OHIO DEPARTMENT OF JOB AND FAMILY SERVICES OHIO MEDICAL ASSISTANCE PROVIDER AGREEMENT FOR MANAGED CARE PLAN CFC ELIGIBLE POPULATION
Exhibit 10.1
Baseline
Covered
Families and Children (CFC) Population
OHIO
DEPARTMENT OF JOB AND FAMILY SERVICES
OHIO
MEDICAL ASSISTANCE PROVIDER AGREEMENT
FOR
MANAGED CARE PLAN
This provider agreement is entered into
this first day of July, 2008, at Columbus, Franklin County, Ohio, between the
State of Ohio, Department of Job and Family Services, (hereinafter referred to
as ODJFS) whose principal offices are located in the City of Columbus, County of
Franklin, State of Ohio, and WellCare of Ohio, Inc, Managed Care Plan
(hereinafter referred to as MCP), an Ohio for-profit corporation, whose
principal office is located in the city of Independence, County of Cuyahoga,
State of Ohio.
MCP is licensed as a Health Insuring
Corporation by the State of Ohio, Department of Insurance (hereinafter referred
to as ODI), pursuant to Chapter 1751. of the Ohio Revised Code and is organized
and agrees to operate as prescribed by Chapter 5101:3-26 of the Ohio
Administrative Code (hereinafter referred to as OAC), and other applicable
portions of the OAC as amended from time to time.
MCP is an entity eligible to enter into
a provider agreement in accordance with 42 CFR 438.6 and is engaged in the
business of providing prepaid comprehensive health care services as defined in
42 CFR 438.2 through the managed care program for the Covered Families and
Children (CFC) eligible population described in OAC rule 5101:3-26-02
(B).
ODJFS, as the single state agency
designated to administer the Medicaid program under Section 5111.02 of the Ohio
Revised Code and Title XIX of the Social Security Act, desires to obtain MCP
services for the benefit of certain Medicaid recipients. In so doing,
MCP has provided and will continue to provide proof of MCP's capability to
provide quality services, efficiently, effectively and economically during the
term of this agreement.
This provider agreement is a contract between ODJFS and the undersigned Managed
Care Plan (MCP), provider of medical assistance, pursuant to the federal
contracting provisions of 42 CFR 434.6 and 438.6 in which the MCP agrees to
provide comprehensive medical services through the managed care program as
provided in Chapter 5101:3-26 of the Ohio Administrative Code, assuming the risk
of loss, and complying with applicable state statutes, Ohio Administrative Code,
and Federal statutes, rules, regulations and other requirements,
including but not limited to title VI of the Civil Rights Act of 1964; title IX
of the Education Amendments of 1972 (regarding education programs and
activities); the Age Discrimination Act of 1975; the Rehabilitation Act of 1973;
and the Americans with Disabilities Act.
A.
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ODJFS
enters into this Agreement in reliance upon MCP’s representations that it
has the necessary expertise and experience to perform its obligations
hereunder, and MCP warrants that it does possess the necessary expertise
and experience.
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B.
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MCP
agrees to report to the Chief of Bureau of Managed Health Care
(hereinafter referred to as BMHC) or his or her designee as necessary to
assure understanding of the responsibilities and satisfactory compliance
with this provider agreement.
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C.
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MCP
agrees to furnish its support staff and services as necessary for the
satisfactory performance of the services as enumerated in this provider
agreement.
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D.
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ODJFS
may, from time to time as it deems appropriate, communicate specific
instructions and requests to MCP concerning the performance of the
services described in this provider agreement. Upon such notice
and within the designated time frame after receipt of instructions, MCP
shall comply with such instructions and fulfill such requests to the
satisfaction of the department. It is expressly understood by
the parties that these instructions and requests are for the sole purpose
of performing the specific tasks requested to ensure satisfactory
completion of the services described in this provider agreement, and are
not intended to amend or alter this provider agreement or any part
thereof.
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E.
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If
the MCP previously had a provider agreement with the ODJFS and the
provider agreement terminated more than two years prior to the effective
date of any new provider agreement, such MCP will be considered a new plan
in its first year of operation with the Ohio Medicaid managed care
program.
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A.
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Upon
approval by the Director of ODJFS this provider agreement shall be in
effect from the date entered through June 30, 2009, unless this provider
agreement is suspended or terminated pursuant to Article VIII prior to the
termination date, or otherwise amended pursuant to Article
IX.
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B.
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It
is expressly agreed by the parties that none of the rights, duties and
obligations herein shall be binding on either party if award of this
Agreement would be contrary to the terms of Ohio Revised Code (“O.R.C.”)
Section 3517.13, O.R.C. Section 127.16, or O.R.C. Chapter
102.
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2
Baseline
Covered
Families and Children (CFC) Population
ARTICLE
III - REIMBURSEMENT
A.
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ODJFS
will reimburse MCP in accordance with rule 5101:3-26-09 of the Ohio
Administrative Code and the appropriate appendices of this provider
agreement.
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A.
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ODJFS
and MCP agree that, during the term of this Agreement, MCP shall be
engaged by ODJFS solely on an independent contractor basis, and neither
MCP nor its personnel shall, at any time or for any purpose, be considered
as agents, servants or employees of ODJFS or the State of Ohio. MCP
shall therefore be responsible for all MCP’s business expenses, including,
but not limited to, employee’s wages and salaries, insurance of every type
and description, and all business and personal taxes, including income and
Social Security taxes and contributions for Workers’ Compensation and
Unemployment Compensation coverage, if
any.
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B.
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MCP
agrees to comply with all applicable federal, state and local laws in the
conduct of the work hereunder.
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C.
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While
MCP shall be required to render services described hereunder for ODJFS
during the term of this Agreement, nothing herein shall be construed to
imply, by reason of MCP’s engagement hereunder on an independent
contractor basis, that ODJFS shall have or may exercise any right of
control over MCP with regard to the manner or method of MCP’s performance
of services hereunder. The management of the work, including the
exclusive right to control or direct the manner or means by which the
work is performed, remains with MCP. ODJFS retains the
right to ensure that MCP's work is in conformity with the terms and
conditions of this Agreement.
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D.
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Except
as expressly provided herein, neither party shall have the right to bind
or obligate the other party in any manner without the other
party’s prior written consent.
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A.
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In
accordance with the safeguards specified in section 27 of the Office of
Federal Procurement Policy Act (41 U.S.C. 423) and other applicable
federal requirements, no officer, member or employee of MCP, the Chief of
BMHC, or other ODJFS employee who exercises any functions or
responsibilities in connection with the review or approval of this
provider agreement or provision of services under this provider agreement
shall, prior to the completion of such services or reimbursement, acquire
any interest, personal or otherwise, direct or indirect, which is
incompatible or in conflict with, or would compromise in any manner or
degree the discharge and fulfillment of his or her functions and
responsibilities with respect to the carrying out of such
services. For purposes of this article,
"members" does not include individuals whose sole connection with MCP is
the receipt of services through a health care program offered by
MCP.
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B.
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MCP
represents, warrants, and certifies that it and its employees engaged in
the administration or performance of this Agreement are knowledgeable of
and understand the Ohio Ethics and Conflicts of Interest laws and
Executive Order 2007-01S. MCP further represents, warrants, and
certifies that neither MCP nor any of its employees will do any act that
is inconsistent with such laws and Executive Order. The
Governor’s Executive Orders may be found by accessing the following
website: xxxx://xxxxxxxx.xxxx.xxx/XxxxxxxxxXxxxxx/XxxxxxxxxXxxxxxXxxxxxxxxx/xxxxx/000/Xxxxxxx.xxxx.
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C.
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MCP
hereby covenants that MCP, its officers, members and employees of the MCP,
shall not, prior to the completion of the work under this Agreement,
voluntarily acquire any interest, personal or otherwise, direct or
indirect, which is incompatible or in conflict with or would compromise in
any manner of degree the discharge and fulfillment of his or
her functions and responsibilities under this provider
agreement. MCP shall periodically inquire of its officers,
members and employees concerning such
interests.
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D.
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Any
such person who acquires an incompatible, compromising or conflicting
personal or business interest, on or after the effective date of this
Agreement, or who involuntarily acquires any such incompatible or
conflicting personal interest, shall immediately disclose his or her
interest to ODJFS in writing. Thereafter, he or she shall not
participate in any action affecting the services under this provider
agreement, unless ODJFS shall determine in its sole discretion that, in
the light of the personal interest disclosed, his or her participation in
any such action would not be contrary to the public
interest. The written disclosure of such interest shall be made
to: Chief, Bureau of Managed Health Care,
ODJFS.
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E.
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No
officer, member or employee of MCP shall promise or give to any ODJFS
employee anything of value that is of such a character as to manifest a
substantial and improper influence upon the employee with respect to his
or her duties. No officer, member or employee of MCP shall
solicit an ODJFS employee to violate any ODJFS rule or policy relating to
the conduct of the parties to this agreement or to violate sections
102.03, 102.04, 2921.42 or 2921.43 of the Ohio Revised
Code.
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F.
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MCP
hereby covenants that MCP, its officers, members and employees are in
compliance with section 102.04 of the Revised Code and that if MCP is
required to file a statement pursuant to 102.04(D)(2) of the Revised Code,
such statement has been filed with the ODJFS in addition to any other
required filings.
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ARTICLE
VI - NONDISCRIMINATION OF EMPLOYMENT
A.
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MCP
agrees that in the performance of this provider agreement or in the hiring
of any employees for the performance of services under this provider
agreement, MCP shall not by reason of race, color, religion, gender,
sexual orientation, age, disability, national origin, veteran's status,
health status, or ancestry, discriminate against any citizen of this state
in the employment of a person qualified and available to perform the
services to which the provider agreement
relates.
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B.
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MCP
agrees that it shall not, in any manner, discriminate against, intimidate,
or retaliate against any employee hired for the performance or services
under the provider agreement on account of race, color, religion, gender,
sexual orientation, age, disability, national origin, veteran's status,
health status, or ancestry.
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C.
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In
addition to requirements imposed upon subcontractors in accordance with
OAC Chapter 5101:3-26, MCP agrees to hold all subcontractors and persons
acting on behalf of MCP in the performance of services under this provider
agreement responsible for adhering to the requirements of paragraphs (A)
and (B) above and shall include the requirements of paragraphs (A) and (B)
above in all subcontracts for services performed under this provider
agreement, in accordance with rule 5101:3-26-05 of the Ohio Administrative
Code.
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A.
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MCP
agrees that all records, documents, writings or other information produced
by MCP under this provider agreement and all records, documents, writings
or other information used by MCP in the performance of this provider
agreement shall be treated in accordance with rule 5101:3-26-06 of the
Ohio Administrative Code. MCP must maintain an appropriate
record system for services provided to members. MCP must retain all
records in accordance with 45 CFR Part
74.
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B.
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All
information provided by MCP to ODJFS that is proprietary shall be held to
be strictly confidential by ODJFS. Proprietary information is
information which, if made public, would put MCP at a disadvantage in the
market place and trade of which MCP is a part [see Ohio Revised Code
Section 1333.61(D)]. MCP is responsible for notifying ODJFS of
the nature of the information prior to its release to
ODJFS. Failure to provide such prior notification is deemed to
be a waiver of the proprietary nature of the information, and a waiver of
any right of MCP to proceed against ODJFS for violation of this agreement
or of any proprietary or trade secret laws. Such failure shall
also be deemed a waiver of trade secret protection in that the MCP will
have failed to make efforts that are reasonable under the circumstances to
maintain the information’s secrecy. ODJFS reserves the right to require
reasonable evidence of MCP's assertion of the proprietary nature of any
information to be provided and ODJFS will make the final determination of
whether any or all of the information identified by the MCP is proprietary
or a trade secret. The provisions of this Article are not
self-executing.
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C.
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MCP
shall not use any information, systems, or records made available to it
for any purpose other than to fulfill the duties specified in this
provider agreement. MCP agrees to be bound by the same
standards of confidentiality that apply to the employees of the ODJFS and
the State of Ohio. The terms of this section shall be included
in any subcontracts executed by MCP for services under this provider
agreement. MCP must implement procedures to ensure that in the
process of coordinating care, each enrollee's privacy is protected
consistent with the confidentiality requirements in 45 CFR parts 160 and
164.
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5
Baseline
Covered
Families and Children (CFC) Population
A.
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This
provider agreement may be suspended or terminated by the department or MCP
upon written notice in accordance with the applicable rule(s) of the Ohio
Administrative Code, with termination to occur at the end of the last day
of a month.
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B.
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MCP,
upon receipt of notice of suspension or termination, shall cease provision
of services on the suspended or terminated activities under this provider
agreement; suspend, or terminate all subcontracts relating to such
suspended or terminated activities, take all necessary or appropriate
steps to limit disbursements and minimize costs, and furnish a report, as
of the date of receipt of notice of suspension or termination describing
the status of all services under this provider
agreement.
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C.
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In
the event of suspension or termination under this Article, MCP shall be
entitled to reconciliation of reimbursements through the end of the month
for which services were provided under this provider agreement, in
accordance with the reimbursement provisions of this provider
agreement. MCP agrees to waive any right to, and shall make no
claim for, additional compensation against ODJFS by reason of such
suspension or termination.
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D.
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ODJFS
may, in its judgment, suspend, terminate or fail to renew this provider
agreement if the MCP or MCP's subcontractors violate or fail to comply
with the provisions of this agreement or other provisions of law or
regulation governing the Medicaid program. Where ODJFS proposes
to suspend, terminate or refuse to enter into a provider agreement, the
provisions of applicable sections of the Ohio Administrative Code with
respect to ODJFS' suspension, termination or refusal to enter into a
provider agreement shall apply, including the MCP's right to request an
adjudication hearing under Chapter 119. of the Revised
Code.
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E.
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When
initiated by MCP, termination of or failure to renew the provider
agreement requires written notice to be received by ODJFS at least 120
days in advance of the termination or renewal date, provided, however,
that termination or non-renewal must be effective at the end of the last
day of a calendar month. In the event of non-renewal of the
provider agreement with ODJFS, if MCP is unable to provide notice to ODJFS
120 days prior to the date when the provider agreement expires, and if, as
a result of said lack of notice, ODJFS is unable to disenroll Medicaid
enrollees prior to the expiration date, then the provider agreement shall
be deemed extended for up to four calendar months beyond the expiration
date and both parties shall, for that time, continue to fulfill their
duties and obligations as set forth herein. If an MCP wishes to terminate
or not renew their provider agreement for a specific region(s), ODJFS
reserves the right to initiate a procurement process to select
additional MCPs to serve Medicaid consumers in that region(s). ODJFS,
at its discretion, may use an MCP’s termination or non-renewal of
this provider agreement as a factor in any future procurement
process.
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ARTICLE
IX - AMENDMENT AND RENEWAL
A.
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This
writing constitutes the entire agreement between the parties with respect
to all matters herein. This provider agreement may be amended
only by a writing signed by both parties. Any written
amendments to this provider agreement shall be prospective in
nature.
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B.
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This
provider agreement may be renewed one or more times by a writing signed by
both parties for a period of not more than twelve months for each
renewal.
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C.
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In
the event that changes in State or Federal law, regulations, an applicable
waiver or state plan amendment, or the terms and conditions of any
applicable federal waiver or state plan amendment, require ODJFS to modify
this agreement, ODJFS shall notify MCP regarding such changes and this
agreement shall be automatically amended to conform to such changes
without the necessity for executing written amendments pursuant to this
Article of this provider agreement.
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D.
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This
Agreement supersedes any and all previous agreements, whether written or
oral, between the parties.
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E.
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A
waiver by any party of any breach or default by the other party under this
Agreement shall not constitute a continuing waiver by such party of any
subsequent act in breach of or in default
hereunder.
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A.
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MCP
agrees to indemnify and to hold ODJFS and the State of Ohio harmless and
immune from any and all claims for injury or damages resulting from the
actions or omissions of MCP or its subcontractors in the fulfillment of
this provider agreement or arising from this Agreement which are
attributable to the MCP’s own actions or omissions of those of its
trustees, officers, employees, subcontractors, suppliers, third parties
utilized by MCP, or joint venturers while acting under this
Agreement. Such claims shall include any claims made under the
Fair Labor Standards Act or under any other federal or state law involving
wages, overtime, or employment matters and any claims involving patents,
copyrights, and trademarks. MCP shall bear all costs associated
with defending ODJFS and the State of Ohio against these
claims.
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B.
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MCP
hereby agrees to be liable for any loss of federal funds suffered by ODJFS
for enrollees resulting from specific, negligent acts or omissions of the
MCP or its subcontractors during the term of this agreement, including but
not limited to the nonperformance of the duties and obligations to which
MCP has agreed under this
agreement.
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C.
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In
the event that, due to circumstances not reasonably within the control of
MCP or ODJFS, a major disaster, epidemic, complete or substantial
destruction of facilities, war, riot or civil insurrection occurs,
neither ODJFS nor MCP will have any liability or obligation on account of
reasonable delay in the provision or the arrangement of covered services;
provided that so long as MCP's certificate of authority remains in full
force and effect, MCP shall be liable for the covered services required to
be provided or arranged for in accordance with this
agreement.
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D.
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In
no event shall either party be liable to the other party for indirect,
consequential, incidental, special or punitive damages, or lost
profits.
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A.
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ODJFS
will not allow the transfer of Medicaid members by one MCP to another MCP
unless this membership has been obtained as a result of an MCP selling
their entire Ohio corporation to another health plan. MCP shall not assign
any interest in this provider agreement and shall not transfer any
interest in the same (whether by assignment or novation) without the prior
written approval of ODJFS and subject to such conditions and provisions as
ODJFS may deem necessary. Any such assignments shall be
submitted for ODJFS’ review 120 days prior to the desired effective
date. No such approval by ODJFS of any assignment shall be
deemed in any event or in any manner to provide for the incurrence of any
obligation by ODJFS in addition to the total agreed-upon reimbursement in
accordance with this agreement.
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B.
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MCP
shall not assign any interest in subcontracts of this provider agreement
and shall not transfer any interest in the same (whether by assignment or
novation) without the prior written approval of ODJFS and subject to such
conditions and provisions as ODJFS may deem necessary. Any such
assignments of subcontracts shall be submitted for ODJFS’ review 30 days
prior to the desired effective date. No such approval by ODJFS
of any assignment shall be deemed in any event or in any manner to provide
for the incurrence of any obligation by ODJFS in addition to the total
agreed-upon reimbursement in accordance with this
agreement.
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A.
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This
agreement is conditioned upon the full disclosure by MCP to ODJFS of all
information required for compliance with federal regulations as requested
by ODJFS.
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B.
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By
executing this agreement, MCP certifies that no federal funds paid to MCP
through this or any other agreement with ODJFS shall be or have been used
to lobby Congress or any federal agency in connection with a particular
contract, grant, cooperative agreement or loan. MCP further
certifies compliance with the lobbying restrictions contained in Section
1352, Title 31 of the U.S. Code, Section 319 of Public Law 101-121 and
federal regulations issued pursuant thereto and contained in 45 CFR Part
93, Federal Register, Vol. 55, No. 38, February 26, 1990, pages
6735-6756. If this provider agreement exceeds $100,000, MCP has
executed the Disclosure of Lobbying Activities, Standard Form LLL, if
required by federal regulations. This certification is material
representation of fact upon which reliance was placed when this provider
agreement was entered into.
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8
Baseline
Covered
Families and Children (CFC) Population
C.
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By
executing this agreement, MCP certifies that neither MCP nor any
principals of MCP (i.e., a director, officer, partner, or person with
beneficial ownership of more than 5% of the MCP’s equity) is presently
debarred, suspended, proposed for debarment, declared ineligible, or
otherwise excluded from participation in transactions by any
Federal agency. The MCP also certifies that it is
not debarred from consideration for contract awards by the Director of the
Department of Administrative Services, pursuant to either O.R.C. Section
153.02 or O.R.C. Section 125.25. The MCP also certifies that
the MCP has no employment, consulting or any other arrangement with any
such debarred or suspended person for the provision of items or services
or services that are significant and material to the MCP’s contractual
obligation with ODJFS. This certification is a material
representation of fact upon which reliance was placed when this provider
agreement was entered into. If it is ever determined that MCP knowingly
executed this certification erroneously, then in addition to any other
remedies, this provider agreement shall be terminated pursuant to Article
VII, and ODJFS must advise the Secretary of the appropriate Federal agency
of the knowingly erroneous
certification.
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D.
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By
executing this agreement, MCP certifies compliance with Article V as well
as agreeing to future compliance with Article V. This
certification is a material representation of fact upon which reliance was
placed when this contract was entered
into.
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E.
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By
executing this agreement, MCP certifies compliance with the executive
agency lobbying requirements of sections 121.60 to 121.69 of the Ohio
Revised Code. This certification is a material representation of fact upon
which reliance was placed when this provider agreement was entered
into.
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F.
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By
executing this agreement, MCP certifies that MCP is not on the most recent
list established by the Secretary of State, pursuant to section 121.23 of
the Ohio Revised Code, which identifies MCP as having more than one unfair
labor practice contempt of court finding. This certification is
a material representation of fact upon which reliance was placed when this
provider agreement was entered
into.
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G.
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By
executing this agreement MCP agrees not to discriminate against
individuals who have or are participating in any work program administered
by a county Department of Job and Family Services under Chapters 5101 or
5107 of the Revised Code.
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H.
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By
executing this agreement, MCP certifies and affirms that, as applicable to
MCP, that no party listed or described in Division (I) or (J) of Section
3517.13 of the Ohio Revised Code who was actually in a listed position at
the time of the contribution, has made as an individual, within the two
previous calendar years, one or more contributions in excess of One
Thousand and 00/100 ($1,000.00) to the present Governor or to the
governor’s campaign committees during any time he/she was a candidate for
office. This certification is a material representation of fact
upon which reliance was placed when this provider agreement was entered
into. If it is ever determined that MCP's certification of this
requirement is false or misleading, and not withstanding any criminal or
civil liabilities imposed by law, MCP shall return to ODJFS all
monies paid to MCP under this provider agreement. The
provisions of this section shall survive the expiration or termination of
this provider agreement.
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I.
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MCP
agrees to refrain from promising or giving to any ODJFS employee anything
of value that is of such a character as to manifest a substantial and
improper influence upon the employee with respect to his or her
duties. MCP also agrees that it will not solicit an ODJFS
employee to violate any ODJFS rule or policy relating to the conduct of
contracting parties or to violate sections 102.03, 102.04, 2921.42 or
2921.43 of the Ohio Revised Code.
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J.
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By
executing this agreement, MCP certifies and affirms that HHS, US
Comptroller General or representatives will have access to books,
documents, etc. of MCP.
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K.
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By
executing this agreement, MCP agrees to comply with the false claims
recovery requirements of Section 6032 of The Deficit Reduction Act of 2005
(also see Section 5111.101 of the Revised
Code).
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L.
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MCP,
its officers, employees, members, any subcontractors, and/or any
independent contractors (including all field staff) associated with this
agreement agree to comply with all applicable state and federal laws
regarding a smoke-free and drug-free workplace. The MCP will
make a good faith effort to ensure that all MCP officers, employees,
members, and subcontractors will not purchase, transfer, use or possess
illegal drugs or alcohol, or abuse prescription drugs in any way while
performing their duties under this
Agreement.
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M.
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MCP
hereby represents and warrants to ODJFS that it has not provided any
material assistance, as that term is defined in O.R.C. Section 2909.33(C),
to any organization identified by and included on the United States
Department of State Terrorist Exclusion List and that it has
truthfully answered “no” to every question on the
“Declaration Regarding Material Assistance/Non-assistance to a
Terrorist Organization.” MCP further represents and warrants
that it has provided or will provide such to ODJFS prior to execution of
this Agreement. If these representations and warranties are
found to be false, this Agreement is void ab initio and MCP shall
immediately repay to ODJFS any funds paid under this
Agreement.
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A.
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This
provider agreement shall be governed, construed and enforced in accordance
with the laws and regulations of the State of Ohio and appropriate federal
statutes and regulations. The provisions of this Agreement are
severable and independent, and if any such provision shall be determined
to be unenforceable, in whole or in part, the remaining provisions and any
partially enforceable provision shall, to the extent enforceable in any
jurisdiction, nevertheless be binding and
enforceable.
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10
Baseline
Covered
Families and Children (CFC) Population
ARTICLE
XIV - INCORPORATION BY REFERENCE
A.
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Ohio
Administrative Code Chapter 5101:3-26 (Appendix A) is hereby incorporated
by reference as part of this provider agreement having the full force and
effect as if specifically restated
herein.
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B.
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Appendices
B through P and any additional appendices are hereby incorporated by
reference as part of this provider agreement having the full force and
effect as if specifically restated
herein.
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C.
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In
the event of inconsistence or ambiguity between the provisions of OAC
Chapter 5101:3-26 and this provider agreement, the provisions of OAC
Chapter 5101:3-26 shall be determinative of the obligations of the parties
unless such inconsistency or ambiguity is the result of changes in federal
or state law, as provided in Article IX of this provider agreement, in
which case such federal or state law shall be determinative of the
obligations of the parties. In the event OAC 5101:3-26 is
silent with respect to any ambiguity or inconsistency, the provider
agreement (including Appendices B through P and any additional
appendices), shall be determinative of the obligations of the
parties. In the event that a dispute arises which is not
addressed in any of the aforementioned documents, the parties agree to
make every reasonable effort to resolve the dispute, in keeping with the
objectives of the provider agreement and the budgetary and statutory
constraints of ODJFS.
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All
notices, consents, and communications hereunder shall be given in writing, shall
be deemed to be given upon receipt thereof, and shall be sent to the addresses
first set forth above.
The
headings in this Agreement have been inserted for convenient reference only and
shall not be considered in any questions of interpretation or construction of
this Agreement.
The
parties have executed this agreement the date first written
above. The agreement is hereby accepted and considered binding in
accordance with the terms and conditions set forth in the preceding
statements.
WELLCARE
OF OHIO, INC.:
BY: /s/ Xxxxx
Xxxxxxxxx
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DATE:
6/23/08
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XXXXX
XXXXXXXXX, CHIEF EXECUTIVE OFFICER AND PRESIDENT
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OHIO
DEPARTMENT OF JOB AND FAMILY SERVICES:
BY: /s/
Xxxxx Xxxxx-Xxxxx
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DATE:
6/30/08
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XXXXX
X. XXXXX-XXXXX, DIRECTOR
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12
CFC PROVIDER AGREEMENT
INDEX
July 1,
2008
APPENDIX TITLE
APPENDIX
A OAC
RULES 5101:3-26
APPENDIX
B
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SERVICE
AREA SPECIFICATIONS – CFC ELIGIBLE
POPULATION
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APPENDIX
C
MCP RESPONSIBILITIES – CFC ELIGIBLE
POPULATION
APPENDIX
D
|
ODJFS
RESPONSIBILITIES – CFC
ELIGIBLE POPULATION
|
APPENDIX
E RATE
METHODOLOGY – CFC ELIGIBLE POPULATION
APPENDIX
F REGIONAL
RATES – CFC ELIGIBLE POPULATION
APPENDIX
G
|
COVERAGE
AND SERVICES – CFC ELIGIBLE
POPULATION
|
APPENDIX
H
|
PROVIDER
PANEL SPECIFICATIONS – CFC ELIGIBLE
POPULATION
|
APPENDIX
I
PROGRAM INTEGRITY– CFC
ELIGIBLE POPULATION
APPENDIX
J
|
FINANCIAL
PERFORMANCE – CFC ELIGIBLE
POPULATION
|
APPENDIX
K
|
QUALITY
ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM – CFC ELIGIBLE
POPULATION
|
APPENDIX
L DATA
QUALITY – CFC ELIGIBLE POPULATION
APPENDIX
M
|
PERFORMANCE
EVALUATION – CFC ELIGIBLE
POPULATION
|
APPENDIX
N
|
COMPLIANCE
ASSESSMENT SYSTEM – CFC ELIGIBLE
POPULATION
|
APPENDIX
O
|
PAY-FOR-PERFORMANCE
(P4P) – CFC ELIGIBLE POPULATION
|
APPENDIX
P
|
MCP
TERMINATIONS/NONRENEWALS/AMENDMENTS – CFC ELIGIBLE
POPULATION
|
Appendix
A
Covered
Families and Children (CFC) Population
APPENDIX
A
OAC
RULES 5101:3-26
The
managed care program rules can be accessed electronically through the BMHC
page of the ODJFS website.
1
Appendix
B
Covered
Families and Children (CFC) Population
APPENDIX
B
SERVICE AREA
SPECIFICATIONS
CFC
ELIGIBLE POPULATION
MCP
: WELLCARE OF OHIO, INC.
The MCP agrees to provide
services to Covered Families and Children (CFC) members residing in
the following service area(s):
Service Area: Northeast
Region – Ashtabula, Cuyahoga, Erie, Geauga, Huron, Lake, Lorain, and
Xxxxxx counties.
1
Appendix
C
Covered
Families and Children (CFC)
population
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.
|
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.
|
2.
|
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.
|
3.
|
The
MCP must designate the following:
|
|
a. |
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.
|
|
b. |
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).
|
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.
4.
|
All
MCP employees are to direct all day-to-day submissions and communications
to their ODJFS-designated Contract Administrator unless otherwise notified
by ODJFS.
|
5.
|
The
MCP must be represented at all meetings and events designated by ODJFS as
requiring mandatory attendance.
|
6.
The MCP must have an administrative
office located in Ohio.
1
Appendix
C
Covered
Families and Children (CFC) population
7.
|
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.
|
8.
|
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.
|
9.
|
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.
|
10.
|
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.
|
11.
|
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.
|
12.
|
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.
|
13.
|
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.
|
14.
|
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.
|
2
Appendix
C
Covered
Families and Children (CFC) population
15.
|
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.
|
|
a.
|
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.
|
|
b.
|
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.
|
|
c.
|
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.
|
16.
|
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.
|
17.
|
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.
|
18.
|
Upon
request, the MCP will provide members and potential members with a copy of
their practice guidelines.
|
19.
|
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.
|
3
Appendix
C
Covered
Families and Children (CFC) population
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:
|
a.
|
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.
|
|
b.
|
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.
|
20.
|
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 provider [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 member
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).
|
|
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.
|
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.
|
22.
|
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. Marketing and
member materials are defined as
follows:
|
|
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.
|
|
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.
|
|
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.
|
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. |
|
e.
|
MCPs
must establish positive working relationships with the CDJFS offices
and must not aggressively solicit from local Directors, MCP County
Coordinators, 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.
|
5
Appendix
C
Covered
Families and Children (CFC) population
23.
|
Advance
Directives – All MCPs must comply with the requirements specified
in 42
CFR 422.128. At a minimum, the MCP must:
|
|
|
a.
|
Maintain
written policies and procedures that meet the requirements for advance
directives, as set forth in 42 CFR Subpart I of part
489.
|
|
b.
|
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:
|
i. Provides
written information to all adult members concerning:
|
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).
|
|
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;
|
|
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
|
|
d.
|
the
right to file complaints concerning noncompliance with the advance
directive requirements with the Ohio Department of
Health.
|
|
ii.
|
Provides
for education of staff concerning the MCP’s policies and procedures on
advance directives;
|
|
iii.
|
Provides
for community education regarding advance directives directly
or in concert with other providers or
entities;
|
|
iv.
|
Requires
that the member’s medical record document whether or not the member has
executed an advance directive; and
|
|
v.
|
Does
not condition the provision of care, or otherwise discriminate against a
member, based on whether the member has executed an advance
directive.
|
6
Appendix
C
Covered
Families and Children (CFC) population
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.
|
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.
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.
|
8
Appendix
C
Covered
Families and Children (CFC) population
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:
|
a.
|
MCPs
shall not use or disclose PHI other than is permitted by this agreement or
required by law.
|
|
b.
|
MCPs
shall use appropriate safeguards to prevent unauthorized use or disclosure
of PHI.
|
|
c.
|
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.
|
|
d.
|
MCPs
shall ensure that all its agents and subcontractors agree to these same
PHI conditions and restrictions.
|
e.
MCPs shall make PHI available for access as required by law.
|
f.
|
MCP
shall make PHI available for amendment, and incorporate amendments as
appropriate as required by law.
|
|
g.
|
MCPs
shall make PHI disclosure information available for accounting as required
by law.
|
|
h.
|
MCPs
shall make its internal PHI practices, books and records available to the
Secretary of Health and Human Services (HHS) to determine
compliance.
|
|
i.
|
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.
|
|
j.
|
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.
|
28.
|
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.
|
9
Appendix
C
Covered
Families and Children (CFC) population
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).
|
|
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.
|
|
c.
|
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.
|
|
d.
|
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.
|
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. |
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. |
10
Appendix
C
Covered
Families and Children (CFC) population
|
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.
|
i.
Transition of Fee-For-Service
Members
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 to the 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.
|
|
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:
|
12
Appendix
C
Covered
Families and Children (CFC) population
|
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.
|
13
Appendix
C
Covered
Families and Children (CFC) population
|
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.
|
|
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:
|
14
Appendix
C
Covered
Families and Children (CFC) population
|
a.
|
Before
an MCP may submit production files ODJFS-specified formats;
and/or
|
|
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
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.
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.
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 payment and remittance
status;
Standard code sets; and
National Provider Identifier
(NPI).
Each EDI
transaction processed by the MCP shall be implemented inconformance 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.
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.
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
16
Appendix
C
Covered
Families and Children (CFC) population
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:
·
|
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.
17
Appendix
C
Covered
Families and Children (CFC) population
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.
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.
|
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.
18
Appendix
C
Covered
Families and Children (CFC) population
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.
|
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.
|
19
Appendix
C
Covered
Families and Children (CFC) population
31. Delivery
Payments
MCPs will
be reimbursed for paid deliveries that are identified in the submitted
encounters using the methodology outlined in the ODJFS Methods for Reimbursing for
Deliveries (as specified in Appendix L). 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. MCPs
are required to submit all delivery encounters to ODJFS no later than one year
after the date of the delivery. Delivery encounters which are submitted after
this time will be denied payment. MCPs will receive notice of the
payment denial on the remittance advice.
If an MCP
is denied payment through ODJFS’ automated payment system because the delivery
encounter was not submitted within a year of the delivery date, then it will be
necessary for the MCP to contact BMHC staff to receive
payment. Payment will be made for the delivery, at the discretion of
ODJFS if a payment had not been made previously for the same
delivery.
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.
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.
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.
20
Appendix
C
Covered
Families and Children (CFC) population
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.
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).
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 receive prior approval from ODJFS that verifies that the proper
safeguards, firewalls, etc., are in place to protect member
data.
|
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.
|
21
Appendix
C
Covered
Families and Children (CFC) population
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.
|
|
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 by October 1, 2008: (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.
22
Appendix
C
Covered
Families and Children (CFC) population
|
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 by October 1, 2008: (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, 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.
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.
|
23
Appendix
D
Covered
Families and Children (CFC) population
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.
|
1
Appendix
D
Covered
Families and Children (CFC) population
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.
|
2
Appendix
D
Covered
Families and Children (CFC) population
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 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
MC 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:
|
3
Appendix
D
Covered
Families and Children (CFC) population
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. For a detailed
description of the MCP Provider Call Center measure, see ODJFS Method for the MCP
Provider Call Center
Measure.)
|
–
|
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 30 days
|
|
–
|
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%)).
|
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.
|
4
Appendix
D
Covered
Families and Children (CFC) population
|
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.
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.
5
Appendix
E
Covered
Families and Children (CFC) population
APPENDIX
E
RATE
METHODOLOGY
CFC
ELIGIBLE POPULATION
FINAL and
CONFIDENTIAL
Chase
Center/Circle
000
Xxxxxxxx Xxxxxx
Xxxxx
000 Xxxxxxxxxxxx,
XX 00000-0000
XXX
Tel x0
000 000 0000
Fax x0000 000
0000
xxxxxxxx.xxx
June
5, 2008
Xx.
Xxx Xxxxxx, Ph.D., Bureau Chief
Bureau
of Managed Health Care
Ohio
Department of Job and Family Services
Lazarus
Building
00
Xxxx Xxxx Xx., Xxxxx 000
Xxxxxxxx,
XX 00000
RE:
|
CAPITATION
RATE CERTIFICATION - COVERED FAMILIES AND CHILDREN (CFC) July
1, 2008 TO
DECEMBER 31,
2008
|
Dear
Xxx:
Xxxxxxxx,
Inc. (Milliman) was retained by the State of Ohio, Department of Job and Family
Services (ODJFS) to develop the calendar year (CV) 2008 actuarially sound
capitation rates for the Covered Families and Children (CFC) Risk Based Managed
Care (RBMC) program. This letter provides the revised capitation rates to be
effective
from July 1,
2008 to
December 31,
2008. The revisions are a result of specific policy changes effective subsequent
to the development of the CY 2008 capitation rates.
The
information contained in this letter, including the enclosures, has been
prepared for the State of Ohio, Department of Job and Family Services and their
consultants and advisors, it is our
understanding that the information contained in this letter may be utilized in a
public document. To the extent that the information contained in this letter is
provided to third parties, the letter should be distributed
in its entirety. Any user of the data must possess a certain level of expertise
in actuarial science and healthcare modeling so as not to misinterpret the data
presented.
Milliman
makes no representations or warranties regarding the contents of this letter to
third parties, Likewise, third parties are instructed that they are to place no
reliance upon this letter prepared for ODJFS by Milliman that would result in
the creation of any duty or. liability under any theory of law by Milliman or
its employees to third parties. Other parties receiving this letter must
rely upon
their own experts in drawing conclusions about the capitation rates,
assumptions, and trends.
The information
contained in this letter was prepared as documentation of the- actuarially sound
capitation rates for Medicaid managed care organization health plans in the
State of Ohio. The information may not be appropriate for any other
purpose.
0
Xxxxxxxx
X
Covered
Families and Children (CFC) population
EXECUTIVE
SUMMARY
The
calendar year (CY) 2008 capitation rates for the Covered Families and Children
(CFC) Risk
Based Managed Care (R.BMC) program were revised for the period of July 1, 2008
to December 31, 2008. The revisions are a result of specific policy changes
effective subsequent to the development of the CY 2008 capitation rates. The
base data and actuarial assumptions underlying the CY 2008
capitation rates remain unchanged from the December 4, 2007 rate
certification and data book.
Table 1 summarizes the current (January to
June 2008) and the revised (July to December 2008) capitation rate
expenditures as well as the
percentage changes by region on a composite all rate group
basis.
Table
1
STATE
OF OHIO
DEPARTMENT
OF JOB AND FAMILY SERVICES
COVERED
FAMILIES AND CHILDREN
Capitation
Comparison - Aggregate Expenditures
($
millions)
Region
|
Jan
– Jun
2008
|
Jul
– Dec
2008
|
Expenditure
Change
|
Percentage
Change
|
||||||||||||
Central
|
$ | 300.7 | $ | 316.4 | $ | 15.8 | 5.2 | % | ||||||||
East
Central
|
$ | 163.3 | $ | 171.9 | $ | 8.6 | 5.3 | % | ||||||||
Northeast
|
$ | 270.0 | $ | 283.8 | $ | 13.8 | 5.1 | % | ||||||||
Northeast
Central
|
$ | 76.8 | $ | 80.8 | $ | 4.0 | 5.2 | % | ||||||||
Northwest
|
$ | 156.9 | $ | 165.4 | $ | 8.5 | 5.4 | % | ||||||||
Southeast
|
$ | 104.8 | $ | 110.4 | $ | 5.6 | 5.3 | % | ||||||||
Southwest
|
$ | 197.5 | $ | 207.0 | $ | 9.5 | 4.8 | % | ||||||||
West
Central
|
$ | 132.1 | $ | 139.2 | $ | 7.1 | 5.4 | % | ||||||||
Statewide
Composite
|
$ | 1,402.1 | $ | 1,475.0 | $ | 72.9 |
5.2% |
|
Note:
Values have been rounded
2
Appendix
E
Covered
Families and Children (CFC) population
In aggregate, the July to
December 2008 capitation rates will result in a
5.2% increase relative to the
current January to June 2008 capitation rates. The
composite rate increase reflects assumed health plan enrollment consistent with the
previously projected CY 2008 estimates. Additionally, the
expenditure estimates assume equal distribution of member months and deliveries
throughout CY 2008.
Enclosure
1 provides the current and proposed capitation rates and expenditures for each
rate group and geographic region as well as on a statewide composite
basis.
Enclosure
2 contains the actuarial certification regarding the actuarial soundness of the
capitation rates.
The
capitation rates for the CFC program were revised for the period of July 1, 2008
to December 31, 2008. The
revisions are a result of specific program changes effective subsequent to the
development of the CY 2008 capitation rates. Table 2 summarizes the changes that
were reflected in the capitation rate change to be effective July 1,
2008.
Table
2
STATE
OF OHIO
DEPARTMENT
OF JOB AND FAMILY SERVICES
COVERED
FAMILIES AND CHILDREN
Prospective
Program Adjustments
Program
Adjustment
|
Effective
Date
|
Service
Category(s)
|
Groups
|
Estimated
Aggregate Impact
|
|
Inpatient
Capital Component
|
1/1/2008
|
Inpatient
(excl.
Nursing Facility)
|
All
Rate Groups (incl. Delivery)
|
2.50%
|
$11.5 M/
0.8%
|
Community
Providers Fee Schedule Increase
|
7/1/2008
|
Community
Based Provider Categories
|
All
Rate Groups (incl.
Delivery)
|
4.13%
|
$25.7
M/
1.8%
|
Dental Benefit Restoration
|
7/1/2008
|
Dental
|
HF M-19 to44
|
30.24%
|
$9.8
M/ 0.7%
|
HF F-19 to 44
|
34.16%
|
||||
HF
M/F -
45 to 64
|
30.18%
|
||||
HST F- 19 to 64
|
49.48%
|
||||
CHIP
III Expansion Revision
|
1/1/2008
|
All
Service Categories
|
HST M/F- 2 to 13
|
(0.34%)
|
($1.4) M/
(0.1%)
|
HST M - 14 to
18
|
|||||
HST F-14 to l8
|
|||||
Improved
TPL Management Revision
|
1/1/2008
|
All
Service Categories
|
All Rate
Groups (incl. Delivery)
|
0.84%
|
$11.5 M/
.8%
|
Franchise
Fee Increase
|
7/1/2008
|
All
Service Categories
|
All
Rate Groups (incl. Delivery)
|
1.06%
|
$15.4 M/
1.1%
|
Franchise
Fee - Timing Adjustment
|
7/1/2008
|
All
Service Categories
|
Delivery
|
0.42%
|
$0.4
M/
<0.1%
|
Note:
Estimated aggregate impact includes administrative cost and franchise fee
components (values have been rounded).
Inpatient Capital
Component
The
capital component of the CY 2008 DRG hospital payment rates was increased on
January 1,
2008. The changes are being reflected in the managed care capitation rates as it
is recognized that the majority of contracts held by the health plans reflect a
percentage of the base FFS reimbursement prior to annual capital settlements
with providers. As such, Milliman reviewed the impact of the capital changes
using a distribution of admissions and paid claims by provider appropriate for
the CFC managed care enrolled population.
The
increase was not included in the capitation rates effective January 1, 2008 due to the
timing of this change. Milliman has included this adjustment into the capitation
rates to be effective from July 1, 2008 to December
31, 2008.
The adjustment reflects a retro-active payment for January to June 2008 as well
as a prospective adjustment for July to December 2008.
Milliman
obtained the hospital capital rates for CY 2007 and CY 2008 by provider as well
as the distribution of paid claims and admissions by provider for SFY 2006. The
adjustment factor was calculated using the following
Methodology:
Adjustment
Factor = [Admissions
SFY2006 X
(Capital CY2008 – Capital
CY2007)] /Total
Paid
SFY2006
Community
Provider Fee Schedule Update
The
fee schedule used to reimburse FFS community providers was updated by ODJFS
effective July 1, 2008. The changes are being reflected in the managed care
capitation rates as it is recognized that the majority of contracts held by the
health plans reflect a percentage of the FFS reimbursement. As such, Milliman
reviewed the impact of the fee changes using a distribution of services and paid
claims appropriate for the CFC managed care enrolled
population.
Milliman
obtained the fee schedule by procedure code and modifier code for the current
fees (prior to July 1, 2008) and the revised fees (post July 1, 2008) as well as
the distribution of paid claims and utilization counts for SFY 2006. The
adjustment factor was calculated using the following
Methodology:
Adjustment
Factor = [Total
Paid SFY2006 X
(Fee Post 7 1 08 / Fee
Prior to 7 1 08)]
/ Total
Paid SFY2006 - 1
Table
3 summarizes the impact of the community provider fee schedule update by
category of service.
0
Xxxxxxxx
X
Covered
Families and Children (CFC) population
Table
3
STATE
OF OHIO
DEPARTMENT
OF JOB AND FAMILY SERVICES
COVERED
FAMILIES AND CHILDREN
Community
Provider Fee Adjustments
Service
Category
|
Impact
of Fee
Changes
|
Outpatient
|
|
Surgery/ASC
|
0.3% |
Professional
|
|
Surgery
|
(1.2%) |
Anesthesia
|
0.0% |
Obstetrics
|
6.5% |
Office
Visits/Consults
|
14.0% |
inpatient
Visits
|
9.2% |
Periodic
Exams
|
5.7% |
Emergency
Room
|
6.7% |
Immunizations
& Injection
|
15.0% |
Physical
Medicine
|
3.2% |
Miscellaneous
Services
|
5.7% |
Rad/Path/Lab
|
|
Radiology
|
(0.6%) |
Path/Lab
|
0.3% |
Other
Benefits
|
|
Mental Health/Substance Abuse | 7.1 % |
Dental
|
2.3% |
Vision
- Optometric
|
6.1% |
Home
Health
|
3.0% |
Non-Emergent Transportation | 2.3 % |
Ambulance
|
2.1% |
Supplies
& DME
|
0.0% |
Miscellaneous
Services
|
2.9% |
Note:
Values have been rounded.
0
Xxxxxxxx
X
Covered
Families and Children (CFC) population
Dental
Benefit Restoration
Dental
benefits will be restored to the adult rate groups effective July 1, 2008. This
impact was calculated and included in previous drafts of the CY 2008 capitation
rates. However, the benefit restoration was delayed and,
as such, was not included in the final capitation rates effective January 1,
2008.
The
adjustment factors summarized in Table 2 for the dental benefit restoration are
consistent with the previously provided amounts, with one exception. The impact
of pent-up
demand previously included was increased from 2% to 4%. This reflects that the
total of the pent-up demand is still assumed to occur; however, it will occur
over only half of the calendar year.
The
capitation rates effective January 1, 2008 included an increase due to the
expansion of coverage to the CHIP program from 200% to 300% FPL. This expansion
has not begun as of this time and remains uncertain for the remainder of the
calendar year. As such, Milliman has included
an adjustment in the capitation rates effective for July to December 2008. The
adjustment reflects a retro-active adjustment for January to June 2008 as well
as a prospective adjustment for July to December 2008 to remove the total impact
of the CHIP
III expansion from the entire calendar year.
The
adjustment factor was calculated by removing the increase from the current
rates
[1
/ (1+0.17%)] and retro-actively removing the
previously increased amount [1-0.17%].
Milliman
and ODJFS will monitor the progress of the CHIP III expansion and may revise the
rates prior to CY 2009 should a material change occur.
The
capitation rates effective January 1, 2008 included a
reduction due to the anticipated improvements in the TPL data and information
that would allow for increased TPL collections and cost avoidance by the health
plans. The
planned improvements have been delayed until October 1, 2008. As such, Milliman
has included an adjustment in the capitation rates effective for July to
December 2008. The adjustment reflects a retro-active payment for January to
June 2008 as well as a prospective adjustment for July to September 2008 to
remove the value of the TPL improvements from the first nine months of calendar
year 2008. The adjustment will be applied to the payments for July to December
2008.
The
adjustment factor was calculated by modifying the reduction from the current
rates and retro-actively restoring the
previously reduced amount [(l+.28%) / (1 -.55%)].
0
Xxxxxxxx
X
Covered
Families and Children (CFC) population
Franchise
Fee Increase
The
franchise fee amount was increased
from 4.5% to 5.5% of the capitation rate effective July 1, 2008. This adjustment
was applied by removing the current franchise fee percent and applying the
revised franchise fee percent for all regions and rate
groups.
Franchise
Fee - Timing
Adjustment
The
revision of the franchise fee amount creates an exposure issue for the health
plans as the timing and methodology of the capitation payments differs from the
collection of the fees by the State. Franchise fee payments included in the
capitation rates are paid based on the incurred dates of service for the
Delivery and Non-Delivery rate groups. Collections of the franchise fee by the State are
based on the date of payment-of the
capitation rate. As such, to the extent there is a lag in payment of the
capitation rate, there is an inherent mis-alignment of payment and collection of
the franchise fee. This issue only arises when a change in the franchise fee
percent occurs.
Milliman reviewed the
lag time of capitation incurred periods to
capitation payment periods to estimate the impact of this change. For the
Non-Delivery rate groups, the capitation payments primarily occur on or 'before the service
month eliminating the impact of this change. For the Delivery rate group, the
capitation payments are paid with significant lag times, similar to the
lag found in FFS claims. As such, Milliman included an adjustment to the
Deliver)' payment for July to December 2008 to reflect this
change.
Table
4 summarizes the percentage of deliver)' capitation payment amounts between
those paid prior to July 1, 2008 and those
paid after July 1, 2008. The
percentages reflect an average historical amount using a 12 month
completion factor estimate, after removing the highest and lowest
values.
0
Xxxxxxxx
X
Covered
Families and Children (CFC) population
Table
4
STATE
OF OHIO
DEPARTMENT
OF JOB AND FAMILY SERVICES
COVERED
FAMILIES AND CHILDREN
Delivery
Rate Group - Lag Factors
Delivery Month
|
Percentage
Paid Prior to July 1, 2008
|
Percentage Paid
After July 1, 2008
|
July
2007
|
99.9%
|
0.1%
|
August
2007
|
99.7%
|
0.3%
|
September
2007
|
99.1%
|
0.9%
|
October
2007
|
98.7%
|
1.3%
|
November
2007
|
98.3%
|
1.7%
|
December
2007
|
97.5%
|
2.5%
|
January
2008
|
96.2%
|
3.8%
|
February
2008
|
93.9%
|
6.1%
|
March
2008
|
86.8%
|
13.2%
|
April
2008
|
59.0%
|
41.0%
|
May
2008
|
17.9%
|
82.1%
|
June
2008
|
0.0%
|
100.0%
|
Note:
Values have been rounded.
If you have any
questions regarding the enclosed information, please do not hesitate to contact
me at
(000)
000-0000.
Sincerely,
Xxxxxx
X. Xxxxxx, FSA,
MAAA
Principal
and Consulting Actuary
RMD/1rb
Enclosures
8
Appendix
E
Covered
Families and Children (CFC) population
ENCLOSURE
1
State of Ohio
Department of Job
and Family Services
Capitation
Rate Comparison - CFC
Region
|
Rate
Group
|
Projected
Jul
- Dec 2008
MMs/Deliveries
|
Jan-Jun
2008
Cap
Rate
|
Jan-Jun
2008
Expenditures
|
Jul-Dec
2008
Cap
Rate
|
Jul-Dec
2008
Expenditures
|
% Change
|
$
Change
|
|||||||||||||||||||||
Central
|
HF/HST
<1 M+F
|
101,760 | $ | 568.17 | $ | 57,816,695 | $ | 596.95 | $ | 60,745,334 | 5.1 | % | $ | 2,928,638 | |||||||||||||||
Central
|
HF/HST
1 M+F
|
79,228 | 146.51 | 11,607,694 | 154.00 | 12,201,112 | 5.1 | % | 593,418 | ||||||||||||||||||||
Central
|
HF/HST
2-13 M+F
|
613,230 | 99.10 | 60,771,093 | 103.23 | 63,303,733 | 4.2 | % | 2,532,640 | ||||||||||||||||||||
Central
|
HF/HST
14-18 F
|
81,608 | 165.19 | 13,480,826 | 172.11 | 14,045,553 | 4.2 | % | 564,727 | ||||||||||||||||||||
Central
|
HF/HST
14-18 M
|
73,398 | 118.54 | 8,700,599 | 122.99 | 9,027,220 | 3.8 | % | 326,621 | ||||||||||||||||||||
Central
|
HF
19-44
F
|
275,119 | 304.31 | 83,721,311 | 322.46 | 88,714,712 | 6.0 | % | 4,993,401 | ||||||||||||||||||||
Central
|
HF
19-44
M
|
84,102 | 198.75 | 16,715,273 | 211.71 | 17,805,234 | 6.5 | % | 1,089,962 | ||||||||||||||||||||
Central
|
HF45+M+F
|
32,705 | 485.77 | 15,886,865 | 509.32 | 16,657,056 | 4.8 | % | 770,191 | ||||||||||||||||||||
Central
|
HST 19-64 F
|
30,857 | 376.25 | 11,609,758 | 401.72 | 12,395,673 | 6.8 | % | 785,915 | ||||||||||||||||||||
Central
|
Composite
Non-Delivery
|
1,372,005 | 204.31 | 280,310,113 | 214.94 | 294,895,626 | 5.2 | % | 14,585,513 | ||||||||||||||||||||
Central
|
Delivery
CFC
|
5,427 | 3,754.26 | 20,374,369 | 3,969.58 | 21,542,911 | 5.7 | % | 1,168,542 | ||||||||||||||||||||
Central
|
Composite
with Delivery
|
1,372,005 | $ | 219.16 | $ | 300,684,482 | $ | 230.64 | $ | 316,438,537 | 5.2 | % | $ | 15,754,055 | |||||||||||||||
East
Central
|
HF/HST
<1 M+F
|
50,472 | $ | 553.95 | $ | 27,958,687 | $ | 582.04 | $ | 29,376,432 | 5.1 | % | $ | 1,417,744 | |||||||||||||||
East
Central
|
HF/HST
1 M+F
|
37,738 | 142.85 | 5,390,873 | 150.15 | 5,666,361 | 5.1 | % | 275,487 | ||||||||||||||||||||
East
Central
|
HF/HST
2-13 M+F
|
334,892 | 96.62 | 32,357,265 | 100.66 | 33,710,229 | 4.2 | % | 1,352,964 | ||||||||||||||||||||
East
Central
|
HF/HST
14-18 F
|
48,233 | 161.06 | 7,768,326 | 167.81 | 8,093,896 | 4.2 | % | 325,569 | ||||||||||||||||||||
East
Central
|
HF/HST
14-18 M
|
44,187 | 115.57 | 5,106,692 | 119.92 | 5,298,905 | 3.8 | % | 192,213 | ||||||||||||||||||||
East
Central
|
HF 19-44 F
|
160,491 | 296.69 | 47,616,075 | 314.41 | 50,459,975 | 6.0 | % | 2,843,901 | ||||||||||||||||||||
East
Central
|
HF
19-44
M
|
45,442 | 193.78 | 8,805,654 | 206.42 | 9,380,034 | 6.5 | % | 574,381 | ||||||||||||||||||||
East
Central
|
HF 45+M+F
|
19,782 | 473.60 | 9,368,518 | 496.60 | 9,823,493 | 4.9 | % | 454,974 | ||||||||||||||||||||
East
Central
|
HST 19-64 F
|
16,944 | 366.84 | 6,215,737 | 391.69 | 6,636,795 | 6.8 | % | 421,058 | ||||||||||||||||||||
East
Central
|
Composite
Non-Delivery
|
758,179 | 198.62 | 150,587.828 | 208.98 | 158,446,120 | 5.2 | % | 7,858,292 | ||||||||||||||||||||
East
Central
|
Delivery
CFC
|
3,193 | 3,990.44 | 12,741,475 | 4,217.02 | 13,464,945 | 5.7 | % | 723,470 | ||||||||||||||||||||
East
Central
|
Composite
with
Delivery
|
758,179 | $ | 215.42 | $ | 163,329,303 | $ | 226.74 | $ | 171,911,065 | 5.3 | % | $ | 8,581,762 | |||||||||||||||
Northeast
|
HF/HST
<l M+F
|
81,194 | $ | 537.65 | $ | 43,653,685 | $ | 564.33 | $ | 45,819,928 | 5.0 | % | $ | 2,166,243 | |||||||||||||||
Northeast
|
HF/HST
1 M+F
|
65,469 | 138.65 | 9,077,208 | 145.58 | 9,530,904 | 5.0 | % | 453,697 | ||||||||||||||||||||
Northeast
|
HF/HST
2-13 M+F
|
580,015 | 93.78 | 54,393,760 | 97.58 | 56,597,815 | 4.1 | % | 2,204,055 | ||||||||||||||||||||
Northeast
|
HF/HST
14-18 F
|
90,422 | 156.32 | 14,134,689 | 162.70 |
14,711,578
|
4.1 | % | 576,889 | ||||||||||||||||||||
Northeast
|
HF/HST
14-18 M
|
82,194 | 112.18 | 9,220,523 | 116.25 | 9,555,053 | 3.6 | % | 334,530 | ||||||||||||||||||||
Northeast
|
HF
19-44 F
|
280,510 | 287.97 | 80,778,321 | 304.84 | 85,510,516 | 5.9 | % | 4,732,195 | ||||||||||||||||||||
Northeast
|
HF 19-44
M
|
59,915 | 188.08 | 11,268,813 | 200.14 | 11,991,388 | 6.4 | % | 722,575 | ||||||||||||||||||||
Northeast
|
HF
45+ M+F
|
39,374 | 459.68 | 18,099,440 | 481.47 | 18,957,400 | 4.7 | % | 857,959 | ||||||||||||||||||||
Northeast
|
HST
19-64 F
|
25,467 | 356.04 | 9,067,271 | 379.76 | 9,671,348 | 6.7 | %. | 604,077 | ||||||||||||||||||||
Northeast
|
Composite
Non-Delivery
|
1,304,558 | 191.40 | 249,693,709 | 201.10 | 262,345,929• | 5.1 | % | 12,652,220 | ||||||||||||||||||||
Northeast
|
Delivery
CFC
|
4,936 | 4,105.75 | 20,263,929 | 4,343.69 | 21,438,282 | 5.8 | %. | 1,174,353 | ||||||||||||||||||||
Northeast
|
Composite
with Delivery
|
1,304,558 | $ | 206.93 | $ | 269,957,638 | $ | 217.53 | $ | 283,784,211 | 5.1 | % | $ | 13,826,573 | |||||||||||||||
Northeast
Central
|
HF/HST
<1 M+F
|
21,399 | $ | 580.71 | $ | 12,426,613 | $ | 610.12 | $ | 13,055,958 | 5.1 | % | $ | 629,345 | |||||||||||||||
Northeast
Central
|
HF/HST
1 M+F
|
16,275 | 149.76 | 2,437,344 | 157.39 | 2,561,522 | 5.1 | % | 124,178 | ||||||||||||||||||||
Northeast
Central
|
HF/HST
2-13 M+F
|
153,239 | 101.29 | 15,521,528 | 105.49 | 16,165,129 | 4.1 | % | 643,602 | ||||||||||||||||||||
Northeast
Central
|
HF/HST
14-18
F
|
23,927 | 168.84 | 4,039,750 | 175.90 | 4,208,671 | 4.2 | % | 168,921 | ||||||||||||||||||||
Northeast
Central
|
HF/HST
14-18 M
|
22,188 | 121.16 | 2,688,298 | 125.70 | 2,789,032 | 3.7 | %, | 100,734 | ||||||||||||||||||||
Northeast
Central
|
HF
19-44 F
|
72,662 | 311.04 | 22,600,633 | 329.58 | 23,947,777 | 6.0 | % | 1,347,144 | ||||||||||||||||||||
Northeast
Central
|
HF
19-44
M
|
20,846 | 203.14 | 4,234,656 | 216.39 | 4,510,866 | 6.5 | % | 276,210 | ||||||||||||||||||||
Northeast
Central
|
HF
45+ M+F
|
9,292 | 496.49 | 4,613,137 | 520.55 | 4,836,690 | 4.8 | % | 223,553 | ||||||||||||||||||||
Northeast
Central
|
HST
19-64 F
|
7,043 | 384.55 | 2,708,193 | 410.58 | 2,891,510 | 6.8 | % | 183,316 | ||||||||||||||||||||
Northeast
Central
|
Composite Non-Delivery
|
346,869 | 205.47 | 71,270,153 | 216.13 | 74,967,156 | 5.2 | % | 3,697,003 | ||||||||||||||||||||
Northeast
Central
|
Delivery
CFC
|
1,342 | 4,113.88 | 5,518,770 | 4,351.17 | 5,837,095 | 5.8 | % | 318,325 | ||||||||||||||||||||
Northeast
Central
|
Composite
with Delivery
|
346,869 | $ | 221.38 |
$
76,788,923
|
$ | 232.95 | $ | 80,804,250 | 5.2 | % | $ | 4,015,327 | ||||||||||||||||
Northwest
|
HF/HST
<1 M+F
|
51,535 | $ | 565.81 | $ | 29,159,018 | $ | 595.46 | $ | 30,687,031 | 5.2 | % | $ | 1,528,013 | |||||||||||||||
Northwest
|
HF/HST
1 M+F
|
38,387 | 145.91 | 5,600,974 | 153.61 | 5,896,550 | 5.3 | % | 295,576 | ||||||||||||||||||||
Northwest
|
HF/HST 2-13
M+F
|
313,927 | 98.69 | 30,981,456 | 102.96 | 32,321,924 | 4.3 | % | 1,340,468 | ||||||||||||||||||||
Northwest
|
HF/HST
14-18 F
|
45,514 | 164.51 | 7,487,508 | 171.68 | 7,813,844 | 4.4 | % | 326,335 | ||||||||||||||||||||
Northwest
|
HF/HST
14-18
M
|
41,124 | 118.04 | 4,854,218 | 122.68 | 5,045,031 | 3.9 | % | 190,813 | ||||||||||||||||||||
Northwest
|
HF
19-44
F
|
145,022 | 303.05 | 43,948,917 | 321.64 | 46,644,876 | 6.1 | % | 2,695,959 | ||||||||||||||||||||
Northwest
|
HF
19-44 M
|
44,005 | 197.94 | 8,710,350 | 211.19 | 9,293,416 | 6.7 | % | 583,066 | ||||||||||||||||||||
Northwest
|
HF
45+ M+F
|
16,482 | 483.76 | 7,973,090 | 508.04 | 8,373,261 | 5.0 | % | 400,171 | ||||||||||||||||||||
Xxxxxxxxx
|
XXX
00-00
F
|
18,071 | 374.69 | 6,771,023 | 400.72 | 7,241,411 | 6.9 | % | 470,388 | ||||||||||||||||||||
Northwest
|
Composite
Non-Delivery
|
714.066 | 203.74 | 145,486,555 | 214.71 | 153,317,344 | 5.4 | % | 7,830,790 | ||||||||||||||||||||
Northwest
|
Delivery*
CFC
|
3,040 | 3,768.39 | 3,981.10 | 12,102,544 | 5.6 | % | 646,638 | |||||||||||||||||||||
Northwest
|
Composite
with Delivery
|
714,066 | $ | 219.79 | $ | 156,942,460 | $ | 231.66 | $ | 165,419,888 | 5.4 | % | $ | 8,477,428 |
0
Xxxxxxxx
X
Covered
Families and Children (CFC) population
State of Ohio
Department of Job
and Family Services
Capitation
Rate Comparison - CFC
Region
|
Rate
Group
|
Projected
Jul-Dec 2008
MMs/Deliveries
|
Jan
- Jun
2008
Cap
Rate
|
Jan-Jun
2008
Expenditures
|
Jul
– Dec 2008
Cap
Rate
|
Jul
- Dec 2008
Expenditures
|
%
Change
|
$
Change
|
|||||||||||||||||||||
Southeast
|
HF/HST <l M+F
|
27,057 | $ | 575.04 | $ | 15,558,570 | $ | 604.37 | $ | 16,352,137 | 5.1 | % | $ | 793,567 | |||||||||||||||
Southeast
|
HF/HST
1 M+F
|
22,178 | 148.29 | 3,288,701 | 155.90 | 3,457,472 | 5.1 | % | 168,771 | ||||||||||||||||||||
Southeast
|
HF/HST 2-13 M+F
|
202,856 | 100.30 | 20,346,407 | 104.51 | 21,200,428 | 4.2 | % | 854,022 | ||||||||||||||||||||
Southeast
|
HF/HST
14-18
F
|
30,272 | 167.19 | 5,061,176 | 174.25 | 5,274,896 | 4.2 | % | 213,720 | ||||||||||||||||||||
Southeast
|
HF/HST
14-18 M
|
28,111 | 119.98 | 3,372,698 | 124.52 | 3,500,319 | 3.8 | % | 127.622 | ||||||||||||||||||||
Southeast
|
HF
19-44
F
|
102,587 | 308.00 | 31,596,796 | 326.47 | 33,491,578 | 6.0 | % | 1,894,782 | ||||||||||||||||||||
Southeast
|
HF 19-44
M
|
45,156 | 201.16 | 9,083,581 | 214.34 | 9,678,737 | 6.6 | % | 595,156 | ||||||||||||||||||||
Southeast
|
HF
45+ M+F
|
13,518 | 491.63 | 6,645,854 | 515.65 | 6,970,557 | 4.9 | % | 324.702 | ||||||||||||||||||||
Xxxxxxxxx
|
XXX
00-00 F
|
9,472 | 380.81 | 3,606,842 | 406.72 | 3,852,248 | 6.8 | % | 245,407 | ||||||||||||||||||||
Southeast
|
Composite
Non-Delivery
|
481,205 | 204.82 | 98,560,625 | 215.66 | 103,778,373 | 5.3 | % | 5,217,748 | ||||||||||||||||||||
Southeast
|
Delivery
CFC
|
1,764 | 3,557.15 | 6,274,813 | 3,765.08 | 6,641,601 | 5.8 | % | 366,789 | ||||||||||||||||||||
Southeast
|
Composite
with Delivery
|
481,205 | $ | 217.86 | $ | 104,835,437 | $ | 229.47 | $ | 110,419,974 | 5.3 | % | $ | 5,584,537 | |||||||||||||||
Southwest
|
HF/HST <1
M+F
|
68,146 | $ | 606.96 | $ | 41,361,896 | $ | 635.17 | $ | 43,284,295 | 4.6 | % | $ | 1,922,399 | |||||||||||||||
Southwest
|
HF/HST 1
M+F
|
49,201 | 156.52 | 7,700,862 | 163.85 | 8,061,502 | 4.7 | % | 360,640 | ||||||||||||||||||||
Southwest
|
HF/HST 2-13
M+F
|
380,559 | 105.87 | 40,289,781 | 109.84 | 41,800,601 | 3.7 | % | 1,510,819 | ||||||||||||||||||||
Southwest
|
HF/HST
14-18 F
|
51,497 | 176.47 | 9,087,676 | 183.12 | 9,430,131 | 3.8 | % | 342.455 | ||||||||||||||||||||
Southwest
|
HF/HST
14-18
M
|
44,200 | 126.64 | 5,597,488 | 130.86 | 5,784,012 | 3.3 | % | 186,524 | ||||||||||||||||||||
Southwest
|
HF 19-44 F
|
160,588 | 325.09 | 52,205,553 | 343.11 | 55,099,349 | 5.5 | % | 2,893,796 | ||||||||||||||||||||
Southwest
|
HF
19-44 M
|
42,270 | 212.34 | 8,975,612 | 225.27 | 9,522,163 | 6.1 | % | 546,551 | ||||||||||||||||||||
Southwest
|
HF
45+ M+F
|
17,095 | 518.94 | 8,871,020 | 541.93 | 9,264,022 | 4.4 | % | 393,003 | ||||||||||||||||||||
Xxxxxxxxx
|
XXX
00-00
F
|
21,442 | 401.95 | 8,618,612 | 427.44 | 9,165,168 | 6.3 | % | 546,557 | ||||||||||||||||||||
Southwest
|
Composite
Non-Delivery
|
834,997 | 218.81 | 182,708,500 | 229.24 | 191,411,242 | 4.8 | % | 8,702,743 | ||||||||||||||||||||
Southwest
|
Delivery
CFC
|
3,675 | 4,011.88 | 14,743,659 | 4,242.15 | 15,589,901 | 5.7 | % | 846,242 | ||||||||||||||||||||
Southwest
|
Composite
with Delivery
|
834,997 | $ | 236.47 | $ | 197,452,159 | $ | 247.91 | $ | 207,001,144 | 4.8 | % | $ | 9,548,985 | |||||||||||||||
West
Central
|
HF/HST <1 M+F
|
44,127 | $ | 572.54 | $ | 25,264,473 | $ | 602.37 | $ | 26,580,781 | 5.2 | % | $ | 1,316,308 | |||||||||||||||
West
Central
|
HF/HST
1 M+F
|
32,928 | 147.65 | 4,861,819 | 155.40 | 5,117,011 | 5.2 | % | 255,192 | ||||||||||||||||||||
West
Central
|
HF/HST
2-13 M+F
|
264,267 | 99.86 | 26,389,703 | 104.16 | 27,526,051 | 4.3 | % | 1,136,348 | ||||||||||||||||||||
West.
Central
|
HF/HST
14-18
F
|
38,572 | 166.47 | 6,420,998 | 173.67 | 6,698,712 | 4.3 | % | 277,715 | ||||||||||||||||||||
West
Central
|
HF/HST
14-18
M
|
33,698 | 119.46 | 4,025,503 | 124.11 | 4,182,197 | 3.9 | % | 156,693 | ||||||||||||||||||||
West
Central
|
HF
19-44 F
|
117,439 | 306.66 | 36,013,844 | 325.39 | 38,213,476 | 6.1 | % | 2,199,632 | ||||||||||||||||||||
West
Central
|
HF
19-44 M
|
33,241 | 200.29 | 6,657,840 | 213.64 | 7,101,607 | 6.7 | % | 443,767 | ||||||||||||||||||||
West
Central
|
HF
45+ M+F
|
13,516 | 489.51 | 6,616,217 | 513.95 | 6,946,548 | 5.0 | % | 330,331 | ||||||||||||||||||||
West
Central
|
HST
19-64 F
|
13,711 | 379.15 | 5,198,526 | 405.37 | 5,558,028 | 6.9 | % | 359,502 | ||||||||||||||||||||
West
Central
|
Composite
Non-Delivery
|
591,498 | 205.32 | 121,448,922 | 216.27 | 127,924,412 | 5.3 | % | 6,475,490 | ||||||||||||||||||||
West
Central
|
Delivery
CFC
|
2,458 | 4,342,68 | 10,674,307 | 4,589.24 | 11,280,352 | 5.7 | % | 606,044 | ||||||||||||||||||||
West
Central
|
Composite
with Delivery
|
591,498 | $ | 223.37 | $ | 132,123,229 | $ | 235.34 | $ | 139,204,764 | 5.4 | % | $ | 7,081,534 | |||||||||||||||
Statewide
|
HF/HST
<l M+F
|
445,688 | $ | 568.11 | $ | 253,199,638 | $ | 596.61 | $ | 265,901,895 | 5.0 | % | $ | 12,702,257 | |||||||||||||||
Statewide
|
HF/HST
1
M+F
|
341,402 | 146.35 | 49,965,476 | 153.76 | 52,492,435 | 5.1 | % | 2,526,959 | ||||||||||||||||||||
Statewide
|
HF/HST
2-13 M+F
|
2,842,984 | 98.86 | 281,050,992 | 102.93 | 292,625,909 | 4.1 | % | 11,574,918 | ||||||||||||||||||||
Statewide
|
HF/HST
14-18 F
|
410,043 | 164.57 | 67,480,948 | 171.39 | 70,277,281 | 4.1 | % | 2,796,333 | ||||||||||||||||||||
Statewide
|
HF/HST
14-18 M
|
369,099 | 118.03 | 43,566,019 | 122.41 | 45,181,768 | 3.7 | % | 1,615,750 | ||||||||||||||||||||
Statewide
|
HF
19-44 F
|
1,314,417 | 303.16 | 398,481,449 | 321.12 | 422,082,259 | 5.9 | % | 23,600,810 | ||||||||||||||||||||
Statewide
|
HF
19-44 M
|
374,977 | 198.55 | 74,451,778 | 211.44 | 79,283,446 | 6.5 | % | 4,831,668 | ||||||||||||||||||||
Statewide
|
HF
45+ M+F
|
161,762 | 482.65 | 78,074,142 | 505.86 | 81,829,027 | 4.8 | % | 3,754,885 | ||||||||||||||||||||
Statewide
|
HST
19-64
F
|
143,006 | 376.18 | 53,795,962 | 401.47 | 57,412,182 | 6.7 | % | 3,616,221 | ||||||||||||||||||||
Statewide
|
Composite
Non-
Delivery
|
6,403,375 | 203.03 | 1,300,066,404 | 213.49 | 1,367.086,203 | 5.2 | % | 67,019,799 | ||||||||||||||||||||
Statewide
|
Delivery
CFC
|
25,834 | 3,950.11 | 102,047,228 | 4,176.57 | 107,897,630 | 5.7 | % | 5,850,403 | ||||||||||||||||||||
Statewide
|
Composite
with Delivery
|
6,403,375 | $ | 218.96 | $ | 1,402,113,632 | $ | 230.34 | $ | 1,474,983,833 | 5.2 | % | $ | 72,870,202 |
00
Xxxxxxxx
X
Covered
Families and Children (CFC) population
ENCLOSURE
2
STATE
OF OHIO
DEPARTMENT
OF JOB AND FAMILY SERVICES
Covered
Families and Children
Capitation
Rates July 1, 2008 to December
1, 2008
Actuarial
Certification
I,
Xxxxxx X.
Xxxxxx, am a
Principal and Consulting
Actuary with the firm of Xxxxxxxx, Inc. I am a
Fellow of the Society of Actuaries and a Member of the American Academy of
Actuaries. 1 was retained by the State of Ohio, Department of Job and Family
Services to perform an actuarial review and certification regarding the
development of the capitation rates to be effective from July 1, 2008 to
December 31, 2008. The capitation rates were developed for the Covered Families
and Children managed care eligible populations. I have experience in the
examination of financial calculations for Medicaid programs and meet the
qualification standards for rendering this opinion.
I
reviewed the historical claims
experience for reasonableness and consistency. I have developed certain
actuarial assumptions and actuarial methodologies regarding the projection of
healthcare expenditures into future periods. I have complied
with the elements of the rate setting checklist CM.S developed for its Regional
Offices regarding 42 CFR 438.6(c) for capitated Medicaid managed care
plans.
The
capitation rates provided with this certification are effective for a six month
rating period beginning July 1, 2008 through December 31, 2008. The
capitation rates associated with this certification were previously certified by
Xxxxxxxx and approved by CMS for the period of Jan 1, 2008 through Dec 31, 2008.
This certification reflects modifications to the rates for policy and program
changes. At the end of the six month period, the capitation rates will be
updated for calendar year 2009. The update may be based on fee-for-service
experience, managed care utilization and trend experience, policy and procedure
changes, and other changes in the health care market. A separate certification
will be provided with the updated rates.
The
capitation rates provided with this certification are considered actuarially
sound, defined as: the capitation rates have been developed in
accordance with generally accepted actuarial principles and
practices;
the capitation rates are appropriate for the populations to be covered, and the
services to be furnished under the contract; and, the capitation rates meet the
requirements of 42 CFR 438.6(c).
This
actuarial certification has been based on the actuarial methods, considerations,
and analyses promulgated from time to time through the Actuarial Standards of
Practice by the Actuarial Standards Board.
/s/ Xxxxxx
Xxxxxx
Xxxxxx
X. Xxxxxx,
FSA
Member,
American Academy of Actuaries
June
5, 2008
Date
Xxxxxxxx
makes
no representations or warranties regarding the contents of this letter to
third parties.
Likewise,
third parties are instructed that they are to place no reliance upon
this letter prepared for ODJFS by Xxxxxxxx that would result in the creation of
any duty or liability under any theory of law
by Xxxxxxxx or its employees
to third parties. Other parties receiving this letter must rely upon their own
experts in drawing conclusions about the capitation rates,
assumptions,
and trends.
12
Appendix
F
Covered
Families and Children (CFC) population
APPENDIX
F
|
|||||||||||||||||||||||||||||||||||||||||
REGIONAL
RATES
|
|||||||||||||||||||||||||||||||||||||||||
1. PREMIUM
RATES WITHOUT THE AT-RISK PAYMENT AMOUNTS FOR 07/01/08 THROUGH
11/30/08 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
|
REGIONAL
|
HF/HST
|
HF/HST
|
HF/HST
|
HF/HST
|
HF/HST
|
HF
|
HF
|
HF
|
HST
|
Delivery
|
||||||||||||||||||||||||||||||
ENROLLMENT
|
STATUS
|
Age
< 1
|
Age
1
|
Age
2-13
|
Age
14-18
|
Age
14-18
|
Age
19-44
|
Age
19-44
|
Age
45
|
Age
19-64
|
Payment
|
||||||||||||||||||||||||||||||
AREA
|
Male
|
Female
|
Male
|
Female
|
and
over
|
Female
|
|||||||||||||||||||||||||||||||||||
Northeast
|
Mandatory
|
$ | 564.33 | $ | 145.58 | $ | 97.58 | $ | 116.25 | $ | 162.70 | $ | 200.14 | $ | 304.84 | $ | 481.47 | $ | 379.76 | $ | 4,343.69 | ||||||||||||||||||||
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.
|
1
Appendix
F
Covered
Families and Children (CFC) population
APPENDIX
F
|
|||||||||||||||||||||||||||||||||||||||||
REGIONAL
RATES
|
|||||||||||||||||||||||||||||||||||||||||
2. AT-RISK
AMOUNTS FOR 07/01/08 THROUGH 11/30/08 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
|
REGIONAL
|
HF/HST
|
HF/HST
|
HF/HST
|
HF/HST
|
HF/HST
|
HF
|
HF
|
HF
|
HST
|
Delivery
|
||||||||||||||||||||||||||||||
ENROLLMENT
|
STATUS
|
Age
< 1
|
Age
1
|
Age
2-13
|
Age
14-18
|
Age
14-18
|
Age
19-44
|
Age
19-44
|
Age
45
|
Age
19-64
|
Payment
|
||||||||||||||||||||||||||||||
AREA
|
Male
|
Female
|
Male
|
Female
|
and
over
|
Female
|
|||||||||||||||||||||||||||||||||||
Northeast
|
Mandatory
|
$ | 0.00 | $ | 0.00 | $ | 0.00 | $ | 0.00 | $ | 0.00 | $ | 0.00 | $ | 0.00 | $ | 0.00 | $ | 0.00 | $ | 0.00 | ||||||||||||||||||||
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.
2
Appendix
F
Covered
Families and Children (CFC) population
APPENDIX
F
|
|||||||||||||||||||||||||||||||||||||||||
REGIONAL
RATES
|
|||||||||||||||||||||||||||||||||||||||||
3. PREMIUM
RATES FOR 07/01/08 THROUGH 11/30/08 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
|
REGIONAL
|
HF/HST
|
HF/HST
|
HF/HST
|
HF/HST
|
HF/HST
|
HF
|
HF
|
HF
|
HST
|
Delivery
|
||||||||||||||||||||||||||||||
ENROLLMENT
|
STATUS
|
Age
< 1
|
Age
1
|
Age
2-13
|
Age
14-18
|
Age
14-18
|
Age
19-44
|
Age
19-44
|
Age
45
|
Age
19-64
|
Payment
|
||||||||||||||||||||||||||||||
AREA
|
Male
|
Female
|
Male
|
Female
|
and
over
|
Female
|
|||||||||||||||||||||||||||||||||||
Northeast
|
Mandatory
|
$ | 564.33 | $ | 145.58 | $ | 97.58 | $ | 116.25 | $ | 162.70 | $ | 200.14 | $ | 304.84 | $ | 481.47 | $ | 379.76 | $ | 4,343.69 | ||||||||||||||||||||
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.
|
3
Appendix
F
Covered
Families and Children (CFC) population
APPENDIX
F
|
|||||||||||||||||||||||||||||||||||||||||
REGIONAL
RATES
|
|||||||||||||||||||||||||||||||||||||||||
1. PREMIUM
RATES WITHOUT THE AT-RISK PAYMENT AMOUNTS FOR 12/01/08 THROUGH
12/31/08 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
|
REGIONAL
|
HF/HST
|
HF/HST
|
HF/HST
|
HF/HST
|
HF/HST
|
HF
|
HF
|
HF
|
HST
|
Delivery
|
||||||||||||||||||||||||||||||
ENROLLMENT
|
STATUS
|
Age
< 1
|
Age
1
|
Age
2-13
|
Age
14-18
|
Age
14-18
|
Age
19-44
|
Age
19-44
|
Age
45
|
Age
19-64
|
Payment
|
||||||||||||||||||||||||||||||
AREA
|
Male
|
Female
|
Male
|
Female
|
and
over
|
Female
|
|||||||||||||||||||||||||||||||||||
Northeast
|
Mandatory
|
$ | 559.00 | $ | 144.20 | $ | 96.66 | $ | 115.15 | $ | 161.16 | $ | 198.25 | $ | 301.96 | $ | 476.92 | $ | 376.17 | $ | 4,302.64 | ||||||||||||||||||||
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
|
4
Appendix
F
Covered
Families and Children (CFC) population
APPENDIX
F
|
|||||||||||||||||||||||||||||||||||||||||
REGIONAL
RATES
|
|||||||||||||||||||||||||||||||||||||||||
2. AT-RISK
AMOUNTS FOR 12/01/08 THROUGH 12/31/08 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
|
REGIONAL
|
HF/HST
|
HF/HST
|
HF/HST
|
HF/HST
|
HF/HST
|
HF
|
HF
|
HF
|
HST
|
Delivery
|
||||||||||||||||||||||||||||||
ENROLLMENT
|
STATUS
|
Age
< 1
|
Age
1
|
Age
2-13
|
Age
14-18
|
Age
14-18
|
Age
19-44
|
Age
19-44
|
Age
45
|
Age
19-64
|
Payment
|
||||||||||||||||||||||||||||||
AREA
|
Male
|
Female
|
Male
|
Female
|
and
over
|
Female
|
|||||||||||||||||||||||||||||||||||
Northeast
|
Mandatory
|
$ | 5.33 | $ | 1.38 | $ | 0.92 | $ | 1.10 | $ | 1.54 | $ | 1.89 | $ | 2.88 | $ | 4.55 | $ | 3.59 | $ | 41.05 | ||||||||||||||||||||
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.
|
5
Appendix
F
Covered
Families and Children (CFC) population
APPENDIX
F
|
|||||||||||||||||||||||||||||||||||||||||
REGIONAL
RATES
|
|||||||||||||||||||||||||||||||||||||||||
3. PREMIUM
RATES FOR 12/01/08 THROUGH 12/31/08 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
|
REGIONAL
|
HF/HST
|
HF/HST
|
HF/HST
|
HF/HST
|
HF/HST
|
HF
|
HF
|
HF
|
HST
|
Delivery
|
||||||||||||||||||||||||||||||
ENROLLMENT
|
STATUS
|
Age
< 1
|
Age
1
|
Age
2-13
|
Age
14-18
|
Age
14-18
|
Age
19-44
|
Age
19-44
|
Age
45
|
Age
19-64
|
Payment
|
||||||||||||||||||||||||||||||
AREA
|
Male
|
Female
|
Male
|
Female
|
and
over
|
Female
|
|||||||||||||||||||||||||||||||||||
Northeast
|
Mandatory
|
$ | 564.33 | $ | 145.58 | $ | 97.58 | $ | 116.25 | $ | 162.70 | $ | 200.14 | $ | 304.84 | $ | 481.47 | $ | 379.76 | $ | 4,343.69 | ||||||||||||||||||||
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.
|
6
Appendix
G
Covered
Families and Children (CFC)
population
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. 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
|
1
Appendix
G
Covered
Families and Children (CFC)
population
|
·
|
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. 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
|
|
·
|
Organ
transplants that are 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*
|
|
·
|
Immunizations
for travel outside of the United
States
|
|
·
|
Services
for the treatment of obesity unless medically
necessary*
|
· Custodial
or supportive care not covered by Medicaid
|
·
|
Sex
change surgery and related services
|
2
Appendix
G
Covered
Families and Children (CFC)
population
|
·
|
Sexual
or marriage counseling
|
|
·
|
Acupuncture
and biofeedback services
|
|
·
|
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.
3
Appendix
G
Covered
Families and Children (CFC)
population
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.
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.
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.
4
Appendix
G
Covered
Families and Children (CFC)
population
Mental Health
Services: There are a number of Medicaid-covered mental health
(MH) services available through ODMH CMHCs.
Where an
MCP is responsible for providing MH services for their members, the MCP is
responsible for ensuring access to counseling and 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)(substance abuse) 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.
|
5
Appendix
G
Covered
Families and Children (CFC)
population
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:
|
|
·
|
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.
|
|
·
|
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.
|
|
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. |
6
Appendix
G
Covered
Families and Children (CFC)
population
3.
|
Care
Coordination
|
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.
7
Appendix
G
Covered
Families and Children (CFC)
population
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.
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.
|
8
Appendix
G
Covered
Families and Children (CFC)
population
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 who require
high-cost and/or extensive services. The MCP’s care management
program must also include a Children with Special Health Care Needs component as
specified below.
|
i.
|
Each
MCP must inform all members and contracting providers of the MCP’s care
management services.
|
|
ii.
|
Children
with Special Health Care Needs
(CSHCN):
|
CSHCN are
a particularly vulnerable population which often have chronic and complex
medical health care conditions. In order to ensure
compliance with the provisions of 42 CFR 438.208, each MCP must establish a
CSHCN component as part of the MCP’s care management program. The MCP
must establish a process for the timely identification, completion of a
comprehensive health assessment, and providing appropriate care management
services for any CSHCN.
CSHCN are defined as children age 17 and under who are pregnant, and members
under 21 years of age with one or more of the following:
-Asthma
-HIV/AIDS
-A
chronic physical, emotional or mental condition for which they are receiving
treatment or counseling
-Supplemental
security income (SSI) for a health-related condition
-A
current letter of approval from the Bureau of Children with Medical Handicaps
(BCMH), Ohio Department of Health
9
Appendix
G
Covered
Families and Children (CFC)
population
|
iii.
|
Care Management
Program
|
|
1.
|
The
MCP must have a process to inform members and their PCPs in writing that
they have been identified as meeting the criteria for care management,
including their enrollment into a care management
program.
|
|
2.
|
The
MCP must assure and coordinate the placement of the member into care
management – including identification of the member’s need for care
management services, completion of the comprehensive health assessment,
and timely development of a care treatment plan. This process
must occur within the following timeframes
for:
|
a) newly enrolled members, 90 days
from the effective date of enrollment; and
b) existing members, 90 days from
identifying their need for care
management.
|
3.
|
The
MCP’s care management program must include, at a minimum, the following
components:
|
a.
|
Identification
|
The MCP
must have a variety of mechanisms in place to identify members potentially
eligible for care management. These mechanisms must include an
administrative data review (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, or home
visits.
|
b.
|
Assessment
|
|
The
MCP must arrange for or conduct an initial comprehensive health assessment
to confirm the results of a positive identification, and determine the
need for care management services.
|
The
comprehensive health assessment must evaluate the member’s medical condition(s),
including physical, behavioral, social, and psychological
needs. The comprehensive 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.
10
Appendix
G
Covered
Families and Children (CFC)
population
The
assessment 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 develop a strategy to assign members to risk stratification levels, based
on the member’s comprehensive health assessment.
c.
|
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 comprehensive health assessment, and reflect the member’s
medical condition(s), including physical, behavioral, social, and psychological
needs, as well as co-morbidities. 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 comprehensive health
assessment and the care treatment plan. At a minimum,
there must be verbal/written contact with the member once every six (6)
months. The MCP must ensure there is a provision for two-way
communication or feedback with the MCP.
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:
Goals and
actions that address health care conditions identified in the comprehensive
health assessment;
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 comprehensive health
assessment;
11
Appendix
G
Covered
Families and Children (CFC)
population
Continuous
review, revision and contact follow-up, as needed,to insure the care treatment
plan is adequately monitored including the following:
|
·
|
Documentation
that services are provided in accordance with the care treatment
plan;
|
|
·
|
Re-evaluation
to determine if the care treatment plan is adequate to meet the member's
health care needs;
|
|
·
|
Identification
of gaps between recommended care and actual care
provided;
|
|
·
|
A
change in needs or status from the re-evaluation that requires revisions
to the care treatment plan; and
|
|
·
|
Re-evaluation
of a member's risk level with adjustment to the level of care management
services provided.
|
4.
Coordination of Care
and Communication
The MCP
must provide care management services for:
|
·
|
all
CSHCN, including the ODJFS mandated conditions as specified in Appendix M,
Care Management Program Performance
Measures;
|
|
·
|
all
members enrolled in an MCP’s CSMM program as specified in Section
G(3)(a)(i); and
|
· adults
whose health conditions warrant care management services.
Care
management services should not be limited only to members with the mandated
conditions.
There
should be an accountable point of contact (i.e., case manager) who can help
obtain medically necessary care, assist with health-related services and
coordinate care needs. 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. At a minimum, 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 communication between service providers, the member, and the member’s
family. 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.
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.
The MCP
must follow best-practice and/or evidence based clinical guidelines when
developing a member’s 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.
The MCP
must identify the staff that will be involved in the operations of the care
management program, including but not limited 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.
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 Xxxxxxxxxxxxxx.Xx order for a member to be submitted as
care managed in CAMS, the MCP must (1) complete the identification process, a
comprehensive health assessment and development of a care
treatment plan for the member; and (2) document the member’s written or verbal
confirmation of his/her care management status in the care management
record. 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.
13
Appendix
G
Covered
Families and Children (CFC)
population
The CAMS
files are due the 15th
calendar day of each month.
|
The
MCP must also have an ODJFS-approved care management program which
includes the items in Section 3.b.. Each MCP should implement
an evaluation process to review, revise and/or update the care management
program. The MCP must annually submit its care management
program for review and approval by ODJFS. Any subsequent changes to an
approved care management program description must be submitted to ODJFS in
writing for review and approval prior to
implementation.
|
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;
|
14
Appendix
G
Covered
Families and Children (CFC)
population
|
·
|
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);
|
|
·
|
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. |
15
Appendix
H
Covered
Families and Children (CFC)
population
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.
1
Appendix
H
Covered
Families and Children (CFC)
population
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 Provider Verification System (PVS) or other designated
process. The PVS 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.
2
Appendix
H
Covered
Families and Children (CFC)
population
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 PVS 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).]
3
Appendix
H
Covered
Families and Children (CFC)
population
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.).
4
Appendix
H
Covered
Families and Children (CFC)
population
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 PVS, 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 PVS, 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.
5
Appendix
H
Covered
Families and Children (CFC)
population
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 PVS 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.
6
Appendix
H
Covered
Families and Children (CFC)
population
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, andorthopedists) - 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 PVS,
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.
7
Appendix
H
Covered
Families and Children (CFC)
population
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 PVS, 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.
|
8
Appendix
H
Covered
Families and Children (CFC)
population
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.
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.
9
Appendix
H
Covered
Families and Children (CFC)
population
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.
|
•
|
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.
10
North East Region -
Hospitals
|
Minimum
Provider Panel Requirements
|
||||||||||
Total
Required Hospitals
|
Ashtabula
|
Cuyahoga
|
Erie
|
Geauga
|
Huron
|
Lake
|
Xxxxxx
|
Xxxxxx
|
Additional
Required Hospitals: Out-of-Region
|
|
General
Hospital1
|
8
2
|
1
|
1
2
|
1
|
1
|
1
|
1
|
1
|
1
|
|
Hospital
System
|
1
|
1
|
1 These
hospitals must provide obstetrical services if such a hospital is
available in the county/region.
|
||||||||||||||
2
The Cuyahoga hospital requirement may be met by either contracting
with (1) a single
hospital system that includes fifty (50) pediatric beds and five (5)
pediatric intensive care unit (PICU) beds OR (2) a single general hospital
that includes fifty (50) pediatric beds and five (5) pediatric intensive
care unit (PICU) beds and a hospital
system.
|
Minimum
Provider Panel Requirements
|
|||||
Total
Required Hospitals
|
Columbiana
|
Mahoning
|
Trumbull
|
Additional
Required Hospitals: Out-of-Region
|
|
General
Hospital1
|
3
|
1
|
1 2
|
1
|
|
Hospital System
|
1 These
hospitals must provide obstetrical services if such a hospital is
available in the county/region, except where a hospital must meet the
criteria specified in footnote #4 below.
|
||||||
2 Must
be a hospital that includes thirty (30) pediatric beds and five
(5) pediatric intensive care unit (PICU) beds.
|
East Central Region -
Hospitals
Minimum
Provider Panel Requirements
|
|||||||||||
Total
Required Hospitals
|
Ashland
|
Xxxxxxx
|
Xxxxxx
|
Portage
|
Richland
|
Xxxxx
|
Summit
|
Tuscarawas
|
Xxxxx
|
Additional
Required Hospitals: Out-of-Region
|
|
General
Hospital1
|
8
|
1
|
1
|
1
|
1
|
1
|
1 2
|
1
|
1
|
||
Hospital
System
|
1
|
1
|
1 These
hospitals must provide obstetrical services if such a hospital is
available in the county/region, except where a hospital must
meet the criteria specified in footnote #4 below.
|
|||||||||||
2 Must
be a hospital that includes one hundred (100) pediatric beds and five (5)
pediatric intensive care unit (PICU) beds.
|
Minimum
Provider Panel Requirements
|
||||||||||||||||||
Total
Required Hospitals
|
Athens
|
Belmont
|
Coshocton
|
Gallia
|
Guernsey
|
Xxxxxxxx
|
Xxxxxxx
|
Jefferson
|
Xxxxxxxx
|
Xxxxx
|
Xxxxxx
|
Xxxxxx
|
Muskingum
|
Noble
|
Xxxxxx
|
Xxxxxxxxxx
|
Additional
Required Hospitals: Out-of-Region
|
|
General
Hospital1
|
11
|
1
|
1
|
1
|
1
|
1
|
1
|
1
|
1
|
Xxxxxx
AND King's
Daughter AND Children's Hospital
Columbus
|
||||||||
Hospital
System
|
1 These hospitals must provide obsetrical services if
such a hospital is available in the
county/region.
Central Region -
Hospitals
Minimum
Provider Panel Requirements
|
||||||||||||||||||||
Total
Required Hospitals
|
Xxxxxxxx
|
Delaware
|
Fairfield
|
Fayette
|
Xxxxxxxx
|
Xxxxxxx
|
Xxxx
|
Licking
|
Logan
|
Madison
|
Xxxxxx
|
Xxxxxx
|
Xxxxx
|
Pickaway
|
Xxxx
|
Xxxx
|
Scioto
|
Union
|
Additional
Required Hospitals: Out-of-Region
|
|
General
Hospital1
|
14
|
1
|
1
|
1
|
1 2
|
1
|
1
|
1
|
1
|
1
|
1
|
1
|
1
|
1
|
Genesis
Health Care System, Inc.
|
|||||
Hospital
System
|
2
|
2
|
1 These
hospitals must provide obstetrical services if such a hospital is
available in the county/region, except where a hospital must
meet the criteria specified in footnote #4 below.
|
||||||||||||||||||
2 Must
be a hospital that includes one hundred fifty (150) pediatric beds and
twenty-five (25) pediatric intensive care unit (PICU)
beds.
|
Minimum
Provider Panel Requirements
|
||||||||||
Total
Required Hospitals
|
Xxxxx
|
Xxxxx
|
Xxxxxx
|
Clermont
|
Xxxxxxx
|
Xxxxxxxx
|
Highland
|
Xxxxxx
|
Additional
Required Hospitals: Out-of-Region
|
|
General
Hospital1
|
6
|
1
|
1
|
1
|
1 2
|
1
|
Grandview
or Miami
Valley
|
|||
Hospital
System
|
2
|
2
|
1 These
hospitals must provide obstetrical services if such a hospital is
available in the county/region, except where a hospital must meet the
criteria specified in footnote #4 below.
|
|||||||||||
2 Must
be a hospital that includes two-hundred (200) pediatric beds
and thirty-five (35) pediatric intensive care unit (PICU)
beds.
|
Minimum
Provider Panel Requirements
|
||||||||||
Total
Required Hospitals
|
Champaign
|
Xxxxx
|
Xxxxx
|
Xxxxxx
|
Miami
|
Xxxxxxxxxx
|
Xxxxxx
|
Xxxxxx
|
Additional
Required Hospitals: Out-of-Region
|
|
General
Hospital1
|
6
|
1
|
1
|
1
|
1
|
1
2
|
1
|
|||
Hospital
System
|
1
|
1
|
1 These
hospitals must provide obsetrical services if such a hospital is available
in the county/region, except where a hospital must meet the criteria
specified in footnote #4 below.
|
||||||||||
2 Must
be a hospital that includes seventy-five (75) pediatric beds and ten
(10) pediatric intensive care unit (PICU) beds.
|
North West Region -
Hospitals
Minimum
Provider Panel Requirements
|
||||||||||||||||||||
Total
Required Hospitals
|
Xxxxx
|
Auglaize
|
Defiance
|
Xxxxxx
|
Xxxxxxx
|
Xxxxxx
|
Xxxxx
|
Xxxxx
|
Xxxxxx
|
Ottawa
|
Paulding
|
Xxxxxx
|
Sandusky
|
Seneca
|
Van
Xxxx
|
Xxxxxxxx
|
Xxxx
|
Wyandot
|
Additional
Required Hospitals: Out-of-Region
|
|
General
Hospital1
|
10
|
1
|
1
|
1
|
1
|
1
|
1
|
1
|
1
|
1
|
Bellevue
Hospital Association
|
|||||||||
Hospital
System
|
1
|
1 2
|
1 These
hospitals must provide obsetrical services if such a hospital is available
in the county/region.
|
||||||||||||||||||||
2 Must
be a hospital system that includes forty-five (45) pediatric beds and ten
(10) pediatric intensive care unit (PICU) beds.
|
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
|
53,000
|
26.50
|
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.
North
East Region - Practitioners
Minimum
Provider Panel Requirements
|
||||||||||
Provider
Types
|
Total
Required Providers1
|
Ashtabula
|
Cuyahoga
|
Erie
|
Geauga
|
Huron
|
Lake
|
Xxxxxx
|
Xxxxxx
|
Additional
Required Providers2
|
Pediatricians4
|
90
|
1
|
66
|
2
|
3
|
8
|
3
|
7
|
||
OB/GYNs
|
25
|
1
|
16
|
1
|
1
|
1
|
2
|
1
|
2
|
|
Vision
|
33
|
1
|
25
|
1
|
1
|
2
|
1
|
2
|
||
General
Surgeons
|
20
|
12
|
1
|
1
|
1
|
2
|
1
|
2
|
||
Otolaryngologist
|
6
|
2
|
1
|
3
|
||||||
Allergists
|
5
|
2
|
1
|
2
|
||||||
Orthopedists
|
16
|
8
|
1
|
1
|
2
|
1
|
3
|
|||
Dentists5
|
89
|
2
|
65
|
1
|
1
|
1
|
5
|
10
|
3
|
1
|
1
All required providers must be located within the
region.
|
2
Additional required providers may be located anywhere within the
region.
|
3
Preferred Providers are the additional provider contracts that must
be secured in order for the MCP to receive bonus
points.
|
4
Half of this number must be certified by the American Board of
Pediatrics.
|
5 No
more than two-thirds of this number can be pediatric
dentists.
|
Minimum
Provider Panel Requirements
|
|||||
Provider
Types
|
Total
Required Providers1
|
Columbiana
|
Mahoning
|
Trumbull
|
Additional
Required Providers2
|
Pediatricians4
|
23
|
2
|
10
|
6
|
5
|
OB/GYNs
|
7
|
1
|
3
|
2
|
1
|
Vision
|
7
|
3
|
2
|
2
|
|
General
Surgeons
|
6
|
1
|
3
|
1
|
1
|
Otolaryngologist
|
2
|
1
|
1
|
||
Allergists
|
1
|
1
|
|||
Orthopedists
|
4
|
2
|
1
|
1
|
|
Dentists5
|
23
|
2
|
11
|
8
|
2
|
1
All required providers must be located within the region.
|
|||||
2
Additional required providers may be located anywhere within the
region.
|
|||||
3
Preferred Providers are the additional provider contracts that must be
secured in order for the MCP to receive bonus points.
|
|||||
4
Half of this number must be certified by the American Board of
Pediatrics.
|
|||||
5 No
more than two-thirds of this number can be pediatric
dentists.
|
East
Central - Practitioners
Minimum
Provider Panel Requirements
|
||||||||||||
Provider
Types
|
Total
Required Providers1
|
Ashland
|
Xxxxxxx
|
Xxxxxx
|
Portage
|
Richland
|
Xxxxx
|
Summit
|
Tuscarawas
|
Xxxxx
|
Additional
Required
Providers2
|
|
Pediatricians4
|
00
|
0
|
0
|
0
|
#
|
#
|
0
|
2
|
5
|
|||
OB/GYNs
|
17
|
1
|
5
|
8
|
1
|
2
|
||||||
Vision
|
18
|
1
|
5
|
8
|
4
|
|||||||
General
Surgeons
|
13
|
1
|
2
|
3
|
4
|
1
|
1
|
1
|
||||
Otolaryngologist
|
7
|
2
|
2
|
3
|
||||||||
Allergists
|
3
|
1
|
1
|
1
|
||||||||
Orthopedists
|
9
|
1
|
2
|
2
|
1
|
3
|
||||||
Dentists5
|
48
|
2
|
3
|
5
|
13
|
17
|
3
|
3
|
2
|
|||
1
All required providers must be located within the region.
|
||||||||||||
2
Additional required providers may be located anywhere within the
region.
|
||||||||||||
3
Preferred Providers are the additional provider contracts that must be
secured in order for the MCP to receive bonus points.
|
||||||||||||
4
Half of this number must be certified by the American Board of
Pediatrics.
|
||||||||||||
5 No
more than two-thirds of this number can be pediatric
dentists.
|
South
East - Practitioners
Minimum
Provider Panel Requirements
|
||||||||||||||||||
Provider
Types
|
Total
Required Providers1
|
Athens
|
Belmont
|
Coshocton
|
Gallia
|
Guernsey
|
Xxxxxxxx
|
Xxxxxxx
|
Jefferson
|
Xxxxxxxx
|
Xxxxx
|
Xxxxxx
|
Xxxxxx
|
Muskingum
|
Noble
|
Xxxxxx
|
Xxxxxxxxxx
|
Additional
Required Providers2
|
Pediatricians4
|
31
|
1
|
1
|
2
|
1
|
1
|
2
|
1
|
22
|
|||||||||
OB/GYNs
|
9
|
1
|
1
|
1
|
1
|
1
|
4
|
|||||||||||
Vision
|
13
|
1
|
1
|
1
|
1
|
1
|
1
|
1
|
2
|
1
|
3
|
|||||||
General
Surgeons
|
8
|
1
|
1
|
1
|
1
|
1
|
1
|
2
|
||||||||||
Otolaryngolo-gist
|
3
|
1
|
1
|
1
|
||||||||||||||
Allergists
|
1
|
1
|
||||||||||||||||
Orthopedists
|
5
|
1
|
4
|
|||||||||||||||
Dentists5
|
30
|
2
|
3
|
1
|
1
|
3
|
1
|
3
|
2
|
3
|
2
|
9
|
||||||
1
All required providers must be located within the region.
|
||||||||||||||||||
2
Additional required providers may be located anywhere within the
region.
|
||||||||||||||||||
3
Preferred Providers are the additional provider contracts that must be
secured in order for the MCP to receive bonus points.
|
||||||||||||||||||
4
Half of this number must be certified by the American Board of
Pediatrics.
|
||||||||||||||||||
5 No
more than two-thirds of this number can be pediatric
dentists.
|
Central
- Practitioners
Minimum
Provider Panel Requirements
|
||||||||||||||||||||
Provider
Types
|
Total
Required Providers1
|
Xxxxxxxx
|
Delaware
|
Fairfield
|
Fayette
|
Xxxxxxxx
|
Xxxxxxx
|
Xxxx
|
Licking
|
Logan
|
Madison
|
Xxxxxx
|
Xxxxxx
|
Xxxxx
|
Pickaway
|
Xxxx
|
Xxxx
|
Scioto
|
Union
|
Additional
Required Providers2
|
Pediatricians4
|
86
|
4
|
3
|
55
|
1
|
2
|
1
|
1
|
2
|
1
|
2
|
2
|
1
|
11
|
||||||
OB/GYNs
|
24
|
2
|
2
|
12
|
1
|
1
|
1
|
1
|
1
|
3
|
||||||||||
Vision
|
31
|
1
|
2
|
2
|
15
|
1
|
1
|
1
|
1
|
1
|
1
|
1
|
1
|
3
|
||||||
General
Surgeons
|
22
|
1
|
1
|
1
|
10
|
1
|
1
|
1
|
1
|
1
|
1
|
1
|
2
|
|||||||
Otolaryngologist
|
6
|
1
|
4
|
1
|
||||||||||||||||
Allergists
|
4
|
2
|
2
|
|||||||||||||||||
Orthopedists
|
13
|
1
|
7
|
1
|
1
|
1
|
2
|
|||||||||||||
Dentists5
|
77
|
1
|
2
|
3
|
1
|
45
|
1
|
2
|
3
|
1
|
1
|
2
|
1
|
1
|
1
|
1
|
3
|
2
|
1
|
5
|
1
All required providers must be located within the region.
|
||||||||||||||||||||
2
Additional required providers may be located anywhere within the
region.
|
||||||||||||||||||||
3
Preferred Providers are the additional provider contracts that must be
secured in order for the MCP to receive bonus points.
|
||||||||||||||||||||
4
Half of this number must be certified by the American Board of
Pediatrics.
|
||||||||||||||||||||
5 No
more than two-thirds of this number can be pediatric
dentists.
|
South
West - Practitioners
Minimum
Provider Panel Requirements
|
||||||||||
Provider
Types
|
Total
Required Providers1
|
Xxxxx
|
Xxxxx
|
Xxxxxx
|
Clermont
|
Xxxxxxx
|
Xxxxxxxx
|
Highland
|
Xxxxxx
|
Additional
Required Providers2
|
Pediatricians4
|
59
|
7
|
2
|
1
|
39
|
10
|
||||
OB/GYNs
|
16
|
1
|
2
|
1
|
1
|
9
|
1
|
1
|
||
Vision
|
21
|
3
|
1
|
1
|
11
|
1
|
1
|
3
|
||
General
Surgeons
|
13
|
2
|
1
|
1
|
7
|
1
|
1
|
|||
Otolaryngologist
|
6
|
1
|
3
|
1
|
1
|
|||||
Allergists
|
7
|
4
|
3
|
|||||||
Orthopedists
|
9
|
2
|
5
|
2
|
||||||
Dentists5
|
50
|
1
|
1
|
10
|
4
|
1
|
26
|
2
|
2
|
3
|
1
All required providers must be located within the region.
|
||||||||||
2
Additional required providers may be located anywhere within the
region.
|
||||||||||
3
Preferred Providers are the additional provider contracts that must be
secured in order for the MCP to receive bonus points.
|
||||||||||
4
Half of this number must be certified by the American Board of
Pediatrics.
|
||||||||||
5 No
more than two-thirds of this number can be pediatric
dentists.
|
||||||||||
Minimum
Provider Panel Requirements
|
||||||||||
Provider
Types
|
Total
Required Providers1
|
Champaign
|
Xxxxx
|
Xxxxx
|
Xxxxxx
|
Miami
|
Xxxxxxxxxx
|
Xxxxxx
|
Xxxxxx
|
Additional
Required Providers2
|
Pediatricians4
|
36
|
2
|
3
|
1
|
22
|
8
|
||||
OB/GYNs
|
12
|
2
|
1
|
1
|
6
|
1
|
1
|
|||
Vision
|
20
|
2
|
1
|
2
|
2
|
10
|
1
|
2
|
||
General
Surgeons
|
10
|
2
|
2
|
1
|
3
|
2
|
||||
Otolaryngologist
|
7
|
1
|
3
|
3
|
||||||
Allergists
|
4
|
2
|
2
|
|||||||
Orthopedists
|
5
|
1
|
2
|
2
|
||||||
Dentists5
|
38
|
1
|
5
|
1
|
3
|
3
|
20
|
1
|
4
|
|
1
All required providers must be located within the region.
|
||||||||||
2
Additional required providers may be located anywhere within the
region.
|
||||||||||
3
Preferred Providers are the additional provider contracts that must be
secured in order for the MCP to receive bonus points.
|
||||||||||
4
Half of this number must be certified by the American Board of
Pediatrics.
|
||||||||||
5 No
more than two-thirds of this number can be pediatric
dentists.
|
North
West - Practitioners
Minimum Provider
Panel Requirements
|
||||||||||||||||||||
Provider
Types
|
Total
Required Providers1
|
Xxxxx
|
Auglaize
|
Defiance
|
Xxxxxx
|
Xxxxxxx
|
Xxxxxx
|
Xxxxx
|
Xxxxx
|
Xxxxxx
|
Ottawa
|
Paulding
|
Xxxxxx
|
Sandusky
|
Seneca
|
Van
Xxxx
|
Xxxxxxxx
|
Xxxx
|
Wyandot
|
Additional
Required Providers2
|
Pediatricians4
|
45
|
4
|
1
|
23
|
1
|
1
|
2
|
13
|
||||||||||||
OB/GYNs
|
13
|
2
|
1
|
5
|
1
|
1
|
1
|
2
|
||||||||||||
Vision
|
18
|
2
|
1
|
1
|
1
|
7
|
1
|
1
|
1
|
2
|
1
|
|||||||||
General
Surgeons
|
13
|
2
|
1
|
4
|
1
|
1
|
2
|
2
|
||||||||||||
Otolaryngologist
|
7
|
1
|
1
|
2
|
3
|
|||||||||||||||
Allergists
|
3
|
1
|
1
|
1
|
||||||||||||||||
Orthopedists
|
7
|
2
|
1
|
2
|
1
|
1
|
||||||||||||||
Dentists5
|
45
|
4
|
1
|
1
|
1
|
2
|
1
|
1
|
20
|
1
|
1
|
1
|
2
|
2
|
1
|
1
|
2
|
1
|
2
|
|
1
All required providers must be located within the region.
|
||||||||||||||||||||
2
Additional required providers may be located anywhere within the
region.
|
||||||||||||||||||||
3
Preferred Providers are the additional provider contracts that must be
secured in order for the MCP to receive bonus points.
|
||||||||||||||||||||
4
Half of this number must be certified by the American Board of
Pediatrics.
|
||||||||||||||||||||
5 No
more than two-thirds of this number can be pediatric
dentists.
|
Appendix
I
Covered
Families and Children (CFC) population
APPENDIX
I
PROGRAM
INTEGRITY
CFC
ELIGIBLE POPULATION
MCPs must
comply with all applicable program integrity requirements, including those
specified in 42 CFR 455 and 42 CFR 438 Subpart H.
In
addition to the specific requirements of OAC rule 5101:3-26-06, MCPs must
have a program that includes administrative and management arrangements or
procedures, including a mandatory compliance plan to guard against fraud and
abuse. The MCP’s compliance plan must designate staff responsibility
for administering the plan and include clear goals, milestones or objectives,
measurements, key dates for achieving identified outcomes, and explain how the
MCP will determine the compliance plan’s effectiveness.
In
addition to the requirements in OAC rule 5101:3-26-06, the MCP’s compliance
program which safeguards against fraud and abuse must, at a minimum,
specifically address the following:
|
a.
|
Employee education
about false claims recovery: In order to comply with
Section 6032 of the Deficit Reduction Act of 2005 MCPs must, as a
condition of receiving Medicaid payment, do the
following:
|
|
i.
|
establish
and make readily available to all employees, including the MCP’s
management, the following written policies regarding false claims
recovery:
|
|
a.
|
detailed
information about the federal False Claims Act and other state and federal
laws related to the prevention and detection of fraud, waste, and abuse,
including administrative remedies for false claims and statements as well
as civil or criminal penalties;
|
|
b.
|
the
MCP’s policies and procedures for detecting and preventing fraud, waste,
and abuse; and
|
|
c.
|
the
laws governing the rights of employees to be protected as
whistleblowers.
|
|
ii.
|
include
in any employee handbook the required written policies regarding false
claims recovery;
|
1
Appendix
I
Covered
Families and Children (CFC) population
|
iii.
|
establish
written policies for any MCP contractors and agents that provide detailed
information about the federal False Claims Act and other state and federal
laws related to the prevention and detection of fraud, waste, and abuse,
including administrative remedies for false claims and statements as well
as civil or criminal penalties,; the laws
governing the rights of employees to be protected as whistleblowers; and
the MCP’s policies and procedures for detecting and preventing fraud,
waste, and abuse. MCPs must make such information readily
available to their subcontractors;
and
|
|
iv.
|
disseminate
the required written policies to all contractors and agents, who must
abide by those written policies.
|
|
b.
|
Monitoring for fraud
and abuse The MCP’s program which safeguards against fraud and
abuse must specifically address the MCP’s prevention, detection,
investigation, and reporting strategies in at least the following
areas:
|
|
i.
|
Embezzlement
and theft – MCPs must monitor activities on an ongoing basis to prevent
and detect activities involving embezzlement and theft (e.g., by staff,
providers, contractors, etc.) and respond promptly to such
violations.
|
|
ii.
|
Underutilization
of services – MCPs must monitor for the potential underutilization of
services by their members in order to assure that all Medicaid-covered
services are being provided, as required. If any underutilized
services are identified, the MCP must immediately investigate and, if
indicated, correct the problem(s) which resulted in such underutilization
of services.
|
The MCP’s monitoring efforts must, at a minimum, include the following
activities: a) an annual review of their prior authorization
procedures to determine that
they do not unreasonably limit a member’s access to Medicaid-covered services;
b) an annual review of the procedures providers are to follow in appealing
the
MCP’s denial of a prior authorization request to determine that the
process does not unreasonably limit a member’s access to Medicaid-covered
services; and c)
ongoing monitoring of MCP service denials and utilization in order to
identify services which may be underutilized.
|
iii.
|
Claims
submission and billing – On an ongoing basis, MCPs must identify and
correct claims submission and billing activities which are potentially
fraudulent including, at a minimum, double-billing and improper coding,
such as upcoding and bundling.
|
2
Appendix
I
Covered
Families and Children (CFC) population
|
c.
|
Reporting MCP fraud
and abuse activities: Pursuant to OAC rule 5101:3-26-06,
MCPs are required to submit annually to ODJFS a report which summarizes
the MCP’s fraud and abuse activities for the previous year in each of the
areas specified above. The MCP’s report must also identify any
proposed changes to the MCP’s compliance plan for the coming
year.
|
|
d.
|
Reporting
fraud and abuse: MCPs are required to promptly report all
instances of provider fraud and abuse to ODJFS and member fraud to the
CDJFS. The MCP, at a minimum, must
report the following information on cases where the
MCP’s investigation has revealed that an incident of fraud
and/or abuse has occurred:
|
|
|
i.
|
provider’s
name and Medicaid provider number or provider reporting number
(PRN);
|
ii. source
of complaint;
iii. type
of provider;
iv. nature
of complaint;
v. approximate
range of dollars involved, if applicable;
vi. results
of MCP’s investigation and actions taken;
vii. name(s)
of other agencies/entities (e.g., medical board, law enforcement)notified by
MCP; and
|
viii.
|
legal
and administrative disposition of case, including actions taken by law
enforcement officials to whom the case has been
referred.
|
|
e.
|
Monitoring for
prohibited affiliations: The MCP’s policies and
procedures for ensuring that, pursuant to 42 CFR 438.610, the MCP will not
knowingly have a relationship with individuals debarred by Federal
Agencies, as specified in Article XII of the
Agreement.
|
3
Appendix
I
Covered
Families and Children (CFC) population
2. Data Certification:
Pursuant
to 42 CFR 438.604 and 42 CFR 438.606, MCPs are required to provide certification
as to the accuracy, completeness, and truthfulness of data and documents
submitted to ODJFS which may affect MCP payment.
|
a.
|
MCP
Submissions: MCPs must submit the appropriate
ODJFS-developed certification concurrently with the submission of the
following data or documents:
|
i.
Encounter Data [as specified in the Data Quality Appendix (Appendix
L)]
|
ii.
|
Prompt
Pay Reports [as specified in the Fiscal Performance Appendix (Appendix
J)]
|
|
iii.
|
Cost
Reports [as specified in the Fiscal Performance Appendix (Appendix
J)]
|
iv. Case
Management Data [as specified in the Data Quality Appendix
(Appendix L)]
|
b.
|
Source of
Certification: The above MCP data submissions must be
certified by one of the following:
|
i.
The MCP’s Chief Executive Officer;
ii. The
MCP’s Chief Financial Officer, or
|
iii.
|
An
individual who has delegated authority to sign for, or who reports
directly to, the MCP’s Chief Executive Officer or Chief Financial
Officer.
|
ODJFS may also require MCPs to certify as to the accuracy, completeness, and
truthfulness of additional submissions.
4
Appendix
J
Covered
Families and Children (CFC)
population
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);
|
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;
|
1
Appendix
J
Covered
Families and Children (CFC)
population
|
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.
|
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 2008, 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:
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.
2
Appendix
J
Covered
Families and Children (CFC)
population
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 membership 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).
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.
3
Appendix
J
Covered
Families and Children (CFC)
population
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 membership freeze. The new membership 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 membership 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.
|
4
Appendix
J
Covered
Families and Children (CFC) population
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.
5
Appendix
J
Covered
Families and Children (CFC)
population
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).
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.
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.
6
Appendix
J
Covered
Families and Children (CFC) population
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.
|
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 membership freeze.
7
Appendix
K
Covered
Families and Children (CFC) population
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 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.
b. UNDER- AND
OVER-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.
1
Appendix
K
Covered
Families and Children (CFC)
population
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 children/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 Health Employer Data Information Set (HEDIS) audited data for the
following measures:
|
i.
|
Well
Child Visits in the First 15 Months of
Life
|
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. 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.
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
Appendix
K
Covered
Families and Children (CFC)
population
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.
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.
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.
3
Appendix
L
Covered
Families and Children (CFC) population
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
case 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; case
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.
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.
1
Appendix
L
Covered
Families and Children (CFC) population
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
|
2
Appendix
L
Covered
Families and Children (CFC) population
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.]
3
Appendix
L
Covered
Families and Children (CFC) population
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:
Transition
to the regional-based approach will occur by region, after the first four
quarters (i.e., full calendar year quarters) of regional
membership. Encounter data volume will be evaluated by MCP, by region
(i.e., one utilization rate per service category for all counties in the
region), after determination of the regional-based data quality
standards. 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.
4
Appendix
L
Covered
Families and Children (CFC) population
Table
4. Standards – Encounter Data Volume (Regional-Based Approach)
Region
|
Category
|
Measure
per 1,000/MM
|
Standard
for Dates of Service
on
or after 7/1/2007
|
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
|
5
Appendix
L
Covered
Families and Children (CFC)
population
Region
|
Category
|
Measure
per 1,000/MM
|
Standard
for Dates of Service
on
or after 7/1/2007
|
Description
|
North-west
|
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
|
|
South-west
|
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
|
6
Appendix
L
Covered
Families and Children (CFC) population
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.
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.
7
Appendix
L
Covered
Families and Children (CFC) population
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.
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.
8
Appendix
L
Covered
Families and Children (CFC) population
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; 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; April – June 2010.
Data Quality Standard for measure
1: Data Quality Standard 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.
9
Appendix
L
Covered
Families and Children (CFC) population
Data Quality Standard for measure
2: The data quality standard is a maximum encounter data
rejection rate for each file type in the ODJFS-specified medium per format as
follows:
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.
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
10
Appendix
L
Covered
Families and Children (CFC) population
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.
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.
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%.
11
Appendix
L
Covered
Families and Children (CFC) population
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.
Payment
information found in MCPs’ claims systems for paid claims that does not match
payment information found on a corresponding encounter will be counted as
omissions.
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 measure is
initiated. This measure is conducted annually.
Data Quality Standard for Measure 2:
For SFY 2009 and SFY 2010, to be determined.
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.
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.
12
Appendix
L
Covered
Families and Children (CFC) population
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.
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.
Data Quality Standard for Measure
2: To be determined.
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.
13
Appendix
L
Covered
Families and Children (CFC) population
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.
2.
CASE MANAGEMENT DATA
|
|
ODJFS
designed a case management system (CAMS) in order to monitor MCP compliance with
program requirements specified in Appendix G, Coverage and
Services. Each MCP’s case management data submissions will be
assessed for completeness and accuracy. The MCP is responsible
for submitting a case management file every month. Failure to
do so jeopardizes
the MCP’s ability to demonstrate compliance with CSHCN
requirements. For detailed descriptions of the case management
measures below, see ODJFS
Methods for Case Management Data Quality Measures.
2.a.
Case Management System Data Accuracy
2.a.i.
Open Case Management Spans for Disenrolled Members (this measure will be discontinued
as of January 2008)
Measure: The
percentage of the MCP’s adult and children case management records in the
Screening, Assessment, and Case Management System that have open case management
date spans for members who have disenrolled from the MCP.
Report Period: For the SFY
2008 contract period, July – September 2007, and October – December
2007.
Statewide and
Regional Data Quality Standard: A rate of open case management
spans for disenrolled members of no more than 1.0%.
14
Appendix
L
Covered
Families and Children (CFC) population
For an MCP which had membership as
of February 1, 2006: Performance will be evaluated using: 1)
region-based results for any active region in which all selected MCPs had at
least 10,000 members during each month of the entire report period; and/or 2)
the statewide result for all counties that were not included in the region-based
results, but in which the MCP had managed care membership as of February 1,
2006.
For any MCP which did not have
membership as of February 1, 2006: Performance will
begin to be evaluated using region-based results for any active
region in which all selected MCPs had at least 10,000 members during
each month of the entire report period.
Regional-Based Approach: MCPs
will be evaluated by region, using results for all counties included in the
region.
Penalty for
noncompliance: If an MCP is noncompliant with the
standard, then the ODJFS will issue a Sanction Advisory informing the MCP that a
monetary sanction will be imposed if the MCP is noncompliant for any future
report periods. Upon all subsequent semi-annual measurements of
performance, if an MCP is again determined to be noncompliant with the standard,
ODJFS will impose a monetary sanction of one-half 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.
Data Quality Submission
Requirement: The MCP must submit Case Management files on a monthly basis
according to the specifications established in ODJFS’ Case 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.
15
Appendix
L
Covered
Families and Children (CFC) population
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.
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 case 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.
16
Appendix
L
Covered
Families and Children (CFC) population
4.b.
Designated PCP for newly enrolled members (only applicable for report periods
prior to January 2008)
Measure: The
percentage of MCP’s newly enrolled members who were designated a PCP by their
effective date of enrollment.
Report
Periods: For the SFY 2008 contract period, performance will be
evaluated using the July-September 2007, and October – December 2007 report
periods.
Data Quality
Standard: SFY 2007 will be informational only. A minimum rate
of 75% of new members with PCP designation by their effective date of enrollment
for quarter one and quarter two of SFY 2008.
Statewide
Approach: MCPs will be evaluated using a statewide result,
including all active regions and counties (Mahoning and Trumbull) in which an
MCP has CFC membership.
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.
4.b.i. Designated
PCP for newly enrolled members (only applicable for report periods
after December 2007)
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 Standards: For SFY 2009, a minimum rate of 85% of new members
with PCP designation by their effective date of enrollment. For SFY
2010, a minimum rate of 85% of new members with PCP designation by their
effective date of enrollment.
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.
17
Appendix
L
Covered
Families and Children (CFC) population
5.
APPEALS AND GRIEVANCES DATA
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
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.
18
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Covered
Families and Children (CFC) population
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.
MCPs
found to have a pattern of repeated or ongoing noncompliance may be subject to a
membership freeze.
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.
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APPENDIX
M
PERFORMANCE
EVALUATION
CFC
ELIGIBLE POPULATION
This
appendix establishes minimum performance standards for managed care plans (MCPs)
in key program areas. The intent is to maintain accountability for
contract requirements. Standards are subject to change based on the
revision or update of applicable national 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.
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.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 2008.
1
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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.
In order
to ensure state compliance with the provisions of 42 CFR 438.208, the
Bureau of Managed Health Care established Children with Special Health Care
Needs (CSHCN) basic program requirements in Appendix G, Coverage and
Services, and corresponding minimum performance standards as
described below. The purpose of these measures is to provide appropriate and
targeted case management services to CSHCN.
1.b.i.
Case Management of Children (applicable to performance
evaluation through December 2007 and P4P through SFY 2009)
Measure: The average monthly
case management rate for children under 21 years of age.
Report Period: For the SFY
2008 contract period: July – September 2007 and October – December
2007 (for evaluation); and April – June 2008 (for P4P) report periods. For the
SFY 2009 contract period: April – June 2009 (for P4P) report
periods.
County-Based
Approach: MCPs with managed care membership as of February 1,
2006 will be evaluated using their county-based statewide result
until regional evaluation is implemented for the county’s applicable
region. The county-based statewide result will include data for all
counties in which the MCP had membership as of February 1, 2006 that are not
included in any regional-based result. Regional-based results will
not be used for evaluation until all selected MCPs in an active region have at
least 10,000 members during each month of the entire report
period. Upon implementation of regional-based evaluation for a
particular county’s region, the county will be included in the MCP’s
regional-based result and will no longer be included in the MCP’s county-based
statewide result. [Example: The county-based statewide 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 in which MCP AAA
had managed care membership as of February 1, 2006). When
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 statewide result for evaluation
of MCP AAA until the West Central regional-based approach is implemented.] 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
2009. A detailed description of the of excellent and superior
standards associated with this measure for P4P determination for SFY 2008 and
SFY 2009 can be found in Appendix O, Section 1.b1 and Section 2.b1.
Regional-Based
Approach: MCPs will be evaluated by region, using
results for all counties included in the region. Performance will
begin to be evaluated using regional-based results for any active region in
which all selected MCPs had at least 10,000 members during each month of the
entire report period.
2
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County and
Regional-Based Minimum
Performance Standard: For the third and fourth quarters of SFY 2007,
a case management rate of 5.0%. For the first and second quarters of
SFY 2008, a case management rate of 5.0%.
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 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.b.ii. Case
Management of Children (applicable to performance
evaluation as of January, 2008 and P4P as of SFY
2010)
Measure: The average monthly
case management rate for children under 21 years of age.
Report Period: For the SFY
2008 contract period, January – March 2008, and April – June 2008 report
periods. For the SFY 2009 contract period, July –
September 2008, October – December 2008, January – March 2009, and April – June
2009 report periods. For the SFY 2010 contract period, July –
September 2009, October – December 2009, January – March 2010, and April – June
2010 report periods.
Regional-Based Statewide
Approach: 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
Target: For the third and fourth quarters of SFY 2008, a case
management rate of 5.0%. For SFY 2009, a case management rate of
5.0%. For SFY 2010, a case management rate of 5.0%.
Regional-Based Statewide Minimum
Performance Standard: The level of improvement must result in
at least a 20% decrease in the difference between the target and the previous
report period’s results.
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 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.
3
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1.b.iii.
Case Management of Children with an ODJFS-Mandated Condition (applicable to performance
evaluation through December 2007)
Measure 1: The
percent of children under 21 years of age with a positive
identification through an ODJFS administrative review of data for the
ODJFS-mandated case management condition of asthma that are case
managed.
Measure 2: The
percent of children age 17 and under with a positive identification
through an ODJFS administrative review of data for the ODJFS-mandated case
management condition of teenage pregnancy
that are case managed.
Measure 3: The
percent of children under 21 years of age with a positive
identification through an ODJFS administrative review of data for the
ODJFS-mandated case management condition of HIV/AIDS that are
case managed.
Report Periods for Measures 1, 2,
and 3: For the SFY 2008 contract period, July – September 2007 and
October – December 2007 report periods.
County-Based
Approach: MCPs with managed care membership as of February 1,
2006 will be evaluated using their county-based statewide result until regional
evaluation is implemented for the county’s applicable region. The
county-based statewide result will include data for all counties in which the
MCP had membership as of February 1, 2006 that are not included in any
regional-based result. Regional-based results will not be used for
evaluation until all selected MCPs in an active region have at least 10,000
members during each month of the entire report period. Upon
implementation of regional-based evaluation for a particular county’s region,
the county will be included in the MCP’s regional-based result and will no
longer be included in the MCP’s county-based statewide result. [Example: The
county-based statewide 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 in which MCP AAA had managed care membership
as of February 1, 2006). When 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 statewide result for evaluation of MCP AAA until the West Central
regional-based approach is implemented.]
Regional-Based Approach: MCPs
will be evaluated by region, using results for all counties included in the
region. Performance will begin to be evaluated using regional-based
results for any
active region in which all selected MCPs had at least 10,000 members during each
month of the entire report period.
4
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County and Regional-Based
Minimum Performance
Standard for Measures 1 and 3: For the third and fourth quarters of SFY
2007, a case management rate of 70%. For the first and second
quarters of SFY 2008, a case management rate of 70%.
County
and Regional-Based Minimum Performance Standard for Measure 2: For the first and
second quarters of SFY 2008, a case management rate of 60%.
Penalty for Noncompliance for
Measures 1 and 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 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. Note: For the first reporting period during
which regional results are used to evaluate performance, measures 1, 2, and 3
are reporting-only measures. For SFY 2008, measure 3 is a
reporting-only measure.
1.b.iv.
Case Management of Children with an ODJFS-Mandated Condition (applicable to performance
evaluation as of January 2008)
Measure 1: The
percent of children under 21 years of age with a positive
identification through an ODJFS administrative review of data for the
ODJFS-mandated case management condition of asthma that are case
managed.
Measure 2: The
percent of children under 21 years of age with a positive identification through
an ODJFS administrative review of data for the ODJFS-mandated case management
condition of HIV/AIDS that are case managed.
Report Periods for Measures 1 and
2: For the SFY 2008 contract period, January – March
2008, and April – June 2008 report periods. For the SFY 2009 contract
period, July – September 2008, October – December 2008, January – March 2009,
and April – June 2009 report periods. For the SFY 2010 contract
period, July – September 2009, October – December 2009, January – March 2010,
and April – June 2010 report periods.
Regional-Based Statewide Approach:
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.
5
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Regional-Based Statewide Target for Measures 1 and 2: For the third and fourth quarters of SFY 2008, a case management rate of 70.0%. For SFY 2009, a case management rate of 80.0%. For SFY 2010, a case management rate of 80.0%.
Regional-Based Statewide Minimum
Performance Standard for Measures 1 and 2: The
level of improvement must result in at least a 20% decrease in the difference
between the target and the previous report period’s results.
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 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. For SFY 2008 and SFY 2009,
measure 2 is a reporting-only measure.
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 standards are subject to change based on
the revision or update of NCQA methods or other national standards, methods or
benchmarks.
6
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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, targets and
performance standards for 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 the counties in which an MCP had membership as of February 1, 2006,
will be 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 (Trumbull and Mahoning)
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.
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, and penalties will be applied for noncompliance.
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: In
order to adhere to the statewide expansion timeline, reporting
periods. 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.
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.
7
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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
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.)
Regional-Based Statewide
Target: To be determined.
Regional-Based Statewide Minimum
Performance Standard: To be determined.
Action Required for
Noncompliance: Beginning SFY 2009, if the standard is not
met and the results are below 44.0% (49.0% for SFY 2010), 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% (49.0% for SFY 0000), XXXXX 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.
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.
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.
Regional-Based Statewide
Target: To be determined.
Regional-Based Statewide Minimum
Performance Standard: To be determined.
Action Required for
Noncompliance: Beginning SFY 2009, if the standard is
not met and the results are below 74.0%(77.0% for SFY 2010), 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% (77.0% for SFY
0000), XXXXX 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.
8
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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.
Regional-Based Statewide
Target: To be
determined.
Regional-Based Statewide Minimum
Performance Standard: To be determined.
Action Required for Noncompliance:
SFY 2009, if the standard is not
met and the results are below 50.0% (54.0% for SFY 2010), 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% (54.0% for SFY 0000),
XXXXX 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.
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.
Regional-Based Statewide
Target: To be
determined.
Regional-Based Statewide Minimum
Performance Standard for Each of the Age Groups: To be
determined.
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Action Required for Noncompliance
(15 month old age group): Beginning SFY 2009, if the
standard is not met and the results are below 42.0% (47.0% for SFY 2010), 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%
(47.0% for SFY 0000), XXXXX 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 (3-6 year
old age group): Beginning SFY 2009, if the
standard is not met and the results are below 57.0% (63.0% for SFY 2010), 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%
(63.0% for SFY 0000), XXXXX 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
(12-21 year old age group): Beginning SFY 2009, if the
standard is not met and the results are below 33.0% (35.0% for SFY 2010), 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%
(35.0% for SFY 0000), XXXXX 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.
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.
Regional-Based Statewide
Target: To be determined.
Regional-Based Statewide Minimum
Performance Standard: To be determined.
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Action Required for
Noncompliance: Beginning SFY 2009, if the standard is not
met and the results are below 84.0% (86.0% for SFY 2010), 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% (86.0% for SFY 0000),
XXXXX 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.
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.
Regional-Based Statewide
Target: To be
determined.
Regional-Based Statewide Minimum
Performance Standard: To be determined.
Action Required for
Noncompliance: Beginning SFY 2009, if the standard is
not met and the results are below 42.0% (43.0% for SFY 2010), 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%
(43.0% for SFY 0000), XXXXX 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.vii.
Lead Screening (For 1
Year Olds and For 2 Year Olds)
The final
report period for these measures is CY 2008.
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.
Regional-Based Statewide
Target: To be determined.
Regional-Based Statewide Minimum
Performance Standard for Each of the Age Groups: To be
determined.
Action Required for Noncompliance (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 (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.
12
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Covered
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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 the P4P for 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.
Regional-Based Statewide Minimum
Performance Standard: To be determined.
Action Required for Noncompliance:
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.
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.
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.
13
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Covered
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population
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, and penalties will be applied for
noncompliance.
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 2008 report period.
County-Based Statewide Minimum
Performance Standard: A maximum PCP Turnover rate of
18.0%.
Regional-Based Statewide Minimum
Performance Standard: To be
determined.
Action Required for
Noncompliance: 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.i.
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.
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.
14
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population
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
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.
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.
2.b.ii.
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.
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.
Penalty for
Noncompliance: If an MCP is noncompliant with the Minimum
Performance Standard, then the MCP must develop and implement a corrective
action plan.
15
Appendix
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Covered
Families and Children (CFC)
population
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, 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.
County-Based Statewide Minimum
Performance Standards:
CY 2007
report period – 63.0% of adults must receive a visit.
CY 2008
report period – 63.0% of adults must receive a visit (P4P only).
Regional-Based
Statewide Minimum Performance Standards:
CY 2008
report period – To be determined. (Evaluation only)
CY 2009
report period –To be determined
Penalty for
Noncompliance: If an MCP is noncompliant with the Minimum
Performance Standard, then the MCP must develop and implement a corrective
action plan.
16
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Covered
Families and Children (CFC) population
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
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 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.
Regional-Based
Statewide Minimum Performance Standard:
CY 2008 –
To be determined.
CY 2009 –
To be determined
Penalty for
Noncompliance: If an MCP is noncompliant with the Minimum
Performance Standard, then the MCP must develop and implement a corrective
action plan.
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, performance in this category will be
determined by the overall satisfaction score. For a comprehensive
description of the Consumer Satisfaction performance measure below, see ODJFS Methods for the Consumer
Satisfaction Performance Measure for the CFC Program.
17
Appendix
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Covered
Families and Children (CFC)
population
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.
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
2008 adult and child survey results) from all MCPs serving CFC membership as a
baseline to establish a measure and determine a minimum statewide performance
standard. 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: TBD
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.
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.
18
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Covered
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population
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.
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.
19
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Covered
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population
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 and the results are
above 1.1%, 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 a number to be determined or more targeted ED
visits during the twelve month reporting period.
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 and
penalties will be applied for noncompliance.
Report Period: For the SFY
2009 contract period, January – December 2008. For the SFY 2010
contract period, January – December 2008.
Regional-Based Statewide Target:
A maximum number to be determined of the eligible population will have a
number to be determined or more targeted ED visits during the reporting
period.
Regional-Based Statewide Minimum
Performance Standard: The level of improvement must result in at least a
percent to be determined decrease in the difference between the target and the
baseline period results.
Penalty for
Noncompliance: If the standard is not met and the results are
above a percent to be determined, 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.
20
Appendix
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Covered
Families and Children (CFC) population
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.
Unless
otherwise noted, the most recent report or study finalized prior to the end of
the contract period will be used in determining the MCP’s performance level for
that contract period.
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.
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.
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.
MCPs
found to have a pattern of repeated or ongoing noncompliance may be subject to
an enrollment freeze.
Requests
for reconsideration of monetary sanctions and enrollment freezes may be
submitted as provided in Appendix N, Compliance Assessment
System.
5.f.
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.
21
Appendix
N
Covered
Families and Children (CFC) population
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.
1
Appendix
N
Covered
Families and Children (CFC) population
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.
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.
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.
2
Appendix
N
Covered
Families and Children (CFC) population
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. 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.).
C.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:
|
•
|
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.
|
|
•
|
Use
of unapproved marketing or member
materials.
|
|
•
|
Failure
to appropriately notify ODJFS or members of provider panel
terminations.
|
|
•
|
Failure
to update website provider directories as
required.
|
3
Appendix
N
Covered
Families and Children (CFC)
population
C.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.
|
D. Fines – Refundable
or nonrefundable fines may be assessed as a penalty separate to or in
combination with other sanctions/remedial actions.
D.1. Unless otherwise
stated, all fines are nonrefundable.
D.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.
D.3. Monetary
sanctions/assurances imposed by ODJFS will be based on the most recent premium
payments.
D.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.
D.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.
4
Appendix
N
Covered
Families and Children (CFC)
population
E. 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.
F. 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
|
G. New Member Selection
Freezes - Notwithstanding any other penalty or point assessment that
ODJFS may impose on the MCP under this Appendix, ODJFS may prohibit an MCP from
receiving new membership through consumer initiated selection or the assignment
process if: (1) the MCP has accumulated a total of 51 or more points during a
rolling 12-month period; (2) or the MCP fails to fully implement a CAP within
the designated time frame; or (3) circumstances exist which
potentially jeopardize the MCP’s members’ access to care. [Examples
of circumstances that ODJFS may consider as jeopardizing member access to care
include:
|
-
|
the
MCP has been found by ODJFS to be noncompliant with the prompt payment or
the non-contracting provider payment requirements;
|
|
-
|
the
MCP has been found by ODJFS to be noncompliant with the provider panel
requirements specified in Appendix H of the
Agreement;
|
|
-
|
the
MCP’s refusal to comply with a program requirement after ODJFS has
directed the MCP to comply with the specific program requirement;
or
|
|
-
|
the
MCP has received notice of proposed or implemented adverse action by the
Ohio Department of Insurance.]
|
5
Appendix
N
Covered
Families and Children (CFC)
population
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.
H. 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 volume in
membership. 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.
I. 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.
J. Specific Pre-Determined
Penalties
I.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.
6
Appendix
N
Covered
Families and Children (CFC)
population
J.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
|
J.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
|
|
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
|
7
Appendix
N
Covered
Families and Children (CFC) population
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.
J.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.
J.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.
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.
8
Appendix
N
Covered
Families and Children (CFC)
population
J.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.
|
J.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.
J.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.
J.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.
9
Appendix
N
Covered
Families and Children (CFC)
population
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.
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.
10
Appendix
O
Covered
Families and Children (CFC) population
APPENDIX
O
PAY-FOR
PERFORMANCE (P4P)
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). 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).
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.
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
2007
3. Adults’
Access to Preventive/Ambulatory Health Services (Appendix M, Section
2.c.)
Report Period: CY 2007
1
Appendix
O
Covered
Families and Children (CFC) population
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
6.
Well-Child Visits - 12 through 21 years old
7.
Use of Appropriate Medications for People with Asthma
8.
Annual Dental Visits
9.
Blood Lead – 1 year olds
|
50%
30%
83%
40%
45%
|
For
qualifying MCPs as determined by Section 1.a., performance will be evaluated on
the measures below to determine the status of the at-risk amount or 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.
2
Appendix
O
Covered
Families and Children (CFC) population
1. Case
Management of Children (Appendix M, Section 1.b.i.)
Report Period: April - June
2008
Excellent Standard:
5.5%
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
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.) 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.
3
Appendix
O
Covered
Families and Children (CFC) population
2.
SFY 2009 P4P
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.
4
Appendix
O
Covered
Families and Children (CFC) population
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
6.
Well-Child Visits - 12 through 21 years old
7.
Use of Appropriate Medications for People with Asthma
8.
Annual Dental Visits
9.
Blood Lead – 1 year olds
|
57%
33%
84%
42%
45%
|
For
qualifying MCPs as determined by Section 2.a., performance will be evaluated on
the measures below to determine the status of the at-risk amount or 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.
1. Case
Management of Children (Appendix M, Section 1.b.i.)
Report Period: April - June
2009
Excellent Standard: To be
determined.
Superior Standard: To be
determined.
2. Use of
Appropriate Medications for People with Asthma (Appendix M, Section
1.c.v.)
Report Period: CY
2008
Excellent Standard: To be
determined.
Superior Standard: To be
determined.
3.
Adults’ Access to Preventive/Ambulatory Health Services (Appendix M, Section
2.c.)
Report Period: CY
2008
Excellent Standard:
77%
Superior Standard:
84%
5
Appendix
O
Covered
Families and Children (CFC) population
2.c.
Determining SFY 2008 P4P
MCP’s
reaching the minimum performance standards described in Section 2.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
2.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 2.b. herein, additional P4P may be
awarded. For MCPs receiving additional P4P, the amount in the P4P
fund (see Section 3.) 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.
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 fully phased in no later than 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.
6
Appendix
O
Covered
Families and Children (CFC) population
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.
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. Because of this requirement, more than 12 months of
at-risk dollars may be included in an MCP’s first regional at-risk status
determination depending on when regional membership starts relative to the
calendar year. Regional premium payments for months prior to July
2009 for members in counties included in the county-based statewide P4P system
for the SFY 2009 P4P determination, will be excluded from the at-risk dollars
included in the first regional-based statewide P4P determination.
3.b.
Determination of at-risk amounts and additional P4P payments
Given
that unforeseen circumstances (e.g., revision or update of 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 will occur
within six months of the end
of the
contract period. Determination of additional P4P payments will be
made at the same time the status of an MCP’s at-risk amount is
determined.
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.
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. Unless otherwise noted, the most recent report or study
finalized prior to the end of the contract period will be used in determining
the MCP’s overall performance level for that contract period.
7
Appendix
P
Covered
Families and Children (CFC) population
APPENDIX
P
MCP
TERMINATIONS/NONRENEWALS/AMENDMENTS
ABD
ELIGIBLE POPULATION
Upon
termination either by the MCP or ODJFS, nonrenewal or denial of an MCP’s
provider agreement, all previously collected refundable monetary sanctions will
be retained by ODJFS.
If an MCP
provides notice of the termination/nonrenewal of their provider agreement to
ODJFS, pursuant to Article VIII of the agreement, the MCP will be required to
submit the following to ODJFS:
a.
|
Refundable
Monetary Assurance and the At-Risk
Amount
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The MCP
will be required to submit a refundable monetary assurance. This monetary
assurance will be held by ODJFS until such time that the MCP has submitted all
outstanding monies owed, data files, and reports, including, but not limited to,
grievance, appeal, encounter and cost report data related to time periods through the
final date of service under the MCP’s provider agreement. The
monetary assurance must be in an amount of either $50,000 or 5 % of the
capitation amount paid by ODJFS in the month the termination/nonrenewal notice
is issued, whichever is greater.
The MCP
must also return to ODJFS the at-risk amount paid to the MCP under the current
provider agreement. The amount to be returned will be based on actual
MCP membership for preceding months and estimated MCP membership through the end
date of the contract. MCP membership for each month between the month
the termination/nonrenewal is issued and the end date of the provider agreement
will be estimated as the MCP membership for the month the termination/nonrenewal
is issued. Any over payment will be determined by comparing actual to estimated
MCP membership and will be returned to the MCP following the end date of the
provider agreement.
The MCP
must remit the monetary assurance and the at-risk amount in the specified
amounts via separate electronic fund transfers (EFT) payable to Treasurer of State, State of
Ohio(ODJFS). The MCP should contact their Contract
Administrator to verify the correct amounts required for the monetary assurance
and the at-risk amount and obtain an invoice number prior to submitting the
monetary assurance and the at-risk amount. Information from the
invoices must be included with each EFT to ensure monies are deposited in the
appropriate ODJFS Fund account. In addition, the MCP must send copies
of the EFT bank confirmations and copies of the invoices to their Contract
Administrator.
If the
monetary assurance and the at-risk amount are not received as specified above,
ODJFS will withhold the MCP’s next month’s capitation payment until such time
that ODJFS receives documentation that the monetary assurance and the at-risk
amount are received by the Treasurer of State. If within one year of the date of
issuance of the invoice, an MCP does not submit all outstanding monies owed and
required submissions, including, but not limited to, grievance, appeal,
encounter and cost report data related to time periods through the final date of
service under the MCP’s provider agreement, the monetary assurance will not be
refunded to the MCP.
1
Appendix
P
Covered
Families and Children (CFC)
population
b.
Data Files
In order
to assist members with continuity of care, the MCP must create data files to be
shared with each newly enrolling MCP. The data files will be provided
in
a consistant format specified by ODJFS and may include information on the
following: case management, prior authorizations, inpatient facility
stays, PCP
assignments, and
pregnant members. The timeline for providing these files will be at
the discretion of ODJFS. The terminating MCP will be responsible for
ensuring
the accuracy and data
quality of the files.
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c.
|
The MCP
must notify contracted providers at least 55 days prior to the effective date of
termination. The provider notification must be approved by ODJFS
prior to distribution.
The MCP
must notify their members of the termination at least 45 days in advance of the
effective date of termination. The member notification must be
approved by ODJFS prior to distribution.
The MCP
must create two notices to assist members and providers with prior authorization
requests received and/or approved during the last month of membership. The first
notice is for prior authorization requests for services to be provided after the
effective date of termination; this notice will direct members and providers to
contact the enrolling MCP. The second notice is for prior
authorization requests for services to be provided before and after the
effective date of termination. The MCP must utilize ODJFS model
language to create the notices and receive approval by ODJFS prior to
distribution. The notices will be mailed to the provider and copied
to the member for all requests received during the last month of MCP
membership.
If ODJFS
initiates the proposed termination, nonrenewal or amendment of an MCP’s
provider
agreement pursuant
to OAC rule 5101:3-26-10 and the MCP appeals that proposed action, the MCP’s
provider agreement will be extended through the issuance of an adjudication
order in the MCP’s
appeal under the R.C. Chapter 119.
2
Appendix
P
Covered
Families and Children (CFC)
population
During
this time, the MCP will continue to accrue points and be assessed penalties for
each
subsequent
compliance assessment occurrence/violation under Appendix N of the provider
agreement. If the MCP exceeds 69 points, each subsequent point
accrual will result in a $15,000 nonrefundable fine.
Pursuant
to OAC rule 5101:3-26-10(H), if ODJFS has proposed the termination, nonrenewal,
denial or amendment of a provider agreement, ODJFS may notify the MCP's members
of this proposed action and inform the members of their right to immediately
terminate their membership with that MCP without cause. If ODJFS has
proposed the termination, nonrenewal, denial or amendment of a
provider agreement and access to medically-necessary covered services is
jeopardized, ODJFS may propose to terminate the membership of all of the MCP's
members. The appeal process for reconsideration of the proposed
termination of members is as follows:
·
|
All
notifications of such a proposed MCP membership termination will be made
by ODJFS via certified or overnight mail to the identified MCP
Contact.
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·
|
MCPs
notified by ODJFS of such a proposed MCP membership termination will have
three working days from the date of receipt to request
reconsideration.
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·
|
All
reconsideration requests must be submitted by either facsimile
transmission or overnight mail to the Deputy Director, Office of Ohio
Health Plans, and received by 3PM Eastern Time (ET) on the third working
day following receipt of the ODJFS notification of termination. The
address and fax number to be used in making these requests will be
specified in the ODJFS notification of termination
document.
|
·
|
The
MCP will be responsible for verifying timely receipt of all
reconsideration requests. All requests must explain in detail
why the proposed MCP membership termination is not
justified. The MCP’s justification for reconsideration will be
limited to a review of the written material submitted by the
MCP.
|
·
|
A
final decision or request for additional information will be made by the
Deputy Director within three working days of receipt of the request for
reconsideration. Should the Deputy Director require
additional time in rendering the final reconsideration decision, the MCP
will be notified of such in
writing.
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·
|
The
proposed MCP membership termination will not occur while an appeal is
under review and pending the Deputy Director’s decision. If the
Deputy Director denies the appeal, the MCP membership termination will
proceed at the first possible effective date. The date may be
retroactive if the ODJFS determines that it would be in the best interest
of the members.
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3