OHIO DEPARTMENT OF JOB AND FAMILY SERVICES OHIO MEDICAL ASSISTANCE PROVIDER AGREEMENT FOR MANAGED CARE PLAN CFC ELIGIBLE POPULATION
Exhibit
10.1
OHIO
DEPARTMENT OF JOB AND FAMILY SERVICES
OHIO
MEDICAL ASSISTANCE PROVIDER AGREEMENT
FOR
MANAGED CARE PLAN
CFC
ELIGIBLE POPULATION
This
provider agreement is entered into
this first day of July, 2007, 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 Beechwood, 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.
ARTICLE
I - GENERAL
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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ARTICLE
II - TIME OF PERFORMANCE
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, 2008, 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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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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ARTICLE
IV - RELATIONSHIP OF PARTIES
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 duringthe term of
this Agreement,
nothing herein shall be construed to imply, by reason ofMCP’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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ARTICLE
V - CONFLICT OF INTEREST; ETHICS LAWS
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
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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
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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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ARTICLE
VII - RECORDS, DOCUMENTS AND INFORMATION
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
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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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ARTICLE
VIII - SUSPENSION AND TERMINATION
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
75 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
75 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 two 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).
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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 the terms and conditions of any applicable federal waiver,
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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ARTICLE
X - LIMITATION OF LIABILITY
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
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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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ARTICLE
XI - ASSIGNMENT
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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ARTICLE
XII - CERTIFICATION MADE BY MCP
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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C.
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By
executing this agreement, MCP certifies that neither MCP nor any
principals of MCP
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(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
ofvalue that is of such a character as to manifest a substantial
and
improper influence uponthe 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
ComptrollerGeneral 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
recoveryrequirements 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
materialassistance, 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
priorto execution of this Agreement. If these representations
and warranties are found to befalse, this Agreement is void ab
initio and MCP shall immediately repay to ODJFS any funds
paid under this Agreement.
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ARTICLE
XIII - CONSTRUCTION
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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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.
|
ARTICLE
XV – NOTICES
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.
ARTICLE
XVI – HEADINGS
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/ Xxxx X. Xxxxx
|
DATE:
6/12/2007
|
XXXX
X. XXXXX, PRESIDENT & CEO
OHIO
DEPARTMENT OF JOB AND FAMILY SERVICES:
BY:
/s/ Xxxxx X Xxxxx
Xxxxx
|
DATE:
6/25/2007
|
XXXXX
X. XXXXX-XXXXX, DIRECTOR
CFC
PROVIDER AGREEMENT INDEX
July
1, 2007
|
|
APPENDIX
|
TITLE
|
APPENDIX
A
|
OAC
RULES 5101:3-26
|
APPENDIX
B
|
SERVICE
AREA SPECIFICATIONS – CFC ELIGIBLE POPULATION
|
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
OAC
RULES 5101:3-26
The
managed care program rules can be accessed electronically through
the BMHC page of the ODJFS website.
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.
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 tohave 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.
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 isdesignated as the primary care physician 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.
|
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.
|
a.
MCPs are required to make transportation available
to any member requestingtransportation 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 ofnecessity for
transportation arrangements (e.g., bus versus cab). MCPs approvedto
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 whendecreasing
or
ceasing any additional benefit(s). When it is beyond the controlof
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 adhere 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.
|
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 providers [e.g., PCPs, Pharmacy
Benefit Managers
(PBMs), and Third Party Administrators (TPAs)], as applicable.
MCPs must
submit
to ODJFS, upon request, detailed information regarding
the MCP’s members
with special
communication needs, which could include individual member
names, their
specific
communication need, and any provision of special services to members
(i.e.,
those special services arranged by the MCP as well as those services
reported to the MCP
which were arranged by the provider).
|
|
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
ororal) that the MCP is endorsed by CMS, the Federal or State government
orsimilar entity.
|
e.
|
MCPs
must establish positive working relationships with the CDJFS offices
and
must not aggressively solicit from local Directors, MCP County
Coordinators, or or
other staff. Furthermore, MCPs are prohibited from offering
gifts of nominal value
(i.e. clipboards, pens, coffee mugs, etc.) to CDJFS offices ormanaged
care
enrollment center (MCEC) staff, as these may influence anindividual’s
decision to select a particular
MCP.
|
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.
24. New
Member Materials
Pursuant
to OAC rule 5101:3-26-08.2
(B)(3), MCPs must provide to each member orassistance group, as applicable,
an
MCP identification (ID) card, a new member letter, amember 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 amethod 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 bemailed to the member
separately from the ID card and new member letter. MCPswillmeet 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 newmember materials on a monthly basis
in
order to monitor the timely receipt of thesematerials. 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
AdministrativeCode (OAC) rule 5101:3-26-08.4(A)(9)]. Therefore,
the member services call centerrequirement 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.
|
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
whichit
becomes aware. Any breach by the MCP or its representatives of
protectedhealth 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.
|
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.
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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
Deferment Requests: When an MCP learns of a current
hospitalized member’s intent to disenroll through the CCR or the 834, the
disenrolling MCP must notify ODJFS within five (5) business
days of receipt of the CCR or 834. When the MCP learns of a new
member’s hospitalization that is eligible for deferment prior
to that member’s discharge, the MCP shall notify the hospital and treating
providers of the potential that the MCP may not be the
payer. The MCP shall work with hospitals, 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 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. When the MCP is
notified by ODJFS of a potential hospital deferment, the MCP must
respond
to ODJFS within five (5) business days of the receipt of the deferment
information from ODJFS.
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|
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.
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g.
|
Eligible
Individuals: If an eligible individual contacts the MCP,
the MCP mustprovide any MCP-specific managed care program information
requested. TheMCP 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.
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|
|
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.
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i. Transition
of Fee-For-Service Members
Providing
care coordination for prescheduled health services and existing care treatment
plans, is critical formembers transitioning from Medicaid fee-for service (FFS)
to managed care. Therefore, MCPs must:
i. Allow
their new members that are transitioning from Medicaidfee-for-service to receive
services from out-of-panel providers if themember 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 anestablished relationship
with an obstetrician and/or deliveryhospital;
b. The
member has been scheduled for an inpatient/outpatient surgeryand has been
prior-approved and/or precertified pursuant to OACrule 5101:3-2-40 (surgical
procedures would also include follow-up care as appropriate);
c. The
member has appointments within the initial month of MCPmembership with specialty
physicians that were scheduled prior tothe effective date of membership;
or
d. The
member is receiving ongoing chemotherapy or radiationtreatment.
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.
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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.
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|
iii.
|
Honor
any current fee-for-service prior authorization to allow their new
members
that are transitioning from Medicaid fee-for-service to receive services
from the authorized provider, whether a panel or out-of-panel provider,
for the following approved
services:
|
|
a.
|
an
organ, bone marrow, or hematapoietic stem cell transplant pursuant
to OAC
rule 5101:3-2-07.1;
|
|
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.
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|
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, with the
exception of organ, bone marrow, or hematapoietic stem cell transplants,
coordinate the transfer of services to a panel provider, if
appropriate.
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.
|
|
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.
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|
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: |
a. Before
an MCP may submit production filesODJFS-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
Claims
Adjudication
The
MCP must have the capacity to
electronically accept and adjudicate all claimsto final status (payment or
denial). Information on claims submission proceduresmust 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 maybe in the form of a claim
payment/remittance advice produced on a routine monthly, or more frequent,
basis.
Electronic
Data
Interchange
The
MCP shall comply with all
applicable provisions of HIPAA includingelectronic data interchange (EDI)
standards for code sets and the followingelectronic 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 implementationguide, as specified by applicable federal rule or
regulation.
The
MCP must have the capacity to
accept the following transactions from theOhio Department of Job and Family
services consistent with EDI processing
specifications
in the transaction
implementation guides and in conformance withthe 820 and 834 Transaction
Companion Guides issued by ODJFS:
ASC
X12 820 - Payroll Deducted and
Other Group Premium Payment forInsurance Products; and
ASC
X12 834 - Benefit Enrollment and
Maintenance.
The
MCP shall comply with the HIPAA
mandated EDI transaction standards andcode sets no later than the required
compliance dates as set forth in the federalregulations.
Documentation
of Compliance with
Mandated EDI Standards
The
capacity of the MCP and/or
applicable trading partners and businessassociates to electronically conduct
claims processing and related transactions incompliance 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 andAccountability Act of
1995)
MCPs
shall comply with the transaction
standards and code sets for sendingand receiving applicable transactions as
specified in 45 CFR Part 162 – HealthInsurance Reform: Standards for
Electronic Transactions (HIPAA regulations) In addition the MCP must
enter into the appropriate trading partner agreement and implemented standard
code sets. If the MCP has obtained third-party certification of HIPAA
compliance for any of the items listed below, that certification may be
submitted in lieu of the MCP’s written verification for the applicable
item(s).
i. Trading
Partner Agreements
ii. Code
Sets
iii. Transactions
a. Health
Care Claims or Equivalent Encounter Information(ASC X12N 837 & NCPDP
5.1)
b. Eligibility
for a Health Plan (ASC X12N 270/271)
c. Referral
Certification and Authorization (ASC X12N 278)
d. Health
Care Claim Status (ASC X12N 276/277)
e. Enrollment
and Disenrollment in a Health Plan (ASC X12N 834)
f. Health
Care Payment and Remittance Advice (ASC X12N 835)
g. Health
Plan Premium Payments (ASC X12N 820)
h. Coordination
of Benefits
Trading
Partner Agreement with
ODJFS
MCPs
must complete and submit an EDI
trading partner agreement in a formatspecified by the
ODJFS. Submission of the copy of the trading partner agreementprior
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 inthe imposition of penalties, as outlined
in Appendix N, ComplianceAssessment 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.
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.
Acceptance
Testing
The
MCP
must have the capability to report all elements in the Minimum Data Set as
set
forth in the ODJFS Encounter Data Specifications and must submit a test file
in
the ODJFS-specified medium in the required formats prior to contracting or
prior
to an information systems replacement or update.
|
Acceptance
testing of encounter data is required as specified in Section 29(a)(v)
of
this Appendix.
|
Encounter
Data File Submission
Procedures
A
certification letter must accompany the submission of an encounter data file
in
the ODJFS-specified medium. The certification letter must be signed by the
MCP’s
Chief Executive Officer (CEO), Chief Financial Officer (CFO), or an individual
who has delegated authority to sign for, and who reports directly to, the MCP’s
CEO or CFO.
Timing
of Encounter Data
Submissions
ODJFS
recommends that MCPs submit encounters no more than thirty-five (35) days after
the end of the month in which they were paid. For example, claims paid in
January are due March 5. ODJFS recommends that MCPs submit files in
the ODJFS-specified medium by the 5th of each month. This will help to ensure
that the encounters are included in the ODJFS master file in the same month
in
which they were submitted.
d. Information
Systems Review
Every
two
(2) years, and before ODJFS enters into a provider agreement with a new MCP,
ODJFS or designee may review the information system capabilities of each MCP.
Each MCP must participate in the review, except as specified below. 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.
|
As
noted above, the information system
review may be performed every twoyears. However, if ODJFS or its designee
identifies significant informationsystem problems, then ODJFS or its designee
may conduct, and the MCP must participate in, a review the following year or
in
such a timeframe as ODJFS, in their sole discretion, deems appropriate to ensure
accuracy and efficiency of the MCP health information system.
If
an MCP had an assessment performed
of its information system through aprivate sector accreditation body or other
independent entity within the two yearspreceding the time when ODJFS or its
designee will be conducting its review, and has not made significant changes
to
its information system since that time, and the information gathered is the
same
as or consistent with the ODJFS or its designee’s proposed review, as determined
by the ODJFS, then the MCP will not required to undergo the IS
review. The MCP must provide ODJFS or its designee with a copy of the
review that was performed so that ODJFS can determine whether or not the MCP
will be required to participate in the IS review. MCPs who are determined to
be
exempt from the IS review must participate in subsequent information system
reviews, as determined by ODJFS.
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.
Rejections
If
a
delivery encounter is not submitted according to ODJFS specifications, it will
be rejected and MCPs will receive this information on the exception report
(or
error report) that accompanies every file in the ODJFS-specified format.
Tracking, correcting and resubmitting all rejected encounters is the
responsibility of the MCP and is required by ODJFS.
Timing
of Delivery Payments
MCPs
will
be paid monthly for deliveries. For example, payment for a delivery
encounter submitted with the required encounter data
submission in March, will be reimbursed
in March. The delivery payment will cover any encounters submitted
with the monthly encounter data submission regardless of the date of the
encounter, but will not cover encounters that occurred over one year
ago.
This
payment will be a part of the weekly update (adjustment payment) that is in
place currently. The third weekly update of the month will include
the delivery payment. The remittance advice is in the same format as
the capitation remittance advice.
Updating
and Deleting Delivery Encounters
The
process for updating and deleting delivery encounters is handled differently
from all other encounters. See the ODJFS Encounter Data Specifications
for detailed instructions on updating and deleting delivery
encounters.
The
process for deleting delivery encounters can be found on page 35 of the UB-92
technical specifications (record/field 20-7) and page III-47 of the NSF
technical specifications (record/field CA0-31.0a).
Auditing
of Delivery Payments
A
delivery payment audit will be conducted periodically. If medical records do
not
substantiate that a delivery occurred related to the payment that was made,
then
ODJFS will recoup the delivery payment from the MCP. Also, if it is determined
that the encounter which triggered the delivery payment was not a paid
encounter, then ODJFS will recoup the delivery payment.
32.
|
If
the MCP will be using the Internet functions that will allow approved
users to access member information (e.g., eligibility verification),
the
MCP must 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.
|
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 4½ 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
providerdirectory available in the same format as their ODJFS-approved
providerdirectory, that allowsmembers 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 websitewhich is
regularly updated to include the most current ODJFS approved
materials.
The
website at a minimum must include:
(1) a list of the counties that are coveredin their service area; (2) the
ODJFS-approved MCP member handbook, recentnewsletters/announcements, MCP contact
information including member services hours and closures; (3) the MCP provider
directory as referenced in section 36(a) of this appendix; (4) the MCP’s current
preferred drug list (PDL), including an explanation of the list, which drugs
require prior authorization (PA), and the PA process; (5) the MCP’s current list
of drugs covered only with PA, the PA process, and the MCP’s policy
for covering generic for brand-name drugs; and
(6)
the ability for members to submitquestions/comments/grievances/appeals/etc.
and
receive a response (membersmust be given the option of a return e-mail or phone
call) within one working day of receipt. MCPs must ensure that all
member materials designated specifically for CFC and/or ABD consumers (i.e.
the
MCP member handbook) are clearly labeled as such. The MCP’s member
website cannot be used as the only means to notify members of new and/or revised
MCP information (e.g., change in holiday closures,
change in additional benefits, revisions to approved member
materialsetc.). ODJFS may require MCPs to include additional
information on the member website,
as needed.
c. On-line
Provider Website – MCPs must have a secure internet-based
website for contracting
providers where they will be able to confirm a consumer’s MCPenrollment and
through this website (or through e-mail process) allow providersto
electronically submit and receive responses to prior authorization
requests. This website must also include: (1) a list of the counties
that are covered in their service area; (2) the MCP’s provider manual;(3) MCP
contact information; (4) a link to the MCP’s on-line provider directory as
referenced in section 37(a) of this appendix; (5) the MCP’s current PDL list,
including an explanation of the list, which drugs require PA, and the PA
process; and (6) the MCP’s current list of drugs covered only with PA, the PA
process, and the MCP’s policy for covering generic for brand-name
drugs. MCPs must ensure that all provider materials designated
specifically for CFC and/or ABD consumers (i.e. the MCP’s provider manual) are
clearly labeled as such. 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,
uponrequest.
39. MCPs
must not use, or propose to use, any offshore programming or call center
services
in
fulfilling the program
requirements.
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.
|
10.
|
On
a monthly basis, ODJFS will provide MCPs with an electronic Master
Provider 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.
|
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 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.
|
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:
|
|
·
|
40%
of statewide Covered Families and Children (CFC) eligible
population; and/or
|
|
·
|
60%
of the CFC eligibles in any region with two MCPs;
and/or
|
|
·
|
40%
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.
|
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.
|
d.
|
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.
|
e.
|
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.
|
|
f.
|
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.
|
|
g.
|
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
MCPperformance including, but not limited to, information on MCP-specific and
statewideexternal 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
toassess whether MCP information is both accessible and updated.
19. Communications
a. ODJFS/BMHC:
The Bureau of Managed Health Care (BMHC) is responsible forthe 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
becontacted 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
meetingprogram requirements, the BMHC will not discuss MCP issueswith the MCPs’
delegated entities unless the applicable MCP is also participating in the
discussion. MCP delegated entities, with the applicable MCP
participating, should only communicate with the specific CA assigned to that
MCP.
APPENDIX E
RATE
METHODOLOGY
CFC
ELIGIBLE POPULATION
XXXXXX
Government
Human Services Consulting
000
Xxxxx
0xx Xxxxxx, Xxxxx 0000
Xxxxxxxxxxx,
XX 00000-0000
xxx.xxxxxxXX.xxx
October
20, 2006
Xx.
Xxx
Xxxxxx
State
of
Ohio
Bureau
of
Managed Health Care
Ohio
Department of Job and Family Services
000
Xxxx
Xxxx Xxxxxx, 0xx Xxxxx
Xxxxxxxx,
XX 00000-0000
Subject:
Calendar
Year 2007 Rate-Setting Methodology: Healthy Families and Healthy
Start
Dear
Xxx:
The
Ohio
Department of Job and Family Services (State) contracted with Xxxxxx Government
Human Services Consulting (Xxxxxx) to develop actuarially sound capitation
rates
for Calendar Year (CY) 2007 for the Healthy Families and Healthy Start (CFC)
managed care populations. Xxxxxx developed CY 2007 capitation rates for the
following seven managed care regions:
Central,
Xxxx Xxxxxxx, Xxxxxxxxx, Xxxxxxxxx, Xxxxxxxxx, Xxxxxxxxx, and West Central.
At
this time. Xxxxxx has not developed rates for the eighth region. Northeast
Central, because managed care implementation has been put on hold for this
region. Once the implementation date is determined for Northeast Central, a
supplemental certification with the Northeast Central rates will be
provided.
The
basic
rate-setting methodology is similar to the county-specific rate methodology
used
in previous years. This methodology letter outlines the rate-setting process,
provides information on data adjustments, and includes a final rate
summary.
The
key
components in the CY 2007 rate-setting process are:
•
Base
data development,
•
Managed
care rate development, and
•
Centers
for Medicare and Medicaid Services (CMS) documentation
requirements.
Each
of
these components is described further throughout the document and is depicted
in
the flowchart included as Appendix X.
XXXXXX
Government
Human Services Consulting
Page
2
October
20, 2006
Xx.
Xxx
Xxxxxx
Ohio
Department of Job and Family Services
Base
Data Development
The
major
steps in the development of the base data are similar to previous years. Xxxxxx
and the State have discussed the available data sources for rate development
and
the applicability of these data sources for each region.
The
data
sources used for CY 2007 rate setting were:
•
Ohio
historical FFS data,
•
MCP
encounter data, and
•
MCP
financial cost report data.
Validation
Process
As
part
of the rate-setting process, Xxxxxx validated each of the data sources that
were
used to develop rates. The validations included a review of the data to be
used
in the rate setting process. During the validation process, Xxxxxx adjusted
the
data for any data miscodes (e.g., males in the delivery rate cohort) that were
found.
Data
Sources
As
Ohio's
Medicaid program matures, the rate-setting methodology for those counties within
each region with stable managed care programs can focus more on plan-reported
managed care data, including encounter data and cost reports. For counties
within each region without established managed care programs, Xxxxxx continued
to use the FFS data as a direct data source. The data sources used in each
region depended on the most credible data sources available within the region.
In regions where there are stable managed care programs, managed care data
for
those counties was combined with the FFS data for those counties without
established managed care programs. The process to prepare these three data
sources for rate-setting is detailed below.
Appendix
B includes a chart detailing how each region's counties have been bucketed
into
mandatory, Preferred Option, voluntary, or new based on the delivery system
in
place during the base period. This determined which data sources were used
in
determining regional CY 2007 rates. Also included in Appendix B is a map that
shows the counties included within each region.
Other
sources of information that were used, as necessary, included state enrollment
reports, state financial reports, projected managed care penetration rates,
information from prior MCP surveys, encounter data issues log, and other ad
hoc
sources.
XXXXXX
Government
Human Services Consulting
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20, 2006
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Xxx
Xxxxxx
Ohio
Department of Job and Family Services
Fee-for-Service
Data
FFS
experience from the base time period of State Fiscal Year (SPY) 2004 (July
1,
2003-June 30, 2004) and SPY 2005 (July 1, 2004-June 30, 2005) was used as a
direct data source for the counties described below:
•
Those
that had a voluntary managed care program during the base time period,
and
•
Those
that did not have a managed care program during the base time
period.
In
addition to the SPY 2004 and SPY 2005 data, SPY 2003 data supplemented the
FFS
base data development as a reasonability measure. For the above counties, the
FFS data was considered the most credible data source and, in some cases, was
the only data available for rate setting.
As
in
previous years, adjustments were applied to the FFS data to reflect the
actuarially equivalent claims experience for the population that will be
enrolled in the managed care program. The State Medicaid Management Information
System (MMIS) includes data for populations and/or services excluded from
managed care and the actual FFS paid claims may be net or gross of certain
factors (e.g., gross adjustments or third party liability (TPL)). As a result,
it is necessary to make adjustments to the FFS base data as documented in
Appendix C and outlined in Appendix A.
Encounter
Data
MCP
encounter experience from the base time period of SFY 2004 and SFY 2005 was
used
as a direct data source for the counties described below:
•
Those
that had a mandatory managed care program during the base time period,
and
•
Those
that had a Preferred Option managed care program during the base time
period.
For
the
above counties, the encounter data was considered a credible data source and
was
used along with the financial cost report data as a direct data
source.
Although
encounter data is generally reflective of the populations and services that
are
the responsibility of the MCPs, adjustments were applied to the encounter data,
as appropriate. Those adjustments, and other considerations, include the
following items:
•
Claims
completion factors,
XXXXXX
Government
Human Services Consulting
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Xxx
Xxxxxx
Ohio
Department of Job and Family Services
|
• Program
changes in the historical base time period (SPY 2004-SFY 2005),
and
|
|
•
Other actuarially appropriate adjustments, as needed, and according
to the
State's direction to reflect such things as incomplete encounter
reporting
or other known data issues.
|
The
adjustments to the encounter data are further documented in Appendix C and
outlined in Appendix A.
During
the rate setting process, shadow pricing was used to assign unit costs to the
encounter data. This process was necessary since, during the base period, paid
amounts were not a required field for reporting encounters. Additional
information on shadow pricing is presented on page six of this
letter.
Financial
Cost Reports
MCP-submitted
financial cost reports from the base time period CY 2004 and CY 2005 were used
as a direct data source for the counties described below:
|
•
Those that had a mandatory managed care program during the base time
period, and
|
|
•
Those that had a Preferred Option managed care program during the
base
time period.
|
For
all
of the above counties, except Mahoning and Trumbull who entered into managed
care on October 1, 2005, the cost reports were considered a credible data
source. In addition, for counties with voluntary managed care programs during
the base time period, the cost reports were taken into consideration when
setting rates, although not used as a direct data source.
As
with
the encounter data, the cost report data typically reflects the populations
and
services that are the responsibility of the MCPs. However, adjustments were
applied to the cost report data, as appropriate. Those adjustments, and other
considerations, include the following items:
|
•
Program changes in the historical base time period (CY 2004-CY
2005),
|
|
•
Incurred claims estimates based on review of claims lag triangles,
and
|
|
•
Other actuarially appropriate adjustments, as needed, to reflect
such
things as incomplete reporting or other known data
issues.
|
Xxxxxx
considered the CY 2004 and CY 2005 cost reports both in the development of
completion factors for the base time period (CY 2004-CY 2005) and in the
development of the final rate.
XXXXXX
Government
Human Services Consulting
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Xxx
Xxxxxx
Ohio
Department of Job and Family Services
The
adjustments for the cost report data are further documented in Appendix C and
outlined in Appendix A.
Managed
Care Rate Development
This
section explains how Xxxxxx developed the final capitation rates paid to
contracted MCPs after the base data was developed and multiple years of data
were blended for each data source. First, Xxxxxx applied trend, programmatic
changes and other adjustments to each data source to project the program cost
into the contract year. Next, the various data sources were blended into a
single managed care rate and an administrative component was applied. Finally,
relational modeling was used to smooth the results within each region. Appendix
A outlines the managed care rate development process. Appendix D provides more
detail behind each of the following adjustments.
Blending
Multiple Years of Data
As
the
programs have matured, we have collected multiple years ofFFS and managed care
data. In order to utilize all available current information, Xxxxxx combined
the
yearly data within each data source using a weighted average methodology similar
to that used in previous years. Prior to blending these years of data, the
base
time period experience was trended to a common time period ofCY 2005. Xxxxxx
applied greater credibility on the most recent year of data to reflect the
expectation that the most recent year may be more reflective of future
experience and to reflect that fewer adjustments are needed to bring the data to
the effective contract period.
Managed
Care Assumptions for the FFS Data Source
In
developing managed care savings assumptions. Xxxxxx applied generally accepted
actuarial principles that reflect the impact ofMCP programs on FFS experience.
Xxxxxx reviewed Ohio's historical FFS experience, CY 2004 and CY 2005 cost
report data, SFY 2004 and SPY 2005 encounter data, and other state Medicaid
managed care experience to develop managed care savings assumptions. These
assumptions have been applied to the FFS data to derive managed care cost
levels. The assumptions are consistent with an economic and efficiently operated
Medicaid managed care plan. The managed care savings assumptions vary by region,
rate cohort and category of service (COS).
Specific
adjustments were made in this step to reflect the differences between pharmacy
contracting for the State and contracting obtained by the MCPs. Xxxxxx reviewed
information
XXXXXX
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Human Services Consulting
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Xxx
Xxxxxx
Ohio
Department of Job and Family Services
related
to discount rates, dispensing fees, rebates, encounter data and MCP cost report
data to make these adjustments. The rates are reflective of MCP contracting
for
these services.
Shadow
Pricing
During
our base period, MCPs were not required to report the amount paid for a
particular service in their encounter submissions. Therefore, Xxxxxx developed
assumed unit costs that were applied to encounter utilization data. For the
inpatient category of service, unit costs were calculated by region based on
the
average daily cost for each hospital peer group. Unit costs for other XXXx
were
calculated based on Ohio Medicaid FFS reimbursement levels. The unit costs
were
then adjusted by rate cohort to reflect the age/sex unit cost differential
apparent in the statewide FFS data. In addition, a unit cost managed care
assumption was applied in the shadow pricing step for the pharmacy
COS.
Prospective
Policy Changes
CMS
also
requires that the rate-setting methodology incorporates the impact of any
programmatic changes that have taken place, or are anticipated to take place,
between the base period (CY 2005) and the contract period (CY
2007).
The
State
provided Xxxxxx with a detailed list of program changes that may have a material
impact on the cost, utilization, or demographic structure of the program prior
to, or within, the contract period and whose impact was not included within
the
base period data. In addition, other potential program changes are being
discussed in the current legislative session. Final programmatic changes
approved for SFY 2007 are reflected in the CY 2007 rates, as appropriate. Please
refer to Appendix D for more information on these programmatic
changes.
Clinical
Measures/Incentives
Per
Appendix M of the Provider Agreement, the State expects the MCPs to reach
certain performance levels for selected clinical measures. Xxxxxx reviewed
the
impact of these standards and incentives on the managed care rates and developed
a set of adjustments based upon the State's expected improvement rates. These
utilization targets were built into the capitation rates. The individual
measures/incentives are outlined in Appendix D.
Caseload
Historically,
the State has experienced significant changes in its Medicaid caseload. These
shifts in caseload have affected the demographics of the remaining Medicaid
population. Xxxxxx
XXXXXX
Government
Human Services Consulting
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Xx.
Xxx
Xxxxxx
Ohio
Department of Job and Family Services
evaluated
recent and expected caseload variations to determine if an adjustment was
necessary to account for demographic changes. Based on the data provided by
the
State, Xxxxxx determined no adjustments were necessary for either the
non-delivery or delivery rate cells.
Selection
Issues
There
are
two selection adjustments that were made in the development of the rates. The
first is adverse selection, which accounts for the "missing" managed care data
and is applied to historical FFS data. This adjustment is explained in more
detail in Appendix C.
The
second selection adjustment is voluntary selection, which accounts for the
fact
that costs associated with individuals who elect to participate in managed
care
are generally lower than the remaining FFS population. Therefore, the voluntary
selection adjustment adjusts for the risk of only those members selecting
managed care.
Both
selection adjustments are reductions to paid claims and utilization for
non-delivery data. Appendix D provides more detail around the voluntary
selection adjustment.
Non-State
Plan Services
According
to the CMS Final Medicaid Managed Care Rule that was implemented August 13,
2003, non-state plan services may not be included in the base data for
rate-setting. The CY 2004 and 2005 cost reports contain information from the
MCPs that was used to adjust the base data for non-state plan services reported
in the cost reports and the encounter data. Please refer to Appendix D for
more
information concerning this adjustment.
Prospective
Trend Development
Trend
is
an estimate of the change in the overall cost of providing a specific benefit
service over a finite period of time. A trend factor is necessary to estimate
the expenses of providing health care services in some future year, based on
expenses incurred in prior years. Trend was applied by COS to the blended base
data costs for CY 2005 to project the data forward to the CY 2007 contract
period.
Cost
report data was reviewed for overall per member per month (PMPM) trend levels
while the FFS data continued to be a primary source in projecting trend. Because
of its role in the rate-setting process, the encounter data was available to
study utilization trend drivers. Xxxxxx integrated the specific data sources'
trend analysis with a broader analysis of other trend resources. These resources
included health care economic factors (e.g., as Consumer Price
Index
XXXXXX
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Xx.
Xxx
Xxxxxx
Ohio
Department of Job and Family Services
(CPI)
and
Data Resource Inc. (DRI)), trends in neighboring states, the State FFS trend
expectations and any Ohio market changes. Moreover, the trend component was
comprised of both unit cost and utilization components.
As
in the
past. Xxxxxx discussed all trend recommendations with the State. We revievred
the potential impact of initiatives targeted to slow or otherwise affect the
trends in the program. Final trend amounts were determined from the many trend
resources and this additional program information. Appendix D provides more
information on trend.
Credibility
Assignment
For
regions composed of only new and voluntary counties, 100% credibility was placed
on the FFS data. For regions with available FFS and managed care data, the
FFS,
encounter and cost report data was blended together.
Cesarean
Delivery Rate
Xxxxxx
reviewed historical FFS delivery data, recent MCP delivery data, and other
program experience to determine an expected cesarean delivery rate under the
managed care program. Please refer to Appendix D for additional information
on
cesarean delivery rates.
Relational
Modeling
Relational
modeling was used to adjust the premiums by rate cohort to produce a relatively
consistent age/sex slope among the regions. The relational modeling adjustments
shift dollars across rate cohorts within a region but do not change the
composite results by region or in aggregate. Through the use of the adjustments,
the range of variances among the regions and rate cohorts was reduced while
maintaining budget neutrality.
The
relational modeling adjustments were applied to the net medical rates in the
Capitation Rate Calculation Sheets (CRCS) to develop new adjusted medical rates.
An administration load factor was then applied as a percent of
premium.
Administration/Contingencies
Xxxxxx
reviewed the components of the administration/contingencies allowance and
evaluated the administration/contingencies rates paid to the MCPs. Factors
that
were taken into consideration in determining the final
administration/contingencies percentages included the State's expectations,
Ohio
health plan experience, other Medicaid program
XXXXXX
Government
Human Services Consulting
Page
9
October
20, 2006
Xx.Xxx
Xxxxxx
Ohio
Department of Job and Family Services
administration/contingencies
allowances, and Ohio health plans' lengths of participation in the program.
In
addition, the MCP franchise fee of 4.5% was incorporated into the final
capitation rate.
Certification
of Final Rates
The
following capitation rates were developed for each of the seven regions for
the
CY 2007 contract period:
•
Healthy
Families/Healthy Start, Less Than 1, Male & Female,
•
Healthy
Families/Healthy Start, 1 Year Old, Male & Female,
•
Healthy
Families/Healthy Start, 2-13 Years Old, Male & Female,
•
Healthy
Families/Healthy Start, 14-18 Years Old, Female,
•
Healthy
Families/Healthy Start, 14-18 Years Old, Male,
•
Healthy
Families, 19-44 Years Old, Female,
•
Healthy
Families, 19-44 Years Old, Male,
•
Healthy
Families, 45 and Over, Male & Female,
•
Healthy
Start, 19-64 Years Old, Female, and
•
Delivery Payment.
A
summary
of the rates is included in Appendix X.
Xxxxxx
certifies the above rates were developed in accordance with generally accepted
actuarial practices and principles by actuaries meeting the qualification
standards of the American Academy of Actuaries for the populations and services
covered under the managed care contract. Rates developed by Xxxxxx are actuarial
projections of future contingent events. Actual MCP costs will differ from
these
projections. Xxxxxx developed these rates on behalf of the State to demonstrate
compliance with the CMS requirements under 42 CFR 438.6(c) and to demonstrate
that rates are in accordance with applicable law and regulations.
MCPs
are
advised that the use of these rates may not be appropriate for their particular
circumstance and Xxxxxx disclaims any responsibility for the use of these rates
by MCPs for any purpose. Xxxxxx recommends any MCP considering contracting
with
the State should analyze its own projected medical expense, administrative
expense, and any other premium needs for comparison to these rates before
deciding whether to contract with the State. Use of these rates for purposes
beyond those stated may not be appropriate.
XXXXXX
Government
Human Services Consulting
Page
10
October
20, 2006
Xx.
Xxx
Xxxxxx
Ohio
Department of Job and Family Services
Sincerely,
/s/ Xxxxxx
XxxXxxx
|
/s/ Xxxxx
Xxxxxx
|
Xxxxxx
XxxXxxx, MAAA, ASA
|
Xxxxx
Xxxxxx, MAAA, FSA
|
Copy:
Xxxxx
Xxxxxx, Xxxxxx Xxxxxx, Xxxxx Xxxxxxxx - State of Ohio Xxxxx Xxxxxx, Xxx
Xxxxxxxxx - Xxxxxx
XXXXXX
Government
Human Services Consulting
Appendix
A - CY 2007 Rate-Setting Methodology
(GRAPH)
XXXXXX
Government
Human Services Consulting
Appendix
B - Regional Delivery System Definition
Regional
Delivery System Definitions
For
regional rate development, counties were bucketed into mandatory. Preferred
Option, voluntary, or new as outlined below. The data for all counties within
the region was used to develop the regional rate. Please see page B-2 for a
map
defining the counties within each region.
Mandatory
and Preferred Option Counties
Encounter
and cost report data was used for counties that were either mandatory or
Preferred Option during the base data period*. These counties
include:
Mandatory:
|
Preferred
Option:
|
Cuyahoga
|
Xxxxxx
|
Xxxxx
|
Xxxxx
|
Xxxxx
|
Xxxxxxxx
|
Summit
|
Xxxxxxxx
|
|
Xxxxxx
|
Xxxxxxxxxx
|
*
Please note Mahoning and Trumbull are not included in the above table
due to
a lack of credible data. Both counties entered into managed care in October
of
2005.
Voluntary
Counties
FFS
data
was used for voluntary counties during the base period and new counties entering
the managed care program since the time of the base data. The voluntary counties
include:
Voluntary
|
Clermont
|
Xxxxxx
|
Pickaway
|
Xxxxxx
|
Xxxx
|
New
counties include all counties that were not mandatory, Preferred Option or
voluntary during the base data period.
X-x
XXXXXX
Government
Human Services Consulting
Medicaid
Managed Care Program Regions for the CFC Population
(MAP)
B-2
XXXXXX
Government
Human Services Consulting
Appendix
C - FFS Data Adjustments
This
section lists adjustments made to the FFS claims and eligibility information
received from the State.
Completion
Factors
The
claims data was adjusted to account for the value of claims incurred but unpaid
on a COS basis. Xxxxxx used claims for SPY 2004 and SFY 2005 that reflect
payments through the dates included in the following table.
SFY
|
Paid
Through
|
2004
|
03/31/05
|
2005
|
12/31/05
|
The
value
of the claims incurred during each of these years, but unpaid, was estimated
using completion factor analysis.
Gross
Adjustment File (GAF)
To
account for gross debit and credit amounts not reflected in the FFS data,
adjustments were applied to the FFS paid claims.
Historical
Policy Changes
As
part
of the rate-setting process, Xxxxxx must account for policy changes that
occurred during the base data time period. Changes only reflected in a portion
of the data must be applied to the remaining data so that all base data reflects
the policy changes. All policy changes implemented during SFY 2004 and SFY
2005
were applied to the FFS data.
The
following table shows the specific policy changes for which Xxxxxx adjusted
the
SFY 2004 and SFY 2005 delivery (where applicable) and non-delivery data. Xxxxxx
calculated the adjustments based on information supplied by the
State.
Policy
Changes
|
Effective
Date
|
Category
of Service Affected
|
Rate
Cohorts Affected
|
Independently-practicing
psychologist services eliminated for adults (>21) and pregnant
women
|
1/1/2004
|
POP,
OB/GYN and Specialists
|
Ages
19+, including delivery
|
All
chiropractic services eliminated for adults (>21) and pregnant
women
|
1/1/2004
|
Other
|
HF,
Age 00-00, X
|
XX,Xxx00-00,X
|
|||
XX,Xxx00x,
M & F
|
|||
HST,
Age 19-64, F
|
|||
Implementation
of $3.00 Copay on Prior-Authorized Drugs
|
1/1/2004
|
Pharmacy
|
All
|
X-x
XXXXXX
Government
Human Services Consulting
Third
Party Liability Recoveries
TPL
can
be identified with two components: "cost-avoidance" and "pay and chase" type
actions. "Cost-avoidance" occurs when the State initially denies paying a claim
because another payer is the primary payer. The State may then pay a residual
portion of the charged amount. Only the residual portion of the claim will
be
included in the FFS data. The portion of the claim paid by another payer has
been avoided and not included in reported claim payments. Participating MCPs
are
expected to pay in a similar fashion and therefore, no adjustment to the FFS
data will be required.
In
a "pay
and chase" scenario, the State pays the claim as though it were the primary
payer. Subsequent to payment, the State makes recovery from a third party.
These
TPL recoveries are not reflected in the FFS MMIS data. Since MCPs are also
expected to take similar recovery actions, the FFS experience was adjusted
to
reflect "pay and chase" recoveries. Xxxxxx made adjustments to both the paid
claims and utilization for all non-delivery and delivery COS. Since MCPs do
not
collect tort recoveries, the data excludes tort collections.
Hospital
Cost Settlements
The
State
provided Xxxxxx with SFY 2004 and SPY 2005 interim cost settlements for
Diagnosis Related Group (DRG) and DRG-exempt hospitals. The DRG-exempt hospital
information included inpatient and outpatient settlements. However, the DRG
hospitals only include capital settlements, which were incorporated into the
adjustment. Therefore, an adjustment has been applied to non-delivery and
delivery inpatient, outpatient, and emergency room (ER) claims to remove these
additional costs.
Fraud
and
Abuse
The
State
does pursue recoveries from fraud and abuse cases. The dollars recovered are
accounted for outside of the State's MMIS system and are not included in the
FFS
data. Since the MCPs are required to pursue fraud and abuse cases, an adjustment
was applied to the FFS claims and utilization in both the delivery and
non-delivery data.
Excluded
Time Periods
The
capitation rates paid to the MCPs reflect the risk of serving the eligible
enrollees from the date of health plan enrollment forward. Therefore, the
non-delivery FFS data has been adjusted to reflect only the time periods for
which the MCPs are at risk. Since newborns are automatically eligible for the
Medicaid program and are enrolled into their mother's MCP at birth, no
adjustment will be applied to the "Less Than 1" age group.
Adverse
Selection
An
adverse selection adjustment was applied to the historical FFS data to account
for the "missing" managed care data. The adverse selection factor adjusts the
associated risk of the FFS members to the entire Medicaid population's risk
by
accounting for the cost of the managed care population. This adjustment varies
by historical managed care penetration and includes a
C-2
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Government
Human Services Consulting
credibility
factor which accounts for differences in State enrollment patterns and data
sources. It has been applied to the paid claims and utilization for non-delivery
FFS base data.
Dual
Eligibles
Dual
eligible persons are not enrolled in managed care and, therefore, are not
included in the managed care rates. Their experience has been excluded from
the
base FFS data used to develop the rates.
Catastrophic
Claims
Since
the
State does not provide reinsurance to the MCPs, the MCPs are expected to
purchase reinsurance on their own. To reflect these costs, all claims, including
claims above the reinsurance threshold, were included in the base FFS data.
The
final rates Xxxxxx calculated reflect the total risk associated with the covered
population and are expected to be sufficient to cover the cost of the required
stop-loss provision.
DSH
Payments
DSH
payments are made by the State to providers and are not the responsibility
of
the MCPs;
therefore,
the information for these payments was excluded from the FFS data used to
develop the rates. No rate adjustment was necessary.
Spend
Down
Persons
Medicaid eligible due to spend down are not enrolled in managed care and
therefore not included in the managed care rates. The base FFS data is net
of
recipient spend down. Therefore, no additional adjustment was needed for the
rate computations.
Graduate
Medical Education (GME)
The
State
does not make supplemental GME payments for services delivered to individuals
covered under the managed care program. Rather, the MCPs negotiate specific
rates with the individual teaching hospitals for the daily cost of care.
Therefore, the GME payments are included in the capitation rates paid to the
MCPs.
C-3
XXXXXX
Government
Human Services Consulting
Appendix
C - Encounter Data Adjustments
Claims
Completion Xxxxxx used CY 2005 cost report lag triangles to complete the MCP
encounter utilization data.
Historical
Policy Changes
As
part
of the rate-setting process, the data must reflect any policy changes that
occurred during the base data time period. Changes only reflected in a portion
of the base data must be applied to the remaining base data to keep the data
similar. Xxxxxx made adjustments to the encounter data to include consideration
for the following policy changes.
Policy
Change
|
Effective
Date
|
Category
of Service Affected
|
Rate
Cohorts Affected
|
Independently-practicing
psychologist services eliminated for adults (>21) and pregnant
women
|
1/1/2004
|
PCP,
OB/GYN and Specialists
|
Ages
19+, including delivery
|
All
chiropractic services eliminated for adults (>21) and pregnant
women
|
1/1/2004
|
Other
|
H
F, Age 19-44, M
|
HF,
Age 19-44, F
|
|||
HF,
Age 45+, M & F
|
|||
HST,
Age 19-64, F
|
The
adjustment for the $3.00 copay on Prior-Authorization Drugs cannot be directly
applied to the encounter data because it only contains utilization. The unit
cost reduction was, however, reflected in the encounter data shadow
prices.
Data
Anomaly Corrections
As
directed by the State, Xxxxxx made adjustments to the encounter data to account
for
incomplete
reporting or other known data issues.
Non-State
Plan Services
Xxxxxx
reviewed NSPS information included in the MCP cost reports. This information
was
used to calculate an adjustment for NSPS, including eye examinations,
chiropractic and psychological services, and routine transportation. The
adjustment was applied to the Specialists, Dental and Other categories of
service in the encounter data, as appropriate.
Third
Party Liability Recoveries
Xxxxxx
reviewed TPL recoveries information contained in Report I of the cost reports
to
remove these from the encounters reported by each health plan. Xxxxxx made
MCP
specific adjustments to the data.
C-4
XXXXXX
Government
Human Services Consulting
Appendix
C - Cost Report Data Adjustments
IBNR
Review/Adjustment
Xxxxxx
used CY 2005 cost report claims restatement Report IV and lag triangles to
adjust the MCP IBNR estimates in the CY 2004 and CY 2005 financial
experience.
Historical
Policy Changes
As
part
of the rate-setting process, the data must reflect any policy changes that
occurred during the base data time period. Changes only reflected in a portion
of the base data must be applied to the remaining base data to keep the data
similar. There were no rate-impacting policy changes implemented after 1/1/2004
and before 12/31/05. Therefore, no policy change adjustments were applied to
the
cost report data.
Data
Anomaly Corrections
Xxxxxx
made cost-neutral adjustments to the CY 2004 cost report data to account for
receding of expenses by category of service. For example, the delivery costs
associated with the "Other" COS in report III-A were shifted to the non-delivery
"Other" COS.
Non-State
Plan Services
Xxxxxx
reviewed NSPS information included in the MCP cost reports. This information
was
used to calculate an adjustment for NSPS, including eye examinations,
chiropractic and psychological services, and routine transportation. The
adjustment was applied to the Specialists, Dental and Other categories of
service in the cost report data, as appropriate.
Third
Party Liability Recoveries
Xxxxxx
reviewed TPL recoveries information contained in Report I of the cost reports
to
remove these from the medical costs reported by each health plan.
C-5
XXXXXX
Government
Human Services Consulting
Appendix
D - Calendar Year 2007 CFC Rate Development
Credibility
By Year
Xxxxxx
placed more credibility on the most recent year of data for each data
source.
FFS
Historical and Managed Care Historical/Prospective Trend
Historical
FFS trend assumptions were used to trend SFY 2004 and SPY 2005 FFS data to
the
base period (CY 2005) for voluntary and new counties. Credibility was then
applied to blend together the trended SFY 2004 and the SFY 2005 FFS
data.
Managed
care historical trend was used to trend SFY 2004 and SFY 2005 encounter data
and
CY 2004 cost report data to the base period (CY 2005) for Preferred Option
and
mandatory counties. Credibility was then applied to blend together the trended
SFY 2004 and the SPY 2005 encounter data and the trended CY 2004 and CY 2005
cost report data.
Prospective
managed care trend assumptions were then applied to the blended FFS, cost
report, and encounter data to develop the CY 2007 regional rates.
Prospective
Policy Changes
The
following items are considered prospective policy changes. These changes were
not reflected in the base data, but were implemented prior to the contract
period. Therefore, Xxxxxx made rate-setting adjustments for each item in the
following table.
Adjustments
Affecting Unit Cost
Policy
Change
|
Effective
Date
|
Category
of Service Affected
|
Rate
Cohorts Affected
|
Implementation
of $2 copay for trade-name preferred drugs for adults (S21)
|
1/1/2006
|
Pharmacy
|
HF,
Age 19-44, F
|
HF,
Age 19-44, M
|
|||
HF,
Age 45+, M & F
|
|||
Implementation
of $3 copay for each dental date of service for adults (2:21)
|
1/1/2006
|
Dental
|
XX,Xxx00
-00,X
|
HF,
Age 19-44, M
|
|||
HF,
Age 45+, M & F
|
|||
Implementation
of $2 copay for vision exams and $1 copay for dispensing services
for
adults (S21)
|
1/1/2006
|
Other
|
HF,
Age 19-44, F
|
HF,
Age 19-44, M
|
|||
HF,
Age 45+, M&F
|
|||
HST,
Age 19-64, F
|
|||
Inpatient
recalibration and outlier policies
|
1/1/2006
|
Inpatient
|
All
|
Inpatient
rate freeze
|
1/1/2006
|
Inpatient
|
All
|
X-x
XXXXXX
Government
Human Services Consulting
Adjustments
Affecting Utilization
Policy
Change
|
Effective
Date
|
Category
of Service Affected
|
Rate
Cohorts Affected
|
Reduction
in coverage of dental services for adults (S21)
|
1/1/2006
|
Dental
|
HF, Age
19-44, F
|
HF, Age
19-44, M
|
|||
HF, Age
45+, M & F
|
|||
HST,
Age 19-64, F
|
The
1/1/2006 policy change in the Federal Poverty Level (FPL) from 100% to 90%
did
not have an impact on the rates.
Clinical
Measures/Incentives
Since
the
State requires the plans to reach, at minimum, the performance standard for
each
of the indicators from Appendix M of the SPY 2007 Provider Agreement, Xxxxxx
built this expectation into the capitation rates. To calculate the adjustments,
Xxxxxx reviewed MCP clinical measures percentages for the CY 2005 base year
and
projected these rates forward by building in the State's expected improvement
rate for counties in managed care as of January 1, 2006. Xxxxxx then calculated
the percent change from base year to the rating period, and applied the
adjustment as a portion of COS. The following chart provides additional detail
on each clinical measure.
D-2
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Government
Human Services Consulting
Clinical
Measure
|
Rate
Cohort
|
Category
of Service Affected
|
Prenatal
Care - Frequency of Ongoing Prenatal Care
Target:
80% of eligible population must receive 81% or more of expected
number of
prenatal visits.
|
HF/HST,
14-18F
HST,
19-64F
HF,
19-44F
|
OB/GYN
Physician
|
Prenatal
Care - Post Partum Visits
Target:
80% of the eligible population must receive a post partum
visit.
|
HF/HST,
00-00 X
XXX,
00-00X
XX,
00-00X
|
XX/XXX
|
Preventive
Care for Children -WelI-Child Visits
Target:
80% of children receive expected number of visits: Children who
turn 15
mos. old; 6+ visits. Children who were 3-6 years old; 1+ visit.
Children
who were 12-21 years old; 1+ visit.
|
HF/HST,
<1 M&F
HF/HST,
1 M&F
HF/HST,
2-13 M&F
HF/HST,
14-18 M
HF/HST,
14-18F
|
Physician
|
Use
of Appropriate Medications for People with Asthma
Target:
95% of eligible Asthma members receive prescribed medications acceptable
as primary therapy for long-term control of asthma.
|
HF/HST,
2-13 M&F
HF/HST,
14-18M
HF/HST,
14-18F
HF,
19-44M
HF,
19-44F
HF,
45+ M&F
HST,
19-64F
|
Pharmacy
|
Annual
Dental Visits
Target:
60% of enrolled children age 4-21 receive 1 dental visit.
|
HF/HST,
2-13 M&F
HF/HST,
14-18M
HF/HST,
14-18F
|
Dental
|
Lead
Screening
Target:
80% of children age 1-2 receive a blood lead screening.
|
HF/HST,
1 M&F
HF/HST,
2-13 M&F
|
Physician
|
Voluntary
Selection
As
a
result of the adverse selection adjustment that was applied in the FFS Data
Summaries, the FFS data already reflects the risk of the entire Medicaid
program
(i.e., FFS and managed care individuals). To solely reflect the risk of the
managed care program. Xxxxxx modified the FFS data based on the projected
managed care penetration levels for CY 2007. This voluntary selection adjustment
modifies the FFS data to reflect the risk to the MCPs (i.e., only those
individuals who enroll in a health plan).
For
the
encounter and cost report data, the original base data reflects the historical
penetration levels in SFY 2004-SFY 2005 and CY 2004-CY 2005, respectively.
Where
projected managed
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Government
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care
penetration levels differ from the historical values, the data was brought
back
to reflect the risk of the entire Medicaid program, and then adjusted forward
(as the FFS data was) to reflect projected managed care levels.
Credibility
by Data Source
For
regions composed of only new and voluntary counties, 100% credibility was
placed
on the FFS data. For regions with available FFS and managed care data, the
FFS
data was used for the new and voluntary counties within the region, while
the
encounter and cost report data were used for the mandatory and Preferred
Option
counties within the region.
C-Section/Vaginal
Percent
Xxxxxx
received MCP cesarean and vaginal rates from CY 2005 encounter data. Based
on
the analysis for all MCPs combined, Xxxxxx determined C-section and vaginal
rate
assumptions.
MCP
Administration/Contingencies
Based
on
a review of MCP reported administration expenses, the MCP administration/
contingencies allowance will remain at 12% of premium prior to the franchise
fee. For existing health plans, 1% of the pre-franchise fee capitation rate
will
be put at risk, contingent upon MCPs meeting performance requirements for
counties with managed care enrollment as of January 1, 2006. The at-risk
amount
for. counties entering managed care after January 1, 2006 will be 0% for
the
first two plan years.
For
plans
new to managed care in Ohio, the administration schedule will be as
follows.
Admin
|
At-Risk
|
|
Plan
Year 1 (months 1-12)
|
13%
|
0%
|
Plan
Year 2 (months 13-24)
|
12%
|
0%
|
Plan
Year 3 (months 25-36)
|
12%
|
1%
|
For
plans
entering Ohio through the acquisition of another Ohio health plan's membership,
the administration schedule will continue as outlined above based on the
plan
year of the acquired health plan membership. The administration schedule
will
not revert back to the Plan Year 1 schedule due to the membership
acquisition.
In
addition, the total capitation rate was adjusted to incorporate the 4.5%
MCP
franchise fee requirement.
D-4
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Appendix
E - Calendar Year 2007 CFC Regional Rate Summary
Appendix
E
Calendar
Year 2007 CFC Regional Rate Summary
|
|||||||||||||||||||||
Region
|
Rate
Cohort
|
Annualized
April 2006 MM/Deliveries
|
%
of MM
|
CY
2007 Guaranteed Rate
|
CY
2007 Rate At Risk
|
CY
2007 Rate
|
|||||||||||||||
Central
|
HF/HST,
Age 0, M & F
|
171,818
|
6.00 | % | $ |
564.92
|
$ |
5.45
|
$ |
570.36
|
|||||||||||
Central
|
HF/HST,
Age 1, M&F
|
146,106
|
5.10 | % | $ |
149.56
|
$ |
1.44
|
$ |
151.01
|
|||||||||||
Central
|
HF/HST,
Age 2-13, M&F
|
1,335,641
|
46.60 | % | $ |
99.74
|
$ |
0.96
|
$ |
100.70
|
|||||||||||
Central
|
HF/HST,
Age 14-18, M
|
191,907
|
6.70 | % | $ |
118.11
|
$ |
1.14
|
$ |
119.25
|
|||||||||||
Central
|
HF/HST,
Age 14-18, F
|
208,187
|
7.30 | % | $ |
166.07
|
$ |
1.60
|
$ |
167.68
|
|||||||||||
Central
|
HF,
Age 19-44, M
|
172,314
|
6.00 | % | $ |
206.93
|
$ |
2.00
|
$ |
208.92
|
|||||||||||
Central
|
HF.Age
19-44, F
|
531,797
|
18.50 | % | $ |
299.33
|
$ |
2.89
|
$ |
302.21
|
|||||||||||
Central
|
HF,
Age 45+, M&F
|
59,319
|
2.10 | % | $ |
487.07
|
$ |
4.70
|
$ |
491.77
|
|||||||||||
Central
|
HST,
Age 19-64, F
|
50,975
|
1.80 | % | $ |
340.59
|
$ |
3.28
|
$ |
343.87
|
|||||||||||
Central
|
Subtotal
|
2,868,064
|
100.00 | % | $ |
191.93
|
$ |
1.85
|
$ |
193.78
|
|||||||||||
Central
|
Delivery
Payment
|
9,465
|
0.30 | % | $ |
4,023.39
|
$ |
38.79
|
$ |
4,062.19
|
|||||||||||
Central
|
Total
|
2,868,064
|
100.00 | % | $ |
205.21
|
$ |
1.98
|
$ |
207.19
|
|||||||||||
East-Central
|
HF/HST,
Age 0, M & F
|
95,509
|
5.60 | % | $ |
554.55
|
$ |
5.35
|
$ |
559.90
|
|||||||||||
East-Central
|
HF/HST,Age1,M&F
|
78,227
|
4.60 | % | $ |
145.80
|
$ |
1.41
|
$ |
147.21
|
|||||||||||
East-Central
|
HF/HST,
Age 2-13, M&F
|
786,577
|
46.40 | % | $ |
98.24
|
$ |
0.95
|
$ |
99.19
|
|||||||||||
East-Central
|
HF/HST,
Age 14-18, M
|
122,231
|
7.20 | % | $ |
114.36
|
$ |
1.10
|
$ |
115.47
|
|||||||||||
East-Central
|
HF/HST,
Age 14-18, F
|
126,757
|
7.50 | % | $ |
158.66
|
$ |
1.53
|
$ |
160.19
|
|||||||||||
East-Central
|
HF,
Age 19-44, M
|
98,371
|
5.80 | % | $ |
200.66
|
$ |
1.93
|
$ |
202.59
|
|||||||||||
East-Central
|
HF,
Age 19-44, F
|
320,557
|
18.90 | % | $ |
290.72
|
$ |
2.80
|
$ |
293.52
|
|||||||||||
East-Central
|
HF,
Age 45+, M&F
|
38,258
|
2.30 | % | $ |
470.93
|
$ |
4.54
|
$ |
475.47
|
|||||||||||
East-Central
|
HST,
Age 19-64, F
|
29,264
|
1.70 | % | $ |
331.03
|
$ |
3.19
|
$ |
334.22
|
|||||||||||
East-Central
|
Subtotal
|
1,695,750
|
100.00 | % | $ |
186.57
|
$ |
1.80
|
$ |
188.37
|
|||||||||||
East-Central
|
Delivery
Payment
|
5,596
|
0.30 | % | $ |
4,132.16
|
$ |
39.84
|
$ |
4,172.00
|
|||||||||||
East-Central
|
Total
|
1,695,750
|
100.00 | % | $ |
200.20
|
$ |
1.93
|
$ |
202.13
|
|||||||||||
Northeast
|
HF/HST,
Age 0, M & F
|
152,915
|
5.20 | % | $ |
529.07
|
$ |
5.10
|
$ |
534.17
|
|||||||||||
Northeast
|
HF/HST,
Age 1, M & F
|
133,744
|
4.50 | % | $ |
140.45
|
$ |
1.35
|
$ |
141.80
|
|||||||||||
Northeast
|
HF/HST,
Age 2-13, M&F
|
1,381,832
|
46.70 | % | $ |
94.02
|
$ |
0.91
|
$ |
94.93
|
|||||||||||
Northeast
|
HF/HST,
Age 14-18, M
|
223,275
|
7.50 | % | $ |
111.31
|
$ |
1.07
|
$ |
112.38
|
|||||||||||
Northeast
|
HF/HST,
Age 14-18, F
|
236,299
|
8.00 | % | $ |
153.26
|
$ |
1.48
|
$ |
154.74
|
|||||||||||
Northeast
|
HF,
Age 19-44 M
|
136,730
|
4.60 | % | $ |
193.74
|
$ |
1.87
|
$ |
195.61
|
|||||||||||
Northeast
|
HF,
Age 19-44 F
|
576,329
|
19.50 | % | $ |
279.38
|
$ |
2.69
|
$ |
282.08
|
|||||||||||
Northeast
|
HF,
Age 45+, M&F
|
75,738
|
2.60 | % | $ |
453.99
|
$ |
4.38
|
$ |
458.37
|
|||||||||||
Northeast
|
HST,
Age 19-64, F
|
41,229
|
1.40 | % | $ |
318.02
|
$ |
3.07
|
$ |
321.09
|
|||||||||||
Northeast
|
Subtotal
|
2,958,090
|
100.00 | % | $ |
177.71
|
$ |
1.71
|
$ |
179.42
|
|||||||||||
Northeast
|
Delivery
Payment
|
9,762
|
0.30 | % | $ |
4,620.33
|
$ |
44.55
|
$ |
4,664.87
|
|||||||||||
Northeast
|
Total
|
2,958,090
|
100.00 | % | $ |
192.96
|
$ |
1.86
|
$ |
194.82
|
|||||||||||
Northwest
|
HF/HST,
Age 0, M & F
|
95,817
|
6.30 | % | $ |
559.84
|
$ |
5.40
|
$ |
565.23
|
|||||||||||
Northwest
|
HF/HST,
Age 1, M&F
|
77,885
|
5.10 | % | $ |
148.68
|
$ |
1.43
|
$ |
150.11
|
|||||||||||
Northwest
|
HF/HST,
Age 2-13, M&F
|
703,072
|
45.90 | % | $ |
97.75
|
$ |
0.94
|
$ |
98.69
|
|||||||||||
Northwest
|
HF/HST,
Age 14-18, M
|
102,361
|
6.70 | % | $ |
115.24
|
$ |
1.11
|
$ |
116.35
|
|||||||||||
Northwest
|
HF/HST,
Age 14-18, F
|
111,868
|
7.30 | % | $ |
162.33
|
$ |
1.57
|
$ |
163.89
|
|||||||||||
Northwest
|
HF,
Age 19-44, M
|
91,211
|
6.00 | % | $ |
202.82
|
$ |
1.96
|
$ |
204.77
|
|||||||||||
Northwest
|
HF.Age
19-44, F
|
289,036
|
18.90 | % | $ |
299.30
|
$ |
2.89
|
$ |
302.18
|
|||||||||||
Northwest
|
HF,
Age 45+, M&F
|
29,822
|
1.90 | % | $ |
483.93
|
$ |
4.67
|
$ |
488.60
|
|||||||||||
Northwest
|
HST,
Age 19-64, F
|
30,803
|
2 | % | $ |
338.79
|
$ |
3.27
|
$ |
342.06
|
|||||||||||
Northwest
|
Subtotal
|
1,531,875
|
100 | % | $ |
191.78
|
$ |
1.85
|
$ |
193.63
|
|||||||||||
Northwest
|
Delivery
Payment
|
5,055
|
0.30 | % | $ |
4,254.97
|
$ |
41.03
|
$ |
4,295.99
|
|||||||||||
Northwest
|
Total
|
1,531,875
|
100.00 | % | $ |
205.82
|
$ |
1.98
|
$ |
207.80
|
Appendix
E
Calendar
Year 2007 CFC Regional Rate Summary
|
|||||||||||||||||||||
Region
|
Rate
Cohort
|
Annualized
April 2006 MM/Deliveries
|
%
of MM
|
CY
2007
Guaranteed
Rate
|
CY
2007
Rate
At Risk
|
CY
2007
Rate
|
|||||||||||||||
Southeast
|
HF/HST,
Age 0, M & F
|
54,686
|
4.9 | % | $ |
523.86
|
$ |
5.05
|
$ |
528.91
|
|||||||||||
Southeast
|
HF/HST,
Age 1, M & F
|
47,093
|
4.2 | % | $ |
138.49
|
$ |
1.34
|
$ |
139.82
|
|||||||||||
Southeast
|
HF/HST,
Age 2-13, M & F
|
487,601
|
43.9 | % | $ |
93.56
|
$ |
0.90
|
$ |
94.46
|
|||||||||||
Southeast
|
HF/HST,
Age 14-18, M
|
82,844
|
7.5 | % | $ |
109.68
|
$ |
1.06
|
$ |
110.74
|
|||||||||||
Southeast
|
HF/HST,
Age 14-18, F
|
84,280
|
7.6 | % | $ |
153.88
|
$ |
1.48
|
$ |
155.37
|
|||||||||||
Southeast
|
HF,
Age 19-44, M
|
98,747
|
8.9 | % | $ |
195.17
|
$ |
1.88
|
$ |
197.06
|
|||||||||||
Southeast
|
HF,
Age 19-44, F
|
211,664
|
19.0 | % | $ |
281.12
|
$ |
2.71
|
$ |
283.83
|
|||||||||||
Southeast
|
HF,
Age 45+, M & F
|
27,930
|
2.5 | % | $ |
458.74
|
$ |
4.42
|
$ |
463.16
|
|||||||||||
Southeast
|
HST,
Age 19-64, F
|
16,667
|
1.5 | % | $ |
320.31
|
$ |
3.09
|
$ |
323.40
|
|||||||||||
Southeast
|
Subtotal
|
1,111,511
|
100.0 | % | $ |
179.73
|
$ |
1.73
|
$ |
181.86
|
|||||||||||
Southeast
|
Delivery
Payment
|
3,668
|
0.3 | % | $ |
4,128.68
|
$ |
39.81
|
$ |
4,168.49
|
|||||||||||
Southeast
|
Total
|
1,111,511
|
100.0 | % | $ |
193.36
|
$ |
1.86
|
$ |
195.22
|
|||||||||||
Southwest
|
HF/HST,
Age 0, M & F
|
121,364
|
6.5 | % | $ |
570.51
|
$ |
5.50
|
$ |
576.01
|
|||||||||||
Southwest
|
HF/HST,
Age 1, M & F
|
97,721
|
5.3 | % | $ |
148.69
|
$ |
1.43
|
$ |
150.13
|
|||||||||||
Southwest
|
HF/HST,
Age 2-13, M & F
|
876,398
|
47.1 | % | $ |
99.74
|
$ |
0.96
|
$ |
100.70
|
|||||||||||
Southwest
|
HF/HST,
Age 14-18, M
|
126,346
|
6.8 | % | $ |
116.29
|
$ |
1.12
|
$ |
117.41
|
|||||||||||
Southwest
|
HF/HST,
Age 14-18, F
|
140,619
|
7.6 | % | $ |
163.87
|
$ |
1.58
|
$ |
165.45
|
|||||||||||
Southwest
|
HF,
Age 19-44, M
|
91,907
|
4.9 | % | $ |
206.77
|
$ |
1.99
|
$ |
208.77
|
|||||||||||
Southwest
|
HF,
Age 19-44, F
|
335,867
|
18.0 | % | $ |
298.60
|
$ |
2.88
|
$ |
301.48
|
|||||||||||
Southwest
|
HF,
Age 45+, M & F
|
35,032
|
1.9 | % | $ |
485.99
|
$ |
4.69
|
$ |
490.68
|
|||||||||||
Southwest
|
HST,
Age 19-64, F
|
35,739
|
1.9 | % | $ |
340.78
|
$ |
3.29
|
$ |
344.06
|
|||||||||||
Southwest
|
Subtotal
|
1,860,993
|
100.0 | % | $ |
192.06
|
$ |
1.85
|
$ |
193.91
|
|||||||||||
Southwest
|
Delivery
Payment
|
6,141
|
0.3 | % | $ |
4,690.50
|
$ |
45.23
|
$ |
4,735.73
|
|||||||||||
Southwest
|
Total
|
1,860,993
|
100.0 | % | $ |
207.53
|
$ |
2.00
|
$ |
209.54
|
|||||||||||
West-Central
|
HF/HST,
Age 0, M & F
|
81,065
|
6.3 | % | $ |
580.47
|
$ |
5.60
|
$ |
586.06
|
|||||||||||
West-Central
|
HF/HST,
Age 1, M & F
|
64,022
|
5.0 | % | $ |
155.39
|
$ |
1.50
|
$ |
156.89
|
|||||||||||
West-Central
|
HF/HST,
Age 2-13, M & F
|
599,936
|
46.5 | % | $ |
102.85
|
$ |
0.99
|
$ |
103.85
|
|||||||||||
West-Central
|
HF/HST,
Age 14-18, M
|
86,948
|
6.7 | % | $ |
122.06
|
$ |
1.18
|
$ |
123.24
|
|||||||||||
West-Central
|
HF/HST,
Age 14-18, F
|
95,920
|
7.4 | % | $ |
169.37
|
$ |
1.63
|
$ |
171.01
|
|||||||||||
West-Central
|
HF,
Age 19-44, M
|
68,617
|
5.3 | % | $ |
211.40
|
$ |
2.04
|
$ |
213.43
|
|||||||||||
West-Central
|
HF,
Age 19-44, F
|
244,883
|
19.0 | % | $ |
310.07
|
$ |
2.99
|
$ |
313.06
|
|||||||||||
West-Central
|
HF,
Age 45+, M & F
|
24,806
|
1.9 | % | $ |
505.52
|
$ |
4.87
|
$ |
510.40
|
|||||||||||
West-Central
|
HST,
Age 19-64, F
|
23,655
|
1.8 | % | $ |
352.42
|
$ |
3.40
|
$ |
355.82
|
|||||||||||
West-Central
|
Subtotal
|
1,289,853
|
100.0 | % | $ |
199.16
|
$ |
1.92
|
$ |
201.08
|
|||||||||||
West-Central
|
Delivery
Payment
|
4,257
|
0.3 | % | $ |
4,509.84
|
$ |
43.48
|
$ |
4,553.32
|
|||||||||||
West-Central
|
Total
|
1,289,853
|
100.0 | % | $ |
214.04
|
$ |
2.06
|
$ |
216.10
|
|||||||||||
All
Regions
|
HF/HST,
Age 0, M & F
|
773,175
|
5.8 | % | $ |
555.52
|
$ |
5.36
|
$ |
560.88
|
|||||||||||
All
Regions
|
HF/HST,
Age 1, M & F
|
644,798
|
4.8 | % | $ |
146.75
|
$ |
1.41
|
$ |
148.16
|
|||||||||||
All
Regions
|
HF/HST,
Age 2-13, M & F
|
6,171,057
|
46.3 | % | $ |
97.86
|
$ |
0.94
|
$ |
98.80
|
|||||||||||
All
Regions
|
HF/HST,
Age 14-18, M
|
935,911
|
7.0 | % | $ |
115.06
|
$ |
1.11
|
$ |
116.17
|
|||||||||||
All
Regions
|
HF/HST,
Age 14-18, F
|
1,003,930
|
7.5 | % | $ |
160.69
|
$ |
1.55
|
$ |
162.24
|
|||||||||||
All
Regions
|
HF,
Age 19-44, M
|
757,896
|
5.7 | % | $ |
202.09
|
$ |
1.95
|
$ |
204.04
|
|||||||||||
All
Regions
|
HF,
Age 19-44, F
|
2,510,133
|
18.9 | % | $ |
293.06
|
$ |
2.83
|
$ |
295.89
|
|||||||||||
All
Regions
|
HF,
Age 45+, M & F
|
290,906
|
2.2 | % | $ |
474.74
|
$ |
4.58
|
$ |
479.32
|
|||||||||||
All
Regions
|
HST,
Age 19-64, F
|
228,331
|
1.7 | % | $ |
334.82
|
$ |
3.23
|
$ |
338.05
|
|||||||||||
All
Regions
|
Subtotal
|
13,316,137
|
100.0 | % | $ |
187.77
|
$ |
1.81
|
$ |
189.58
|
|||||||||||
All
Regions
|
Delivery
Payment
|
43,943
|
0.3 | % | $ |
4,345.63
|
$ |
41.90
|
$ |
4,387.53
|
|||||||||||
All
Regions
|
Total
|
13,316,137
|
100.0 | % | $ |
202.11
|
$ |
1.95
|
$ |
204.06
|
APPENDIX
F
|
|||||||||||
REGIONAL
RATES
|
|||||||||||
1. PREMIUM
RATES WITHOUT THE AT-RISK PAYMENT AMOUNTS FOR 12/01/07 THROUGH
12/31/07 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
|
$534.17
|
$141.80
|
$94.93
|
$112.38
|
$154.74
|
$195.61
|
$282.08
|
$458.37
|
$321.09
|
$4,664.87
|
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 2008 contract period, MCPs will be put at-risk for a portion
of
the premiums received for members in counties 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
counties they began serving after January 1, 2006, beginning with
the MCP's twenty-fifth month of membership in each county's
region.
|
|||||||||||
|
|||||||||||
Page
1 of 3
|
APPENDIX
F
|
|||||||||||
REGIONAL
RATES
|
|||||||||||
2. AT-RISK
AMOUNTS FOR 12/01/07 THROUGH 12/31/07 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 2008 contract period, MCPs will be put at-risk for a portion
of
the premiums received for members in counties 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
counties they began serving after January 1, 2006, beginning with
the
MCP's twenty-fifth month of membership in each county's
region.
|
|||||||||||
|
|||||||||||
Page
2 of 3
|
APPENDIX
F
|
|||||||||||
REGIONAL
RATES
|
|||||||||||
3. PREMIUM
RATES FOR 12/01/07 THROUGH 12/31/07 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
|
$534.17
|
$141.80
|
$94.93
|
$112.38
|
$154.74
|
$195.61
|
$282.08
|
$458.37
|
$321.09
|
$4,664.87
|
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 2008 contract period, MCPs will be put at-risk for a portion
of
the premiums received for members in counties 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
counties they began serving after January 1, 2006, beginning with
the MCP's twenty-fifth month of membership in each county's
region.
|
|||||||||||
|
|||||||||||
Page
3 of 3
|
APPENDIX
F
|
|||||||||||
REGIONAL
RATES
|
|||||||||||
1. PREMIUM
RATES WITHOUT THE AT-RISK PAYMENT AMOUNTS FOR 07/01/07 THROUGH
11/30/07 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
|
$540.31
|
$143.43
|
$96.02
|
$113.67
|
$156.52
|
$197.86
|
$285.32
|
$463.64
|
$324.78
|
$4,718.49
|
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 2008 contract period, MCPs will be put at-risk for a portion
of
the premiums received for members in counties 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
counties they began serving after January 1, 2006,
beginning
|
|||||||||||
with
the MCP's twenty-fifth month of membership in each county's
region.
|
|||||||||||
Page
1 of 3
|
APPENDIX
F
|
|||||||||||
REGIONAL
RATES
|
|||||||||||
2. AT-RISK
AMOUNTS FOR 07/01/07 THROUGH 11/30/07 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 2008 contract period, MCPs will be put at-risk for a portion
of
the premiums received for members in counties 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
counties they began serving after January 1, 2006,
beginning
|
|||||||||||
with
the MCP's twenty-fifth month of membership in each county's
region.
|
|||||||||||
Page
2 of 3
|
APPENDIX
F
|
|||||||||||
REGIONAL
RATES
|
|||||||||||
3. PREMIUM
RATES FOR 07/01/07 THROUGH 11/30/07 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
|
$540.31
|
$143.43
|
$96.02
|
$113.67
|
$156.52
|
$197.86
|
$285.32
|
$463.64
|
$324.78
|
$4,718.49
|
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 2008 contract period, MCPs will be put at-risk for a portion
of
the premiums received for members in counties 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
counties they began serving after January 1, 2006,
beginning
|
|||||||||||
with
the MCP's twenty-fifth month of membership in each county's
region.
|
|||||||||||
Page
3 of 3
|
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 [not covered for adults age twenty-one (21) and
older]
|
|
·
|
Physical
therapy, occupational therapy, and speech
therapy
|
|
·
|
Nurse-midwife,
certified family nurse practitioner, and certified pediatric nurse
practitioner services
|
|
·
|
Prescription
drugs
|
|
·
|
Ambulance
and ambulette services
|
|
·
|
Dental
services
|
·
|
Durable
medical equipment and medical
supplies
|
|
·
|
Vision
care services, including eyeglasses
|
|
·
|
Short-term rehabilitative
stays in a nursing facility as specified in OAC rule
5101:3-26-03
|
|
·
|
Hospice
care
|
|
·
|
Behavioral
health services (see section G.2.b.iii of this appendix). Note:
Independent psychologist services not covered for adults age twenty-one
(21) and older.
|
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
|
|
·
|
Sexual
or marriage counseling
|
|
·
|
Court
ordered testing
|
|
·
|
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.
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.
iii. Behavioral
Health Services
Coordination
of Services: MCPs must have a process to coordinate benefits of
and referrals to the publicly funded community behavioral health
system. MCPs must ensure that members have access to all
medically-necessary behavioral health services covered by the Ohio Medicaid
FFS
program and are responsible for coordinating those services with other medical
and support services. MCPs must notify members via the member
handbook and provider directory of where and how to access behavioral health
services, including the ability to self-refer to mental health services offered
through ODMH community mental health centers (CMHCs) as well as substance
abuse
services offered through Ohio Department of Alcohol and Drug Addiction Services
(ODADAS)-certified Medicaid providers. Pursuant to ORC Section 5111.16, alcohol,
drug addiction and mental health services covered by Medicaid are not to
be paid
by the managed care program when the nonfederal share of the cost of those
services is provided by a board of alcohol, drug addiction, and mental health
services or a state agency other than ODJFS. MCPs are also not
responsible for providing mental health services to persons between 22 and
64
years of age while residing in private or public free-standing psychiatric
hospitals.
MCPs
must
provide Medicaid-covered behavioral health services for members who are unable
to timely access services or are unwilling to access services through community
providers.
Mental
Health Services: There are a number of Medicaid-covered mental health
(MH) services available through ODMH CMHCs.
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.
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 and methadone
maintenance.
Financial
Responsibility for Behavioral Health Services: MCPs are
responsible for the following:
|
·
|
payment
of Medicaid-covered prescription drugs prescribed by an ODMH CMHC
or
ODADAS-certified provider when obtained through an MCP’s panel
pharmacy;
|
|
·
|
payment
of Medicaid-covered services provided by an MCP’s panel laboratory when
referred by an ODMH CMHC
or ODADAS-certified
provider;
|
|
|
|
·
|
payment
of all other Medicaid-covered behavioral health services obtained
through
providers other than those who are ODMH CMHCs or ODADAS-certified
providers when arranged/authorized by the
MCP.
|
Limitations:
|
·
|
Pursuant
to ORC Section 5111.16, alcohol, drug addiction and mental health
services
covered by Medicaid are not to be paid by the managed care program
when
the nonfederal share of the cost of those services is provided
by a board
of alcohol, drug addiction, and mental health services or a state
agency
other than ODJFS. As part of this
limitation:
|
|
·
|
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 samedrugs covered by the Ohio
Medicaid fee-for-service program.
|
|
MCPs
may establish a preferred drug list for members and providers which
includes a listing of the drugs that they prefer to have prescribed.
Preferred drugs requiring prior authorization approval must be
clearly
indicated as such. Pursuant to ORC §5111.72, ODJFS may approve
MCP-specific pharmacy program utilization management strategies
(see
appendix G.3.a).
|
v.
|
Organ
Transplants: MCPs must ensure coverage for
organtransplants and related services in accordance with OAC 5101-3-2-07.1
(B)(4)&(5). Coverage for all organ transplant services,
exceptkidney 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, iscontingent upon review
and
recommendation by the “OhioHematapoietic Stem Cell Transplant Consortium” again
based oncriteria 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.
3.
|
Care
Coordination
|
a. Utilization
Management (Modification) Programs
General
Provisions - Pursuant to OAC rule 5101:3-26-03.1(A)(7), MCPs must implement
a utilization management program to maximize the effectiveness of the care
provided to members and may develop other utilization management programs,
subject to prior approval by ODJFS. For the purposes of this
requirement, the specific utilization management programs
which require ODJFS prior-approval are those programs
designed by the MCP with the purpose of redirecting or restricting access
to a
particular service or service location. These programs are referred
to as utilization modification programs. MCP care
coordination and case management activities which are designed to enhance
the
services provided to members with specific health care needs would not be
considered utilization management programs nor would the designation of specific
services requiring prior approval by the MCP or the member=s
PCP. MCPs must also implement the ODJFS-required emergency department
diversion (EDD) program for frequent users. In that ODJFS has
developed the parameters for an MCP’s EDD program, it therefore does not require
ODJFS approval.
Pharmacy
Programs - Pursuant to ORC Sec. 5111.172 and OAC rule 5101:3-26-03(A) and
(B), MCPs subject to ODJFS prior-approval, may implement strategies,
including prior authorization and limitations on the type of provider and
locations where certain medications may be administered, for the management
of
pharmacy utilization.
|
Prior
Authorizations: MCPs must receive prior approval
from ODJFS
on the types of medication that they wish to cover through
prior authorizations. MCPs must establish their prior
authorization
system so that it does not unnecessarily impede member
access to medically-necessary Medicaid-covered services. MCPs
must comply with the provisions of 1927(d)(5) of the
Social
|
Security
Act, 42 USC
1396r-8(k)(3), and OAC rule 5101:3-26-03.1regarding the timeframes
for prior authorization of covered outpatientdrugs.
MCPs
may
also, with ODJFS prior approval, implement pharmacy utilization modification
programs designed to address members demonstrating high or inappropriate
utilization of specific prescription drugs.
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.
|
b. Case
Management Programs
In
accordance with 5101:3-26-03.1(A)(8), MCPs must offer and provide comprehensive
case management services which coordinate and monitor the care of members
with specific diagnoses, or who require high-cost and/or extensive
services. The MCP’s comprehensive case 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 case 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 comprehensive case management
program. The MCP must establish a process for the timely
identification, completion of a comprehensive needs assessment, and providing
appropriate and targeted case 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
|
iii.
|
The
MCP’s comprehensive case 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 case 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 a comprehensive assessment of the member’s physical
and/or behavioral health condition(s) to confirm the results of a positive
identification, and determine the need for case management
services. 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 another
medical professional, there should be
oversight
and monitoring by either a registered nurse or physician.
For
CSHCN, the comprehensive assessment must include, at a minimum, the use of
the
ODJFS CSHCN Standard Assessment Tool.
|
c.
|
Case
Management-
|
|
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 case management,
including their enrollment into case management
services.
|
2. The
MCP must assure and coordinate the placement of the member into case management
– including identification of the member’s need for case management services,
completion of the comprehensive health needs 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 case
management.
|
3. The
development of the care treatment plan must be based on the comprehensive
health assessment. The MCP must offer both the member and the
member’s PCP/specialist the opportunity to participate in the development
of, and any subsequent revisions to, the care treatment
plan. The MCP must have a process for re-evaluating the
member’s need for case management and updating the care treatment plan,
if
necessary, on a semi-annual basis.
|
|
4.
|
The
MCP must have a process to facilitate, maintain,
and
|
coordinate
communication between service providers, the member, and the member’s
family. 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.
5. The
MCP must follow best-practice and/or evidence based clinical guidelines when
developing a member’s care treatment plan and coordinating the case management
needs. The MCP must develop and implement mechanisms to educate and
equip
providers
and case managers with evidence-based clinical guidelines or best practice
approaches to assist in providing a high level of quality of care to
members.
6. The
MCP must implement mechanisms to notify all CSHCN 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.
|
7.
|
The
MCP must provide case management services for all CSHCN, including
the
ODJFS mandated conditions as specified in Appendix M Case Management
Program Performance Measures. The MCP should also focus on all
members, including adults, whose health conditions warrant case
management
services and should not limit these services only to members with
the
mandated conditions.
|
The
MCP must submit a monthly
electronic report to theCase Management System (CAMS) for all members
whoare case managed by the MCP as outlined in the ODJFSCase
Management File and Submission Specifications. In order for a
member to be submitted as case managed in CAMS, the MCP must (1) complete
the
identification process, a comprehensive health needs assessment and
development of a care treatment plan for the member; and (2) document the
member’s written or verbal confirmation of his/her case management status in the
case 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 case management
record.
The
CAMS
files are due the 10th business
day of
each month.
|
iv.
|
The
MCP must have an
ODJFS-approved case management program which
includes the items in Sections 3.b.i - iii of Appendix G. Each
MCP should implement an evaluation process to review, revise and/or
update
the case management program. The MCP must annually submit its
case management program for review and approval by ODJFS. Any
subsequent changes to an approved case 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 sharespecific information with certain ODJFS-designated
non-contracting providers in order to ensure that these providers have been
supplied with specific information needed to coordinate care for the
MCP’s members. Once an MCP has obtained a provider
agreement, but within the first month of operation, the MCP must provide
to the
ODJFS-designated providers (i.e., ODMH Community Mental Health Centers,
ODADAS-certified Medicaid providers, FQHCs/RHCs, QFPPs, CNMs, CNPs [if
applicable], and hospitals) a quick reference information packet which includes
the following:
|
i.
|
A
brief cover letter explaining the purpose of the mailing;
and
|
|
ii.
|
A
brief summary document that includes the following
information:
|
|
|
·
|
Claims
submission information including the MCP’s Medicaid provider number for
each region;
|
|
·
|
The
MCP’s prior authorization and referral procedures or the MCP’s website
which includes this information;
|
|
·
|
A
picture of the MCP’s member identification card (front and
back);
|
|
·
|
Contact
numbers and/or 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 ofservices from a provider who does not have an
executed subcontract mustensure 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.i.c. of Appendix C.
e. Integration
of Member Care
The
MCP must ensure that a discharge
plan is in place to meet a member’shealth care needs following discharge from a
nursing facility, andintegrated into the member’s continuum of
care. The discharge plan must address the services to be
provided for the member and must be developed prior to the date of discharge
from the nursing facility. The MCP must ensure follow-up
contact occurs with the member, or authorized representative, within thirty
(30)
days of the member’s discharge from the nursing facility to ensure that the
member’s health care needs are being met.
APPENDIX
H
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.
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). 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 Physicians (PCPs)
Primary
Care Physicians (PCPs) may be individuals or group practices/clinics [Primary
Care Clinics (PCCs)]. Acceptable specialty types for PCPs are
family/general practice, internal medicine, pediatrics and
obstetrics/gynecology(OB/GYNs). 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. 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 physician
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 physicians to serve as
PCPs
for some special needs members. Also, in some situations (e.g.,
continuity of care) a PCP may only want to serve a very small number of members
for an MCP. In these situations it will not be necessary for the MCP
to submit these PCPs to ODJFS for prior approval. These PCPs will not
be included in the ODJFS PVS database and therefore may not appear as PCPs
in
the MCP’s provider directory. 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).]
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.).
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. All MCP-contracting
OB/GYNs must have current hospital delivery privileges at
a hospital under contract with the MCP in the region.
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.
Contracting
CNMs must have hospital delivery privileges at a hospital under contract
to the
MCP in the region. 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.
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. 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.
Behavioral
Health Providers – MCPs must assure member access to all Medicaid-covered
behavioral health services for members as specified in Appendix
G.b.ii. Although ODJFS is aware that certain outpatient substance
abuse services may only be available through Medicaid providers certified
by the Ohio Department of Drug and Alcohol Addiction
Services (ODADAS) in some areas, MCPs must maintain an
adequate number of contracted mental health providers in the region to assure
access for members who are unable to timely access services or
unwilling to access services through community mental health
centers. MCPs are
advised
not to contract with community mental health centers as all services they
provide to MCP members are to be billed to ODJFS.
Other
Specialty Types (pediatricians, general surgeons, otolaryngologists,
allergists, and orthopedists) - MCPs must contract with the specified
number of all other ODJFS designated specialty provider types. In order to
be
counted toward meeting the provider panel requirements, these specialty
providers must maintain a full-time practice at a site(s) located within
the
specified county/region. Contracting general surgeons, orthopedists and
otolaryngologists must have admitting privileges at a hospital under
contract with the MCP in the region.
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 haveadequate
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.
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.
MCP
provider directories must utilize a format specified by ODJFS. Directories
may
be region-specific or include multiple regions, however, the providers within
the directory must be divided by region, county, and provider type, in that
order.
The
directory must also specify:
|
•
|
provider
address(es) and phone number(s);
|
|
•
|
an
explanation of how to access providers (e.g. referral required
vs.
self-referral);
|
|
•
|
an
indication of which providers are available to members on a self-referral
basis
|
|
•
|
foreign-language
speaking PCPs and specialists and the specific foreign language(s)
spoken;
|
|
•
|
how
members may obtain directory information in alternate formats
that takes
into consideration the special needs of eligible individuals
including but
not limited to, visually-limited, LEP, and LRP eligible individuals;
and
|
|
•
|
any
PCP or specialist practice
limitations.
|
Printed
Provider Directory
Prior
to
receiving a provider agreement, all MCPs must develop a printed provider
directory that shall be prior-approved by ODJFS for each covered
population. For example, an MCP who serves CFC and ABD in the Central
Region would have two provider directories, one for CFC and one for
ABD. Once approved, this directory may be regularly updated with provider
additions or deletions by the MCP without ODJFS prior-approval, however,
copies
of the revised directory (or inserts) must be submitted to ODJFS prior to
distribution to members.
On
a
quarterly basis, MCPs must create an insert to
each printed directory that lists those providers deleted
from the MCP’s provider panel during the previous three
months. Although
this
insert does not need to be prior approved by ODJFS, copies of the insert
must be
submitted to ODJFS two weeks prior to distribution to members.
Internet
Provider Directory
MCPs
are
required to have an internet-based provider directory available in the same
format as their ODJFS-approved printed directory. This internet
directory must allow members to electronically search for MCP panel providers
based on name, provider type, and geographic proximity, and population (e.g.
CFC
and/or ABD). If an MCP has one internet-based
directory
for
multiple populations, each provider must include a description of which
population they serve.
The
internet directory may be updated at any time to include providers who are
not one of the ODJFS-required provider types listed on the
charts included with this appendix. ODJFS-required providers
must be added to the internet directory within one week of
the
MCP’s notification of ODJFS-approval of the provider via the Provider
Verification process. Providers being
deleted from the MCP’s panel must deleted from the internet directory within one
week of notification from the provider to the MCP. Providers
being deleted from the MCP’s panel must be posted to the internet directory
within one week of notification from the provider to the MCP of the
deletion. These deleted providers must be included in the inserts to
the MCP’s provider directory referenced above.
6
.
|
FEDERAL
ACCESS STANDARDS
|
MCPs
must
demonstrate that they are in compliance with the following federally
defined provider panel access standards as required by 42 CFR
438.206:
In
establishing and maintaining their provider panel, MCPs must consider the
following:
|
•
|
The
anticipated Medicaid membership.
|
|
•
|
The
expected utilization of services, taking into consideration the
characteristics and health care needs of specific Medicaid populations
represented in the MCP.
|
|
•
|
The
number and types (in terms of training, experience, and specialization)
of
panel providers required to deliver the contracted Medicaid
services.
|
|
•
|
The
geographic location of panel providers and Medicaid members, considering
distance, travel time, the means of transportation ordinarily used
by
Medicaid members, and whether the location provides physical access
for
Medicaid members with disabilities.
|
|
•
|
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.
MCPs
are to follow the procedures specified in the current MCP PVS
Instructional Manual, posted on the ODJFS website, in order
to comply with these federal access requirements.
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.
|
North
East Region - PCP Capacity
|
||||||||||
Minimum
PCP Capacity Requirements
|
||||||||||
PCPs
|
Total
Required
|
Ashtabula
|
Cuyahoga
|
Erie
|
Geauga
|
Huron
|
Lake
|
Xxxxxx
|
Xxxxxx
|
Additional
Required: In-Region *
|
Capacity
1
|
98,212
|
5,256
|
66,564
|
2,873
|
1,111
|
2,612
|
5,210
|
11,431
|
3,155
|
|
FTEs
|
49.11
|
2.63
|
33.28
|
1.44
|
0.56
|
1.31
|
2.61
|
5.72
|
1.58
|
|
1 Based
on an FTE of 2000 members
|
||||||||||
*
Must be located within the region.
|
North
East 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.
|
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.
1. Fraud
and Abuse Program:
|
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
complianceprogram which safeguards against fraud and abuse must,
at a
minimum, specificallyaddress 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 theMCP’s
management, the following written policies regarding false
claimsrecovery:
|
|
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 regardingfalse
claims recovery;
|
|
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
|
|
|
|
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.
|
|
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 ofprovider 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 reportingnumber
(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
forensuring that, pursuant to 42 CFR 438.610, the MCP will not knowingly have
arelationship with individuals debarred by Federal Agencies, as specified in
Article XII of the Agreement.
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)]
|
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.
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;
|
|
i.
|
Notification
of requests for information and copies of information released pursuant
to
a tort action (i.e., third party recovery), as outlined in OAC rule
5101:3-26-09.1;
|
|
j.
|
Financial,
utilization, and statistical reports, when ODJFS requests such reports,
based on a concern regarding the MCP’s quality of care, delivery of
services, fiscal operations or solvency, in accordance with OAC rule
5101:3-26-06(D);
|
k.
|
In
accordance with ORC Section 5111.76 and Appendix C, MCP Responsibilities,
MCPs must submit ODJFS-specified franchise fee reports in hard
copy and electronic formats pursuant to ODJFS
specifications.
|
|
|
2. FINANCIAL
PERFORMANCE MEASURES AND STANDARDS
This
Appendix establishes specific expectations concerning the financial performance
of MCPs. In the interest of administrative simplicity and
nonduplication of areas of the ODI authority, ODJFS’ emphasis is on
the assurance of access to and quality of care. ODJFS will focus only on a
limited number of indicators and related standards to monitor plan
performance. The three indicators and standards for this contract
period are identified below, along with the calculation
methodologies. The source for each indicator will be the NAIC
Quarterly and Annual Financial Statements.
Report
Period: Compliance will be determined based on the annual Financial
Statement.
a. Indicator: Net
Worth as measured by Net Worth Per Member
|
Definition:
|
Net
Worth = Total Admitted Assets minus Total Liabilities divided by
Total
Members across all lines of
business
|
|
Standard:
|
For
the financial report that covers calendar year 2007, a minimum net
worth
per member of $151.00, 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.
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.
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.
|
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 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 annualODI financial statement. |
f. | scatter diagram or bar graph from the last calendar year that shows thenumber of reinsurance claims that exceeded the current reinsurancedeductible. |
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.
Penalty
for noncompliance: If it is determined that an MCP failed to have
reinsurance coverage, that an MCP’s deductible exceeds $75,000.00 without
approval from ODJFS, or that the MCP’s reinsurance for non-transplant services
covers less than 80% of inpatient costs in excess of the deductible incurred
by
one member for one year without approval from ODJFS, then the MCP will be
required to pay a monetary penalty to ODJFS. The amount of the
penalty will be the difference between the estimated amount, as determined
by
ODJFS, of what the MCP would have paid in premiums for the reinsurance policy
if
it had been in compliance and what the MCP did actually pay while it was out
of
compliance plus 5%. For example, if the MCP paid $3,000,000.00 in
premiums during the period of non-compliance and would have paid $5,000,000.00
if the requirements had been met, then the penalty would be
$2,100,000.00.
If
it is
determined that an MCP’s reinsurance for transplant services covers less than
50% of inpatient costs incurred by one member for one year, the MCP will be
required to develop a corrective action plan (CAP).
|
4.
|
PROMPT
PAY REQUIREMENTS
|
In
accordance with 42 CFR 447.46, MCPs must pay 90% of all submitted clean claims
within 30 days of the date of receipt and 99% of such claims within 90 days
of
the date of receipt, unless the MCP and its contracted provider(s) have
established an alternative payment schedule that is mutually agreed upon and
described in their contract. The 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.
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 ODJFS annually, no later
than
30 days after the close of the state fiscal year and upon any modification
of
the MCP’s physician incentive plan:
|
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.
|
6. NOTIFICATION
OF REGULATORY ACTION
Any
MCP
notified by the ODI of proposed or implemented regulatory action must report
such notification and the nature of the action to ODJFS no later than one
working day after receipt from ODI. The ODJFS may request, and the
MCP must provide, any additional information as necessary to assure continued
satisfaction of program requirements. MCPs may request that
information related to such actions be considered proprietary in accordance
with
established ODJFS procedures. Failure to comply with this provision
will result in an immediate membership freeze.
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.
In
addition, as noted in Appendix M, if an MCP fails to meet the Minimum
Performance Standard for selected Clinical Performance Measures, the MCP
will be
required to complete a PIP.
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.
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
|
ii. Child
Immunization Status
iii. Adolescent
Immunization Status
The
measures must have received a “report” designation from the HEDIS certified
auditor and must be specific to the Medicaid population. Data must be
submitted annually and in an electronic format. 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.
2. EXTERNAL
QUALITY REVIEW
In
addition to the following requirements, MCPs must participate in external
quality review activities as outlined in OAC 5101:3-26-07.
a.
EQRO
ADMINISTRATIVE REVIEW AND NON-DUPLICATION OF MANDATORY
ACTIVITIES
The
EQRO
will conduct administrative compliance assessments and QAPI program reviews
for
each MCP every three (3) years. The review will include, but not be
limited to, the following domains as specified by ODJFS: member
rights and services, QAPI program, access standards, provider network, grievance
system, case management, coordination and continuity of care, and utilization
management. 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. Non-duplication exemptions
may not be requested for SFY 08.
|
b.
|
ANNUAL
REVIEW OF QAPI AND CASE MANAGEMENT
PROGRAM
|
|
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.
|
The
annual QAPI and case management/CSHCN (refer to Appendix G) program submissions
are subject to an administrative review by the EQRO. If the EQRO
identifies deficiencies during its review, the MCP must develop and implement
Corrective Action Plan(s) that are prior approved by ODJFS. Serious
deficiencies may result in immediate termination or non-renewal of the provider
agreement.
c. EXTERNAL
QUALITY REVIEW PERFORMANCE
In
accordance with OAC 5101: 3-26-07, each MCP must participate in
clinical or non-clinical focused quality of care studies as part of the annual
external quality review survey. If the EQRO cites a deficiency in
clinical or non-clinical performance, the MCP will be required to complete
a
Corrective Action Plan (e.g., ODJFS technical assistance session), Quality
Improvement Directives or Performance Improvement Projects depending on the
severity of the deficiency. (An example of a deficiency is if an MCP
fails to meet certain clinical or administrative standards as supported by
national evidence-based guidelines or best
practices.) Serious deficiencies may result in immediate
termination or non-renewal of the provider agreement. These quality
improvement measures recognize the importance of ongoing MCP performance
improvement related to clinical care and service delivery.
APPENDIX
L
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): Encounter Data Omissions,
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.
1.a.i.
Encounter Data Volume
Measure: The
volume measure for each service category, as listed in Table 2 below, is
the
rate of utilization (e.g., discharges, visits) per 1,000 member months
(MM).
Report
Period: The report periods for the SFY 2008 and SFY 2009
contract periods are listed in Table 1. below.
Table
1. Report Periods for the SFY 2008 and 2009 Contract
Periods
Quarterly
Report Periods
|
Data
Source:
Estimated
Encounter Data File Update
|
Quarterly
Report
Estimated
Issue Date
|
Contract
Period
|
Qtr 3
& Qtr 4 2004, 2005, 2006
Qtr
1 2007
|
July
2007
|
August
2007
|
SFY
2008
|
Qtr
3 & Qtr 4 2004, 2005, 2006
Qtr
1, Qtr 2 2007
|
October 2007
|
November 2007
|
|
Qtr
4 2004, 2005, 2006Qtr 1 thru Qtr 3 2007
|
January 2008
|
February 2008
|
|
Qtr
1 thru Qtr 4: 2005, 2006, 2007
|
April 2008
|
May
2008
|
|
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
|
Qtr1
=
January to
March
Qtr2 = April to
June Qtr3
= July to SeptemberQtr4 = October to December
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.]
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
|
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 or interim
regional-based approach, or both, 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.
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, 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.
1.a.ii. Encounter
Data Omissions
Omission
studies will evaluate the completeness of the encounter data.
Measure: This
study will compare the medical records of members during the time of membership
to the encounters submitted. Omission rates will be calculated per
MCP.
The
encounters documented in the medical record that do not appear in the encounter
data 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.
Medical
records retrieval from the provider and submittal to ODJFS or its designee
is an
integral component of the omission measure. 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 the records
requested for the study.
Data
Quality Standard: The data quality standard is a maximum
omission rate of 15% for studies with report periods
ending in CY 2007 and CY 2008.
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.
1.a.iii.
Incomplete Outpatient Hospital Data
Since
July 1, 1997, MCPs have been required to provide both the revenue code and
the
HCPCS code on applicable outpatient hospital encounters. ODJFS will be
monitoring, on a quarterly basis, the percentage of hospital encounters which
contain a revenue code and CPT/HCPCS code. A CPT/HCPCS code must
accompany certain revenue center codes. These codes are listed in Appendix
B of
Ohio Administrative Code rule 5101:3-2-21 (fee-for-service outpatient hospital
policies) and in the methods for calculating the completeness
measures.
Measure:
The percentage of outpatient hospital line items with certain revenue center
codes, as explained above, which had an accompanying valid procedure (CPT/HCPCS)
code. The measure will be calculated per MCP.
Report
Period: For the SFY 2008 and SFY 2009 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.
Penalty
for noncompliance: The first time an MCP is noncompliant with a
standard for this measure, ODJFS will issue a Sanction Advisory informing
the
MCP that any future noncompliance instances with the standard for this measure
will result in ODJFS imposing a monetary sanction.
Upon
all
subsequent quarterly measurements of performance, if an MCP is again determined
to be noncompliant with the standard, ODJFS will impose a monetary sanction
(see
Section 6) of one percent of the current month’s premium
payment. Once the MCP is performing at standard levels and
violations/deficiencies are resolved to the satisfaction of ODJFS, the money
will be refunded.
1.a.iv. Incomplete
Data For Last Menstrual Period
As
outlined in ODJFS Encounter Data Specifications, the last menstrual
period (LMP) field is a required encounter data field. It is discussed in
Item
14 of the “HCFA 1500 Billing Instructions.” The date of the LMP is essential for
calculating the clinical performance measures and allows the ODJFS to adjust
performance expectations for the length of a pregnancy.
The
occurrence code and date fields on the UB-92, which are “optional” fields, can
also be used to submit the date of the LMP. These fields are described in
Items
32a & b, 33a & b, 34a & b, 35a & b of the “Inpatient Hospital”
and “Outpatient Hospital UB-92 Claim Form Instructions.”
An
occurrence code value of ‘10’ indicates that a LMP date
was provided. The actual date of the LMP would be given in the
‘Occurrence Date’ field.
Measure: The
percentage of recipients with a live birth during the report period where a
“valid” LMP date was given on one or more of the recipient’s perinatal claims.
If the LMP date is before the date of birth and there is a difference of
between
119 and 315 days between the date the recipient gave birth and the LMP date,
then the LMP date will be considered a valid date. The measure will
be calculated per MCP (i.e., to include the MCP’s service area for the
CFC.
Report
Period: For the SFY 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.
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.
1.a.v. 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 2008 contract period, performance will be
evaluated using the following report periods: April - June 2007; July
- September 2007; October - December 2007, January - March 2008, and April
–
June 2008. For the SFY 2009 contract period, performance will be
evaluated using the following report periods: July - September 2008;
October - December 2008, January - March 2009, and April – June
2009.
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.
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.
0.x.xx. Acceptance
Rate
This
measure only applies to MCPs that have had Medicaid membership for one year
or
less.
Measure: The
rate of encounters that are submitted to ODJFS and accepted (accepted
encounters per 1,000 member months). The measure will be calculated
per MCP
Report
Period: The report period for this measure is
monthly. Results are calculated and performance is monitored monthly.
The first reporting month begins with the third month of
enrollment.
Data
Quality Standard: The data quality standard is a monthly minimum
accepted rate of encounters for each file type in the ODJFS-specified medium
per
format as follows:
Third
through sixth month with membership:
|
50
encounters per 1,000 MM for NCPDP
|
65 encounters per 1,000 MM for NSF |
20 encounters per 1,000 MM for UB-92 |
Sevenththrough
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 |
Determination
of Compliance: Performance is monitored once every month.
Compliance determination with the standard applies only to the month under
consideration and does not include performance in previous months.
Penalty
for Noncompliance: If the MCP is determined to be noncompliant
with the standard, ODJFS will impose a monetary sanction of one percent of
the
MCP’s current month’s premium payment. The monetary sanction will be
applied for each file type in the ODJFS-specified medium per format that
is
determined to be out of compliance. The monetary sanction will be applied
only
once per file type per compliance determination period and will not exceed
a
total of two percent of the MCP’s current month’s premium
payment. Once the MCP is performing at standard levels and
violations/deficiencies are resolved to the satisfaction of ODJFS, the money
will be refunded. Special consideration will be made for MCPs with
less than 1,000 members.
1.a.vii. Incomplete
Birth Weight Data
Measure:
The percentage of newborn delivery inpatient encounters during the report
period
which contained a birth weight. If a value of "88" through
"96" is found on any of the five condition code fields on the UB-92 inpatient
claim format, then the encounter will be considered to have a birth weight.
The
condition code fields are described in Items 24-30 of the "Inpatient Hospital,
UB-92 Claim Form Instructions." The measure will be calculated per
MCP (i.e., to include the MCP’s entire service area for the CFC
membership.
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.
Data
Quality Standard: The data quality standard is a minimum rate of
90%.
Penalty
for noncompliance: If an MCP
is determined to be noncompliant with the standard, ODJFS will impose
a monetary sanction (see Section 6.) of one percent of the current month’s
premium payment. Once the MCP is performing at standard levels and
violations/deficiencies are resolved to the satisfaction of ODJFS, the money
will be refunded.
1.b. Encounter
Data Accuracy
As
with
data completeness, MCPs are responsible for assuring the collection and
submission of accurate data to ODJFS. Failure to do so jeopardizes
MCPs’ performance, credibility and, if not corrected, will be assumed to
indicate a failure in actual performance.
1.b.i. Encounter
Data Accuracy Studies
Measure
1: The focus of this accuracy study will be on delivery
encounters. Its primary purpose will be to verify that MCPs submit
encounter data accurately and to ensure only one payment is made per
delivery. The rate of appropriate payments will be determined by
comparing a sample of delivery payments to the medical record. The
measure will be calculated per MCP (i.e., to include the MCP’s entire
service area for the CFC membership.
Report
Period: In order to provide timely feedback on the accuracy rate
of encounters, the report period will be the most recent from when the measure
is initiated. This measure is conducted annually.
Medical
records retrieval from the provider and submittal to ODJFS or its designee
is an
integral component of the validation process. ODJFS has optimized the
sampling to minimize the number of records required. This methodology
requires a high record submittal rate. To aid MCPs in
achieving
a
high
submittal rate, ODJFS will give at least an 8 week period to retrieve and
submit
medical records as a part of the validation process. A record
submittal rate will be calculated as a percentage of all records requested
for
the study.
Data
Quality Standard 1 for Measure 1: For results
that are finalized during the contract year, the accuracy rate for encounters
generating delivery payments is 100%.
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: TBD for SFY 2008 and
SFY 2009 based on study conducted in SFY 2007 (standard to be released in
June,
2007).
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.
1.b.ii. Generic
Provider Number Usage
Measure:
This measure is the percentage of non-pharmacy encounters with the generic
provider number. Providers submitting claims which do not have an
MMIS provider number must be submitted to ODJFS with the generic provider
number
9111115. The measure will be calculated per MCP.
All
other
encounters are required to have the MMIS provider number of the servicing
provider. The report period for this measure
is quarterly.
Report
Period: For the SFY 2008 and SFY 2009 contract periods,
performance will be evaluated using the report periods listed in 1.a.i.,
Table
1.
Data
Quality Standard: A maximum generic provider number usage rate of
10%.
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.
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 three percent of the current month’s premium
payment. Once the MCP is performing at standard levels and
violations/deficiencies are resolved to the satisfaction of ODJFS, the money
will be refunded.
1.c.
Timely Submission of Encounter Data
1.c.i. Timeliness
ODJFS
recommends submitting encounters no later than thirty-five days after the
end of
the month in which they were paid. ODJFS does not monitor standards
specifically for timeliness, but the minimum claims volume (Section 1.a.i.)
and
the rejected encounter (Section 1.a.v.) standards are based on encounters
being
submitted within this time frame.
1.c.ii. Submission
of Encounter Data Files in the ODJFS-specified medium per
format
Information
concerning the proper submission of encounter data may be obtained from the
ODJFS Encounter Data File and Submission Specifications
document. The MCP must submit a letter of certification, using the
form required by ODJFS, with each encounter data file in the ODJFS-specified
medium per format.
The
letter of certification must be signed by the MCP’s Chief Executive Officer
(CEO), Chief Financial Officer (CFO), or an individual who has delegated
authority to sign for, and who reports directly to, the MCP’s CEO or
CFO.
|
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
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 2007 contract period, January – March 2007, and April –
June 2007 report periods. For the SFY 2008 contract
period, July – September 2007, October – December 2007, 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.
Statewide
and Regional Data Quality Standard: A rate of open case
management spans for disenrolled members of no more than 1.0%.
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.
2.b. Timely
Submission of Case Management Files
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. The 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 the clinical
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.
If
an MCP
does not complete a study because too few medical records are submitted,
accurate evaluation of clinical quality in the study area cannot be determined
for the individual MCP and the assurance of adequate clinical quality for
the
program as a whole is jeopardized.
3.a.
Independent External Quality Review
Measure: The
percentage of requested records for a study conducted by the External Quality
Review Organization (EQRO) that are submitted by the managed care
plan.
Report
Period: The report period is one year. Results are calculated
and performance is monitored annually. Performance is measured with
each review.
Data
Quality Standard: A minimum record submittal rate of 85% for each clinical
measure.
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 physician 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 ODJFSMember’s PCP Data File and Submission
Specifications.
Penalty
for noncompliance: See Appendix N, Compliance Assessment System,
for the penalty for noncompliance with this requirement.
4.b. Designated
PCP for newly enrolled members
Measure: The
percentage of MCP’s newly enrolled members who were designated a PCP by their
effective date of enrollment.
Report
Periods: For the SFY 2007 contract period, performance will be
evaluated quarterly using the January – March 2007 and April – June 2007 report
periods. For the SFY 2008 contract period, performance will be evaluated
quarterly using the July-September 2007, October – December 2007, January –
March 2008 and April – June 2008 report periods. For the SFY 2009
contract period, performance will be evaluated quarterly using the
July-September 2008, October – December 2008, January – March 2009 and April –
June 2009 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 1 and quarter 2 of
SFY
2008. A minimum rate of 85% of new members with PCP
designation by their effective
date
of
enrollment for quarter 3 and quarter 4 of SFY 2008. For SFY 2009, a
minimum rate of 85% of new members with PCP designation by their effective
date
of enrollment.
Statewide
Approach: MCPs will be evaluated using a statewide result,
including all regions 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 physician (PCP) prior
to
their effective date of coverage. Therefore, MCPs are subject to
additional corrective action measures under Appendix N,
Compliance Assessment System, for failure to meet this
requirement.
5.
APPEALS AND GRIEVANCES DATA
Pursuant
to OAC rule 5101:3-26-08.4, MCPs are required to submit information at least
monthly to ODJFS regarding appeal and grievance activity. ODJFS
requires these submissions to be in an electronic data file format pursuant
to
the Appeal File and Submission Specifications and Grievance File
and Submission Specifications.
The
appeal data file and the grievance data file must include all appeal and
grievance activity, respectively, for the previous month, and must be submitted
by the ODJFS-specified due date. These
data
files must be submitted in the ODJFS-specified format and with the
ODJFS-specified filename in order to be successfully processed.
Penalty
for noncompliance: MCPs who fail to submit their monthly
electronic data files to the ODJFS by the specified due date or who fail
to
resubmit, by no later than the end of that month, a file which meets the
data
quality requirements will be subject to penalty as stipulated under the
Compliance Assessment System (Appendix N).
6. NOTES
6.a.
|
Penalties,
Including Monetary Sanctions, for
Noncompliance
|
Penalties
for noncompliance with standards outlined in this appendix, including monetary
sanctions, will be imposed as the results are finalized. With the
exception of Sections 1.a.i., 1.a.iii., 1.a.v., 0.x.xx.,
and 0.x.xx, 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.
6.b.
Combined Remedies
If
ODJFS
determines that one systemic problem is responsible for multiple deficiencies,
ODJFS may impose a combined remedy which will address all areas of deficient
performance. The total fines assessed in any one month will not
exceed 15% of the MCP’s monthly premium payment.
6.c. Membership
Freezes
MCPs
found to have a pattern of repeated or ongoing noncompliance may be subject
to a
membership freeze.
6.d. Reconsideration
Requests
for reconsideration of monetary sanctions and enrollment freezes may be
submitted as provided in Appendix N, Compliance Assessment
System.
6.e. Contract
Termination, Nonrenewals, or Denials
Upon
termination either by the MCP or ODJFS, nonrenewal, or denial of an MCP provider
agreement, all previously collected refundable monetary sanctions will be
retained by ODJFS.
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. The Ohio
Medicaid managed care program will transition to a regional-based system
as
managed care expands statewide, beginning in SFY 2007. Evaluation of
performance will transition to a regional-based approach after completion
of the
statewide expansion. 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. Due to
differences in data and reporting requirements, transition to the regional-based
approach will vary by performance measure. Unless otherwise noted, performance
measures and standards (see Sections 1, 2, 3 and 4) will be applicable for
all
counties in which the MCP has membership as of February 1, 2006, until the
regional-based approach is developed.
Selected
measures in this appendix will be used to determine pay-for-performance
(P4P) as specified in Appendix O, Pay for Performance.
1. QUALITY
OF CARE
1.a.i.
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 both an administrative review
and
focused quality of care studies as outlined in Appendix K.
Report
Period: Performance will be evaluated using the reviews conducted
during SFY 2008.
Action
Required for Deficiencies: For all reviews conducted during the
contract period, if the EQRO cites a deficiency in the administrative review
or
quality of care studies, the MCP will be required to complete a Corrective
Action Plan, Quality Improvement Directive, or Performance Improvement Project
as outlined in Appendix K. Serious deficiencies may result in
immediate termination or non-renewal of the provider agreement.
1.b. Children
with Special Health Care Needs (CSHCN)
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.
0.x.x.Xxxx
Management of Children
Measure:
The average monthly case management rate for children under 21 years
of
age.
Report
Period: For the SFY 2007 contract period, January – March 2007, and April –
June 2007 report periods. For the SFY 2008 contract
period, July – September 2007, October – December 2007, 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.
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.
County
and Regional-Based Minimum Performance Standard: For the
third and fourth quarters of SFY 2007, a case management rate of
5.0%. For SFY 2008, a case management rate of 5.0%. For
SFY 2009, a case management rate of 6.0%.
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 with an ODJFS-Mandated
Condition
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 2007 contract period,
January – March 2007, and April – June 2007 report periods. For the
SFY 2008 contract period, July – September 2007, October – December
2007, 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.
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.
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 SFY 2008, a case management rate of 70%. For SFY
2009, a case management rate of 80%.
County
and Regional-Based Minimum Performance Standard for Measure 2:For
the third and fourth quarters of SFY 2007, a case management rate of
60%. For SFY 2008, a case management rate of 60%. For SFY
2009, a case management rate of 70%.
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 and SFY 2009,
measure 3 is a reporting-only measure.
1.c.
Clinical Performance Measures
MCP
performance will be assessed based on the analysis of submitted encounter
data
for each year. For certain measures, standards are established; the
identification of these standards is not intended to limit the assessment
of
other indicators for performance improvement activities. Performance
on multiple measures will be assessed and reported to the MCPs and others,
including Medicaid consumers.
The
clinical performance measures described below closely follow the National
Committee for Quality Assurance’s Health Plan Employer Data and Information Set
(HEDIS). Minor adjustments to HEDIS measures were 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 Medicaid 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.
For
an MCP which had membership as of February 1, 2006: Prior to the transition
to the regional-based approach, MCP performance will be evaluated using an
MCP’s
statewide result for the counties in which the MCP had membership as of February
1, 2006. For reporting periods CY 2007 and 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 approach for any active region in which the MCP had
membership.
Regional-Based
Approach: MCPs will be evaluated by region, using results for all counties
included in the region. CY 2008 will be the first reporting year that
MCPs will be held accountable to the performance standards for an active
region,
and penalties will be applied for noncompliance. CY 2007 will be the
first baseline reporting year for an active region.
ODJFS
will use a sufficient amount of data needed per performance measure from
all
MCPs serving an active region to determine performance standards and targets
for
that region. For example, should a measure call for one calendar year
of baseline data, first full calendar year data will be used. CY 2008
will be the first reporting year for measures that call for one year of baseline
data. Should a measure call for two calendar years of baseline data, the
first
two full calendar years of data will be used. CY 2009 will be the
first reporting year for measures that call for two years of baseline
data.
Report
Period: In order to adhere to the statewide expansion timeline,
reporting periods may be adjusted based on the number of months of managed
care
membership. For the SFY 2007 contract period, performance will be
evaluated using the January - December 2006 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.
1.c.i. Perinatal
Care – Frequency of Ongoing Prenatal Care
Measure: The
percentage of enrolled women with a live birth during the year who received
the
expected number of prenatal visits. The number of observed versus
expected visits will be adjusted for length of enrollment.
County-Based
Target: At least 80% of the eligible population must receive
81% or more of the expected number of prenatal visits.
County-Based
Minimum Performance Standard: The level of improvement
must result in at least a 10% decrease in the difference between the target
and
the previous report period’s results. (For example, if last year’s results were
20%, then the difference between the target and last year’s results is
60%. In this example, the standard is an improvement in performance
of 10% of this difference or 6%. In this example, results of 26% or better
would
be compliant with the standard.)
Action
Required for Noncompliance: If the standard is not met and the
results are below 42% (44% for SFY 2009), then the MCP is required to complete
a
Performance Improvement Project, as described in Appendix
K, Quality Assessment and Performance Improvement Program,
to address the area of noncompliance. If the standard is not met and the
results are at or above 42% (44% for SFY 2009), then ODJFS will issue a Quality
Improvement Directive which will notify the MCP of noncompliance and may
outline
the steps that the MCP must take to improve the results.
1.c.ii. Perinatal
Care - Initiation of Prenatal Care
Measure: The
percentage of enrolled women with a live birth during the year who had a
prenatal visit within 42 days of enrollment or by the end of the first trimester
for those women who enrolled in the MCP during the early stages of
pregnancy.
County-Based
Target: At least 90% of the eligible population initiate
prenatal care within the specified time.
County-Based
Minimum Performance Standard: The level of improvement must result
in at least a 10% decrease in the difference between the target and the previous
year’s results.
Action
Required for Noncompliance: If the standard is not met and the
results are below 71% (74% for SFY 2009), then the MCP is required to complete
a
Performance Improvement Project, as described in Appendix
K, Quality Assessment and Performance Improvement Program,
to address the area of noncompliance. If the standard is not met and the
results
are at or above 71% (74% for SFY 2009), then ODJFS will issue a Quality
Improvement Directive which will notify the MCP of noncompliance and may
outline
the steps that the MCP must take to improve the results.
1.c.iii. Perinatal
Care - Postpartum Care
Measure: The
percentage of women who delivered a live birth who had a postpartum visit
on or
between 21 days and 56 days after delivery.
County-Based
Target: At least 80% of the eligible population must receive a
postpartum visit.
County-Based
Minimum Performance Standard: The level of improvement must result
in at least a 5% decrease in the difference between the target and the previous
year’s results.
Action
Required for Noncompliance: If the standard is not met and the
results are below 48% (50% for SFY 2009), then the MCP is required to complete
a
Performance Improvement Project, as described in Appendix
K, Quality Assessment and Performance Improvement Program,
to address the area of noncompliance. If the standard is not met and the
results
are at or above 48% (50% for SFY 2009), then ODJFS will issue a Quality
Improvement Directive which will notify the MCP of noncompliance and may
outline
the steps that the MCP must take to improve the results.
1.c.iv. Preventive
Care for Children - Well-Child Visits
Measure: The
percentage of children who received the expected number of well-child visits
adjusted by age and enrollment. The expected number of visits is as
follows:
Children
who turn 15 months old: six or more well-child visits.
Children
who were 3, 4, 5, or 6, years old: one or more well-child visits.
Children
who were 12 through 21 years old: one or more well-child visits.
County-Based
Target: At least 80% of the eligible children receive the
expected number of well-child visits.
County-Based
Minimum Performance Standard for Each of the Age
Groups: The level of improvement must result in at least a 10%
decrease in the difference between the target and the previous year’s
results.
Action
Required for Noncompliance (15 month old age group): If the
standard is not met and the results are below 34% (42% for SFY 2009), then
the
MCP is required to complete a Performance Improvement Project, as described
in Appendix K, Quality Assessment and Performance
Improvement Program, to address the area of noncompliance. If the standard
is not met and the results are at or above 34% (42% for SFY 2009), then 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 (3-6 year old age group): If the
standard is not met and the results are below 50% (57% for SFY 2009), then
the
MCP is required to complete a Performance Improvement Project, as described
in Appendix K, Quality Assessment and Performance
Improvement Program, to address the area of noncompliance. If the standard
is not met and the results are at or above 50% (57% for SFY 2009), then 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 (12-21 year old age group): If the
standard is not met and the results are below 30% (33% for SFY 2009), then
the
MCP is required to complete a Performance Improvement Project, as described
in Appendix K, Quality Assessment and Performance
Improvement Program, to address the area of noncompliance. If the standard
is not met and the results are at or above 30% (33% for SFY 2009), then ODJFS
will issue a Quality Improvement Directive which will notify the MCP of
noncompliance and may outline the steps that the MCP must take to improve
the
results.
1.c.v. Use
of Appropriate Medications for People with Asthma
Measure:
The percentage of members with persistent asthma who were enrolled for
at
least 11 months with the plan during the year and who received prescribed
medications acceptable as primary therapy for long-term control of
asthma.
County-Based
Target: At least 95% of the eligible population must receive
the recommended medications.
County-Based
Minimum Performance Standard: The level of improvement must result
in at least a 10% decrease in the difference between the target and the previous
year’s results.
Action
Required for Noncompliance: If the standard is not met and the
results are below 83% (84% for SFY 2009), then the MCP is required to complete
a
Performance Improvement Project, as described in Appendix K, Quality
Assessment and Performance Improvement Program, to address the area of
noncompliance. If the standard is not met and the results are at or above
83%
(84% for SFY 2009), then ODJFS will issue a Quality Improvement Directive
which
will notify the MCP of noncompliance and may outline the steps that the MCP
must
take to improve the results.
0.x.xx. Annual
Dental Visits
Measure:
The percentage of enrolled members age 4 through 21 who were enrolled for
at
least 11 months with the plan during the year and who had at least one dental
visit during the year.
County-Based
Target: At least 60% of the eligible population receive a dental
visit.
County-Based
Minimum Performance Standard: The level of improvement must result
in at least a 10% decrease in the difference between the target and the previous
year’s results.
Action
Required for Noncompliance: If the standard is not met and the
results are below 40% (42% for SFY 2009), then the MCP is required to complete
a
Performance Improvement Project, as described in Appendix
K, Quality Assessment and Performance Improvement Program,
to address the area of noncompliance. If the standard is not met and the
results
are at or above 40% (42% for SFY 2009), then ODJFS will issue a Quality
Improvement Directive which will notify the MCP of noncompliance and may
outline
the steps that the MCP must take to improve the results.
1.c.vii. Lead
Screening
Measure:
The percentage of one and two year olds who received a blood lead screening
by age group.
County-Based
Target: At least 80% of the eligible population receive a blood
lead screening.
County-Based
Minimum Performance Standard for Each of the Age Groups: The level
of improvement must result in at least a 10% decrease in the difference between
the target and the previous year’s results.
Action
Required for Noncompliance (1 year olds): If the standard is not met and
the results are below 45% then the MCP is required to complete a Performance
Improvement Project, as described in Appendix
K, Quality Assessment and Performance Improvement Program,
to address the area of noncompliance. If the standard is not met and the
results
are at or above 45%, then 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): If the standard is not met and
the results are below 28% then the MCP is required to complete a
Performance Improvement Project, as described in Appendix
K, Quality Assessment and Performance Improvement Program,
to address the area of noncompliance. If the standard is not met and
the results are at or above 28%, then ODJFS will issue a Quality Improvement
Directive which will notify the MCP of noncompliance and may outline the
steps
that the MCP must take to improve the results.
2. ACCESS
Performance
in the Access category will be determined by the following measures: Primary
Care Physician (PCP) Turnover, Children’s Access to Primary Care, and Adults’
Access to Preventive/Ambulatory Health Services. For a comprehensive
description of the access performance measures below, see ODJFS Methods for
Access Performance Measures for the Medicaid CFC Managed Care
Program.
2.a.
PCP Turnover
A
high
PCP turnover rate may affect continuity of care and may signal poor management
of providers. However, some turnover may be expected when MCPs end
contracts with physicians 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 physicians 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: Prior to the transition to the regional-based approach, MCP
performance will be evaluated using an MCP’s 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 statewide result for the counties in
which the MCP had membership as of February 1, 2006. The last
reporting year using the MCP’s 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 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
approach for any active region in which the MCP had membership.
Regional-Based
Approach: MCPs will be evaluated by region, using results for all counties
included in the region. ODJFS will use the first full calendar year of data
(which may be adjusted based on the number of months of managed care
membership). from all MCPs serving an active region to determine a minimum
performance standard for that region. CY 2008 will be the first
reporting year that MCPs will be held accountable to the performance standards
for an active region, and penalties will be applied for
noncompliance.
Report
Period: In order to adhere to the statewide expansion timeline,
reporting periods may be adjusted based on the number of months of managed
care
membership. For the SFY 2007 contract period, performance will be
evaluated using the January - December 2006 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.
County-Based
Minimum Performance Standard: A maximum PCP Turnover
rate of 18%.
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 an action plan to address the findings.
2.b.
Children’s Access to Primary Care
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: Prior
to the transition to the regional-based approach, MCP performance will be
evaluated using an MCP’s 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 statewide
result for the counties in which the MCP had membership as of February 1,
2006. The last reporting year using the
MCP’s
statewide
result for the counties in which the MCP had membership as of February 1,
2006
is CY 2008.
For
any MCP which did not have membership as of February
1, 2006: Performance will be evaluated using a
regional-based approach for any active region in which the MCP had
membership.
Regional-Based
Approach: MCPs will be evaluated by region, using results for all counties
included in the region. ODJFS will use the first two full calendar years
of data
(which may be adjusted based on the number of months of managed care
membership) from all MCPs serving an active region to determine a
minimum performance standard for that region. CY 2009 will be the first
reporting year that MCPs will be held accountable to the performance standards
for an active region, and penalties will be applied for
noncompliance. Performance measure results for that region 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 may be adjusted based on the number of months
of
managed care membership. For the SFY 2007 contract period, performance will
be evaluated using the January - December 2006 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.
County-Based Minimum
Performance Standards:
CY
2006
report period – 70% of children must receive a visit.
CY
2007
report period – 71% of children must receive a visit
CY
2008
report period – TBD (in May 2007)
Penalty
for Noncompliance: If an MCP is noncompliant with the Minimum
Performance Standard, then the MCP must develop and implement a corrective
action plan.
2.c.
Adults’ Access to Preventive/Ambulatory Health Services
This
measure indicates whether adult members are accessing health
services.
Measure:
The percentage of members age 20 and older who had an ambulatory or
preventive-care visit.
For
an MCP which had membership as of February 1,
2006: Prior to the transition to the regional-based approach, MCP
performance will be evaluated using an MCP’s 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 statewide result for the counties in which the MCP
had membership as of February 1, 2006. The last reporting
year using the MCP’s statewide result for the counties in which the
MCP had membership as of February 1, 2006 for performance evaluation is
CY2007; the last reporting year using the MCP’s 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
approach for any active region in which the MCP had membership.
Regional-Based
Approach: MCPs will be evaluated by region, using results for all counties
included in the region. ODJFS will use the first full calendar year of data
(which may be adjusted based on the number of months of managed care membership)
from all MCPs serving an active region to determine a minimum performance
standard for that region. CY 2008 will be the first reporting year that MCPs
will be held accountable to the performance standards for an active region,
and
penalties will be applied for noncompliance. Performance measure
results for that region 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 may be adjusted based on the number of
months of managed care membership. For the SFY 2007 contract period,
performance will be evaluated using the January - December 2006 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.
County-Based Minimum
Performance Standards:
CY
2006
report period – 63% of adults must receive a visit.
CY
2007
report period – 63% of adults must receive a visit.
CY
2008
report period – TBD (in May 2007)
Penalty
for Noncompliance: If an MCP is noncompliant with the Minimum
Performance Standard, then the MCP must develop and implement a corrective
action plan.
2.d.
Members’ Access to Designated PCP
The
MCP
must encourage and assist CFC members without a designated primary care
physician (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
Approach: MCPs will be evaluated by region, using results for all counties
included in the region. ODJFS will use the first full calendar year
of data (CY2007) as a baseline from all MCPs serving CFC membership to determine
a minimum performance standard for that region. CY 2008 will be the
first reporting year that MCPs will be held accountable to the performance
standards for an active region and penalties will be applied for
noncompliance. Performance measure results for that region 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.
Minimum
Performance Standards: TBD
Penalty
for Noncompliance: If an MCP is noncompliant with the Minimum
Performance Standard, then the MCP must develop and implement a corrective
action plan.
3.
CONSUMER SATISFACTION
In
accordance with federal requirements and in the interest of assessing enrollee
satisfaction with MCP performance, ODJFS annually conducts 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 2007 and 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 Consumer Satisfaction Performance
Measures for the Medicaid CFC Managed Care Program.
Measure:Overall
Satisfaction with MCP: The average rating of the respondents to the
Consumer Satisfaction Survey who were asked to rate their overall satisfaction
with their MCP. The results of this measure are reported
annually.
County-Based
Approach: Prior to the transition to the regional-based approach, MCP
performance will be evaluated using an MCP’s statewide result. For
performance evaluation, the last year to use the county-based approach will
be
SFY 2008, using CY 2008 data. For P4P (Appendix
O), the last year to use the county-based approach will be SFY
2009, using CY 2009 data.
Regional-Based
Approach: MCPs will be evaluated by region, using results for all
counties included in the region. ODJFS will use the first full
calendar year of regional data (CY 2008 adult and child survey results from
all
MCPs serving CFC membership to establish a measure and determine regional
minimum performance standards. For performance evaluation, the first
year to use the regional-based approach will be SFY 2009, using CY 2009
data. For P4P (Appendix O), the first year to
use the regional-based approach will be SFY 2010, using CY 2010
data.
Report
Period: For the SFY 2007 contract period, performance
will be evaluated using the results from the most recent consumer
satisfaction survey completed prior to the end of the SFY
2007. For the SFY 2008 contract period, performance will be
evaluated using the results from the most recent consumer satisfaction survey
completed prior to the end of the SFY 2008. For the SFY 2009 contract
period, performance will be evaluated using the results from the most
recent consumer satisfaction survey completed prior to the end of the
SFY 2009.
County-Based
Minimum Performance Standard: An average score of no
less than 7.0.
Penalty
for noncompliance: If an MCP is determined noncompliant with the
Minimum Performance Standard, then the MCP must develop a corrective action
plan
and provider agreement renewals may be affected.
4.
ADMINISTRATIVE CAPACITY
The
ability of an MCP to meet administrative requirements has been found to be
both
an indicator of current plan performance and a predictor of future
performance. Deficiencies in administrative capacity make the
accurate assessment of performance in other categories difficult, with findings
uncertain. Performance in this category will be determined by the
Compliance Assessment System, and the emergency department diversion
program. For a comprehensive description of the Administrative
Capacity performance measures below, see ODJFS Methods for Administrative
Capacity Performance Measures for the Medicaid CFC Managed Care
Program.
4.a.
Compliance Assessment System
Measure: The
number of points accumulated during a rolling 12-month period through the
Compliance Assessment System.
Report
Period: For the SFY 2008 and SFY 2009 contract
periods, 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
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: Prior to the transition to the regional-based approach, MCP
performance will be evaluated using an MCP’s statewide result for the counties
in which the MCP had membership as of February1, 2006. The minimum
performance standard and the target in this Appendix (4.b) will be
applicable to the MCP’s statewide result for the counties in which the MCP had
membership as of February 1, 2006. The last reporting
period using the MCP’s 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 statewide result
for the counties in which the MCP had membership as of February 1, 2006 for
P4P
(Appendix O) is July-December 2006.
For
any MCP which did not have membership as of February 1,
2006: Performance will be evaluated using a regional-based
approach for any active region in which the MCP had membership.
Regional-Based
Approach: MCPs will be evaluated by region, using results for all counties
included in the region. The reporting period will be a full calendar
year. ODJFS will use the first full calendar year of data, which may
be adjusted based on the number of months of managed care
membership, as a baseline from all MCPs serving an active region to
determine a minimum performance standard and a target for that
region. CY 2008 will be the first reporting year that MCPs will be
held accountable to the performance standards for an active region, and
penalties will be applied for noncompliance. Performance measure
results for that region 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.
Regional-Based
Measure: The percentage of members who had TBD or more ED visits
during the 12 month reporting period.
Report
Period: In order to adhere to the statewide expansion timeline,
reporting periods may be adjusted based on the number of months of managed
care
membership. For the SFY 2007 contract period, a baseline level of
performance will be set using the January - June 2006 report
period. Results will be calculated for the reporting period of July -
December 2006 and compared to the baseline results to determine if the minimum
performance standard is met. For the SFY 2008 contract period, a
baseline level of performance will be set using the January - June 2007 report
period (which may be adjusted based on the number of months of managed care
membership). 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. SFY 2008 is also the first year
for regional based reporting, using January – December 2007 as a
baseline. For the SFY 2009 contract period, results will be
calculated for the reporting period January – December 2008 and compared to the
baseline.
County-Based
Target: A maximum of 0.70% of the eligible population will
have four or more ED visits during the reporting period.
County-Based
Minimum Performance Standard: The level of improvement must result
in at least a 10% decrease in the difference between the target and the baseline
period results.
Penalty
for Noncompliance: 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.
5.
NOTES
Given
that unforeseen circumstances (e.g., revision or update of applicable national
standards, methods or benchmarks, or issues related to program implementation)
may impact performance assessment as specified in Sections 1 through
4, ODJFS reserves the right to apply the most appropriate penalty to
the area of deficiency identified with any individual measure, notwithstanding
the penalties specified in this Appendix.
5.a.
Report Periods
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.
5.b.
Monetary Sanctions
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 compliance is 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.
5.c. Combined
Remedies
If
ODJFS
determines that one systemic problem is responsible for multiple deficiencies,
ODJFS may impose a combined remedy which will address all areas of deficient
performance. The total fines assessed in any one month will not
exceed 15% of the MCP’s monthly capitation.
5.d.
Enrollment Freezes
MCPs
found to have a pattern of repeated or ongoing noncompliance may be subject
to
an enrollment freeze.
5.e.
Reconsideration
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 contact, 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.
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
CASassesses 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.
H.
For
purposes of the CAS, the date that ODJFS first becomes aware of an MCP’s program
violation is considered the date on which the violation
occurred. Therefore, program violations that technically reflect
noncompliance from the previous compliance term will be subject to remedial
action under CAS at the time that ODJFS first becomes aware of this
noncompliance.
I.
In
cases where an MCP contracted healthcare provider is found to have violated
a
program requirement (e.g., failing to provide adequate contract termination
notice, marketing to potential members, inappropriate member billing, etc.),
ODJFS will not assess points if: (1) the MCP can document that they provided
sufficient notification/education to providers of applicable program
requirements and prohibited activities; and (2) the MCP takes immediate and
appropriate action to correct the problem and to ensure that it does not
happen
again to the satisfaction of ODJFS. Repeated incidents will be
reviewed to determine if the MCP has a systemic problem in this area, and
if so,
sanctions/remedial actions may be assessed, as determined by ODJFS.
J.
All
notices of noncompliance will be issued in writing via email and facsimile
to
the identified MCP contact.
II.
Types of Sanctions/Remedial Actions
ODJFS
may
impose the following types of sanctions/remedial actions, including, but
not
limited to, the items listed below. The following are examples of
program violations and their related penalties. This list is not all
inclusive. As with any instance of noncompliance, ODJFS retains the
right to use their sole discretion to determine the most appropriate penalty
based on the severity of the offense, pattern of repeated noncompliance,
and
number of consumers affected. Additionally, if an MCP has received
any previous written correspondence regarding their duties and obligations
under
OAC rule or the Agreement, such notice may be taken into consideration when
determining penalties and/or remedial actions.
A.
Corrective Action Plans (CAPs)– A CAP is a structured activity/process
implemented by the MCP to improve identified operational
deficiencies.
MCPs
may
be required to develop CAPs for any instance of noncompliance, and CAPs are
not
limited to actions taken in this Appendix. All CAPs requiring ongoing
activity on the part of an MCP to ensure their compliance with a program
requirement remain in effect for twenty-four months.
In
situations where ODJFS has already determined the specific action which must
be
implemented by the MCP or if the MCP has failed to submit a CAP, ODJFS may
require the MCP to comply with an ODJFS-developed or “directed”
CAP.
In
situations where a penalty is assessed for a violation an MCP has previously
been assessed a CAP (or any penalty or any other related written
correspondence), the MCP may be assessed escalating penalties.
B.
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.).
B.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.
|
B.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.
|
C.
Fines– Refundable or nonrefundable fines may be assessed as a penalty
separate to or in combination with other sanctions/remedial
actions.
C.1.
Unless otherwise stated, all fines are nonrefundable.
C.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.
C.3.
Monetary sanctions/assurances imposed by ODJFS will be based on the most
recent
premium payments.
C.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.
C.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.
D.
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.
E.
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 |
F.
New
Member Selection Freezes - Notwithstanding any other penalty or point
assessment that ODJFS may impose on the MCP under this Appendix, ODJFS may
prohibit an MCP from receiving new membership through consumer initiated
selection or the assignment process if: (1) the MCP has accumulated a total
of
51 or more points during a rolling 12-month period; (2) or the MCP fails
to
fully implement a CAP within the designated time frame; or (3)
circumstances exist which potentially jeopardize the MCP’s members’ access to
care. [Examples of circumstances that ODJFS may consider as
jeopardizing member access to care include:
|
-
|
the
MCP has been found by ODJFS to be noncompliant with the prompt
payment or
the non-contracting provider
payment requirements;
|
|
-
|
the
MCP has been found by ODJFS to be noncompliant with the provider
panel
requirements specified in Appendix H of the
Agreement;
|
|
-
|
the
MCP’s refusal to comply with a program requirement after ODJFS has
directed the MCP to comply with the specific program requirement;
or
|
|
-
|
the
MCP has received notice of proposed or implemented adverse action
by the
Ohio Department of Insurance.]
|
Payments
provided for under the Agreement will be denied for new enrollees, when and
for
so long as, payments for those enrollees are denied by CMS in accordance
with
the requirements in 42 CFR 438.730.
G.
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.
H.
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.
I.
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.
I.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
|
I.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
|
PVS
survey forms
|
|
o
|
Failure
to provide ODJFS with a required submission after ODJFS has notified
the
MCP that the prescribed deadline for that submission has
passed
|
If
an MCP
determines that they will be unable to meet a program deadline or
data/documentation submission deadline, the MCP must submit a written request
to
its Contract Administrator for an extension of the deadline, as soon as
possible, but no later than 3 PM EST on the date of the deadline in question.
Extension requests should only be submitted in situations where unforeseeable
circumstances have occurred which make it impossible for the MCP to meet
an
ODJFS-stipulated
deadline and all such requests will be evaluated upon this
standard. Only written approval as may be granted by ODJFS of a
deadline extension will preclude the assessment of compliance action for
untimely submissions.
I.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.
I.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.
I.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.
|
I.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.
I.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.
I.9.
Refusal to Comply with Program Requirements - If ODJFS has instructed an MCP
that they must comply with a specific program requirement and the MCP refuses,
such refusal constitutes documentation that the MCP is no longer operating
in
the best interests of the MCP’s members or the state of Ohio and ODJFS will move
to terminate or nonrenew the MCP’s provider agreement.
III.
Request for Reconsiderations
MCPs
may
request a reconsideration of remedial action taken under the CAS for penalties
that include points, fines, reductions in assignments and/or selection
freezes. Requests for reconsideration must be submitted on the ODJFS
required form as follows:
A.
MCPs
notified of ODJFS’ imposition of remedial action taken under the CAS
will have ten (10) working days from the date of receipt of the facsimile
to request reconsideration, although ODJFS will impose enrollment freezes
based
on an access to care concern concurrent with initiating notification to the
MCP. Any information that the MCP would like reviewed as part of the
reconsideration request must be submitted at the
time
of
submission of the reconsideration request, unless ODJFS extends the time
frame
in writing.
B.
All
requests for reconsideration must be submitted by either facsimile transmission
or overnight mail to the Chief, Bureau of Managed Health Care, and received
by
ODJFS by
the
tenth
business day after receipt of the faxed notification of the imposition of
the
remedial action by ODJFS.
C.
The
MCP will be responsible for verifying timely receipt of all reconsideration
requests. All requests for reconsideration must explain in detail why
the specified remedial action should not be imposed. The MCP’s
justification for reconsideration will be limited to a review of the written
material submitted by the MCP. The Bureau Chief will review all
correspondence and materials related to the violation in question in making
the
final reconsideration decision.
D.
Final
decisions or requests for additional information will be made by ODJFS within
ten (10) business days of receipt of the request for
reconsideration.
E.
If
additional information is requested by ODJFS, a final reconsideration decision
will be made within three (3) business days of the due date for the
submission. Should ODJFS require additional time in rendering the
final reconsideration decision, the MCP will be notified of such in
writing.
F.
If a
reconsideration request is decided, in whole or in part, in favor of the
MCP,
both the penalty and the points associated with the incident, will be rescinded
or reduced, in the sole discretion of ODJFS. The MCP may still be
required to submit a CAP if ODJFS, in its sole discretion, believes that
a CAP
is still warranted under the circumstances.
APPENDIX
O
PAY-FOR
PERFORMANCE (P4P)
CFC
ELIGIBLE POPULATION
This
Appendix establishes P4P for managed care plans (MCPs) to improve performance
in
specific areas important to the Medicaid MCP members. P4P include the
at-risk amount included with the monthly premium payments (see Appendix
F,
Rate Chart), and possible additional monetary rewards up to
$250,000.
To
qualify for consideration of any P4P, MCPs must meet minimum performance
standards established in Appendix M, Performance Evaluation on selected
measures, and achieve P4P standards established for selected Clinical
Performance Measures. For qualifying MCPs, higher performance
standards for three measures must be reached to be awarded a portion of
the
at-risk amount and any additional P4P (see Sections 1 and 2). 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 P4P system (SFY 2006 through SFY 2009),
the
county-based 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 P4P system.
1.
SFY 2007 P4P
1.a.
Qualifying Performance Levels
To
qualify for consideration of the SFY 2007 P4P, an MCP’s performance level
must:
1)
Meet
the minimum performance standards set in Appendix M, Performance
Evaluation, for the measures listed below; and
2) Meet
the P4P standards established for the Emergency Department Diversion and
Clinical Performance Measures 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 2007 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
2006
2.
Children’s Access to Primary Care (Appendix M, Section 2.b.)
Report
Period: CY
2006
3. Adults’
Access to Preventive/Ambulatory Health Services (Appendix M, Section
2.c.)
Report
Period: CY
2006
4.
Overall Satisfaction with MCP (Appendix M, Section 3.)
Report
Period: The most recent consumer satisfaction survey completed prior to
the
end of the SFY 2007 contract period.
For
the
EDD performance measure, the MCP must meet the P4P standard for the
report period of July - December, 2006 to be considered for SFY 2007
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, Section 4.b.;
or
2)
The
Medicaid benchmark of a performance level at or below 1.1%.
For
each
clinical performance measure listed below, the MCP must meet the P4P standard
to
be considered for SFY 2007 P4P. The MCP meets the P4P standard if one
of two criteria are met. The P4P standard is a performance level of
either:
1)
The
minimum performance standard established in Appendix M, Performance
Evaluation, for seven of the nine clinical performance measures listed
below; or
2)
The
Medicaid benchmarks for seven of the nine clinical performance measures
listed
below. The Medicaid benchmarks are subject to change based on the
revision or update of applicable national standards, methods or
benchmarks.
Clinical
Performance Measure
|
Medicaid
Benchmark
|
1.
Perinatal Care - Frequency of Ongoing Prenatal Care
|
42%
|
2.
Perinatal Care - Initiation of Prenatal Care
|
71%
|
3.
Perinatal Care - Postpartum Care
|
48%
|
4.
Well-Child Visits – Children who turn 15 months old
|
34%
|
5.
Well-Child Visits - 3, 4, 5, or 6, years old
|
50%
|
6.
Well-Child Visits - 12 through 21 years old
|
30%
|
7.
Use of Appropriate Medications for People with Asthma
|
83%
|
8.
Annual Dental Visits
|
40%
|
9.
Blood Lead – 1 year olds
|
45%
|
1.b.
Excellent and Superior Performance Levels
For
qualifying MCPs as determined by Section 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.ii.)
Report
Period: April - June
2007
Excellent
Standard:
5.5%
Superior
Standard:
6.5%
2.
Use of
Appropriate Medications for People with Asthma (Appendix M, Section
0.x.xx.)
Report
Period: CY
2006
Excellent
Standard:
86%
Superior
Standard:
88%
3.
Adults’ Access to Preventive/Ambulatory Health Services (Appendix M, Section
2.c.)
Report
Period: CY
2006
Excellent
Standard:
76%
Superior
Standard:
83%
1.c.
Determining SFY 2007 P4P
MCPs
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 2.) 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.
2.
SFY 2008 P4P
2.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
4.
Overall Satisfaction with MCP (Appendix M, Section 3.)
Report
Period: The most recent consumer satisfaction survey completed prior to
the
end of the SFY2008.
For
each
clinical performance measure listed below, the MCP must meet the P4P standard
to
be considered for SFY 2008 P4P. The MCP meets the P4P standard if one
of two criteria are met. The P4P standard is a performance level of
either:
1)
The
minimum performance standard established in Appendix M, Performance
Evaluation, for seven of the nine clinical performance measures listed
below; or
2)
The
Medicaid benchmarks for seven of the nine clinical performance measures
listed
below. The Medicaid benchmarks are subject to change based on the
revision or update of applicable national standards, methods or
benchmarks.
Clinical
Performance Measure
|
Medicaid
Benchmark
|
1.
Perinatal Care - Frequency of Ongoing Prenatal Care
|
42%
|
2.
Perinatal Care - Initiation of Prenatal Care
|
71%
|
3.
Perinatal Care - Postpartum Care
|
48%
|
4.
Well-Child Visits – Children who turn 15 months old
|
34%
|
5.
Well-Child Visits - 3, 4, 5, or 6, years old
|
50%
|
6.
Well-Child Visits - 12 through 21 years old
|
30%
|
7.
Use of Appropriate Medications for People with Asthma
|
83%
|
8.
Annual Dental Visits
|
40%
|
9.
Blood Lead – 1 year olds
|
45%
|
2.b.
Excellent and Superior Performance Levels
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
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%
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.
NOTES
3.a. Initiation
of the 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.
3.b.
Determination of at-risk amounts and additional P4P
payments
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.
Transition from a county-based to a regional-based P4P
system.
The
current county-based P4P system will transition to a regional-based system
as
managed care expands statewide. The regional-approach will be fully
phased in no later than SFY 2010. The regional-based P4P system will
be modeled after the county-based system with adjustments to performance
standards where appropriate to account for regional differences.
3.c.i.
County-based P4P system
During
the transition to a regional-based system (SFY 2006 through SFY 2009),
MCPs with
membership as of February 1, 2006 will continue in the county-based
P4P system until the
transition
is complete. These MCPs will be put at-risk for a portion of the
premiums received for members in counties they are serving as of February
1,
2006.
3.c.ii.
Regional-based P4P system
All
MCPs
will be included in the regional-based 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
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 P4P system for
the SFY
2009 P4P determination, will be excluded from the at-risk dollars included
in
the first regional P4P determination.
3.d.
Contract Termination, Nonrenewals, or Denials
Upon
termination, nonrenewal or denial of an MCP contract, the at-risk amount
paid to
the MCP under the current provider agreement will be returned to
ODJFS in accordance with Appendix P.,
Terminations/Nonrenewals/Amendments, of the provider
agreement.
Additionally,
in accordance with Article XI of the provider agreement, the return of
the
at-risk amount paid to the MCP under the current provider agreement will
be a
condition necessary for ODJFS’ approval of a provider agreement
assignment.
3.e.
Report Periods
The
report period used in determining the MCP’s performance levels varies for each
measure depending on the frequency of the report and the data
source. 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.
APPENDIX
P
MCP
TERMINATIONS/NONRENEWALS/AMENDMENTS
CFC
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.
MCP-INITIATED
TERMINATIONS/NONRENEWALS
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 a refundable monetary assurance. This monetary assurance will
be held by ODJFS until such time that the MCP has submitted all outstanding
monies owed 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.
ODJFS-INITIATED
TERMINATIONS
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 R.C. Chapter 119.
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.
|
·
|
MCPs
notified by ODJFS of such a proposed MCP membership termination
will have three working days from the date of receipt to request
reconsideration.
|
·
|
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 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.
|
·
|
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.
|