PROVIDER AGREEMENT BETWEEN STATE OF OHIO DEPARTMENT OF JOB AND FAMILY SERVICES AND WELLCARE OF OHIO, INC. Amendment No. 2
Exhibit
10.1
BETWEEN
STATE OF
OHIO
DEPARTMENT
OF JOB AND FAMILY SERVICES AND
WELLCARE
OF OHIO, INC.
Amendment
No. 2
Pursuant
to Article IX.A. the Provider Agreement between the State of Ohio, Department
of
Job and Family Services, (hereinafter referred to as "ODJFS") and WELLCARE
OF
OHIO, INC. (hereinafter referred to as "MCP") for the Aged, Blind or Disabled
(hereinafter referred to as "ABD") population dated December 1, 2006, is hereby
amended as follows:
1.
Appendix C is modified as attached.
2.
All
other terms of the provider agreement are hereby affirmed.
The
amendment contained herein shall be effective March 1, 2007.
|
WELLCARE
OF OHIO, INC.:
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||||
|
BY:
|
/s/
Xxxx X. Xxxxx
|
DATE:
|
2/19/2007
|
|
|
XXXX
X. XXXXX, PRESIDENT & CEO
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||||
|
OHIO
DEPARTMENT OF JOB AND FAMILY SERVICES:
|
||||
|
BY:
|
/s/
Xxxxx X. Xxxxx-Xxxxx
|
DATE:
|
2/27/2007 | |
|
XXXXX
X. XXXXX-XXXXX, DIRECTOR
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||||
APPENDIX
C
MCP
RESPONSIBILITIES ABD 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).
If
an MCP
serves both the CFC and ABD populations, they are not required to designate
a
separate provider relations representative or Medicaid Coordinator for each
population group.
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.
Appendix
C
Page
2
7.
Upon
request by ODJFS, the MCP must submit information on the current status of
their
company's operations not specifically covered under this 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 their Contract Administrator of the termination of an MCP panel
provider that is designated as the primary care physician for ≥100
of the MCP's ABD 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
Appendix
C
Page
3
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 that must travel
thirty (30) miles or more from their home to receive a medically-necessary
Medicaid-covered service. If the MCP offers transportation to their members
as
an additional benefit and this transportation benefit only covers a limited
number of trips, the required transportation listed above may not be counted
toward this trip limit.
b.
Additional benefits may not vary by county within a region except out of
necessity for transportation arrangements (e.g., bus versus cab). MCPs approved
to serve consumers in more than one region may vary additional benefits between
regions.
c.
MCPs
must give ODJFS and members ninety (90) days prior notice when decreasing or
ceasing any additional benefit(s). When it is beyond the control of the MCP,
as
demonstrated to ODJFS' satisfaction, ODJFS must be notified within one (1)
working day.
16.
MCPs
must comply with any applicable Federal and State laws that pertain to member
rights and ensure that its staff adhere to such laws when furnishing services
to
its membrs. 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:
Appendix
C
Page
4
a.
When
10% or more of the ABD eligible individuals in the MCP's service areahave 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 ABD 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
member 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).
Appendix
C
Page
5
Additional
requirements specific to
providing assistance to hearing-impaired, vision-impaired, limited reading
proficient (LRP), and LEP members and eligible individuals are found in OAC
rules 5101:3-26-03.1, 5101:3-26-05(D), 5101:3-26-05.1(A), 5101:3-26-08, and
5101-3-26-08.2.
21.
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 ofmembers.
Member health education materials that are produced by a source other than
the
MCP and which do not include any reference to the MCP are not considered to
be
member materials.
c.
All
MCP marketing and member materials must represent the MCP in an honest and
forthright manner and must not make statements which are inaccurate, misleading,
confusing, or otherwise misrepresentative, or which defraud eligible individuals
or ODJFS.
d.
All
MCP marketing cannot contain any assertion or statement (whether written or
oral) that the MCP is endorsed by CMS, the Federal or State government or
similar entity.
e.
MCPs
must establish positive working relationships with the CDJFS offices and must
not aggressively solicit from local Directors, MCP County Coordinators, or
or
other staff. Furthermore, MCPs are prohibited from offering gifts of nominal
value (i.e. clipboards, pens, coffee mugs, etc.) to CDJFS offices or SSE staff,
as these may influence an individual'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
Appendix
C
Page
6
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.
Appendix
C
Page
7
24.
New
Member Materials
Pursuant
to OAC rule 5101:3-26-08.2 (B)(3), MCPs must provide to each member an MCP
identification (ID) card, a new member letter, a member handbook, a provider
directory, and information on advance directives.
a.
MCPs
must use the model language specified by ODJFS for the new member
letter.
b.
The ID
card and new member letter must be mailed together to the member via a method
that will ensure its receipt prior to the member's effective date of coverage.
No other materials may be included with this mailing.
c.
The
member handbook, provider directory and advance directives information must
be
mailed separately from the ID card and new member letter. MCPs will meet the
timely receipt requirement for these materials if they are mailed to the member
within twenty-four (24) hours of the MCP receiving the ODJFS-produced monthly
membership roster (MMR). This is provided the materials are mailed via a method
with an expected delivery date of five (5) days. If the MCP is unable to mail
the materials within twenty-four (24) hours, the materials must be mailed via
a
method that will ensure receipt by no later than the effective date of
coverage.
d.
MCPs
must designate two (2) MCP staff members to receive a copy of the new member
materials on a monthly basis in order to monitor the timely receipt of these
materials. At least one of the staff members must receive the materials at
their
home address.
25.
Call
Center Standards
The
MCP
must provide assistance to members through a member services toll-free call-in
system pursuant to OAC rule 5101:3-26-08.2(A)(1). MCP member services staff
must
be available nationwide to provide assistance to members through the toll-free
call-in system every Monday through Friday, at all times during the hours of
7:00 am to 7:00 pm Eastern Time, except for the following major
holidays:
•
New
Year's Day
•
Xxxxxx
Xxxxxx Xxxx'x Birthday
•
Memorial Day
•
Independence Day
•
Labor
Day
•
Thanksgiving Day
•
Christmas Day
•
2
optional closure days: These days can be used independently or in combination
with any of
the
major holiday closures but cannot both be
Appendix
C
Page
8
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, toll-free call-in system, available nationwide,
pursuant to OAC rule 5101:3-26-03.1(A)(6). The twenty-four (24)/7 hour 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 twenty-four (24) hour toll-free call-in systems
to
ODJFS. ODJFS will inform the MCPs of any changes/updates to these URAC call
center standards.
MCPs
are
not permitted to delegate grievance/appeal functions [Ohio Administrative Code
(OAC) rule 5101:3-26-08.4(A)(9)]. Therefore, the member services call center
requirement may not be met through the execution of a Medicaid Delegation
Subcontract Addendum or Medicaid Combined Services Subcontract
Addendum.
26.
Notification
of Optional MCP Membership
In
order
to comply with the terms of the ODJFS State Plan Amendment for the managed
care
program (i.e., 42 CFR 438.50), MCPs in mandatory membership service areas must
inform new members, as applicable, that MCP membership is optional for certain
populations. Specifically, MCPs must inform any applicable pending member or
member that the following ABD population is 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, except as permitted under
42 C.F.R
438.50(d)(21).
Appendix
C
Page
9
27.
HIPAA
Privacy Compliance Requirements
The
Health Insurance Portability and Accountability Act (HIPAA) Privacy Regulations
at 45 CFR. § 164.502(e) and § 164.504(e) require ODJFS to have agreements with
MCPs as a means of obtaining satisfactory assurance that the MCPs will
appropriately safeguard all personal identified health information. Protected
Health Information (PHI) is information received from or on behalf of ODJFS
that
meets the definition of PHI as defined by HIPAA and the regulations promulgated
by the United States Department of Health and Human Services, specifically
45
CFR 164.501, and any amendments thereto. MCPs must agree to the
following:
a.
MCPs
shall not use or disclose PHI other than is permitted by this Agreement or
required by law.
b.
MCPs
shall use appropriate safeguards to prevent unauthorized use or disclosure
of
PHI.
c.
MCPs
shall report to ODJFS any unauthorized use or disclosure of PHI of which it
becomes aware. Any breach by the MCP or its representatives of protected health
information (PHI) standards shall be immediately reported to the State HIPAA
Compliance Officer through the Bureau of Managed Health Care. MCPs must provide
documentation of the breach and complete all actions ordered by the HIPAA
Compliance Officer.
d.
MCPs
shall ensure that all its agents and subcontractors agree to these same PHI
conditions and restrictions.
e.
MCPs
shall make PHI available for access as required by law.
f.
MCP
shall make PHI available for amendment, and incorporate amendments as
appropriate as required by law.
g.
MCPs
shall make PHI disclosure information available for accounting as required
by
law.
h.
MCPs
shall make its internal PHI practices, books and records available to the
Secretary of Health and Human Services (HHS) to determine
compliance.
i.
Upon
termination of their agreement with ODJFS, the MCPs, at ODJFS' option, shall
return to ODJFS, or destroy, all PHI in its possession, and keep no copies
of
the information, except as requested by ODJFS or required by law.
j.
ODJFS
will propose termination of the MCP's provider agreement if ODJFS determines
that the MCP has violated a material breach under this section of the agreement,
unless inconsistent with statutory obligations of ODJFS or the
MCP.
Appendix
C
Page
10
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 selection services contractor (SSC) 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 SSC-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 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.
c.
Monthly
Premiums:
The MCP
must be able to receive monthly premiums in a method specified by ODJFS. (ODJFS
monthly prospective premium issue dates are provided in advance to the MCPs.)
Various retroactive premium payments and recovery of premiums paid (e.g.,
retroactive terminations of membership, deferments, etc.,) may occur via any
ODJFS weekly remittance.
d.
Hospital
Deferment Requests:
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 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
Appendix
C
Page
11
deferment-eligible
hospitalization, the MCP shall make every effort to notify ODJFS and request
the
deferment as soon as possible. When the MCP is notified by ODJFS of a potential
hospital deferment, the MCP must make every effort to respond to ODJFS within
ten (10) business days of the receipt of the deferment information.
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.
Eligible
Individuals:
If an
eligible individual contacts the MCP, the MCP must provide any MCP-specific
managed care program information requested. The MCP must not attempt to assess
the eligible individual's health care needs. However, if the eligible individual
inquires about continuing/transitioning health care services, MCPs shall provide
an assurance that all MCPs must cover all medically necessary Medicaid-covered
health care services and assist members with transitioning their health care
services.
g.
Pending
Member If
a
pending member (i.e., an eligible individual subsequent to plan selection 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, 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.
h.
Transition
of Fee-For-Service Members Providing
care coordination, access to preventive and specialized care, case management,
member services, and education with minimal disruption to members' established
relationships with providers and existing care treatment plans is critical
for
members transitioning from Medicaid fee-for-service to managed care. MCPs
must:
i.
Develop a transition plan that outlines how the MCP will effectively address
the
unique care coordination issues for members in their first three months of
MCP
membership that includes at a minimum:
Appendix
C
Page
12
ii.
An
effective outreach process to identify each
new
member's existing and/or potential health care needs that results in a new
member profile that includes, but is not limited to identification
of:
a.
Health
care needs, including those services received through state sub-recipient
agencies [e.g., the Ohio Department of Mental Health (ODMH), the Ohio Department
of Mental Retardation and Developmental Disabilities (ODMR/DD), and the Ohio
Department of Alcohol and Drug Addiction Services (ODADAS);
b.
Existing sources of care (i.e., primary physicians, specialists, case
manager(s), ancillary and other care givers); and
c.
Current care therapies for all aspects of health care services, including
scheduled health care appointments, planned and/or approved surgeries (inpatient
or outpatient), ancillary or medical therapies, prescribed drugs, approved
home
health care, scheduled lab/radiology tests, necessary/approved durable medical
equipment, supplies and needed/approved transportation
arrangements.
iii.
Strategies for how each new member will obtain care therapies from appropriate
sources of care as an MCP member including reported scheduled health services
as
described in Section 28.i.(ii-iv) of this Appendix.
iv.
Allow
their new members that are transitioning from Medicaid fee-for-service to
receive services from out-of-panel providers if the members contact the MCP
to
discuss the scheduled health services in advance of the service date and one
of
the following applies:
a.
The
member has appointments within the initial three months of the MCP membership
with a primary physician or specialty physicians that were scheduled prior
to
the effective date of the MCP membership;
b.
The
member has been approved to receive an organ, bone marrow, or hematapoietic
stem
cell transplant pursuant to OAC rule 5101:3-2-07.1;
Appendix
C
Page
13
c.
The
member is in her third trimester of pregnancy and has an established
relationship with an obstetrician and/or delivery hospital;
d.
The
member has been scheduled for an inpatient/outpatient surgery and has been
prior-approved and/or precertified pursuant to OAC rule 5101:3-2-40 (surgical
procedures would also include follow-up care as appropriate);
e.
The
member is receiving ongoing chemotherapy or radiation treatment;
f.
The
member has been released from the hospital within the last thirty (30) days
and
is following a treatment plan;
g.
The
member has been pre-certified to receive durable medical equipment (DME) which
has not yet been received.
v.
Reimburse out-of-panel providers that agree to provide the transition services
identified in section 28.i.section ii at 100% of the current Medicaid
fee-for-service provider rate for the service(s).
vi.
Document the provision of transition services as follows:
a.
As
expeditiously as the situation warrants, contact the provider's offices via
telephone to confirm that the service(s) meets the above criteria.
b.
For
services that meet the above criteria, inform the provider that the MCP is
sending a form for signature to document that they accept/do not accept the
terms for the provision of the services and copy the member on the
form.
c.
If the
provider agrees to the terms, notify the member and provider of the MCP's
authorization and ensure that the MCP's claims processing system will not deny
the claim payment because the provider is out-of-panel. MCPs must include their
non-contracting provider materials as outlined in Appendix G.4.e with the
provider notice.
d.
If the
provider does not agree to the terms, notify the member and assist the member
with locating a provider as expeditiously as the member's condition
warrants.
Appendix
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14
e.
Use
the ODJFS-specified model language for the provider and member
notices.
f.
Maintain documentation of all member and/or provider contacts relating to such
out-of-panel services, including but not limited to telephone calls and
letters.
vii.
Not
require prior-authorization of any prescription drug that does not require
prior
authorization by Medicaid fee-for-service for the initial three months of a
member's MCP membership. Additionally, all atypical anti-psychotic drugs, that
do not require prior authorization by Medicaid fee-for-service, must be exempted
from prior authorization requirements for all MCP ABD members through December
2007, after which time ODJFS will re-evaluate the continuation of this pharmacy
utilization strategy.
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)(l), each MCP must collect data on member and
provider characteristics and on services furnished to its members.
iii.
As
required by 42 CFR 438.242(b)(2), each MCP must ensure that data received from
providers is accurate and complete by verifying the accuracy and timeliness
of
reported data; screening the data for completeness, logic, and consistency;
and
collecting service information in standardized formats to the extent feasible
and appropriate.
Appendix
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15
iv.
As
required by 42 CFR
438.242(b)(3), each MCP must make all collected data available upon request
by
ODJFS or the Center for Medicare and Medicaid Services (CMS).
v.
Acceptance testing of any data that is electronically submitted to ODJFS is
required:
a.
Before
an MCP may submit production files
b.
Whenever an MCP changes the method or preparer of the electronic media;
and/or
c.
When
the ODJFS determines an MCP's data submissions have an unacceptably high error
rate.
MCPs
that
change or modify information systems that are involved in producing any type
of
electronically submitted files, either internally or by changing vendors, are
required to submit to ODJFS for review and approval a transition plan including
the submission of test files in the ODJFS-specified formats. Once an acceptable
test file is submitted to ODJFS, as determined solely by ODJFS, the MCP can
return to submitting production files. ODJFS will inform MCPs in writing when
a
test file is acceptable. Once an MCP's new or modified information system is
operational, that MCP will have up to ninety (90) days to submit an acceptable
test file and an acceptable production file.
Submission
of test files can start before the new or modified information system is in
production. ODJFS reserves the right to verify any MCP's capability to report
elements in the minimum data set prior to executing the provider agreement
for
the next contract period. Penalties for noncompliance with this requirement
are
specified in Appendix N, Compliance Assessment System of the Provider
Agreement.
b.
Electronic Data Interchange and Claims Adjudication Requirements
Claims
Adjudication
The
MCP
must have the capacity to electronically accept and adjudicate all claims to
final status (payment or denial). Information on claims submission procedures
must be provided to non-contracting providers within thirty (30) days of a
request. MCPs must inform providers of its ability to electronically process
and
adjudicate claims and the process for submission. Such information must be
initiated by the MCP and not only in response to provider requests.
The
MCP
must notify providers who have submitted claims of claims status [paid, denied,
pended (suspended)] within one month of receipt. Such notification may be in
the
form of a claim payment/remittance advice produced on a routine monthly, or
more
frequent, basis.
Appendix
C
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16
Electronic
Data Interchange
The
MCP
shall comply with all applicable provisions of HIPAA including electronic data
interchange (EDI) standards for code sets and the following electronic
transactions:
Health
care claims;
Health
care claim status request and response;
Health
care payment and remittance status; and Standard code sets.
Each
EDI
transaction processed by the MCP shall be implemented in conformance with the
appropriate version of the transaction implementation guide, as specified by
applicable federal rule or regulation.
The
MCP
must have the capacity to accept the following transactions from the Ohio
Department of Job and Family services consistent with EDI processing
specifications in the transaction implementation guides and in conformance
with
the 820 and 834 Transaction Companion Guides issued by ODJFS:
ASC
XI 2
820 - Payroll Deducted and Other Group Premium Payment for Insurance Products;
and
ASC
X12
834 - Benefit Enrollment and Maintenance.
The
MCP
shall comply with the HIPAA mandated EDI transaction standards and code sets
no
later than the required compliance dates as set forth in the federal
regulations.
Documentation
of Compliance with Mandated EDI Standards
The
capacity of the MCP and/or applicable trading partners and business associates
to electronically conduct claims processing and related transactions in
compliance with standards and effective dates mandated by HIPAA must be
demonstrated, to the satisfaction of ODJFS, as outlined below.
Verification
of Compliance with HIPAA (Health Insurance Portability and Accountability Act
of
1995)
MCPs
shall submit written verification to ODJES for transaction standards
and
Appendix
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17
code
sets
specified in 45 CFR Part 162 - Health Insurance Reform: Standards for Electronic
Transactions (HIPAA regulations), that the MCP has established the capability
of
sending and receiving applicable transactions in compliance with the HIPAA
regulations. The written verification shall specify the date that the MCP has:
1) achieved capability for sending and/or receiving the following transactions,
2) entered into the appropriate trading partner agreements, and 3) 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 X 12N 276/277)
e.
Enrollment and Disenrollment in a Health Plan (ASC X12N 834) f. Health Care
Payment and Remittance Advice (ASC X12N 835)
g.
Health
Plan Premium Payments (ASC X12N 820)
h.
Coordination of Benefits
Trading
Partner Agreement with ODJFS
MCPs
must
complete and submit an EDI trading partner agreement in a format specified
by
the ODJFS. Submission of the copy of the trading partner agreement prior to
entering into this Agreement may be waived at the discretion of
ODJFS;
if
submission prior to entering into the Agreement is waived, the trading partner
agreement must be submitted at a subsequent date determined by
ODJFS.
Noncompliance
with the EDI and claims adjudication requirements will result in the imposition
of penalties, as outlined in Appendix N, Compliance Assessment System, of the
Provider Agreement.
c.
Encounter
Data Submission Requirements
General
Requirements
Each
MCP
must collect data on services furnished to members through an encounter data
system and must report encounter data to the ODJFS. MCPs are required to submit
this data electronically to ODJFS on a monthly basis in the following standard
formats:
Appendix
C
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18
•
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.
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 new-born)
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
Appendix
C
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19
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.
No
more
than two production files in the ODJFS-specified medium per format (e.g., NSF)
should be submitted each month. If it is necessary for an MCP to submit more
than two production files in the ODJFS-specified medium for a particular format
in a month, they must request and receive permission to do so from their
designated Contract Administrator.
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.
Appendix
C
Page
20
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 two years. However,
if ODJFS or its designee identifies significant information system 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 a private sector
accreditation body or other independent entity within the two years preceding
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.
Appendix
C
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21
31.
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 written approval from ODJFS that verifies that the proper safeguards,
firewalls, etc., are in place to protect member data.
32.
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).
33.
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.
34.
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.
35.
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 4'/2 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.
36.
Information
Required for MCP Websites
a.
On-line
Provider Directory
- MCPs
must have an internet-based provider directory available in the same format
as
their ODJFS-approved provider
Appendix
C
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22
directory,
that allows members to electronically search for the MCP panel providers based
on name, provider type, geographic proximity, and population (as specified
in
Appendix H). MCP provider directories must include all MCP-contracted providers
[except as specified by ODJFS] as well as certain ODJFS non-contracted
providers.
b.
On-line
Member Website
- MCPs
must have a secure internet-based website
which
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 covered
in their service area; (2) the ODJFS-approved MCP member handbook, recent
newsletters/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 submit
questions/comments/grievances/appeals/etc, and receive a response (members
must
be given the option of a return e-mail or phone call). Responses regarding
questions or comments are expected within one working day of receipt, whereas
responses regarding grievances and appeals must be within the timeframes
specified in OAC rule 5101:3-26-08.4. 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 materials etc.). 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 providers where they will be
able
to confirm a consumer's MCP enrollment and through this website (or through
e-mail process) allow providers to 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
iTianual.;(3) MCP contact information; (4) a link to the MCP's on-line provider
directory as referenced in section 36(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.
Appendix
C
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23
37.
MCPs
must provide members with a printed version of their PDL and PA lists, upon
request.
38.
MCPs
must not use, or propose to use , any offshore programming or call center
services in fulfilling the program requirements.
39.
PCP
Feedback
- The
MCP must have the administrative capacity to offer feedback to individual
providers on their: 1) adherence to evidence-based practice guidelines; and
2)
positive and negative care variances from standard clinical pathways that may
impact outcomes or costs. In addition, 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
programs.
