PROVIDER AGREEMENT BETWEEN STATE OF OHIO
Exhibit
10.2
PROVIDER
AGREEMENT BETWEEN
STATE
OF OHIO
DEPARTMENT
OF JOB AND FAMILY SERVICES AND
WELLCARE
OF OHIO, INC.
Amendment
No. 1
Pursuant
to Article IX.A. the Provider Agreement between the State of Ohio, Department
of
Job and Family Services, (hereinafter referred to as "ODJFS") and WELLCARE
OF
OHIO, INC. (hereinafter referred to as "MCP") for the Covered Families and
Children (hereinafter referred to as "CFC") population dated November 1,
2006,
is hereby amended as follows:
1.
Baseline, Index and Appendices A, B, C, D, E, F, G, H, I, J, K, L, M, N,
O and P
are modified as attached.
2.
All
other terms of the provider agreement are hereby affirmed.
The
amendment contained herein shall be effective January 1, 2007.
|
WELLCARE
OF OHIO, INC.:
BY:
/s/
Xxxx X. Xxxxx
XXXX
X. XXXXX, PRESIDENT & CEO
|
Date:
12/18/2006
|
|
OHIO
DEPARTMENT OF JOB AND FAMILY SERVICES:
BY:
/s/
Xxxxxxx X. Xxxxx
XXXXXXX
X. XXXXX, DIRECTOR
|
Date:
12/22/2006
|
Covered
Families and Children (CFC) population
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 January, 2006, 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.
Covered
Families and Children (CFC) population
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This
provider agreement is a contract between the 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 1.973; and the
Americans with Disabilities Act.
ARTICLE
I
- GENERAL
A.
MCP
agrees to report to the Chief of Bureau of Managed Health Care (hereinafter
referred to as BMHC) or their designee as necessary to assure understanding
of
the responsibilities and satisfactory compliance with this provider
agreement.
B.
MCP
agrees to furnish its support staff and services as necessary for the
satisfactory performance of the services as enumerated in this provider
agreement.
C.
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.
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.
ARTICLE
II - TIME OF PERFORMANCE
A.
Upon
approval by the Director of ODJFS this provider agreement shall be in effect
from the date entered through June 30, 2007, unless this provider agreement
is
suspended or terminated pursuant to Article VIII prior to the termination
date,
or otherwise amended pursuant to Article IX.
ARTICLE
III - REIMBURSEMENT
A.
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.
Covered
Families and Children (CFC) population
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ARTICLE
IV - MCP INDEPENDENCE
A.
MCP
agrees that no agency, employment, joint venture or partnership has been
or will
be created between the parties hereto pursuant to the terms and conditions
of
this agreement. MCP also agrees that, as an independent contractor, MCP
assumes
all responsibility for any federal, state, municipal or other tax liabilities,
along with workers compensation and unemployment compensation, and insurance
premiums which may accrue as a result of compensation received for services
or
deliverables rendered hereunder. MCP certifies that all approvals, licenses
or
other qualifications necessary to conduct business in Ohio have been obtained
and are operative. If at any time during the period of this provider agreement
MCP becomes disqualified from conducting business in Ohio, for whatever
reason,
MCP shall immediately notify OD.1FS of the disqualification and MCP shall
immediately cease performance of its obligation hereunder in accordance
with OAC
Chapter 5101:3-26.
ARTICLE
V
- CONFLICT OF INTEREST; ETHICS LAWS
A.
In
accordance with the safeguards specified in section 27 of the Office of
Federal
Procurement Policy Act (41 U.S.C. 423) and other applicable federal
requirements, no officer, member or employee of MCP. the Chief of BMHC,
or other
ODJFS employee who exercises any functions or responsibilities in connection
with the review or approval of this provider agreement or provision of
services
under this provider agreement shall, prior to the completion of such services
or
reimbursement, acquire any interest, personal or otherwise, direct or indirect,
which is incompatible or in conflict with, or would compromise in any manner
or
degree the discharge and fulfillment of his or her functions and
responsibilities with respect to the carrying out of such services. For
purposes
of this article, "members" does not include individuals whose sole connection
with MCP is the receipt of services through a health care program offered
by
MCP.
B.
MCP
hereby covenants that MCP, its officers, members and employees of the MCP
have
no 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.
C.
Any
person who acquires an incompatible, compromising or conflicting personal
or
business 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 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.
Covered
Families and Children (CFC) population
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D.
No
officer, member or employee ofMCP 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 ofMCP 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.
E.
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.
ARTICLE
VI - EQUAL EMPLOYMENT OPPORTUNITY
A.
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, sex, sexual orientation,
age,
disability, national origin, veteran's status, health status, or ancestry,
discriminate against any citizen of this state in the employment of a person
qualified and available to perform the services to which the provider agreement
relates.
B.
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, sex, sexual orientation,
age, disability, national origin, veteran's status, health status, or
ancestry.
C.
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.
ARTICLE
VII - RECORDS, DOCUMENTS AND INFORMATION
A.
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 74.
B.
All
information provided by MCP to ODJFS that is proprietary shall be held
to be
strictly
Covered
Families and Children (CFC) population
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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. 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 this assertion is supported. The provisions
of
this Article are not self-executing.
C.
MCP
shall not use any information, systems, or records made available to it
for any
purpose other than to fulfill the duties specified in this provider agreement.
MCP agrees to be bound by the same standards of confidentiality that apply
to
the employees of the ODJFS and the State of Ohio. The terms of this section
shall be included in any subcontracts executed by MCP for services under
this
provider agreement. MCP must implement procedures to ensure that in the
process
of coordinating care, each enrollee's privacy is protected consistent with
the
confidentiality requirements in 45 CFR parts 160 and 164. .
ARTICLE
VIII - SUSPENSION AND TERMINATION
A.
This
provider agreement may be canceled 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.
B.
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.
C.
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.
D.
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 a public hearing under Chapter 119. of the Revised
Code.
Covered
Families and Children (CFC) population
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E.
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).
ARTICLE
IX - AMENDMENT AND RENEWAL
A.
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.
B.
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.
C.
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.
ARTICLE
X
- LIMITATION OF LIABILITY
A.
MCP
agrees to indemnify the State of Ohio for any liability resulting from
the
actions or omissions of MCP or its subcontractors in the fulfillment of
this
provider agreement.
B.
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.
C.
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
Covered
Families and Children (CFC) population
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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.
ARTICLE
XI - ASSIGNMENT
A.
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.
B.
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.
ARTICLE
XII - CERTIFICATION MADE BY MCP
A.
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.
B.
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.
C.
By
executing this agreement, MCP certifies that neither MCP nor any principals
of
MCP (i.e., a director, officer, partner, or person with beneficial ownership
of
more than 5% of the MCP's equity) is presently debarred, suspended, proposed
for
debarment, declared ineligible, or otherwise excluded from participation
in
transactions by any Federal
Covered
Families and Children (CFC) population
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agency.
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.
D.
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.
E.
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.
F.
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.
G.
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.
H.
By
executing this agreement, MCP certifies and affirms that, as applicable
to MCP,
no party listed in Division (I) or (J) of Section 3517.13 of the Ohio Revised
Code or spouse of such party has made, as an individual, within the two
previous
calendar years, one or more contributions in excess of $1.000.00 to the
Governor
or to his campaign committees. 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.
I.
By
executing this agreement, MCP certifies and affirms that HHS, US Comptroller
General or representatives will have access to books, documents, etc. of
MCP.
J.
By
executing this agreement. MCP agrees to comply with the false claims recovery
requirements of Section 6032 of The Deficit Reduction Act of 2005 (also
see
Section 5111.101 of the Revised Code).
Covered
Families and Children (CFC) population
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ARTICLE
XIII - CONSTRUCTION
A.
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. If any portion of this provider agreement is found
unenforceable by operation of statute or by administrative or judicial
decision,
the operation of the balance of this provider agreement shall not be affected
thereby; provided, however, the absence of the illegal provision does not
render
the performance of the remainder of the provider agreement
impossible.
ARTICLE
XIV - INCORPORATION BY REFERENCE
A.
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.
B.
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.
C.
In the
event of inconsistence or ambiguity between the provisions ofOAC 5101:3-26
and
this provider agreement, the provision of OAC 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.
Covered
Families and Children (CFC) population
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.
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WELLCARE
OF OHIO, INC.:
BY:
_______________________
XXXX
X. XXXXX, PRESIDENT & CEO
|
Date:
|
|
OHIO
DEPARTMENT OF JOB AND FAMILY SERVICES:
BY:
__________________________
XXXXXXX
X. XXXXX, DIRECTOR
|
Date:
|
CFC
PROVIDER AGREEMENT INDEX
JANUARY
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
to
have separate provider relations representatives or Medicaid
coordinators.
4.
All
MCP employees are to direct all day-to-day submissions and communications
to
their ODJFS-designated Contract Administrator unless otherwise notified
by
ODJFS.
5.
The
MCP must be represented at all meetings and events designated by ODJFS
as
requiring mandatory attendance.
6.
The
MCP must have an administrative office located in Ohio.
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.
Appendix
C
Page
2
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 ^500 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.
Appendix
C
Page
3
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 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
Appendix
C
Page
4
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 (PEI) 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).
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(0),
5101:3-26-05.1(A), 5101:3-26-08, and 5101-3-26-08.2.
21.
The
MCP is responsible for ensuring that all member materials use easily understood
language and format. The determination of what materials comply with this
requirement is in the sole discretion of ODJFS.
22.
Pursuant to OAC rules 5101:3-26-08 and 5101:3-26-08.2, the MCP is responsible
for ensuring that all MCP marketing and member materials are prior approved
by
ODJFS before being used or shared with members. Marketing and member materials
are defined as follows:
a.
Marketing materials are those items produced in any medium, by or on behalf
of
an MCP, including gifts of nominal value (i.e.. items worth no more than
$15.00), which can reasonably be interpreted as intended to market to eligible
individuals.
b.
Member
materials are those items developed, by or on behalf of an MCP, to fulfill
MCP
program requirements or to communicate to all members or a group of members.
Member health education materials that are produced by a source other than
the
MCP and which do not include any reference to the MCP are not considered
to be
member materials.
c.
All
MCP marketing and member materials must represent the MCP in an honest
and
forthright manner and must not make statements which are inaccurate, misleading,
confusing, or otherwise misrepresentative, or which defraud eligible individuals
or ODJFS.
d.
All
MCP marketing cannot contain any assertion or statement (whether written
or
oral) that the MCP is endorsed by CMS, the Federal or State government
or
similar entity.
e.
MCPs
must establish positive working relationships with the CDJFS offices and
must
not aggressively solicit from local Directors, MCP County Coordinators,
or 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
directives, as set forth in 42 CFR Subpart I of part 489.
Appendix
C
Page
6
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
Appendix
C
Page
7
Pursuant
to OAC rule 5101:3-26-08.2 (B)(3), MCPs must provide to each member or
assistance group, as applicable, an MCP identification (ID) card, a new
member
letter, a member handbook, a provider directory, and information on advance
directives.
a.
MCPs
must use the model language specified by ODJFS for the new member
letter.
b.
The ID
card and new member letter must be mailed together to the member via a
method
that will ensure 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 no more than 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 a.m to 7:00 p.m 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.
Appendix
C
Page
8
If
a
major holiday falls on a Saturday, the MCP member services line may be
closed on
the preceding Friday. If a major holiday falls on a Sunday, the member
services
line may be closed on the following Monday. MCP member services closure
days
must be specified in the MCP's member handbook, member newsletter, or other
some
general issuance to the MCP's members at least (thirty) 30 days in advance
of
the closure.
The
MCP
must also provide access to medical advice and direction through a centralized
twenty-four-hour, seven day (24/7) toll-free call-in system, available
nationwide, pursuant to OAC rule 5101:3-26-03.1(A)(6). The 24/7 call-in
system
must be staffed by appropriately trained medical personnel. For the purposes
of
meeting this requirement, trained medical professionals are defined as
physicians, physician assistants, licensed practical nurses, and registered
nurses.
MCPs
must
meet the current American Accreditation HealthCare Commission/URAC-designed
Health Call Center Standards (HCC) for call center abandonment rate, blockage
rate and average speed of answer. By the 10th
of each
month, MCPs must self-report their prior month performance in these three
areas
for their member services and 24/7 toll-free call-in systems to ODJFS.
ODJFS
will inform the MCPs of any changes/updates to these URAC call center
standards.
MCPs
are
not permitted to delegate grievance/appeal functions [Ohio Administrative
Code
(OAC) rule 5101:3-26-08.4(A)(9)]. Therefore, the member services call center
requirement may not be met through the execution of a Medicaid Delegation
Subcontract Addendum or Medicaid Combined Services Subcontract
Addendum.
26.
Notification
of Optional MCP Membership
In
order
to comply with the terms of the ODJFS State Plan Amendment for the managed
care
program (i.e., 42 CFR 438.50), MCPs in mandatory membership service areas
must
inform new members that MCP membership is optional for certain populations.
Specifically, MCPs must inform any applicable pending member or member
that the
following CFC populations are not required to select an MCP in order to
receive
their Medicaid healthcare benefit and what steps they need to take if they
do
not wish to be a member of an MCP:
-
Indians
who are members of federally-recognized tribes.
-
Children under 19 years of age who are:
o
Eligible for Supplemental Security Income under title XVI;
o
In
xxxxxx care or other out-of-home placement;
o
Receiving xxxxxx care of adoption assistance;
o
Receiving services through the Ohio Department of Health's Bureau
for
Appendix
C
Page
9
Children
with Medical Handicaps (BCMH) or any other family-centered, community-based,
coordinated care system that receives grant funds under section 501(a)(l)(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 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.
Appendix
C
Page
10
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 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 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.
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.
Appendix
C
Page
11
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 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 leams of a deferment-eligible hospitalization,
the
MCP shall make every effort to notify the 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.
Newborn
Notifications:
The MCP
is required to submit newborn notifications to ODJFS in accordance with
the
ODJFS Newborn Notification File and Submissions Specifications.
g.
Eligible
Individuals:
If an
eligible individual contacts the MCP, the MCP must provide any MCP-specific
managed care program information requested. The MCP must not attempt to
assess
the eligible individual's health care needs. However, if the eligible individual
inquires about continuing/transitioning health care services, MCPs shall
provide
an assurance that all MCPs must cover all medically necessary Medicaid-covered
health care services and assist members with transitioning their health
care
services.
h.
Pending
Member
If
a
pending member (i.e., an eligible individual subsequent to plan selection
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.
Appendix
C
Page
12
i.
Transition
of Fee-For-Service Members
Providing
care coordination for prescheduled health services is critical for members
transitioning from Medicaid fee-for service (FFS) to managed care. Therefore,
MCPs must:
i.
Allow
their new members that are transitioning from Medicaid fee-for-service
to receive services from out-of-panel providers if the member or authorized
representative contacts the MCP to discuss the scheduled health services
in
advance of the service date and one of the following applies:
a.
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.
b.
The
member is in her third trimester of pregnancy and has an established
relationship with an obstetrician and/or delivery hospital;
c.
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);
d.
The
member has appointments within the initial month of MCP
membership
with specialty physicians that were scheduled prior to the effective date
of
membership; or
e.
The
member is receiving ongoing chemotherapy or radiation treatment.
ii.
Reimburse out-of-panel providers that agree to provider the transition
services
identified in this section at 100% of the current Medicaid fee-for-service
provider rate for the service(s).
iii.
Document the provision of transition of services as follows:
a.
As
expeditiously as the situation warrants, contact the
provider's
office via telephone to confirm that the service(s) meet(s) the above
criteria.
Appendix
C
Page
13
b.
For
services that meet the above criteria, inform the provider 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
authorization and ensure that the 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.
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.
30.
Health
Information System Requirements
The
ability to develop and maintain information management systems capacity
is
crucial to successful plan performance. OD.IFS 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
ofMedicaid 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
Appendix
C
Page
14
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 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
Appendix
C
Page
15
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.
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
XI 2
834 - Benefit Enrollment and Maintenance.
The
MCP
shall comply with the HIPAA mandated EDI transaction standards and code
sets no
later than the required compliance dates as set forth in the federal
regulations.
Documentation
of Compliance with Mandated EDI Standards The
capacity of the MCP and/or applicable trading partners and business associates
to electronically conduct claims processing and related transactions in
compliance with standards and effective dates mandated by HIPAA must be
demonstrated, to the satisfaction of ODJFS, as outlined below.
Appendix
C
Page
16
Verification
of Compliance with HIPAA (Health Insurance Portability and Accountability
Act of
1995)
MCPs
shall submit written verification to ODJFS for transaction standards and
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 (ASCX12N 837&NCPDP5.1)
b.
Eligibility for a Health Plan (ASC X12N 270/271)
c.
Referral Certification and Authorization (ASC X 12N 278)
d.
Health
Care Claim Status (ASC X 12N 276/277)
e.
Enrollment and Disenrollment in a Health Plan (ASC XI 2N 834)
f.
Health
Care Payment and Remittance Advice (ASC X12N 835)
g.
Health
Plan Premium Payments (ASC X 12N 820)
h.
Coordination of Benefits
Trading
Partner Agreement with ODJFS
MCPs
must
complete and submit an EDI trading partner agreement in a format specified
by
the ODJFS. Submission of the copy of the trading partner agreement prior
to
entering into this Agreement may be waived at the discretion of ODJFS;
if
submission prior to entering into this Agreement is waived, the trading
partner
agreement must be submitted at a subsequent date determined by
ODJFS.
Noncompliance
with the EDI and claims adjudication requirements will result in the imposition
of penalties, as outlined in Appendix N, Compliance Assessment System,
of the
Provider Agreement.
c.
Encounter
Data Submission Requirements
General
Requirements
Each
MCP
must collect data on services furnished to members through an encounter
data
system and must report encounter data to the ODJFS. MCPs are
Appendix
C
Page
17
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.
Appendix
C
Page
18
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.
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 desimee will:
Appendix
C
Page
19
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 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 oi-ks
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.
Appendix
C
Page
20
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 stillboms 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.
Appendix
C
Page
21
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 111-47 of the NSF
technical specifications (record/field CAO-31 .Oa).
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.
Appendix
C
Page
22
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 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.
37.
Information
Required for MCP Websites
a.
On-line
Provider Directory
- MCPs
must have an internet-based provider directory available in the same format
as
their ODJFS-approved provider directory, that allows members to electronically
search for the MCP panel providers based on name. provider type. geographic
proximity, and population (as specified in Appendix H). MCP provider directories
must include all MCP-contracted providers [except as specified by ODJFS]
as well
as certain ODJFS non-contracted providers.
b.
On-line
Member Website
- MCPs
must have a secure internet-based website which 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
Appendix
C
Page
23
must
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 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
manual; (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 member materials designated specifically for CFC and/or
ABD
consumers 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,
upon
request.
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 OD.IFS-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
Appendix
D
Page
2
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 H1PAA privacy concerns to FAX, telephone, or hard
copy.
The use ofTLS 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'cun-ent 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.
Appendix
D
Page
3
15.
Membership
Selection and Premium Payment
a.
The
Selection Services Entity (SSE) also known as Selection Services Contractor
(SSC): The ODJFS-contracted SSC will provide unbiased education, selection
services, and community outreach for the Medicaid managed care program.
The SSC
shall operate a statewide toll-free telephone center to assist eligible
individuals in selecting an MCP or choosing a health care delivery
option.
The
SSC
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 SSC-initiated MCP assignment processed through
the SSC.
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.
Appendix
D
Page
4
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 MCP
performance including, but not limited to, information on MCP-specific
and
statewide external quality review organization surveys, focused clinical
quality
of care studies, consumer satisfaction surveys and provider
profiles.
18.
ODJFS
will periodically review a random sample of online and printed directories
to
assess whether MCP information is both accessible and updated.
19.
Communications
a.
ODJFS/BMHC:
The
Bureau of Managed Health Care (BMHC) is responsible for the oversight of
the
MCPs' provider agreements with ODJFS. Within the BMHC. a specific Contract
Administrator (CA) has been assigned to each MCP. Unless expressly directed
otherwise, MCPs shall first contact their designated CA for questions/assistance
related to Medicaid and/or the MCP's program requirements /responsibilities.
If
their CA is not available and the MCP needs immediate assistance, MCP staff
should request to speak to a supervisor within the Contract Administration
Section. MCPs should take all necessary and appropriate steps to ensure
all MCP
staff are aware of, and follow, this communication process.
b.
ODJFS
contracting-entities:
ODJFS-contracting entities should never be contacted by the MCPs unless
the MCPs
have been specifically instructed to contact the ODJFS contracting entity
directly.
c.
MCP
delegated entities:
In that
MCPs are ultimately responsible for meeting program requirements, the BMHC
will
not discuss MCP issues
Appendix
D
Page
5
with
the
MCPs' delegated entities unless the applicable MCP is also participating
in the
discussion. MCP delegated entities, with the applicable MCP participating,
should only communicate with the specific CA assigned to that MCP.
APPENDIX
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
Columbus.OH43215.5222
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,
East Central. Northeast, Northwest. Southeast. Southwest, 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
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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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October
20, 2006
Xx.
Xxx
Xxxxxx
Ohio
Department of Job and Family Services
Fee-for-Service
Data
FFS
experience from the base time period of State Fiscal Year (SFY) 2004 (July
1,
2003-June 30, 2004) and SFY 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 SFY 2004 and SFY 2005 data, SFY 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 (MM1S) 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,
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20, 2006
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Xxx
Xxxxxx
Ohio
Department of Job and Family Services
•
Program
changes in the historical base time period (SFY 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.
|
Mercer
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.
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October
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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 Mercer 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, Mercer 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. Mercer 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. Mercer
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. Mercer applied generally accepted
actuarial principles that reflect the impact ofMCP programs on FFS experience.
Mercer reviewed Ohio's historical FFS experience, CY 2004 and CY 2005 cost
report data, SPY 2004 and SFY 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. Mercer
reviewed
information
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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, Mercer 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 Mercer 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. Mercer 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. Mercer
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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, Mercer 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. Mercer 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
MERCER
Government
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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. Mercer discussed all trend recommendations with the State. We reviewed
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
Mercer
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
Mercer
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
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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 Mercer are
actuarial
projections of future contingent events. Actual MCP costs will differ from
these
projections. Mercer 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 Mercer disclaims any responsibility for the use of these
rates
by MCPs for any purpose. Mercer 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.
MERCER
Government
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2006
Xx.
Xxx
Xxxxxx
Ohio
Department of Job and Family Services
Sincerely,
|
/s/
Xxxxxx XxxXxxx
Xxxxxx
XxxXxxx, MAAA, ASA
|
/s/
Xxxxx Xxxxxx
Xxxxx
Xxxxxx, MAAA, FSA
|
|
Copy:
Xxxxx
Xxxxxx, Xxxxxx Xxxxxx, Xxxxx Xxxxxxxx - State of Ohio Xxxxx Xxxxxx,
Xxx
Xxxxxxxxx - Xxxxxx
|
|
MMC
Xxxxx
& McLennan Companies
MERCER
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Appendix
A - CY 2007 Rate-Setting Methodology
[Chart]
MERCER
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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.
B-
1
MERCER
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[Medicaid
Managed Care Program Regions for the CFC Population Map]
B-2
MERCER
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Appendix
C - FFS Data Adjustments
This
section lists adjustments made to the FFS claims and eligibility information
received from the State.
Completion
Factors
|
SFY
|
Paid
Through
|
|
2004
|
03/31/05
|
|
2005
|
12/31/05
|
The
claims data was adjusted to account for the value of claims incurred but
unpaid
on a COS basis. Mercer used claims for SFY 2004 and SPY 2005 that reflect
payments through the dates included in the following table.
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, Mercer 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 Mercer adjusted
the
SFY 2004 and SFY 2005 delivery (where applicable) and non-delivery data.
Mercer
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
|
PCP,
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,Xxx
00-00, X
|
|||
|
XX,Xxx00x,
M & F
|
|||
|
HST,
Age 19-64, F
|
|||
|
Implementation
of $3.00 Copay on Prior-Authorized Drugs
|
1/1/2004
|
Pharmacy
|
All
|
C-
1
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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. Mercer 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 Mercer with SPY 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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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 Mercer 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. TMo 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
MERCER
Government
Human Services Consulting
Appendix
C - Encounter Data Adjustments
Claims
Completion
Mercer
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. Mercer 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
|
HF,
Age 00-00, X
|
|
XX,
Xxx 00-00, X
|
|||
|
XX,Xxx00x,
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, Mercer made adjustments to the encounter data
to account
for incomplete reporting or other known data issues.
Non-State
Plan Services
Mercer
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
Mercer
reviewed TPL recoveries information contained in Report I of the cost
reports to
remove these from the encounters reported by each health plan. Mercer
made MCP
specific adjustments to the data.
C-4
MERCER
Government
Human Services Consulting
Appendix
C - Cost Report Data Adjustments
IBNR
Review/Adjustment
Mercer
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
Mercer
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 111-A were shifted to the non-delivery
"Other" COS.
Non-State
Plan Services
Mercer
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
Mercer
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
MERCER
Government
Human Services Consulting
Appendix
D - Calendar Year 2007 CFC Rate Development
Credibility
By Year Mercer 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 SFY 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 SFY 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, Mercer 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 (≥21)
|
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
(≥21)
|
1/1/2006
|
Dental
|
HF,
Age 19-44, F
|
|
HF,Age
19-44, M
|
|||
|
HF,Age45+,M&F
|
|||
|
Implementation
of $2 copay for vision exams and $1 copay for dispensing services
for
adults (≥21)
|
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,Age45+,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,
Mercer
built this expectation into the capitation rates. To calculate the adjustments,
Mercer 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. Mercer 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
MERCER
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 Par-turn Visits
Target:
80% of the eligible population must receive a post partum
visit.
|
HF/HST,
14-18F
HST,
19-64F
HF,19-44F
|
OB/GYN
|
|
Preventive
Care for Children -Well-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, 14-18 M
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, 14-18 M
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 SPY 2004-SFY 2005 and CY 2004-CY 2005, respectively.
Where
projected managed
D-3
XXXXXX
Government
Human Services Consulting
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, w^xxxx
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
XXXXXX
Government
Human Services Consulting
Appendix
E - Calendar Year 2007 CFC Regional Rate Summary
State
of
Ohio
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
|
6.0%
|
$
564.92
|
$
5.45
|
$
570.36
|
|
Central
|
HF/HST,
Age 1,M & F
|
146,106
|
5.1%
|
$
149.56
|
$
1.44
|
$
151.01
|
|
Central
|
HF/HST,
Age 2-13, M & F
|
1,335,641
|
46.6%
|
$
99.74
|
$
0.96
|
$
100.70
|
|
Central
|
HF/HST,
Age 14-18, M
|
191,907
|
6.7%
|
$
118.11
|
$
1.14
|
$
119.25
|
|
Central
|
HF/HST,
Age 14-18, F
|
208,187
|
7.3%
|
$
166.07
|
$
1.60
|
$
167.68
|
|
Central
|
HF
Age 19-44, M
|
172,314
|
6.0%
|
$
206.93
|
$
2.00
|
$
208.92
|
|
Central
|
HF
Age 19-44, F
|
531,797
|
18.5%
|
$
299.33
|
$
2.89
|
$
302.21
|
|
Central
|
HP
Age 45+, M & F
|
59,319
|
2.1%
|
$
487.07
|
$
4.70
|
$
491.77
|
|
Central
|
HST
Age 19-64, F
|
50,975
|
1.8%
|
$
340.59
|
$
3.28
|
$
343.87
|
|
Central
|
Subtotal
|
2,868,064
|
100.0%
|
$
191.93
|
$
1.85
|
$
193.78
|
|
Central
|
Delivery
Payment
|
9,465
|
0.3%
|
$
4,023.39
|
$
38.79
|
$
4,062.19
|
|
Central
|
Total
|
2,868.064
|
100.0%
|
$
205.21
|
$
1.98
|
$
207.19
|
|
East-Central
|
HF/HST,
Age 0, M & F
|
95,509
|
5.6%
|
$
554.55
|
$
5.35
|
$
559.90
|
|
East-Central
|
HF/HST,
Age 1,M&F
|
78,227
|
4.6%
|
$
145.80
|
$
1.41
|
$
147.21
|
|
East-Central
|
HF/HST.
Age 2-13, M&F
|
786,577
|
46.4%
|
$
98.24
|
$
0.95
|
$
99.19
|
|
East-Central
|
HF/HST,
Age 14-18, M
|
122,231
|
7.2%
|
$
114.36
|
$
1.10
|
$
115.47
|
|
East-Central
|
HF/HST,
Age 14-18, F
|
126,757
|
7.5%
|
$
158,66
|
$
1.53
|
$
160.19
|
|
East-Central
|
HF
Age 19-44, M
|
98,371
|
5.8%
|
$
200.66
|
$
1.93
|
$
202.59
|
|
East-Central
|
HF
Age 19-44, F
|
320,557
|
18.9%
|
$
290.72
|
$
2.80
|
$
293.52
|
|
East-Central
|
HF,
Age 45 +,M & F
|
38,258
|
2.3%
|
$
470.93
|
$
4,54
|
$
475.47
|
|
East-Central
|
HST
Age 19-64, F
|
29,264
|
1.7%
|
$
331.03
|
$
3.19
|
$
334.22
|
|
East-Central
|
Subtotal
|
1.695,750
|
100.0%
|
$
186.57
|
$
1.80
|
$
188.37
|
|
East-Central
|
Delivery
Payment
|
5,596
|
0.3%
|
$
4,132.16
|
$
39.84
|
$
4,172.00
|
|
East-Central
|
Total
|
1,695,750
|
100.0%
|
$
200.20
|
$
1.93
|
$
202.13
|
|
Northeast
|
HF/HST,
Age 0, M & F
|
152,915
|
5.2%
|
$
529.07
|
$
5.10
|
$
534.17
|
|
Northeast
|
HF/HST,
Age 1, M&F
|
133,744
|
4.5%
|
$
140.45
|
$
1.35
|
$
141.80
|
|
Northeast
|
HF/HST,
Age 2-13, M&F
|
1,381,832
|
46.7%
|
$
94.02
|
$
0.91
|
$
94.93
|
|
Northeast
|
HF/HST,
Age 14-18, M
|
223,275
|
7.5%
|
$
111.31
|
$
1.07
|
$
112.38
|
|
Northeast
|
HF/HST,
Age 14-18, F
|
236,299
|
8.0%
|
$
153.26
|
$
1.48
|
$
154.74
|
|
Northeast
|
HF.Age
19-44, M
|
136,730
|
4.6%
|
$
193.74
|
$
1.87
|
$
195.61
|
|
Northeast
|
HF
Age 19-44, F
|
576,329
|
19.5%
|
$
279.38
|
$
2.69
|
$
282.08
|
|
Northeast
|
HF,
Age45+. M&F
|
75,738
|
2,6%
|
$
453.99
|
$
4.38
|
$
458.37
|
|
Northeast
|
HST,
Age 19-64, F
|
41,229
|
1.4%
|
$
318.02
|
$
3.07
|
$
321.09
|
|
Northeast
|
Subtotal
|
2.958,090
|
100,0%
|
$
177.71
|
$
1.71
|
$
179.42
|
|
Northeast
|
Delivery
Payment
|
9,762
|
0.3%
|
S
4.620.33
|
$
44.55
|
$
4,664.87
|
|
Northeast
|
Total
|
2,958,090
|
100.0%
|
$
192.96
|
S
1.86
|
$
194.82
|
|
Northwest
|
HF/HST,
Age 0, M & F
|
95,817
|
6.3%
|
$
559.84
|
$
5.40
|
$
565.23
|
|
Northwest
|
HF/HST,
Age 1, M & F
|
77,885
|
5.1%
|
$
148.68
|
$
1.43
|
$
150.11
|
|
Northwest
|
HF/HST.
Age 2-13, M&F
|
703,072
|
45.9%
|
$
97.75
|
$
0.94
|
$
98.69
|
|
Northwest
|
HF/HST,
Age 14-18, M
|
102,361
|
6.7%
|
$
115.24
|
$1.11
|
$
116.35
|
|
Northwest
|
HF/HST,
Age 14-18, F
|
111,868
|
7.3%
|
$
162.33
|
$
1.57
|
$
163.89
|
|
Northwest
|
HF,
Age 19-44, M
|
91,211
|
6.0%
|
$
202.82
|
$
1.96
|
$
204.77
|
|
Northwest
|
HF
Age 19-44. F
|
289,036
|
18.9%
|
$
299,30
|
$
2.89
|
$
302.18
|
|
Northwest
|
HF,
Age 45+, M&F
|
29,822
|
1.9%
|
$
483.93
|
$
4.67
|
$
488.60
|
|
Northwest
|
HST,
Age 19-64.F
|
30,803
|
2,0%
|
$
338.79
|
$
3.27
|
$
342.06
|
|
Northwest
|
Subtotal
|
1,531,875
|
100,0%
|
$
191.78
|
$
1.85
|
$
193.63
|
|
Northwest
|
Delivery
Payment
|
5.055
|
0.3%
|
$
4,254,97
|
$
41.03
|
$
4,295.99
|
|
Northwest
|
Total
|
1,531,875
|
100.0%
|
$
205.82
|
$
1.98
|
$
207.80
|
Xxxxxx
Government Human Services Consulting
E-1
State
of
Ohio
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
|
$
181.46
|
|
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
|
Xxxxxx
Government Human Services Consulting
APPENDIX
F
REGIONAL
RATES
1.
PREMIUM RATES WITHOUT THE AT-RISK PAYMENT AMOUNTS FOR 01/01/07, THROUGH
06/30/07, 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 0, performance
incentives.
MCP:
WellCare of Ohio, Inc.
|
SERVICE
ENROLLMENT AREA
|
VOLUNTARY/
MANDATORY**
|
HF/HST
Age<
1
|
HF/HST
Age
1
|
HF/HST
Age
2-13
|
HF/HST
Age
14-18 Male
|
HF/HST
Age
14-18 Female
|
HF
Age
19-44 Male
|
HF
Age
19-44 Female
|
HF
Age
45 and over
|
HST
Age
19-64 Female
|
Delivery
Payment
|
|
Northeast
|
Mandatory
|
$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 ADC cash
-
MA-T
Children under 21
-
MA-Y
Transitional Medicaid
Healthy
Start: - MA-P Pregnant Women and Children
Note:
An
MCP's county membership for this program must not exceed their Primary
Care
Physician (PCP) capacity for that county as verified by the ODJFS provider
database.
For
the
SFY 2007 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 01/01/07, THROUGH 06/30/07, 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 0, performance
incentives.
MCP:
WellCareofOhio,lnc.
AT-RISK
AMOUNTS*
|
SERVICE
ENROLLMENT AREA
|
VOLUNTARY/
MANDATORY**
|
HF/HST
Age
< 1
|
HF/HST
Age
1
|
HF/HST
Age
2-13
|
HF/HST
Age 14-18 Male
|
HF/HST
Age 14-18 Female
|
HF
Age 19-44 Male
|
HF
Age 19-44 Female
|
HF
Age 45 and over
|
HST
Age 19-64 Female
|
Delivery
Payment
|
|
|
Northeast
|
Mandatory
|
$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 ADC cash
-
MA-T
Children under 21
-
MA-Y
Transitional Medicaid
Healthy
Start: - MA-P Pregnant Women and Children
Note:
An
MCP's county membership for this program must not exceed their Primary
Care
Physician (PCP) capacity for that county as verified by the ODJFS provider
database.
For
the
SFY 2007 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 01/01/07, THROUGH 06/30/07, 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 0, performance
incentives.
MCP:
WellCare of Ohio, Inc.
|
I
SERVICE ENROLLMENT AREA
|
VOLUNTARY/
MANDATORY**
|
HF/HST
Age
< 1
|
HF/HST
Age
1
|
HF/HST
Age
2-13
|
HF/HST
Age
14-18
Male
|
HF/HST
Age
14-18 Female
|
HF
Age
19-44
Male
|
HF
Age
19-44 Female
|
HF
Age
45
and
over
|
HST
Age
19-64 Female
|
Delivery
Payment
|
|
Northeast
|
Mandatory
|
$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 ADC cash
-
MA-T
Children under 21
-
MA-Y
Transitional Medicaid
Healthy
Start: - MA-P Pregnant Women and Children
Note:
An
MCP's county membership for this program must not exceed their Primary
Care
Physician (PCP) capacity for that county as verified by the ODJFS provider
database.
For
the
SFY 2007 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 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
Appendix
G
Page
2
•
Short-term rehabilitative stays in a nursing facility
•
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
•
Sex
change surgery and related services
•
Sexual
or marriage counseling
Appendix
G
Page
3
•
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 OD.IFS.
*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(0) 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 OD.IFS if they intend to impose
a
co-payment. OD.IFS 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. IfODJFS
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 "Annual Opportunity'"
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.
Appendix
G
Page
4
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 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
must
provide 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 various Medicaid-covered mental health (MH) services
available
through the CMHCs.
Appendix
G
Page
5
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 free-standing
psychiatric hospital.
Substance
Abuse Services:
There
are a number of various 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:
MCPs are
responsible for the payment of Medicaid-covered prescription drugs prescribed
by
a CMHC or ODADAS-certified provider when obtained through an MCP's panel
pharmacy. MCPs are also responsible for the payment of Medicaid-covered
services
provided by an MCP's panel laboratory when referred by a CMHC or
ODADAS-certified provider. Additionally. MCPs are responsible for the
payment of
all other behavioral health services obtained through providers other
than those
who are CMHC or ODADAS-certified providers when an-anged/authorized by
the MCP.
MCPs are not responsible for paying for behavioral health services provided
through CMHCs and ODADAS-certified Medicaid providers. MCPs are also
not
required to cover the payment of partial hospitalization (mental health),
inpatient psychiatric care in a free-standing inpatient psychiatric hospital,
outpatient detoxification, or methadone maintenance.
iv.
Pharmacy
Benefit:
In
providing the Medicaid pharmacy benefit to their members. MCPs must cover
the
same drugs covered by the Ohio Medicaid fee-for-service program.
Appendix
G
Page
6
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 organ transplants and related services in accordance
with OAC 5101-3-2-07.1 (B)(4)&(5). Coverage for all organ transplant
services, except kidney transplants, is contingent upon review and
recommendation by the "Ohio Solid Organ Transplant Consortium" based
on criteria
established by Ohio organ transplant surgeons and authorization from
the ODJFS
prior authorization unit. Reimbursement for bone marrow transplant and
hematapoietic stem cell transplant services, as defined in OAC 3701:84-01,
is
contingent upon review and recommendation by the "Ohio Hematapoietic
Stem Cell
Transplant Consortium" again based on criteria established by Ohio experts
in
the field of bone marrow transplant. While MCPs may require prior authorization
for these transplant services, the approval criteria would be limited
to
confirming the consumer is being considered and/or has been recommended
for a
transplant by either consortium and authorized by ODJFS. Additionally,
in
accordance with OAC 5101:3-2-03 (A)(4) all services related to organ
donations
are covered for the donor recipient when the consumer is Medicaid
eligible.
3. Care
Coordination
a.
Utilization
Management (Modification) Programs
General
Provisions
-
Pursuant to OAC rule 5101:3-26-03.1(A)(7), MCPs must implement the
ODJFS-required emergency department diversion (EDD) 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 disease 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.
Appendix
G
Page
7
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 5101:3-26-03.1 regarding the timeframes for
prior
authorization of covered outpatient drugs.
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.
Appendix
G
Page
8
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
In
accordance with 5101:3-26-03.1(A)(8), MCPs must offer and provide case
management services which coordinate and monitor the care of members
with
specific diagnoses, or who require high-cost and/or extensive
services.
i.
Each
MCP must inform all members and contracting providers of the MCP's case
management services.
ii..
The
MCP's case management system must include, at a minimum, the following
components:
a.
specification of the criteria used by the MCP to identify those potentially
eligible for case management services, including diagnosis, cost threshold
and/or amount of service utilization, and the methodology or process
(e.g.
administrative data, provider referrals, self-referrals) used to identify
the
members who meet the criteria for case management;
b.
a
process for comprehensive assessment of the member's health condition
to confirm
the results of a positive identification, and determine the need for
case
management, including information regarding the credentials of the staff
performing the assessments ofCSHCN;
c.
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;
d.
the
procedure by which the MCP will assure the timely development of a care
treatment plan for any member receiving case management services; offer
both the
member and the member's PCP/specialist the opportunity to participate
in the
care treatment plan's development based on the health needs assessment;
and
provide for the periodic
review of the member's need for case management and updating of the care
treatment plan;
Appendix
G
Page
9
e.
a
process to facilitate, maintain, and
coordinate
communication between service providers, and member/family, including
an
accountable point of contact to help obtain medically necessary care,
and assist
with health-related services and coordinate care needs.
iii.
MCPs
must submit a monthly electronic report to the Case Management System
(CAMS) for
all members who are case managed by the MCP as outlined in the OD.IFS
''Case
Management File and Submission Specifications^
The CAMS
files are due the 10th
business
day of each month.
iv.
MCPs
must have an ODJFS-approved case management system which includes the
items in
Section GJ.b.i. and Section GJ.b.ii. of this Appendix. Each MCP must
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
system
description must be submitted to ODJFS in writing for review and approval
prior
to implementation.
c.
Children
with Special Health Care Needs
Children
with special health care needs (CSHCN) are a particularly vulnerable
population
which often have chronic and complex medical health care conditions.
In order to
ensure state compliance with the provisions of 42 CFR 438.208, ODJFS
has
implemented program requirements for the identification, assessment,
and case
management of CSHCN.
Each
MCP
must establish a CSHCN program with the goal of conducting timely identification
and screening, assuring a thorough and comprehensive assessment, and
providing
appropriate and targeted case management services for any CSHCN.
Appendix
G
Page
10
i.
Definition of 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 need or 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
ii.
Identification of CSHCN
All
MCPs
must implement mechanisms to identify CSHCN.
MCPs
are
expected to use a variety of mechanisms to identify children that meet
the
definition of CSHCN and are in need of a follow-up assessment including:
MCP
administrative review; information as reported by the SSC during membership
selection; PCP referrals; outreach; and contacting newly-enrolled children.
The
MCP must annually submit the process used to identify and assess CSHCN
for
review and approval by ODJFS as part of their CSHCN program.
iii.
Assessment of CSHCN
All
MCPs
must implement mechanisms to assess children with a positive identification
as a
CSHCN. A positive assessment confirms the results of the positive identification
and should assist the MCP in determining the need for case
management.
This
assessment mechanism must include, at a minimum:
•
The
use
of the ODJFS
CSHCN Standard Assessment Tool
to
assess all children with a positive identification using the methods
described
in Section 2.c., Children with Special Health Care Needs, of this appendix
as
having a condition that may warrant case management.
Appendix
G
Page
11
See
ODJFS
CSHCN Program Requirements for a description of the ODJFS
CSHCN Standard Assessment Tool.
Completion
of the assessment by a physician, physician assistant,
RN,
LPN,
licensed social worker, or a graduate of a two or four year allied health
program.
The
oversight and monitoring by either a registered nurse or a physician,
if the
assessment is completed by another medical professional.
iv.
Case
Management of CSHCN
All
MCPs
must implement mechanisms to provide case management services for all
CSHCN with
a positive assessment, including those children with an ODJFS mandated
condition. The ODJFS mandated conditions for case management are HIV/AIDS,
asthma, and pregnant teens as specified by the ODJFS methods outlined
in
Appendix M Case Management System Performance Measures. This case management
mechanism must include, at a minimum:
•
The
components required in Section 3. b.. Case Management, of this
Appendix.
•
Case
management of CSHCN must include at a minimum, the elements listed in
the
Minimum
Case Management Components
document. See ODJFS
CSHCN Program Requirements
for a
description of the Minimum
Case Management Components.
v.
Access
to Specialists for CSHCN
All
MCPs
must implement mechanisms -to notify all CSHCN with a positive assessment
and
determined to need case management 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.
Appendix
G
Page
12
vi.
Submission of Data on CSHCN
MCPs
must
submit to ODJFS all case management records as specified by the ODJFS
Case Management File and Submission Specifications.
vii.
MCPs
must have an ODJFS-approved CSHCN system which includes the items specified
in
Section G.3.c.ii-vi of this Appendix. Each MCP should implement an evaluation
process to review, revise and/or update the CSHCN program. The MCP must
annually
submit its CSHCN program for review and approval by ODJFS. Any subsequent
changes to an approved CSHCN system description must be submitted to
ODJFS in
writing for review and approval prior to implementation.
d.
Care
Coordination with ODJFS-Designated Providers
Per
OAC
rule 5101:3-26-03.1(A)(4). MCPs are required to share specific information
with
certain ODJFS-designated non-contracting providers in order to ensure
that these
providers have been supplied with specific information needed to coordinate
care
for the MCP's members. Within the first month of operation, after an
MCP has
obtained a provider agreement, the MCP must provide to the ODJFS-designated
providers (i.e., ODMH Community 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;
•
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
Appendix
G
Page
13
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).
The
MCP
must notify ODJFS when this requirement has been fulfilled.
e.
Care
coordination with Non-Contracting Providers
Per
OAC
rule 5101:3-26-05(A)(9), MCPs authorizing the delivery of services from
a
provider who does not have an executed subcontract must ensure that they
have a
mutually agreed upon compensation amount for the authorized service and
notify
the provider of the applicable provisions of paragraph D of OAC rule
5101:3-26-05. This notice is provided when an MCP authorizes a non-contracting
provider to furnish services on a one-time or infrequent basis to an
MCP member
and must include required ODJFS-model language and information. This
notice must
also be included with the transition of services form sent to providers
as
outlined in paragraph 29.i.e. of Appendix C.
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 that must
travel
30 miles or more from their home to receive a medically-necessary
Medicaid-covered service. If the MCP offers transportation to their members
as
an additional benefit and this transportation benefit only covers a limited
number of trips, the required transportation listed above may
not
be
counted toward this trip limit (as specified in Appendix C).
In
developing the provider panel requirements, ODJFS considered, on a
county-by-county basis, the population size and utilization patterns
of the
Covered Families and Children (CFC) consumers, as well as the potential
availability of the designated provider types. ODJFS has integrated existing
utilization patterns into the provider network requirements to avoid
disruption
of care. Most provider panel requirements are county-specific but in
certain
circumstances, ODJFS requires providers to be located anywhere in the
region.
Although all provider types listed in this appendix are required provider
types,
only those listed on the attached charts must be submitted for ODJFS prior
approval.
2.
PROVIDER SUBCONTRACTING
Unless
otherwise specified in this appendix or OAC rule 5101:3-26-05, all MCPs
are
required to enter into fully-executed subcontracts with their providers.
These
subcontracts must include a baseline contractual agreement, as well as
the
appropriate ODJFS-approved Model Medicaid Addendum. The Model Medicaid
Addendum
incorporates all applicable Ohio Administrative Code rule requirements
specific
to provider subcontracting and therefore cannot be modified except to
add
personalizing information such as the MCP's name.
Appendix
H
Page
2
ODJFS
must prior approve all MCP providers in the ODJFS- required provider
type
categories before they can begin to provide services to that MCP's members.
MCPs
may not employ or contract with providers excluded from participation
in Federal
health care programs under either section 1128 or section 1128A of the
Social
Security Act. As part of the prior approval process, MCPs must submit
documentation verifying that all necessary contract documents have been
appropriately completed. ODJFS will verify the approvability of the submission
and process this information using the ODJFS 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, and to be included in the MCP's total PCP capacity calculation.
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).
Appendix
H
Page
3
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). ODJFS may also compare a PCP's capacity against
the
number of members assigned to that PCP, and/or the number of patient
encounters
attributed to that PCP to determine if the reported capacity number reasonably
reflects a PCP's expected caseload for a specific MCP. Where indicated,
ODJFS
may set a cap on the maximum amount of capacity that we will 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.
Also, no PCP capacity will be counted for these providers. These PCPs
will,
however, need to execute a subcontract with the MCP which includes the
appropriate Model Medicaid Addendum.
The
PCP
requirement is based on an MCP having sufficient PCP capacity to serve
55% of
the eligibles in the region. At a, 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)(l)(iii).]
In
addition to the PCP FTE capacity requirement. MCPs must also contract
with the
specified number
ofpediatric 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 ofpediatric PCPs must also be
certified
Appendix
H
Page
4
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 OD-lFS-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).
Appendix
H
Page
5
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 ofOB/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.
Appendix
H
Page
6
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-tf& refer to family planning services
provided by a QFPP. A QFPP is defined as any public or not-^- tor-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
H1PAA
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
Appendix
H
Page
7
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 have
adequate access to the services in
question.
|
If
an MCP
is unable to contract with or maintain a sufficient number of providers
to meet
the ^^ ODJFS-speciMed 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.
Appendix
H
Page
8
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
ofODJFS-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
Appendix
H
Page
9
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.
Appendix
H
Page
10
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
Hospital3
|
84
|
1
|
14
|
1
|
1
|
1
|
1
|
1
|
1
|
|
|
Hospital
System
|
1
|
1
|
||||||||
1
Preferred Providers are the additional provider contracts that must be
secured
in order for the MCP to receive bonus points.
2
These
hospitals cannot be included under any subcontract used to meet the minimim
required provider panel requirements.
3
These
hospitals must provide obstetrical services if such a hospital is available
in
the county/region.
4
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 Central Region -
Hospitals
|
Minimum
Provider Panel Requirements
|
|||||
|
Total
Required Hospitals
|
Columbiana
|
Mahoning
|
Trumbull
|
Additional
Required Hospitals: Out-of-Region
|
|
|
General
Hospital3
|
3
|
1
|
14
|
1
|
|
|
Hospital
System
|
|||||
1
Preferred Providers are the additional provider contracts that must be
secured
in order for the MCP to receive bonus points.
2
These
hospitals cannot be included under any subcontract used to meet the minimim
required provider panel requirements.
3
These
hospitals must provide obstetrical services if such a hospital is available
in
the county/region, except where a hospital must meet the criteria specified
in
footnote #4 below.
4
Must be
a hospital that includes thirty (30) pediatric
beds and five (5) pediatric intensive care unit (PICU) beds.
East
Central Region - Hospitals
|
Minimum
Provider Panel Requirements
|
|||||||||||
|
Total
Required
Hospitals
|
Ashland
|
Xxxxxxx
|
Xxxxxx
|
Portage
|
Richland
|
Start
|
Summit
|
Tuscarawas
|
Xxxxx
|
Additional
Required
Hospitals: Out-of-Region
|
|
|
General
Hospital3
|
8
|
1
|
1
|
1
|
1
|
1
|
14
|
1
|
1
|
||
|
Hospital
System
|
1
|
1
|
|||||||||
1
Preferred Providers are the additional provider contracts that must be
secured
in order for the MCP to receive bonus points.
2
These
hospitals cannot be included under any subcontract used to meet the minimim
required provider panel requirements.
3
These
hospitals must provide obstetrical services if such a hospital is available
in
the county/region, except where a hospital must meet the criteria specified
in
footnote #4 below.
4
Must be
a hospital that includes one hundred (100) pediatric
beds and five (5) pediatric intensive care unit (PICU) beds.
South
East Region - Hospitals
|
Minimum
Provider Panel Requirements
|
||||||||||||||||||
|
|
Total
Required Hospitals
|
Athens
|
Belmont
|
Coshocton
|
Gallia
|
Guernsey
|
Xxxxxxxx
|
Xxxxxxx
|
Xxxxxxxxx
|
Xxxxxxxx
|
Xxxxx
|
Xxxxxx
|
Xxxxxx
|
Muskingum
|
Noble
|
Xxxxxx
|
Xxxxxxxxxx
|
Additional
Required
Hospitals: Out-of-Region
|
|
General
Hospital3
|
11
|
1
|
1
|
1
|
1
|
1
|
1
|
1
|
1
|
Xxxxxx
AND King's Daughter AND Children's Hospital
Columbus
|
||||||||
|
Hospital
System
|
|
|
|
|
|
|
|
|
|
|||||||||
1
Preferred Providers are the additional provider contracts that must be
secured
in order for the MCP to receive bonus points.
2
These
hospitals cannot be included under any subcontract used to meet the minimim
required provider panel requirements.
3
These
hospitals must provide obsetrical services if such a hospital is available
in
the county/region.
Central
Region - Hospitals
|
Minimum
Provider Panel Requirements
|
||||||||||||||||||||
|
|
Total
Required Hospitals
|
Xxxxxxxx
|
Delaware
|
fairfield
|
Fayette
|
Xxxxxxxx
|
Xxxxxxx
|
Xxxx
|
Licking
|
Logan
|
Madison
|
Xxxxxx
|
Xxxxxx
|
Xxxxx
|
Pickaway
|
Xxxx
|
Xxxx
|
Scioto
|
Union
|
Additional
Required
Hospitals:
Out-of-Region
|
|
General
Hospital3
|
14
|
1
|
1
|
1
|
1
4
|
1
|
1
|
1
|
1
|
1
|
1
|
1
|
1
|
1
|
Genesis
Health Care System, Inc.
|
|||||
|
Hospital
System
|
2
|
2
|
||||||||||||||||||
1
Preferred Providers are the additional provider contracts that must be
secured
in order for the MCP to receive bonus points.
2
These
hospitals cannot be included under any subcontract used to meet the minimim
required provider panel requirements.
3
These
hospitals must provide obstetrical services if such a hospital is available
in
the county/region, except where a hospital must meet the criteria specified
in
footnote #4 below.
4
Must be
a hospital that includes one hundred fifty (150) pediatric beds and twenty-five
(25) pediatric intensive care unit (PICU) beds.
South
West Region - Hospitals
|
Minimum
Provider Panel Requirements
|
||||||||||
|
Total
Required Hospitals
|
Xxxxx
|
Xxxxx
|
Xxxxxx
|
Clermont
|
Xxxxxxx
|
Xxxxxxxx
|
Highland
|
Xxxxxx
|
Additional
Required Hospitals: Out-of-Region
|
|
|
General
Hospital3
|
6
|
1
|
1
|
1
|
1
4
|
1
|
Grandview
or Miami Valley
|
|||
|
Hospital
System
|
2
|
2
|
||||||||
1
Preferred
Providers are the additional provider contracts that must be secured
in order
for the MCP to receive bonus points.
2
These
hospitals cannot be included under any subcontract used to meet the minimim
required provider panel requirements.
3
These
hospitals must provide obstetrical services if such a hospital is available
in
the county/region, except where a hospital must meet the criteria specified
in
footnote #4
below.
4
Must be
a hospital that includes two-hundred (200)
pediatric
beds and thirty-five (35) pediatric intensive care unit (PICU)
beds.
West
Central Region - Hospitals
|
Minimum
Provider Panel Requirements
|
||||||||||
|
Total
Required Hospitals
|
Champaign
|
Xxxxx
|
Xxxxx
|
Xxxxxx
|
Miami
|
Xxxxxxxxxx
|
Xxxxxx
|
Xxxxxx
|
Additional
Required Hospitals: Out-of-Region
|
|
|
General
Hospital3
|
6
|
1
|
1
|
1
|
1
|
14
|
1
|
|||
|
Hospital
System
|
1
|
1
|
||||||||
1
Preferred Providers are the additional provider contracts that
must be
secured in order for the MCP to receive bonus points.
2
These
hospital cannot be included under any subcontract used to meet the minimim
required provider panel requirements.
3
These
hospitals must provide obsetrical services if such a hospital is available
in
the county/region, except where a hospital must meet the criteria specified
in footnote #4 below.
4
Must be
a hospital that includes seventy-five
(75)
pediatric beds and ten (10) pediatric intensive care unit (PICU)
beds.
North
West Region - Hospitals
|
Minimum
Provider Panel Requirements
|
||||||||||||||||||||
|
|
Total
Required
Hospitals
|
Xxxxx
|
Auglaize
|
Defiance
|
Xxxxxx
|
Xxxxxxx
|
Xxxxxx
|
Xxxxx
|
Xxxxx
|
Xxxxxx
|
Ottawa
|
Paulding
|
Xxxxxx
|
Sandusky
|
Seneca
|
Van
Xxxx
|
Xxxxxxxx
|
Xxxx
|
Wyandot
|
Additional
Required
Hospitals:
Out-of-Region
|
|
General
Hospital3
|
10
|
1
|
1
|
1
|
1
|
1
|
1
|
1
|
1
|
1
|
Bellevue
Hospital
Association
|
|||||||||
|
Hospital
System
|
1
|
|
14
|
|
|
|||||||||||||||
1
Preferred Providers are the additional provider contracts that must be
secured
in order for the MCP to receive bonus points.
2
These
hospitals cannot be included under any subcontract used to meet minimim
required
provider panel requirements.
3
These
hospitals must provide obsetrical services if such a hospital is available
in
the county/region.
4
Must be
a hospital system that includes forty-five (45) pediatric beds and ten
(10)
pediatric intensive care unit (PICU) beds.
Xxxxx
Xxxx Xxxxxx - XXX Xxxxxxxx
|
Minimum
PCP Capacity Requirements
|
||||||||||
|
PCPs
|
Total
Required
|
Ashtabula
|
Cuyahoga
|
Erie
|
Geauga
|
Huron
|
Lake
|
Xxxxxx
|
Xxxxxx
|
Additional
Required:
In-Region
*
|
|
Capacity
1
|
146,000
|
6,560
|
111,520
|
3,680
|
2,080
|
3,960
|
3,680
|
11,320
|
3,200
|
|
|
FTEs
|
73.00
|
3.28
|
55.76
|
1.84
|
1.04
|
1.98
|
1.84
|
5.66
|
1.60
|
|
1Based
on an FTE of 2000 members
*
Must be
located within the region.
North
East Central Region - PCP Capacity
|
Minimum
PCP Capacity Requirements
|
|||||
|
PCPs
|
Total
Required
|
Columbiana
|
Mahoning
|
Trumbull
|
Additional
Required: In-Region *
|
|
Capacity
1
|
39,140
|
6,440
|
16,340
|
11,360
|
5,000
|
|
FTEs
|
19.57
|
3.22
|
8.17
|
5.68
|
2.50
|
Based
on
an FTE of 2000 members
*
Must be
located within the region.
Xxxx
Xxxxxxx Xxxxxx - XXX Xxxxxxxx
|
Minimum
PCP Capacity Requirements
|
|||||||||||
|
PCPs
|
Total
Required
|
Ashland
|
Xxxxxxx
|
Xxxxxx
|
Portage
|
Richland
|
Xxxxx
|
Summit
|
Tuscarawas
|
Xxxxx
|
Additional
Required: In-Region *
|
|
Capacity
1
|
84,000
|
2,940
|
2,000
|
2,000
|
4,520
|
7,400
|
22,660
|
33,560
|
4,360
|
4,560
|
|
|
FTEs
|
42.00
|
1.47
|
1.00
|
1.00
|
2.26
|
3.70
|
11.33
|
16.78
|
2.18
|
2.28
|
|
Based
on
an FTE of 2000 members
*
Must be
located within the region.
Xxxxx
Xxxx Xxxxxx - XXX Xxxxxxxx
|
Xxxxxx
|
Capacity
|
FTEs
|
|
Total
Required
|
53,000
|
26.50
|
|
Athens
|
5,000
|
2.50
|
|
Belmont
|
2,880
|
1.44
|
|
Coshocton
|
2,400
|
1.20
|
|
Gallia
|
7,220
|
3.61
|
|
Guernsey
|
3,820
|
1.91
|
|
Xxxxxxxx
|
940
|
0.47
|
|
Xxxxxxx
|
1,000
|
0.50
|
|
Jefferson
|
4,340
|
2.17
|
|
Xxxxxxxx
|
4,020
|
2.01
|
|
Meigs
|
700
|
0.35
|
|
Monroe
|
780
|
0.39
|
|
Morgon
|
1,260
|
0.63
|
|
Muskingum
|
7,400
|
3.70
|
|
Noble
|
600
|
0.30
|
|
Vinton
|
820
|
0.41
|
|
Washington
|
2,820
|
1.41
|
|
Additional
Required: In-Region
*
|
7,000
|
3.50
|
Based
on
an FTE of 2000 members
Must
be
located within the region.
Central
Region - PCP Capacity
|
County
|
Capacity1
|
FTEs
|
|
Total
Required
|
138,000
|
69.00
|
|
Xxxxxxxx
|
2,720
|
1.36
|
|
Delaware
|
1,900
|
0.95
|
|
Fairfield
|
5,660
|
2,83
|
|
Fayette
|
1,320
|
0.66
|
|
Franklin
|
84,200
|
42.10
|
|
Hocking
|
1,860
|
0.93
|
|
Xxxx
|
2,800
|
1.40
|
|
Licking
|
6,740
|
3.37
|
|
Xxxxx
|
2,380
|
1.19
|
|
Madison
|
980
|
0.49
|
|
Xxxxxx
|
4,080
|
2.04
|
|
Xxxxxx
|
1,620
|
0.81
|
|
Perry
|
2,200
|
1.10
|
|
Pickaway
|
2,000
|
1.00
|
|
Pike
|
2,400
|
1,20
|
|
Xxxx
|
6,620
|
3.31
|
|
Scioto
|
6,940
|
3.47
|
|
Union
|
1,580
|
0.79
|
|
Additional
Required: In-Region *
|
Based
on
an FTE of 2000 members
*
Must be
located within the region.
South
West Region - PCP Capacity
|
Minimum
PCP Capacity Requirements
|
||||||||||
|
PCPs
|
Total
Required
|
Xxxxx
|
Xxxxx
|
Xxxxxx
|
Clermont
|
Xxxxxxx
|
Xxxxxxxx
|
Highland
|
Xxxxxx
|
Additional
Required:
In
Region
*
|
|
Capacity
1
|
88,000
|
2,420
|
2,540
|
12,500
|
2,860
|
2,940
|
59,680
|
2,620
|
2,440
|
|
|
FTEs
|
44.00
|
1.21
|
1.27
|
6.25
|
1.43
|
1.47
|
29.84
|
1.31
|
1.22
|
|
Based
on
an FTE of 2000 members
Must
be
located within the region.
Xxxx
Xxxxxxx Xxxxxx - XXX Xxxxxxxx
|
Minimum
PCP Capacity Requirements
|
||||||||||
|
PCPs
|
Total
Required
|
Champaign
|
Xxxxx
|
Xxxxx
|
Xxxxxx
|
Miami
|
Xxxxxxxxxx
|
Xxxxxx
|
Xxxxxx
|
Additional
Required:
In-Region
*
|
|
Capacity
1
|
59,600
|
1,140
|
9,360
|
1,320
|
4,700
|
4,020
|
35,660
|
1,400
|
2,000
|
|
|
FTEs
|
29.80
|
0.57
|
4.68
|
0.66
|
2.35
|
2.01
|
17.83
|
0.70
|
1.00
|
|
1
Based
on an FTE of 2000 members
*
Must be
located within the region
As
of November 20, 0000
Xxxxx
Xxxx Xxxxxx - XXX Xxxxxxxx
|
Xxxxxx
|
Capacity1
|
FTEs
|
|
Total
Required
|
90,860
|
45.43
|
|
Alien
|
7,780
|
3.89
|
|
Auglaize
|
1,260
|
0.63
|
|
Defiance
|
2,600
|
1,30
|
|
Xxxxxx
|
1,300
|
0.65
|
|
Xxxxxxx
|
3,620
|
1.81
|
|
Xxxxxx
|
1,220
|
0,61
|
|
Xxxxx
|
1,200
|
0.60
|
|
Xxxxx
|
38,620
|
19,31
|
|
Xxxxxx
|
1,080
|
0.54
|
|
Ottawa
|
1,200
|
0,60
|
|
Paulding
|
900
|
0.45
|
|
Xxxxxx
|
960
|
0.48
|
|
Sandusky
|
2,700
|
1.35
|
|
Seneca
|
2,340
|
1.17
|
|
Van
Xxxx
|
1,020
|
0.51
|
|
Xxxxxxxx
|
1,900
|
0.95
|
|
Wood
|
2,000
|
1.00
|
|
Wyandot
|
960
|
0.48
|
|
Additional
Required: In-Region *
|
18,200
|
9.10
|
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
|
90
|
3
|
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.
North
East Central- Practitioners
|
Minimum
Provider Panel Requirements
|
|||||
|
Provider
Types
|
Total
Required Providers1
|
Columbiana
|
Mahoning
|
Trumbull
|
Additional
Required Providers2
|
|
Pediatricians4
|
23
|
2
|
10
|
6
|
5
|
|
OB/GYNs
|
7
|
1
|
3
|
2
|
1
|
|
Vision
|
7
|
3
|
2
|
2
|
|
|
General
Surgeons
|
6
|
1
|
3
|
1
|
1
|
|
Otolaryngologist
|
2
|
1
|
1
|
||
|
Allergists
|
1
|
1
|
|||
|
Orthopedists
|
4
|
2
|
1
|
1
|
|
|
Dentists5
|
23
|
2
|
11
|
8
|
2
|
1
All
required providers must be located within the region.
2
Additional required providers may be located anywhere within the
region.
3
Preferred Providers are the additional provider contracts that must be
secured
in order for the MCP to receive bonus points.
4
Half of
this number must be certified by the American Board of Pediatrics.
5
No more
than two-thirds of this number can be pediatric dentists.
East
Central - Practitioners
|
Minimum
Provider Panel Requirements
|
|||||||||||
|
Provider
Types
|
Total
Required Providers1
|
Ashland
|
Xxxxxxx
|
Xxxxxx
|
Portage
|
Richland
|
Xxxxx
|
Summit
|
Tuscarawas
|
Xxxxx
|
Additional
Required Providers2
|
|
Pediatricians4
|
49
|
1
|
|
|
2
|
3
|
14
|
20
|
2
|
2
|
5
|
|
OB/GYNs
|
17
|
|
|
|
|
1
|
5
|
8
|
|
1
|
2
|
|
Vision
|
18
|
|
|
|
|
1
|
5
|
8
|
|
|
4
|
|
General
Surgeons
|
13
|
|
|
|
1
|
2
|
3
|
4
|
1
|
1
|
1
|
|
Otolaryngologist
|
7
|
|
|
|
|
|
2
|
2
|
|
|
3
|
|
Allergists
|
3
|
|
|
|
|
|
1
|
1
|
|
|
1
|
|
Orthopedists
|
9
|
|
|
|
|
1
|
2
|
2
|
|
1
|
3
|
|
Dentists5
|
48
|
2
|
|
|
3
|
5
|
13
|
17
|
3
|
3
|
2
|
1
All
required providers must be located within the region,
2
Additional required providers may be located anywhere within the
region.
3
Preferred Providers are the additional provider contracts that must be
secured
in order for the MCP to receive bonus points.
4
Half of
this number must be certified by the American Board of Pediatrics.
5
No more
than two-thirds of this number can be pediatric dentists.
South
East-practitioners
|
Minimum
Provider Panel Requirements
|
||||||||||||||||||
|
Provider
Types
|
Total
Required Providers1
|
Athens
|
Belmont
|
Coshocton
|
Gallia
|
Guernsey
|
Xxxxxxxx
|
Xxxxxxx
|
Jefferson
|
Xxxxxxxx
|
Xxxxx
|
Xxxxxx
|
Xxxxxx
|
Muskingum
|
Noble
|
Xxxxxx
|
Xxxxxxxxxx
|
Additional
Required Providers2
|
|
Pediatricians4
|
31
|
1
|
1
|
|
2
|
1
|
|
|
1
|
|
|
|
|
2
|
|
|
1
|
22
|
|
OB/GYNs
|
9
|
1
|
|
|
|
1
|
|
|
1
|
|
|
|
|
1
|
|
|
1
|
4
|
|
Vision
|
13
|
1
|
1
|
|
1
|
1
|
|
1
|
1
|
1
|
|
|
|
2
|
|
|
1
|
3
|
|
General
Surgeons
|
8
|
|
1
|
|
1
|
1
|
|
|
1
|
|
|
|
|
1
|
|
|
1
|
2
|
|
Otolaryngologist
|
3
|
|
|
|
1
|
|
|
|
|
|
|
|
|
1
|
|
|
|
1
|
|
Allergists
|
1
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
1
|
|
Orthopedists
|
5
|
|
|
|
1
|
|
|
|
|
|
|
|
|
1
|
|
|
1
|
2
|
|
Dentists5
|
30
|
2
|
3
|
1
|
1
|
3
|
|
1
|
3
|
2
|
|
|
|
3
|
|
|
2
|
9
|
1
All
required providers must be located within the region.
2
Additional required providers may be located anywhere within the
region.
3
Preferred Providers are the additional provider contracts that must be
secured
in order for the MCP to receive bonus points.
4
Half of
this number must be certified by the American Board of Pediatrics.
5
No more
than two-thirds of this number can be pediatric dentists.
Central
- Practitioners
|
Minimum
Provider Panel Requirements
|
||||||||||||||||||||
|
Provider
Types
|
Total
Required Providers1
|
Xxxxxxxx
|
Delaware
|
Fairfield
|
Fayette
|
Xxxxxxxx
|
Xxxxxxx
|
Xxxx
|
Licking
|
Logan
|
Madison
|
Xxxxxx
|
Xxxxxx
|
Xxxxx
|
Pickaway
|
Xxxx
|
Xxxx
|
Scioto
|
Union
|
Additional
Required Providers2
|
|
Pediatricians4
|
86
|
4
|
3
|
55
|
1
|
2
|
1
|
1
|
2
|
1
|
2
|
2
|
1
|
11
|
||||||
|
OB/GYNs
|
24
|
2
|
2
|
12
|
1
|
1
|
1
|
1
|
1
|
3
|
||||||||||
|
Vision
|
31
|
1
|
2
|
2
|
15
|
1
|
1
|
1
|
1
|
1
|
1
|
1
|
1
|
3
|
||||||
|
General
Surgeons
|
22
|
1
|
1
|
1
|
10
|
1
|
1
|
1
|
1
|
1
|
1
|
1
|
2
|
|||||||
|
Otolaryngologist
|
6
|
1
|
4
|
1
|
||||||||||||||||
|
Allergists
|
4
|
2
|
2
|
|||||||||||||||||
|
Orthopedists
|
13
|
1
|
7
|
1
|
1
|
1
|
2
|
|||||||||||||
|
Dentists5
|
77
|
1
|
2
|
3
|
1
|
45
|
1
|
2
|
3
|
1
|
1
|
2
|
1
|
1
|
1
|
1
|
3
|
2
|
1
|
5
|
1
All
required providers must be located within the region.
2
Additional required providers may be located anywhere within the
region.
3
Preferred Providers are the additional provider contracts that must be
secured
in order for the MCP to receive bonus points.
4
Half of
this number must be certified by the American Board of Pediatrics.
5
No more
than two-thirds of this number can be pediatric dentists.
South
West - Practitioners
|
Minimum
Provider Panel Requirements
|
||||||||||
|
Provider
Types
|
Total
Required Providers1
|
Xxxxx
|
Xxxxx
|
Xxxxxx
|
Clermont
|
Xxxxxxx
|
Xxxxxxxx
|
Highland
|
Xxxxxx
|
Additional
Required Providers2
|
|
Pediatricians4
|
59
|
|
|
7
|
2
|
1
|
39
|
|
|
10
|
|
OB/GY
|
16
|
|
1
|
2
|
1
|
1
|
9
|
|
1
|
1
|
|
Vision
|
21
|
|
|
3
|
1
|
1
|
11
|
1
|
1
|
3
|
|
General
Surgeons
|
13
|
|
|
2
|
1
|
1
|
7
|
|
1
|
1
|
|
Otolaryngologist
|
6
|
|
|
1
|
|
|
3
|
|
1
|
1
|
|
Allergists
|
7
|
|
|
|
|
|
4
|
|
|
3
|
|
Orthopedists
|
9
|
|
|
2
|
|
|
5
|
|
|
2
|
|
Dentists5
|
50
|
1
|
1
|
10
|
4
|
1
|
26
|
2
|
2
|
3
|
1
All
required providers must be located within the region.
2
Additional required providers may be located anywhere within the
region.
3
Preferred Providers are the additional provider contracts that must be
secured
in order for the MCP to receive bonus points.
4
Half of
this number must be certified by the American Board of Pediatrics.
5
No more
than two-thirds of this number can be pediatric dentists.
West
Central - Practitioners
|
Minimum
Provider Panel Requirements
|
||||||||||
|
Provider
Types
|
Total
Required Providers1
|
Champaign
|
Xxxxx
|
Xxxxx
|
Xxxxxx
|
Miami
|
Xxxxxxxxxx
|
Xxxxx
|
Xxxxxx
|
Additional
Required Providers2
|
|
Pediatricians4
|
36
|
2
|
3
|
1
|
22
|
8
|
||||
|
OB/GYNs
|
12
|
2
|
1
|
1
|
6
|
1
|
1
|
|||
|
Vision
|
20
|
2
|
1
|
2
|
2
|
10
|
1
|
2
|
||
|
General
Surgeons
|
10
|
2
|
2
|
1
|
3
|
2
|
||||
|
Otolaryngologist
|
7
|
1
|
3
|
3
|
||||||
|
Allergists
|
4
|
2
|
2
|
|||||||
|
Orthopedists
|
6
|
2
|
2
|
2
|
||||||
|
Dentists5
|
39
|
1
|
5
|
1
|
3
|
3
|
20
|
1
|
1
|
4
|
1
All
required providers must be located within the region.
2
Additional required providers may be located anywhere within the
region.
3
Preferred Providers are the additional provider contracts that must be
secured
in order for the MCP to receive bonus points.
4
Half of
this number must be certified by the American Board of Pediatrics.
5
No more
than two-thirds of this number can be pediatric dentists.
North
West - Practitioners
|
Minimum
Provider Panel Requirements
|
||||||||||||||||||||
|
Provider
Types
|
Total
Required Providers1
|
Xxxxx
|
Auglaize
|
Defiance
|
Xxxxxx
|
Xxxxxxx
|
Xxxxxx
|
Xxxxx
|
Xxxxx
|
Xxxxxx
|
Ottawa
|
Paulding
|
Xxxxxx
|
Sandusky
|
Seneca
|
Van
Xxxx
|
Xxxxxxxx
|
Xxxx
|
Wyandot
|
Additional
Required Providers2
|
|
Pediatricians4
|
45
|
4
|
1
|
23
|
1
|
1
|
2
|
13
|
||||||||||||
|
OB/GYNs
|
13
|
2
|
1
|
5
|
1
|
1
|
1
|
2
|
||||||||||||
|
Vision
|
18
|
2
|
1
|
1
|
1
|
7
|
1
|
1
|
1
|
2
|
1
|
|||||||||
|
General
Surgeons
|
13
|
2
|
1
|
4
|
1
|
1
|
2
|
2
|
||||||||||||
|
Otolaryngologist
|
7
|
1
|
1
|
2
|
3
|
|||||||||||||||
|
Allergists
|
3
|
1
|
1
|
1
|
||||||||||||||||
|
Orthopedists
|
7
|
2
|
1
|
2
|
1
|
1
|
||||||||||||||
|
Dentists5
|
45
|
4
|
1
|
1
|
1
|
2
|
1
|
1
|
20
|
1
|
1
|
1
|
2
|
2
|
1
|
1
|
2
|
1
|
2
|
|
1
All
required providers must be located within the region.
2
Additional required providers may be located anywhere within the
region.
3
Preferred Providers are the additional provider contracts that must be
secured
in order for the MCP to receive bonus points.
4
Half of
this number must be certified by the American Board of Pediatrics.
5
No more
than two-thirds of this number can be pediatric dentists.
As
of
November 20, 2006
APPENDIX
I
PROGRAM
INTEGRITY
CFC
ELIGIBLE POPULATION
MCPs
must
comply with all applicable program integrity requirements, including
those
specified in 42 CFR 455 and 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 compliance
program which safeguards against fraud and abuse must, at a minimum,
specifically address the following:
a.
Employee
education about false claims recovery:
In order
to comply with Section 6032 of the Deficit Reduction Act of 2005 MCPs
must, as a
condition of Medicaid participation, do the following:
i.
establish and make available to all employees through the MCP's employee
handbook the following written materials regarding false claims
recovery:
a.
policies 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;
b.
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.
establish written policies for subcontractors 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, and the MCP's policies and procedures for detecting and
preventing fraud, waste, and abuse. MCPs must make such information available
to
their subcontractors.
Appendix
I
Page
2
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 of provider fraud and abuse
to ODJFS
and member fraud to the CDJFS. The MCP, at a minimum, must report the
following
information on cases where the MCP's investigation has revealed that
an incident
of fraud and/or abuse has occurred:
Appendix
I
Page
3
i.
provider's name and Medicaid provider number or provider reporting number
(PRN);
ii.
source of complaint;
iii.
type
of provider;
iv.
nature of complaint;
v.
approximate range of dollars involved, if applicable;
vi.
results ofMCP's investigation and actions taken;
vii.
name(s) of other agencies/entities (e.g., medical board, law enforcement)
notified by MCP; and
viii.
legal and administrative disposition of case, including actions taken
by law
enforcement officials to whom the case has been referred.
e.
Monitoring
for prohibited affiliations:
The
MCP's policies and procedures for ensuring that. pursuant to 42 CFR 438.610.
the
MCP will not knowingly have a relationship with individuals debarred
by Federal
Agencies, as specified in Article ^& XII of the Agreement.
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 (Apendix
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
Appendix
I
Page
4
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.
APPENDIX
J
FINANCIAL
PERFORMANCE
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(8). 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.
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);
f.
Reinsurance agreements, as outlined in OAC rule 5101:3-26-09(C);
g.
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;
Appendix
J
Page
2
h.
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;
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);
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.
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 2006, a minimum net worth
per member
of $156.00, 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
Appendix
J
Page
3
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 divided by Total Revenue
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 divided by Total Revenue
Medical
Expense Ratio = Medical Expenses divided by Total Revenue
Standard:
Overall
Expense Ratio not to exceed 100% as determined frorr 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.
Appendix
J
Page
4
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 nan-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 TMAIC 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.
Appendix
J
Page
5
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
ess
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.
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.
Appendix
J
Page
6
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 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 c aim 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-
Appendix
J
Page
7
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 make this information available
to
ODJFS upon request:
a.
A
description of the types of physician incentive arrangements the MCP has
in
place which indicates whether they involve a withhold, bonus, capitation,
or
other arrangement. If a physician incentive arrangement involves a withhold
or
bonus, the percent of the withhold or bonus must be specified.
b.
A
description of 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. ,
c.
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 result^ 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.
Upon
request by a member or a potential member and no later than 14 calendar days
after the request, the MCP must provide the following information to the
member:
(1) whether the MCP uses a physician incentive plan that affects the use
of
referral services; (2) the type of incentive arrangement; (3) whether stop-loss
protection is provided; and (4) a summary of the survey results if the MCP
was
required to conduct a survey. The information provided by the MCP must
adequately address the member's request.
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
workingi 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)
mpst 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 w.'ill 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.
Appendix
K
Page
2
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, beginning in SPY 2005, 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 (HED1S) audited data for the following
measures:
i.
Comprehensive Diabetes Care
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
review
activities as outlined in OAC 5101 ;3-26-07.
Appendix
K
Page
3
a.
EQRO
ADMINISTRATIVE REVIEW AND NON-DUPLICATION OF MANDATORY
ACTIVITIES
The
EQRO
will conduct administrative compliance assessments 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
07.
b.
ANNUAL
REVIEW OF OAPI 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 rule 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.
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.
l.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.
l.a.i.
Encounter Data Volume
Measure:
The
volume measure for each service category, as listed in Table 1 below, is
the
rate of utilization (e.g., discharges, visits) per 1.000 member months
(MM).
Report
Period:
The
report periods for the SPY 2007 and SFY 2008 contract periods are listed
in the
table
below.
Appendix
L
Page
2
Table
1. Report Periods for the SFY 2007 and 2008 Contract
Periods
|
Quarterly
Report Periods
|
Data
Source: Estimated Encounter Data File Update
|
Quarterly
Report Estimated Issue Date
|
Contract
Period
|
|
Qtr
3 & Qtr 4 2003, 2004, 2005 Qtrl 2006
|
July
2006
|
August
2006
|
SFY
2007
|
|
Qtr
3 & Qtr 4 2003, 2004, 2005 Qtrl, Qtr 2 2006
|
October
2006
|
November
2006
|
|
|
Qtr
4 2003,2004,2005 Qtr 1 thru Qtr 3 2006
|
January
2007
|
February
2007
|
|
|
Qtr
1 thru Qtr 4: 2004, 2005. 2006
|
April
2007
|
May
2007
|
|
|
Qtr
2 thru Qtr 4 2004, Qtr 1 thru Qtr4: 2005, 2006 Qtrl 2007
|
July
2007
|
August
2007
|
SFY
2008
|
|
Qtr
3. Qtr4:2004, Qtrl thru Qtr 4: 2005, 2006 Qtrl, Qtr 2 2007
|
October
2007
|
November
2007
|
|
|
Qtr4:2004.
Qtr I thru Qtr 4: 2005,2006 Qtr 1 thru Qtr 3 2007
|
January
2008
|
February
2008
|
|
|
Qtr
1 thru Qtr 4: 2005, 2006, 2007
|
April
2008
|
May
2008
|
Qtrl
=
January to March Qtr2
=
April to June Qtr3
=
July to September Qtr4
=
October to December
Appendix
L
Page
3
|
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 Centra) regions, will include Franklin, Pickaway, Xxxxxxxxxx,
Xxxxxx and dark 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;
Xxxxxxxxxx, Xxxxxx. and dark counties will remain in the county-based results
for MCP AAA until the West Central regional measure is
implemented.]
Data
Quality Standard, County-Based Approach:
The
standards in Table 2 apply to the MCP's county-based results (see County-Based
Approach
above).
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.
Appendix
L
Page
4
Interim
Regional-Based Approach:
Prior
to
the transition to the regional-based approach, encounter data volume will
be
evaluated by MCP, by region, using an interim approach. All regions with
managed
care membership will be included in results for an interim regional-based
encounter data volume measure until regional evaluation is implemented for
the
applicable region (see Regional-Based Approach below). Encounter data volume
will be evaluated by MCP (i.e., one utilization rate per service category
for
all counties in the region). The utilization rate for all service categories
listed in Table 3 must be equal to or greater than the standard established
in
Table 3 below. The standards listed in Table 3 below are based on utilization
data for counties with managed care membership as of February 1, 2006, and
have
been adjusted to accommodate estimated differences in utilization for all
counties in a region, including counties that did not have membership as
of
February 1, 2006.
Prior
to
implementation of the regional-based approach, an MCP's encounter data volume
will be evaluated using the county-based approach and the interim regional-based
approach. A county with managed care membership as of February 1, 2006. will
be
included in both the County-Based approach and the Interim Regional-Based
approach until regional evaluation is implemented for the county's applicable
region. I
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
|
Appendix
L
Page
5
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.
l.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 (i.e..
to
include all counties serviced by the 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 all records requested for the study.
Appendix
L
Page
6
Data
Quality Standard:
The data
quality standard is a maximum omission rate of 15% for studies
with
time
periods ending in the CY 2006 and CY 2007 contract periods.
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.
l.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,
i
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 (i.e., to include all counties serviced
by the MCP).
Report
Period:
For the
SPY 2007 and SPY 2008 contract periods, performance will be evaluated using
the
report periods listed in 1 .a.i.. Table 1.
Data
Qualify Standard:
The data
quality standard is a minimum rate of 95%.
Determination
of Compliance: Performance is monitored once every quarter/or all report
periods. If the standard is not met in all report periods, then the MCP will
be
determined to be noncomplianl.
Penalty/or
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.
Appendix
L
Page
7
l.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 all counties in which the MCP has CFC
membership).
Report
Period:
For the
SPY 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.
Data
Quality Standard:
The data
quality standard is 80%.
Penalty/or
noncompiiance:
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 noncompiiance
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.
l.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 (i.e., to include all counties serviced by the
MCP).
Appendix
L
Page
8
Report
Period:
For the
SFY 2007 contract period, performance will be evaluated using the following
report periods: April - June 2006; July - September 2006; October - December
2006 ^nd January - March 2007. For the SFY 2008 contract period, performance
will be evaluated using the following report periods: April - June 2007;
July -
September 2007; October - December 2007 and January - March 2008.
Data
Quality Standard 1:
Data
Quality Standard 1 is a maximum encounter data rejection rate of 10% for
each
file intheODJFS-specified medium per format for encounters submitted in SFY
2004
and thereafter. The measure will be calculated per MCP (i.e., to include
all
counties serviced by the 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. I
Penalty
for noncompliance with Data Quality Standard 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 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
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
v be
calculated per MCP (i.e., to include all counties serviced by the
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 2:
The data
quality standard is a maximum encounter data rejection rate for each file
in the
ODJFS-specified medium per format as follows:
Third
through sixth months with membership: 50% Seventh through twelfth month with
membership: 25%
Appendix
L
Page
9
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 Data Qualify Standard 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 only once per measure 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.
x.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 (i.e.. to include
all counties serviced by the 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
in the ODJFS-specified medium per format as follows:
Third
through sixth month with membership:
50
encounters per 1,000 MM for NCPDP
65
encounters per 1.000 MM for NSF
20
encounters per 1,000 MM for UB-92
Seventh
through twelfth month of membership:
250
encounters per 1,000 MM for NCPDP
350
encounters per 1.000 MM for NSF
100
encounters per 1,000 MM for UB-92
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/or
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
Appendix
L
Page
10
payment.
The monetary sanction will be applied only once per measure 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.
l.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 all
counties in which the MCP has CFC membership).
Report
Period:
For the
SFY 2007 contract period, performance w ill 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.
Data
Quality Standard:
The data
quality standard is 90%.
Penalty/or
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.
l.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.
l.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 w'ill
be
determined by comparing a sample of delivery payments to the medical record.
The
measure will be calculated per MCP (i.e., to include all counties serviced
by
the MCP).
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.
Appendix
L
Page
11
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
results that are finalized during the contract year, the accuracy rate for
encoLinters 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/or Measure 2:
A
minimum record submittal rate of 85%.
Penalty/or
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 cata
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 (i.e.. to include
all
counties serviced by the 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/or Measure 2:
TBD for
SFY 2008 based on study conducted in SPY 2007
Penalty/or
Noncompliance:
Does not
apply for SFY 2006 or SFY 2007. 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.
Appendix
L
Page
12
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.
x.x.xx.
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 MM1S provider number
must be submitted to ODJFS with the generic provider number 9111115. The
measure
will be calculated per MCP (i.e., to include all counties serviced by the
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 2007 and SFY 2008 contract periods, performance will be evaluated using
the
report periods listed in 1 .a.i.. Table 1.
Data
Quality Standard:
A
maximum generic provider usage rate of 10%.
Determination
of Compliance: Performance is monitored once every quarter/or all report
periods. I/the standard is not met in all report periods, then the MCP will
be
determined to be noncompliant.
Penalty/or
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 w'ill 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.
I.c.
Timely Submission of Encounter Data
l.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 l.a.i.) and the rejected
encounter (Section l.a.v.) standards are based on encounters being submitted
within this time frame.
x.x.xx.
Submission of Encounter Data Files in the ODJFS-specified medium per
format
MCP
submissions of encounter data files in the ODJFS-specified medium per format
to
ODJFS are limited to two per format per month. Should an MCP wish to send
additional files in the ODJFS-specified medium per format, permission to
do so
must be obtained by contacting BMHC.
Appendix
L
Page
13
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/or Case Management Data Qualify 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
SPY 2007 contract period. July - September 2006, October - December 2006,
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.
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.
Appendix
L
Page
14
For
any MCP which did not have membership as a/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/or
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/or
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. TheOAC 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 either their encounter data is of insufficient
quality or 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.
Appendix
L
Page
15
3.a.
Independent External Quality Review
Measure:
The
independent external quality review covers both administrative and clinical
focus areas of study.
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 1:
Sufficient encounter data quality in each study area to draw a sample as
determined by the external quality review organization
Penalty
for noncompliance with Data Quality Standard 1:
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.
Data
Quality Standard 2:
A
minimum record submittal rate of 85% for each clinical measure.
Penalty/or
noncompliance for Data Quality Standard 2:
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; however,
no CFC
member may have more than one PCP identified.
4.a.
Timely submission of Member's PCP Data
Data
Quality Submission Requirement:
The MCP
must submit a Members' Designated PCP Data file on a monthly basis according
to
the specifications established in ODJFS
Member's PCP Data File and Submission Specifications.
Penalty
for noncompliance'.
See
Appendix N, Compliance Assessment System, for the penalty for noncompliance
with
this requirement.
4.b.
Designated PCP for newly enrolled members
Measure:
The
percentage of MCP's newly enrolled members who were designated a PCP by their
effective date of enrollment.
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
Appendix
L
Page
16
contract
period, performance will be evaluated quarterly using the July-September
2007,
October - December 2007. January - March 2008 and April - June 2008 report
periods.
Data
Qualify 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 w ith PCP designation by their
effective date of enrollment for quarter 3 and quarter 4 of SFY
2008.
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 Hies 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.v., and 1 .x.xx., no monetary sanctions described
in this
appendix will be imposed if the MCP is in its first contract
Appendix
L
Page
17
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 w
ill
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. If statewide expansion is not complete by December 31. 2006. OD.IFS
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 0, Pay
for Performance.
1.
QUALITY OF CARE
l.a.i
Independent External Quality Review [Only use in SFY2006 Incentive System;
only
applicable for MCPs with membership as of February I,
2006]
In
accordance with federal law and regulations state Medicaid agencies must
annually provide for an external 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 component
and
clinical focus areas of study. The overall score is weighted to emphasize
clinical performance.
Report
Period:
For the
SFY 2006 contract period, performance will be evaluated using the review's
that
are finalized during SFY 2006.
Minimum
Performance Standard 1:
A
minimum score of 75% for each clinical study and the administrative component.
|
Action
Required for Noncompliance with the Minimum Performance Standard
1:
For all
studies that are finalized during this contract period, if an MCP is
noncompliant with the standard, then the MCP is required to complete a
Performance Improvement Project, as described in Appendix K.
Appendix
M
Page
2
Quality
Assessment and Performance Improvement Program,
to
address the area(s) of noncompliance.
Minimum
Performance Standard 2:
Each MCP
must achieve an overall
score of
at least 75%.
Penalty
for Noncompliance with the Minimum Performance Standard 2:
A
serious deficiency may result in immediate termination or nonrenew al of
the
provider agreement. (Examples of an external quality review serious deficiency
are a score of less than 75 percent for each clinical study or a score of
less
than 75 percent for the administrative component with a score of less than
75
percent on the preponderance of clinical studies).
l.a.ii
Independent External Quality Review (Effective SFY 2007]
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
2007.
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.
l.b.
Children with Special Health Care Needs (CSHCN)
In
order
to ensure state compliance with theprovisionsof42CFR438.208.the Bureau of
Managed Health Care established Children w'ith 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.
l.b.i.
Case Management of Children (Use
in SFY2006 Incentive System; only applicable/or MCPs with membership as of
January
7, 2006)
Measure:
The
average monthly case management rate for children 6 months and over and under
21
years of age.
Appendix
M
Page
3
Report
Period:
For the
SFY 2006 contract period, performance will be evaluated using the January
- June
2005 and July - December 2005 report periods. For the SFY 2007 contract period,
performance will be evaluated using the January - June 2006 report
period
Performance
Target:
A
minimum case management rate of 5.0%.
Minimum
Performance Standard:
For
results that are below the performance target the performance standard is
an
improvement level that results in a 20% decrease between the target and the
previous reporting period's results. For MCPs that reach or surpass the
performance target, then the standard is to keep the results at or above
the
performance target,
Penalty/or
Noncompliance:
The
first time an MCP is noncompliant with the 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 semi-annual measurements of performance,
if an MCP is again determined to be noncompliant with the standard for this
measure. ODJFS will impose a monetary sanction (see Section 5) of one half
of
one percent of the current month's premium payment. Once the MCP is performing
at standard levels and the violations/deficiencies are resolved to the
satisfaction of ODJFS, the money will be refunded.
x.x.xx.
Case 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. July - September 2006, October - December 2006,
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.
County-Based
Approach:
MCPs
with managed care membership as of February 1. 2006 w'ill 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-bdsed 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 dark 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;
Xxxxxxxxxx. Xxxxxx. and dark counties will remain in the county-based statewide
result for evaluation of MCP AAA until the West Central regional-based approach
is implemented.]
Appendix
M
Page
4
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.
Minimum
Performance Standard:
For the
first and second quarters of SFY 2007, a case management rate of 4.5%. For
the
third and fourth quarters of SFY 2007, a case management rate of 5.0%. For
SFY
2008, a case management rate of 6.0%.
Penally
for Noncompliance:
The
first time an MCP is noncompliant with the standard for this measure. ODJFS
w'ill issue a Sanction Advisory informing the MCP that any future noncompliance
instances with the standard for this measure will result in new member selection
freezes or a reduction of assignments will occur as outlined in Appendix
N of
the Provider Agreement. Once the MCP is performing at standard levels and
the
violations/deficiencies are resolved to the satisfaction of ODJFS, the new
member selection freeze/reduction of assignments will be lifted.
l.b.iii. Case
Management of Children with an ODJFS-Mandated Condition (only
applicable for MCPs with membership as of January
7, 2006)
Measure
I:
The
percent of children 6 months and over and 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.
Report
Period:
For the
SFY 2006 contract period, performance will be evaluated using the July
-September 2005 and January - March 2006 report periods. 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.
Report
Period:
For the
SFY 2006 contract period, performance will be evaluated using the -January
-
June 2005 and July - December 2005 report periods. For the SFY 2007 contract
period. performance will be evaluated using the January - June 2006 report
period.
Measure
3:
The
percent of children 6 months and over and under 21 years of age with a positive
identification through an ODJFS administrative review of data for the
ODJFS-mandated case management condition ofP-HV/AIDS that are case
managed.
Report
Period:
For the
SFY 2006 contract period, performance will be evaluated using the July September
2005 and January - March 2006 report periods.
Performance
Target for Measures 1. 2, and 3:
A
minimum case management rate of 80%.
Minimum
Performance Standard for Measures I. 2, and 3:
For
results that are below the performance target the performance standard is
an
improvement level that results in a 20% decrease between the target and the
previous reporting period's results. For MCPs that reach or surpass the
performance target, then the standard is to keep the results at or above
the
performance target.
Appendix
M
Page
5
Penalty
for Nonconipliance for Measures 1 and 2:
The
first time an MCP is noncompliant with the 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 semi-annual measurements of performance,
if an MCP is again determined to be noncompliant with the standard (see Section
5) for measures 1 or 2, 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 the violations/deficiencies are resolved to the satisfaction
of ODJFS, the money will be refunded. Note: For SFY 2006, measure 3 is a
reporting-only measure.
x.x.xx. Case
Management of Children with an ODJFS-Mandated Condition
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 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. July - September 2006. October- December 2006.
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.
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, w'ill include Franklin. Pickaway. Xxxxxxxxxx. Xxxxxx
and dark 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 dark counties will remain in the county-based statewide
result for evaluation of MCP AAA until the West Central regional-based approach
is implemented.]
Appendix
M
Page
6
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.
Minimum
Performance Standard/or Measures 1 and 3:
For the
first and second quarters of SFY 2007, a case management rate of 65%. For
the
third and fourth quarters of SFY 2007. a case management rate of 70%. For
SFY
2008, a case management rate of 80%.
Minimum
Performance Standard/or Measure 2:
For the
first and second quarters of SFY 2007. a case management rate of 55%. For
the
third and fourth quarters of SFY 2007, a case management rate of 60%. For
SFY
2008, a case management rate of 70%.
Penalty
for Noncompliance for Measures 1 and 2:
The
first time an MCP is noncompliant with the standard for this measure. OD.IFS
will issue a Sanction Advisory informing the MCP that any future noncompliance
instances with the standard for this measure will result in new member selection
freezes or a reduction of assignments will occur as outlined in Appendix
N of
the Provider Agreement. Once the MCP is performing at standard levels and
the
violations/deficiencies are resolved to the satisfaction of OD.IFS the new
member selection freeze/reduction of assignments will be lifted. 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 both SFY
2007
and 2008. measure 3 is a reporting-only measure.
I.e.
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
forthe
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,
OD.IFS
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 2003 results (the baseline
period) and calendar year 2004 results. The methods will be updated and a
new
baseline will be created during 2005 for calendar year 2004 results. These
results will then serve as the baseline to evaluate whether improvement occurred
from calendar year 2004 to calendar year 2005. 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
Appendix
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7
Clinical
Performance Measures/or (he Medicaid CFC Managed Care Program.
Performance standards are subject to change based on the revision or update
ofNCQA methods or other national standards, methods or benchmarks.
For
an MCP which had membership as of February51,
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 (l.c.i - l.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
7, 2006:
Performance will be evaluated using a regional-based approach for any active
region in which the MCP had membership.
Regional-BasedApproach:
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 tw''o 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 SPY 2006
contract period, performance will be evaluated using the January - December
2005
report period. 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.
l.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.
Target:
80% of
the eligible population must receive 81% or more of the expected number of
prenatal visits.
Appendix
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8
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%, 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%, 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.
x.x.xx.
Perinatal Care - Initiation of Prenatal Care
Measure:
The
percentage of enrolled women w ith 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.
Target:
90% of
the eligible population initiate prenatal care within the specified
time.
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 %, 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%, 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.
l.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.
Target:
At least
80% of the eligible population must receive a postpartum visit.
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%, 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%, then ODJFS will issue a Quality
Appendix
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Improvement
Directive which will notify the MCP ofnoncompliance and may outline the steps
that the MCP must take to improve the results.
x.x.xx.
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.
Target:
At least
80% of
the eligible children receive the expected number of well-child
visits.
Minimum
Performance Standard/or 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%. 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 ofnoncompliance. If the standard is not met and the results
are
at or above 34%. then OD.IFS will issue a Quality Improvement Directive which
will notify the MCP ofnoncompliance 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%. then the MCP is required
to
complete a Performance Improvement Project, as described in Appendix K,
Qua!
fly 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%. then OD.IFS will issue a Quality Improvement Directive
which will notify the MCP ofnoncompliance 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%. 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 ofnoncompliance. If the standard is not met and the results
are
at or above 30%, then ODJFS will issue a Quality Improvement Directive which
will notify the MCP ofnoncompliance and may outline the steps that the MCP
must
take to improve the results.
l.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 x.xx received prescribed medications
acceptable as primary therapy for long-term control of asthma.
Appendix
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10
Target:
95% of
the eligible population must receive the recommended medications.
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%, 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%, 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.
x.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.
Target:
At least
60% of the eligible population receive a dental visit.
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%. 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%. 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.
l.c.vii.
Lead Screening
Measure:
The
percentage of one and two year olds who received a blood lead screening by
age
group.
Target:
At least
80% of the eligible population receive a blood lead screening.
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
w ill notify the MCP of noncompliance and may outline the steps that the
MCP
must take to improve the results.
Appendix
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11
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 the
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
0)
is CY
2008.
For
any MCP which did not hare membership as of February J, 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.
Appendix
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12
Report
Period:
In order
to adhere to the statew ide expansion timeline. reporting periods may be
adjusted based on the number of months of managed care membership. For the
SPY
2006 contract period, performance will be evaluated using the January - December
2005 report period. 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.
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 end 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 the
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 tw'o 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
w'ill 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 2006
contract period, performance will be evaluated using the January - December
2005
report period. For the
Appendix
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13
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.
Minimum
Performance Standards:
CY
2005
report period - 70% of the children must receive a visit. CY 2006 report
period
- 70% of the children must receive a visit. CY 2007 report period - 71% of
the
children must receive a visit.
Penaltyfor
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 w'hether 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 the 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
0}
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 statew ide expansion timeline. reporting periods may be
adjusted based on the number of months of managed care membership. For the
SFY
2006 contract period, performance will be evaluated using the January - December
2005 report period. For the SFY 2007 contract period, performance will be
evaluated using the January - December 2006 report
Appendix
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14
period.
For the SFY 2008 contract period, performance will be evaluated using the
January December 2007 report period.
Minimum
Performance Standards:
63% of
the adults must receive a visit.
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.
Adults' Access to Designated PCP (new measure pending
review)
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 w
ill be evaluated by region, using results for all counties included in the
region. ODJFS will use the first full calendar year of data 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
w'ill 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 w'ith the Minimum Performance Standard, then the MCP
must
develop and implement a corrective action plan.
3.
CONSUMER SATISFACTION
The
regional approach for this measure is to be determined for SFY 2008. The
county-based approach remains effective in SFY 2007; the county-based approach
is only applicable for MCPs with membership as of February 1,2006 and for
the
counties in which the MCPs had membership as of February 1. 2006.
In
accordance with federal requirements and in the interest of assessing enrollee
satisfaction with MCP performance. ODJFS periodically 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. Performance in this category will be determined by the
overall satisfaction score. For a comprehensive description of the Consumer
Satisfaction
Appendix
M
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15
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 Consuner Satisfaction Survey who
were
asked to rate their overall satisfaction with their MCP. The results of this
measure are reported annually.
Report
Period:
For the
SFY 2006 contract period, performance will be evaluated using the results
from
the most recent consumer satisfaction survey completed prior to the end of
the
SFY 2006. 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, the measure is
under
review and the report period has not been determined.
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 for one contract year (one state fiscal year)
through the Compliance Assessment System.
Report
Period:
For the
SFY 2005 contract period, performance will be evaluated using the July 2004
-
June 2005 report period. For the SFY 2006 contract period, performance will
be
evaluated using the July 2005 - June 2006 report period.
Minimum
Performance Standard:
No more
than 25 points
Penalty
for Noncompliance:
Penalties for points are established in Appendix N, Compliance
Assessment System.
4.b.
Emergency Department Diversion
Appendix
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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 regioral-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!. 2006. The minimum performance standard and the target in
the.
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
0)
is
July-December 2008.
For
any MCP which did not have membership as of February I, 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 statew'ide expansion timeline, reporting periods may be
adjusted based on the number of months of managed care membership. For the
SFY
2006 contract period, a baseline level of performance will be set using the
January - June 2005 report period. Results will be calculated for the reporting
period of July-December 2005 and compared to the baseline results to determine
if the minimum performance standard is met. 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
Appendix
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17
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.
Target:
A
maximum of 0.70% of the eligible population will have four or more ED visits
during reporting period.
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.
Penaltyfor
NoncompJiance:
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
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. I
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. |
Appendix
M
Page
18
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 (CAS)
CFC
ELIGIBLE POPULATION
The
Compliance Assessment System (CAS) is designed to improve the quality of
each
MCP's performance through actions taken by ODJFS to address identified failures
to meet certain program requirements. The CAS assesses progressive remedies
with
specified values (occurrences or points) assigned for certain documented
failures to satisfy the deliverables required by the Agreement. Remedies
are
progressive based upon the severity of the violation. or a repeated pattern
of
violations. The CAS does not include categories which require subjective
assessments or which are not within the MCPs control. CAS allows the accumulated
point total to reflect both patterns of less serious violations as well as
less
frequent, more serious violations.
The
CAS
focuses on clearly identifiable deliverables and occurrences/points are only
assessed in documented and verified instances ofnoncompliance. The CAS does
not
replace ODJFS' abi|lity to require corrective action plans (CAPs) and program
improvements, or to impose any of the sanctions specified in Ohio Administrative
Code (OAC) rule 5101:3-26-10. including the proposed termination, amendment,
or
nonrenewal of the MCP's provider agreement.
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.
Corrective
Action Plans (CAPs)
- MCPs
may be required to develop CAPs for any instance of noncompliance. and CAPs
are
not limited to actions taken under ihe CAS. All CAPs requiring ongoing activity
on the part of an MCP to ensure their compliance with a program requirement
remain in effect for the next provider agreement period. 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 an ODJFS-approvable CAP, ODJFS
may
require the MCP to comply with an OD.IFS-developed or "directed"
CAP.
Appendix
N
Page
2
Occurrences
and Points
-
Occurrences and points are defined and applied as follows:
Occurrences
— Failures to meet program requirements, including but not limited to.
noncompliance with administrative requirements.
Examples
include:
| - |
Use
of unapproved marketing materials.
|
| - |
Failure
to attend a required meeting.
|
| - |
Second
failure to meet a call center standard.
|
5
Points
— Failures to meet program requirements, including but not limited to, actions
which could impair the member's ability to access information regarding services
in a timely manner or which could impair a member's rights.
Examples
include:
| - |
24-hour
call-in system is not staffed by medical
personnel.
|
| - |
Failure
to notify a member of their right to a state hearing when the MCP
proposes
to deny. reduce, suspend 01-terminate a Medicaid-covered
service.
|
| - |
Failure
to appropriately notify ODJFS of provider panel
terminations.
|
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 member to access
covered services.
Examples
include:
| - |
Failure
to comply with the minimum provider panel requirements specified
in
Appendix H of the Agreement.
|
| - |
Failure
to provide medically-necessary Medicaid covered services to
members.
|
| - |
Failure
to meet the electronic claims adjudication
requirements.
|
Failure
to submit or comply with CAPs will result in the assessment of occurrences
or
points based on the nature of the violation under correction.
Appendix
Page
3
Notwithstanding
the assessment of occurrences and/or points as a result of individual events,
the following cumulative actions will be imposed for repeated
violations.
After
accumulating a total of three occurrences within a contract term. all subsequent
occurrences during the period will be assessed as 5-point violations, regardless
of the number of 5-point violations which have been accrued by the MCP.
After
accumulating a total of three 5-point violations within a contract term,
all
subsequent 5-point violations during the period will be assessed as 8-point
violations. except as specified above.
After
accumulating a total of two 10-point violations within a contract term, all
subsequent 10-point violations during the period will be assessed as 15-point
violations.
Occurrences
and points will accumulate over the contract term of the Agreement. Upon
the
beginning of a new Agreement, the MCP will begin the new contract term with
a
score of zero unless the MCP has accrued a total of 55 points or more during
the
prior provider agreement period. Those MCPs who have accrued a total of 55
points or more during the contract term of a prior provider agreement will
carry
these points over for the first three (3) months of their next provider
agreement. If the MCP does not accrue any additional points during this three
(3) month period the MCP will then have their point total reduced to zero
and
continue on in the new contract term. If the MCP does accrue additional points
during this three-month period, the MCP will continue to carry the points
accrued from the prior provider agreement plus any additional points accrued
during the new provider agreement contract term.
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
provider agreement period will be subject to remedial action under CAS at
the
time that ODJFS first becomes aware of this noncompliance.
In
cases
where an MCP subcontracting provider is found to have violated a program
requirement (e.g., failing to provide adequate contract termination notice,
marketing to potential members. unapprovable billing of members, etc.). ODJFS
will not assess occurrences or 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. occurrences
or points may be assessed, as determined by ODJFS.
All
required submissions to be received by their specified deadline. Unless
otherwise specified, late submissions will initially be addressed through
CAPs.
with repeated instances of untimely
Appendix
N
Page
4
submissions
resulting in escalating penalties, as may be determined by ODJFS.
If
an MCP
determines that they will be unable to meet a program deadline, the MCP must
verbally inform the designated ODJFS contact person (or their supervisor)
of
such and submit a written request (by facsimile transmission) 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 arisen which make it
impossible for the MCP to meet an ODJFS-stipulated deadline and all such
requests will be evaluated upon the basis and with that in mind. Only written
approval as may be granted by ODJFS of a deadline extension will preclude
the
assessment of a CAP, occurrence or points for untimely submissions.
I
No
points
or occurrences 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.).
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 issued under the CAS are nonrefundable.
1
-9
Points Corrective Action Plan (CAP)
10-19
Points CAP + $5.000 fine
20-29
Points CAP + $ 10.000 fine
30-39
Points CAP + $20.000 fine
40-69
Points CAP + $30.000 fine
70+
Points Proposed Contract Termination
Appendix
N
Page
5
New
Member Selection Freezes:
Notwithstanding
any other penalty, occurrence or point assessment that ODJFS may impose on
MCP
under this Appendix. ODJFS may prohibit an MCP from receiving new membership
through consumer initiated selection or the assignment process (selection
freeze) in one or more counties if: (1) the MCP has accumulated a total of
20 or
more points during a contract term; (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 is denied by CMS in accordance with
the
requirements in 42 CFR 438.730.
Reduction
of Assignments
ODJFS
may
reduce the number of assignments an MCP receives if ODJFS, in its sole
discretion. determines that the MCP lacks sufficient administrative capacity
to
meet the needs of the increased volume in membership. Examples of circumstances
which ODJFS may deten|nine demonstrate a lack of sufficient administrative
capacity include, but are not limited to an MCP's failure to: 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.
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
N
Page
6
Appendix
C of the Agreement, ODJFS will assess the MCP with a 10-point penalty and
a
monetary sanction of $20,000 per day for the period of noncompliance. ODJFS
may
assess additional penalty points based on the length of noncompliance, as
it may
determine in its sole discretion.
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.
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 the contract
term will result in the assessment of 5 points, quarterly prompt pay reporting,
and submission of monthly status reports to ODJFS until the next quarterly
report is due. The second and any subsequent violation during the contract
term
will result in the submission of monthly status reports, assessment of 10
points
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.
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 a
selection freeze of not less than three (3) months duration.
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.
•
A
10
point penalty assessment for the period of noncompliance.
Appendix
N
Page
7
•
Proposed termination or non-renewal of the MCP's Medicaid provider agreement
ma^
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.
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.
Noncompliance
with Encounter Data Submissions:
Submission
of unpaid encounters (except for immunization services as specified in Appendix
L) will result in the assessment of a nonrefundable $1.000 fine for each
violation.
Noncompliance
with Abortion and Sterilization Payment
Noncompliance
with abortion and sterilization requirements as specified by ODJFS will result
in the assessment of a nonrefundable $1-000 fine for each documented violation.
Additionally, MCPs must take all appropriate action to correct each such
ODJFS-documented violation.
Negligent
Breach of Protected Health Information (PHI) Standards
Non-compliance
with the HIPAA Privacy Regulations and negligent breach of protected health
information (PHI) standards will be assessed in accordance with Appendix
C.27.
Therefore, the progressive remedies specified under Appendix N, Compliance
Assessment System will not be utilized for assessing non-compliance with
the
HIPAA Privacy Regulations and negligent breach of PHI.
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.
General
Provisions:
All
notifications of the imposition by ODJFS of a fine or freeze will be made
via
certified or overnight mail to the identified MCP Medicaid
Coordinator.
Appendix
N
Page
8
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 w7!!!
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.
Refundable
monetary sanctions/assurances applied by ODJFS will be based on the premium
payment for the month in which the MCP was cited for the deficiency. Any
monies
collected through the imposition of such a 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. 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.
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.
In
addition, 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.
In
addition to the remedies imposed under the CAS, remedies related to areas
of
data quality and financial performance may also be imposed pursuant to
Appendices J, L, and M respectively, of the Agreement.
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, the ODilFS may. pursuant to the provisions of OAC rule 5101:3-26-10(A):
(1) notify the MCP's members that they may terminate from the MCP without
cause;
and/or (2) suspend any further new member selections.
Appendix
N
Page
9
REQUESTS
FOR RECONSIDERATIONS
Requests
for reconsiderations of remedial action taken under the CAS shall be submitted
to ODJFS as follows:
|
•
|
MCPs
notified of ODJFS' imposition of remedial action taken under the
CAS
(i.e.. occurrences, points, fines, assignment reductions and selection
freezes), will have five (5) working days from the date of receipt
to
request reconsideration, although ODJFS will impose selection freezes
based on an access to care concern concurrent with initiating notification
to the MCP. (All notifications of the imposition of a fine or a
freeze
will be made via certified or overnight mail to the identified
MCP
Contact.) 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.
|
•
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 fifth business day after receipt of notification of the imposition
of the remedial action by ODJFS.
|
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.
|
•
Final
decisions or requests for additional information will be made by ODJFS within
five (5) business days of receipt of the request for
reconsideration.
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.
•
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
N Page 10
POINT
COMPLIANCE SYSTEM - POINT VALUES
OCCURRENCES:
Failures
to meet program requirements, including but not limited to. noncompliance
with
administrative requirements, as determined by ODJFS. Examples include. but
are
not limited to, the following:
•
Unapproved use of marketing/member materials.
•
Failure
to attend ODJFS-required meetings or training sessions.
•
Failure
to maintain ODJFS-required documentation.
•
Use
of
unapproved subcontracting providers where prior approval is required by
ODJFS.
•
Use
of
unapprovable subcontractors (e.g.. not in good standing with Medicaid and/or
Medicare programs, provider listed in directory but no current contract,
etc.)
where prior-approval is not required by ODJFS.
|
•
|
Failure
to provide timely notification to members, as required by ODJFS
(e.g.,
notice of PCP or hospital termination from provider
panel).
|
•
Participation in a prohibited or unapproved marketing activity.
•
Second
failure to meet the monthly call-center requirements for either the member
services or 24-hour call-in system lines.
•
Failure
to submit and/or comply with a Corrective Action Plan (CAP) requested by
ODJFS
as the result of an occurrence, or when no occurrence was designated for
the
precipitating violation of OAC rules or provider agreement
•
Failure
to comply with the physician incentive plan requirements, except for
noncompliance where member rights are violated (i.e. failure to complete
required patient satisfaction surveys or to provide members with requested
physician incentive information) or where false, misleading or inaccurate
information is provided to ODJFS.
Appendix
N
Page
11
5
POINTS:
Failures
to meet program requirements, including but not limited to, actions which
could
impair the member's ability to access information regarding services in a
timely
manner or which could impair a consumer's or member's rights, as determined
by
ODJFS. Examples include, but are not limited to, the following:
•
Violations which result in selection or termination counter to the recipient's
preference (e.g., a recipient makes a selection decision based on inaccurate
provider panel information from the MCP).
•
Any
violation of a member's rights. |
•
Failure
to provide member materials to new members in a timely manner.
•
Failure
to comply with appeal, grievance, or state hearing requirements, including
timely submission to ODJFS. Failure to staff 24-hour call-in system with
appropriate trained medical personnel.
•
Third
failure to meet the monthly call-center requirements for either the member
services or the 24-hour call-in system lines.
•
Failure
to submit and/or comply with a CAP as a result of a 5-point violation. Failure
to meet the prompt payment requirements (first violation). Provision of false,
inaccurate or materially misleading information to health care providers,
the
MCP's members, or any eligible individuals.
•
Failure
to submit a required monthly CAMS file (as specified in Appendix L of the
Agreement) by the end of the month the submission was required.
•
Failure
to submit a required monthly Members' Designated PCP file (as specified in
Appendix L of the Agreement) by the end of the month the submission was
required.
Appendix
N Page 12
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:
•
Failure
to meet any of the provider panel requirements as specified in Appendix H
of the
Agreement.
•
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 process prior authorization requests within prescribed time
frame.
•
Failure
to remit any ODJFS-required payments within the specified time
frame.
•
Failure
to meet the electronic claims adjudication requirements.
• Failure
to submit and/or comply with a CAP as a result of a 10-point
violation.
•
Failure
to meet the prompt payment requirements (second and subsequent
violations).
•
Fourth
and any subsequent failure to meet the monthly call-center requirements for
either the member services or the 24-hour call-in system lines.
•
Failure
to provide OD.IFS with a required submission after ODJFS has notified the
MCP
that the prescribed deadline for that submission has passed.
•
Failure
to submit a required monthly appeal or grievance file (as specified in Appendix
L of the Agreement) by the end of the month the submission was
required.
•
Misrepresentation or falsification of information that the MCP furnishes
to the
ODJFS or to the Centers for Medicare and Medicaid Services.
APPENDIX
0
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 the Emergency
Department Diversion and selected Clinical Performance Measures. For qualifying
MCPs. higher performance standards for three measures must be readied 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 (SPY 2006 through SFY 2009).
the
cou ity-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 ]. 2006 w'ill be used to calculate performance levels for the
county-based P4P system.
1.
SFY 2006 P4P l.a. Qualifying Performance Levels
To
qualify for consideration of the SFY 2006 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 oftheODJFS website.
Measures
for which the minimum performance standard for SFY 2006 established in Appendix
M, Performance
Evaluation,
must be
met to qualify for consideration of P4P are as follows:
1.
Independent External Quality Review (Appendix M, Section l.a.i. - Minimum
Performance Standard 2)
Appendix
O
Page
2
Report
Period:
The most
recent Independent External Quality Review completed prior to the end of
the SPY
2006 contract period.
2.
PCP
Turnover (Appendix M, Section 2.a.)
Report
Period:
CY
2005
3.
Children's Access to Primary Care (Appendix M, Section 2.b.)
Report
Period:
CY
2005
4.
Adults' Access to Preventive/Ambulatory Health Services (Appendix M, Section
2.c.)
Report
Period:
CY
2005
5.
Overall Satisfaction with MCP (Appendix M. Section 3.)
Report
Period:
The most
recent consumer satisfaction survey completed prior to the end of the SFY
2006
contract period.
For
the
EDD performance measure, the MCP must meet the P4P standard for the report
period of July - December. 2005 to be considered for SFY 2006 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 2006 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.
|
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
|
59%
|
|
8.
Annual Dental Visits
|
40%
|
|
9.
Blood Lead - 1 year olds
|
45%
|
Appendix
O
Page
3
l.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.
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 l.b.i.)
Report
Period:
July -
December 2005
Excellent
Standard:
2.5%
Superior
Standard:
3.8%
2.
Use of
Appropriate Medications for People with Asthma (Appendix M. Section 1 .x.xx.)
Report
Period:
CY 2005
Excellent.
Standard:
59%
Superior
Standard:
68%
3.
Adults' Access to Preventive/Ambulatory Health Services (Appendix M, Section
2.c.)
Report
Period:
CY
2005
Excellent
Standard:
76%
Superior
Standard:
83%
I.e.
Determining SFY 2006 P4P
MCP's
reaching the minimum performance standards described in Section 2.a. 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. 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., 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 amount, among all
MCPs'
Aged. Blind or Disabled (ABD) and/or Covered Families and Children (CFC)
receiving additional P4P. The maximum amount to be awarded to a single plan
P4P
additional to the at-
Appendix
O
Page
4
risk
amount is $250,000 per contract year. 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 2007 P4P
2.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 OD.IFS 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 (Xxxxxxxx X, Xxxxxxx
0,x.)
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%.
Appendix
0
Page
5
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%
|
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 x.x.xx.)
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 1 .x.xx.)
Report
Period:
CY
2006
Appendix
O
Page
6
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%
2.c.
Determining SFY 2007 P4P
MCP's
reaching the minimum performance standards described in Section 2.a. 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. 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., 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 amount, among: all
MCPs'
Aged, Blind or Disabled (ABD) and/or Covered Families and Children (CFC)
receiving additional P4P. The maximum amount to be awarded to a single plan
P4P
additional to the at-risk amount is $250,000 per contract year. 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 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 aw'arded for superior performance.
Starting
with the tw'enty-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.
Appendix
O
Page
7
3.b.
Determination ofat-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 SPY 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.L
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
fu|ll calendar years to determine an MCP's performance level. If statewide
expansion is not complete by December 3 I, 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 ofat-risk dollars
may be included in an MCP's first regional at-risk status | determination
depending on w'hen 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 w ill be returned to ODJFS in
accordance with Appendix P., Terminalioris/Nonrenewals/Amendments,
of the
provider agreement.
Appendix
O
Page
8
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
MCPTERMINATIONS/NONRENEWALS/AMENDMENTS
CFC
EEIGIBLE POPULATION
Upon
termination either by the MCP or ODJFS. nonrenewal or denial of an MCP's
provider agreement, all previously collected refundable monetary sanctions
w ill
be retained by ODJFS.
MCP-1N1T1ATEDTERMINAT10NS/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 iss-ied, 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 wi 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.
Appendix
X
Xxxx
2
ODJFS-INIT1ATED
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 duration
of
the appeals process,
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 $15,300 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. IfODJFS 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 either of these proposed actions 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 3P1V1 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 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.
