is an improvement in performance of 10.0% of this difference or
6.0%. In this example, results of 26.0% or better would be compliant with the
standard.)
Action Required for Noncompliance
with the County-Based Statewide Standard: For SFY 2009, if the standard
is not met and the results are below 44.0%, the MCP is required to complete a
Corrective Action Plan to address the area of noncompliance. If the standard is
not met and the results are at or above 44.0%, ODJFS will issue a Quality
Improvement Directive which will notify the MCP of noncompliance and may outline
the steps that the MCP must take to improve the results.
Interim Regional-Based Statewide
Minimum Performance Standard: For SFY 2009, each MCP must implement a
quality improvement plan (QIP) which identifies areas needing quality
improvement, includes a root-cause analysis of the areas needing improvement,
and establishes strategies and implementation activities to achieve continuous
quality improvement for this measure. The QIP must be submitted to ODJFS for
review and implemented no later than May, 1, 2009.
Regional-Based Statewide Target:
To be determined (in Spring, 2009).
Regional-Based Statewide Minimum
Performance Standard: To be determined (in Spring,
2009).
Action Required for Noncompliance
with the Regional-Based Statewide Standard: Beginning SFY 2010, if the
standard is not met and the results are below TBD% the MCP is required to
complete a Corrective Action Plan to address the area of noncompliance. If the
standard is not met and the results are at or above TBD%, ODJFS will issue a
Quality Improvement Directive which will notify the MCP of noncompliance and may
outline the steps that the MCP must take to improve the
results.
1.c.ii.
Perinatal Care - Initiation of Prenatal Care
Measure: The percentage of
enrolled women with a live birth during the year who had a prenatal visit within
42 days of enrollment or by the end of the first trimester for those women who
enrolled in the MCP during the early stages of pregnancy.
County-Based Statewide Target:
At least 90.0% of the eligible population initiates prenatal care within
the specified time.
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County-Based Statewide Minimum
Performance Standard: The level of improvement must result in at least a
10.0% decrease in the difference between the target and the previous year’s
results.
Action Required for Noncompliance
with the County-Based Statewide Standard: For SFY 2009, if the standard
is not met and the results are below 74.0%, the MCP is required to complete a
Corrective Action Plan to address the area of noncompliance. If the standard is
not met and the results are at or above 74.0%, ODJFS will issue a Quality
Improvement Directive which will notify the MCP of noncompliance and may outline
the steps that the MCP must take to improve the results.
Interim Regional-Based Statewide
Minimum Performance Standard: For SFY 2009, each MCP must implement a
quality improvement plan (QIP) which identifies areas needing quality
improvement, includes a root-cause analysis of the areas needing improvement,
and establishes strategies and implementation activities to achieve continuous
quality improvement for this measure. The QIP must be submitted to ODJFS for
review and implemented no later than May, 1, 2009.
Regional-Based Statewide Target:
To be determined (in Spring, 2009).
Regional-Based Statewide Minimum
Performance Standard: To be determined (in Spring,
2009).
Action Required for Noncompliance
with the Regional-Based Statewide Standard: Beginning SFY 2010, if the
standard is not met and the results are below TBD% the MCP is required to
complete a Corrective Action Plan to address the area of noncompliance. If the
standard is not met and the results are at or above TBD%, ODJFS will issue a
Quality Improvement Directive which will notify the MCP of noncompliance and may
outline the steps that the MCP must take to improve the
results.
1.c.iii.
Perinatal Care - Postpartum Care
Measure: The percentage of
women who delivered a live birth who had a postpartum visit on or between 21
days and 56 days after delivery.
County-Based Statewide Target:
At least 80.0% of the eligible population must receive a postpartum
visit.
County-Based Statewide Minimum
Performance Standard: The level of improvement must result in at least a
5.0% decrease in the difference between the target and the previous year’s
results.
Action Required for Noncompliance
with the County-Based Statewide Standard: For SFY 2009, if the standard
is not met and the results are below 50.0%, the MCP is required to complete a
Corrective Action Plan to address the area of noncompliance. If the standard is
not met and the results are at or above 50.0%, ODJFS will issue a Quality
Improvement Directive which will notify the MCP of noncompliance and may outline
the steps that the MCP must take to improve the results.
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Interim Regional-Based Statewide
Minimum Performance Standard: For SFY 2009, each MCP must implement a
quality improvement plan (QIP) which identifies areas needing quality
improvement, includes a root-cause analysis of the areas needing improvement,
and establishes strategies and implementation activities to achieve continuous
quality improvement for this measure. The QIP must be submitted to ODJFS for
review and implemented no later than May, 1, 2009.
Regional-Based Statewide Target:
To be determined (in Spring, 2009).
Regional-Based Statewide Minimum
Performance Standard: To be determined (in Spring,
2009).
Action Required for Noncompliance
with the Regional-Based Statewide Standard: Beginning SFY 2010, if the
standard is not met and the results are below TBD%, the MCP is required to
complete a Corrective Action Plan to address the area of noncompliance. If the
standard is not met and the results are at or above TBD%, ODJFS will issue a
Quality Improvement Directive which will notify the MCP of noncompliance and may
outline the steps that the MCP must take to improve the
results.
1.c.iv.
Preventive Care for Children - Well-Child Visits
Measure: The percentage of
children who received the expected number of well-child visits adjusted by age
and enrollment. The expected number of visits is as follows:
Children
who turn 15 months old: six or more well-child visits.
Children
who were 3, 4, 5, or 6, years old: one or more well-child visits.
Children
who were 12 through 21 years old: one or more well-child
visits.
County-Based Statewide Target:
At least 80.0% of the eligible children receive the expected number of
well-child visits.
County-Based Statewide Minimum
Performance Standard for Each of the Age Groups: The level of improvement
must result in at least a 10.0% decrease in the difference between the target
and the previous year’s results.
Action Required for Noncompliance
with the County-Based Statewide Standard (15 month old age group): For SFY 2009, if the
standard is not met and the results are below 42.0%, the MCP is required to
complete a Corrective Action Plan to address the area of noncompliance. If the
standard is not met and the results are at or above 42.0%, ODJFS will issue a
Quality Improvement Directive which will notify the MCP of noncompliance and may
outline the steps that the MCP must take to improve the
results.
Action Required for Noncompliance
with the County-Based Statewide Standard (3-6 year old age group): For SFY 2009, if the
standard is not met and the results are below 57.0%, the MCP is required to
complete a Corrective Action Plan to address the area of noncompliance. If the
standard is not met and the results are at or above 57.0%, ODJFS will issue a
Quality Improvement Directive which will notify the MCP of noncompliance and may
outline the steps that the MCP must take to improve the
results.
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Action Required for Noncompliance
with the County-Based Statewide Standard (12-21 year old age group): For SFY 2009, if the
standard is not met and the results are below 33.0%, the MCP is required to
complete a Corrective Action Plan to address the area of noncompliance. If the
standard is not met and the results are at or above 33.0%, ODJFS will issue a
Quality Improvement Directive which will notify the MCP of noncompliance and may
outline the steps that the MCP must take to improve the
results.
Interim Regional-Based Statewide
Minimum Performance Standard for Each of the Age Groups: For SFY 2009,
each MCP must implement a quality improvement plan (QIP) which identifies areas
needing quality improvement, includes a root-cause analysis of the areas needing
improvement, and establishes strategies and implementation activities to achieve
continuous quality improvement for this measure. The QIP must be submitted to
ODJFS for review and implemented no later than May, 1, 2009.
Regional-Based Statewide Target:
To be determined (in Spring, 2009).
Regional-Based Statewide Minimum
Performance Standard for Each of the Age Groups: To be determined (in
Spring, 2009).
Action Required for Noncompliance
with the Regional-Based Statewide Standard (15 month old age group): Beginning SFY 2010,
if the standard is not met and the results are below TBD%, the MCP is required
to complete a Corrective Action Plan to address the area of noncompliance. If
the standard is not met and the results are at or above TBD%, ODJFS will issue a
Quality Improvement Directive which will notify the MCP of noncompliance and may
outline the steps that the MCP must take to improve the
results.
Action Required for Noncompliance
with the Regional-Based Statewide Standard (3-6 year old age group): Beginning SFY 2010,
if the standard is not met and the results are below TBD% , the MCP is required
to complete a Corrective Action Plan to address the area of noncompliance. If
the standard is not met and the results are at or above TBD%, ODJFS will issue a
Quality Improvement Directive which will notify the MCP of noncompliance and may
outline the steps that the MCP must take to improve the
results.
Action Required for Noncompliance
with the Regional-Based Statewide Standard (12-21 year old age group): Beginning SFY
2010, if the standard is not met and the results are below TBD%, the MCP is
required to complete a Corrective Action Plan to address the area of
noncompliance. If the standard is not met and the results are at or above TBD%,
ODJFS will issue a Quality Improvement Directive which will notify the MCP of
noncompliance and may outline the steps that the MCP must take to improve the
results.
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1.c.v. Use of
Appropriate Medications for People with Asthma
Measure: The percentage of
members with persistent asthma who were enrolled for at least 11 months with the
plan during the year and who received prescribed medications acceptable as
primary therapy for long-term control of asthma.
County-Based Statewide Target:
At least 95.0% of the eligible population must receive the recommended
medications.
County-Based Statewide Minimum
Performance Standard: The level of improvement must result in at least a
10.0% decrease in the difference between the target and the previous year’s
results.
Action Required for Noncompliance
with the County-Based Statewide Standard: For SFY 2009, if the standard
is not met and the results are below 84.0%, the MCP is required to complete a
Corrective Action Plan to address the area of noncompliance. If the standard is
not met and the results are at or above 84.0%, ODJFS will issue a Quality
Improvement Directive which will notify the MCP of noncompliance and may outline
the steps that the MCP must take to improve the results.
Interim Regional-Based Statewide
Minimum Performance Standard: For SFY 2009, each MCP must implement a
quality improvement plan (QIP) which identifies areas needing quality
improvement, includes a root-cause analysis of the areas needing improvement,
and establishes strategies and implementation activities to achieve continuous
quality improvement for this measure. The QIP must be submitted to ODJFS for
review and implemented no later than May, 1, 2009.
Regional-Based Statewide Target:
To be determined (in Spring, 2009).
Regional-Based Statewide Minimum
Performance Standard: To be determined (in Spring,
2009).
Action Required for Noncompliance
with the Regional-Based Statewide Standard: Beginning SFY 2010, if the
standard is not met and the results are below TBD%, the MCP is required to
complete a Corrective Action Plan to address the area of noncompliance. If the
standard is not met and the results are at or above TBD%, ODJFS will issue a
Quality Improvement Directive which will notify the MCP of noncompliance and may
outline the steps that the MCP must take to improve the
results.
0.x.xx.
Annual Dental Visits
Measure: The percentage of
enrolled members age 4 through 21 who were enrolled for at least 11 months with
the plan during the year and who had at least one dental visit during the
year.
County-Based Statewide Target:
At least 60.0% of the eligible population receives a dental
visit.
County-Based Statewide Minimum
Performance Standard: The level of improvement must result in at least a
10.0% decrease in the difference between the target and the previous year’s
results.
Action Required for Noncompliance
with the County-Based Statewide Standard: For SFY 2009, if the standard
is not met and the results are below 42.0%, the MCP is required to complete a
Corrective Action Plan to address the area of noncompliance. If the standard is
not met and the results
are at or above 42.0%, ODJFS will issue a Quality Improvement Directive which
will notify the MCP of noncompliance and may outline the steps that the MCP must
take to improve the results.
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Interim Regional-Based Statewide
Minimum Performance Standard: For SFY 2009, each MCP must implement a
quality improvement plan (QIP) which identifies areas needing quality
improvement, includes a root-cause analysis of the areas needing improvement,
and establishes strategies and implementation activities to achieve continuous
quality improvement for this measure. The QIP must be submitted to ODJFS for
review and implemented no later than May, 1, 2009.
Regional-Based Statewide Target:
To be determined (in Spring, 2009).
Regional-Based Statewide Minimum
Performance Standard: To be determined (in Spring,
2009).
Action Required for Noncompliance
with the Regional-Based Statewide Standard: Beginning SFY 2010, if the
standard is not met and the results are below TBD%, the MCP is required to
complete a Corrective Action Plan to address the area of noncompliance. If the
standard is not met and the results are at or above TBD%, ODJFS will issue a
Quality Improvement Directive which will notify the MCP of noncompliance and may
outline the steps that the MCP must take to improve the
results.
1.c.vii. Lead Screening (For 1 Year Olds and For 2 Year
Olds)
The final
report period for these measures is CY 2008 (SFY 2009).
Measure: The percentage of
one and two year olds who received a blood lead screening by age
group.
County-Based Statewide Target:
At least 80.0% of the eligible population receives a blood lead
screening.
County-Based Statewide Minimum
Performance Standard for Each of the Age Groups: The level of improvement
must result in at least a 10.0% decrease in the difference between the target
and the previous year’s results.
Action Required for Noncompliance
with the County-Based Statewide Standard (1 year olds): Beginning SFY
2007, if the standard is not met and the results are below 45.0% the MCP is
required to complete a Corrective Action Plan to address the area of
noncompliance. If the standard is not met and the results are at or above 45.0%,
ODJFS will issue a Quality Improvement Directive which will notify the MCP of
noncompliance and may outline the steps that the MCP must take to improve the
results.
Action Required for Noncompliance
with the County-Based Statewide Standard (2 year olds): Beginning SFY
2007, if the standard is not met and the results are below 28.0% the MCP is
required to complete a Corrective Action Plan to address the area of
noncompliance. If the standard is not met and the results are at or above 28.0%,
ODJFS will issue a Quality Improvement Directive which will notify the MCP of
noncompliance and may outline the steps that the MCP must take to improve the
results.
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1.c.viii.
Lead Testing in Children
The
initial report period for this measure is CY 2009 (SFY 2010). This measure will
replace the Lead Screening for 1 Year Olds and for 2 Year Olds in the P4P system
(Appendix O) in SFY
2010.
Measure: The percentage of
children who have turned two years of age during the reporting year who have
received one lead test on or before their second birthday.
Regional-Based Statewide Target:
To be determined (in Spring, 2009).
Regional-Based Statewide Minimum
Performance Standard: To be determined (in Spring,
2009).
Action Required for Noncompliance
with the Regional-Based Statewide Standard: Beginning SFY 2010, if the
standard is not met and the results are below TBD% the MCP is required to
complete a Corrective Action Plan to address the area of noncompliance. If the
standard is not met and the results are at or above TBD%, ODJFS will issue a
Quality Improvement Directive which will notify the MCP of noncompliance and may
outline the steps that the MCP must take to improve the
results.
2.
ACCESS
Performance
in the Access category will be determined by the following measures: Primary
Care Provider (PCP) Turnover, Children’s Access to Primary Care, Adults’ Access
to Preventive/Ambulatory Health Services, and Members’ Access to Designated PCP.
For a comprehensive description of the access performance measures below, see
ODJFS Methods for Access
Performance Measures for the CFC Managed Care Program.
2.a.
PCP Turnover
A high
PCP turnover rate may affect continuity of care and may signal poor management
of providers. However, some turnover may be expected when MCPs end contracts
with providers who are not adhering to the MCP’s standard of care. Therefore,
this measure is used in conjunction with the children and adult access measures
to assess performance in the access category.
Measure: The percentage of
primary care providers affiliated with the MCP as of the beginning of the
measurement year who were not affiliated with the MCP as of the end of the
year.
For an MCP which had membership as
of February 1, 2006: MCP performance will be evaluated using an MCP’s
county-based statewide result for the counties in which the MCP had membership
as of February 1, 2006. The minimum performance standard in this Appendix (2.a) will be
applicable to the MCP’s county-based statewide result for the counties in which
the MCP had membership as of February 1, 2006. The last reporting year using the
MCP’s county-based statewide result for the counties in which the MCP had
membership as of February 1, 2006 for performance evaluation is CY 2007; the
last reporting year using the MCP’s county-based statewide result for the
counties in which the MCP had membership as of February 1, 2006 for P4P (Appendix O) is CY
2008.
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For any MCP which did not have
membership as of February 1, 2006: Performance will be
evaluated using a regional-based statewide approach for all active regions and
counties (Mahoning and Trumbull) in which the MCP has
membership.
Regional-Based Statewide Approach:
MCPs will be evaluated statewide, using results for all regions and
counties (Mahoning and Trumbull) in which the MCP has membership. ODJFS will use
the first full calendar year of data (CY 2007) from all MCPs serving CFC
membership as a baseline to determine a statewide minimum performance standard.
CY 2008 will be the first reporting year that MCPs will be held accountable to
the statewide performance standard for statewide reporting .
Report Period: For the SFY
2008 contract period, performance will be evaluated using the January -December
2007 report period. For the SFY 2009 contract period, performance will be
evaluated using the January - December 2008 report period. For the SFY 2010
contract period, performance will be evaluated using the January - December 2009
report period.
County-Based Statewide Minimum
Performance Standard: A maximum PCP Turnover rate of
18.0%.
Interim Regional-Based Statewide
Minimum Performance Standard: For SFY 2009, each MCP must implement a
quality improvement plan (QIP) which identifies areas needing quality
improvement, includes a root-cause analysis of the areas needing improvement,
and establishes strategies and implementation activities to achieve continuous
quality improvement for this measure. The QIP must be submitted to ODJFS for
review and implemented no later than May, 1, 2009.
Regional-Based Statewide Minimum
Performance Standard: A maximum PCP Turnover rate of
18.0%.
Action Required for Noncompliance
with the Regional-Based Statewide Minimum Performance Standard: MCPs are required
to perform a causal analysis of the high PCP turnover rate and assess the impact
on timely access to health services, including continuity of care. If access has
been reduced or coordination of care affected, then the MCP must develop and
implement a corrective action plan to address the findings.
2.b. Children’s Access to Primary
Care (applicable to
performance evaluation through SFY 2010)
This
measure indicates whether children aged 12 months to 11 years are accessing PCPs
for sick or well-child visits.
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Measure: The percentage of
members age 12 months to 11 years who had a visit with an MCP PCP-type
provider.
For an MCP which had membership as
of February 1, 2006: MCP performance will be evaluated using an MCP’s
county-based statewide result for the counties in which the MCP had membership
as of February 1, 2006. The minimum performance standard in this Appendix (2.b) will be
applicable to the MCP’s county-based statewide result for the counties in which
the MCP had membership as of February 1, 2006. The last reporting year using the
MCP’s county-based statewide result for the counties in which the MCP had
membership as of February 1, 2006 is CY 2008.
For any MCP which did not have
membership as of February 1, 2006: Performance will be evaluated using a
regional-based statewide approach for all active regions and counties (Mahoning
and Trumbull) in which the MCP has membership.
Regional-Based Statewide Approach:
MCPs will be evaluated statewide, using results for all active regions
and counties (Mahoning and Trumbull) in which the MCP has membership. ODJFS will
use the first two full calendar years of data (CY 2007 and CY 2008) from all
MCPs serving CFC membership as a baseline to determine a statewide minimum
performance standard. CY 2009 will be the first reporting year that MCPs will be
held accountable to the statewide performance standard for statewide reporting,
and penalties will be applied for noncompliance. Statewide performance measure
results will be calculated after a sufficient amount of time has passed after
the end of the report period in order to allow for claims run
out.
Report Period: For the SFY
2008 contract period, performance will be evaluated using the January -December
2007 report period. For the SFY 2009 contract period, performance will be
evaluated using the January - December 2008 report period. For the SFY 2010
contract period, performance will be evaluated using the January – December 2009
report period.
County-Based Statewide Minimum
Performance Standards:
CY 2007
report period – 71.0% of children must receive a visit
CY 2008
report period – 74.0% of children must receive a visit
Regional-Based Statewide Minimum
Performance Standards:
CY 2009
report period – To be determined (in Spring, 2009).
Penalty for Noncompliance with the
County-Based and Regional-Based Statewide Minimum Performance Standards:
If an MCP
is noncompliant with the Minimum Performance Standard, the MCP must develop and
implement a corrective action plan.
2.b.i. Children’s Access to Primary
Care (applicable to
performance evaluation as of SFY 2011)
This
measure indicates whether children aged 12 months to 19 years are accessing PCPs
for sick or well-child visits.
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Measure: The percentage of
members age 12 months to 19 years who had a visit with an MCP PCP-type
provider.
Regional-Based Statewide Approach:
MCPs will be evaluated statewide, using results for all active regions
and counties in which the MCP has membership. ODJFS will use CY 2008 and CY 2009
data from all MCPs serving CFC membership as a baseline to determine a statewide
minimum performance standard. CY 2010 will be the first reporting year that MCPs
will be held accountable to the statewide performance standard for statewide
reporting, and penalties will be applied for noncompliance. Statewide
performance measure results will be calculated after a sufficient amount of time
has passed after the end of the report period in order to allow for claims run
out.
Report Period: For the SFY
2011 contract period, performance will be evaluated using the January - December
2010 report period.
Regional-Based Statewide Minimum
Performance Standards: CY 2010 report period – To be determined (in
Spring, 2010).
Penalty for Noncompliance: If
an MCP is noncompliant with the Minimum Performance Standard, then the MCP must
develop and implement a corrective action plan.
2.c.
Adults’ Access to Preventive/Ambulatory Health Services
This
measure indicates whether adult members are accessing health
services.
Measure: The percentage of
members age 20 and older who had an ambulatory or preventive-care
visit.
For an MCP which had membership as
of February 1, 2006: MCP performance will be evaluated using an MCP’s
county-based statewide result for the counties in which the MCP had membership
as of February 1, 2006. The minimum performance standard in this Appendix (2.c) will be
applicable to the MCP’s county-based statewide result for the counties in which
the MCP had membership as of February 1, 2006. The last reporting year using the
MCP’s county-based statewide result for the counties in which the MCP had
membership as of February 1, 2006 for performance evaluation is CY 2007; the
last reporting year using the MCP’s county-based statewide result for the
counties in which the MCP had membership as of February 1, 2006 for P4P (Appendix O) is CY
2008.
For any MCP which did not have
membership as of February 1, 2006: Performance will be evaluated using a
regional-based statewide approach for all active regions and counties (Mahoning
and Trumbull) in which the MCP has membership.
Regional-Based Statewide Approach:
MCPs will be evaluated statewide, using results for all active regions
and counties (Mahoning and Trumbull) in which the MCP has membership. ODJFS will
use the first full calendar year of data (CY 2007 ) from all MCPs serving CFC
membership as a baseline to determine a statewide minimum performance standard.
CY 2008 will be the first reporting year that MCPs will be held accountable to
the statewide performance standard for statewide reporting. Statewide
performance measure results will be calculated after a sufficient amount of time
has passed after the end of the report period in order to allow for claims run
out.
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Report Period: For the SFY
2008 contract period, performance will be evaluated using the January -December
2007 report period. For the SFY 2009 contract period, performance will be
evaluated using the January - December 2008 report period. For the SFY 2010
contract period, performance will be evaluated using the January - December 2009
report period.
County-Based Statewide Minimum
Performance Standards:
CY 2007
report period – 63% of adults must receive a visit.
CY 2008
report period – 63% of adults must receive a visit (P4P
only).
Interim Regional-Based Statewide
Minimum Performance Standard: For SFY 2009, each MCP must implement a
quality improvement plan (QIP) which identifies areas needing quality
improvement, includes a root-cause analysis of the areas needing improvement,
and establishes strategies and implementation activities to achieve continuous
quality improvement for this measure. The QIP must be submitted to ODJFS for
review and implemented no later than May, 1, 2009.
Regional-Based
Statewide Minimum Performance Standards:
CY 2009
report period – 75% of adults must receive a visit (may be adjusted in Spring,
2009).
Penalty for Noncompliance with the
Regional-Based Statewide Minimum Performance Standard: I f an MCP is
noncompliant with the Minimum Performance Standard, then the MCP must develop
and implement a corrective action plan.
2.d.
Members’ Access to Designated PCP
The MCP
must encourage and assist CFC members without a designated primary care provider
(PCP) to establish such a relationship, so that a designated PCP can coordinate
and manage a member’s health care needs. This measure is to be used to assess
MCPs’ performance in the access category.
Measure: The percentage of
members who had a visit through members’ designated PCPs.
Regional-Based Statewide Approach:
MCPs will be evaluated statewide, using results for all active regions
and counties (Mahoning and Trumbull) in which the MCP has membership. ODJFS will
use the first full calendar year of data (CY 2007) from all MCPs serving CFC
membership as a baseline to determine a statewide minimum performance standard.
CY 2008 will be the first reporting year that MCPs will be held accountable to
the performance standard. Statewide performance measure results will be
calculated after a sufficient amount of time has passed after the end of the
report period in order to allow for claims run out.
Report Period: For the SFY
2009 contract period, performance will be evaluated using the January - December
2008 report period. For the SFY 2010 contract period, performance will
be
evaluated
using the January - December 2009 report period.
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Interim Regional-Based Statewide
Minimum Performance Standard: For SFY 2009, each MCP must implement a
quality improvement plan (QIP) which identifies areas needing quality
improvement, includes a root-cause analysis of the areas needing improvement,
and establishes strategies and implementation activities to achieve continuous
quality improvement for this measure. The QIP must be submitted to ODJFS for
review and implemented no later than May, 1, 2009.
Regional-Based
Statewide Minimum Performance Standard:
CY 2009 –
A level of improvement must results in at least a 10% decrease in the
difference
between
the target and the previous report period’s results.
Regional-Based
Statewide Target:
CY 2009 -
80.0% of members must have one (1) or more visits with designated
PCP.
Penalty for Noncompliance with the
Regional-Based Statewide Minimum Performance Standard: If an MCP is
noncompliant with the Minimum Performance Standard, then the MCP must develop
and implement a corrective action plan.
3.
CONSUMER SATISFACTION
In
accordance with federal requirements and in the interest of assessing enrollee
satisfaction with MCP performance, ODJFS conducts annual independent consumer
satisfaction surveys. Results are used to assist in identifying and correcting
MCP performance overall and in the areas of access, quality of care, and member
services. For SFY 2008 and SFY 2009, performance in this category will be
determined by the overall satisfaction score. ODJFS intends to change the
measure and standard used to evaluate performance in this category beginning
with SFY 2010. ODJFS will use results from the SFY 2009 survey as a baseline to
establish a measure and set a standard (in Fall, 2009). For a comprehensive
description of the Consumer Satisfaction performance measure below, see ODJFS Methods for the Consumer
Satisfaction Performance Measure for the CFC Program.
Measure: Overall Satisfaction with
MCP: The average rating of the respondents to the Consumer Satisfaction
Survey who were asked to rate their overall satisfaction with their MCP. The
results of this measure are reported annually.
For an MCP which had membership as
of February 1, 2006: MCP performance will be evaluated using an MCP’s
county-based statewide result for the counties in which the MCP had membership
as of February 1, 2006. The minimum performance standard in this Appendix (3.) will be
applicable to the MCP’s county-based statewide result for the counties in which
the MCP had membership as of February 1, 2006. For performance evaluation,
the last year to use the county-based statewide approach for the counties in
which the MCP had membership as of February 1, 2006 will be SFY 2008,
using CY 2008 data. For P4P (Appendix O), the last year to
use the county-based statewide approach for the counties in which the MCP had
membership as of February 1, 2006 will be SFY 2009, using
CY 2009 data.
Appendix M
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For any MCP which did not have
membership as of February 1, 2006: Performance will be evaluated using a
regional-based statewide approach for all active regions in which the MCP has
membership.
Regional-Based Statewide Approach:
MCPs will be evaluated statewide, using results for all active regions in
which the MCP has membership. For performance evaluation, the first year to use
the statewide regional-based approach will be SFY 2009, using CY 2009 data. For
P4P (Appendix O), the first year to use the statewide regional-based approach
will be SFY 2010, using CY 2010 data.
Report Period: For the SFY
2008 contract period, performance will be evaluated using the results from the
CY 2008 consumer satisfaction survey. For the SFY 2009 contract period,
performance will be evaluated using the results from the CY 2009 consumer
satisfaction survey. For the SFY 2010 contract period, performance will be
evaluated using the results from the CY 2010 consumer satisfaction
survey.
County-Based Statewide Minimum
Performance Standard: An average score of no less than
7.0.
Regional-Based Statewide Minimum
Performance Standard: An average score of no less than
7.0.
Penalty for noncompliance: If
an MCP is determined noncompliant with the Minimum Performance Standard, then
the MCP must develop a corrective action plan and provider agreement renewals
may be affected.
4.
ADMINISTRATIVE CAPACITY
The
ability of an MCP to meet administrative requirements has been found to be both
an indicator of current plan performance and a predictor of future performance.
Deficiencies in administrative capacity make the accurate assessment of
performance in other categories difficult, with findings uncertain. Performance
in this category will be determined by the Compliance Assessment System, and the
emergency department diversion program. For a comprehensive description of the
Administrative Capacity performance measures below, see ODJFS Methods for the Administrative
Capacity Performance Measure for the CFC Managed Care
Program.
4.a.
Compliance Assessment System
Measure: The number of points
accumulated during a rolling 12-month period through the Compliance Assessment
System.
Report Period: For the SFY
2009 contract period, performance will be evaluated using a rolling 12-month
report period.
Performance Standard: A
maximum of 15 points
Penalty for Noncompliance:
Penalties for points are established in Appendix N, Compliance Assessment
System.
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4.b. Emergency Department Diversion
(applicable to
performance evaluation through SFY 2008)
Managed
care plans must provide access to services in a way that assures access to
primary and urgent care in the most effective settings and minimizes
inappropriate utilization of emergency department (ED) services. MCPs are
required to identify high utilizers of ED services and implement action plans
designed to minimize inappropriate ED utilization.
Measure: The percentage of
members who had four or more ED visits during the six month reporting
period.
For an MCP which had membership as
of February 1, 2006: MCP performance will be evaluated using an MCP’s
county-based statewide result for the counties in which the MCP had membership
as of February 1, 2006. The minimum performance standard and the target in this
Appendix (4.b) will be
applicable to the MCP’s county-based statewide result for the counties in which
the MCP had membership as of February 1, 2006. The last reporting period using
the MCP’s county-based statewide result for the counties in which the MCP had
membership as of February 1, 2006 for performance evaluation is July-December
2007; the last reporting period using the MCP’s county-based statewide result
for the counties in which the MCP had membership as of February 1, 2006 for P4P
(Appendix O) is
July-December 2006.
Report Period: For the SFY
2008 contract period, a baseline level of performance will be set using the
January - June 2007 report period. Results will be calculated for the reporting
period of July -December 2007 and compared to the baseline results to determine
if the minimum performance standard is met
County-Based Statewide Target:
A maximum of 0.70% of the eligible population will have four or more ED
visits during the reporting period.
County-Based Statewide Minimum
Performance Standard: The level of improvement must result in at least a
10.0% decrease in the difference between the target and the baseline period
results.
Penalty for Noncompliance: If
the standard is not met then the MCP must develop a corrective action plan, for
which ODJFS may direct the MCP to develop the components of their EDD program as
specified by ODJFS. If the standard is not met and the results are at or below
1.1%, then the MCP must develop a Quality Improvement
Directive.
4.b.i. Emergency Department Diversion
(applicable to
performance evaluation as of SFY 2009)
Managed
care plans must provide access to services in a way that assures access to
primary and urgent care in the most effective settings and minimizes
inappropriate utilization of emergency department (ED) services. MCPs are
required to identify high utilizers of targeted ED services and implement action
plans designed to minimize inappropriate, preventable and/or primary care
sensitive ED utilization.
Measure: The percentage of
members who had two or more targeted ED visits during the twelve month reporting
period.
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Regional-Based Statewide Approach:
MCPs will be evaluated statewide, using results for all active regions
and counties (Mahoning and Trumbull) in which the MCP has membership. ODJFS will
use the first full calendar year of data (CY 2007) from all MCPs serving CFC
membership as the first baseline reporting year for statewide reporting and to
determine a statewide minimum performance standard and target. CY 2008 will be
the first reporting year that MCPs will be held accountable to the performance
standard.
Report Period: For the SFY
2009 contract period, January – December 2008. For the SFY 2010 contract period,
January – December 2009.
Interim Regional-Based Statewide
Minimum Performance Standard: For SFY 2009, each MCP must implement a
quality improvement plan (QIP) which identifies areas needing quality
improvement, includes a root-cause analysis of the areas needing improvement,
and establishes strategies and implementation activities to achieve continuous
quality improvement for this measure. The QIP must be submitted to ODJFS for
review and implemented no later than May, 1, 2009.
Regional-Based Statewide Target:
For SFY 2010, a maximum of 3.00% of the eligible population will have two
or more targeted ED visits during the reporting period.
Regional-Based Statewide Minimum
Performance Standard: For SFY 2010, the level of improvement must result
in at least a 10% decrease in the difference between the target and the baseline
period results.
Penalty for Noncompliance with the
Regional-Based Statewide Minimum Performance Standard: If the standard is
not met, then the MCP must develop a corrective action plan, for which ODJFS may
direct the MCP to develop the components of their EDD program as specified by
ODJFS. If the standard is not met and the results are at or below a percent to
be determined, then the MCP must develop a Quality Improvement
Directive.
5.
NOTES
Given
that unforeseen circumstances (e.g., revision or update of applicable national
standards, methods or benchmarks, or issues related to program implementation)
may impact performance assessment as specified in Sections 1 through 4, ODJFS
reserves the right to apply the most appropriate penalty to the area of
deficiency identified with any individual measure, notwithstanding the penalties
specified in this Appendix.
5.a.
Penalties, Including Monetary Sanctions, for Noncompliance
Penalties
for noncompliance with individual standards in this appendix will be imposed as
the results are finalized. Penalties for noncompliance with individual standards
for each period of compliance, as determined in this appendix, will not exceed
$250,000.
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Refundable
monetary sanctions will be based on the capitation payment in the month of the
cited deficiency and due within 30 days of notification by ODJFS to the MCP of
the amount. Any monies collected through the imposition of such a sanction would
be returned to the MCP (minus any applicable collection fees owed to the
Attorney General’s Office, if the MCP has been delinquent in submitting payment)
after they have demonstrated improved performance in accordance with this
appendix. If an MCP does not comply within two years of the date of notification
of noncompliance, then the monies will not be refunded.
5.b.Combined
Remedies
If ODJFS
determines that one systemic problem is responsible for multiple deficiencies,
ODJFS may impose a combined remedy which will address all areas of deficient
performance. The total fines assessed in any one month will not exceed 15.0% of
the MCP’s monthly capitation.
5.c.Enrollment
Freezes
MCPs
found to have a pattern of repeated or ongoing noncompliance may be subject to
an enrollment freeze.
5.d.Reconsideration
Requests
for reconsideration of monetary sanctions and enrollment freezes may be
submitted as provided in Appendix N, Compliance Assessment
System.
5.e.Contract
Termination, Nonrenewals or Denials
Upon
termination, nonrenewal or denial of an MCP contract, all monetary sanctions
collected under this appendix will be retained by ODJFS. The at-risk amount paid
to the MCP under the current provider agreement will be returned to ODJFS in
accordance with Appendix P, Terminations, of the provider
agreement.
5.f.
Report and Compliance Periods
ODJFS
reserves the right to revise report periods (and corresponding compliance
periods), as needed, due to unforeseen circumstances.
Unless
otherwise noted, the most recent report or study finalized prior to the end of
the contract period may be used in determining the MCP’s performance level for
the current contract period.
Appendix
N
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APPENDIX
N
COMPLIANCE
ASSESSMENT SYSTEM
CFC
ELIGIBLE POPULATION
I.
General Provisions of the Compliance Assessment System
A. The Compliance Assessment System
(CAS) is designed to improve the quality of each managed care plan’s (MCP’s)
performance through actions taken by the Ohio
Department of Job and Family Services (ODJFS) to address identified
failures to meet program requirements. This appendix applies to the MCP
specified in the baseline of this
MCP Provider Agreement (hereinafter referred to as the
Agreement).
B. The CAS assesses progressive remedies with specified values (e.g.,
points, fines, etc.) assigned for certain documented failures to satisfy the
deliverables required by Ohio
Administrative Code (OAC) rule or the Agreement. Remedies are progressive based
upon the severity of the violation, or a repeated pattern of violations. The CAS
allows the
accumulated point total to reflect patterns of less serious violations as
well as less frequent, more serious violations.
C. The CAS focuses on clearly identifiable deliverables and
sanctions/remedial actions are only assessed in documented and verified
instances of noncompliance. The CAS
does not include categories which require subjective assessments or which
are not within the MCPs control.
D. The CAS does not replace ODJFS’ ability to require corrective
action plans (CAPs) and program improvements, or to impose any of the sanctions
specified in OAC rule
5101:3-26-10, including the proposed termination, amendment, or nonrenewal
of the MCP’s Provider Agreement.
E. As stipulated in OAC rule 5101:3-26-10(F), regardless of
whether ODJFS imposes a sanction, MCPs are required to initiate corrective
action for any MCP program violations
or deficiencies as soon as they are identified by the MCP or
ODJFS.
F. In addition to the remedies imposed in Appendix N, remedies
related to areas of financial performance, data quality, and performance
management may also be imposed
pursuant to Appendices J, L, and M respectively, of the
Agreement.
G. If ODJFS determines that an MCP has violated any of the
requirements of sections 1903(m) or 1932 of the Social Security Act which are
not specifically identified within the
CAS, ODJFS may, pursuant to the provisions of OAC rule 5101:3-26-10(A),
notify the MCP’s members that they may terminate from the MCP without cause
and/or suspend
any further new member selections.
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H. For purposes of the CAS, the date that ODJFS first becomes aware of an MCP’s
program violation is considered the date on which the violation occurred.
Therefore,
program violations that technically reflect noncompliance from the
previous compliance term will be subject to remedial action under CAS at the
time that ODJFS first becomes
aware of this noncompliance.
I. In cases where an MCP contracted healthcare provider is found to have
violated a program requirement (e.g., failing to provide adequate contract
termination notice,
marketing to potential members, inappropriate member billing, etc.), ODJFS will
not assess points if: (1) the MCP can document that they provided
sufficient
notification/education to providers of applicable program requirements and
prohibited activities; and (2) the MCP takes immediate and appropriate action to
correct the problem
and to ensure that it does not happen again to the satisfaction of ODJFS.
Repeated incidents will be reviewed to determine if the MCP has a systemic
problem in this area, and
if so, sanctions/remedial actions may be assessed, as determined by
ODJFS.
J. All notices of noncompliance will be issued in writing via email and
facsimile to the identified MCP contact.
II.
Types of Sanctions/Remedial Actions
ODJFS may impose the following types of sanctions/remedial actions, including,
but not limited to, the items listed below. The following are examples of
program violations
and their
related penalties. This list is not all inclusive. As with any instance of
noncompliance, ODJFS retains the right to use their sole discretion to determine
the most
appropriate penalty based on the severity of the offense, pattern of repeated
noncompliance, and number of consumers affected. Additionally, if an MCP has
received any
previous written correspondence regarding their duties and obligations under OAC
rule or the Agreement, such notice may be taken into consideration when
determining
penalties and/or remedial actions.
A. Corrective Action Plans
(CAPs) – A CAP is a structured activity/process implemented
by the MCP to improve identified operational deficiencies.
MCPs may be required to develop CAPs for any instance of noncompliance, and CAPs
are not limited to actions taken in this Appendix. All CAPs requiring ongoing
activity
on the part of an MCP to ensure their compliance with a program
requirement remain in effect for twenty-four months.
In situations where ODJFS has already determined the specific action which must
be implemented by the MCP or if the MCP has failed to submit a CAP, ODJFS may
require the
MCP to comply with an ODJFS-developed or “directed”
CAP.
Appendix
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In situations where a penalty is assessed for a violation an MCP has previously
been assessed a CAP (or any penalty or any other related written
correspondence), the MCP
may be assessed escalating penalties.
B. Quality Improvement
Directives (QIDs) – A QID is a general instruction that directs the MCP
to implement a quality improvement initiative to improve identified
administrative or clinical deficiencies. All QIDs remain in effect for
twelve months from the date of implementation.
MCPs may be required to develop QIDs for any instance of
noncompliance.
In
situations where ODJFS has already determined the specific action which must be
implemented by the MCP or if the MCP has failed to submit a QID, ODJFS may
require the
MCP to comply with an ODJFS-developed or “directed”
QID.
In situations where a penalty is assessed for a violation an MCP has previously
been assessed a QID (or any penalty or any other related written
correspondence), the MCP
may be assessed escalating penalties.
C. Quality Improvement Plan
(QIDs) - A quality improvement plan (QIP) is a written description of the
managed care plan's process to improve access and quality of care in
a
clinical or administrative topic area. A QIP consists of three
components: data analysis, root cause analysis, and the resulting quality
improvement initiative, including the
implementation and completion timeline. QIPs will be required when an MCP
must comply with Interim Performance Measure Standards as specified by
ODJFS.
D. Points
- Points will accumulate over a rolling 12-month schedule. Each
month, points that are more than 12-months old will expire. Points will be
tracked and monitored
separately for each Agreement the MCP concomitantly holds with the BMHC,
beginning with the commencement of this Agreement (i.e., the MCP will have zero
points at the
onset of this Agreement).
No points will be assigned for any violation where an MCP is able to document
that the precipitating circumstances were completely beyond their control and
could not have
been foreseen (e.g., a construction crew xxxxxx a phone line, a lightning
strike blows a computer system, etc.).
D.1. 5 Points -- Failures to meet program requirements, including but not
limited to, actions which could impair the member’s ability to obtain correct
information
regarding services or which could impair a consumer’s or member’s
rights, as determined by ODJFS, will result in the assessment of 5 points.
Examples include, but are
not limited to, the following:
Appendix
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4
•
|
Violations
which result in a member’s MCP selection or termination based on
inaccurate provider panel information from the
MCP.
|
•
|
Failure
to provide member materials to new members in a timely
manner.
|
•
|
Failure
to comply with appeal, grievance, or state hearing
requirements, including the failure to notify a member of their right to a
state hearing when the MCP proposes to deny, reduce, suspend or terminate
a Medicaid-covered service.
|
•
|
Failure
to staff 24-hour call-in system with appropriate trained medical
personnel.
|
•
|
Failure
to meet the monthly call-center requirements for either the member
services or the 24-hour call-in system
lines.
|
•
|
Provision
of false, inaccurate or materially misleading information to health care
providers, the MCP’s members, or any eligible
individuals.
|
•
|
Failure
to appropriately notify ODJFS or members of provider panel
terminations.
|
•
Failure to update website provider directories as required.
D.2. 10 Points -- Failures to meet program requirements, including but not
limited to, actions which could affect the ability of the MCP to deliver or the
consumer to
access covered services, as
determined by ODJFS. Examples include, but are not limited to, the
following:
•
|
Discrimination
among members on the basis of their health status or need for health care
services (this includes any practice that would reasonably be expected to
encourage termination or discourage selection by individuals whose medical
condition indicates probable need for substantial future medical
services).
|
•
|
Failure
to assist a member in accessing needed services in a timely manner after
request from the member.
|
•
|
Failure
to provide medically-necessary Medicaid covered services to
members.
|
•
|
Failure
to process prior authorization requests within the prescribed time
frames.
|
E. Fines – Refundable or nonrefundable
fines may be assessed as a penalty separate to or in combination with other
sanctions/remedial actions.
E.1. Unless otherwise stated, all fines are
nonrefundable.
E.2. Pursuant to procedures as established by ODJFS, refundable and
nonrefundable monetary sanctions/assurances must be remitted to ODJFS within
thirty (30)
days of receipt
of the invoice by the MCP. In addition, per Ohio Revised
Code Section 131.02, payments not received within forty-five (45) days will be
certified to the
Attorney General’s
(AG’s) office. MCP payments certified to the AG’s office will be assessed the
appropriate collection fee by the AG’s office.
Appendix
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E.3. Monetary
sanctions/assurances imposed by ODJFS will be based on the most recent premium
payments.
E.4. Any monies collected
through the imposition of a refundable fine will be returned to the MCP (minus
any applicable collection fees owed to the Attorney
General’s Office if the
MCP has been delinquent in submitting payment) after they have demonstrated full
compliance, as determined by ODJFS, with the particular
program requirement. If an MCP does
not comply within one (1) year of the date of notification of noncompliance
involving issues of case management and two (2)
years of the date of notification of noncompliance
in issues involving encounter data, then the monies will not be
refunded.
E.5. MCPs are required to
submit a written request for refund to ODJFS at the time they believe is
appropriate before a refund of monies will be considered.
F. Combined Remedies -
Notwithstanding any other action ODJFS may take under this Appendix, ODJFS may
impose a combined remedy which will address all areas of
noncompliance if ODJFS determines, in its sole discretion, that (1) one systemic
problem is responsible for multiple areas of noncompliance and/or (2) that there
are a number of
repeated instances of noncompliance with the same program requirement.
G. Progressive Remedies
- Progressive remedies will be based on the number of points accumulated at the
time of the most recent incident. Unless specifically otherwise
indicated in this appendix, all fines are nonrefundable. The designated fine
amount will be assessed when the number of accumulated points falls within the
ranges specified
below:
0 -15
Points Corrective
Action Plan (CAP)
16-25
Points CAP
+ $5,000 fine
26-50
Points CAP
+ $10,000 fine
51-70
Points CAP
+ $20,000 fine
71-100
Points CAP
+ $30,000 fine
100+
Points
Proposed
Contract Termination
Appendix
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H. New Enrollment 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 enrollment 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.
I. Reduction of
Assignments – ODJFS has sole discretion over how member
auto-assignments are made. ODJFS may reduce the number of assignments an MCP
receives to
assure program stability within a region or if ODJFS determines that the MCP
lacks sufficient capacity to meet the needs of the increased enrollment volume.
Examples of
circumstances which ODJFS may determine demonstrate a lack of sufficient
capacity include, but are not limited to an MCP’s failure to: maintain an
adequate provider network;
repeatedly provide new member materials by the member’s effective date; meet the
minimum call center requirements; meet the minimum performance standards for
identifying
and assessing children with special health care needs and members needing case
management services; and/or provide complete and accurate appeal/grievance,
member’s PCP
and CAMS data
files.
J. Termination, Amendment, or
Nonrenewal of MCP Provider Agreement - ODJFS
can at any time move to terminate, amend or deny renewal of a provider
agreement. Upon
such termination, nonrenewal, or denial of an MCP provider agreement, all
previously collected monetary sanctions will be retained by
ODJFS.
Appendix
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7
K. Specific Pre-Determined
Penalties
K.1. Adequate network-minimum provider panel
requirements - Compliance with
provider panel requirements will be assessed quarterly. Any deficiencies in
the
MCP’s provider network
as specified in Appendix H of the Agreement or by ODJFS, will result in the
assessment of a $1,000 nonrefundable fine for each category
(practitioners, PCP capacity,
hospitals), for each county, and for each population (e.g., ABD, CFC). For
example if the MCP did not meet the following minimum panel
requirements,
the MCP would be
assessed (1) a $3,000 nonrefundable fine for the failure to meet CFC panel
requirements; and, (2) a $1,000 nonrefundable fine for the
failure
to meet ABD panel requirements).
• practitioner requirements in
Franklin county for the CFC population
• practitioner requirements in
Franklin county for the ABD population
• hospital requirements
in Franklin county for the CFC population
• PCP capacity requirements in
Fairfield county for the CFC population
In addition to the pre-determined penalties, ODJFS may assess additional
penalties pursuant to this Appendix (e.g. CAPs, points, fines) if member
specific access issues are
identified resulting from provider panel noncompliance.
K.2. Geographic Information
System - Compliance with the Geographic Information System
(GIS) requirements will be assessed semi-annually. Any failure to meet
GIS
requirements
as specified in Appendix H of the Agreement will result a $1,000 nonrefundable
fine for each county and for each population (e.g., ABD, CFC, etc.). For
example if the MCP
did not meet GIS requirements in the following counties, the MCP would be
assessed (1) a nonrefundable $2,000 fine for the failure to meet
GIS
requirements for the CFC
population and (2) a $1,000 nonrefundable fine for the failure to meet GIS
requirements for the ABD population.
• GIS requirements
in Franklin county for the CFC population
• GIS requirements in Fairfield county
for the CFC population
• GIS requirements in Franklin county
for the ABD population
K.3. Late Submissions - All required
submissions/data and documentation requests must be received by their specified
deadline and must represent the MCP in an
honest and forthright
manner. Failure to provide ODJFS with a required submission or any
data/documentation requested by ODJFS will result in the assessment of
a
nonrefundable fine of $100 per
day, unless the MCP requests and is granted an extension by ODJFS. Assessments
for late submissions will be done monthly.
Examples of such program violations include,
but are not limited to:
• Late required
submissions
Appendix
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o Annual delegation assessments
o Call center report
o Franchise fee documentation
o Reinsurance information (e.g., prior approval of
changes)
o State hearing
notifications
• Late required data
submissions
o Appeals and grievances, case management, or PCP data
• Late required information
requests
o Automatic call distribution
reports
o Information/resolution
regarding consumer or provider complaint
o Just cause
or other coordination care request from ODJFS o Provider
panel
documentation
o Failure to
provide ODJFS with a required submission after ODJFS has
notified the MCP that the prescribed deadline for that
submission has passed
If an MCP determines that they will be unable to meet a program deadline or
data/documentation submission deadline, the MCP must submit a written request to
its
Contract Administrator
for an extension of the deadline, as soon as possible, but no later than 3 PM
EST on the date of the deadline in question. Extension requests
should
only be submitted
in situations where unforeseeable circumstances have occurred which make it
impossible for the MCP to meet an ODJFS-stipulated
deadline and all such requests will be
evaluated upon this standard. Only written approval as may be granted by ODJFS
of a deadline extension will preclude the
assessment of compliance action for untimely submissions.
K.4. Noncompliance with Claims
Adjudication Requirements - If ODJFS finds that an MCP is unable
to (1) electronically accept and adjudicate claims to final status
and/or (2) notify
providers of the status of their submitted claims, as stipulated in Appendix C
of the Agreement, ODJFS will assess the MCP with a monetary
sanction
of $20,000 per day for the
period of noncompliance.
If ODJFS has identified specific instances where an MCP has failed to take the
necessary steps to comply with the requirements specified in Appendix C of
the
Agreement for (1)
failing to notify non-contracting providers of procedures for claims submissions
when requested and/or (2) failing to notify contracting and non-
contracting
providers of the
status of their submitted claims, the MCP will be assessed 5 points per incident
of noncompliance.
K.5.
Noncompliance with Prompt Payment: - Noncompliance with the prompt
pay requirements as specified in Appendix J of the Agreement will result in
progressive
penalties. The first
violation during a rolling 12-month period will result in the submission of
quarterly prompt pay and monthly status reports to ODJFS until the
next
quarterly report is due.
The
second violation during a rolling 12-month period will result in the submission
of monthly status reports and a refundable fine equal to 5%
of the MCP’s monthly premium
payment or $300,000, whichever is less. The refundable fine will be applied in
lieu of a nonrefundable fine and the money will be
refunded by ODJFS only after the MCP
complies with the required standards for two (2) consecutive quarters.
Subsequent violations will result in an enrollment
freeze.
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If an MCP is found to have not been in compliance with
the prompt pay requirements for any time period for which a report and signed
attestation have been
submitted representing
the MCP as being in compliance, the MCP will be subject to an enrollment freeze
of not less than three (3) months duration.
K.6.
Noncompliance with Franchise Fee Assessment Requirements -
In accordance with ORC Section 5111.176, and in addition to the imposition of
any other penalty,
occurrence
or points under this Appendix, an MCP that does not pay the franchise permit fee
in full by the due date is subject to any or all of the
following:
•
|
A
monetary penalty in the amount of $500 for each day any part of the fee
remains unpaid, except the penalty will not exceed an amount equal to 5 %
of the total fee that was due for the calendar quarter for which the
penalty was imposed;
|
•
|
Withholdings
from future ODJFS capitation payments. If an MCP fails to pay the full
amount of its franchise fee when due, or the full amount of the imposed
penalty, ODJFS may withhold an amount equal to the remaining amount due
from any future ODJFS capitation payments. ODJFS will return all withheld
capitation payments when the franchise fee amount has been paid in
full;
|
•
|
Proposed
termination or non-renewal of the MCP’s Medicaid provider agreement may
occur if the MCP:
|
a.
|
Fails
to pay its franchise permit fee or fails to pay the fee
promptly;
|
b.
|
Fails
to pay a penalty imposed under this Appendix or fails to pay the penalty
promptly;
|
c.
|
Fails
to cooperate with an audit conducted in accordance with ORC Section
5111.176.
|
K.7.
Noncompliance with Clinical Laboratory Improvement Amendments
-Noncompliance with CLIA requirements as specified by ODJFS will
result in the assessment
of a nonrefundable
$1,000 fine for each violation.
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K.8. Noncompliance
with Abortion and Sterilization Payment - Noncompliance with
abortion and sterilization requirements as specified by ODJFS will result in
the
assessment of a
nonrefundable $2,000 fine for each documented violation. Additionally, MCPs must
take all appropriate action to correct each ODJFS-documented
violation.
K.9. Refusal to Comply with Program
Requirements - If ODJFS has instructed an MCP that they must
comply with a specific program requirement and the MCP
refuses, such refusal
constitutes documentation that the MCP is no longer operating in the best
interests of the MCP’s members or the state of Ohio and ODJFS will
move to terminate or nonrenew
the MCP’s provider agreement.
III. Request
for Reconsiderations
MCPs may request a reconsideration of remedial action taken under the CAS for
penalties that include points, fines, reductions in assignments and/or selection
freezes.
Requests for reconsideration must be submitted on the ODJFS required form
as follows:
A. MCPs notified of ODJFS’ imposition of remedial action taken under
the CAS will have ten (10) working days from the date of receipt of the
facsimile to request
reconsideration, although ODJFS will impose enrollment freezes based on an
access to care concern concurrent with initiating notification to the MCP. Any
information that
the MCP would like reviewed as part of the reconsideration request must be
submitted at the time of submission of the reconsideration request, unless ODJFS
extends the time
frame in writing.
B. All requests for reconsideration must be submitted
by either facsimile transmission or overnight mail to the Chief, Bureau of
Managed Health Care, and received by ODJFS
by the tenth business day after receipt of the faxed
notification of the imposition of the remedial action by
ODJFS.
C. The MCP will be responsible for verifying timely receipt of all
reconsideration requests. All requests for reconsideration must explain in
detail why the specified remedial
action should not be imposed. The MCP’s justification for reconsideration
will be limited to a review of the written material submitted by the MCP. The
Bureau Chief will review
all correspondence and materials related to the violation in question in
making the final reconsideration decision.
D. Final decisions or requests for additional information will be
made by ODJFS within ten (10) business days of receipt of the request for
reconsideration.
E. If additional information is requested by ODJFS, a final
reconsideration decision will be made within three (3) business days of the due
date for the submission. Should
ODJFS
require additional time in rendering the final reconsideration decision, the MCP
will be
notified of such in writing.
Appendix
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F. If a reconsideration request is decided, in whole or in part, in favor of the MCP, both the penalty and the points associated with the incident, will be rescinded or reduced, in
the sole discretion of ODJFS. The MCP may still be required to submit a
CAP if ODJFS, in its sole discretion, believes that a CAP is still warranted
under the circumstances.
Appendix
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APPENDIX
O
PAY-FOR
PERFORMANCE (P4P)
CFC
ELIGIBLE POPULATION
This
Appendix establishes P4P for managed care plans (MCPs) to improve performance in
specific areas important to the Medicaid MCP members. P4P include the at-risk
amount included with the monthly premium payments (see Appendix F, Rate Chart), and possible
additional monetary rewards up to $250,000.
To
qualify for consideration of any P4P, MCPs must meet minimum performance
standards established in Appendix M, Performance Evaluation on
selected measures, and achieve P4P standards established for selected Clinical
Performance Measures. For qualifying MCPs, higher performance standards for
three measures must be reached to be awarded a portion of the at-risk amount and
any additional P4P (see Sections 1 and 2 of this appendix). An excellent and
superior standard is set in this Appendix for each of the three measures.
Qualifying MCPs will be awarded a portion of the at-risk amount for each
excellent standard met. If an MCP meets all three excellent and superior
standards, they may be awarded additional P4P (see Section 3 of this
appendix).
Prior to
the transition to a regional-based statewide P4P system (SFY 2006 through SFY
2009), the county-based statewide P4P system (sections 1 and 2 of this Appendix)
will apply to MCPs with membership as of February 1, 2006. Only counties with
membership as of February 1, 2006 will be used to calculate performance levels
for the county-based statewide P4P system. The first regional-based statewide
P4P determination will be SFY 2010 and will include at-risk amounts from July,
2009 through June, 2010.
1.
SFY 2008 P4P
1.a.
Qualifying Performance Levels
To
qualify for consideration of the SFY 2008 P4P, an MCP’s performance level must
meet the minimum performance standards set in Appendix M, Performance Evaluation, for
the measures listed below. A detailed description of the methodologies for each
measure can be found on the BMHC page of the ODJFS website.
Measures
for which the minimum performance standard for SFY 2008 established in Appendix
M, Performance
Evaluation, must be met to qualify for consideration of P4P are as
follows:
1.
PCP Turnover (Appendix M, Section 2.a.)
Report Period: CY 2007
2. Children’s
Access to Primary Care (Appendix M, Section 2.b.)
Report Period: CY 0000
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3. Adults’
Access to Preventive/Ambulatory Health Services (Appendix M, Section
2.c.)
Report Period: CY 2007
4.
Overall Satisfaction with MCP (Appendix M, Section 3)
Report Period: The most recent consumer satisfaction survey completed
prior to the end of SFY 2008.
For each
clinical performance measure listed below, the MCP must meet the P4P standard to
be considered for SFY 2008 P4P. The MCP meets the P4P standard if one of two
criteria are met. The P4P standard is a performance level of
either:
1) The
minimum performance standard established in Appendix M, Performance Evaluation, for
seven of the nine clinical performance measures listed below;
or
2) The
Medicaid benchmarks for seven of the nine clinical performance measures listed
below. The Medicaid benchmarks are subject to change based on the revision or
update of
applicable national standards, methods or benchmarks.
Clinical Performance
Measure
|
Medicaid
Benchmark
|
|
1.
|
Perinatal
Care - Frequency of Ongoing Prenatal Care
|
42%
|
2.
|
Perinatal
Care - Initiation of Prenatal Care
|
71%
|
3.
|
Perinatal
Care - Postpartum Care
|
48%
|
4.
|
Well-Child
Visits – Children who turn 15 months old
|
34%
|
5.
|
Well-Child
Visits - 3, 4, 5, or 6, years old
|
50%
|
6.
|
Well-Child
Visits - 12 through 21 years old
|
30%
|
7.
|
Use
of Appropriate Medications for People with Asthma
|
83%
|
8.
|
Annual
Dental Visits
|
40%
|
9.
|
Blood
Lead – 1 year olds
|
45%
|
1.b.
Excellent and Superior Performance Levels
For
qualifying MCPs as determined by Section 1.a. of this appendix, performance will
be evaluated on the measures listed below to determine the status of the at-risk
amount and any additional P4P that may be awarded. Excellent and Superior
standards are set for the three measures described below. The standards are
subject to change based on the revision or update of applicable national
standards, methods or benchmarks.
A brief
description of these measures is provided in Appendix M, Performance Evaluation. A
detailed description of the methodologies for each measure can be found on the
BMHC page of the ODJFS website.
Appendix
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1. Care
Management of Children (Appendix M, Section 1.b.i.)
Report Period: April - June 2008
Excellent Standard: 5.5% or the submission of a Proof of Action (POA)
delineating an active care management program from April, 2008 through June,
2008. This POA must be
determined sufficient by ODJFS.
Superior Standard: 6.5%
2. Use
of Appropriate Medications for People with Asthma (Appendix M, Section
1.c.v.)
Report Period: CY 2007
Excellent
Standard: 86%
Superior Standard: 88%
3. Adults’
Access to Preventive/Ambulatory Health Services (Appendix M, Section
2.c.)
Report Period: CY 2007
Excellent Standard:
76%
Superior Standard: 84%
1.c.
Determining SFY 2008 P4P
MCPs that
do not meet the minimum performance standards described in Section 1.a. herein,
will not be considered for P4P and must return to ODJFS one hundred percent of
their at-risk amount used in the SFY 2008 P4P determination. MCP’s reaching the
minimum performance standards described in Section 1.a. herein, will be
considered for P4P including retention of the at-risk amount and any additional
P4P. For each Excellent standard established in Section 1.b. herein, that an MCP
meets, one-third of the at-risk amount may be retained. For MCPs meeting all of
the Excellent and Superior standards established in Section 1.b. herein,
additional P4P may be awarded. For MCPs receiving additional P4P, the amount in
the P4P fund (see Section 3 of this appendix) will be divided equally, up to the
maximum additional amount, among all MCPs’ ABD and/or CFC programs receiving
additional P4P. The maximum additional amount to be awarded per plan, per
program, per contract year is $250,000. An MCP may receive up to $500,000 should
both of the MCP’s ABD and CFC programs achieve the Superior Performance
Levels.
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2.
SFY 2009 P4P
2.a.
Qualifying Performance Levels
To
qualify for consideration of the SFY 2009 P4P, an MCP’s performance level must
meet the minimum performance standards set in Appendix M, Performance Evaluation, for
the measures listed below. A detailed description of the methodologies for each
measure can be found on the BMHC page of the ODJFS website.
Measures
for which the minimum performance standard for SFY 2009 established in Appendix
M, Performance
Evaluation, must be met to qualify for consideration of P4P are as
follows:
1.
PCP Turnover (Appendix M, Section 2.a.)
Report Period: CY 2008
2.
Children’s Access to Primary Care (Appendix M, Section 2.b.)
Report Period: CY 2008
3.
Adults’ Access to Preventive/Ambulatory Health Services (Appendix M, Section
2.c.)
Report Period: CY 2008
4.
Overall Satisfaction with MCP (Appendix M, Section 3)
Report Period: The most recent consumer satisfaction survey completed
prior to the end of SFY 2009.
For each
clinical performance measure listed below, the MCP must meet the P4P standard to
be considered for SFY 2009 P4P. The MCP meets the P4P standard if one of two
criteria is met. The P4P standard is a performance level of
either:
1) The
minimum performance standard established in Appendix M, Performance Evaluation, for
seven of the nine clinical performance measures listed below;
or
2) The
Medicaid benchmarks for seven of the nine clinical performance measures listed
below. The Medicaid benchmarks are subject to change based on the revision or
update of applicable national standards, methods or
benchmarks.
Appendix
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Clinical Performance
Measure
|
Medicaid
Benchmark
|
|
1.
|
Perinatal
Care - Frequency of Ongoing Prenatal Care
|
44%
|
2.
|
Perinatal
Care - Initiation of Prenatal Care
|
74%
|
3.
|
Perinatal
Care - Postpartum Care
|
50%
|
4.
|
Well-Child
Visits – Children who turn 15 months old
|
42%
|
5.
|
Well-Child
Visits - 3, 4, 5, or 6, years old
|
57%
|
6.
|
Well-Child
Visits - 12 through 21 years old
|
33%
|
7.
|
Use
of Appropriate Medications for People with Asthma
|
84%
|
8.
|
Annual
Dental Visits
|
42%
|
9.
|
Blood
Lead – 1 year olds
|
45%
|
2.b.
Excellent and Superior Performance Levels
For
qualifying MCPs as determined by Section 2.a. of this appendix, performance will
be evaluated on the measures listed below to determine the status of the at-risk
amount. The standards are subject to change based on the revision or update of
applicable national standards, methods or benchmarks.
A brief
description of these measures is provided in Appendix M, Performance Evaluation. A
detailed description of the methodologies for each measure can be found on the
BMHC page of the ODJFS website.
1. Care
Management of High Risk Members (Appendix M, Section 1.b.ii.)
Excellent Standard: The Interim Regional-Based Statewide Minimum
Performance Standard established in Appendix M, Section
1.b.ii.
Superior Standard: N/A
2.
Use of Appropriate Medications for People with Asthma (Appendix M, Section
1.c.v.)
Report Period: CY 2008
Excellent Standard: 86%
Superior Standard: 88%
3.
Adults’ Access to Preventive/Ambulatory Health Services (Appendix M, Section
2.c.)
Report Period: CY 2008
Excellent
Standard: 77%
Superior Standard: 84%
Appendix
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2.c.
Determining SFY 2009 P4P
MCPs that
do not meet the minimum performance standards described in Section 2.a. herein,
will not be considered for P4P and must return to ODJFS one hundred percent of
their at-risk amount used in the SFY 2009 P4P determination. MCPs reaching the
minimum performance standards described in Section 2.a. herein, will be
considered for P4P (retention of the at-risk amount). For each Excellent
standard established in Section 2.b. herein, that an MCP meets, one-third of the
at-risk amount used in the SFY 2009 P4P determination may be retained. No
additional P4P will be awarded in SFY 2009.
3.
NOTES
3.a.
Transition from a county-based statewide to a regional-based statewide P4P
system.
The
current county-based statewide P4P system will transition to a regional-based
statewide system as managed care expands statewide. The regional-based statewide
approach will be implemented in SFY 2010. The regional-based statewide P4P
system will be modeled after the county-based statewide system with adjustments
to performance standards where appropriate.
3.a.i.
County-based statewide P4P system
For MCPs
in their first twenty-four months of Ohio Medicaid CFC Managed Care Program
participation, the status of the at-risk amount will not be determined because
compliance with many of the standards cannot be determined in an MCP’s first two
contract years (see Appendix F., Rate Chart). In addition,
MCPs in their first two contract years are not eligible for the additional P4P
amount awarded for superior performance.
Starting
with the twenty-fifth month of participation in the program, a new MCP’s at-risk
amount will be included in the P4P system. The determination of the status of
this at-risk amount will be after at least three full calendar years of
membership as many of the performance standards require three full calendar
years to determine an MCP’s performance level. Because of this requirement, more
than 12 months of at-risk dollars may be included in an MCP’s first at-risk
status determination depending on when an MCP starts with the program relative
to the calendar year.
During
the transition to a regional-based statewide system (SFY 2006 through SFY 2009),
MCPs with membership as of February 1, 2006 will continue in the county-based
statewide P4P system until the transition is complete. These MCPs will be put
at-risk for a portion of the premiums received for members in counties they are
serving as of February 1, 2006.
3.a.ii.
Regional-based statewide P4P system
All MCPs
will be included in the regional-based statewide P4P system. The at-risk amount
will be determined separately for each region an MCP
serves.
Appendix
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The
status of the at-risk amount for counties not included in the county-based
statewide P4P system will not be determined for the first twenty-four months of
regional membership. Starting with the twenty-fifth month of regional
membership, the MCP’s at-risk amount will be included in the P4P system. The
determination of the status of this at-risk amount will be after at least three
full calendar years of regional membership as many of the performance standards
require three full calendar years to determine an MCP’s performance level. Given
that statewide expansion was not complete by December 31, 2006, ODJFS may adjust
performance measure reporting periods based on the number of months an MCP has
had regional membership. The first regional-based statewide P4P determination
will be SFY 2010 and will include at-risk amounts from July, 2009 through June,
2010.
For MCPs
with membership in the NEC region, the first regional-based statewide P4P
determination (SFY 2010) will include at-risk dollars from Columbiana county
from March, 2010 through June, 2010 and at-risk dollars from Mahoning and
Trumbull counties from July, 2009 through June, 2010.
Regional
premium payments at-risk for months prior to July, 2009, for counties not
included in the county-based statewide P4P determination, will be determined as
follows:
MCPs
which meet the Interim Minimum Performance Standards set in Appendix M, Performance Evaluation, for
all of the measures listed in Table 1 below may retain one hundred percent of
their at-risk amount for months prior to July, 2009, for counties not included
in the county-based statewide P4P determination. MCPs which do not meet the
Interim Minimum Performance Standards set in Appendix M, Performance Evaluation, for
all of the measures listed in Table 1 below must return to ODJFS one hundred
percent of their at-risk amount for months prior to July, 2009, for counties not
included in the county-based statewide P4P determination. This determination
will be made by December 31, 2009.
Appendix
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Table
1. Measures Used to Determine the Status of the At-Risk Amount for Months Prior
to July, 2009, for Counties Not Included in the County-Based Statewide P4P
System
Measures
|
|
1.
|
Care Management of High Risk
Members
|
2.
|
Care Management of
Members
|
3.
|
PCP Turnover
|
4.
|
Adults' Access to Preventive/Ambulatory Health
Services
|
5.
|
Members Access to Designated
PCP
|
6.
|
Emergency Department
Diversion
|
7.
|
Perinatal Care - Frequency of Ongoing Prenatal
Care
|
8.
|
Perinatal Care - Initiation of Prenatal
Care
|
9.
|
Perinatal Care - Postpartum
Care
|
10.
|
Well Child Visits - 15 Months
Old
|
11.
|
Well Child Visits - 3, 4, 5, or 6 Years
Old
|
12.
|
Well Child Visits - 12 through 21 Years
Old
|
13.
|
Annual Dental Visits
|
14.
|
Use of Appropriate Medications for People with
Asthma
|
3.b.
Determination of at-risk amounts and additional P4P
payments
Given
that unforeseen circumstances (e.g., revision or update of measure(s),
applicable national standards, methods or benchmarks, or issues related to
program implementation) may impact the determination of the status of an MCP’s
at-risk amount and any additional P4P payments, ODJFS reserves the right to
calculate an MCP’s at-risk amount (the status of which is determined in
accordance with this appendix) using a lesser percentage than that established
in Appendix F (Regional Rates) and to award additional P4P in an amount lesser
than that established in this appendix.
For MCPs
that have participated in the Ohio Medicaid Managed Care Program long enough to
calculate performance levels for all of the performance measures included in the
P4P system, determination of the status of an MCP’s at-risk amount may occur
within six months of the end of the contract period. Where applicable,
determination of additional P4P payments will be made at the same time the
status of an MCP’s at-risk amount is determined. Given that unforeseen
circumstances may impact the determination of the status of an MCP’s at-risk
amount and any additional P4P payments, ODJFS reserves the right to revise the
time frame in which the determination will be made (i.e. the determination may
be made more than six months after the end of the contract
period).
Appendix
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3.c.
Contract Termination, Nonrenewals, or Denials
Upon
termination, nonrenewal or denial of an MCP contract, the at-risk amount paid to
the MCP under the current provider agreement will be returned to ODJFS in
accordance with Appendix P., Terminations/Nonrenewals/Amendments,
of the provider agreement.
Additionally,
in accordance with Article XI of the provider agreement, the return of the
at-risk amount paid to the MCP under the current provider agreement will be a
condition necessary for ODJFS’ approval of a provider agreement
assignment.
3.d.
Measures and Report Periods
The
report period used in determining the MCP’s performance levels varies for each
measure depending on the frequency of the report and the data source. ODJFS
reserves the right to revise P4P measures and report periods, as needed, due to
unforeseen circumstances. Unless otherwise noted, the most recent report or
study finalized prior to the end of the contract period may be used in
determining the MCP’s overall performance level for the current contract
period.