PROVIDER AGREEMENT
Exhibit
10.1
BETWEEN
STATE
OF
OHIO
DEPARTMENT
OF JOB AND FAMILY SERVICES
AND
WELLCARE
OF OHIO, INC.
Amendment
No.
1
Pursuant
to Article IX.A. the Provider Agreement between the State of Ohio, Department
of
Job and Family Services, (hereinafter referred to as “ODJFS”) and WELLCARE OF
OHIO, INC. (hereinafter
referred to as “MCP”) for the Covered Families and Children (hereinafter
referred to as “CFC”) population dated July 1, 2007, is hereby amended as
follows:
1.
Appendices C, D, E, F, G, H, J, K, L, M, N and O are modified as
attached.
2.
All other terms of the provider agreement are hereby affirmed.
The
amendment contained herein shall be
effective January 1, 2008.
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WELLCARE
OF OHIO, INC.:
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BY: /s/ Xxxx
Xxxxxxx
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DATE:
1/4/08
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XXXX
XXXXXXX, SENIOR VICE PRESIDENT
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OHIO
DEPARTMENT OF JOB AND FAMILY SERVICES:
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BY: Xxxxx
Xxxxx-Xxxxxx
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DATE:
1/7/08
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XXXXX
X. XXXXX-XXXXXX, DIRECTOR
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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.
8. The
MCP must have all new employees
trained on
applicable program requirements, and represent, warrant and certify to ODJFS
that such training occurs, or has occurred.
9. If
an MCP determines that
it does not wish to provide, reimburse, or cover a counseling service or
referral service due to an objection to the service on moral or religious
grounds, it must immediately notify ODJFS to coordinate the implementation
of
this change. MCPs will be required to notify their members of this
change at least thirty (30)
days
prior to the effective date. The MCP’s member handbook and provider directory,
as well as all marketing materials, will need to include information specifying
any such services that the MCP will not provide.
10. For
any data and/or
documentation that MCPs are required to maintain, ODJFS may request that MCPs provide analysis of
this data
and/or documentation to ODJFS in an aggregate format, such format to be solely
determined by ODJFS.
11. The
MCP is responsible for determining
medical necessity for services and supplies requested for their members
as specified in OAC rule 5101:3-26-03. Notwithstanding such
responsibility, ODJFS retains the right to make the final determination on
medical necessity in specific member situations.
12. In
addition to the
timely submission of medical records at no cost for the annual external quality
review as specified in OAC rule 5101:3-26-07, the MCP may be
required for other purposes to submit medical records at no cost to
ODJFS and/or designee upon request.
13. The
MCP must notify the BMHC of
the termination of an MCP panel
provider that is designated
as the primary care
provider for 500
or more of the MCP’s CFC members.
The
MCP must provide notification within
one working day of the MCP
becoming aware of
the
termination.
14. Upon
request by ODJFS, MCPs may be
required to provide written notice to members of any significant
change(s) affecting contractual requirements, member services or access to
providers.
15. MCPs
may elect to provide services that
are in addition to those covered under the Ohio Medicaid fee-for-service
program. Before MCPs notify potential or current members of the
availability of these services, they must first notify ODJFS and advise ODJFS
of
such planned services availability. If an MCP elects to provide
additional services, the MCP must ensure to the satisfaction of ODJFS that
the
services are readily available and accessible to members who are eligible
to receive them.
a.
MCPs
are required to make
transportation available to any member
requesting
transportation when they
must travel
(thirty) 30 miles or more from
their home to receive a medically-necessary Medicaid-covered
service. If the MCP
offers transportation to
their members as an additional benefit and this transportation benefit
only covers a limited
number of
trips, the required
transportation listed above may not be counted toward
this
trip
limit.
b.
Additional
benefits may not vary by
county within a region except out of necessity
for transportation
arrangements (e.g., bus
versus cab). MCPs approved to serve consumers in
more than one
region may vary additional
benefits between regions.
c.
MCPs must give ODJFS and members
(ninety) 90 days prior notice when decreasing or ceasing any additional
benefit(s). When it is beyond the control of the MCP, as demonstrated
to ODJFS’ satisfaction, ODJFS must be notified within (one) 1 working
day.
16. MCPs
must comply with any applicable
Federal and State laws that pertain to member rights and ensure that its staff
adheres to
such laws when furnishing services to
its members. MCPs shall include a requirement in its contracts with
affiliated providers that such providers also adhere to applicable Federal
and
State laws when providing services to members.
17. MCPs
must comply with any other
applicable Federal and State laws (such as Title VI of the Civil rights Act
of
1964, etc.) and other laws regarding privacy and confidentiality, as such may
be
applicable to this Agreement.
18. Upon
request, the MCP will provide
members and potential members with
a copy of their practice
guidelines.
19. The
MCP is responsible for promoting the
delivery of services in a culturally competent manner, as solely determined
by
ODJFS, to all members, including those with limited English proficiency (LEP)
and diverse cultural and ethnic backgrounds.
All
MCPs
must comply with the requirements specified in OAC rules 5101:3-26-03.1,
5101:3-26-05(D),
5101:3-26-05.1(A), 5101:3-26-08 and 5101:3-26-08.2 for providing assistance
to
LEP members and eligible individuals. In addition, MCPs must provide
written translations of certain MCP materials in the prevalent non-English
languages
of members and eligible individuals in accordance with the
following:
a. When
10% or more of the CFC eligible
individuals in the
MCP’s service area have a
common primary
language other than English, the MCP must translate all ODJFS-approved marketing
materials into the primary language of that group. The MCP must
monitor changes in the eligible population on an ongoing basis and conduct
an
assessment no less often than annually to determine which, if any, primary
language groups meet the 10% threshold for the eligible individuals in each
service area. When the 10% threshold is
met, the MCP must
report this information to ODJFS, in a format as requested by ODJFS, translate
their marketing materials, and make these marketing materials available to
eligible individuals. MCPs must submit to ODJFS, upon request, their
prevalent non-English language analysis of eligible individuals and the results
of this analysis.
b. When
10% or more of an MCP's CFC
members in
the
MCP’s service
area have a common primary
language other than English, the MCP must translate all ODJFS-approved member
materials into the primary language of that group. The MCP must monitor their
membership and conduct a quarterly assessment to determine which, if any,
primary language groups
meet the 10% threshold. When the 10% threshold is met, the MCP must
report this information to ODJFS, in a format as requested by ODJFS, translate
their member materials, and make these materials available to their
members. MCPs must submit to ODJFS, upon request, their prevalent non-English
language
member analysis and the results of this analysis.
20. The
MCP must utilize a
centralized database which records the special communication needs of all MCP
members (i.e., those with limited English proficiency, limited
reading proficiency,
visual impairment, and
hearing impairment) and the provision of related services
(i.e., MCP materials in
alternate format, oral interpretation, oral translation services,
written translations of MCP
materials, and sign language services). This database
must include all MCP member
primary language information (PLI) as well as all other
special communication needs
information for MCP members, as indicated above, when
identified by any source including
but not limited to ODJFS, ODJFS selection services
entity, MCP staff,
providers, and
members. This centralized database must be readily
available to MCP
staff and
be used in coordinating
communication and services to members,
including the selection
of a PCP who speaks the
primary language of an LEP
member,
when such
a provider
is available. MCPs must share
specific
communication needs
information with their providers
[e.g., PCPs, Pharmacy Benefit Managers
(PBMs), and Third Party
Administrators (TPAs)], as applicable. MCPs must submit
to ODJFS, upon request, detailed
information regarding the MCP’s members with special
communication needs, which could
include individual member names, their specific
communication need, and any provision
of
special services
to members (i.e.,
those special services arranged
by the MCP as well as those services
reported to the MCP
which were arranged by
the provider).
Additional
requirements specific to providing
assistance to hearing-impaired, vision-impaired, limited reading proficient
(LRP), and LEP members
and eligible individuals
are found
in OAC rules 5101:3-26-03.1,
5101:3-26-05(D),
5101:3-26-05.1(A),
5101:3-26-08, and
5101-3-26-08.2.
21. The
MCP is responsible for ensuring that
all member materials use easily understood language and format. The
determination of what materials comply with this requirement is in the sole
discretion of ODJFS.
22.
Pursuant
to OAC rules 5101:3-26-08 and
5101:3-26-08.2, the MCP is responsible for ensuring that all MCP marketing
and
member materials are prior approved by ODJFS before being used or shared with
members. Marketing and member materials are defined as
follows:
a. Marketing
materials are those items produced in any medium, by or on behalf of an MCP,
including gifts of nominal value (i.e., items worth no more than $15.00), which
can reasonably be interpreted as intended to market to eligible
individuals.
b. Member
materials are those items developed, by or on behalf of an MCP, to fulfill
MCP
program requirements or to communicate to all members or a group of
members. Member health education materials that are produced by a
source other than the MCP and which do not include any reference to the MCP
are
not considered to be member materials.
c.
All
MCP marketing and member materials must represent the MCP in an honest and
forthright manner and must not make statements which are inaccurate, misleading,
confusing, or otherwise misrepresentative, or which defraud eligible individuals
or ODJFS.
d. All
MCP marketing cannot contain any
assertion or statement (whether written 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 managed
care enrollment center (MCEC)
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.
b. Maintain
written policies and procedures concerning advance directives with respect
to
all adult individuals receiving medical care by or through the MCP to ensure
that the MCP:
i.
Provides written information to all adult members concerning:
a. the
member’s rights under state law to make decisions concerning their medical care,
including the right to accept or refuse medical or surgical treatment and the
right to formulate advance
directives. (In meeting this requirement, MCPs must utilize form JFS
08095 entitled You
Have the Right,
or include the text from
JFS 08095 in their ODJFS-approved member handbook).
b. the
MCP’s policies concerning the implementation of those rights including a clear
and precise statement of any limitation regarding the implementation of advance
directives as a matter of conscience;
c. any
changes in state law regarding advance directives as soon as possible but no later than (ninety) 90 days
after the proposed effective date of the change; and
d. the
right to file complaints concerning noncompliance with the advance directive
requirements with the Ohio Department of Health.
ii. Provides
for education of staff concerning the MCP’s policies and procedures on advance
directives;
iii. Provides
for community education regarding advance directives directly or in
concert with other providers or entities;
iv. Requires
that the member’s medical record document whether or not the member has executed
an advance directive; and
v. Does
not condition the provision of care, or otherwise discriminate against a member,
based on whether the member has executed an advance directive.
24. New
Member
Materials
Pursuant
to OAC rule 5101:3-26-08.2 (B)(3), MCPs must provide to each member or
assistance group, as applicable, an MCP identification (ID) card, a new member
letter, a member handbook, a provider directory, and information on advance
directives.
a.
MCPs
must use the model language specified by ODJFS for the new member
letter.
b.
The ID
card and new member letter must be mailed together to the member via a
method that will ensure their receipt prior to the member’s effective date
of coverage.
c.
The
member handbook, provider directory
and advance directives information may
be mailed
to the member separately from the
ID card and new member letter. MCPs will
meet
the timely receipt requirement for
these materials if they are mailed to the member
within (twenty-four) 24 hours of
the MCP receiving the ODJFS produced monthly
membership roster (MMR). This is
provided the materials are mailed via a method
with an expected delivery date of
no more than five (5) days. If the member handbook,
provider directory and advance
directives information are mailed separately from
the ID card and new member letter
and the MCP is unable to mail the materials within
twenty-four (24) hours, the
member handbook, provider
directory and advance
directives
information must be mailed
via a method that will
ensure receipt by no later
than
the effective date of coverage. If
the MCP mails the ID card
and new member letter
with
the other materials (e.g., member
handbook, provider
directory, and advance
directives),
the MCP must ensure that
all
materials are mailed via a method
that
will ensure
their receipt prior
to the member’s effective date of
coverage.
d.
MCPs
must designate two (2) MCP staff members to receive a copy of the new
member materials on a monthly basis in order to monitor the timely receipt
of these materials. At least one of the staff members must receive the
materials at their home address.
25. Call
-Center
Standards
The
MCP must provide assistance to
members through a member services toll-free call-in system pursuant to OAC
rule
5101:3-26-08.2(A)(1). MCP member services staff must be available
nationwide to provide assistance to members through the toll-free call-in system
every Monday through Friday, at all times during the hours of 7:00 am to 7:00
pm Eastern
Time, exceptfor the following
major
holidays:
·
New Year’s
Day
·
Xxxxxx Xxxxxx
Xxxx’x Birthday
· Memorial
Day
· Independence
Day
· Labor
Day
· Thanksgiving
Day
· Christmas
Day
·
2 optional
closure days: These days can be used independently or in combination with any of the major holiday
closures but cannot both be used within the same closure period.
Before
announcing any optional closure dates to members and/or staff, MCPs must receive
ODJFS prior-approval which verifies that the optional closure days meet the
specified criteria.
If
a
major holiday falls on a Saturday, the MCP member services line may be closed
on
the preceding Friday. If a major holiday falls on a Sunday, the
member services line may be closed on the following Monday. MCP
member services closure days must be specified in the MCP’s member handbook,
member newsletter, or other some
general issuance to the
MCP’s members at least (thirty) 30 days in
advance of
the closure.
The
MCP must also provide access to
medical advice and direction through a centralized twenty-four-hour, seven
day
(24/7) toll-free call-in system, available nationwide, pursuant to OAC
rule 5101:3-26-03.1(A)(6). The
24/7 call-in system must be staffed by appropriately trained medical
personnel. For the purposes of meeting this requirement, trained medical
professionals are defined as physicians, physician assistants, licensed
practical nurses, and registered nurses.
MCPs
must
meet the current American Accreditation HealthCare Commission/URAC-designed
Health Call Center Standards (HCC) for call center abandonment rate, blockage
rate and average speed of answer. By the 10th
of each
month, MCPs must self-report their prior month performance in these three areas
for their member services and 24/7
toll-free call-in
systems to ODJFS. ODJFS will inform the MCPs of any changes/updates to these
URAC call center standards.
MCPs
are not permitted to delegate
grievance/appeal functions [Ohio Administrative Code
(OAC) rule
5101:3-26-08.4(A)(9)]. Therefore, the member services call center
requirement
may not be met through the
execution of a Medicaid Delegation Subcontract Addendum
or Medicaid Combined Services
Subcontract Addendum.
26. Notification
of Optional MCP Membership
In
order to comply with the terms of the
ODJFS State Plan Amendment for the managed care program (i.e., 42 CFR
438.50), MCPs in mandatory membership service areas must inform new
members that MCP membership is optional for certain
populations. Specifically, MCPs must inform any applicable pending
member or member that the following CFC populations are not required to select
an MCP in order to receive their Medicaid healthcare benefit and what steps they need
to take if they do
not wish to be a member of an MCP:
- Indians
who are members of
federally-recognized tribes.
- Children
under 19 years of age who
are:
o Eligible
for Supplemental Security
Income under title XVI;
o In
xxxxxx care or other out-of-home
placement;
o Receiving
xxxxxx care of adoption
assistance;
o Receiving
services through the Ohio
Department of Health’s Bureau for Children with Medical Handicaps (BCMH) or any
other family-centered, community-based, coordinated care system that receives
grant funds under section 501(a)(1)(D) of title V, and is defined by the State
in terms of either program participation or special health care
needs.
27. HIPAA
Privacy Compliance Requirements
The
Health Insurance Portability and
Accountability Act (HIPAA) Privacy Regulations at 45 CFR. § 164.502(e) and §
164.504(e) require ODJFS to have agreements with MCPs as a means of obtaining
satisfactory assurance that the MCPs will appropriately safeguard all personal
identified health information. Protected Health Information (PHI) is
information received from or on behalf of ODJFS that meets the definition of
PHI
as defined by HIPAA and the regulations promulgated by the United States
Department of Health and Human Services, specifically 45 CFR 164.501, and any
amendments thereto. MCPs must agree to the following:
a. MCPs
shall not use or disclose PHI other
than is permitted by this agreement or required by law.
b. MCPs
shall use appropriate safeguards to
prevent unauthorized use or disclosure of PHI.
c. MCPs
shall report to ODJFS any
unauthorized use or disclosure of PHI of which it becomes aware. Any breach
by the MCP or its representatives of protected health information (PHI)
standards shall
be immediately reported to the State HIPAA Compliance Officer
through the
Bureau of Managed Health Care. MCPs must provide documentation
of the breach
and complete all actions ordered by the HIPAA Compliance
Officer.
d. MCPs
shall ensure that all its agents and subcontractors agree to these same PHI
conditions and restrictions.
e. MCPs
shall make PHI available for access as required by law.
f. MCP
shall make PHI available for amendment, and incorporate amendments as
appropriate as required by law.
g. MCPs
shall make PHI disclosure information available for accounting as required
by
law.
h. MCPs
shall make its internal PHI practices, books and records available to the
Secretary of Health and Human Services (HHS) to determine
compliance.
i. Upon
termination of their agreement with ODJFS, the MCPs, at ODJFS’ option, shall
return to ODJFS, or destroy, all PHI in its possession, and keep no copies
of
the information, except as requested by ODJFS or required by law.
j. ODJFS
will propose termination of the MCP’s provider agreement if ODJFS determines
that the MCP has violated a material breach under this section of the agreement,
unless inconsistent with statutory obligations of ODJFS or the MCP.
28. Electronic
Communications – MCPs are
required to purchase/utilize Transport Layer Security (TLS) for all e-mail
communication between ODJFS and the MCP. The MCP’s e-mail gateway
must be able to support the sending and receiving of e-mail using Transport
Layer Security (TLS) and the MCP’s gateway must be able to enforce the sending
and receiving of email via TLS.
29. MCP
Membership acceptance, documentation and reconciliation
a. Selection
Services Contractor: The MCP shall provide
to
the MCEC ODJFS prior-approved MCP materials
and
directories for distribution to eligible individuals who request
additional information about the MCP.
b. Monthly
Reconciliation of
Membership and Premiums: The MCP shall reconcile member data as reported
on the MCEC produced
consumer contact record (CCR) with the ODJFS-produced monthly member roster
(MMR) and report to the ODJFS any difficulties in interpreting or reconciling
information received. Membership reconciliation questions must be
identified and reported to the ODJFS prior to the first of the month to assure
that no member is left without coverage. The MCP shall reconcile membership
with
premium payments and delivery payments as reported on the monthly remittance
advice (RA).
The
MCP
shall work directly with the ODJFS, or other ODJFS-identified entity, to resolve
any difficulties in interpreting or reconciling premium information. Premium
reconciliation questions must be identified within thirty (30) days of receipt
of the RA.
c. Monthly
Premiums and
Delivery Payments: The MCP must be able to receive monthly premiums and
delivery payments in a method specified by ODJFS. (ODJFS monthly
prospective premium and delivery payment issue dates are provided in advance
to
the MCPs.) Various retroactive premium payments (e.g., newborns), and recovery
of premiums paid (e.g., retroactive terminations of membership for children
in
custody, deferments, etc.,) may occur via any ODJFS weekly
remittance.
d.
Hospital/Inpatient Facility Deferment: When an MCP learns of a currently
hospitalized member’s intent to disenroll through the CCR or the 834, the
disenrolling MCP must notify the hospital/inpatient facility and treating
providers as well as the enrolling MCP of the change in enrollment within five
(5) business days of receipt of the CCR or 834. The disenrolling MCP must notify
the inpatient facility that it will remain responsible for the inpatient
facility charges through the date of discharge; and must notify the treating
providers that it will remain responsible for provider charges through the
date
of disenrollment.
When
the
enrolling MCP learns through the disenrolling MCP, through ODJFS or other
means, that a new member who was previously enrolled with another MCP was
admitted prior to the effective date of enrollment and remains an inpatient
on the effective date of enrollment, the enrolling MCP shall contact
the hospital/inpatient facility within five (5) business days of learning
of the hospitalization. The enrolling MCP shall verify that it
is responsible for all medically necessary Medicaid covered services from
the effective date of MCP membership, including treating provider services
related to the inpatient stay; the enrolling MCP must reiterate that the
admitting/disenrolling MCP remains responsible for the hospital/inpatient
facility charges through the date of discharge. The
enrolling MCP shall work with the hospital/inpatient facility to facilitate
discharge planning and authorize services as needed.
When
an
MCP learns that a new member who was previously on Medicaid fee for
service was admitted prior to the effective date of enrollment and
remains an inpatient on the effective date of enrollment, the enrolling MCP
shall notify the hospital/ inpatient facility and treating providers that
the MCP may not be the payer. The MCP shall work with hospital/inpatient
facility, treating providers and the ODJFS to assure that discharge
planning assures continuity of care and accurate payment. Notwithstanding
the MCP’s right to request a hospital deferment up to six (6) months following
the member’s effective date, when the enrolling MCP learns of a
deferment-eligible hospitalization, the MCP shall notify the ODJFS and request the deferment
within five (5) business days of learning of the potential
deferment.
e. Just
Cause Requests:
The
MCP shall follow procedures as
specified by ODJFS in assisting the ODJFS in resolving member requests for
member-initiated requests affecting membership.
f. Newborn
Notifications: The MCP is required to
submit newborn notifications to ODJFS in accordance with the ODJFS Newborn
Notification File and Submissions Specifications.
g. Eligible
Individuals: If
an eligible individual contacts the MCP, the MCP must provide
any MCP-specific managed care
program information requested. The MCP must not attempt
to assess the
eligible individual’s health care needs. However, if the eligible
individual
inquires about continuing/transitioning health care services, MCPs shall
provide an assurance that all MCPs
must cover all medically
necessary Medicaid-covered health care services
and assist members
with transitioning their
health care services.
h. Pending
Member: If
a pending member (i.e., an eligible individual
subsequent to
plan selection
or assignment, but prior to
their membership effective date) contacts
the selected
MCP, the MCP must provide any membership
information
requested, including but not
limited to, assistance in determining
whether the current
medications require prior authorization. The
MCP must also ensure that any care
coordination (e.g., PCP selection, prescheduled
services and transition of
services) information provided by the
pending member is logged in the
MCP’s system and forwarded to the appropriate
MCP staff for processing as
required. MCPs may confirm any information
provided on the CCR at this
time. Such communication does not
constitute confirmation of
membership. MCPs are prohibited from initiating
contact with a pending
member. Upon receipt of the 834, the MCP may contact a pending
member to
confirm information provided on the
CCR or the 834, assist with care
coordination and transition of care, and
inquire if the pending member has
any membership questions.
i. Transition
of
Fee-For-Service Members
Providing
care coordination for
prescheduled health services and existing care treatment plans, is critical
for
members
transitioning from Medicaid
fee-for service (FFS) to managed care. Therefore, MCPs
must:
i. Allow
their new members that are
transitioning from Medicaid fee-for-service to receive services from
out-of-panel providers if the member or provider contacts the
MCP to
discuss the
scheduled health services
in advance of the service date and one
of the
following
applies:
a. The
member is in her third trimester of
pregnancy and has an established relationship
with an
obstetrician and/or delivery hospital;
b. The
member has been scheduled for an
inpatient/outpatient surgery and has been prior-approved
and/or
precertified pursuant to OAC rule 5101:3-2-40 (surgical
procedures
would also include follow- up
care as
appropriate);
c. The
member has appointments within
the initial month of MCP membership with specialty physicians that were
scheduled prior to the effective date of membership; or
d. The
member is receiving ongoing
chemotherapy or radiation treatment.
If
contacted by the member, the MCP must
contact the provider’s office as expeditiously as the situation warrants to
confirm that the service(s) meets the above criteria.
ii. Allow
their new members that are
transitioning from Medicaid fee-for-service
to continue receiving
home care services (i.e., nursing, aide,
and skilled therapy services) and
private duty nursing (PDN) services if the member or provider contacts the
MCP
to discuss the health services in advance of the service date. These
services must be covered from the date of the member or provider contact at
the
current service level, and with the current provider, whether a panel or
out-of-panel provider, until the MCP conducts a medical necessity review and
renders an authorization decision pursuant to OAC rule
5101:3-26-03.1. As soon as the MCP becomes aware of the member’s
current home care services, the MCP must initiate contact with the current
provider and member as applicable to ensure continuity of care and coordinate
a
transfer of services to a panel provider, if appropriate.
iii. Honor
any current fee-for-service prior
authorization to allow their new members that are transitioning from Medicaid
fee-for-service to receive services from the authorized provider, whether a
panel or out-of-panel provider, for the following approved
services:
a. an
organ, bone marrow, or hematapoietic
stem cell transplant pursuant to OAC rule 5101:3-2-07.1;
b. dental
services that have not yet been
received;
c. vision
services that have not yet been
received;
d. durable
medical equipment (DME) that has
not yet been received. Ongoing
DME services and supplies are to
be covered by the MCP as previously-authorized until the MCP conducts a medical
necessity review and renders an authorization decision pursuant to OAC rule
5101:3-26-03.1.
e. private
duty nursing (PDN)
services. PDN services must be covered at the previously-authorized
service level until the MCP conducts a medical necessity review and renders
an
authorization decision pursuant to OAC rule 5101:3-26-03.1.
As
soon as the MCP becomes aware of the
member’s current fee-for-service authorization approval, the MCP must initiate
contact with the authorized provider and member as applicable to ensure
continuity of care. The MCP must implement a plan to meet the
member’s immediate and ongoing medical needs and, with the exception of organ,
bone marrow, or hematapoietic stem cell transplants, coordinate the transfer
of
services to a panel provider, if appropriate.
When
an MCP medical necessity review
results in a decision to reduce, suspend, or terminate services previously
authorized by fee-for-service Medicaid, the MCP must notify the member of their
state hearing rights no less than 15 calendar days prior to the effective date
of the MCP’s proposed action, per rule 5101:3-26-08.4 of the Administrative
Code.
iv. Reimburse
out-of-panel providers that
agree to provide the transition services at 100% of the current Medicaid
fee-for-service provider rate for the service(s) identified in Section 29.i.
(i., ii., and iii.) of this appendix.
v. Document
the provision of transition of
services identified in Section 29.i. (i., ii., and iii.) of this appendix as
follows:
a. For
non-panel providers, notification to
the provider confirming the provider’s agreement/disagreement to provide the
service and accept 100% of the current Medicaid fee-for-service rate as
payment. If the provider agrees, the distribution of the MCP’s
materials as outlined
in
Appendix G.3.e.
b. Notification
to the member of the
non-panel provider’s agreement /disagreement to provide the
service. If the provider disagrees, notification to the member of the
MCP’s availability to assist with locating a provider as expeditiously as the
member’s health condition warrants.
c. For
panel providers, notification to the
provider and member confirming the MCP’s responsibility to cover the
service.
MCPs
must use the ODJFS-specified model
language for the provider and
member notices and maintain
documentation of all member and/or provider
contacts relating to such
services.
30. Health
Information System Requirements
The
ability to develop and maintain
information management systems capacity is crucial to
successful plan performance. ODJFS
therefore requires MCPs to demonstrate their ongoing capacity in this area
by
meeting several related specifications.
a. Health
Information
System
i. As
required by 42 CFR 438.242(a), each
MCP must maintain a health information system that collects, analyzes,
integrates, and reports data. The system must provide information on
areas including, but not limited to, utilization, grievances and appeals, and
MCP membership terminations for other than loss of Medicaid
eligibility.
ii. As
required by 42 CFR 438.242(b)(1),
each MCP must collect data on member and provider characteristics and on
services furnished to its members.
iii. As
required by 42 CFR 438.242(b)(2),
each MCP must ensure that data received from providers is accurate and complete
by verifying the accuracy and timeliness of reported data; screening the data
for completeness, logic, and consistency; and collecting service information
in
standardized formats to the extent feasible and appropriate.
iv. As
required by 42 CFR 438.242(b)(3),
each MCP must make all collected data available upon request by ODJFS or the
Center for Medicare and Medicaid Services (CMS).
v. Acceptance
testing of any data that is electronically submitted to ODJFS is
required:
a. Before
an MCP may submit production
files ODJFS-specified
formats;
and/or
b. Whenever
an MCP changes the method or
preparer of the electronic media; and/or
c. When
the ODJFS determines an MCP’s data
submissions have an unacceptably high error rate.
MCPs
that change or modify information
systems that are involved in producing any type of electronically submitted
files, either internally or by changing vendors, are required to submit to
ODJFS
for review and approval a
transition plan including the submission of test files in the ODJFS-specified
formats. Once an acceptable test file is submitted to ODJFS, as
determined solely by ODJFS, the MCP can return to submitting production
files. ODJFS will inform MCPs in writing when a test file is
acceptable. Once an MCP’s new or modified information
system is
operational,
that MCP will have up to
ninety (90) days to submit an acceptable test file and an acceptable production
file.
Submission
of test files can start
before the new or modified information system is
in
production. ODJFS reserves the right to verify any MCP’s capability
to report elements in the
minimum data set prior to executing the provider agreement for the next contract
period. Penalties for noncompliance with this requirement are specified in
Appendix N, Compliance
Assessment
System of the
Provider Agreement.
b. Electronic
Data Interchange and Claims Adjudication Requirements
Claims
Adjudication
The
MCP
must have the capacity to electronically accept and adjudicate all claims
to final status (payment or denial). Information on claims submission procedures
must
be provided to non-contracting
providers within thirty (30) days of a
request. MCPs must inform providers of its ability to
electronically process and adjudicate claims and the process for
submission. Such information must be initiated by the MCP and
not only in response to provider requests.
The
MCP must notify providers who have
submitted claims of claims status [paid, denied,
pended
(suspended)]
within one month of
receipt. Such notification may be in the form of a claim
payment/remittance advice produced on a routine monthly, or more frequent,
basis.
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;
Standard
code sets;
and
National
Provider Identifier
(NPI).
Each
EDI
transaction processed by the MCP shall be implemented in conformance with the appropriate version
of the
transaction implementation guide,
as specified by applicable
federal rule or regulation.
The
MCP
must have the capacity to accept the following transactions from the Ohio
Department of Job and Family services consistent with EDI processing
specifications in the transaction implementation guides and in conformance
with the 820 and 834 Transaction Companion Guides issued by
ODJFS:
ASC
X12 820 - Payroll Deducted and Other Group Premium Payment for Insurance
Products; and
ASC
X12
834 - Benefit Enrollment and Maintenance.
The
MCP shall comply with the HIPAA mandated EDI transaction standards and
code sets no later than the required compliance dates as set forth in the
federal regulations.
Documentation
of Compliance
with Mandated EDI Standards
The
capacity of the MCP and/or applicable trading partners and business
associates to electronically conduct claims processing and related
transactions in compliance with standards and effective dates mandated by
HIPAA must be demonstrated,
to the satisfaction of ODJFS, as outlined below.
Verification
of Compliance
with HIPAA (Health Insurance Portability and Accountability
Act of
1995)
MCPs
shall comply with the transaction
standards and code sets for sending and
receiving applicable transactions as
specified in 45 CFR Part 162 – Health Insurance
Reform: Standards
for Electronic Transactions (HIPAA regulations). In
addition the MCP must enter into the
appropriate trading partner agreement and implemented
standard code
sets. If the MCP has obtained third-party certification of
HIPAA compliance for any of the items
listed below, that certification may be submitted
in lieu of the MCP’s written
verification for the applicable item(s).
i. Trading
Partner
Agreements
ii. Code
Sets
iii. Transactions
a. Health
Care Claims or Equivalent Encounter Information (ASC
X12N 837 & NCPDP 5.1)
b. Eligibility
for a Health Plan (ASC X12N 270/271)
c. Referral
Certification and Authorization (ASC X12N 278)
d. Health
Care Claim Status (ASC X12N 276/277)
e. Enrollment
and Disenrollment in a Health Plan (ASC X12N 834)
f. Health
Care Payment and Remittance Advice (ASC X12N 835)
g. Health
Plan Premium Payments (ASC X12N 820)
h. Coordination
of Benefits
Trading
Partner Agreement
with ODJFS
MCPs
must
complete and submit an EDI trading partner agreement in a format specified
by the ODJFS. Submission of the copy of the trading partner agreement
prior to entering into this
Agreement may be waived at the discretion of ODJFS; if submission prior
to entering into this
Agreement is waived, the trading partner agreement must be
submitted at a subsequent date determined by ODJFS.
Noncompliance
with the EDI and claims adjudication requirements will result in the
imposition of penalties, as outlined in Appendix N, Compliance Assessment
System, of the
Provider Agreement.
c. Encounter
Data Submission
Requirements
General
Requirements
Each
MCP
must collect data on services furnished to members through an encounter data
system and must report encounter data to the ODJFS. MCPs are required to submit
this data electronically to ODJFS on a monthly basis in the following
standard formats:
· Institutional
Claims - UB92 flat file
· Noninstitutional
Claims - National standard format
· Prescription
Drug Claims - NCPDP
ODJFS
relies heavily on encounter data for monitoring MCP performance. The ODJFS
uses
encounter data to measure clinical performance, conduct access and utilization
reviews, reimburse MCPs for newborn deliveries and aid in setting MCP capitation
rates. For these reasons, it is important that
encounter
data is timely, accurate, and complete. Data quality, performance measures
and
standards are described in the Agreement.
An
encounter represents all of the services, including medical supplies and
medications, provided to a member of the MCP by a particular provider,
regardless of the payment arrangement between the MCP and the provider. For
example, if a member had an emergency department visit and was examined by
a
physician,
this would constitute two encounters, one related to the hospital provider
and
one related to the physician provider. However, for the purposes of calculating
a utilization measure, this would be counted as a single emergency department
visit. If a member visits their PCP and the PCP examines the member
and has laboratory procedures done within the office, then this is one encounter
between the member and their PCP.
If
the
PCP sends the member to a lab to have procedures performed, then this is two
encounters; one with the PCP and another with the lab. For pharmacy
encounters, each prescription filled is a separate encounter.
Encounters
include services paid for retrospectively through fee-for-service payment
arrangements, and prospectively through capitated arrangements. Only encounters
with services (line items) that are paid by the MCP, fully or in part, and
for
which no further payment is anticipated, are acceptable encounter data
submissions, except for immunization services. Immunization services submitted
to the MCP must be submitted to ODJFS if these services were paid for by another
entity (e.g., free vaccine program).
All
other
services that are unpaid or paid in part and for which the MCP anticipates
further payment (e.g., unpaid services rendered during a delivery of a newborn)
may not be submitted to ODJFS until they are paid. Penalties for noncompliance
with this requirement are specified in Appendix N, Compliance Assessment System of
the Agreement.
Acceptance
Testing
The
MCP
must have the capability to report all elements in the Minimum Data Set as
set
forth in the ODJFS Encounter Data Specifications and must submit a test file
in
the ODJFS-specified medium in the required formats prior to contracting or
prior
to an information systems replacement or update.
Acceptance
testing of encounter data is
required as specified in Section 29(a)(v) of this Appendix.
Encounter
Data File
Submission Procedures
A
certification letter must accompany the submission of an encounter data file
in
the ODJFS-specified medium. The certification letter must be signed by the
MCP’s
Chief Executive Officer (CEO), Chief Financial Officer (CFO), or an individual
who has delegated authority to sign for, and who reports directly to, the MCP’s
CEO or CFO.
Timing
of Encounter Data
Submissions
ODJFS
recommends that MCPs submit encounters no more than thirty-five (35) days
after
the end of the month in which they were paid. For example, claims paid in
January are due March 5. ODJFS recommends that MCPs submit
files in the ODJFS-specified medium by the 5th of each month. This will
help to ensure that the encounters are included in the ODJFS master file in
the
same month in which they were submitted.
d. Information
Systems
Review
ODJFS
or
its designee may review the information system capabilities of each MCP, before
ODJFS enters into a provider agreement with a new MCP, when a participating
MCP
undergoes a major information system upgrade or change, when there is
identification of significant information system problems, or at ODJFS’
discretion. Each MCP must participate in the review. The review will assess
the
extent to which MCPs are capable of maintaining a health information system
including producing valid encounter data, performance measures, and other data
necessary to support quality assessment and improvement, as well as managing
the
care delivered to its members.
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.
31.
Delivery
Payments
MCPs
will be reimbursed for paid
deliveries that are identified in the submitted encounters using the
methodology outlined in the ODJFS Methods for Reimbursing
for
Deliveries (as specified in Appendix L). The delivery payment represents
the facility and professional service costs associated with the delivery event
and postpartum care that is rendered in the hospital immediately following
the
delivery event; no prenatal or neonatal experience is included in the delivery
payment.
If
a
delivery occurred, but the MCP did not reimburse providers for any costs
associated with the delivery, then the MCP shall not submit the delivery
encounter to ODJFS and is not entitled to receive payment for the delivery.
MCPs
are required to submit all delivery encounters to ODJFS no later than one year
after the date of the delivery. Delivery encounters which are submitted after
this time will be denied payment. MCPs will receive notice of the
payment denial on the remittance advice.
If
an MCP
is denied payment through ODJFS’ automated payment system because the delivery
encounter was not submitted within a year of the delivery date, then it will
be
necessary for the MCP to contact BMHC staff to receive
payment. Payment will be made for the delivery, at the discretion
of ODJFS
if a payment had not been made previously for the same
delivery.
To
capture deliveries outside of institutions (e.g., hospitals) and deliveries
in
hospitals without an accompanying physician encounter, both the institutional
encounters (UB-92) and the noninstitutional encounters (NSF) are searched for
deliveries.
If
a
physician and a hospital encounter is found for the same delivery, only one
payment will be made. The same is true for multiple births; if multiple delivery
encounters are submitted, only one payment will be made. The method for
reimbursing for deliveries includes the delivery of stillborns where the MCP
incurred costs related to the delivery.
Rejections
If
a
delivery encounter is not submitted according to ODJFS specifications, it will
be rejected and MCPs will receive this information on the exception report
(or
error report) that accompanies every file in the ODJFS-specified format.
Tracking, correcting and resubmitting all rejected encounters is the
responsibility of the MCP and is required by ODJFS.
Timing
of Delivery
Payments
MCPs
will
be paid monthly for deliveries. For example, payment for a delivery
encounter submitted with the required encounter data submission in March, will be
reimbursed in March. The delivery payment will cover any encounters
submitted with the monthly encounter data submission regardless of the date
of
the encounter, but will not cover encounters that occurred over one year
ago.
This
payment will be a part of the weekly update (adjustment payment) that is in
place currently. The third weekly update of the month will include
the delivery payment. The remittance advice is in the same format as
the capitation remittance advice.
Updating
and Deleting
Delivery Encounters
The
process for updating and deleting delivery encounters is handled differently
from all other encounters. See the ODJFS Encounter Data
Specifications for detailed instructions on updating and deleting
delivery encounters.
The
process for deleting delivery encounters can be found on page 35 of the UB-92
technical specifications (record/field 20-7) and page III-47 of the NSF
technical specifications (record/field CA0-31.0a).
Auditing
of Delivery
Payments
A
delivery payment audit will be conducted periodically. If medical records do
not
substantiate that a delivery occurred related to the payment that was made,
then
ODJFS will recoup the delivery payment from the MCP. Also, if it is determined
that the encounter which triggered the delivery payment was not a paid
encounter, then ODJFS will recoup the delivery payment.
32. If
the MCP will be using the Internet
functions that will allow approved users to access member information (e.g.,
eligibility verification), the MCP must receive prior approval from ODJFS that
verifies that the proper safeguards, firewalls, etc., are in place to
protect member
data.
33. MCPs
must receive prior written approval
from ODJFS before adding any information to their website that would require
ODJFS prior approval in hard copy form (e.g., provider listings, member handbook
information).
34. Pursuant
to 42 CFR 438.106(b), the MCP
acknowledges that it is prohibited from holding a member liable for services
provided to the member in the event that the ODJFS fails to make payment to
the
MCP.
35. In
the event of an insolvency
of an MCP, the
MCP, as directed by ODJFS, must cover the continued provision of services to
members until the end of the month in which insolvency has occurred, as well
as
the continued provision of inpatient services until the date of discharge for
a member who is
institutionalized when insolvency occurs.
36. Franchise
Fee Assessment Requirements
a. Each
MCP is required to pay
a franchise permit fee to ODJFS for each calendar quarter as required by ORC Section
5111.176. The current fee
to be paid is an amount
equal to 4½ percent of the
managed care premiums, minus Medicare
premiums
that the MCP received from any
payer in the quarter to which the fee applies. Any
premiums the MCP
returned or refunded to members or premium
payers during that quarter are
excluded from the fee.
b. The
franchise fee is due to ODJFS in the
ODJFS-specified format on or before the 30th
day following the end of the
calendar quarter to which the fee applies.
c. At
the time the fee is submitted, the MCP must also submit to ODJFS a completed
form and any supporting documentation pursuant to ODJFS
specifications.
d. Penalties
for noncompliance with this requirement are specified in Appendix N, Compliance Assessment System of
the Provider Agreement and in ORC Section 5111.176.
37. Information
Required for MCP Websites
a.
On-line
ProviderDirectory–
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 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 contracting 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 37(a) of this appendix;
(5) the MCP’s current PDL list, including an explanation of the list, which
drugs require PA, and the PA process; (6) the MCP’s current list
of drugs covered only with PA, the PA process, and the MCP’s policy
for covering generic for brand-name drugs. MCPs must ensure
that all provider materials designated specifically for CFC and/or
ABD consumers (i.e. the MCP’s provider manual) are clearly
labeled as such; and (7) information regarding the availability of
expedited prior authorization requests, as well as the information that is
required from that provider in order to substantiate an expedited prior
authorization
request.
ODJFS
may
require MCPs to include additional information on the provider website, as
needed.
38. MCPs
must provide members with a printed
version of their PDL and PA lists, upon request.
39. MCPs
must not use, or propose to use,
any offshore programming or call center services in
fulfilling the program
requirements.
40. Coordination
of
Benefits
When
a
claim is denied due to third party liability, the managed care plan must timely
share appropriate and available information regarding the third party to
the provider for the purposes of coordination of benefits, including, but
not limited to third party liability information received from the
Ohio Department of Job and Family Services.
APPENDIX
D
ODJFS
RESPONSIBILITIES
CFC
ELIGIBLE
POPULATION
The
following are ODJFS responsibilities or clarifications that are not otherwise
specifically stated in OAC Chapter 5101: 3-26 or elsewhere in the ODJFS-MCP
provider agreement.
General
Provisions
1. ODJFS
will provide MCPs with an opportunity to review and comment on the rate-setting
time line and proposed rates, and proposed changes to the OAC program rules
or
the provider agreement.
2. ODJFS
will notify MCPs of managed
care program policy and procedural changes and, whenever possible, offer
sufficient time for comment and implementation.
3. ODJFS
will provide regular opportunities for MCPs to receive program updates and
discuss program
issues with ODJFS staff.
4. ODJFS
will provide technical assistance sessions where MCP attendance and
participation is required. ODJFS will also provide optional technical assistance
sessions to MCPs, individually or as a group.
5. ODJFS
will provide MCPs with an annual MCP Calendar of Submissions outlining major
submissions and due dates.
6. ODJFS
will identify contact staff, including the Contract Administrator, selected
for
each MCP.
7. ODJFS
will recalculate the minimum
provider panel specifications if ODJFS determines that significant
changes have occurred in the availability of specific provider types and the
number and composition of the eligible population.
8. ODJFS
will recalculate the geographic
accessibility standards, using the geographic information systems (GIS)
software, if ODJFS determines that significant changes have occurred
in the availability of specific provider types and the number and composition
of
the eligible population and/or the ODJFS provider panel
specifications.
9. On
a monthly basis, ODJFS will provide
MCPs with an electronic file containing their MCP’s provider panel as reflected
in the ODJFS Provider Verification System (PVS) database, or other
designated system.
10. On
a monthly basis, ODJFS will provide
MCPs with an electronic Master Provider File containing all the Ohio Medicaid
fee-for-service providers, which includes their Medicaid Provider Number, as well
as all
providers who have been assigned a provider reporting number for current encounter
data
purposes.
11. It
is the intent of ODJFS to utilize
electronic commerce for many processes and procedures
that are now limited by HIPAA
privacy concerns to FAX, telephone, or hardcopy. The
use of TLS will
mean that private health information (PHI) and the identification of consumers
as Medicaid recipients can be shared between ODJFS and the contracting MCPs
via
e-mail such as reports, copies of letters, forms, hospital claims, discharge
records, general discussions of member-specific information,
etc. ODJFS may revise data/information exchange policies and
procedures for many functions that are now restricted to FAX, telephone,
and
hard copy, including, but not limited to, monthly membership and premium
payment reconciliation requests,
newborn reporting, Just Cause disenrollment requests, information requests
etc.
(as specified in Appendix C).
12. ODJFS
will immediately report to Center
for Medicare and Medicaid Services (CMS) any breach
in privacy or security that
compromises protected health information (PHI), when reported
by the MCP or ODJFS
staff.
13. Service
Area
Designation
Membership
in a service area is
mandatory unless
ODJFS approves membership in the
service area for consumer
initiated selections only.
It is ODJFS’current
intention
to implement
a mandatory
managed
care program in
service areas wherever choice and
capacity allow and the criteria in 42 CFR 438.50(a) are met.
14. Consumer
information
a. ODJFS
or its delegated entity will
provide membership notices, informational materials, and instructional
materials relating to members and eligible individuals in a manner and format
that may be easily understood. At least annually, ODJFS or designee will provide
MCP eligible individuals, including current MCP members, with a Consumer Guide.
The Consumer Guide will describe the managed care program and include
information on the MCP options in the service area and
other information regarding the managed care program as specified
in 42 CFR 438.10.
b. ODJFS
will notify members or ask MCPs to notify members about significant changes
affecting contractual requirements, member services or access to
providers.
c. If
an MCP elects not to provide, reimburse, or cover a counseling service or
referral service due to an objection to the service on moral or religious
grounds, ODJFS will provide coverage and reimbursement for these services for
the MCP’s members. ODJFS will provide information on what services
the MCP will not cover and how and where the MCP’s members may obtain these
services in the applicable Consumer Guides.
15. Membership
Selection and Premium Payment
a. The
managed
care enrollment center
(MCEC): The
ODJFS-contracted MCEC
will
provide unbiased
education, selection services, and community outreach for the Medicaid
managed care program. The
MCEC
shall
operate a statewide toll-free
telephone center to assist eligible individuals in selecting an MCP or choosing
a health care delivery option.
The
MCEC
shalldistribute the
most current Consumer Guide that
includes the managed care
program
information
as specified in 42 CFR 438.10, as well as ODJFS prior-approved MCP materials,
such as solicitation brochures and provider directories, to consumers who
request additional materials.
b. Auto-Assignment
Limitations – In order to
ensure market and program stability, ODJFS may limit
an MCP’s auto-assignments if they
meet any of the following enrollment thresholds:
· 40%
of statewide
Covered Families and
Children (CFC) eligible population;
and/or
· 60%
of the CFC eligibles in any
region with two
MCPs;
and/or
· 40%
of the CFC eligibles in any
region with three
MCPs.
Once
an MCP meets one of these
enrollment thresholds, the MCP will only be permitted to receive the additional
new membership (in the region or statewide, as applicable) through: (1)
consumer-initiated enrollment; and (2) auto-assignments which are based on
previous enrollment in that MCP or an historical provider relationship with
a
provider who is not on the panel of any other MCP in that region. In the
event that an MCP in
a
region meets one or more of these enrollment thresholds, ODJFS, in their sole
discretion, may not impose the auto-assignment limitation and auto-assign
members to the MCPs in that region as ODJFS deems appropriate.
c. Consumer
Contact
Record (CCR): ODJFS or their designated
entity shall forward CCRs to MCPs on no less than a weekly basis. The
CCRs are a record of
each consumer-initiated MCP enrollment, change, or termination, and each MCEC
initiated MCP assignment processed through the MCEC. The CCR contains information
that is not included on the monthly member roster.
d. Monthly
member roster (MR): ODJFS
verifies managed care plan enrollment on a monthly
basis via the monthly membership
roster. ODJFS or its designated entityprovides
a full member roster (F) and a
change roster (C) via HIPAA 834 compliant transactions.
e. Monthly
Premiums and Delivery Payments: ODJFS will remit payment
to
the MCPs via an electronic funds transfer (EFT), or at the discretion of ODJFS,
by paper warrant.
f. Remittance
Advice: ODJFS
will confirm all premium payments and delivery payments
paid to
the MCP during the month via a
monthly remittance advice (RA), which is sent to the MCP the week following
state cut-off. ODJFS or its designated
entity provides a record of each payment via HIPAA 820 compliant
transactions.
g. MCP
Reconciliation Assistance: ODJFS will work with
an
MCP-designated contact(s) to resolve the MCP’s member and newborn
eligibility inquiries,
premium
and
delivery payment inquiries/discrepancies
and to review/approve hospital
deferment requests.
16. ODJFS
will make available a website
which includes current program information.
17. ODJFS
will regularly provide information
to MCPs regarding different aspects of MCP performance including,
but not limited
to, information on MCP-specific and statewide external
quality
review organization surveys,
focused clinical quality of care studies, consumer satisfaction
surveys and
provider profiles.
18. ODJFS
will periodically review a random
sample of online and printed directories to assess whether MCP information
is both accessible and
updated.
19. Communications
a. ODJFS/BMHC:
The Bureau of Managed Health Care
(BMHC) is responsible for the oversight of the
MCPs’ provider
agreements with ODJFS. Within
the BMHC, a specific Contract
Administrator
(CA) has been assigned to
each MCP. Unless expressly directed otherwise, MCPs shall
first contact
their designated CA for questions/assistance
related to Medicaid
and/or the MCP’s program requirements
/responsibilities.
If their CA is not available and the MCP needs immediate
assistance,
MCP staff should request to
speak to a supervisor within the Contract Administration Section. MCPs should take all
necessary and appropriate steps to ensure
all MCP staff are aware of, and
follow, this communication process.
b. ODJFS
contracting-entities: ODJFS-contracting entities
should never be contacted by the MCPs
unless the MCPs
have been specifically instructed to contact
the ODJFS contracting entity
directly.
c. MCP
delegated entities: In that
MCPs are ultimately responsible for meeting program requirements,
the BMHC will not
discuss MCP issues with the MCPs’ delegated entities unless
the applicable MCP is also
participating in the discussion. MCP delegated entities, with the
applicable MCP
participating, should only communicate with the specific CA assigned to
that
MCP.
APPENDIX
E
RATE
METHODOLOGY
CFC
ELIGIBLE POPULATION
|
Chase
Center/Circle
|
|
|
000
Xxxxxxxx Xxxxxx
|
|
|
Xxxxx
000
|
|
|
Xxxxxxxxxxxx,
XX 00000-0000
|
|
|
XXX
|
|
|
Tel x0
000 000 0000
Fax x0
000 000 0000
|
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xxxxxxxx.xxx
|
FINAL
and CONFIDENTIAL
December
12, 2007
Xx.
Xxx
Xxxxxx, Ph.D., Bureau Chief
Bureau
of
Managed Health Care
Ohio
Department of Job and Family Services
Lazarus
Building
00
Xxxx
Xxxx Xx., Xxxxx 000
Xxxxxxxx,
XX 00000
|
|
RE:CY
2008 RATE
DEVELOPMENT METHODOLOGY - COVERED FAMILIES AND
CHILDREN
|
Dear
Xxx:
Xxxxxxxx,
Inc. (Milliman) was retained by the State of Ohio, Department of Job
and Family
Services (ODJFS) to develop the calendar year 2008 actuarially sound
capitation
rates for the Covered Families and Children (CFC) Risk Based Managed
Care (RBMC)
program. This letter provides the documentation for the actuarially
sound
capitation rates.
LIMITATIONS
The
information contained in this letter, including the enclosures, has
been
prepared for the State of Ohio. Department of Job and Family Services
and their
consultants and advisors. It is our understanding that the information
contained
in this letter may be utilized in a public document. To the extent
that the
information contained in this letter is provided to third parties,
the letter
should be distributed in its entirety. Any user of the data must possess
a
certain level of expertise in actuarial science and healthcare modeling
so as
not to misinterpret the data presented.
Milliman
makes no representations or warranties regarding the contents of this
letter to
third parties. Likewise, third parties are instructed that they are
to place no
reliance upon this letter prepared for ODJFS by Milliman that would
result in
the creation of any duty or liability under any theory of law by Milliman
or its
employees to third parties. Other parties receiving this letter must
rely upon
their own experts in drawing conclusions about the capitation rates,
assumptions, and trends.
The
information contained in this letter was prepared as documentation
of the
actuarially sound capitation rates for Medicaid managed care organization
health
plans in the State of Ohio. The information may not be appropriate
for any other
purpose.
FINAL
and CONFIDENTIAL
SUMMARY
OF
METHODOLOGY
ODJFS
contracted with Milliman to
develop the CY 2008 CFC actuarially sound capitation rates. The actuarially
sound capitation rates were developed from historical claims and enrollment
data
for the fee for service (FFS) and managed care populations. The composite
of the
FFS and managed care populations are considered a comparable population
to the
population enrolled with the health plans. The historical experience
was
converted to a per member per month (PMPM) basis and stratified by
region, age /
gender rating group, and category of service. The historical experience
was
trended forward using projected trend rates to a center point of July
1, 2008
for the 2008 calendar year contract period. The historical experience
was
adjusted to reflect adjustments to the utilization and average cost
per service
that would be expected in a managed care environment.
Appendix
1 contains a chart outlining the methodology that was used to develop
the CY
2008 capitation rates for the CFC populations.
Appendix
2 contains the actuarial certification regarding the actuarial soundness
of the
capitation rates.
Appendix
3 contains the CY 2008 capitation rates by rate group and region, including
the
segmentation of the administrative cost allowance between guaranteed
and at-risk
components.
DETAILS
OF
METHODOLOGY
I. COVERED
POPULATION
The
CY
2008 CFC capitation rates have been developed using historical experience
for
the population eligible for managed care enrollment based on age, gender,
and
program assignment. The program assignments shown in Table 1 were included
in
the development of the CY 2008 CFC capitation rates.
FINAL
and CONFIDENTIAL
Table
1
STATE
OF OHIO
DEPARTMENT
OF JOB AND FAMILY SERVICES
Summary
of Managed Care Eligible Population
|
Program
Assignment
|
Description
|
|
PREG
|
Healthy
Start Pregnant Women
|
|
PREGE
|
Healthy
Start Pregnant Women Expansion
|
|
PREGEX
|
Healthy
Start Expedited Pregnant Women
|
|
RPREGEX
|
Healthy
Start Expedited Pregnant Women RMF
|
|
HSC
|
Healthy
Start Children
|
|
HSCE
|
Healthy
Start Expansion <=150%
|
|
RHSC
|
Healthy
Start Children RMF
|
|
CHIP1
|
Healthy
Start CHIP 1 <=150%
|
|
CHIP2
|
Healthy
Start CHIP 0 000-000%
|
|
RCHIP1
|
Healthy
Start CHIP 1 <=150% RMF
|
|
RCHIP2
|
Healthy
Start CHIP 0 000-000% RMF
|
|
RCHSUP
|
Healthy
Family Child Support Extended RMF
|
|
CHSUP
|
Healthy
Family Child Support Extended
|
|
OWFFAM
|
Ohio
Works First Families - Cash
|
|
ROWFFAM
|
Ohio
Works First Families - Cash RMF
|
|
LIFAM
|
Low
Income Families
|
|
RLIFAM
|
Low
Income Families RMF
|
|
HYFAM
|
Healthy
Families (Expansion 7/00 Reduced 1/06)
|
|
TRANS
|
Transitional
|
|
LIIND
|
Low
Income Individuals
|
|
RLIIND
|
Low
Income Individuals RMF
|
Milliman
extracted the eligible population information from historical data.
The eligible
population includes the Healthy Start and Healthy Families populations.
If a
member was ineligible during a month, all claims and eligibility for
the month
were excluded from the actuarial models.
II.
CATEGORY OF SERVICE DEFINITIONS
The
categories of service listed in Table 2 describe the actuarial model
service
groupings. The units associated with the categories have been indicated.
Further, the primary method of classifying the claims has been
provided.
FINAL
and CONFIDENTIAL
Table
2
STATE
OF OHIO
DEPARTMENT
OF JOB AND FAMILY SERVICES
Categories
of Service
|
Categories
of ServiceType
of Service
|
Service
Category
|
Utilization
Units
|
Classification
Basis
|
|
Inpatient
Hospital
|
Medical/Surgical
|
Admits/Days
|
COS,
DRG
|
|
MH/SA
|
Admits/Days
|
||
|
Well
Newborn
|
Admits/Days
|
||
|
Maternity
Non-Deliveries
|
Admits/Days
|
||
|
Nursing
Facility
|
Admits/Days
|
||
|
Other
Inpatient
|
Admits/Days
|
||
|
Outpatient
Hospital
|
Emergency
Room
|
Claims
|
COS,
Revenue Code
|
|
Surgery/ASC
|
Services
|
||
|
Cardiovascular
|
Services
|
||
|
PT/ST/OT
|
Services
|
||
|
Clinic
|
Services
|
||
|
Other
|
Services
|
||
|
Professional
|
Inpatient/Outpatient
Surgery
|
Services
|
COS,
Provider Type, Procedure, Modifier
|
|
Anesthesia
|
Line
Items
|
||
|
Obstetrics
|
Services
|
||
|
Office
Visits/Consults
|
Services
|
||
|
Hospital
Inpatient Visits
|
Services
|
||
|
Periodic
Exams
|
|||
|
Emergency
Room Visits
|
Services
|
||
|
Immunization
& Injections
|
Services
|
||
|
Physical
Medicine
|
Services
|
||
|
Miscellaneous
Services
|
Line
Items, Services
|
||
|
Rad/Path/Lab
|
Radiology
|
Services
|
COS,
Revenue Code, Provider Type. Procedure
|
|
Pathology/Laboratory
|
Services
|
||
|
Ancillaries
|
MH/SA
|
Services
|
COS,
Provider Type, Procedure
|
|
FQHC/RHF/OP
Health Facility
|
Services
|
COS
|
|
|
Pharmacy
|
Line
Items
|
COS
|
|
|
Dental
|
Services
|
COS
|
|
|
Vision
|
Services
|
COS,
Provider Type, Procedure
|
|
|
Home
Health
|
Line
Items
|
COS
|
|
|
Non-Emergent
Transportation
|
Line
Items
|
COS
|
|
|
Ambulance
|
Line
Items
|
COS,
Procedure Code
|
|
|
Supplies
and DME
|
Line
Items
|
COS,
Provider Type, Procedure
|
|
|
Miscellaneous
Services
|
Line
Items
|
COS
|
FINAL
and CONFIDENTIAL
III.
RATE GROUPS
The
CY
2008 CFC capitation rates are segmented by region and rate group. Table
3
contains the rate groups
used for the CFC population. The non-delivery rate groups vary by
age, gender, and program assignment. The delivery rate group is determined
based on the
CFC Program Delivery Payment Reporting Procedures for ODJFS
Managed Care Plans, effective September 7, 2005.
Table
3
STATE
OF OHIO
DEPARTMENT
OF JOB AND FAMILY SERVICES
Rate
Groups
|
Age/Gender
Groups
|
Benefit
Type
|
Population
|
|
M/F
- <1
|
Non
- Delivery
|
Healthy
Start / Healthy Families
|
|
M/F
- 1
|
Non
- Delivery
|
Healthy
Start / Healthy Families
|
|
M/F
- 2 to 13
|
Non
- Delivery
|
Healthy
Start / Healthy Families
|
|
M-
14 to 18
|
Non
- Delivery
|
Healthy
Start / Healthy Families
|
|
F-
14 to 18
|
Non
– Delivery
|
Healthy
Start / Healthy Families
|
|
M
-
19 to 44
|
Non
– Delivery
|
Healthy
Families
|
|
F
-
19 to 44
|
Non
– Delivery
|
Healthy
Families
|
|
M/F
- 45 to 64
|
Non
– Delivery
|
Healthy
Families
|
|
F
-
19 to 64
|
Non
– Delivery
|
Healthy
Start
|
|
F
-
All Ages
|
Delivery
|
Healthy
Start / Healthy Families
|
IV.
DEVELOPMENT OF CY 2006 ADJUSTED FFS DATA
a.
Historical Data Summaries
The
CY
2008 CFC capitation rates were developed, in part, using FFS claims
for two
state fiscal year (SFY) periods:
|
§
|
SFY
2005 (Incurred during the 12
months ending June 30, 2005 paid through May 31,
2007).
|
|
§
|
SFY
2006 (Incurred during the 12
months ending June 30, 2006 paid through May 31,
2007).
|
The
claims data was provided by ODJFS from the data warehouse. The
experience was stratified into geographic region based on the member's
county of
residence.
The
reimbursement amounts captured on the FFS actuarial models reflect
the amount
paid by ODJFS, net of third party liability recoveries and member co-payment
amounts. The reimbursement amounts have not been adjusted for payments
made
outside the claims processing system. These amounts are discussed later
in the
documentation.
FINAL
and CONFIDENTIAL
The
FFS
data summaries represent historical experience for those services that
re
included in the capitation payment. Services that are not covered
under the capitation payment have been excluded from the
experience. The excluded services were identified by the ODJFS
defined category of service field, as shown in Table 4
Table
4
STATE
OF OHIO
DEPARTMENT
OF JOB AND FAMILY SERVICES
Claims
Excluded from the FFS Data Summaries
|
COS
Field Value
|
Description
|
|
08
|
PACE
|
|
13
|
ICF/MR
Public
|
|
18
|
ICF/MR
Private
|
|
35
|
Core
Services
|
|
36
|
Home
Care Facilitator Services
|
|
41
|
Mental
Health Services
|
|
42
|
Mental
Retardation
|
|
46
|
Model
50 Waiver Services
|
|
58
|
HMO
Services
|
|
59
|
Mental
Health Support Services
|
|
60
|
Mental
Retardation Support Services
|
|
63
|
PPO
Services
|
|
64
|
Passport
|
|
66
|
Passport
Waiver III
|
|
67
|
OBRA
MR/DD Waiver
|
|
80
|
Alcohol
and Drug Abuse
|
|
82
|
Department
of Education
|
|
84
|
ODADAS
|
b.
Completion Factors
Milliman
utilized 24 months of claims experience for the FFS population that
was incurred
through June 2006 and paid through May 2007 (eleven months of
run-out). Milliman applied claim completion factors to the twelve
months of SFY 2005 and twelve months of SFY 2006 claims
experience. The claim completion factors were developed by service
category based on claims experience for the FFS population incurred
and paid
through May 2007.
c.
Historical Program Adjustments
The
base
FFS data summaries represent a historical time period from which projections
were developed. Certain
program changes have occurred during and subsequent to the base data
time
period. The program adjustments were estimated and applied to the
portion of the base experience data prior to the program
FINAL
and CONFIDENTIAL
change
effective date. For example, a program change implemented on January
1, 2006 will only be reflected in the second half of SFY 2006. As
such, an adjustment was applied to all of SFY 2005 and half of SFY
2006 to
include the program change in all periods of the base experience
data.
ODJFS
has
provided a listing of all program changes impacting the base experience
data. Table 5 summarizes the historical program changes that were
reflected in the development of the CY 2008 capitation rates.
Table
5
STATE
OF OHIO
DEPARTMENT
OF JOB AND FAMILY SERVICES
Historical
Program Adjustments – FFS
|
Program
Adjustment
|
Effective
Date
|
Service
Category(s)
|
Rate
Group
|
|
Inpatient
Market Basket Increase
|
1/1/2005
|
Inpatient
Hospital
|
All
Rate Groups (incl Delivery)
|
|
Dental
Fee Schedule Reduction
|
1/1/2006
|
Dental
|
All
Rate Groups (incl. Delivery)
|
|
Inpatient
Recalibration and Outlier Policy
|
1/1/2006
|
Inpatient
|
All
Rate Groups (incl. Delivery)
|
|
Pharmacy
Co-pay
($2
Per Brand Prescription)
|
1/1/2006
|
Pharmacy
|
HF
M -19 to 44
|
|
HF
F-19 to 44
|
|||
|
HF
M/F- 45 to 64
|
|||
|
Dental
Co-pay
($3
Per Date of Service)
|
1/1/2006
|
Dental
|
HF
M -19 to 44
|
|
HFF-19
to 44
|
|||
|
HF
M/F-45 to 64
|
|||
|
HSTF-19
to 64
|
|||
|
Vision
Exam Co-Pay ($2 Per Exam)
|
1/1/2006
|
Vision
/ Optometric
|
HF
M-19 to 44
|
|
HF
F-19 to 44
|
|||
|
HF
M/F-45 to 64
|
|||
|
HSTF-19
to 64
|
|||
|
Vision
Hardware Co-Pay ($1 Per Item)
|
1/1/2006
|
Vision
/ Optometric
|
HFM-19
to 44
|
|
HFF-19
to 44
|
|||
|
HF
M/F-45 to 64
|
|||
|
HSTF-19
to 64
|
|||
|
ER
Co-Pay
($3
Per Non-Emergency Visit)
|
1/1/2006
|
Emergency
Room
|
HF
M -I9 to 44
|
|
HF
F-19 to 44
|
|||
|
HF
M/F-45 to 64
|
|||
|
HSTF-19
to 64
|
|||
|
Dental
Benefit Reduction
|
1/1/2006
|
Dental
|
HFM-19
to 44
|
|
HFF-19
to 44
|
|||
|
HF
M/F- 45 to 64
|
|||
|
HST
F – 19 to 64
|
|||
|
HSTF-19
to 64
|
FINAL
and CONFIDENTIAL
d.
Third-Party Liability
The
FFS
experience was calculated using the net paid claim data from the FFS
data
provided by ODJFS. The paid amounts reflect a reduction for the amounts
paid by
third party carriers. Additionally, Milliman reduced the FFS
experience to reflect third party liability recoveries following payment
of
claims. The reduction represents the average third party liability
recovery rate
received by the state under the “pay-and-chase” recovery program for each base
year. It is expected that the health plans will collect the third party
liability recoveries for managed care enrolled individuals.
e.
Fraud and Abuse
The
FFS
experience was calculated using the net paid claim data from the FFS
data
provided by ODJFS. Milliman reduced the FFS experience to reflect fraud
and
abuse recoveries following payment of claims. The reduction represents
the
average fraud and abuse recovery rate received by the state for each
base year.
It is expected that the health plans will pursue fraud and abuse detection
activities for managed care enrolled individuals.
x.
Xxxxx Adjustments
The
FFS
experience was calculated using the net paid claim data from the FFS
data
provided by ODJFS. Milliman adjusted the FFS experience to reflect
payments/refunds occurring outside of normal claim adjudication. Milliman
received a "gross adjustments" file from ODJFS containing the additional
adjustments.
g.
Non-State Plan Services
CMS
requires removal of non-state plan services from
rate-setting. The FFS data does not contain any such services.
As such, no adjustment was applied to the base FFS data for non-state
plan
services.
h.
Historical Selection Adjustments
Milliman
applied a historical selection adjustment to the base FFS data to reflect
that
the base period contains a combination of FFS and managed care enrollment.
The
historical selection adjustment is intended to normalize the FFS experience
to
the morbidity level of the entire managed care eligible population
and is
similar in methodology to previous years.
FINAL
and CONFIDENTIAL
i.
Trends/Inflation to CY 2006
Milliman
developed trend rates to progress the historical experience from SFY
2005 and
SFY 2006 forward to a common center point (CY 2006). Milliman
reviewed historical experience and performed linear regression on the
experience
data to develop trend rates by category of service for both utilization
and unit
cost. Additionally, Milliman reviewed the resulting trends with
internal data sources to develop the trends used in the development
of the CY
2008 CFC capitation rates.
The
base
experience data was normalized for artificial program adjustments prior
to the
trend rate development. Milliman did not consider items such as fee
schedule
changes or benefit modifications as standard components of trend. Removing
the
impact of historical changes allows for transparent inclusion of prospective
program changes for future periods.
j.
Blend Base Experience Years
Each
of
the base experience years was trended to CY 2006. At this point, each
base year
was on a comparable basis and could be aggregated. The weighting was
developed
with the intention of placing more credibility on the most recent experience
and
is consistent with the CY 2007 methodology. Specifically, SFY 2005
received a
weight of 30% and SFY 2006 received a weight of 70%.
k.
Managed Care Adjustments
Utilization
and cost per service adjustments were developed for each rate group,
service
category, and region.
Utilization
Milliman
adjusted the FFS utilization and cost per service to reflect the managed
care
environment. After reviewing utilization benchmarks in the Milliman
Medicaid
Guidelines (Guidelines)
as well as
other sources, Milliman calculated percentage adjustments to
reflect the utilization differential between an economic and efficiently
managed
plan and the FFS base experience.
Cost
Per
Service
Milliman
adjusted the cost per service amounts to reflect changes in the mix
/ intensity
of services due to the management of health care. The reimbursement
rate changes
were also developed following a review of benchmark in the Guidelines as well as
other
sources.
In
addition to the intensity adjustments applied to the cost per service
amounts,
Milliman also included adjustments to reflect the health plan contracted
rates
with providers in the managed care adjustments.
FINAL
and CONFIDENTIAL
V.
DEVELOPMENT OF CY 2006 ADJUSTED ENCOUNTER DATA
a.
Historical Data Summaries
|
|
The
CY 2008 CFC capitation rates were developed, in part, using
Encounter
claims for two SFY periods:
|
|
·
|
SFY
2005 (Incurred during the 12 months ending June 30, 2005
paid through May
31, 2007).
|
|
·
|
SFY
2006 (Incurred during the 12
months ending June 30, 2006 paid through May 31,
2007).
|
The
claims data was provided by ODJFS from the data warehouse. The
experience was stratified into geographic region based on the member's
county of
residence.
The
Encounter data summaries represent historical experience for those
services that
are included in the capitation payment. Services that are not covered
under the
capitation payment have been excluded from the experience. The excluded
services
were identified by the ODJFS defined category of service field, as
shown in
Section IV, Table 4.
The
historical data summaries for the base encounter experience reflect
only region,
county, health plan combinations with sufficient experience to be considered
credible. As such, counties considered '"voluntary" and health plans
with low
enrollment were not included in the base data. Table 6 provides the
region/county and health plan combinations contained in the capitation
rate
development.
Table
6
STATE
OF OHIO
DEPARTMENT
OF JOB AND FAMILY SERVICES
Region/County
and Health Plan Inclusions – Encounter
|
Region
- County
|
Health
Plans
|
|
Central
- Franklin
|
Caresource;
Molina
|
|
East
Central - Xxxxx
|
Buckeye;
Caresource; Mediplan
|
|
East
Central - Summit
|
Buckeye;
Caresource; Summacare
|
| Northeast - Cuyahoga | Caresource; Anthem/Qualchoice |
|
Northeast
- Lorain
|
Caresource;
Anthem/Qualchoice
|
|
Northeast
Central - Mahoning
|
Caresource;
Gateway; Unison
|
|
Northeast
Central - Trumbull
|
Caresource;
Gateway; Unison
|
|
Northwest
- Xxxxx
|
Buckeye;
Paramount
|
|
Southwest
- Xxxxxx
|
Amerigroup;
Caresource
|
|
Southwest
- Xxxxxxxx
|
Amerigroup;
Caresource
|
|
West
Central -
Xxxxx
|
Caresource;
Molina
|
|
West
Central - Xxxxxxxxxx
|
Caresource;
Molina
|
FINAL
and CONFIDENTIAL
b.
Imputed Cost per Service
Milliman
applied a cost per service amount to the managed care encounter data
to reflect
the missing financial information in the base managed care encounter
experience.
The cost per service was applied by rate group on a statewide basis
for all
categories of service except for inpatient services. The cost per service
was
applied by rate group and region for inpatient services.
Additionally,
the cost per service was re-priced based on the mix/intensity of services
included in the encounter base experience. The cost per service was
developed
from the Medicaid FFS reimbursement rates. In addition to reflecting
the health
plan mix of services, the cost per service was adjusted for other managed
care
factors as described below.
c.
Completion Factors
Milliman
utilized 24 months of claims experience for the managed care population
that was
incurred through June 2006 and paid through May 2007 (eleven months
of run-out).
Milliman applied claim completion factors to the twelve months of SFY
2005 and
twelve months of SFY 2006 claims experience. The claim completion factors
were
developed by service category based on utilization experience for the
managed
care population incurred and paid through May 2007.
d.
Historical Program Adjustments
The
base
experience data represents a historical time period from which projections
were
developed. Certain program changes have occurred during and subsequent
to the
base data time period. The program adjustments were estimated and applied
to the
portion of the base experience data prior to the program change effective
date.
For example, a program change implemented on January 1, 2006 will only
be
reflected in the second half of SFY 2006. As such, an adjustment was
applied to
all of SFY 2005 and half of SFY 2006 to include the program change
in all
periods of the base experience data.
ODJFS
has
provided a listing of all program changes impacting the base experience
data.
Section IV, Table 5 summarizes the historical program changes that
were
reflected in the development of the CY 2008 capitation rates.
e.
Third-Party Liability and Fraud-Abuse Recoveries
The
cost
reports submitted by the health plans contained information related
to
third-party liability and fraud-abuse recoveries. Milliman calculated
the average recoveries and applied the reduction to the base encounter
data.
FINAL
and CONFIDENTIAL
f.
Non-State Plan Services
CMS
requires removal of non-state plan services from
rate-setting. The encounter data contains certain claims that
are considered non-state plan services. The health plan
submitted cost reports were used as the source of information for the
non-state
plan service adjustments.
g.
Historical Selection Adjustments
Milliman
applied a historical selection adjustment to the base encounter data
to reflect
that the base period contains a combination of FFS and managed care
enrollment.
The historical selection adjustment is intended to normalize the encounter
experience to the morbidity level of the entire managed care eligible
population.
h.
Trends/Inflation to CY 2006
Milliman
developed trend rates to progress the historical experience from SFY
2005 and
SFY 2006 forward to a common center point (CY 2006). Milliman reviewed
historical experience and performed linear regression on the experience
data to
develop trend rates by category of service for both utilization and
unit cost.
Additionally, Milliman reviewed the resulting trends with internal
data sources
to develop the trends used in the development of the CY 2008 CFC capitation
rates.
The
base
experience data was normalized for artificial program adjustments prior
to the
trend rate development. Milliman did not consider items such as fee
schedule
changes or benefit modifications as standard components of trend. Removing
the
impact of historical changes allows for transparent inclusion of prospective
program changes for future periods.
i.
Blend Base Experience Years
Each
of
the base experience years was trended to CY 2006. At this point, each
base year
was on a comparable basis and could be aggregated. The weighting was
developed
with the intention of placing more credibility on the most recent experience.
Generally, SFY 2006 was given 70% weight except where insufficient
experience
existed in either SFY 2005 or SFY 2006. In these situations, either
SFY 2005 or
SFY 2006 was given 100% credibility.
j.
Managed Care Adjustments
Utilization
and cost per service adjustments were developed for each rate group,
service
category, and region.
FINAL
and CONFIDENTIAL
Utilization
Milliman
adjusted the encounter utilization and cost per service to reflect
changes
anticipated in the managed care environment. After reviewing
utilization benchmarks in the Milliman Medicaid Guidelines (Guidelines) as well
as other
sources, Milliman calculated percentage adjustments to reflect utilization
differential between an economic and efficiently managed plan and the
encounter
base experience.
Cost
Per
Service
Milliman
adjusted the average reimbursement rates to reflect changes in the
mix /
intensity of services due to the management of health care. The reimbursement
rate changes were also developed following a review of benchmarks in
the Guidelines as well as
other
sources.
In
addition to the intensity adjustments applied to the cost per service
amounts,
Milliman also included adjustments to reflect the health plan contracted
rates
with providers in the managed care adjustments.
VI.
DEVELOPMENT OF CY 2006 ADJUSTED COST REPORT DATA
a.
Historical Data Summaries
The
CY
2008 CFC capitation rates were developed, in part, using health plan
submitted
cost reports for two calendar year (CY) periods:
|
§
|
CY
2005 (Incurred during the 12 months ending December 31, 2005
paid through
December 31, 2006).
|
|
§
|
CY
2006 (Incurred during the 12 months ending December 31, 2006
paid through
December 31, 2007).
|
The
historical data summaries for the base cost report experience reflect
only
region, county, health plan combinations with sufficient experience
to be
considered credible. As such, counties considered "voluntary" and health
plans
with low enrollment were not included in the base data. Table 7 provides
the
region/county and health plan combinations contained in the capitation
rate
development.
FINAL
and CONFIDENTIAL
|
|
Table
7
|
|
|
STATE
OF OHIO
|
|
|
DEPARTMENT
OF JOB AND FAMILY SERVICES
|
|
|
Region/County
and Health Plan Inclusions – Cost Report
|
|
Region
-
County
|
Health
Plans
|
|
Central
- Franklin
|
Caresource;
Molina
|
|
East
Central - Xxxxx
|
Buckeye;
Caresource
|
|
East
Central - Summit
|
Buckeye;
Caresource
|
|
Northeast
- Cuyahoga
|
Caresource:
Anthem/Qualchoice
|
|
Northeast
- Lorain
|
Caresource;
Anthem/Qualchoice
|
|
Northeast
Central - Mahoning
|
Caresource;
Gateway; Unison
|
|
Northeast
Central - Trumbull
|
Caresource;
Gateway; Unison
|
|
Northwest
- Xxxxx
|
Buckeye;
Paramount
|
|
Southwest
- Xxxxxx
|
Amerigroup;
Caresource
|
|
Southwest
- Xxxxxxxx
|
Amerigroup;
Caresource
|
|
West
Central - Xxxxx
|
Caresource;
Molina
|
|
West
Central - Xxxxxxxxxx
|
Caresource;
Molina
|
b. Completion
Factors
The
cost
reports contained claim experience incurred through December 31, 2006
and paid
through December 31, 2006, as well as health plan estimated 1BNR reserve
amounts. Milliman reviewed the claims completion contained in the submitted
cost
reports for reasonableness. During this review, Milliman estimated
a high and
low completion percentage on a statewide basis. The claims completion
implemented by the health plans in aggregate was within the range and,
as such,
no further adjustments were applied.
c. Historical
Program Adjustments
The
base
experience data represents a historical time period from which projections
were
developed. Certain program changes have occurred during and subsequent
to the
base data time period. The program adjustments were estimated and applied
to the
portion of the base experience data prior to the program change effective
date.
For example, a program change implemented on January 1, 2006 will only
be
reflected in the CY 2006 experience. As such, an adjustment was applied
to CY
2005 to include the program change m all periods of the base experience
data.
ODJFS
has provided a listing of all
program changes impacting the base experience data. Section IV, Table
5 summarizes the historical program changes that were reflected in
the
development of the CY 2008 capitation rates.
FINAL
and CONFIDENTIAL
d. Third-Party
Liability and Fraud-Abuse Recoveries
The
cost
reports submitted by the health plans contained information related
to
third-party liability and fraud-abuse recoveries. Milliman calculated
the average recoveries and applied the reduction to the base cost report
data.
e. Non-State
Plan Services
CMS
requires removal of non-state plan services from rate-setting. The
cost report
claims that are considered non-state plan services. The health plan
submitted
cost the source of information for the non-state plan service
adjustments.
f.
Historical
Selection
Adjustments
Milliman
applied a historical selection adjustment to the base cost report data
to
reflect that the base period contains a combination of FFS and managed
care
enrollment. The historical selection adjustment is intended to normalize
the
cost report experience to the morbidity level of the entire managed
care
eligible population.
g. Trends/Inflation
to CY 2006
Milliman
developed trend rates to progress the historical experience from calendar
years
2005 and 2006 forward to a common center point (CY 2006). Milliman
reviewed
historical experience and performed linear regression on the experience
data to
develop trend rates by category of service for both utilization and
unit cost.
Additionally, Milliman reviewed the resulting trends with internal
data sources
to develop the trends used in the development of the CY 2008 capitation
rates.
The
base
experience data was normalized for artificial program adjustments prior
to the
trend rate development. Milliman did not consider items such as fee
schedule
changes or benefit modifications as standard components of trend. Removing
the
impact of historical changes allows for transparent inclusion of prospective
program changes for future periods.
h. Blend
Base Experience Years
The
base
CY 2005 year was trended to CY 2006. At this point, each base year
was on a
comparable basis and could be aggregated. The weighting was developed
with the
intention of placing more credibility on the most recent
experience. Generally, CY 2006 was given 70% weight except where
insufficient experience existed in either CY 2005 or CY 2006. In
these situations, either CY 2005 or CY 2006 was given 100%
credibility.
FINAL
and CONFIDENTIAL
i. Managed
Care Adjustments
Milliman
adjusted the cost report experience data to reflect changes anticipated
in the
managed care environment. The cost report base experience was
adjusted using the same managed care adjustments as the base encounter
data with
the exception of the health plan provider contracting adjustment. The
health
plan rate of provider reimbursement is already included in the cost
report base
experience.
Adjustments
were developed for each rate group, service category, and
region.
VII. CY
2006 ADJUSTED BASE DATA TO CY 2008 CAPITATION RATES
The
adjusted CY 2006 utilization and cost per service rates are trended
forward to
CY 2008 and adjusted for prospective program changes that will be effective
for
the CY 2008 contract period. The resulting PMPM establishes the regional
adjusted claim cost for the health plans in CY 2008. The administrative
cost
allowance and franchise fee components are applied to the adjusted
claim cost to
develop the CY 2008 capitation rates.
a. Trend
to CY 2008
The
trend
rates that were used to progress the CY 2006 experience forward to
the CY 2008
rating period were developed from the historical experience, the experience
from
other Medicaid managed care programs, and our actuarial judgment. The
trend
rates include a component for utilization and unit cost by major category
of
service.
b. Prospective
Program Adjustments
The
SFY
2008/2009 Budget contains several program changes that impacted the
development
of the capitation rates. The program changes include items such as
provider fee
changes, benefit changes, and administrative changes. Adjustments to
the CY 2006
experience were developed for each item based on its expected impact
to the
prospective claims cost. Table 8 lists the program changes that were
included in
the CY 2008 capitation rate development.
FINAL
and CONFIDENTIAL
Table
8
|
|
STATE
OF OHIO
|
|
|
DEPARTMENT
OF JOB AND FAMILY SERVICES
|
|
|
Prospective
Program Adjustments
|
|
Program
Adjustment
|
Effective
Date
|
Service
Category
|
Rate
Groups
|
|
Nursing
Facility Fee Increase
|
7/1/2007
7/1/2008
|
Nursing
Facility
|
All
Rate Groups (excl. Delivery)
|
|
Chiropractor
Benefit Restoration
|
1/1/2008
|
Miscellaneous
Services
|
HF
M – 19 to 44
HF
F – 19 to 44
HF
M/F – 45 to 64
HST
F – 19 to 64
|
|
Independent
Psychologists Benefit Restoration
|
1/1/2008
|
Mental
Health / Substance Abuse
|
HF
M – 19 to 44
HF
F – 19 to 44
HF
M/F – 45 to 64
HST
F – 19 to 64
|
|
Occupational
Therapy-Independent Provider Status
|
1/1/2008
|
Miscellaneous
Services
|
All
Rate Groups (excl. Delivery)
|
|
Developmental
Therapies
|
1/1/2008
|
Miscellaneous
Services
|
HST
M/F - <
1
|
|
Xxxxxx
Children Expansion
|
1/1/2008
|
All
Service Categories
|
HST
M – 14 to 18
|
|
CHIP
III Expansion
|
1/1/2008
|
All
Service Categories
|
HST
F – 14 to 18
HF
M – 19 to 44
HF
F – 19 to 44
HST
F – 19 to 64
HST
M/F – 2 to 13
|
|
Pregnant
Women Expansion
|
1/1/2008
|
All
Service Categories
|
HST
M – 14 to 18
HST
F – 14 to 18
HST
F – 19 to 64
|
|
Improved
TPL Management
|
1/1/2008
|
All
Service Categories
|
Delivery
All
Rate Groups (incl. Delivery)
|
|
Expedite
Managed Care Enrollment
|
1/1/2008
|
All
Service Categories
|
All
Rate Groups (incl. Delivery)
|
|
Expedite
Newborn Enrollment
|
1/1/2008
|
All
Service Categories
|
HST
M/F - <
1
|
|
Short
Term Nursing Facility Policy Change (consistent with ABD)
|
1/1/2008
|
Nursing
Facility
|
All
Rate Groups (excl. Delivery)
|
|
Prior
Authorization Policy Change
|
1/1/2008
|
Pharmacy
|
All
Rate Groups (excl. Delivery)
|
|
Prior
Authorization of Atypical Anti-Psychotic Medication
|
1/1/2008
|
Pharmacy
|
All
Rate Group (excl. Delivery)
|
FINAL
and CONFIDENTIAL
c.
Prospective Selection Adjustment
Milliman
adjusted the base experience data to reflect the morbidity of the entire
managed
care eligible population. Subsequently, a prospective selection
adjustment was deleloped to reflect that less than 100% of managed
care
eligibles will enroll in managed care. Table 9 provides that taget
managed care penetration used in the development of the CY 2008 capitation
rates.
Table
9
STATE
OF OHIO
DEPARTMENT
OF JOB AND FAMILY SERVICES
Prospective
Selection Adjustments
|
Region
|
June
0000 XX Xxxxxxxxxxx
|
Target
MC Penetration
|
|
Central
|
93.4%
|
95%
|
|
East
Central
|
94.6%
|
95%
|
|
Northeast
|
95.2%
|
95%
|
|
Northeast
Central
|
75.8%
|
95%
|
|
Northwest
|
94.5%
|
95%
|
|
Southeast
|
94.9%
|
95%
|
|
Southwest
|
93.6%
|
95%
|
|
West
Central
|
94.0%
|
95%
|
d.
Clinical Measures Adjustments
Appendix
M of the provider agreement between contracted health plans and ODJFS
contains
certain clinical measures that each health plan must achieve. The agreement
stipulates that, at a minimum, the experience improvement must reduce
the
discrepancy between the ultimate target and the actual rate by a certain
percentage. Milliman developed adjustments to the capitation rates
to reflect
this required improvement in performance based on the CY 2006 actual
results.
Table 10 illustrates the measures for which adjustment factors were
applied by
category of service and rate group.
Table
10
STATE
OF OHIO
DEPARTMENT
OF JOB AND FAMILY SERVICES
Clinical
Measures Adjustments
|
Clinical
Measure Description
|
Measure
|
Service
Category
|
Rate
Groups
|
|
Ongoing
Prenatal Care
|
80%
receive 81+% of expected visits
|
Office
Visits / Consults
|
HST
F – 14 to 18
HF
F – 19 to 44
HST
F – 19 to 64
|
|
Postpartum
Care
|
80%
receive a visit
|
Obstetrics
|
HST
F – 14 to 18
HF
F – 19 to 44
HST
F – 19 to 64
|
|
Well
Child Visits
|
80%
receive expected visits
|
Periodic
Exams
|
HST
M/F – <1
HST
M/F – 1
HST
M/F – 2 to 13
HST
F – 14 to 18
HST
M – 14 to 18
|
|
Asthma
Medications
|
95%
receive appropriate medications
|
Pharmacy
|
HST
M/F – 2 to 13
HST
F – 14 to 18
HST
M – 14 to 18
HF
F – 19 to 44
HF
M – 19 to 44
HF
M/F – 45 to 64
HST
F – 19 to 64
|
|
Annual
Dental Visits
|
60%
receive a visit
|
Dental
|
HST
M/F – 2 to 13
HST
F – 14 to 18
HST
M – 14 to 18
|
|
Lead
Screening
|
80%
receive screening
|
Pathology
/ Laboratory
|
HST
M/F – 1
HST
M/F – 2 to 13
|
e.
Delivery of Cesarean Section Rates
Milliman
reviewed the cesarean rates for both the FFS and managed care populations
in the
base period data summaries. In the previous years, the capitation
rates were adjusted to target a specific cesarean rate. For 2008,
Milliman did not adjust the regional cost summaries, up or down, to reflect
a
different cesarean rate.
f.
Blend FFS / Encounter / Cost Report
The
FFS,
encounter, and cost report data sets were projected to CY 2008 and composited
to
establish the CY 2008 total claims cost. The credibility between data
sources
was based upon the amount of managed care
experience in the case data. The encounter and cost report data
sources were given equal weight in each region.
FINAL
and CONFIDENTIAL
g. Age/Gender Realignment
Milliman
developed the 2008 capitation rates by rate group and region. The resulting
capitation rates by rate group were then adjusted within each region
to realign
the age/gender relativities among regions. The realignment maintains
the
composite capitation rates for each region and in aggregate while allowing
for
more consistent age/gender relativities.
h.
Administrative Allowances
Milliman
included an administrative cost allowance in the development of the
actuarially
sound capitation rates for CY 2008. The administrative cost allowance
contains
provision for administrative expenses, profit/contingency, and surplus
contribution and was calculated as a percentage of the capitation rate
prior to
the franchise fee. As such, the pre-franchise fee capitation rate will
be
determined by dividing the projected managed care claim cost by one
minus the
administrative cost allowance. By determining the pre-franchise fee
capitation
rate in this manner, the administrative allowance may be expressed
as a
percentage of the pre-franchise fee capitation rate. Milliman developed
the
administrative cost allowance following a review of actual health plan
cost
information contained in the cost reports as well as information from
other
representative Medicaid managed care organizations.
For
health plans in plan year 3 or later, 1% of the administrative component
will be
at-risk and contingent upon performance requirements defined in the
ODJFS
provider agreements. Table 11 provides the administrative cost allowance
for
each plan year.
Table
11
STATE
OF OHIO
DEPARTMENT
OF JOB AND FAMILY SERVICES
Administrative
Cost Allowance
Non-Delivery
|
Plan
Year
|
Guaranteed
%
|
At-Risk
%
|
Total
%
|
|
Plan
Year 1 (1-12 Months)
|
12.5%
|
0.0%
|
12.5%
|
|
Plan
Year 2 (13-24 Months)
|
11.5%
|
0.0%
|
11.5%
|
|
Plan
Year 3 (25 + Months)
|
10.5%
|
1.0%
|
11.5%
|
FINAL
and CONFIDENTIAL
Delivery
|
Plan
Year
|
Guaranteed
%
|
At-Risk
%
|
Total
%
|
|
Plan
Year 1 (142 Months)
|
6.0%
|
0.0%
|
6.0%
|
|
Plan
Year 2 (13-24 Months)
|
5.0%
|
0.0%
|
5.0%
|
|
Plan
Year 3 (25 + Months)
|
4.0%
|
1.0%
|
5.0%
|
The
administrative cost allowance percentages contained in Table 11 reflect
a change
from the 2007 methodology.
i.
Franchise Fee
Milliman
included a franchise fee component in the development of the actuarially
sound
capitation rates for CY 2008. The franchise fee was calculated as a
percentage
of the capitation rates. Therefore, the capitation rate will be determined
by
dividing the pre-franchise fee capitation rate by one minus the franchise
fee
component. By determining the pre-franchise fee capitation rate in
this manner,
the franchise fee may be expressed as a percentage of the capitation
rate. The
franchise fee component is 4.5% of the capitation rate.
DATA
RELIANCE
In
developing the CY 2008 CFC capitation rates, we have relied upon certain
data
and information from ODJFS. While limited review was performed for
reasonableness, the data and information was accepted without audit.
To the
extent that the data and information was not accurate or complete,
the values
shown in this letter will need to be revised.
If
you
have any questions regarding the enclosed information, please do not
hesitate to
contact me at 000-000-0000.
Sincerely,
/s/
Xxxxxx
X. Xxxxxx
Xxxxxx
X.
Xxxxxx, FSA, MAAA Principal and Consulting Actuary
|
|
RMD/mle
|
|
cc:
|
Xxx
Xxxxx (ODJFS)
|
| MitaliGhatak (ODJFS) | |
| Xxxxxx Xxxxx (ODJF1 ) |
APPENDIX
1
Illustration
of Rate Development Methodology
[Graph]
APPENDIX
2
STATE
OF OHIO
DEPARTMENT
OF JOB AND FAMILY SERVICES
Covered
Families and Children – CY 2008 Capitation Rates
Actuarial
Certification
I,
Xxxxxx
X. Xxxxxx, am a Principal and Consulting Actuary with the firm of Xxxxxxxx,
Inc.
I am a Fellow of the Society of Actuaries and a Member of the American
Academy
of Actuaries. I was retained by the State of Ohio, Department of Job
and Family
Services to perform an actuarial review and certification regarding
the
development of the capitation rates to be effective for calendar year
2008. The
capitation rates were developed for the Covered Families and Children
managed
care eligible populations. I have experience in the examination of
financial
calculations for Medicaid programs and meet the qualification standards
for
rendering this opinion.
I
reviewed the historical claims experience for reasonableness and consistency.
I
have developed certain actuarial assumptions and actuarial methodologies
regarding the projection of healthcare expenditures into future periods.
I have
complied with the elements of the rate setting checklist CMS developed
for its
Regional Offices regarding 42 CFR 438.6(c) for capitated Medicaid managed
care
plans.
The
capitation rates provided with this certification are effective for
a one-year
rating period beginning January 1, 2008 through December 31, 2008.
At the end of
the one-year period, the capitation rates will be updated for calendar
year
2009. The update may be based on fee-for-service experience, managed
care
utilization and trend experience, policy and procedure changes, and
other
changes in the health care market. A separate certification will be
provided
with the updated rates.
The
capitation rates provided with this certification are considered actuarially
sound, defined as:
• the
capitation rates have been developed in accordance with generally accepted
actuarial principles and practices;
• the
capitation rates are appropriate for the populations to be covered,
and the
services to be furnished under the contract; and,
• the
capitation rates meet the requirements of 42 CFR 438.6(c).
This
actuarial certification has been based on the actuarial methods, considerations,
and analyses promulgated from time to time through the Actuarial Standards
of
Practice by the Actuarial Standards Board.
/s/ Xxxxxx
X. Xxxxxx
Xxxxxx
X.
Xxxxxx, FSA
Member,
American Academy of Actuaries
|
|
December
4,
2007
|
APPENDIX
3
FINAL
AND CONFIDENTIAL
State
of Ohio
Department
of Job and Family Services
Capitation
Rate Summary – Rate Group Level
[Table]
|
APPENDIX
F
|
|||||||||||
|
REGIONAL
RATES
|
|||||||||||
|
1. PREMIUM
RATES WITHOUT THE AT-RISK PAYMENT AMOUNTS FOR 01/01/08 THROUGH
06/30/08 SHALL BE AS FOLLOWS:
|
|||||||||||
|
An
at-risk amount of 1% is applied
to the MCP rates. The status of the at-risk amount is
determined in accordance with Appendix O, performance
incentives.
|
|||||||||||
|
MCP: WellCare
of Ohio,
Inc.
|
|||||||||||
|
SERVICE
|
REGIONAL
|
HF/HST
|
HF/HST
|
HF/HST
|
HF/HST
|
HF/HST
|
HF
|
HF
|
HF
|
HST
|
Delivery
|
|
ENROLLMENT
|
STATUS
|
Age
<
1
|
Age
1
|
Age
2-13
|
Age
14-18
|
Age
14-18
|
Age
19-44
|
Age
19-44
|
Age
45
|
Age
19-64
|
Payment
|
|
AREA
|
Male
|
Female
|
Male
|
Female
|
and
over
|
Female
|
|||||
|
Northeast
|
Mandatory
|
$537.65
|
$138.65
|
$93.78
|
$112.18
|
$156.32
|
$188.08
|
$287.97
|
$459.68
|
$356.04
|
$4,105.75
|
|
List
of Eligible Assistance Groups
(AGs)
|
|||||||||||
| Healthy Families: |
- MA-C Categorically
eligible due to TANF cash
- MA-T Children
under 21
- MA-Y Transitional
Medicaid
|
||||||||||
| Healthy Start: | - MA-P Pregnant Women and Children | ||||||||||
|
For
the SFY 2008 contract
period, MCPs will be put at-risk for a portion of the premiums
received
for members in counties they served as of January 1, 2006, provided
the MCP has participated in the program for more than twenty-four
months.
|
|||||||||||
|
|
|||||||||||
|
MCPs
will be put at-risk for
a portion of the premiums received for members in counties they
began
serving after January 1, 2006, beginning with the MCP's
twenty-fifth month of membership in each county's region.
|
|||||||||||
|
|
|||||||||||
|
Page
1 of
3
|
|||||||||||
|
APPENDIX
F
|
|||||||||||
|
REGIONAL
RATES
|
|||||||||||
|
2. AT-RISK
AMOUNTS
FOR 01/01/08 THROUGH 06/30/08 SHALL BE AS
FOLLOWS:
|
|||||||||||
|
An
at-risk amount of 1% is applied
to the MCP rates. The status of the at-risk amount is
determined in accordance with Appendix O, performance
incentives.
|
|||||||||||
|
MCP: WellCare
of Ohio,
Inc.
|
|||||||||||
|
SERVICE
|
REGIONAL
|
HF/HST
|
HF/HST
|
HF/HST
|
HF/HST
|
HF/HST
|
HF
|
HF
|
HF
|
HST
|
Delivery
|
|
ENROLLMENT
|
STATUS
|
Age
<
1
|
Age
1
|
Age
2-13
|
Age
14-18
|
Age
14-18
|
Age
19-44
|
Age
19-44
|
Age
45
|
Age
19-64
|
Payment
|
|
AREA
|
Male
|
Female
|
Male
|
Female
|
and
over
|
Female
|
|||||
|
Northeast
|
Mandatory
|
$0.00
|
$0.00
|
$0.00
|
$0.00
|
$0.00
|
$0.00
|
$0.00
|
$0.00
|
$0.00
|
$0.00
|
|
List
of Eligible Assistance Groups
(AGs)
|
|||||||||||
| Healthy Families: |
- MA-C Categorically
eligible due to TANF cash
- MA-T Children
under 21
- MA-Y Transitional
Medicaid
|
||||||||||
|
|
|||||||||||
| Healthy Start: | - MA-P Pregnant Women and Children | ||||||||||
|
For
the SFY 2008 contract
period, MCPs will be put at-risk for a portion of the premiums
received
for members in counties they served as of January 1, 2006, provided
the MCP has participated in the program for more than twenty-four
months.
|
|||||||||||
|
|
|||||||||||
|
MCPs
will be put at-risk for
a portion of the premiums received for members in counties they
began
serving after January 1, 2006, beginning with the MCP's
twenty-fifth month of membership in each county's region.
|
|||||||||||
|
|
|||||||||||
|
Page
2 of
3
|
|||||||||||
|
APPENDIX
F
|
|||||||||||
|
REGIONAL
RATES
|
|||||||||||
|
3. PREMIUM
RATES FOR
01/01/08 THROUGH 06/30/08 SHALL BE AS FOLLOWS:
|
|||||||||||
|
An
at-risk amount of 1% is applied
to the MCP rates. The status of the at-risk amount is
determined in accordance with Appendix O, performance
incentives.
|
|||||||||||
|
MCP: WellCare
of Ohio,
Inc.
|
|||||||||||
|
SERVICE
|
REGIONAL
|
HF/HST
|
HF/HST
|
HF/HST
|
HF/HST
|
HF/HST
|
HF
|
HF
|
HF
|
HST
|
Delivery
|
|
ENROLLMENT
|
STATUS
|
Age
<
1
|
Age
1
|
Age
2-13
|
Age
14-18
|
Age
14-18
|
Age
19-44
|
Age
19-44
|
Age
45
|
Age
19-64
|
Payment
|
|
AREA
|
Male
|
Female
|
Male
|
Female
|
and
over
|
Female
|
|||||
|
Northeast
|
Mandatory
|
$537.65
|
$138.65
|
$93.78
|
$112.18
|
$156.32
|
$188.08
|
$287.97
|
$459.68
|
$356.04
|
$4,105.75
|
|
List
of Eligible Assistance Groups
(AGs)
|
|||||||||||
| Healthy Families: |
- MA-C Categorically
eligible due to TANF cash
- MA-T Children
under 21
- MA-Y Transitional
Medicaid
|
||||||||||
|
|
|||||||||||
| Healthy Start: | - MA-P Pregnant Women and Children | ||||||||||
|
|
|||||||||||
|
For
the SFY 2008 contract
period, MCPs will be put at-risk for a portion of the premiums
received
for members in counties they served as of January 1, 2006, provided
the MCP has participated in the program for more than twenty-four
months.
|
|||||||||||
|
|
|||||||||||
|
MCPs
will be put at-risk for
a portion of the premiums received for members in counties they
began
serving after January 1, 2006, beginning with the MCP's
twenty-fifth month of membership in each county's region.
|
|||||||||||
|
|
|||||||||||
|
Page
3 of
3
|
|||||||||||
APPENDIX
G
COVERAGE
AND
SERVICES
CFC
ELIGIBLE
POPULATION
1. Basic
Benefit
Package
Pursuant
to OAC rule 5101:3-26-03(A), with limited exclusions (see section G.2 of this
appendix), MCPs must ensure that members have access to medically-necessary
services covered by the Ohio Medicaid fee-for-service (FFS)
program. For information on Medicaid-covered services, MCPs must
refer to the ODJFS website. The following is a general
list of the benefits
covered by the Ohio Medicaid
fee-for-service program:
· Inpatient
hospital services
· Outpatient
hospital services
· Rural
health clinics (RHCs) and
Federally qualified health centers (FQHCs)
· Physician
services whether furnished in the physician’s office, the covered person’s home,
a hospital, or elsewhere
· Laboratory
and
x-ray services
· Screening,
diagnosis, and treatment services to children under the age of twenty-one (21)
under the HealthChek (EPSDT) program
· Family
planning services and supplies
· Home
health
and private duty nursing
services
· Podiatry
· Chiropractic
services
· Physical
therapy, occupational therapy, developmental therapy and speech
therapy
· Nurse-midwife,
certified family nurse practitioner, and certified pediatric nurse practitioner
services
· Prescription
drugs
· Ambulance
and
ambulette services
· Dental
services
· Durable
medical equipment and medical supplies
· Vision
care
services, including eyeglasses
· Short-term
rehabilitative stays in a nursing facility as specified in OAC rule
5101:3-26-03
· Hospice
care
· Behavioral
health services (see section G.2.b.iii of this appendix)
2. Exclusions,
Limitations and
Clarifications
a. Exclusions
MCPs
are
not required to pay for Ohio Medicaid FFS program (Medicaid) non-covered
services. For information regarding Medicaid noncovered services, MCPs must
refer to the ODJFS website. The following is a general list of the services
not
covered by the Ohio Medicaid fee-for-service program:
· Services
or
supplies that are not medically necessary
· Experimental
services and procedures, including drugs and equipment, not covered by
Medicaid
· Organ
transplants that are not covered by Medicaid
· Abortions,
except in the case of a reported rape, incest, or when medically necessary
to save the life of the mother
· Infertility
services for males or females
· Voluntary
sterilization if under 21 years of age or legally incapable of consenting to
the procedure
·
Reversal of voluntary sterilization procedures
· Plastic
or cosmetic surgery that is
not
medically necessary*
· Immunizations
for travel outside of the United States
· Services
for
the treatment of obesity unless medically necessary*
· Custodial
or
supportive care not covered by
Medicaid
· Sex
change
surgery and related services
· Sexual
or
marriage counseling
· Acupuncture
and biofeedback services
· Services
to
find cause of death (autopsy)
· Comfort
items
in the hospital (e.g., TV or phone)
· Paternity
testing
MCPs
are
also not required to pay for non-emergency services or supplies received without
members following the directions in their MCP member handbook, unless otherwise
directed by ODJFS.
*These
services
could be deemed medically necessary if medical complications/conditions in
addition to the obesity or physical imperfection are present.
b. Limitations
&
Clarifications
i. Member
Cost-Sharing
As
specified in OAC rules 5101:3-26-05(D) and 5101:3-26-12, MCPs
are permitted to impose the applicable member co-payment amount(s) for dental
services, vision services, non-emergency emergency department services, or
prescription drugs, other than generic drugs. MCPs must notify ODJFS if they
intend to impose a co-payment. ODJFS must approve the notice to be
sent to the MCP’s members and the timing of when the co-payments will begin to
be imposed. If ODJFS determines that an MCP’s decision to impose a
particular co-payment on their members would constitute a significant change
for
those members, ODJFS may require the effective date of the co-payment to
coincide with the “Open
Enrollment” month.
Notwithstanding
the preceding paragraph, MCPs must provide an ODJFS-approved notice to all
their
members 90 days in advance of the date that the MCP will impose the co-payment.
With the exception of member co-payments the MCP has elected to implement in
accordance with OAC rules 5101:3-26-05(D) and 5101:3-26-12, the MCP’s payment
constitutes payment in full for any covered services and their subcontractors
must not charge members
or ODJFS any additional co-payment, cost sharing, down-payment, or similar
charge, refundable or otherwise.
ii. Abortion
and
Sterilization
The
use
of federal funds to pay for abortion and sterilization services is prohibited
unless the specific criteria found in 42 CFR 441 and OAC rules 5101:3-17-01
and
5101:3-21-01 are met. MCPs must verify that all of the information on
the required forms (JFS 03197, 03198, and 03199) is provided and that the
service meets the required criteria before any such claim is paid.
Additionally,
payment must not be made for associated services such as anesthesia, laboratory
tests, or hospital services if the abortion or sterilization itself does not
qualify for payment. MCPs are responsible for educating their
providers on the requirements; implementing internal procedures including
systems edits to ensure that claims are only paid once the MCP has determined
if
the applicable forms are completed and the required criteria are met, as
confirmed by the appropriate certification/consent forms; and for maintaining
documentation to justify any such claim payments.
iii. Behavioral
Health
Services
Coordination
of Services: MCPs must have a process
to
coordinate benefits of and referrals to the publicly funded community behavioral
health system. MCPs must ensure that members have access to all
medically-necessary behavioral health services covered by the Ohio
Medicaid FFS program and are responsible for coordinating those services with
other medical and support services. MCPs must notify members via the
member handbook and provider directory of where and how to access behavioral
health services, including the ability to self-refer to mental health services
offered through ODMH community
mental health centers (CMHCs) as well as substance abuse services offered
through Ohio Department of Alcohol and Drug Addiction Services
(ODADAS)-certified Medicaid providers. Pursuant to ORC Section 5111.16, alcohol,
drug addiction and mental health services covered by Medicaid are not to be
paid
by the managed care program when the nonfederal share of the cost of those
services is provided by a board of alcohol, drug addiction, and mental health
services or a state agency other than ODJFS. MCPs are also not
responsible for providing mental health services to persons between 22
and 64 years of age while residing in an institution for mental disease (IMD)
as
defined in Section 1905(i) of the Social Security Act.
MCPs
must
provide Medicaid-covered
behavioral health services for members who are unable to timely access
services or are unwilling to access services through community
providers.
Mental
Health
Services: There are a number of Medicaid-covered mental health (MH) services available
through ODMH
CMHCs.
Where
an
MCP is responsible for providing MH services for their members, the MCP is
responsible for ensuring access to counseling and psychotherapy,
physician/psychologist/psychiatrist services, outpatient clinic services,
general hospital outpatient psychiatric services, pre-hospitalization screening,
diagnostic assessment (clinical evaluation), crisis intervention, psychiatric
hospitalization in general hospitals (for all ages), and Medicaid-covered
prescription drugs and laboratory services. MCPs are not required
to cover partial hospitalization,
or inpatient psychiatric care in a private or public free-standing psychiatric
hospital. However, MCPs are required to cover the payment of physician services
in a private or public free-standing psychiatric hospital when such services
are
billed independent of the
hospital.
Substance
Abuse
Services: There are a number of Medicaid-covered substance
abuse services available through ODADAS-certified Medicaid
providers.
Where
an
MCP is responsible for providing substance abuse services for their members,
the
MCP is responsible for ensuring access to alcohol and other drug (AOD)
urinalysis screening, assessment, counseling,
physician/psychologist/psychiatrist AOD treatment services, outpatient clinic
AOD treatment services, general hospital outpatient AOD treatment services,
crisis intervention, inpatient detoxification services in a general hospital,
and Medicaid-covered prescription drugs and laboratory services. MCPs are not
required to cover outpatient detoxification and methadone
maintenance.
Financial
Responsibility
for Behavioral Health Services: MCPs are responsible
for the
following:
· payment
of Medicaid-covered prescription drugs prescribed by an ODMH CMHC or ODADAS-certified
provider when obtained through an MCP’s panel pharmacy;
· payment
of Medicaid-covered services
provided by an MCP’s panel laboratory when referred by an ODMH CMHC or
ODADAS-certified provider;
· payment
of all other Medicaid-covered
behavioral health services obtained through providers other than those who
are
ODMH CMHCs or ODADAS-certified providers when arranged/authorized by the
MCP.
Limitations:
· Pursuant
to ORC Section 5111.16,
alcohol, drug addiction and mental health services covered by Medicaid are
not
to be paid by the managed care program when the nonfederal share of the cost
of
those services is provided by a board of alcohol, drug addiction, and mental
health services or a state agency other than ODJFS. As part of this
limitation:
· MCPs
are not responsible for paying for
behavioral health services provided through ODMH CMHCs and ODADAS-certified
Medicaid providers;
· MCPs
are not responsible for payment of
partial hospitalization (mental health), inpatient psychiatric care in a private
or public free-standing inpatient psychiatric hospital, outpatient
detoxification, intensive outpatient programs (IOP) (substance abuse) or
methadone maintenance.
· However,
MCPs are required to cover the
payment of physician services in a private or public free-standing psychiatric
hospital when such services are billed independent of the
hospital.
iv. Pharmacy
Benefit: In providing the Medicaid pharmacy benefit to their
members, MCPs must cover the
same drugs covered by the Ohio
Medicaid fee-for-service program.
MCPs
may establish a preferred drug list for members and providers which includes
a
listing of the drugs that they prefer to have prescribed. Preferred drugs
requiring prior authorization approval must be clearly indicated as
such. Pursuant to ORC §5111.172, 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
Programs
General
Provisions -
Pursuant to OAC rule 5101:3-26-03.1(A)(7), MCPs must
implement a utilization
management (UM)
program to maximize the effectiveness of the care provided to members and may
develop other UM programs, subject to prior approval by ODJFS. For
the purposes of this requirement, the specific UM programs which
require ODJFS prior-approval are an MCP’s general pharmacy program, a controlled
substances and member management program, and any other program designed by
the
MCP with the purpose of redirecting or restricting access to a particular
service or service location.
i. Pharmacy
Programs - Pursuant to ORC Sec. 5111.172 and OAC rule 5101:3-26-03(A) and
(B), MCPs may, subject to ODJFS prior- approval, implement strategies for
the management of pharmacy utilization. Pharmacy utilization
management strategies may include developing preferred drug lists,
requiring prior authorization for certain drugs, placing limitations on the
type
of provider and locations where certain medications may
be administered, and developing and implementing a specialized pharmacy
program to address the utilization of controlled substances, as defined in
section 3719.01 of the Ohio Revised Code.
Drug
Prior Authorizations: MCPs must receive prior approval from ODJFS for the
medications that they wish to cover through prior
authorization. MCPs must establish their prior authorization
system so that it does not unnecessarily impede member access to
medically-necessary Medicaid-covered services. MCPs must
make their approved list of drugs covered only with prior
authorization available to members and providers, as outlined in
paragraphs 37(b) and (c) of Appendix C.
Beginning
January 1, 2008, MCPs may require prior authorization for the
coverage of antipsychotic drugs with ODJFS approval. MCPs must,
however, allow any member to continue receiving a specific antipsychotic
drug if the member is stabilized on that particular
medication. The MCP must continue to cover that specific
drug for the stabilized member for as long as that medication
continues to be effective for the member. MCPs may also
implement a drug utilization review program designed to promote the
appropriate clinical prescribing of antipsychotic drugs. This
can be accomplished through the MCP’s retrospective analysis of drug
claims to identify potential inappropriate use and provide education to
those providers who are outliers to acceptable standards for
prescribing/dispensing antipsychotic drugs.
MCPs
must comply with the provisions of
1927(d)(5) of the Social Security Act, 42 USC 1396r-8(k)(3), and
OAC rule 5101:3-26- 03.1 regarding
the timeframes for prior
authorization of covered outpatient drugs.
Controlled
Substances and Member Management Programs: MCPs may also, with ODJFS prior
approval, develop and implement Controlled Substances and Member
Management (CSMM) programs designed to address use of
controlled substances. Utilization management strategies may include prior
authorization as a condition of obtaining a controlled substance, as
defined in section 3719.01 of the Ohio Revised Code. CSMM
strategies may also include processes for requiring MCP members at high risk
for
fraud or abuse involving controlled substances to have their narcotic
medications prescribed by a designated provider/providers and filled by a
pharmacy, medical provider, or health care facility designated by the
program.
ii. Emergency
Department
Diversion (EDD) – MCPs must
provide access to services in a way that assures access to
primary, specialist and urgent care in the most appropriate settings
and that minimizes frequent, preventable utilization of emergency
department (ED) services. OAC rule 5101:3-26-03.1(A)(7)(d) requires MCPs to
implement the ODJFS-required emergency department diversion (EDD)
program for frequent utilizers.
Each
MCP must establish an ED diversion (EDD) program with the goal of minimizing
frequent ED utilization. The MCP’s EDD program must include the monitoring of ED
utilization, identification of frequent ED utilizers, and targeted approaches
designed to reduce avoidable ED utilization. MCP EDD programs must, at a
minimum, address those ED visits which could have been prevented through
improved education, access, quality or care management approaches.
Although
there is often an assumption that frequent ED visits are solely the result
of a
preference on the part of the member and education is therefore the standard
remedy, it
is also important to
ensure that a
member’s frequent ED utilization is not due to problems such as their PCP’s lack
of accessibility or failure to make appropriate specialist
referrals. The MCP’s EDD program must therefore also include the
identification of providers who serve as PCPs for a substantial number of
frequent ED utilizers and the implementation of corrective action with these
providers as so indicated.
This
requirement does not replace the MCP’s responsibility to inform and educate all
members regarding the appropriate use of the ED.
b. Case
Management
Programs
In
accordance with 5101:3-26-03.1(A)(8),
MCPs must offer and provide comprehensive case management services which
coordinate and monitor the care of members with specific diagnoses,
or who require high-cost and/or extensive services. The MCP’s
comprehensive case management program must also include a Children with Special
Health Care Needs component as specified below.
i. Each
MCP must inform all members and
contracting providers of the MCP’s case management services.
ii. Children
with Special Health Care Needs
(CSHCN):
CSHCN
are a particularly vulnerable
population which often have chronic and complex medical health care
conditions. In order to ensure
compliance with the provisions of
42 CFR 438.208, each MCP must establish a CSHCN component as part of the MCP’s
comprehensive case management program. The MCP must establish a
process for the timely identification, completion of a comprehensive needs
assessment, and providing appropriate and targeted case management services
for
any CSHCN.
CSHCN
are defined as children age 17 and
under who are pregnant, and members under 21 years of age with one or more
of
the following:
- Asthma
- HIV/AIDS
- A
chronic physical, emotional or mental
condition for which they are receiving treatment or
counseling
- Supplemental
security income (SSI) for a
health-related condition
- A
current letter of approval from the
Bureau of Children with Medical Handicaps (BCMH), Ohio Department of
Health
iii. Comprehensive
Case
Management Program
1. The
MCP must have a process to inform members and their PCPs in writing that they
have been identified as meeting the criteria for case management, including
their enrollment into case management services.
2. The
MCP must assure and coordinate the placement of the member into case management
– including identification of the member’s need for case management services,
completion of the comprehensive health needs assessment, and timely development
of a care treatment plan. This process must occur within the
following timeframes for:
a)
newly enrolled members, 90 days from the effective date of enrollment;
and
b)
existing members, 90 days from identifying their need for case
management.
3. The
MCP’s comprehensive case management program must include, at a minimum, the following
components:
a. Identification
The
MCP must have a variety of
mechanisms in place to identify members potentially eligible for case
management. These mechanisms must include an administrative data
review (e.g., diagnosis, cost threshold, and/or service utilization)
and may include
provider/self referrals, telephone interviews, information as reported by MCEC
during membership selection, or home visits.
b. Assessment
The
MCP must arrange for or conduct a
comprehensive assessment of the member’s physical and/or behavioral health
condition(s) to confirm the results of a positive identification, and determine
the need for case management services. The assessment must be
completed by a physician, physician assistant, RN, LPN, licensed social worker,
or a graduate of a two- or four-year allied health program. If the
assessment is completed by another medical professional, there should be
oversight and monitoring by either a registered nurse or
physician.
For
CSHCN, the comprehensive assessment
must include, at a minimum, the use of the ODJFS
CSHCN Standard
Assessment Tool.
c. Care
Treatment
Plan
The
care treatment plan is defined by ODJFS as the one developed by the MCP
for the member. The development of the care treatment
plan must be based on the comprehensive health assessment and reflect the
member's primary medical diagnosis and health conditions, any
co-morbidities, and the member's psychological, behavioral health and
community support needs. The care treatment plan must also
include specific provisions for periodic reviews (i.e., no less than
semi- annually) of the member's condition and appropriate updates to
the plan. The member and the member's PCP must be actively involved
in the development of and revisions to the care treatment
plan. The designated PCP is the provider, or specialist, who
will manage and coordinate the overall care for the
member. Ongoing communication regarding the status of the care
treatment plan may be accomplished between the MCP and the PCP's designee
(i.e., qualified health professional). Revisions to the
clinical portion of the care treatment plan should be completed in
consultation with the PCP.
The
elements of a comprehensive care treatment plan include:
Goals
and actions that address medical, social, behavioral and psychological
needs;
Member
level interventions (i.e., referrals and making appointments) that assist
members in obtaining services, providers and programs;
Continuous
review, revision and contact follow-up, as needed, to insure the care
treatment plan is adequately monitored including the
following:
·
Documentation
that
services are provided in accordance with the care treatment plan;
·
Re-evaluation
to
determine if the care treatment plan is adequate to meet the member's current
needs;
·
Identification
of
gaps between recommended care and actual care provided;
·
A
change in needs
or status from the re-evaluation that requires revisions to the care treatment
plan;
·
Active
participation by the member or representative in the care treatment plan
development;
·
Monitoring
of
specific service delivery including service utilization; and
·
Re-evaluation
of a
member's risk level with adjustment to the level of case management services
provided.
4. Coordination
of Care and
Communication
The
MCP
must provide case management services for:
·
all
CSHCN,
including the ODJFS mandated conditions as specified in Appendix M, Case
Management Program Performance Measures;
·
all
members
enrolled in an MCP’s CSMM program as specified in Section G(3)(a)(i);
and
·
adults
whose health
conditions warrant case management services.
Case
management services should not be limited only to members with the mandated
conditions.
There
should be an accountable point of contact (i.e., case manager) who can help
obtain medically necessary care, assist with health-related services and
coordinate care needs. The MCP must arrange or provide for professional
case management services that are performed collaboratively by a team of
professionals appropriate for the member’s condition and health care
needs. At a minimum, the MCP’s case manager must attempt to
coordinate with the member’s case manager from other health systems, including
behavioral health. The MCP must have a process to facilitate,
maintain, and coordinate communication between service providers, the member,
and the member’s family. The MCP must have a provision to disseminate
information to the member/caregiver concerning the health condition, types
of
services that may be available, and how to access the
services.
The
MCP must implement mechanisms to notify all Members with
Special Health Care Needs of their right to directly access a
specialist. Such access may be assured through, for example, a
standing referral or an approved number of visits, and documented in the
care treatment plan.
iv. Case
Management Strategies
The
MCPmust follow best-practice
and/or
evidence based clinical guidelines when developing a member’s care treatment
plan and coordinating the case management needs. The MCP must develop and
implement mechanisms to educate and equip providers and case managers with
evidence-based clinical guidelines or best practice approaches to assist in
providing a high level of quality of care to members.
v. Case
Management Program
Staffing
The
MCP
must identify the staff that will be involved in the operations of the case
management program, including but not limited to: case manager
supervisors, case manager, and administrative support staff. The MCP
must identify the role and functions of each case management staff member as
well as the educational requirements, clinical licensure standards,
certification and relevant experience with care management standards and/or
activities. The MCP must provide case manager staff/member ratios
based on the member risk stratification and different levels of care being
provided to members.
vi. Case
Management Data
Submission
The
MCP 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 ODJFS
Case
Management File
and Submission Specifications. In
order for a member to be submitted as
case managed
in CAMS, the MCP must (1)
complete the identification
process, a comprehensive
health needs assessment and
development of
a care treatment plan for the
member; and (2) document the
member’s written or verbal
confirmation of his/her case
management status in the
case management
record. ODJFS, or its designated
entity,
the external quality review
vendor, will validate on an
annual basis the accuracy of the
information contained in
CAMS with the member’s case
management record.
The
CAMS files are due the
10th
business day of each
month.
The
MCP
must also have
an ODJFS-approved case
management program which includes the items in Section
3.b. Each MCP
should implement an evaluation process to review, revise and/or update the
case
management program. The MCP must annually submit its case management
program for review and approval by ODJFS. Any subsequent changes
to an approved
case management program description must be submitted to ODJFS in writing for
review and approval prior to implementation.
c. Care
Coordination with ODJFS-Designated
Providers
Per
OAC rule 5101:3-26-03.1(A)(4),
MCPs are required
to share specific
information with certain ODJFS-designated non-contracting providers
in order to ensure
that these providers have been supplied with specific
information
needed to coordinate care for the
MCP’s members. Once an MCP has obtained a
provider agreement,
but within the first month of operation, the MCP must provide to the ODJFS-designated
providers (i.e., ODMH Community Mental Health
Centers,
ODADAS-certified Medicaid providers,
FQHCs/RHCs,QFPPs, CNMs, CNPs [if
applicable], and
hospitals) a quick reference
information packet which includes the following:
i. A
brief cover letter explaining the
purpose of the mailing; and
ii. A
brief summary document that includes
the following information:
· Claims
submission information including
the MCP’s Medicaid provider number for each region;
· The
MCP’s prior authorization and
referral procedures or the MCP’s website which includes this
information;
· A
picture of the MCP’s member
identification card (front and back);
· Contact
numbers and website location for
obtaining information for eligibility verification, claims processing,
referrals/prior authorization, and information regarding the MCP’s behavioral
health administrator;
· A
listing of the MCP’s major pharmacy
chains and the contact number for the MCP’s pharmacy benefit administrator
(PBM);
· A
listing of the MCP’s laboratories and
radiology providers; and
·
A
listing of the MCP’s
contracting behavioral health providers and how to access services through
them
(this information is only to be provided to non-contracting community mental
health and substance abuse providers).
d. Care
coordination with Non-Contracting Providers
Per
OAC rule 5101:3-26-05(A)(9), MCPs
authorizing the delivery of services
from a provider who does not
have an executed subcontract must ensure that
they
have a mutually agreed upon
compensation amount for the authorized service and notify the provider of the
applicable provisions of paragraph D of OAC rule 5101:3-26-05. This
notice is provided when an
MCP authorizes a non-contracting
provider to furnish services on a one-time or infrequent basis to an MCP member
and must include required ODJFS-model language and information. This notice
must
also be
included with the transition of
services form sent to providers as outlined
in paragraph 29.h of
Appendix C.
e. Integration
of Member
Care
The
MCP must ensure that a discharge
plan is in place to meet a member’s healthcare
needs following discharge from a
nursing facility, and integrated
into the member’s continuum
of care. The discharge plan must address the services to be
provided for the member and must be developed prior to the date of
discharge from the
nursing facility. The MCP must ensure
follow-up contact occurs with the
member, or authorized representative, within thirty (30) days of the member’s
discharge from
the nursing facility to ensure that
the member’s health care needs are being
met.
APPENDIX
H
PROVIDER
PANEL SPECIFICATIONS
CFC
ELIGIBLE
POPULATION
1.
GENERAL
PROVISIONS
MCPs
must
provide or arrange for the
delivery of all medically necessary, Medicaid-covered health services, as well
as assure that they meet all applicable provider panel requirements for their
entire designated
service area. The
ODJFS provider panel requirements are specified in the charts included with
this
appendix and must be met prior to the MCP receiving a provider agreement with
ODJFS. The MCP must remain in compliance with these requirements for
the duration of the provider agreement.
If
an MCP is unable to provide the
medically necessary, Medicaid-covered services through their contracted provider
panel, the MCP must ensure access to these services on an as needed
basis. For
example, if an MCP meets the
pediatrician requirement but a member is unable to obtain a timely appointment
from a pediatrician on the MCP’s provider panel, the MCP will be required to
secure an appointment from a panel pediatrician or arrange for an out-of-panel
referral to a pediatrician.
MCPs
are
required
to make transportation available to any
member requesting transportation when they must travel 30 miles
or more from their home to receive
a
medically-necessary Medicaid-covered service. If the MCP offers
transportation to their members as an additional benefit and this transportation
benefit only covers a limited number of trips, the required transportation
listed above may not
be counted toward this trip limit (as
specified in Appendix C).
In
developing the provider panel requirements, ODJFS considered, on a
county-by-county basis, the population size and utilization patterns of the
Covered Families and Children (CFC) consumers, as well as the potential availability of the
designated
provider types. ODJFS has integrated existing
utilization patterns into the provider
network requirements to avoid disruption of care. Most provider panel
requirements are
county-specific but in certain
circumstances, ODJFS requires providers to be located anywhere in the region.
Although all provider types listed in this appendix are required provider types,
only those listed on the attached charts must be submitted for ODJFS prior
approval.
2. PROVIDER
SUBCONTRACTING
Unless
otherwise specified in this
appendix or OAC rule 5101:3-26-05, all MCPs are required to enter into
fully-executed subcontracts with their providers. These subcontracts
must include a baseline contractual agreement, as well as the appropriate
ODJFS-approved Model Medicaid
Addendum. The Model Medicaid
Addendum incorporates all applicable Ohio Administrative
Code rule requirements
specific to provider subcontracting and therefore cannot be
modified except to add personalizing information such as the MCP’s
name.
ODJFS
must prior approve all MCP providers in the ODJFS- required provider type
categories before they can begin to provide services to that MCP’s
members. MCPs may not employ or contract with providers excluded from
participation in Federal health care programs under either section 1128 or
section 1128A of the Social Security Act. As part of the prior
approval process, MCPs must submit documentation verifying
that all necessary contract documents have been appropriately
completed. ODJFS will verify the approvability of the submission and
process this information using the ODJFS Provider Verification System (PVS)
or
other designated process. The PVS is a centralized database
system
that maintains information on the status of all MCP-submitted
providers.
Only
those providers who meet the
applicable criteria specified in this document, as determined by ODJFS, will
be
approved by ODJFS. MCPs must credential/recredential providers
in accordance with the standards specified by the National Committee for Quality
Assurance (or receive approval from ODJFS to use an alternate industry standard)
and must have completed the credentialing review before submitting any provider
to ODJFS for approval. Regardless of whether ODJFS has approved a
provider, the MCP must ensure that the provider has met all applicable
credentialing criteria before the provider can render services to the MCP’s
members.
MCPs
must
notify ODJFS of the addition and deletion of their contracting providers as
specified in OAC rule 5101:3-26-05, and must notify ODJFS within one working
day
in instances where the MCP has identified that they are not in compliance with
the provider panel requirements specified in this appendix.
3. PROVIDER
PANEL REQUIREMENTS
The
provider network criteria that must be met by each MCP are as
follows:
a. Primary
Care
Providers (PCPs)
Primary
Care Provider (PCP) means an individual physician (M.D. or D.O.), certain
physician group practice/clinic (Primary Care Clinics [PCCs]), or an advanced
practice nurse (APN) as defined in ORC 4723.43 or advanced practice nurse group
practice within an acceptable specialty, contracting with an MCP to provide
services as specified in paragraph (B) of OAC rule 5101:
3-26-03.1. Acceptable specialty types for PCPs include family/general
practice, internal medicine, pediatrics, and obstetrics/gynecology
(OB/GYN). Acceptable
PCCs include FQHCs, RHCs and the acceptable group practices/clinics specified
by
ODJFS. As part of their subcontract with an MCP, PCPs must stipulate
the total Medicaid member capacity that they can ensure for that individual
MCP.
Each
PCP must have the capacity and
agree to serve at least 50 Medicaid members at each practice site in order
to be
approved by ODJFS as a PCP. The capacity-by-site requirement must be
met for all ODJFS-approved PCPs.
In
determining whether an MCP has
sufficient PCP capacity for a region, ODJFS considers aprovider
who can serve as a PCP for 2000
Medicaid MCP members as one full-time equivalent(FTE).
ODJFS
reviews the capacity totals for
each PCP to determine if they appear excessive. ODJFS
reserves the right to request
clarification from an MCP for any PCP whose total stated capacity
for all MCP networks added
together exceeds 2000 Medicaid members (i.e., 1 FTE). Where indicated,
ODJFS may set a cap on the
maximum amount of capacity that we will recognize for a specific
PCP. ODJFS may allow up to an
additional 750 member capacity for each nurse practitioner
or physician’s assistant
that is used to provide clinical support for a PCP.
For
PCPs contracting with more than one
MCP, the MCP must ensure that the capacity figure stated by the PCP in their
subcontract reflects only the capacity the PCP intends to provide for that
one
MCP. ODJFS utilizes each approved PCP’s capacity figure to determine if an MCP
meets the provider panel requirements and this stated capacity figure does
not
prohibit a PCP from actually having a caseload that exceeds the capacity figure
indicated in their subcontract.
ODJFS
recognizes that MCPs will need to
utilize specialty providers to serve as PCPs for some special needs
members. Also, in some situations (e.g., continuity of care) a PCP
may only want to serve a very small number of members for an MCP. In
these situations it will not be necessary for the MCP to submit these PCPs
to
ODJFS for prior approval. These PCPs will not be included in the
ODJFS PVS database, or other designated process, and therefore may not appear
as
PCPs in the MCP’s provider directory. These PCPs will, however, need
to execute a subcontract with the MCP which includes the appropriate Model
Medicaid Addendum.
The
PCP requirement is based on an MCP
having sufficient PCP capacity to serve 40%
of the eligibles in the region if
three MCPs are serving the region and 55% of the eligibles in the region if
two
MCPs are serving the region. At
a minimum, each MCP must meet both
the PCP FTE requirement for that region, and a ratio of one PCP FTEfor each 2,000 of their
Medicaid members
in that region. MCPs must also satisfy a PCP geographic accessibility
standard. ODJFS will match the PCP practice sites and the stated PCP capacity
with the geographic location of the eligible population in that region (on
a
county-specific basis) and perform analysis using Geographic Information Systems
(GIS) software. The analysis will be used to determine if at least 40% of the
eligible population is located within 10 miles of PCP with available capacity
in
urban counties and 40% of the eligible population within 30 miles of a PCP
with
available capacity in rural counties. [Rural areas are defined pursuant to
42
CFR 412.62(f)(1)(iii).]
In
addition to the PCP FTE capacity requirement, MCPs must also contract with
the
specified number of pediatric
PCPs for each region. These pediatric PCPs
will have their stated capacity counted toward the PCP FTE
requirement.
A
pediatric PCP must maintain
a general pediatric practice (e.g., a pediatric neurologist would not
meet this definition unless this physician also operated a practice as a general
pediatrician) at a site(s) located within the county/region and be listed as
a
pediatrician with the Ohio State Medical Board. In addition, half of
the required number of pediatric PCPs must also be certified by the American
Board of Pediatrics. The provider panel requirements for
pediatricians are included in the practitioner charts in this
appendix.
Until
July 1, 2008, MCPs may only use PCPs who are individual physicians (M.D. or
D.O.), physician group practices, or PCCs to meet capacity and FTE
requirements.
b. Non-PCP
Provider
Network
In
addition to the PCP capacity requirements, each MCP is also required to maintain
adequate capacity in the remainder of its provider network within the following
categories: hospitals, dentists, pharmacies, vision care providers,
obstetricians/gynecologists (OB/GYNs), allergists, general surgeons,
otolaryngologists, orthopedists, certified nurse midwives (CNMs), certified nurse practitioners
(CNPs),
federally qualified health centers (FQHCs)/rural health centers (RHCs)
and qualified family planning providers (QFPPs). CNMs,
CNPs, FQHCs/RHCs and QFPPs are
federally-required provider types.
All
Medicaid-contracting MCPs must provide all medically-necessary Medicaid-covered
services to their members and therefore their complete provider
network will include many other additional specialists and provider
types. MCPs must ensure that all non-PCP network providers follow
community standards in the scheduling of routine appointments (i.e., the amount
of time members must wait from the time of their request to the first available
time when the visit can occur).
Although
there are currently no FTE capacity requirements of the non-PCP required
provider types, MCPs are required to ensure that adequate access is available
to
members for all required provider types. Additionally, for certain
non-PCP required provider types, MCPs must ensure that these providers maintain
a full-time practice at a site(s) located in the
specified county/region
(i.e., the ODJFS-specified
county within the region or anywhere within the region if no particular county
is specified). A full-time practice is defined as one where the
provider is available to patients at their practice site(s) in the specified
county/region for at least 25 hours a week. ODJFS will monitor access to
services through a variety of data sources, including: consumer
satisfaction surveys; member appeals/grievances/complaints and state hearing
notifications/requests; clinical quality studies; encounter data volume;
provider complaints, and clinical performance measures.
Hospitals
-
MCPs must contract with
the
number and type of hospitals specified by ODJFS for each county/region. In
developing these hospital requirements, ODJFS considered, on a county-by-county
basis, the population size and utilization patterns of the Covered Families
and
Children
(CFC) consumers and integrated
the existing utilization patterns into the hospital network requirements to
avoid disruption of care. For this reason, ODJFS may require that
MCPs contract with out-of-state hospitals (i.e. Kentucky,
West
Virginia, etc.).
For
each Ohiohospital,
ODJFS utilizes the hospital’s
most current Annual Hospital Registration and Planning Report, as filed with
the
Ohio Department of Health, in verifying types of services that hospital
provides. Although ODJFS has the authority, under certain situations,
to obligate a non-contracting hospital to provide non-emergency hospital
services to an MCP’s members, MCPs must still contract with the specified number
and type of hospitals unless ODJFS approves a provider panel exception (see
Section 4 of this appendix – Provider Panel Exceptions).
If
an
MCP-contracted hospital elects not to provide specific Medicaid-covered hospital
services because of an objection on moral or religious grounds, the MCP must
ensure that these hospital services are available to its members through another
MCP-contracted hospital in the specified
county/region.
OB/GYNs-
MCPs must contract with the
specified number of OB/GYNs for each county/region, all of whom must
maintain a full-time obstetrical practice at a site(s) located in the
specified
county/region. Only MCP-contracting OB/GYNs with current
hospital privileges at a hospital under contract with the MCP in the region
can
be submitted to the PVS, or other system, count towards MCP minimum panel
requirements, and be listed in the MCPs’ provider directory.
Certified
Nurse Midwives (CNMs)
and
Certified Nurse Practitioners (CNPs) - MCPs must ensure access to CNM
and CNP services in
the region if such provider types are present within the
region. The
MCP may contract directly with the CNM
or CNP providers, or with a physician or other provider entity who is able
to
obligate the participation of a CNM or CNP. If an MCP does not
contract for CNM or CNP services and such providers are present within the
region, the MCP will be required to allow members to receive CNM or CNP services
outside of the MCP’s provider network.
Only
CNMs
with hospital delivery privileges at a hospital under contract with the MCP
in
the region can be submitted to the PVS, or other system, count towards MCP
minimum panel requirements, and be listed in the MCPs’ provider directory.The
MCP must ensure a member’s access to CNM and CNP services if such providers are
practicing within the region.
Vision
Care Providers - MCPs
must contract with the specified number of ophthalmologists/optometrists
for each
specified county/region
,
all of whom must maintain
a
full-time practice at a site(s) located in the specified county/region. All
ODJFS-approved vision providers must regularly perform routine eye
exams.
(MCPs will be expected
to
contract with an adequate number of ophthalmologists as part of their overall
provider panel, but only ophthalmologists who regularly perform routine eye
exams can be used to meet the vision care provider panel requirement.)
If optical dispensing
is
not sufficiently available in a region through the MCP’s contracting
ophthalmologists/optometrists, the MCP must
separately
contract with an adequate
number of optical dispensers located in the region.
Dental
Care
Providers - MCPs must
contract with the specified number of dentists. In order to assure
sufficient access
to adult MCP members, no more
than two-thirds of the dentists used to meet the provider
panel requirement may be
pediatric dentists.
Federally
Qualified Health
Centers/Rural Health Clinics(FQHCs/RHCs) - MCPs are
required to ensure member access
to any federally qualified health center or rural health clinic
(FQHCs/RHCs), regardless of contracting status. Contracting FQHC/RHC
providers must be submitted for ODJFS approval via the PVS process, or
other designated process. Even if no FQHC/RHC is
available within the region, MCPs must have mechanisms in place to ensure
coverage for FQHC/RHC services in the event that a member accesses these
services outside of the region.
In
order
to ensure that any FQHC/RHC has the ability
to
submit a claim to ODJFS for the state’s supplemental payment, MCPs must offer
FQHCs/RHCs reimbursement pursuant to the following:
• MCPs
must provide expedited reimbursement on a service-specific basis in an amount
no
less than the payment made to other providers for the same or similar
service.
• If
the MCP has no comparable service-specific rate structure, the MCP must use
the
regular Medicaid
fee-for-service payment schedule for non-FQHC/RHC providers.
• MCPs
must make all efforts to pay FQHCs/RHCs as quickly as possible and not just
attempt to pay these claims within the prompt pay time frames.
MCPs
are
required to educate their staff and providers on the need to assure member
access to FQHC/RHC services.
Qualified
Family Planning Providers
(QFPPs) - All MCP members must be permitted to self-refer to family
planning services provided by a QFPP. A QFPP is defined as
any public or not-for-profit health care provider that complies with Title
X
guidelines/standards, and receives
either
Title X funding or family planning funding from the Ohio Department of
Health. MCPs must reimburse all medically-necessary
Medicaid-covered family planning services provided to eligible
members by a QFPP provider (including on-site pharmacy
and
diagnostic services) on a patient self-referral
basis, regardless of the
provider’s status as a panel or non-panel provider. MCPs will be
required to work with QFPPs in the region to develop mutually-agreeable HIPAA
compliant policies and procedures to preserve patient/provider confidentiality,
and conveypertinent
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 areadvised
not to contract with community
mental health centers as all services they provide to MCP members are to be
billed to ODJFS.
Other
Specialty
Types(pediatricians,
general surgeons, otolaryngologists, allergists, and orthopedists) - MCPs must contract
with the specified
number of all other ODJFS designated specialty provider types. In order to
be
counted toward meeting the provider panel requirements, these specialty
providers must maintain a full-time practice at a site(s) located within the
specified county/region. Only contracting general surgeons, orthopedists,
and otolaryngologists with admitting privileges at a hospital under contract
with the MCP in the region can be submitted to the PVS, or other system, count
towards MCP minimum panel requirements, and be listed in the MCPs’ provider
directory.
4. PROVIDER
PANEL
EXCEPTIONS
ODJFS
may specify provider panel
criteria for a service area that deviates from that specified in this appendix
if:
- the
MCP presents sufficient
documentation to ODJFS to verify that they have been unable to meet or maintain
certain provider panel requirements in a particular service area despite all
reasonable efforts on their part to secure such a contract(s),
and
- if
notified
by ODJFS, the provider(s) in
question fails to provide a reasonable argument why they would not contract
with
the MCP, and
- the
MCP presents sufficient assurances
to ODJFS that their members will have adequate access to the
services in
question.
If
an MCP is unable to contract with or
maintain a sufficient number of providers to meet the ODJFS-specified provider
panel criteria, the MCP may request an exception to these criteria by submitting
a provider panel exception request as specified by ODJFS. ODJFS will
review the exception request and determine whether the MCP has sufficiently
demonstrated that all reasonable efforts were made to obtain contracts with
providers of the type in question and that they will be able to provide access
to the services in question.
ODJFS
will aggressively monitor
access to all services
related to the approvalof
a provider
panel exception request through
a variety of data sources, including: consumer satisfaction
surveys; member
appeals/grievances/complaints and state hearingnotifications/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
tothe
services in question. If
ODJFS determines that an MCP has not provided sufficient access to these
services, the MCP may be subject to sanctions.
5. PROVIDER
DIRECTORIES
MCP
provider directories must include
all MCP-contracted providers [except as specified by ODJFS] as well as certain
non-contracted providers. At the time of ODJFS’ review, the
information listed in the MCP’s provider directory for all ODJFS-required
provider types specified on the attached charts must exactly match the data
currently on file in the ODJFS PVS,
or
other designated process.
MCP
provider directories must utilize a
format specified by ODJFS. Directories may be region-specific or include
multiple regions, however, the providers within the directory must be divided
by
region, county, and provider type, in that order.
The
directory must also specify:
• provider
address(es) and phone
number(s);
• an
explanation of how to access
providers (e.g. referral required vs. self-referral);
• an
indication of which providers are
available to members on a self-referral basis
• foreign-language
speaking PCPs and
specialists and the specific foreign language(s) spoken;
• how
members may obtain directory information in alternate formats that takes into
consideration the special needs of eligible individuals including but not
limited to, visually-limited, LEP, and LRP eligible individuals;
and
• any
PCP or specialist practice limitations.
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 toeach printed
directory that lists those
providers deleted
from
the MCP’s provider panel during the
previous three months. Althoughthis
insert does not need to be prior
approved by ODJFS, copies of the insert must be submitted to ODJFS two weeks
prior to distribution to members.
Internet
Provider Directory
MCPs
are required to have an
internet-based provider directory available in the same format as their
ODJFS-approved printed directory. This internet directory must allow
members to electronically search for MCP panel providers based on name, provider
type, and geographic proximity, and population
(e.g. CFC
and/or ABD). If an MCP has one internet-based directory for multiple
populations, each provider must include a description of which population they
serve.
The
internet directory may be updated at
any time to include providers who are not
one
of the ODJFS-required provider types
listed on the charts included with this appendix. ODJFS-required
providers must
be
added to the internet directory
within one week of the MCP’s notification of ODJFS-approval of the provider via
the Provider Verification process. Providers being
deleted from the MCP’s panel must
deleted from the internet directory within one week of notification from the
provider to the MCP. Providers
being deleted from the MCP’s
panel must be posted to the internet directory within one week of notification
from the providerto the MCP
of the deletion. These deleted providers must be included in the
inserts to the MCP’s provider directory referenced above.
6
. FEDERAL ACCESS
STANDARDS
MCPs
must
demonstrate that they are in compliance with the following federally
defined provider panel access standards as required by 42 CFR
438.206:
In
establishing and maintaining their provider panel, MCPs must consider the
following:
• The
anticipated Medicaid membership.
• The
expected utilization of services, taking into consideration the characteristics
and health care needs of specific Medicaid populations represented in the
MCP.
• The
number and types (in terms of
training, experience, and specialization) of panel providers required to deliver
the contracted Medicaid services.
• The
geographic location of panel
providers and Medicaid members, considering distance, travel time, the means
of
transportation ordinarily used by Medicaid members, and whether the
location provides physical access for Medicaid members with
disabilities.
• MCPs
must adequately and timely cover services to an out-of-network provider if
the
MCP’s contracted provider panel is unable to provide the services covered under
the MCP’s provider agreement. The MCP must cover the out-of-network
services for as long as the MCP network is unable to provide the services. MCPs must coordinate
with
the out-of-network provider with respect to payment and ensure that the provider
agrees with the applicable requirements.
Contracting
providers must offer hours of operation that are no less than the hours of
operation offered to commercial members or comparable to Medicaid
fee-for-service, if the provider serves only Medicaid members. MCPs
must ensure that services are available 24 hours a day, 7 days a week, when
medically necessary. MCPs must establish mechanisms to ensure that
panel providers comply with timely access requirements, and must take corrective action
if there is failure to comply.
In
order
to demonstrate adequate provider panel capacity and services, 42 CFR 438.206
and
438.207 stipulates that the MCP must submit documentation to ODJFS, in a format
specified by ODJFS, that demonstrates it offers an appropriate range of
preventive, primary care and specialty services
adequate for the anticipated number of members in the service area, while maintaining a
provider panel that is sufficient in number, mix, and geographic distribution
to
meet the needs of the number of members in the service area.
This
documentation of assurance of adequate capacity and services must be submitted
to ODJFS no less frequently than at the time the MCP enters into a contract
with
ODJFS; at any time there is a significant change (as defined by
ODJFS) in the MCP’s operations that would affect adequate capacity
and services (including changes in services, benefits, geographic service or
payments); and at any time there is enrollment of a new population in the
MCP.
WellCare
APPENDIX
J
FINANCIAL
PERFORMANCE
CFC
ELIGIBLE POPULATION
1. SUBMISSION
OF FINANCIAL STATEMENTS AND REPORTS
MCPs
must submit the following financial reports to ODJFS:
a. The
National Association of Insurance Commissioners (NAIC) quarterly and annual
Health Statements (hereafter referred to as the “Financial Statements”), as
outlined in Ohio Administrative Code (OAC) rule 5101:3-26-09(B). The
Financial Statements must include all required Health Statement filings,
schedules and exhibits as stated in the NAIC Annual Health Statement
Instructions including, but not limited to, the following
sections: Assets, Liabilities, Capital and Surplus Account, Cash
Flow, Analysis of Operations by Lines of Business, Five-Year Historical Data,
and the Exhibit of Premiums, Enrollment and Utilization. The
Financial Statements must be submitted to BMHC even if the Ohio Department
of
Insurance (ODI) does not require the MCP to submit these statements to
ODI. A signed hard copy and an electronic copy of the reports in the
NAIC-approved format must both be provided to ODJFS;
b. Hard
copies of annual financial statements for those entities who have an ownership
interest totaling five percent or more in the MCP or an indirect interest of
five percent or more, or a combination of direct and indirect interest equal
to
five percent or more in the MCP;
c. Annual
audited Financial Statements prepared by a licensed independent external auditor
as submitted to the ODI, as outlined in OAC rule 5101:3-26-09(B);
d. Medicaid
Managed Care Plan Annual Ohio Department of Job and Family Services (ODJFS)
Cost
Report and the auditor’s certification of the cost report, as outlined in OAC
rule 5101:3-26-09(B);
e. Medicaid
MCP Annual Restated Cost Report for the prior calendar year. The
restated
cost report shall be audited upon BMHC request;
f. Annual
physician incentive plan disclosure statements and disclosure of and changes
to
the MCP’s physician incentive plans, as outlined in OAC rule
5101:3-26-09(B);
g. Reinsurance
agreements, as outlined in OAC rule 5101:3-26-09(C);
h. Prompt
Pay Reports, in accordance with OAC rule 5101:3-26-09(B). A hard copy and an
electronic copy of the reports in the ODJFS-specified format must be provided
to
ODJFS;
i. Notification
of requests for information and copies of information released pursuant to
a
tort action (i.e., third party recovery), as outlined in OAC rule
5101:3-26-09.1;
j. Financial,
utilization, and statistical reports, when ODJFS requests such reports, based
on
a concern regarding the MCP’s quality of care, delivery of services, fiscal
operations or solvency, in accordance with OAC rule
5101:3-26-06(D);
k. In
accordance
with ORC Section 5111.76 and Appendix C, MCP Responsibilities, MCPs must
submit ODJFS-specified franchise fee reports in hard copy and
electronic formats pursuant to ODJFS specifications.
2. FINANCIAL
PERFORMANCE MEASURES AND STANDARDS
This
Appendix establishes specific expectations concerning the financial performance
of MCPs. In the interest of administrative simplicity and
nonduplication of areas of the ODI authority, ODJFS’ emphasis is on
the assurance of access to and quality of care. ODJFS will focus only on a
limited number of indicators and related standards to monitor plan
performance. The three indicators and standards for this contract
period are identified below, along with the calculation
methodologies. The source for each indicator will be the NAIC
Quarterly and Annual Financial Statements.
Report
Period: Compliance
will be determined based on the annual Financial Statement.
a. Indicator: Net
Worth as measured by
Net
Worth Per Member
Definition: Net
Worth =
Total Admitted Assets minus Total Liabilities divided by Total Members across
all lines of business
Standard: For
the
financial report that covers calendar year 2008, a minimum net worth per member
of $151.00, as determined from the annual Financial Statement submitted to
ODI
and the ODJFS.
The
Net
Worth Per Member (NWPM) standard is the Medicaid Managed Care Capitation amount
paid to the MCP during the preceding calendar year, including delivery payments,
but excluding the at-risk amount, expressed as a per-member per-month figure,
multiplied by the applicable proportion below:
0.75
if
the MCP had a total membership of 100,000 or more during that calendar
year
0.90
if
the MCP had a total membership of less than 100,000 for that calendar
year
If
the
MCP did not receive Medicaid Managed Care Capitation payments during the
preceding calendar year, then the NWPM standard for the MCP is the average
Medicaid Managed Care capitation amount paid to Medicaid-contracting MCPs during
the preceding calendar year, including delivery payments, but excluding the
at-risk amount, multiplied by the applicable proportion above.
b. Indicator: Administrative
Expense Ratio
Definition: Administrative
Expense Ratio = Administrative Expenses minus Franchise Fees divided by Total
Revenue minus Franchise Fees.
Standard: Administrative
Expense Ratio not to exceed 15%, as determined from the annual
Financial Statement submitted to ODI and ODJFS.
c. Indicator: Overall
Expense
Ratio
Definition: Overall
Expense Ratio = The sum of the Administrative Expense Ratio
and the Medical Expense Ratio.
Administrative
Expense Ratio = Administrative Expenses minus Franchise Fees divided by Total
Revenue minus Franchise Fees.
Medical
Expense Ratio = Medical Expenses divided by Total Revenue minus Franchise
Fees.
Standard: Overall
Expense Ratio not to exceed 100% as determined from the annual Financial
Statement submitted to ODI and ODJFS.
Penalty
for noncompliance:
Failure to meet any standard on 2.a., 2.b., or 2.c. above will result in ODJFS
requiring the MCP to complete a corrective action plan (CAP) and specifying
the
date by which compliance must be demonstrated. Failure to meet the
standard or otherwise comply with the CAP by the specified date will result
in a
new membership freeze unless ODJFS determines that the deficiency does not
potentially jeopardize access to or quality of care or affect the MCP’s ability
to meet administrative requirements (e.g., prompt pay
requirements). Justifiable reasons for noncompliance may include
one-time events (e.g., MCP investment in information system
products).
If
the
financial statement is not submitted to ODI by the due date, the MCP
continues
to be obligated to submit the report to ODJFS by ODI’s originally specified
due date unless the MCP requests and is granted an extension by ODJFS.
Failure
to submit complete quarterly and annual Financial Statements on a timely basis
will be deemed a failure to meet the standards and will be subject to the
noncompliance penalties listed for indicators 2.a., 2.b., and 2.c., including
the imposition of a new membership freeze. The new membership freeze will take
effect at the first of the month following the month in which the determination
was made that the MCP was non-compliant for failing to submit financial reports
timely.
In
addition, ODJFS will review two liquidity indicators if a plan demonstrates
potential problems in meeting related administrative requirements or the
standards listed above. The two standards, 2.d and
2.e, reflect ODJFS’ expected level of performance. At this
time, ODJFS has not established penalties for noncompliance with these
standards; however, ODJFS will consider the MCP’s performance regarding the
liquidity measures, in addition to indicators 2.a., 2.b., and 2.c., in
determining whether to impose a new membership freeze, as outlined above, or
to
not issue or renew a contract with an MCP. The source for each
indicator will be the NAIC Quarterly and annual Financial
Statements.
Long-term
investments that can be liquidated without significant penalty within 24 hours,
which a plan would like to include in Cash and Short-Term Investments in the
next two measurements, must be disclosed in footnotes on the NAIC
Reports. Descriptions and amounts should be
disclosed. Please note that “significant penalty” for this purpose is
any penalty greater than 20%. Also, enter the amortized cost of the investment,
the market value of the investment, and the amount of the penalty.
d. Indicator: Days
Cash on Hand
Definition: Days
Cash on
Hand = Cash and Short-Term Investments divided by (Total Hospital and Medical
Expenses plus Total Administrative Expenses) divided by 365.
Standard: Greater
than
25 days as determined from the annual Financial Statement submitted to ODI
and
ODJFS.
e. Indicator: Ratio
of Cash to Claims
Payable
Definition: Ratio
of
Cash to Claims Payable = Cash and Short-Term Investments divided by claims
Payable (reported and unreported).
Standard: Greater
than
0.83 as determined from the annual Financial Statement submitted to ODI and
ODJFS.
3. REINSURANCE
REQUIREMENTS
Pursuant
to the provisions of OAC rule 5101:3-26-09 (C), each MCP must carry reinsurance
coverage from a licensed commercial carrier to protect against inpatient-related
medical expenses incurred by Medicaid members.
The
annual deductible or retention amount for such insurance must be specified
in
the reinsurance agreement and must not exceed $75,000.00, except as provided
below. Except for transplant services, and as provided below, this
reinsurance must cover, at a minimum, 80% of inpatient costs incurred by one
member in one year, in excess of $75,000.00.
For
transplant services, the reinsurance must cover, at a minimum, 50% of
inpatient transplant
related costs incurred by one member in one year, in excess of
$75,000.00.
An
MCP
may request a higher deductible amount and/or that the reinsurance cover less
than 80% of inpatient costs in excess of the deductible amount. If
the MCP does not have more than 75,000 members in Ohio, but does have more
than
75,000 members between Ohio and other states, ODJFS may consider alternate
reinsurance arrangements. However, depending on the corporate
structures of the Medicaid MCP, other forms of security may be required in
addition to reinsurance. These other security tools may include
parental guarantees, letters of credit, or performance bonds. In determining
whether or not the request will be approved, the ODJFS may consider any or
all
of the following:
a. whether
the MCP has sufficient reserves available to pay unexpected claims;
b. the
MCP’s history in complying with financial indicators 2.a., 2.b., and 2.c., as
specified in this Appendix.
c. the
number of members covered by the MCP;
d. how
long the MCP has been covering Medicaid or other members on a full risk
basis.
e. risk
based capital ratio greater than 2.5 calculated from the last annual ODI
financial statement.
f. scatter
diagram or bar graph from the last calendar year that shows the number of
reinsurance claims that exceeded the current
reinsurance deductible.
The
MCP
has been approved to have a reinsurance policy with a deductible
amount of $75,000 that covers 80% of inpatient costs in excess of the
deductible amount for non-transplant services.
Penalty
for noncompliance: If
it is determined that an MCP failed to have reinsurance coverage, that an MCP’s
deductible exceeds $75,000.00 without approval from ODJFS, or that the MCP’s
reinsurance for non-transplant services covers less than 80% of inpatient costs
in excess of the deductible incurred by one member for one year without approval
from ODJFS, then the MCP will be required to pay a monetary penalty to
ODJFS. The amount of the penalty will be the difference between the
estimated amount, as determined by ODJFS, of what the MCP would have paid in
premiums for the reinsurance policy if it had been in compliance and what the
MCP did actually pay while it was out of compliance plus 5%. For
example, if the MCP paid $3,000,000.00 in premiums during the period of
non-compliance and would have paid $5,000,000.00 if the requirements had been
met, then the penalty would be $2,100,000.00.
If
it is
determined that an MCP’s reinsurance for transplant services covers less than
50% of inpatient costs incurred by one member for one year, the MCP will be
required to develop a corrective action plan (CAP).
4. PROMPT
PAY REQUIREMENTS
In
accordance with 42 CFR 447.46, MCPs must pay 90% of all submitted clean claims
within 30 days of the date of receipt and 99% of such claims within 90 days
of
the date of receipt, unless the MCP and its contracted provider(s) have
established an alternative payment schedule that is mutually agreed upon
and described in their contract. The prompt pay requirement applies
to the processing of both electronic and paper claims for contracting and
non-contracting providers by the MCP and delegated claims processing
entities.
The
date
of receipt is the date the MCP receives the claim, as indicated by its date
stamp on the claim. The date of payment is the date of the check or
date of electronic payment transmission. A claim means a xxxx from a
provider for health care services that is assigned a unique
identifier. A claim does not include an encounter form.
A
“claim”
can include any of the following: (1) a xxxx for services; (2) a line
item of services; or (3) all services for one recipient within a
xxxx. A “clean claim” is a claim that can be processed without
obtaining additional information from the provider of a service or from a third
party.
Clean
claims do not include payments made to a provider of service or a third party
where the timing of the payment is not directly related to submission of a
completed claim by the provider of service or third party (e.g.,
capitation). A clean claim also does not include a claim from a
provider who is under investigation for fraud or abuse, or a claim under review
for medical necessity.
Penalty
for
noncompliance: Noncompliance with prompt pay requirements will
result in progressive penalties to be assessed on a quarterly basis, as outlined
in Appendix N of the Provider Agreement.
5. PHYSICIAN
INCENTIVE PLAN DISCLOSURE REQUIREMENTS
MCPs
must
comply with the physician incentive plan requirements stipulated in 42 CFR
438.6(h). If
the MCP operates a physician incentive plan, no specific payment can be made
directly or indirectly under this physician incentive plan to a physician or
physician group as an inducement to reduce or limit medically necessary services
furnished to an individual.
If
the
physician incentive plan places a physician or physician group at substantial
financial risk [as determined under paragraph (d) of 42 CFR 422.208] for
services that the physician or physician group does not furnish itself, the
MCP
must assure that all physicians and physician groups at substantial financial
risk have either aggregate or per-patient stop-loss protection in accordance
with paragraph (f) of 42 CFR 422.208, and conduct periodic surveys in accordance
with paragraph (h) of 42 CFR 422.208.
In
accordance with 42 CFR 417.479 and 42 CFR 422.210, MCPs must maintain copies
of
the following required documentation and submit to ODJFS annually, no later
than
30 days after the close of the state fiscal year and upon any modification
of
the MCP’s physician incentive plan:
a. A
description of the types of physician incentive arrangements the MCP has in
place which indicates whether they involve
a
withhold, bonus, capitation, or other arrangement. If a physician
incentive arrangement involves a withhold or bonus, the percent of the withhold
or bonus must be specified.
b. A
description of information/data feedback to a physician/group on their: 1)
adherence to evidence-based practice guidelines; and 2) positive
and/or negative care variances from standard clinical pathways that may impact
outcomes or costs. The feedback information may be used by the MCP
for activities such as physician performance improvement projects that include
incentive programs or the development of quality improvement
initiatives.
c. A
description of the panel size for each physician incentive plan. If
patients are pooled, then the pooling method used to determine if substantial
financial risk exists must also be specified.
d. If
more than 25% of the total potential payment of a physician/group is at risk
for
referral services, the MCP must maintain a copy of the results of the required patient
satisfaction survey and documentation verifying that the physician
or
physician group has adequate stop-loss protection, including the type of
coverage (e.g., per member per year, aggregate), the threshold amounts, and
any
coinsurance required for amounts over the threshold.
6. NOTIFICATION
OF REGULATORY ACTION
Any
MCP
notified by the ODI of proposed or implemented regulatory action must report
such notification and the nature of the action to ODJFS no later than one
working day after receipt from ODI. The ODJFS may request, and the
MCP must provide, any additional information as necessary to assure continued
satisfaction of program requirements. MCPs may request that
information related to such actions be considered proprietary in accordance
with
established ODJFS procedures. Failure to comply with this provision
will result in an immediate membership freeze.
APPENDIX K
QUALITY
ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM
AND
EXTERNAL
QUALITY REVIEW
CFC
ELIGIBLE POPULATION
1. As
required by federal regulation, 42 CFR 438.240, each managed care plan (MCP)
must have an ongoing Quality Assessment and Performance Improvement Program
(QAPI) that is annually prior-approved by the Ohio Department of Job and
Family
Services (ODJFS). The program must include the following
elements:
a. PERFORMANCE
IMPROVEMENT
PROJECTS
Each
MCP
must conduct performance improvement projects (PIPs), including those specified
by ODJFS. PIPs must achieve, through periodic measurements and
intervention, significant and sustained improvement in clinical and non-clinical
areas which are expected to have a favorable effect on health outcomes and
satisfaction. MCPs must adhere to ODJFS PIP content and format
specifications.
All
ODJFS-specified PIPs must be prior-approved by ODJFS. As part of the
external quality review organization (EQRO) process, the EQRO will assist
MCPs
with conducting PIPs by providing technical assistance and will annually
validate the PIPs. In addition, the MCP must annually submit to ODJFS
the status and results of each PIP.
MCPs
must
initiate the following PIPs:
i. Non-clinical
Topic: Identifying children/members with special health care
needs.
ii.
Clinical
Topic: Well-child visits during the first 15 months of
life.
iii.
Clinical
Topic: Percentage of members aged 2-21 years that access
dental care services.
Initiation
of PIPs will begin in the second year of participation in the Medicaid managed
care program.
b. UNDER-
AND
OVER-UTILIZATION
Each
MCP
must have mechanisms in place to detect under- and over-utilization of health
care services. The MCP must specify the mechanisms used to monitor
utilization in its annual submission of the QAPI program to ODJFS.
It
should
also be noted that pursuant to the program integrity provisions outlined
in
Appendix I, MCPs must monitor for the potential under-utilization of services
by
their members in order to assure that all Medicaid-covered services are being
provided, as required. If any under-utilized services are identified,
the MCP must immediately investigate and correct the problem(s) which resulted
in such under-utilization of services.
In
addition the MCP must conduct an ongoing review of service denials and must
monitor utilization on an ongoing basis in order to identify services which
may
be under-utilized.
c. SPECIAL
HEALTH CARE
NEEDS
Each
MCP
must have mechanisms in place to assess the quality and appropriateness of
care
furnished to children/members with special health care needs. The MCP
must specify the mechanisms used in its annual submission of the QAPI program
to
ODJFS.
d. SUBMISSION
OF PERFORMANCE
MEASUREMENT DATA
Each
MCP
must submit clinical performance measurement data as required by ODJFS that
enables ODJFS to calculate standard measures. Refer to Appendix M
“Performance Evaluation” for a more comprehensive description of the clinical
performance measures.
Each
MCP
must also submit clinical performance measurement data as required by ODJFS
that
uses standard measures as specified by ODJFS. MCPs are required to
submit Health Employer Data Information Set (HEDIS) audited data for the
following measures:
i. Well
Child Visits in the First 15 Months
of Life
ii. Child
Immunization
Status
The
measures must have received a “report” designation from the HEDIS certified
auditor and must be specific to the Medicaid population. Data must be
submitted annually and in an electronic format. Data will be used for
MCP clinical performance monitoring and will be incorporated into comparative
reports developed by the EQRO.
Initiation
of submission of performance data will begin in the second year of participation
in the Medicaid managed care program.
e. QAPI
PROGRAM
SUBMISSION
Each
MCP
must implement an evaluation process to review, revise, and/or update the
QAPI
program. The MCP must annually submit its QAPI program for review and
approval by ODJFS.
2. EXTERNAL
QUALITY REVIEW
In
addition to the following requirements, MCPs must participate in external
quality review activities as outlined in OAC 5101:3-26-07.
a. EQRO
ADMINISTRATIVE
REVIEWS
The
EQRO
will conduct annual focused administrative compliance assessments for each
MCP
which will include, but not be limited to, the following domains as specified
by
ODJFS: member rights and services, QAPI program, case management,
provider networks, grievance system, coordination and continuity of care,
and
utilization management. In addition, the EQRO will complete a
comprehensive administrative compliance assessment every three (3) years
as
required by 42 CFR 438.358 and specified by ODJFS.
In
accordance with 42 CFR 438.360 and 438.362, MCPs with accreditation
from a national accrediting organization approved by the Centers for Medicare
and Medicaid Services (CMS) may request a non-duplication exemption from
certain
specified components of the administrative review. Non-duplication
exemptions may not be requested for SFY 2008.
b. EXTERNAL
QUALITY REVIEW
PERFORMANCE
In
accordance with OAC 5101: 3-26-07, each MCP must participate in
an annual external
quality review survey. If the EQRO cites a deficiency in performance,
the MCP will be required to complete a Corrective Action Plan (e.g., ODJFS
technical assistance session) or Quality Improvement Directives depending
on the
severity of the deficiency. (An example of a deficiency is if an MCP
fails to meet certain clinical or administrative standards as supported by
national evidence-based guidelines or best
practices.) Serious deficiencies may result in immediate
termination or non-renewal of the provider agreement. These quality
improvement measures recognize the importance of ongoing MCP performance
improvement related to clinical care and service delivery.
APPENDIX
L
DATA
QUALITY
CFC
ELIGIBLE
POPULATION
A
high
level of performance on the data quality measures established in this appendix
is crucial in order for the Ohio Department of Job and Family Services (ODJFS)
to determine the value of the Medicaid Managed Health Care Program and to
evaluate Medicaid consumers’ access to and quality of services. Data collected
from MCPs are used in key performance assessments such as the external quality
review, clinical performance measures, utilization review, care coordination
and
case management, and in determining incentives. The data will also be
used in conjunction with the cost reports in setting the premium payment
rates. The following
measures, as specified in this appendix, will be calculated per MCP and include
all Ohio Medicaid members receiving services from the MCP (i.e., Covered
Families and Children (CFC) and Aged, Blind, or Disabled (ABD) membership,
if
applicable): Incomplete Outpatient Hospital Data, Rejected
Encounters, Acceptance Rate, Encounter Data Accuracy, and Generic Provider
Number Usage.
Data
sets
collected from MCPs with data quality standards include: encounter data;
case
management data; data used in the external quality review; members’ PCP data;
and appeal and grievance data.
1.
ENCOUNTER DATA
For
detailed descriptions of the
encounter data quality measures below, see ODJFS
Methods for
Encounter Data Quality Measures for
CFC and
ABD.
1.a. Encounter
Data Completeness
Each
MCP’s encounter data submissions will be assessed for
completeness. The MCP is responsible for collecting information from
providers and reporting the data to ODJFS in accordance with program
requirements established in Appendix C, MCP
Responsibilities. Failure to do so jeopardizes the MCP’s
ability to demonstrate compliance with other performance standards.
1.a.i.
Encounter Data Volume
Measure: The
volume measure for each
service category, as listed in Table 2 below,
is the rate of utilization (e.g.,
discharges, visits) per 1,000 member months (MM).
Report
Period: The
report periods for the SFY
2008 and SFY 2009 contract
periods are listed in Table
1. below.
Table
1. Report Periods for the
SFY 2008 and
2009 ContractPeriods
|
Quarterly
Report
Periods
|
Data
Source:
Estimated
Encounter Data File Update
|
Quarterly
Report
Estimated
Issue
Date
|
Contract
Period
|
|
Qtr 3
& Qtr
4 2004, 2005,
2006
Qtr
1 2007
|
July2007
|
August2007
|
SFY2008
|
|
Qtr3
&Qtr
4 2004,
2005,
2006
Qtr
1, Qtr 2
2007
|
October
2007
|
November
2007
|
|
|
Qtr
4 2004,2005,
2006Qtr 1 thru Qtr 3
2007
|
January
2008
|
February
2008
|
|
|
Qtr
1 thru Qtr 4: 2005, 2006,
2007
|
April 2008
|
May
2008
|
|
|
Qtr
2 thru Qtr 4
2005,
Qtr
1 thru Qtr 4: 2006,
2007
Qtr
1 2008
|
July
2008
|
August
2008
|
SFY
2009
|
|
Qtr
3, Qtr 4:
2005,
Qtr
1 thru Qtr 4: 2006,
2007
Qtr
1, Qtr 2
2008
|
October 2008
|
November 2008
|
|
|
Qtr
4: 2005,
Qtr
1 thru Qtr 4: 2006,
2007
Qtr
1 thru Qtr 3:
2008
|
January 2009
|
February 2009
|
|
|
Qtr
1 thru Qtr 4: 2006, 2007,
2008
|
April 2009
|
May 2009
|
Qtr1
=
January to March Qtr2 = April to
June Qtr3 = July to
September Qtr4 = October to
December
Table
2. Standards – Encounter Data Volume
(County-Based
Approach)
Data
Quality
Standard, County-Based Approach: The standards in Table
2
apply to the MCP’s county-based results (see County-Based
Approachbelow). The utilization rate
for all service categories
listed in Table 2 must be
equal to or greater than the standard established in Table 2
below.
|
Category
|
Measure
per 1,000/MM
|
Standard
for Dates of Service
7/1/2003
thru
6/30/2004
|
Standard
for Dates of Service
7/1/2004thru
6/30/2006
|
Standard
for Dates of
Service
on
or after
7/1/2006
|
Description
|
|
Inpatient
Hospital
|
Discharges
|
5.4
|
5.0
|
5.4
|
General/acute
care, excluding newborns and mental health and chemical dependency
services
|
|
Emergency
Department
|
Visits
|
51.6
|
51.4
|
50.7
|
Includes
physician and hospital emergency department encounters
|
|
Dental
|
38.2
|
41.7
|
50.9
|
Non-institutional
and hospital dental visits
|
|
|
Vision
|
11.6
|
11.6
|
10.6
|
Non-institutional
and hospital outpatient optometry and ophthalmology
visits
|
|
|
Primary
and Specialist Care
|
220.1
|
225.7
|
233.2
|
Physician/practitioner
and hospital outpatient visits
|
|
|
Ancillary
Services
|
144.7
|
123.0
|
133.6
|
Ancillary
visits
|
|
|
Behavioral
Health
|
Service
|
7.6
|
8.6
|
10.5
|
Inpatient
and outpatient behavioral encounters
|
|
Pharmacy
|
Prescriptions
|
388.5
|
457.6
|
492.2
|
Prescribed
drugs
|
County-Based
Approach: All
counties with managed care
membership as of February 1, 2006, will be included in a county-based
encounter data volume measure until regional evaluation is implemented for
the
county’s applicable region.. Upon
implementation of
regional-based
evaluation for a
particular county’s region, the county will be included in the MCP’s
regional-based results and will no longer be included in the MCP’s county-based
results. County-based results will be determined by MCP (i.e., one utilization
rate per service category for all applicable counties) and must be equal
to or
greater than the standards established in Table 2 above. [Example:
The county-based result for MCP AAA, which has contracts in the Central and
West
Central regions, will include Franklin, Pickaway, Xxxxxxxxxx, Xxxxxx and
Xxxxx
counties (i.e., counties with managed care membership as of February 1,
2006). When the
regional-based
evaluation
is implemented for
the
Central region, Franklin and Pickaway counties, along with all other counties
in
the region, will then be included in the Central region results for MCP AAA;
Montgomery, Greene, and Xxxxx counties
will remain in the county-based
results for MCP AAA until the West Central regional measure is
implemented.]
Interim
Regional-Based
Approach:
Prior
to the transition to the
regional-based approach, encounter data volume will be evaluated by MCP,
by
region, using an interim approach. All regions with managed care
membership will be included in results for an interim regional-based encounter
data volume measure until regional evaluation is implemented for the applicable
region (see Regional-Based Approach below). Encounter data volume
will be evaluated by MCP ( i.e., one utilization rate per service category
for
all counties in the region). The utilization rate for all service
categories listed
in Table 3 must be equal to or greater than the standard established in Table
3
below. The standards listed in Table 3 below are based on utilization
data for counties with managed care membership as of February 1, 2006, and
have
been adjusted to
accommodate estimated differences in
utilization for all counties in a region, including counties that did not
have
membership as of February 1, 2006.
Prior
to implementation of the
regional-based approach, an MCP’s encounter data volume will be evaluated using
the county-based approach and the interim regional-based approach. A
county with managed care membership as of February 1, 2006, will be
included in both the County-Based approach and the Interim Regional-Based
approach until regional
evaluation is implemented for the county’s applicable
region.
Data
Quality
Standard, Interim Regional-Based Approach: The standards in Table
3
apply to the MCP’s interim regional-based results. The utilization
rate for all service categories listed in Table 3 must be equal to or greater
than the standard established in Table 3 below.
Table
3. Standards – Encounter Data Volume (Interim Regional-Based
Approach)
|
Category
|
Measure
per 1,000/MM
|
Standard
for Dates of
Service
on
or after
7/1/2006
|
Description
|
|
Inpatient
Hospital
|
Discharges
|
2.7
|
General/acute
care, excluding newborns and mental health and chemical dependency
services
|
|
Emergency
Department
|
Visits
|
25.3
|
Includes
physician and hospital emergency department encounters
|
|
Dental
|
25.5
|
Non-institutional
and hospital dental visits
|
|
|
Vision
|
5.3
|
Non-institutional
and hospital outpatient optometry and ophthalmology
visits
|
|
|
Primary
and Specialist Care
|
116.6
|
Physician/practitioner
and hospital outpatient visits
|
|
|
Ancillary
Services
|
66.8
|
Ancillary
visits
|
|
|
Behavioral
Health
|
Service
|
5.2
|
Inpatient
and outpatient behavioral encounters
|
|
Pharmacy
|
Prescriptions
|
246.1
|
Prescribed
drugs
|
Determination
of
Compliance:Performance is
monitored once every quarter for the entire report period. If the
standard is not met for every service category in all quarters of the report
period in either the
county-based or interim regional-based approach, or both, then the MCP will be
determined to be
noncompliant for the report period.
Penalty
for
noncompliance: The first time an MCP is noncompliant with a
standard for this measure, ODJFS will issue a Sanction Advisory informing
the
MCP that any future noncompliance instances with the standard for this measure
will result in ODJFS imposing a monetary sanction. Upon all subsequent
measurements of performance, if an MCP is again determined to be noncompliant
with the standard, ODJFS will impose a monetary sanction (see Section 6.)
of two
percent of the current month’s premium payment. Monetary
sanctions will
not be levied for
consecutive quarters
that an MCP is determined to be
noncompliant. If an MCP is noncompliant for three consecutive quarters,
membership will
be frozen. Once
the MCP is determined to be
compliant with the standard and the violations/deficiencies are resolved
to the
satisfaction of ODJFS, the penalties will be lifted, if applicable, and monetary
sanctions will be returned.
Regional-Based
Approach: Transition to the
regional-based approach will occur by region, after the first four
quarters (i.e., full calendar year quarters) of regional
membership. Encounter data volume will be evaluated by MCP, by
region, after determination of the regional-based data quality
standards. ODJFS will use the first four quarters of data (i.e., full
calendar year quarters) from all MCPs serving in an active region to determine
minimum encounter volume data quality standards for that
region.
1.a.ii.
Incomplete Outpatient Hospital Data
Since
July 1, 1997, MCPs have been required to provide both the revenue code and
the
HCPCS code on applicable outpatient hospital encounters. ODJFS will be
monitoring, on a quarterly basis, the percentage of hospital encounters which
contain a revenue code and CPT/HCPCS code. A CPT/HCPCS code must
accompany certain revenue center codes. These codes are listed in Appendix
B of
Ohio Administrative Code rule 5101:3-2-21 (fee-for-service outpatient hospital
policies) and in the methods for calculating the completeness
measures.
Measure:
The percentage of outpatient hospital
line
items with certain revenue center codes, as explained above, which had an
accompanying valid procedure (CPT/HCPCS) code. The measure will be
calculated per
MCP.
Report
Period: For
the SFY 2008
and SFY 2009 contractperiods,
performance will be evaluated
using the report periods listed in
1.a.i., Table 1.
Data
Quality Standard: The
data quality standard is a minimum rate of 95%.
Determination
of
Compliance: Performance is monitored
once every
quarter for all report periods.
For
quarterly reports that are issued on
or after July 1, 2007, an MCP will be determined to be noncompliant for the
quarter if the standard is not met in any report period and the initial instance
of noncompliance in a report period is determined on or after July 1,
2007. An initial instance of noncompliance means that the result for
the applicable report period was in compliance as determined in the prior
quarterly report, or the instance of noncompliance is the first determination
for an MCP’s first quarter of measurement.
Penalty
for
noncompliance: The first time an MCP is noncompliant with a
standard for this measure, ODJFS will issue a Sanction Advisory informing
the
MCP that any future noncompliance instances with the standard for this measure
will result in ODJFS imposing a monetary sanction.
Upon
all
subsequent quarterly measurements of performance, if an MCP is again determined
to be noncompliant with the standard, ODJFS will impose a monetary sanction
(see
Section 6) of one percent of the current month’s premium
payment. Once the MCP is performing at standard levels and
violations/deficiencies are resolved to the satisfaction of ODJFS, the money
will be refunded.
1.a.iii.
Incomplete Data For Last Menstrual Period
As
outlined in ODJFS Encounter
Data Specifications, the last menstrual period (LMP) field is a required
encounter data field. It is discussed in Item 14 of the “HCFA 1500 Billing
Instructions.” The date of the LMP is essential for calculating the clinical
performance measures and allows the ODJFS to adjust performance expectations
for
the length of a pregnancy.
The
occurrence code and date fields on the UB-92, which are “optional” fields, can
also be used to submit the date of the LMP. These fields are described in
Items
32a & b, 33a & b, 34a & b, 35a & b of the “Inpatient Hospital”
and “Outpatient Hospital UB-92 Claim Form Instructions.”
An
occurrence code value of ‘10’ indicates that a LMP date
was provided. The actual date of the LMP would be given in the
‘Occurrence Date’ field.
Measure: The
percentage of
recipients with a live birth during the report
period where a “valid”
LMP date was given on one or more of
the recipient’s
perinatal claims. If the LMP date is
before the date of birth and there is a difference of between 119 and 315
days
between the date the recipient gave birth and the LMP date, then the LMP
date
will be considered a valid date. The measure will be
calculated per
MCP (i.e., to include
the MCP’s service area for the
CFC.
Report
Period: For the SFY 2008 contract
period,
performance will be evaluated using the January - December 2007 report
period. For the SFY 2009 contract period, performance will be
evaluated using the January - December 2008 report period.
Data
Quality
Standard: The data quality
standard is a
minimum rate of 80%.
Penalty
for
noncompliance: The first time an MCP is noncompliant with a
standard for this measure, ODJFS will issue a Sanction Advisory informing
the
MCP that any future noncompliance instances
with the standard for this measure will result in ODJFS imposing a monetary
sanction. Upon all subsequent measurements of performance, if an MCP is again
determined to be noncompliant with the standard, ODJFS will impose a monetary
sanction (see Section 6.) of one percent of the current month’s premium
payment. Once the MCP is performing at standard levels and
violations/deficiencies are resolved to the satisfaction of ODJFS, the money
will be refunded.
1.a.iv.
Rejected Encounters
Encounters submitted
to ODJFS that are incomplete or inaccurate are rejected and reported
back to the MCPs on the Exception Report. If an MCP does not resubmit
rejected encounters, ODJFS’ encounter data set will be incomplete.
Measure
1 only applies to
MCPs that have had Medicaid membership for more than one
year.
Measure
1: The
percentage of encounters submitted to ODJFS that are
rejected. The
measure will be calculated per MCP.
Report
Period: For the
SFY 2008 contract period, performance will be evaluated using the following
report periods: April - June 2007;
July - September 2007; October -
December 2007,
January - March 2008, and April – June
2008. For the SFY 2009 contract period, performance will be evaluated
using the following report periods: July - September 2008; October -
December 2008, January - March 2009, and April – June
2009.
Data
Quality Standard
for
measure 1: Data
Quality Standard 1 is a
maximum encounter data rejection rate of 10% for each file type in the ODJFS-specified
medium
performat for encounters
submitted in SFY 2004 and thereafter. The measure will be
calculated per
MCP.
Determination
of
Compliance: Performance is monitored
once every quarter. Compliance determination with the standard applies only
to
the quarter under consideration and does not include performance in previous
quarters.
Penalty
for
noncompliance with the
Data
Quality
Standard for
measure
1: The first
time
an MCP is noncompliant with a standard for this measure, ODJFS will issue
a
Sanction Advisory informing the MCP that any future noncompliance instances
with
the standard for this measure will result in ODJFS imposing a monetary sanction.
Upon all subsequent measurements of performance, if an MCP is again determined
to be noncompliant with the standard, ODJFS will impose a monetary sanction
(see
Section 6.) of one percent of the current month’s premium
payment. The monetary sanction will be applied for each file
type in the ODJFS-specified medium
per format that is
determined to be out of compliance. Once the MCP is performing
at standard levels and violations/deficiencies are resolved to the satisfaction
of ODJFS, the money will be refunded.
Measure
2 only applies to
MCPs that have had Medicaid membership for one year or less.
Measure
2: The
percentage of encounters submitted to ODJFS that are rejected. The
measure will be calculated per
MCP.
Report
Period: The report period
for Measure 2 is monthly. Results
are calculated and performance
is monitored monthly.
The
first reporting month begins
with
the
third month of
enrollment.
Data
Quality Standard
for
measure 2: The
data quality standard
is a maximum encounter data rejection rate for each file type in the ODJFS-specified
medium per format as follows:
|
Third
through sixth months with
membership: 50%
|
|
|
Seventh
through twelfth month with
membership: 25%
|
|
Files
in the ODJFS-specified medium per
format that are
totally rejected will not be considered in the determination of
noncompliance.
Determination
of
Compliance: Performance is monitored once every
month. Compliance
determination with the
standard applies only to the month under
consideration and does not include
performance in previous quarters.
Penalty
for
Noncompliance withthe
Data
Quality
Standard for
measure
2: If
the MCP is determined to
be noncompliant for either standard, ODJFS will impose a monetary sanction
of
one percent of the MCP’s current month’s premium
payment. The
monetary sanction will be applied for each file type in the ODJFS-specified
medium per format that is determined to be out of
compliance. The
monetary sanction will be applied only once per file type per
compliance determination period and
will not exceed a total of two percent of the MCP’s current month’s premium
payment. Once the MCP is performing at standard levels and
violations/deficiencies are resolved to the satisfaction of ODJFS, the money
will be refunded. Special consideration will be made for MCPs
with less than 1,000 members.
1.a.v.
Acceptance Rate
This
measure only applies to
MCPs that have had Medicaid membership for one year or less.
Measure: The
rate of encounters
that are submitted to
ODJFSand accepted (accepted
encounters per
1,000 member months). The
measure will be calculated per
MCP.
Report
Period: The
report period for this measure is monthly. Results
are calculated and performance
is monitoredmonthly. The
first reporting month
begins with the third month
of enrollment.
Data
Quality
Standard: The data quality standard is a monthly minimum
accepted rate of encounters for each file
type in the ODJFS-specified
medium per
format as
follows:
|
Third
through sixth month with
membership:
|
50
encounters per 1,000 MM for
NCPDP
|
|
65
encounters per 1,000 MM for
NSF
|
|
|
20
encounters per 1,000 MM for
UB-92
|
|
|
Seventh
through twelfth month of
membership:
|
250
encounters per 1,000 MM for
NCPDP
|
|
350
encounters per 1,000 MM for
NSF
|
|
|
100
encounters per 1,000 MM for
UB-92
|
Determination
of
Compliance: Performance is monitored
once every month.
Compliance
determination
with the standard applies only to the month under
consideration and does not include
performance in previous months.
Penalty
for
Noncompliance: If the MCP is determined
to
be noncompliant with the standard, ODJFS will impose a monetary sanction
of one
percent of the MCP’s current month’s premium payment. The monetary sanction
will be applied
for each file type in the ODJFS-specified medium per format that is determined
to be out of compliance. The monetary sanction
will be applied
only once per file type
per
compliance
determination period and will not exceed a total of two percent of the MCP’s
current month’s premium payment. Once the MCP is performing at
standard levels and violations/deficiencies are resolved to the satisfaction
of
ODJFS, the money will be refunded. Special consideration
will be made for
MCPs with less than 1,000 members.
1.b. Encounter
Data
Accuracy
As
with data completeness, MCPs are
responsible for assuring the collection and submission of accurate data to
ODJFS. Failure to do so jeopardizes MCPs’ performance,
credibility
and, if not corrected, will
be assumed to indicate a failure in actual performance.
1.b.i. Encounter
Data
Accuracy Studies
Measure
1: The
focus of this accuracy
study will be on delivery
encounters. Its primary purpose will be to verify that MCPs submit
encounter data accurately and to ensure only one payment is made per
delivery. The rate of appropriate payments will be determined by
comparing a sample of delivery payments to the medical
record. The
measure will be calculated per MCP (i.e., to include the
MCP’s entire service area for the
CFC membership.
Report
Period: In
order to provide timely feedback on the accuracy rate of encounters, the
report
period will be the most recent from when the measure is
initiated. This measure is conducted annually.
Medical
records retrieval from the provider and submittal to ODJFS or its designee
is an
integral component of the validation process. ODJFS has optimized the
sampling to minimize the number of records required. This methodology
requires a high record submittal rate. To aid MCPs in achieving
a
high
submittal rate, ODJFS will give at least an 8 week period to retrieve and
submit
medical records as a part of the validation process. A record
submittal rate will be calculated as a percentage of all records requested
for
the study.
Data
Quality Standard
1
for
Measure 1:For
results that are finalized during
the contract year, the accuracy rate for encounters generating delivery payments
is 100%.
Penalty
for
noncompliance: The MCP must
participate in a detailed review of delivery payments made for deliveries
during
the report period. Any duplicate or unvalidated delivery payments
must be returned to ODJFS.
Data
Quality
Standard 2
for
Measure
1: A
minimum record
submittal rate of 85%.
Penalty
for
noncompliance: For all encounter data accuracy studies that
are completed during this contract period, if an MCP is noncompliant with
the
standard, ODJFS will impose a non-refundable $10,000 monetary
sanction.
Measure
2: This accuracy
study will compare the
accuracy and completeness of payment data stored
in MCPs’
claims systems during the study period to payment data submitted to and accepted
by
ODJFS. The measure will
be
calculated per MCP.
Payment
information found in MCPs’
claims systems for paid claims that does not match payment information found
on
a corresponding encounter will be counted as omissions.
Report
Period: In order
to provide timely feedback on the omission rate of encounters, the report
period
will be the most recent from when the measure is initiated. This
measure is conducted annually.
Data
Quality
Standard for
Measure 2: TBD
for SFY 2008 and SFY 2009 based on study conducted in SFY 2007 (standard
to be
released in June, 2007).
Penalty
for
Noncompliance: The first time an MCP
is
noncompliant with a standard for this measure, ODJFS will issue a Sanction
Advisory informing the MCP that any future noncompliance instances with the
standard for this measure will result in ODJFS imposing a monetary sanction.
Upon all subsequent measurements of performance, if an MCP is again determined
to be noncompliant with the standard, ODJFS will impose a monetary sanction
(see
Section 6) of one percent of the current month’s premium
payment. Once the MCP is performing at standard levels and
violations/deficiencies are resolved to the satisfaction of ODJFS, the money
will be refunded.
1.b.ii. Generic
Provider Number Usage
Measure:
This measure is the
percentage of non-pharmacy encounters with the generic provider
number. Providers submitting claims which do not have an MMIS
provider number must be submitted to ODJFS with the generic provider number
9111115. The
measure will be calculated per MCP.
All
other
encounters are required to have the MMIS provider number of the servicing
provider. The report period for this measure
is quarterly.
Report
Period: For
the SFY 2008 and SFY 2009
contract periods,
performance will be evaluated using the report periods listed in 1.a.i.,
Table
1.
Data
Quality
Standard:A maximum generic
provider number
usage
rate of
10%.
Determination
of
Compliance: Performance is
monitored once every quarter for all report periods. For quarterly reports
that are issued on
or after July 1, 2007, an MCP will be determined to be noncompliant for the
quarter if the standard is not met in any report period and the initial instance
of noncompliance in a report period is determined on or after July 1,
2007. An initial instance of noncompliance means that the result for
the applicable report period was in compliance as determined in the prior
quarterly report, or the instance of noncompliance is the first determination
for an MCP’s first quarter of measurement.
Penalty
for
noncompliance: The first time an MCP is noncompliant
with a standard for this measure, ODJFS will issue a Sanction Advisory informing
the MCP that any future noncompliance instances with the standard for this
measure will result in ODJFS imposing a monetary sanction.
Upon
all
subsequent measurements of performance, if an MCP is again determined to
be
noncompliant with the standard, ODJFS will impose a monetary sanction (see
Section 6.) of three percent of the current month’s premium
payment. Once the MCP is performing at standard levels and
violations/deficiencies are resolved to the satisfaction of ODJFS, the money
will be refunded.
1.c.
Timely Submission of Encounter Data
1.c.i. Timeliness
ODJFS
recommends submitting encounters no later than thirty-five days after the
end of
the month in which they were paid. ODJFS does not monitor standards
specifically for timeliness, but the minimum claims volume (Section 1.a.i.)
and
the rejected encounter (Section 1.a.v.) standards are based on encounters
being
submitted within this time frame.
1.c.ii. Submission
of Encounter Data Files
in the ODJFS-specified medium per
format
Information
concerning the proper submission of encounter data may be obtained from the
ODJFS Encounter Data File
and
Submission Specifications document. The MCP must submit a
letter of certification, using the form required by ODJFS, with each
encounter data file
in the ODJFS-specified medium per
format.
The
letter of certification must be signed by the MCP’s Chief Executive Officer
(CEO), Chief Financial Officer (CFO), or an individual who has delegated
authority to sign for, and who reports directly to, the MCP’s CEO or
CFO.
2.
CASE MANAGEMENT DATA
ODJFS
designed a case management system
(CAMS) in order to monitor MCP compliance with program requirements
specified in Appendix G, Coverage and
Services. Each MCP’s case management data submissions will be
assessed for completeness and accuracy. The MCP is responsible
for submitting a case
management file every month. Failure to do so jeopardizes the
MCP’s
ability to demonstrate compliance with CSHCN requirements. For
detailed descriptions of the case management measures below, see ODJFS Methods for Case
Management
Data Quality Measures.
2.a. Case
Management System Data Accuracy
2.a.i.
Open Case Management Spans for
Disenrolled Members (this measure will
be discontinued
as of January 2008)
Measure: The
percentage of the MCP’s adult and children case management records in the
Screening, Assessment, and Case Management System that have open case management
date spans for members who have disenrolled from the MCP.
Report
Period: For the third and fourth
quarters
of SFY 2007, January – March 2007, and April – June 2007 report
periods. For the SFY 2008 contract period, July –
September 2007, and October – December 2007.
Statewide
and
Regional Data Quality Standard: A rate of open case
management spans for disenrolled members of no more than
1.0%.
For
an MCP which had
membership
as of
February 1, 2006: Performance will be
evaluated using: 1)
region-based results for any active region in which all selected MCPs
had at least 10,000 members during each month of the entire report period;
and/or 2) the statewide result for all counties that were not included in
the
region-based results, but in which the MCP had managed care membership as
of
February 1, 2006.
For
any MCP which
did not have membership as of
February 1,
2006: Performance will
begin to be evaluated
using region-based results for any active region in which all
selected MCPs had at least 10,000 members during each month of the entire
report
period.
Regional-Based
Approach:MCPs will be
evaluated by region, using results for all counties included in the
region.
Penalty
for
noncompliance: If an MCP is noncompliant with the
standard, then the ODJFS will issue a Sanction Advisory informing the MCP
that a
monetary sanction will be imposed if the MCP is noncompliant for any future
report periods. Upon all subsequent semi-annual measurements of
performance,
if an MCP is again determined to be noncompliant with the standard, ODJFS
will
impose a monetary sanction of one-half of one percent of the current month’s
premium payment. Once the MCP is performing at standard levels and
violations/deficiencies are resolved to the satisfaction of ODJFS, the money
will be refunded.
2.b. Timely
Submission of Case Management Files
Data
Quality Submission
Requirement: The MCP must submit Case Management files on a monthly basis
according to the specifications established in ODJFS’ Case Management File and
Submission Specifications.
Penalty
for
noncompliance :See Appendix
N, Compliance
Assessment
System, for
the penalty for noncompliance with
this requirement.
3.
EXTERNAL QUALITY REVIEW DATA
In
accordance with federal law and regulations, ODJFS is required to
conduct an independent quality review of contracting managed care
plans. The OAC rule 5101:3-26-07(C) requires MCPs to submit data and
information as requested by ODJFS or its designee for the annual external
quality review.
Two
information sources are integral to these studies: encounter data and medical
records. Because encounter data is used to draw samples for these studies,
quality must be sufficient to ensure valid sampling.
An
adequate number of medical records must then be retrieved from
providers and submitted to ODJFS or its designee in order to generalize results
to all applicable members. To aid MCPs in achieving the required
medical record submittal rate, ODJFS will give at least an eight week period
to
retrieve and submit medical records.
3.a.
Independent External Quality Review
Measure: The
percentage of requested records for
a study conducted by the External Quality Review Organization (EQRO) that
are
submitted by the managed care plan.
Report
Period: The
report period is one year. Results are calculated and performance is monitored
annually. Performance is measured with each review.
Data
Quality Standard: A
minimum record submittal rate of 85% for each clinical measure.
Penalty
for noncompliance for Data
Quality Standard: For each study that is completed during this
contract period, if an MCP is noncompliant with the standard, ODJFS will
impose
a non-refundable $10,000 monetary sanction.
4. MEMBERS’
PCP DATA
The
designated PCP is the
provider who
will manage and coordinate the
overall care for CFC members, including
those who have case
management needs. The MCP must submit a Members’
Designated PCP file every month. Specialists may and should be
identified as the PCP as appropriate for the member’s condition per the
specialty types specified for the CFC population in ODJFS Member’s
PCP Data
File and Submission Specifications; however, no CFC member
may have more
than one PCP identified for a given month.
4.a. Timely
submission of
Member’s PCP Data
Data
Quality Submission
Requirement: The MCP must submit a Members’ Designated PCP
Data file on a monthly basis according to the specifications established
in
ODJFS Member’s
PCP Data File and
Submission Specifications.
Penalty
for
noncompliance: See Appendix
N, ComplianceAssessment
System, for the penalty for noncompliance
with
this requirement.
4.b. Designated
PCP for newly enrolled members (only
applicable for report periods
prior to January 2008)
Measure: The
percentage of MCP’s newly enrolled
members who were designated a PCP by their effective date of
enrollment.
Report
Periods: For the third and fourth quarters of SFY 2007,
performance will be evaluated using the January – March 2007 and April – June
2007 report periods. For the SFY 2008 contract period, performance
will be evaluated using the July-September 2007, and October – December 2007
report periods.
Data
Quality
Standard: SFY
2007 will be informational only. A minimum rate of 75% of new members
with PCP designation by their effective date of enrollment for quarter one
and
quarter two of SFY 2008.
Statewide
Approach: MCPs
will be evaluated using a statewide result, including all active regions
and counties (Mahoning and Trumbull) in which an MCP has CFC membership.
Penalty
for
noncompliance: If an MCP is noncompliant
with the
standard, ODJFS will impose a monetary sanction of one-half of one percent
the
current month’s premium payment. Once the MCP is performing at
standard levels and violations/deficiencies are resolved to the satisfaction
of
ODJFS, the money will be refunded. As stipulated in OAC rule
5101:3-26-08.2, each new member must have a designated primary care
provider (PCP) prior to their effective date of
coverage. Therefore, MCPs are subject to additional corrective action
measures under Appendix N, Compliance Assessment System, for failure to meet
this requirement.
4.b.i. Designated
PCP for
newly enrolled members (only applicable
for report periods
after December 2007)
Measure: The
percentage of MCP’s newly enrolled members who were designated a PCP by their
effective date of enrollment.
Statewide
Approach: MCPs will be evaluated using their
statewide result, including all active regions and counties (Mahoning and
Trumbull) in which an MCP has CFC membership.
Report
Periods: For the SFY 2009 contract period, performance will be
evaluated annually using CY 2008.
Data
Quality Standards: For SFY 2009, a minimum rate of 85% of new members
with PCP designation by their effective date of enrollment.
Penalty
for
noncompliance: If an MCP is noncompliant with the standard,
ODJFS will impose a monetary sanction of one-half of one percent the current
month’s premium payment. Once the MCP is performing at standard
levels and violations/deficiencies are resolved to the satisfaction of ODJFS,
the money will be refunded. As stipulated in OAC rule 5101:3-26-08.2,
each new member must have a designated primary care provider (PCP) prior
to
their effective date of coverage. Therefore, MCPs are subject to
additional corrective action measures under Appendix N, Compliance Assessment
System, for failure to meet this requirement.
5.
APPEALS AND GRIEVANCES DATA
Pursuant
to OAC rule 5101:3-26-08.4, MCPs are required to submit information at least
monthly to ODJFS regarding appeal and grievance activity. ODJFS
requires these submissions to be in an electronic data file format pursuant
to
the Appeal File and Submission
Specifications and Grievance File and
Submission
Specifications.
The
appeal data file and the grievance data file must include all appeal and
grievance activity, respectively, for the previous month, and must be submitted
by the ODJFS-specified due date. These data
files must be submitted in the ODJFS-specified format and with the
ODJFS-specified filename in order to be successfully processed.
Penalty
for
noncompliance: MCPs who fail to submit their monthly
electronic data files to the ODJFS by the specified due date or who fail
to
resubmit, by no later than the end of that month, a file which meets the
data
quality requirements will be subject to penalty as stipulated under the Compliance
Assessment System (Appendix
N).
6. NOTES
|
6.a.
|
Penalties,
Including Monetary
Sanctions, for Noncompliance
|
Penalties
for noncompliance with standards
outlined in this appendix, including monetary sanctions, will be imposed
as the
results are finalized. With the exception of Sections
1.a.i., 1.a.iii.,
1.a.v.,
0.x.xx., and 0.x.xx, no
monetary sanctions described in this
appendix will be imposed if the MCP is in its first contract year of Medicaid
program participation. Notwithstanding the penalties specified in
this
Appendix, ODJFS reserves the
right to apply the most appropriate penalty to the area of deficiency identified
when an MCP is determined to be noncompliant with a
standard. Monetary penalties for noncompliance with any individual
measure, as determined in this appendix, shall not exceed
$300,000 during each evaluation period.
Refundable
monetary sanctions will be based
on the
premium payment in the month of the cited deficiency and due within
30 days of notification by ODJFS to the MCP of the amount.
Any
monies collected through the imposition of such a sanction will be returned
to
the MCP (minus any applicable collection fees owed to the Attorney General’s
Office, if the MCP has been delinquent in submitting payment) after the MCP
has
demonstrated full compliance with the particular program requirement and
the
violations/deficiencies are resolved to the satisfaction of ODJFS. If
an MCP does not comply within two years of the date of notification of
noncompliance, then the monies will not be refunded.
6.b.
Combined Remedies
If
ODJFS
determines that one systemic problem is responsible for multiple deficiencies,
ODJFS may impose a combined remedy which will address all areas of deficient
performance. The total fines assessed in any one month will not
exceed 15% of the MCP’s monthly premium payment.
6.c. Membership
Freezes
MCPs
found to have a pattern of repeated or ongoing noncompliance may be subject
to a
membership freeze.
6.d. Reconsideration
Requests
for reconsideration of monetary sanctions and enrollment freezes may be
submitted as provided in Appendix
N, Compliance
Assessment
System.
6.e. Contract
Termination, Nonrenewals, or Denials
Upon
termination either by the MCP or ODJFS, nonrenewal, or denial of an MCP provider
agreement, all previously collected refundable monetary sanctions will be
retained by ODJFS.
APPENDIX
M
PERFORMANCE
EVALUATION
CFC
ELIGIBLE
POPULATION
This
appendix establishes minimum
performance standards for managed care plans (MCPs) in key program
areas. The intent is to maintain accountability for contract
requirements. Standards are subject to change based on the revision
or update of applicable national standards, methods or
benchmarks. Performance will be evaluated in the categories of
Quality of Care, Access, Consumer Satisfaction, and Administrative
Capacity. Each performance measure has an accompanying minimum
performance standard. MCPs with performance levels below the minimum performance
standards will be required to take corrective action.
With
the
statewide expansion of the Ohio Medicaid Managed Care Program for the Covered
Families and Children (CFC) population nearly complete, evaluation of
performance will transition to a statewide approach encompassing all members
who
meet the criteria specified per the given methodology for each measure (i.e.,
measures will include members in any county who meet criteria per the given
methodology as opposed to only those members with managed care membership
as of
February 1, 2006).
The
statewide approach will be implemented beginning January 1, 2008. Due
to differences in data and reporting requirements, transition to statewide
measurement will vary by performance measure. Given that the original intent
of
the SFY 2007 and SFY 2008
Covered Families and Children Provider Agreements, Appendix M, was to
transition to a regional-based system of evaluation, several performance
measures have used regional-based results for performance monitoring.
Regional-based performance monitoring will be discontinued for all measures
in
Appendix M for report periods from January, 2008 onward. Unless
otherwise noted, performance measures and standards (see Sections 1, 2, 3
and 4
of this appendix) will be applicable for all counties in which the MCP has
membership as of February 1, 2006, until statewide measurement is
implemented.
Selected
measures in this appendix will
be used to determine pay-for-performance (P4P) as specified in Appendix O,
Pay
for
Performance.
1. QUALITY
OF CARE
1.a.
Independent External Quality
Review
In
accordance with federal law and
regulations, state Medicaid agencies must annually provide for an external
quality review of the quality outcomes and timeliness of, and access to,
services provided by Medicaid-contracting MCPs [(42
CFR 438.204(d)]. The
external review assists
the state in assuring MCP compliance with program requirements and facilitates
the collection of accurate and reliable information concerning MCP
performance.
Measure: The
independent external quality review covers a review of clinical and non-clinical
performance as outlined in Appendix K.
Report
Period: Performance
will be evaluated using the reviews conducted during SFY2008.
Action
Required for Deficiencies: For
all reviews conducted
during the contract period, if the EQRO cites a deficiency in performance,
the MCP will
be required to complete a Corrective Action Plan or Quality Improvement
Directive depending on the severity of the deficiency. Serious
deficiencies may result in immediate termination or non-renewal of the provider
agreement.
1.b. Children
with Special Health Care Needs (CSHCN)
In
order
to ensure state compliance with the provisions of 42 CFR 438.208, the
Bureau of Managed Health Care established Children with Special Health Care
Needs (CSHCN) basic program requirements in Appendix G, Coverage and
Services, and corresponding minimum performance standards as
described below. The purpose of these measures is to provide appropriate
and
targeted case management services to CSHCN.
1.b.i.
Case Management
of Children (applicable
to performance
evaluation through December 2007 and P4P through SFY 2009)
Measure:
The average monthly
case
management rate for children under 21 years of age.
Report
Period:For the SFY 2007
contract period, January – March 2007, and April – June 2007 report
periods. For the SFY 2008 contract period, July –
September 2007, and October
–
December
2007 report
periods.
County-Based
Approach: MCPs
with managed care membership as
of February 1,
2006 will be evaluated
using their county-based statewide result until regional evaluation
is implemented
for the county’s applicable
region. The county-based statewide result will include data for all
counties in which the MCP had membership as of February
1,
2006 that are not included
in any
regional-based result. Regional-based results will not be used for
evaluation until all selected MCPs in anactive
region have at least 10,000
members during each
month of the entire report period. Upon implementation of
regional-based evaluation for a particular county’s region, the county will be
included in the MCP’s regional-based result and will no longer be included in
the MCP’s county-based statewide result. [Example: The county-based statewide
result for MCP AAA, which has contracts in the Central and West Central regions,
will include Franklin, Pickaway, Xxxxxxxxxx, Xxxxxx and Xxxxx counties (i.e.,
counties in which MCP AAA had managed care membership as of February 1,
2006). When regional-based evaluation is implemented for the Central
region, Franklin
and
Pickaway counties,
along with all other counties in the region,
will then be
included in the Central region results for MCP AAA; Montgomery, Greene, and
Xxxxx counties will remain in the county-based statewide result for evaluation
of MCP AAA until the West Central regional-based approach is
implemented.] The last report period using the MCP’s
county-based statewide result for the counties in which the MCP had membership
as of February 1, 2006 for P4P (Appendix O) is April-June
2009.
Regional-Based
Approach: MCPs
will be evaluated by region, using
results for all counties included in the region. Performance will
begin to be evaluated using regional-based results for any active region in
which all selected
MCPs had at least 10,000 members during each month of the entire report
period.
County
and
Regional-Based Minimum
Performance
Standard: For
the third and fourth quarters of SFY
2007, a case management rate of 5.0%. For the
first and second
quarters of SFY
2008, a case management
rate of
5.0%.
Penalty
for
Noncompliance: The
first time an MCP is noncompliant
with a standard for this measure, ODJFS will issue a Sanction Advisory informing
the MCP that any future noncompliance instances with the standard for this
measure will result in ODJFS imposing a monetary sanction. Upon all
subsequent measurements of performance, if an MCP is again determined to
be
noncompliant with the standard, ODJFS will impose a monetary sanction (see
Section 5) of two percent of the current month’s premium payment. Monetary
sanctions will not be levied for consecutive quarters that an MCP is determined
to be noncompliant. If an MCP is noncompliant for a subsequent
quarter, new member selection freezes or a reduction of assignments will
occur
as outlined in Appendix N of the Provider Agreement. Once the MCP is
determined to be compliant with the standard and the violations/deficiencies
are
resolved to the satisfaction of ODJFS, the penalties will be lifted, if
applicable, and monetary sanctions will be returned.
1.b.ii.
Case Management of Children
(applicable to
performance evaluation as of January, 2008)
Measure:
The
average monthly
case management rate for children under 21 years of age.
Report
Period: For the SFY
2008 contract period, January – March 2008, and April – June 2008 report
periods. For the SFY 2009 contract period, July –
September 2008, October – December 2008, January – March 2009, and April – June
2009 report periods.
Regional-Based
Statewide
Approach: Performance will be evaluated using a regional-based
statewide approach for all active regions and counties (Mahoning and Trumbull)
in which the MCP has membership.
Regional-Based
Statewide
Target: For the third and fourth quarters of SFY 2008, a case
management rate of 5.0%. For SFY 2009, a case management rate of
5.0%.
Regional-Based
Statewide Minimum
Performance Standard: The level of improvement must result in
at least a 20% decrease in the difference between the target and the previous
report period’s results.
Penalty
for
Noncompliance: The first time an MCP is noncompliant with a
standard for this measure, ODJFS will issue a Sanction Advisory informing
the
MCP that any future noncompliance instances with the standard for this measure
will result in ODJFS imposing a monetary sanction. Upon all
subsequent measurements of performance, if an MCP is again determined to
be
noncompliant with the standard, ODJFS will impose a monetary sanction (see
Section 5) of two percent of the current month’s premium payment. Monetary
sanctions will not be levied for consecutive quarters that an MCP is determined
to be noncompliant. If an MCP is noncompliant for a subsequent
quarter, new member selection freezes or a reduction of assignments will
occur
as outlined in Appendix N of the Provider Agreement. Once the MCP is
determined to be compliant with the standard and the violations/deficiencies
are
resolved to the satisfaction of ODJFS, the penalties will be lifted, if
applicable, and monetary sanctions will be returned.
1.b.iii.
Case Management
of
Children with an ODJFS-Mandated Condition (applicable
to performance
evaluation through December 2007)
Measure
1: The percent
of children under 21 years of age with a positive identification
through an ODJFS administrative review of data for the ODJFS-mandated case
management condition of asthma
that are case
managed.
Measure
2: The percent
of children age 17 and under with a positive identification through
an ODJFS administrative review of data for the ODJFS-mandated case management
condition of teenage
pregnancy that are case
managed.
Measure
3: The percent
of children under 21 years of age with a positive identification
through an ODJFS administrative review of data for the ODJFS-mandated case
management condition of HIV/AIDS
that are case
managed.
Report
Periods for
Measures 1, 2, and 3: For
the SFY 2007 contract period,
January – March 2007, and April – June 2007 report periods. For the
SFY 2008 contract period, and July
–
September
2007, October –
December 2007 report
periods.
County-Based
Approach: MCPs
with managed care membership as of February 1, 2006 will
be evaluated using their
county-based statewide result until regional evaluation is implemented for
the
county’s applicable region. The county-based statewide result will
include data for all counties in which the MCP had membershipas 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’sregion, the county
will be included in
the MCP’s regional-based result and will no longer be included in the MCP’s
county-based statewide result. [Example: The county-based statewide result
for
MCP AAA, which has contracts in the Central and West Central regions, will
include Franklin, Pickaway, Xxxxxxxxxx,
Xxxxxx
and Xxxxx counties (i.e.,
counties in which MCP AAA had managed care membership as
of February 1, 2006). When
regional-based
evaluation is implemented for the Central region, Franklinnd
Pickaway counties, along with all
other counties in the region, will then be included in the Central region
results for MCP AAA;
Montgomery, Greene, and Xxxxx counties will remain in the county-based statewide
result for evaluation of MCP AAA until the West Central regional-based approach
is implemented.]
Regional-Based
Approach: MCPs will be
evaluated by region, using results for all counties included in the
region. Performance will begin to be evaluated using regional-based
results for any active region in which all selected MCPs had at least
10,000 members during each month of the entire report
period.
County
and
Regional-Based Minimum
Performance
Standard for Measures 1 and 3: For the third and fourth
quarters
of SFY 2007, a case management rate of 70%. For the first and second
quarters of SFY 2008, a case management rate of 70%.
County
and Regional-Based Minimum Performance Standard for Measure 2: For the third
and
fourth quarters of SFY 2007, a case management rate of 60%. For the
first and second quarters of SFY 2008, a case management rate of
60%.
Penalty
for
Noncompliance for Measures 1 and 2: The first time an MCP
is
noncompliant with a standard for this measure, ODJFS will issue a Sanction
Advisory informing the MCP that any future noncompliance instances with the
standard for this measure will result in ODJFS imposing a monetary
sanction. Upon all subsequent measurements of performance, if an MCP
is again determined to be noncompliant with the standard, ODJFS will impose
a
monetary sanction (see Section 5) of two percent of the current month’s premium
payment. Monetary sanctions will not be levied for consecutive quarters that
an
MCP is determined to be noncompliant. If an MCP is noncompliant for a
subsequent quarter, new member selection freezes or a reduction of assignments
will occur as outlined in Appendix N of the Provider Agreement. Once the MCP is determined
to be compliant with the standard and the violations/deficiencies are resolved
to the satisfaction of ODJFS, the
penalties will be lifted, if
applicable, and monetary sanctions will be
returned. Note: For the first reporting period during
which regional results are used to evaluate performance, measures 1, 2, and
3
are reporting-only measures. For SFY 2008, measure 3 is a
reporting-only measure.
1.b.iv.
Case Management of Children
with an ODJFS-Mandated Condition (applicable
to performance
evaluation as of January 2008)
Measure
1: The
percent of children under 21 years of age with a positive
identification through an ODJFS administrative review of data for the
ODJFS-mandated case management condition of asthma that are case
managed.
Measure
2: The
percent of children under 21 years of age with a positive
identification through an ODJFS administrative review of data for the
ODJFS-mandated case management condition of HIV/AIDS that are case
managed.
Report
Periods for Measures
1 and 2: For the SFY 2008 contract period,
January – March 2008, and April – June 2008 report periods. For the
SFY 2009 contract period, July – September 2008, October – December
2008, January – March 2009, and April – June 2009 report periods.
Regional-Based
Statewide Approach:
Performance will be evaluated using a regional-based statewide approach
for all active regions and counties (Mahoning and Trumbull) in which the
MCP has
membership.
Regional-Based
Statewide Target for
Measures 1 and 2: For the third and fourth quarters of SFY
2008, a case management rate of 70%. For SFY 2009, a case management
rate of 80%.
Regional-Based
Statewide Minimum
Performance Standard for Measures 1 and 2: The
level of improvement must result in at least a 20% decrease in the difference
between the target and the previous report period’s results.
Penalty
for Noncompliance for
Measure 1: The first time an MCP is noncompliant
with a standard for this measure, ODJFS will issue a Sanction Advisory informing
the MCP that any future noncompliance instances with the standard for this
measure will result in ODJFS imposing a monetary sanction. Upon all
subsequent measurements of performance, if an MCP is again determined to
be
noncompliant with the standard, ODJFS will impose a monetary sanction (see
Section 5) of two percent of the current month’s premium payment. Monetary
sanctions will not be levied for consecutive quarters that an MCP is determined
to be noncompliant. If an MCP is noncompliant for a subsequent
quarter, new member selection freezes or a reduction of assignments will
occur
as outlined in Appendix N of the Provider Agreement. Once the MCP is
determined to be compliant with the standard and the violations/deficiencies
are
resolved to the satisfaction of ODJFS, the penalties will be lifted, if
applicable, and monetary sanctions will be returned. For SFY 2008 and SFY
2009,
measure 2 is a reporting-only measure.
1.c.
Clinical Performance
Measures
MCP
performance will be assessed based on the analysis of submitted encounter
data
for each year. For certain measures, standards are established; the
identification of these standards is not intended to limit the assessment
of
other indicators for performance improvement activities. Performance
on multiple measures will be assessed and reported to the MCPs and others,
including Medicaid consumers.
The
clinical performance measures described below closely follow the National
Committee for Quality Assurance’s Health Plan Employer Data and Information Set
(HEDIS). Minor adjustments to HEDIS measures are required to account
for the differences between the commercial population and the Medicaid
population, such as shorter
and interrupted enrollment periods. NCQA may annually change its method for
calculating a measure. These changes can make it difficult to
evaluate whether improvement occurred from a prior
year. For this reason, ODJFS will use the same
methods to calculate the baseline results and the results for the period
in
which the MCP is being held
accountable. For example, the same methods were being used to
calculate calendar year 2005 results (the baseline
period) and
calendar year 2006 results. The methods will be updated
and a new baseline will be created during 2007 for
calendar year 2006 results. These results will
then serve as the baseline to evaluate whether improvement occurred from
calendar year 2006 to calendar year 2007. Clinical performance
measure results will be calculated after a sufficient amount of time has
passed
after the end of the report period in order to allow for claims
runout. For a comprehensive description of the clinical performance
measures below, see ODJFS
Methods for
Clinical Performance Measures
for the
CFC Managed
Care
Program. Performance standards
are
subject to change based on the revision or update of NCQA
methods or other national
standards, methods or benchmarks.
For
an MCP which had membership as
of February 1, 2006: MCP performance will be evaluated using an MCP’s
county-based statewide result for the counties in which the MCP had membership
as of February 1, 2006. For reporting periods CY 2007 and CY 2008,
targets and performance standards for Clinical Performance Measures
in
this Appendix (1.c.i – 1.c.vii) will be applicable to all counties in
which MCPs had membership as of February 1, 2006. The final reporting
year for the counties in which an MCP had membership as of February 1, 2006,
will be CY 2008.
For
any MCP which did not have
membership as of February 1,
2006: Performance will be evaluated using a regional-based
statewide approach for all active regions and counties (Trumbull and Mahoning)
in which the MCP has membership.
Regional-Based
Statewide
Approach: MCPs will be evaluated statewide, using results for all active
regions and counties (Mahoning and Trumbull) in which the MCP has
membership.
For
measures requiring one year of baseline data, ODJFS will use the first full
calendar year of data (CY 2007 - which may be adjusted based on the number
of
months of managed care membership) from all MCPs serving CFC membership to
determine statewide minimum performance standards. CY 2008 will be
the first reporting year that MCPs will be held accountable to the statewide
performance standards for one year measures, and penalties will be applied
for
noncompliance.
For
measures requiring two years of baseline data, ODJFS will use the first two
full
calendar years of data (CY 2007 and CY 2008 - which may be adjusted based
on the
number of months of managed care membership) from all MCPs serving CFC
membership to determine statewide minimum performance standards. CY
2009 will be the first reporting year that MCPs will be held accountable
to the
statewide performance standards for two year measures, and penalties will
be
applied for noncompliance.
Statewide
performance measure results will be calculated after a sufficient amount
of time
has passed after the end of the report period in order to allow for claims
runout.
Report
Period: In order
to adhere to the statewide expansion timeline, reporting periods may be adjusted
based on the number of months of managed care membership. For
the SFY 2007 contract period,
performance will be evaluated using the January - December
2006 report
period. For the SFY 2008 contract period, performance will be
evaluated using the January - December 2007 report period. For
the SFY 2009 contract period,
performance will be evaluated using the January – December 2008 report
period.
1.c.i. Perinatal
Care – Frequency of Ongoing Prenatal Care
Measure: The
percentage of enrolled women with a live birth during the year who received
the
expected number of prenatal visits. The number of observed versus
expected visits will be adjusted for length of enrollment.
County-Based
Statewide
Target: At
least 80% of the eligible
population must receive 81% or more of the expected number of prenatal
visits.
County-Based
Statewide Minimum
Performance Standard: The level of improvement must result in
at least a 10% 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.)
Regional-Based
Statewide
Target: TBD
Regional-Based
Statewide Minimum
Performance Standard: TBD
Action
Required for
Noncompliance: Beginning
SFY
2007, if
the standard is not met and the results
are below 42% (44% for SFY 2009), the MCP is required to complete a
Corrective Action Plan to
address the area of noncompliance. If the standard is not met and the
results are at or above 42% (44% for SFY 0000), XXXXX will issue a Quality
Improvement Directive which will notify the MCP of noncompliance and may
outline
the steps that the MCP must take to improve the results.
1.c.ii. Perinatal
Care -
Initiation of Prenatal Care
Measure: The
percentage of enrolled women with a live birth during the year who had a
prenatal visit within 42 days of enrollment or by the end of the first trimester
for those women who enrolled in the MCP during the early stages of
pregnancy.
County-Based
Statewide Target:
At least 90% of the eligible population initiate prenatal care within
the
specified time.
County-Based Statewide
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.
Regional-Based
Statewide
Target: TBD
Regional-Based
Statewide Minimum
Performance Standard: TBD
Action
Required for
Noncompliance: Beginning SFY 2007,
if the standard is not
met and the
results are below 71% (74% for SFY 2009), the MCP is required to complete
a Corrective Action Plan to address the area of noncompliance. If the standard
is not met and the results are at or above 71% (74% for SFY 0000), XXXXX
will
issue a Quality Improvement Directive which will notify the MCP of noncompliance
and may outline the steps that the MCP must take to improve the
results.
1.c.iii. Perinatal
Care - Postpartum Care
Measure: The
percentage of women who delivered a live birth who had a postpartum visit
on or
between 21 days and 56 days after delivery.
County-Based Statewide
Target: At least
80% of the eligible population must receive a postpartum visit.
County-Based
Statewide Minimum
Performance
Standard: The
level of improvement must result in
at least a 5% decrease in the difference between the target and the previous
year’s results.
Regional-Based
Statewide
Target: TBD
Regional-Based
Statewide Minimum
Performance Standard: TBD
Action
Required for Noncompliance:
Beginning SFY 2007, if the standard
is not
met and the results are below 48% (50% for SFY 2009), the MCP is required
to
complete a Corrective Action Plan to address the area of noncompliance. If
the
standard is not met and the results are at or above 48% (50% for SFY 0000),
XXXXX will issue a Quality Improvement Directive which will notify the MCP
of
noncompliance and may outline the steps that the MCP must take to improve the
results.
1.c.iv. Preventive
Care for Children - Well-Child Visits
Measure: The
percentage of children who received the expected number of well-child visits
adjusted by age and enrollment. The expected number of visits is as
follows:
Children
who turn 15 months old: six or more well-child visits.
Children
who were 3, 4, 5, or 6, years old: one or more well-child visits.
Children
who were 12 through 21 years old: one or more well-child visits.
County-Based
Statewide
Target: At least 80% of the eligible children receive the
expected number of well-child visits.
County-Based Statewide
Minimum Performance Standard for Each of the Age Groups: The
level of improvement must result in at least a 10% decrease in the difference
between the target and the previous year’s results.
Regional-Based
Statewide
Target: TBD
Regional-Based
Statewide Minimum
Performance Standard for Each of the Age
Groups: TBD
Action
Required for Noncompliance
(15 month old age group): Beginning SFY 2007, if
the standard is not met and the results are below 34% (42% for SFY 2009),
the
MCP is required to complete a Corrective Action Plan to address the area
of
noncompliance. If the standard is not met and the results are at or above
34%
(42% for SFY 0000), XXXXX will issue a Quality Improvement Directive which
will
notify the MCP of noncompliance and may outline the steps that the MCP must
take
to improve the results.
Action
Required for
Noncompliance (3-6
year
old age group): Beginning SFY 2007, if the standard
is not met and the results are below 50% (57% for SFY 2009), the MCP is required
to complete a Corrective Action Plan to address the area of noncompliance.
If
the standard is not met and the results are at or above 50% (57% for SFY
0000),
XXXXX will issue a Quality Improvement Directive which will notify the MCP
of
noncompliance and may outline the steps that the MCP must take to improve
the
results.
Action
Required
for
Noncompliance (12-21
year old age group): Beginning SFY 2007, if the standard is
not met and the results are below 30% (33% for SFY 2009), the MCP is required
to
complete a Corrective Action Plan to address the area of noncompliance. If
the
standard is not met and the results are at or above 30% (33% for SFY 0000),
XXXXX will issue a Quality Improvement Directive which will notify the MCP
of
noncompliance and may outline the steps that the MCP must take to improve
the
results.
1.c.v. Use
of Appropriate Medications for People with Asthma
Measure:
The
percentage of
members with persistent asthma who were enrolled for at least 11 months with
the
plan during the year and who received prescribed medications acceptable as
primary therapy for long-term control of asthma.
County-Based
Statewide
Target: At least 95% of the eligible population must receive the
recommended medications.
County-Based
Statewide Minimum
Performance Standard: The level of improvement must result in at least a
10% decrease in the difference between the target and the previous year’s
results.
Regional-Based
Statewide
Target: TBD
Regional-Based
Statewide Minimum
Performance Standard: TBD
Action
Required for Noncompliance:
Beginning SFY 2007, if the standard
is not
met and the results are below 83% (84% for SFY 2009), the MCP is required
to
complete a Corrective Action Plan to address the area of noncompliance. If
the
standard is not met and the results are at or above 83% (84% for SFY 0000),
XXXXX will issue a Quality Improvement Directive which will notify the MCP
of
noncompliance and may outline the steps that the MCP must take to improve
the
results.
0.x.xx. Annual
Dental Visits
Measure:
The percentage of
enrolled members age 4 through 21 who were enrolled for at least 11 months
with
the plan during the year and who had at least one dental visit during the
year.
County-Based
Statewide
Target:At
least 60% of the eligible population
receive a dental visit.
County-Based
Statewide 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.
Regional-Based
Statewide
Target: TBD
Regional-Based
Statewide Minimum
Performance Standard: TBD
Action
Required for
Noncompliance: Beginning SFY 2007, if the standard
is not met and the results are below 40% (42% for SFY 2009), the MCP is required
to complete a Corrective Action Plan to address the area of noncompliance.
If
the standard is not met and the results are at or above 40% (42% for SFY
0000),
XXXXX will issue a Quality Improvement Directive which will notify the MCP
of
noncompliance and may outline the steps that the MCP must take to improve
the
results.
1.c.vii. Lead
Screening
Measure:
The
percentage of
one and two year olds who received a blood lead screening by age
group.
County-Based
Statewide
Target: At least 80% of the eligible population receive a blood lead
screening.
County-Based
Statewide Minimum
Performance Standard for Each of the Age Groups: The level of improvement
must result in at least a 10% decrease in the difference between the target
and
the previous year’s results.
Regional-Based
Statewide
Target: TBD
Regional-Based
Statewide Minimum
Performance Standard for Each of the Age
Groups: TBD
Action
Required for Noncompliance (1
year olds): Beginning SFY 2007, if the standard is not met and
the results are below 45% the MCP is required to complete a Corrective Action
Plan to address the area of noncompliance. If the standard is not met and
the
results are at or above 45%, ODJFS will issue a Quality Improvement Directive
which will notify the MCP of noncompliance and may outline the steps that
the
MCP must take to improve the results.
Action
Required for Noncompliance (2
year olds): Beginning SFY 2007, if the standard is not met and the
results are below 28% the MCP is required to complete a Corrective
Action Plan to address the area of noncompliance. If the standard is
not met and the results are at or above 28%, ODJFS will issue a Quality
Improvement Directive which will notify the MCP of noncompliance and may
outline
the steps that the MCP must take to improve the results.
2. ACCESS
Performance
in the Access category will be determined by the following measures: Primary
Care Provider (PCP) Turnover, Children’s Access to Primary Care, Adults’ Access
to Preventive/Ambulatory Health Services, and Members’ Access to Designated
PCP. For a comprehensive description of the access performance
measures below, see ODJFS
Methods for Access Performance Measures for the CFC Managed Care
Program.
2.a.
PCP Turnover
A
high
PCP turnover rate may affect continuity of care and may signal poor management
of providers. However, some turnover may be expected when MCPs end
contracts with providers who are not adhering to the MCP’s standard of
care. Therefore, this measure is used in conjunction with the
children and adult access measures to assess performance in the access
category.
Measure:
The percentage of
primary care providers affiliated with the MCP as of the beginning of the
measurement year who were not affiliated with the MCP as of the end of the
year.
For
an MCP which had membership as
of February1, 2006:
MCP performance
will be evaluated using an MCP’s county-based statewide
result for the counties in which the MCP had membership as
of February 1, 2006. The minimum performance standard in
this Appendix (2.a)
will be applicable to the MCP’s county-based statewide result for the counties
in which the MCP had membership as of February 1, 2006. The last
reporting year using the MCP’s county-based statewide result for the
counties in which the MCP had membership as of February 1, 2006 for performance
evaluation is CY 2007; the last reporting year using the MCP’s county-based
statewide result for the counties in which the MCP had membership as of February
1, 2006 for P4P (Appendix
O) is CY 2008.
For
any MCP which did not have
membership as of February 1,
2006: Performance will be evaluated using a regional-based
statewide approach for all active regions and counties (Mahoning and Trumbull)
in which the MCP has membership.
Regional-Based
Statewide
Approach: MCPs will be evaluated statewide, using results for
all regions and counties (Mahoning and Trumbull) in which the MCP has
membership. ODJFS will use the first full calendar year of data (CY 2007
- which
may be adjusted based on the number of months of managed care membership)
from
all MCPs serving CFC membership as a baseline to determine a statewide minimum
performance standard. CY 2008 will be the first reporting year that
MCPs will be held accountable to the statewide performance standard for
statewide reporting, and penalties will be applied for
noncompliance.
Report
Period: In order to
adhere to the statewide expansion timeline, reporting periods may be adjusted
based on the number of months of managed care membership. For the SFY
2007 contract period, performance will be evaluated using the January - December
2006 report period. For the SFY 2008 contract period, performance
will be evaluated using the January - December 2007 report
period. For the SFY 2009 contract period, performance will be
evaluated using the January - December 2008 report period.
County-Based
Statewide Minimum
Performance Standard: A maximum PCP Turnover rate of
18%.
Regional-Based
Statewide Minimum
Performance Standard: TBD
Action
Required for
Noncompliance: MCPs are required to perform a causal analysis
of the high PCP turnover rate and assess the impact on timely access to health
services, including continuity of care. If access has been reduced or
coordination of care affected, then the MCP must develop and implement a
corrective action plan to address the findings.
2.b.
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: MCP performance will
be evaluated using an MCP’s county-based statewide result for the
counties in which the MCP had membership as of February 1, 2006. The
minimum performance standard in this Appendix (2.b) will be
applicable to the MCP’s county-based statewide result for the counties in which
the MCP had membership as of February 1, 2006. The last reporting
year using the MCP’s county-based statewide result for the counties
in which the MCP had membership as of February 1, 2006 is CY 2008.
For
any MCP which did not have
membership as of February 1, 2006: Performance will be
evaluated using a regional-based statewide approach for all active regions
and
counties (Mahoning and Trumbull) in which the MCP has
membership.
Regional-Based
Statewide
Approach: MCPs will be evaluated statewide, using results for all active
regions and counties (Mahoning and Trumbull) in which the MCP has membership.
ODJFS will use the first two full calendar years of data (CY 2007 and CY
2008 -
which may be adjusted based on the number of months of managed care
membership) from all MCPs serving CFC membership as a
baseline to determine a statewide minimum performance
standard. CY 2009 will be the first reporting year that MCPs will be
held accountable to the statewide performance standard for statewide reporting,
and penalties will be applied for noncompliance. Statewide
performance measure results will be calculated after a sufficient amount
of time
has passed after the end of the report period in order to allow for claims
runout.
Report
Period: In
order
to adhere to the statewide expansion timeline, reporting periods may be adjusted
based on the number of months of managed care membership. For the SFY
2007 contract period, performance will be evaluated using the January - December
2006 report period. For
the SFY 2008 contract period,
performance
will be evaluated using the January - December 2007 report
period. For the SFY 2009 contract period, performance will be
evaluated using the January - December 2008 report period.
County-Based Statewide
Minimum Performance
Standards:
CY
2006
report period – 70% of children must receive a visit.
CY
2007 report period – 71% of children
must receive a visit
CY
2008
report period – 74% of children must receive a visit
Regional-Based
Statewide Minimum Performance Standards: TBD
Penalty
for
Noncompliance: If an MCP is noncompliant with the Minimum
Performance Standard, then the MCP must develop and implement a corrective
action plan.
2.c.
Adults’ Access to Preventive/Ambulatory Health Services
This
measure indicates whether adult members are accessing health
services.
Measure:
The percentage of
members age 20 and older who had an ambulatory or preventive-care
visit.
For
an MCP which had membership as
of February1, 2006:
MCP performance
will be evaluated using an MCP’s county-based statewide
result for the counties in which the MCP had membership as of February 1,
2006. The minimum performance standard in this Appendix (2.c) will be
applicable to the MCP’s county-based statewide result for the counties in which
the MCP had membership as of February 1, 2006. The last
reporting year using the MCP’s county-based statewide result for the
counties in which the MCP had membership as of February 1, 2006 for performance
evaluation is CY 2007; the last reporting year using the MCP’s county-based
statewide result for the counties in which the MCP had membership as
of February 1, 2006 for P4P (Appendix
O) is CY 2008.
For
any MCP which did not have
membership as of February 1, 2006: Performance will be
evaluated using a regional-based statewide approach for all active regions
and
counties (Mahoning and Trumbull) in which the MCP has
membership.
Regional-Based
Statewide
Approach: MCPs will be evaluated statewide, using results for
all active regions and counties (Mahoning and Trumbull) in which the MCP
has
membership. ODJFS will use the first full calendar year of data (CY 2007
- which
may be adjusted based on the number of months of managed care
membership) from all MCPs serving CFC membership as a baseline to
determine a statewide minimum performance standard. CY 2008 will be
the first reporting year that MCPs will be held accountable to the statewide
performance standard for statewide reporting, and penalties will be applied
for
noncompliance. Statewide performance measure results will be
calculated after a sufficient amount of time has passed after the end of
the
report period in order to allow for claims runout.
Report
Period: In
order
to adhere to the statewide expansion timeline, reporting periods may be adjusted
based on the number of months of managed care membership. For the SFY
2007 contract period, performance will be evaluated using the January - December
2006 report period. For the SFY
2008 contract period, performance will be evaluated using the January - December
2007 report period. For
the SFY 2009 contract period,
performance will be evaluated using the January - December 2008 report
period.
County-Based
Statewide Minimum
Performance Standards:
CY
2006
report period – 63% of adults must receive a visit.
CY
2007
report period – 63% of adults must receive a visit.
CY
2008
report period – 63% of adults must receive a visit.
Regional-Based
Statewide Minimum Performance Standards: TBD
Penalty
for
Noncompliance: If an MCP is noncompliant with the Minimum
Performance Standard, then the MCP must develop and implement a corrective
action plan.
2.d.
Members’ Access to Designated PCP
The
MCP must encourage and assist CFC
members without a designated primary care provider (PCP) to establish
such a relationship, so that a designated PCP can coordinate and manage a
member’s health care needs. This measure is to be used to assess
MCPs’ performance in the access
category.
Measure: The
percentage of members who had a
visit through members’ designated PCPs.
Regional-Based
Statewide Approach:
MCPs will be evaluated statewide, using results for all active
regions and counties (Mahoning and Trumbull) in which the MCP has
membership. ODJFS will use the first full calendar year of data (CY
2007 - which may be adjusted based on the number of months of managed care
membership) from all MCPs serving CFC membership as a baseline to determine
a
statewide minimum performance standard. CY 2008 will be the first
reporting year that MCPs will be held accountable to the performance standard
and penalties will be applied for noncompliance. Statewide
performance measure results will be calculated after a sufficient amount
of time
has passed after the end of the report period in order to allow for claims
runout.
Report
Period: For
the SFY 2009 contract period, performance will be evaluated using the January
-
December 2008 report period.
Regional-Based
Statewide Minimum
Performance Standard:
TBD
Penalty
for
Noncompliance: If an MCP is noncompliant
with the
Minimum Performance Standard, then the MCP must develop and implement a
corrective action plan.
3.
CONSUMER SATISFACTION
In
accordance with federal requirements
and in the interest of assessing enrollee satisfaction with MCP performance,
ODJFS annually conducts
independent consumer
satisfaction surveys. Results are used to assist in identifying and correcting
MCP performance overall and in the areas of access, quality of care, and
member
services. For
SFY 2007 and SFY 2008, performance in this
category will be
determined by the overall satisfaction score. For a comprehensive
description of the Consumer
Satisfaction performance measure below, see ODJFS
Methods for the Consumer
Satisfaction Performance Measure for the CFC Program.
Measure: Overall
Satisfaction
with MCP: The average
rating of the respondents to the Consumer Satisfaction Survey who were asked
to
rate their overall satisfaction with their MCP. The results of this
measure are reported annually.
For
an MCP which had membership as
of February 1, 2006: MCP performance will be evaluated using an MCP’s
county-based statewide result for the counties in which the MCP had membership
as of February 1, 2006. The minimum performance standard in this
Appendix (3.) will be
applicable to the MCP’s county-based statewide result for the counties in which
the MCP had membership as of February 1, 2006. For performance
evaluation, the last year to use the county-based statewide approach for
the
counties in which the MCP had membership as of February 1, 2006 will be SFY
2008, using CY 2008 data. For P4P (Appendix O), the
last year to use the county-based statewide approach for the counties in
which
the MCP had membership as of February 1, 2006 will be SFY 2009, using CY
2009
data.
For
any MCP which did not have
membership as of February 1, 2006: Performance will be
evaluated using a regional-based statewide approach for all active regions
and
counties (Mahoning and Trumbull) in which the MCP has
membership.
Regional-Based
Statewide Approach:
MCPs will be evaluated statewide, using results for all active regions
and counties (Mahoning and Trumbull) in which the MCP has
membership. ODJFS will use the first full calendar year of data (CY
2008 adult and child survey results) from all MCPs serving CFC membership
as a
baseline to establish a measure and determine a minimum statewide performance
standard. For performance evaluation, the first year to use the
statewide regional-based approach will be SFY 2009, using CY 2009
data. For P4P (Appendix O), the first year to
use the statewide regional-based approach will be SFY 2010, using CY 2010
data.
Report
Period: For the SFY
2007
contract period, performance will be evaluated using the results from the
CY
2007 consumer satisfaction survey. For the SFY 2008 contract
period, performance will be evaluated using the results from the CY 2008
consumer satisfaction survey. For the SFY 2009 contract period,
performance will be evaluated using the results from the CY 2009 consumer
satisfaction survey.
County-Based
Statewide Minimum Performance
Standard: An average score of no less than 7.0.
Regional-Based
Statewide Minimum Performance Standard: TBD
Penalty
for
noncompliance: If an MCP is determined
noncompliant with the Minimum Performance Standard, then the MCP must develop
a
corrective action plan and provider agreement renewals may be
affected.
4.
ADMINISTRATIVE
CAPACITY
The
ability of an MCP to meet
administrative requirements has been found to be both an indicator of current
plan performance and a predictor of future performance. Deficiencies
in administrative capacity make the accurate assessment of performance in
other
categories difficult, with findings uncertain. Performance in this
category will be determined by the Compliance Assessment
System, and the
emergency department diversion program. For a comprehensive
description of the Administrative Capacity performance measures
below, see
ODJFS
Methods for the
Administrative Capacity Performance Measure for the CFC Managed Care
Program.
4.a.
Compliance Assessment
System
Measure: The
number of points accumulated
during a rolling 12-month
period through the Compliance
Assessment System.
Report
Period: For
the SFY 2008 and SFY 2009 contract
periods, performance will be evaluated using a rolling 12-month report
period.
Performance
Standard: A
maximum of 15
points
Penalty
for
Noncompliance: Penalties
for points are established in Appendix N, Compliance
Assessment System.
4.b. Emergency
Department
Diversion (applicable
to performance
evaluation through SFY 2008 and P4P through SFY
2007)
Managed
care plans must provide access
to services in a way that assures access to primary and urgent care in the
most
effective settings and minimizes inappropriate utilization of emergency
department (ED) services. MCPs are required to identify high
utilizers of ED services and implement action plans designed to minimize
inappropriate ED utilization.
Measure: The
percentage of members who
had four or more ED visits during
the six month reporting period.
For
an MCP
which
had membership as of February 1,
2006:
MCP performance will
be
evaluated using an MCP’s county-based statewide result for the counties
in which the MCP had membership as of February 1, 2006. The minimum
performance standard and the target in this Appendix (4.b) will be
applicable to the MCP’s county-based statewide result for the counties in which
the MCP had membership as of February 1, 2006. The last
reporting period using the MCP’s county-based statewide result for
the counties in which the MCP had membership as of February 1, 2006 for
performance evaluation is July-December 2007; the last reporting period using
the MCP’s county-based statewide result for the counties in which the MCP had
membership as of February 1, 2006 for P4P (Appendix O) is July-December
2006.
Report
Period: For
the SFY 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. Results will be calculated for the
reporting period of July - December 2007 and compared to the baseline results
to
determine if the minimum performance standard is met
County-Based Statewide
Target:
A maximum of 0.70% of the eligible population will have four
or more ED visits during the reporting period.
County-Based
Statewide Minimum
Performance Standard: The level of improvement must result in at least a
10% decrease in the difference between the target and the baseline period
results.
Penalty
for
Noncompliance: If the standard is not met and the results are
above 1.1%, then the MCP must develop a corrective action plan, for which
ODJFS
may direct the MCP to develop the components of their EDD program as specified
by ODJFS. If the standard is not met and the results are at or below
1.1%, then the MCP must develop a Quality Improvement Directive.
4.b.i.
Emergency Department Diversion
(applicable to
performance evaluation as of SFY 2009)
Managed
care plans must provide access to services in a way that assures access to
primary and urgent care in the most effective settings and minimizes
inappropriate utilization of emergency department (ED) services. MCPs
are required to identify high utilizers of targeted ED services and implement
action plans designed to minimize inappropriate, preventable and/or primary
care
sensitive ED utilization.
Measure: The
percentage of members who had TBD or more targeted ED visits during the twelve
month reporting period.
Regional-Based
Statewide Approach:
MCPs will be evaluated statewide, using results for all active
regions and counties (Mahoning and Trumbull) in which the MCP has
membership. ODJFS will use the first full calendar year of
data (CY 2007 - which may be adjusted based on the number of months of managed
care membership) from all MCPs serving CFC membership as the first baseline reporting
year
for statewide reporting and to determine a statewide minimum
performance standard and target. CY 2008 will be the first reporting
year that MCPs will be held accountable to the performance standard and
penalties will be applied for noncompliance.
Report
Period: For the SFY
2009 contract period, January – December 2008.
Regional-Based
Statewide Target:
A maximum of TBD of the eligible population will have TBD or
more targeted ED visits during the reporting period.
Regional-Based
Statewide Minimum
Performance Standard: The level of improvement must result in at least a
TBD decrease in the difference between the target and the baseline period
results.
Penalty
for
Noncompliance: If the standard is not met and the results are
above TBD%, 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
TBD%, then the MCP must develop a Quality Improvement Directive.
5.
NOTES
Given
that unforeseen circumstances
(e.g., revision or update
of applicable national standards, methods or benchmarks, or issues related
to
program implementation) may impact performance assessment as specified in
Sections 1 through 4, ODJFS reserves the
right to apply the
most appropriate penalty to the area of deficiency identified with any
individual measure, notwithstanding the penalties specified in this
Appendix.
5.a.
Report Periods
Unless
otherwise noted, the most recent
report or study finalized prior to the end of the contract period will be
used
in determining the MCP’s performance level for that contract
period.
5.b.
Monetary
Sanctions
Penalties
for noncompliance with individual standards in this appendix will be imposed
as
the results are finalized. Penalties for noncompliance with individual standards
for each period of compliance, as determined in this appendix, will not exceed
$250,000.
Refundable
monetary sanctions will be based on the capitation payment in the month
of the cited deficiency and due within 30 days of notification by
ODJFS to the MCP of the amount. Any monies collected through the
imposition of such a sanction would be returned to the MCP (minus any applicable
collection fees owed to the Attorney General’s Office, if the MCP has been
delinquent in submitting payment) after they have demonstrated improved
performance in accordance with this appendix. If an MCP does not
comply within two years of the date of notification of noncompliance, then
the
monies will not be refunded.
5.c. Combined
Remedies
If
ODJFS
determines that one systemic problem is responsible for multiple deficiencies,
ODJFS may impose a combined remedy which will address all areas of deficient
performance. The total fines assessed in any one month will not
exceed 15% of the MCP’s monthly capitation.
5.d.
Enrollment Freezes
MCPs
found to have a pattern of repeated or ongoing noncompliance may be subject
to
an enrollment freeze.
5.e.
Reconsideration
Requests
for reconsideration of monetary sanctions and enrollment freezes may be
submitted as provided in Appendix N, Compliance
Assessment
System.
5.f.
Contract Termination, Nonrenewals or Denials
Upon
termination, nonrenewal or denial of an MCP contract, all monetary sanctions
collected under this appendix will be retained by ODJFS. The at-risk amount
paid
to the MCP under the current provider agreement will be returned to
ODJFS in accordance with Appendix P, Terminations,
of the provider agreement.
APPENDIX
N
COMPLIANCE
ASSESSMENT SYSTEM
CFC
ELIGIBLE POPULATION
I.
General Provisions of the Compliance Assessment System
A.
The
Compliance Assessment System
(CAS) is designed
to improve the
quality of each managed care plan’s (MCP’s) performance through actions taken by
the Ohio Department of Job and Family Services (ODJFS) to address identified
failures to meet program requirements. This appendix applies to the
MCP specified in the baseline of this MCP Provider Agreement (hereinafter referred to as
the
Agreement).
B.
The
CAS assesses
progressive remedies with
specified values (e.g., points, fines, etc.) assigned for certain documented
failures to satisfy the deliverables required by Ohio Administrative
Code (OAC) rule or
the Agreement. Remedies
are progressive based upon the
severity of the violation, or a repeated pattern of violations. The CAS
allows the accumulated point total to
reflect patterns of less serious violations as well as less frequent, more
serious violations.
C.
The
CAS focuses on clearly
identifiable deliverables and sanctions/remedial actions are only assessed
in
documented and verified instances of noncompliance. The CAS
does not include categories which
require subjective assessments or which are not within the MCPs
control.
D.
The
CAS does not replace ODJFS’ ability to require corrective action plans (CAPs)
and program improvements, or to impose any of the sanctions specified
in OAC rule 5101:3-26-10, including the proposed termination, amendment,
or
nonrenewal of the MCP’s Provider Agreement.
E.
As
stipulated in OAC rule 5101:3-26-10(F), regardless of whether ODJFS imposes
a
sanction, MCPs are required to initiate corrective action for any MCP program
violations or deficiencies as soon as they are identified by the MCP or
ODJFS.
F.
In addition to the remedies imposed
in Appendix N, remedies related to areas of financial performance,
data
quality,and
performance
management may also be imposed
pursuant to
Appendices J, L, and M respectively, of the Agreement.
G.
If
ODJFS determines that an MCP has violated any of the requirements of sections
1903(m) or 1932 of the Social Security Act which are not specifically identified
within the CAS, ODJFS may, pursuant to the provisions of OAC rule
5101:3-26-10(A), notify the MCP’s members that they may terminate from the MCP
without cause and/or suspend any further new member selections.
H.
For
purposes of the CAS, the date that ODJFS first becomes aware of an MCP’s program
violation is considered the date on which the violation
occurred. Therefore, program violations that technically reflect
noncompliance from the previous compliance term will be subject to remedial
action under CAS at the time that ODJFS first becomes aware of this
noncompliance.
I.
In
cases where an MCP contracted healthcare provider is found to have violated
a
program requirement (e.g., failing to provide adequate contract termination
notice, marketing to potential members, inappropriate member billing, etc.),
ODJFS will not assess points if: (1) the MCP can document that they provided
sufficient notification/education to providers of applicable program
requirements and prohibited activities; and (2) the MCP takes immediate and
appropriate action to correct
the
problem and to ensure that it does not happen again to the satisfaction of
ODJFS. Repeated incidents will be reviewed to determine if the MCP
has a systemic problem in this area, and if so, sanctions/remedial actions
may
be assessed, as determined by ODJFS.
J.
All
notices of noncompliance will be issued in writing via email and facsimile
to
the identified MCP contact.
II.
Types of Sanctions/Remedial Actions
ODJFS
may
impose the following types of sanctions/remedial actions, including, but
not
limited to, the items listed below. The following are examples of
program violations and their related penalties. This list is not all
inclusive. As with any instance of noncompliance, ODJFS retains the
right to use their sole discretion to determine the most appropriate penalty
based on the severity of the offense, pattern of repeated noncompliance,
and
number of consumers affected. Additionally, if an MCP has received
any previous written correspondence regarding their duties and obligations
under
OAC rule or the Agreement, such notice may be taken into consideration when
determining penalties and/or remedial actions.
A.
Corrective Action Plans
(CAPs)– A CAP is a structured activity/process implemented by the MCP to
improve identified operational deficiencies.
MCPs
may
be required to develop CAPs for any instance of noncompliance, and CAPs are
not
limited to actions taken in this Appendix. All CAPs requiring ongoing
activity on the part of an MCP to ensure their compliance with a program
requirement remain in effect for twenty-four months.
In
situations where ODJFS has already determined the specific action which must
be
implemented by the MCP or if the MCP has failed to submit a CAP, ODJFS may
require the MCP to comply with an ODJFS-developed or “directed”
CAP.
In
situations where a penalty is assessed for a violation an MCP has previously
been assessed a CAP (or any penalty or any other related written
correspondence), the MCP may be assessed escalating penalties.
B.
Quality Improvement
Directives (QIDs)– A QID is a general instruction that directs
the MCP to implement a quality improvement initiative to improve
identified administrative or clinical deficiencies. All QIDs
remain in effect for twelve months from the date of
implementation.
MCPs
may be required to develop QIDs for any instance of noncompliance.
In
situations where ODJFS has already determined the specific action which must
be
implemented by the MCP or if the MCP has failed to submit a QID, ODJFS may
require the MCP to comply with an ODJFS-developed or “directed”
QID.
In
situations where a penalty is assessed for a violation an MCP has previously
been assessed a QID (or any penalty or any other related written
correspondence), the MCP may be assessed escalating
penalties.
C.
Points - Points will accumulate
over a rolling
12-month schedule. Each month, points that are more than 12-months
old will expire. Points will be tracked and monitored separately for
each Agreement the MCP concomitantly holds with the BMHC, beginning with
the
commencement of this Agreement (i.e., the MCP will have zero points at the
onset
of this Agreement).
No
points
will be assigned for any violation where an MCP is able to document that
the
precipitating circumstances were completely beyond their control and could
not
have been foreseen (e.g., a construction crew xxxxxx a phone line, a lightning
strike blows a computer system, etc.).
C.1.5
Points -- Failures
to meet program requirements, including but not limited to, actions which could impair the member’s
ability to obtain correct information
regarding services or which could
impair a consumer’s or member’s rights, as determined by ODJFS, will result in
the assessment of 5 points. Examples include, but are not limited to,
the following:
• Violations
which result in a member’s MCP selection or termination based on inaccurate
provider panel information from the MCP.
• Failure
to provide member materials to new members in a timely manner.
• Failure
to comply with appeal, grievance, or state hearing
requirements, including the failure to notify a member of their right to
a state
hearing when the MCP proposes to deny, reduce, suspend or terminate a
Medicaid-covered service.
• Failure
to staff 24-hour call-in system with appropriate trained medical
personnel.
• Failure
to meet the monthly call-center requirements for either the member services
or
the 24-hour call-in system lines.
• Provision
of
false, inaccurate or materially misleading information to health care providers, the MCP’s members, or any
eligible individuals.
• Use
of unapproved marketing or member
materials.
• Failure
to appropriately notify ODJFS or members of provider panel
terminations.
•
Failure
to update website provider directories as required.
C.2.
10 Points --
Failures to meet program requirements, including but not limited to, actions
which could affect the ability of the MCP to deliver or the consumer to access covered
services, as determined by ODJFS. Examples include, but are not
limited to, the following:
•
Discrimination among members on the basis of their health status or need
for
health care services (this includes any practice that would reasonably be
expected to encourage termination or discourage selection by individuals
whose
medical condition indicates probable need for substantial future medical
services).
• Failure
to assist a member in accessing needed services in a timely manner after
request
from the member.
• Failure
to provide medically-necessary Medicaid covered services to
members.
• Failure
to process prior authorization requests within the prescribed time
frames.
D.
Fines– Refundable
or nonrefundable fines may be assessed as a penalty separate to or in
combination with other sanctions/remedial actions.
D.1.
Unless otherwise
stated, all fines are nonrefundable.
D.2.
Pursuant to
procedures as established by ODJFS, refundable and nonrefundable monetary
sanctions/assurances must be remitted to ODJFS within thirty (30) days of
receipt of the invoice by the MCP. In addition, per Ohio Revised Code
Section 131.02, payments not received within forty-five (45) days will be
certified to the Attorney General’s (AG’s) office. MCP payments certified to the
AG’s office will be assessed the appropriate collection fee by the AG’s
office.
D.3.
Monetary
sanctions/assurances imposed by ODJFS will be based on the most recent
premium
payments.
D.4.
Any monies
collected through the imposition of a refundable fine will be returned to
the
MCP (minus any applicable collection fees owed to the Attorney General’s Office
if the MCP has been delinquent in submitting payment) after they have
demonstrated full compliance, as determined by ODJFS, with the particular
program requirement. If an MCP does not comply within one (1) year of
the date of notification of noncompliance involving issues of case management
and two (2) years of the date of notification of noncompliance in issues
involving encounter data, then the monies will not be refunded.
D.5.
MCPs are
required to submit a written request for refund to ODJFS at the time they
believe is appropriate before a refund of monies will be
considered.
E.
Combined Remedies
- Notwithstanding any other action ODJFS may take under this Appendix, ODJFS
may
impose a combined remedy which will address all areas of noncompliance if
ODJFS
determines, in its sole discretion, that (1) one systemic problem is responsible
for multiple areas of noncompliance and/or (2) that there are a number of
repeated instances
of noncompliance with the same program requirement.
F.
Progressive
Remedies - Progressive remedies will be based on the number of points
accumulated at the time of the most recent incident. Unless
specifically otherwise indicated in this appendix, all fines are
nonrefundable. The designated fine amount will be assessed when the
number of accumulated points falls within the ranges specified
below:
|
0
-15 Points
|
Corrective
Action Plan
(CAP)
|
|
16-25
Points
|
CAP
+ $5,000
fine
|
|
26-50
Points
|
CAP
+ $10,000
fine
|
|
51-70
Points
|
CAP
+ $20,000
fine
|
|
71-100
Points
|
CAP
+ $30,000
fine
|
|
100+
Points
|
Proposed
Contract Termination
|
G.
New Member Selection
Freezes - Notwithstanding any other penalty or point assessment that
ODJFS may impose on the MCP under this Appendix, ODJFS may prohibit an MCP
from
receiving new membership through consumer initiated selection or the assignment
process if: (1) the MCP has accumulated a total of 51 or more points during
a
rolling 12-month period; (2) or
the MCP fails to fully implement a CAP within the designated time frame;
or (3) circumstances exist which potentially jeopardize the MCP’s
members’ access to care. [Examples of circumstances that ODJFS may
consider as jeopardizing member access to care include:
- the
MCP has been found by
ODJFS to be noncompliant with the prompt payment or the non-contracting provider
payment requirements;
- the
MCP has been found by ODJFS
to be noncompliant with the provider panel requirements specified in Appendix
H
of the Agreement;
- the
MCP’s refusal to comply
with a program requirement after ODJFS has directed the MCP to comply with
the
specific program requirement; or
- the
MCP has received notice of
proposed or implemented adverse action by the Ohio Department of
Insurance.]
Payments
provided for under the
Agreement will be denied for new enrollees, when and for so long as, payments
for those enrollees are denied by CMS in accordance with the requirements
in 42
CFR 438.730.
H.
Reduction of Assignments
– ODJFS has sole discretion over how member auto-assignments are
made. ODJFS may reduce the number of assignments an MCP receives to
assure program stability within a region or if ODJFS determines that the
MCP
lacks sufficient capacity to meet the needs of the increased volume in
membership. Examples of circumstances which ODJFS may determine
demonstrate a lack of sufficient capacity include, but are not limited to
an
MCP’s failure to: maintain an adequate provider network; repeatedly provide new
member materials bythe
member’s effective date; meet the minimum call center requirements; meet the
minimum performance standards for identifying and assessing children with
special health care needs and members needing case management services; and/or
provide complete and accurate appeal/grievance, member’s PCP and CAMS data
files.
I.
Termination, Amendment,
or Nonrenewal of MCP Provider Agreement - ODJFS can at any time move to
terminate, amend or deny renewal of a provider agreement. Upon such
termination, nonrenewal, or denial
of an MCP provider agreement, all previously collected monetary sanctions
will
be retained by ODJFS.
J.
Specific Pre-Determined
Penalties
I.1.
Adequate
network-minimum provider panel requirements - Compliance with provider
panel requirements will be assessed quarterly. Any deficiencies in
the MCP’s provider network as specified in Appendix H of the Agreement or by
ODJFS, will result in the assessment of a $1,000 nonrefundable fine for each
category (practitioners, PCP capacity, hospitals), for each county, and for
each
population (e.g., ABD, CFC). For example if the MCP did not meet the
following minimum panel requirements, the MCP would be assessed (1) a $3,000
nonrefundable fine for the failure to meet CFC panel requirements; and, (2)
a
$1,000 nonrefundable fine for the failure to meet ABD panel
requirements).
· practitioner
requirements in Franklin county for the CFC population
· practitioner
requirements in Franklin county for the ABD population
· hospital
requirements in Franklin county for the CFC population
· PCP
capacity requirements in Fairfield county for the CFC population
In
addition to the pre-determined penalties, ODJFS may assess additional penalties
pursuant to this Appendix (e.g. CAPs, points, fines) if member specific access
issues are identified resulting from provider panel noncompliance.
J.2.
Geographic Information
System - Compliance with the Geographic Information System (GIS)
requirements will be assessed semi-annually. Any failure to meet GIS
requirements as specified in Appendix H of the Agreement will result a $1,000
nonrefundable fine for each county and for each population (e.g., ABD, CFC,
etc.). For example if the MCP did not meet GIS requirements in the
following counties, the MCP would be assessed (1) a nonrefundable $2,000
fine
for the failure to meet GIS requirements for the CFC population and (2) a
$1,000
nonrefundable fine for the failure to meet GIS requirements for the ABD
population.
· GIS
requirements in Franklin county for the CFC population
· GIS
requirements in Fairfield county for the CFC population
· GIS
requirements in Franklin county for the ABD population
J.3.
Late Submissions
- All required submissions/data and documentation requests must be received
by
their specified deadline and must represent the MCP in an honest and
forthright
manner. Failure
to provide ODJFS with a required submission or any data/documentation
requested
by ODJFS will result in the
assessment of a nonrefundable fine of $100 per day, unless the MCP requests
and
is granted an extension by ODJFS. Assessments for late submissions
will be done monthly. Examples of such program violations include,
but are not limited to:
· Late
required
submissions
o
Annual delegation
assessments
o
Call center
report
o
Franchise fee
documentation
o
Reinsurance
information (e.g., prior approval of changes)
o
State hearing
notifications
· Late
required data
submissions
o
Appeals and grievances, case
management, or PCP data
· Late
required information
requests
o
Automatic call distribution
reports
o
Information/resolution regarding
consumer or provider complaint
o
Just cause or other coordination
care request from ODJFS
o
Provider panel documentation
o
Failure to provide ODJFS with a required submission after ODJFS has notified
the
MCP that the prescribed deadline for that submission has passed
If
an MCP
determines that they will
be
unable to meet a program deadline or data/documentation submission deadline,
the
MCP must submit a written request to its Contract Administrator for an extension
of the deadline, as soon as possible, but no later than 3 PM EST on the date
of
the deadline in question. Extension requests should only be submitted in
situations where unforeseeable circumstances have occurred which make it
impossible for the MCP to meet an ODJFS-stipulated deadline and all such
requests will be evaluated upon this standard. Only written approval
as may be granted by ODJFS of a deadline extension will preclude the assessment
of compliance action for untimely submissions.
J.4.
Noncompliance with
Claims Adjudication Requirements - If ODJFS finds that an MCP is unable
to (1) electronically accept and adjudicate claims to final status and/or
(2)
notify providers of the status of their submitted claims, as stipulated in
Appendix C of the Agreement, ODJFS will assess the MCP with a monetary sanction
of $20,000 per day for the period of noncompliance.
If
ODJFS
has identified specific instances where an MCP has failed to take the necessary
steps to comply with the requirements specified in Appendix C of the Agreement
for (1) failing to notify non-contracting providers of procedures for claims
submissions when requested and/or (2) failing to notify contracting and
non-contracting providers of the status of their submitted claims, the MCP
will
be assessed 5 points per incident of noncompliance.
J.5.
Noncompliance with
Prompt Payment: - Noncompliance with the prompt pay requirements as specified in Appendix
J of the
Agreement will result in progressive penalties. The first
violation
during a rolling 12-month
period will result in the submission of quarterly prompt pay and monthly
status
reports to ODJFS until the next quarterly report is due. The second
violation during
a rolling 12-month period will
result in the submission of monthly status reports and a refundable fine
equal to 5% of the MCP’s monthly premium payment or $300,000, whichever is
less. The refundable fine will be applied in lieu of a nonrefundable
fine and the money will be
refunded by ODJFS only after the MCP complies with the required standards
for
two (2) consecutive quarters. Subsequent violations will result in an
enrollment freeze.
If
an MCP is found to have not been in
compliance with the prompt pay requirements for any time period for which
a
report and signed attestation have been submitted representing the MCP as
being
in compliance, the MCP will be subject to an enrollment freeze of not less
than
three (3) months duration.
J.6.
Noncompliance with
Franchise Fee Assessment Requirements - In accordance with ORC Section
5111.176, and in addition to the imposition of any other penalty, occurrence
or
points under this Appendix, an MCP that does not pay the franchise permit
fee in
full by the due date is subject to any or all of the following:
· A
monetary penalty in the amount of $500 for each day any part of the fee remains
unpaid, except the penalty will not exceed an amount equal to 5 % of the
total
fee that was due for the calendar quarter for which the penalty was
imposed;
·
Withholdings from future ODJFS capitation payments. If an MCP fails to pay
the
full amount of its franchise fee when due, or the full amount of the imposed
penalty, ODJFS may withhold an amount equal to the remaining amount due from
any
future ODJFS capitation payments. ODJFS will return all withheld capitation payments when
the franchise
fee amount has been paid in full;
·
Proposed termination or
non-renewal of the MCP’s Medicaid provider agreement may occur if the
MCP:
a.
Fails
to pay its franchise permit fee or
fails to pay the fee promptly;
b. Fails
to pay a penalty imposed under
this Appendix or fails to pay the penalty promptly;
c. Fails
to cooperate with an audit
conducted in accordance with ORC Section 5111.176.
J.7.
Noncompliance with
Clinical Laboratory Improvement Amendments - Noncompliance with CLIA
requirements as specified by ODJFS will result in the assessment of a
nonrefundable $1,000 fine for each violation.
J.8.
Noncompliance with
Abortion and Sterilization Payment - Noncompliance with abortion and
sterilization requirements as specified by ODJFS will result in the assessment
of a nonrefundable $2,000
fine for each documented violation. Additionally, MCPs must take all
appropriate action to correct each ODJFS-documented violation.
J.9.
Refusal to Comply with
Program Requirements - If ODJFS has instructed an MCP that they must
comply with a specific program requirement and the MCP refuses, such refusal
constitutes documentation that the MCP is no longer operating in the best
interests of the MCP’s members or the state of Ohio and ODJFS will move to
terminate or nonrenew the MCP’s provider agreement.
III.
Request for
Reconsiderations
MCPs
may
request a reconsideration of remedial action taken under the CAS for penalties
that include points, fines, reductions in assignments and/or selection
freezes. Requests for reconsideration must be submitted on the
ODJFS required
form as follows:
A.
MCPs notified of ODJFS’ imposition of
remedial action taken under the CAS will have ten (10) working days
from the date of receipt of the facsimile to request reconsideration,
although
ODJFS will impose enrollment freezes based on an access to care concern
concurrent with initiating notification to the MCP. Any information that
the MCP would like
reviewed as part of the reconsideration request must be submitted at the
time of
submission of the reconsideration request, unless ODJFS extends the time
frame
in writing.
B.
All requests for reconsideration must
be submitted by either facsimile transmission or overnight mail to the Chief,
Bureau of Managed Health Care, and received by ODJFS by the tenth business
day
after receipt of the faxed notification of the imposition of the remedial
action by ODJFS.
C.
The
MCP will be responsible for verifying timely receipt of all reconsideration
requests. All requests for reconsideration must explain in detail why
the specified remedial action
should not be imposed. The MCP’s justification for reconsideration
will be limited to a review of the written material submitted by the
MCP. The Bureau Chief will review all correspondence and materials
related to the violation in question in making the final reconsideration
decision.
D.
Final decisions or requests for
additional information will be made by ODJFS within ten (10) business days
of
receipt of the request for reconsideration.
E.
If additional information is
requested by ODJFS, a final reconsideration decision will be made within
three
(3) business days of the due date for the submission. Should ODJFS
require additional time in rendering the final reconsideration decision,
the MCP
will be notified of such in writing.
F.
If a reconsideration request is
decided, in whole or in part, in favor of the MCP, both the penalty and the
points associated
with the incident, will be
rescinded or reduced, in the sole discretion
of ODJFS. The MCP
may still be required to submit a CAP if ODJFS, in its sole discretion, believes
that a CAP is still warranted under the
circumstances.
APPENDIX
O
PAY-FOR
PERFORMANCE (P4P)
CFC
ELIGIBLE
POPULATION
This
Appendix establishes P4P for
managed care plans (MCPs) to improve performance in specific areas important
to
the Medicaid MCP members. P4P include the at-risk amount included
with the monthly premium payments (see Appendix F, Rate
Chart), and possible
additional monetary rewards up to $250,000.
To
qualify for consideration of any P4P,
MCPs must meet minimum performance standards established in Appendix M,
Performance
Evaluationon selected
measures, and achieve P4P standards established for selected Clinical
Performance Measures. For qualifying MCPs, higher performance
standards for three measures must be reached to be awarded a portion of the
at-risk amount and any additional P4P (see Sections 1 and 2). An
excellent and superior standard is set in this Appendix for each of the three
measures. Qualifying MCPs will be awarded a portion of the at-risk
amount for each excellent standard met. If an MCP meets all three
excellent and superior standards, they may be awarded additional P4P (see
Section 3).
Prior
to the transition to a
regional-based statewide P4P system (SFY 2006 through SFY 2009), the
county-based statewide P4P system (sections 1 and 2 of this Appendix) will
apply
to MCPs with membership as of February 1, 2006. Only
counties with membership as of February 1, 2006 will be used
to
calculate performance levels for the county-based statewide P4P system.
1.
SFY 2007 P4P
1.a.
Qualifying Performance Levels
To
qualify for consideration of the SFY
2007 P4P,
an MCP’s performance level
must:
1)
Meet the minimum performance
standards set in Appendix M, Performance
Evaluation, for the
measures listed below; and
2) Meet
the P4P standards
established for the Emergency
Department Diversion and Clinical Performance Measures
below.
A
detailed description of the
methodologies for each measure can be found on the BMHC page of the ODJFS
website.
Measures
for which the minimum
performance standard for SFY 2007 established in Appendix M, Performance
Evaluation, must be met to
qualify for consideration of P4P are
as follows:
1. PCP
Turnover (Appendix M,
Section 2.a.)
Report
Period: CY
2006
2.
Children’s Access to Primary Care
(Appendix M, Section 2.b.)
Report
Period: CY
2006
3. Adults’
Access
to
Preventive/Ambulatory Health Services (Appendix M, Section
2.c.)
Report
Period: CY
2006
4.
Overall Satisfaction with MCP
(Appendix M, Section 3.)
Report
Period: The
most recent consumer satisfaction
survey completed prior to the end of the SFY 2007 contract
period.
For
the EDD performance measure, the MCP
must meet the P4P standard
for the report period of July -
December, 2006 to be considered for SFY 2007 P4P. The
MCP meets the
P4P standard
if one of two criteria are
met. The P4P standard
is a performance level of
either:
1)
The minimum performance standard
established in Appendix M, Section 4.b.; or
2)
The Medicaid benchmark of a
performance level at or below 1.1%.
For
each clinical performance measure
listed below, the
MCP must meet the P4P standard to be considered for SFY 2007 P4P. The
MCP meets the P4P
standard if one of two criteria are met. The P4Pstandard
is a performance level of
either:
1)
The minimum performance standard
established in Appendix M,
Performance
Evaluation, for seven of
the nine clinical performance measures listed below; or
2)
The Medicaid benchmarks for seven of
the nine clinical performance measures listed below. The Medicaid
benchmarks are subject to change based on the revision or update of applicable
national standards, methods or benchmarks.
|
Clinical
Performance Measure
|
Medicaid
Benchmark
|
|
1.
Perinatal Care - Frequency of
Ongoing Prenatal Care
|
42%
|
|
2.
Perinatal Care - Initiation of
Prenatal Care
|
71%
|
|
3.
Perinatal Care - Postpartum
Care
|
48%
|
|
4.
Well-Child Visits – Children
who turn 15 months old
|
34%
|
|
5.
Well-Child Visits - 3, 4, 5, or
6, years old
6.
Well-Child Visits - 12 through
21 years old
7.
Use of Appropriate Medications
for People with Asthma
8.
Annual Dental
Visits
9.
Blood Lead – 1 year
olds
|
50%
30%
83%
40%
45%
|
1.b.
Excellent and Superior Performance
Levels
For
qualifying MCPs as determined by
Section 2.a., performance will be evaluated on the
measures below to
determine the status of the at-risk amount or any additional P4P that
may be
awarded. Excellent and Superior standards
are set for the three measures
described below. The standards are subject to change based on the
revision or update of applicable national standards, methods or
benchmarks.
A
brief description of these measures is
provided in Appendix M, Performance
Evaluation. A
detailed description of the methodologies for each measure can be found on
the
BMHC page of the ODJFS website.
1.
Case Management of Children (Appendix
M, Section 1.b.ii.)
Report
Period: April - June
2007
Excellent
Standard:
5.5%
Superior
Standard:
6.5%
2.
Use of Appropriate Medications for
People with Asthma (Appendix M, Section 0.x.xx.)
Report
Period: CY
2006
Excellent
Standard:
86%
Superior
Standard:
88%
3.
Adults’ Access to
Preventive/Ambulatory Health Services (Appendix M, Section
2.c.)
Report
Period: CY
2006
Excellent
Standard:
76%
Superior
Standard:
83%
1.c.
Determining SFY 2007 P4P
MCPs
reaching
the minimum performance
standards described in Section 1.a. herein, will be considered for P4P including
retention of the at-risk amount and any additional P4P. For each
Excellent standard established in Section 1.b. herein, that an MCP
meets, one-third of the at-risk amount may be retained. For MCPs
meeting all of the Excellent and Superior standards
established in Section 1.b.
herein, additional P4P may be awarded. For MCPs receiving additional
P4P, the amount in the P4P fund
(see section 2.) will be divided
equally, up to the maximum
additional amount, among
all MCPs’ABD and/or CFC programs receiving
additional P4P. The
maximum additional
amount
to be awarded per plan, per program, per contract year is
$250,000. An MCP may receive up to $500,000 should both of the MCP’s
ABD and CFC programs achieve the Superior Performance
Levels.
2.
SFY 2008 P4P
2.a.
Qualifying Performance
Levels
To
qualify for consideration of the SFY
2008 P4P,
an MCP’s performance level must meet
the minimum performance standards set in Appendix M, Performance
Evaluation, for the
measures listed below. A detailed description of the methodologies
for each measure can be found on the BMHC page of the ODJFS
website.
Measures
for which the minimum
performance standard for SFY 2008 established in Appendix M, Performance
Evaluation, must be met to
qualify for consideration of P4P are
as follows:
1. PCP
Turnover (Appendix M,
Section 2.a.)
Report
Period: CY
2007
2.
Children’s Access to Primary Care
(Appendix M, Section 2.b.)
Report
Period: CY
2007
3. Adults’
Access
to
Preventive/Ambulatory Health Services (Appendix M, Section
2.c.)
Report
Period: CY
2007
4.
Overall Satisfaction with MCP
(Appendix M, Section 3.)
Report
Period: The most recent
consumer satisfaction survey completed prior to the end of the SFY
2008.
For
each clinical performance measure
listed below, the MCP must meet the P4P standard to be considered for SFY
2008P4P. The
MCP meets the P4P
standard if one of two criteria are met. The P4P standard
is a performance level of
either:
1)
The minimum performance standard
established in Appendix M, Performance
Evaluation, for seven of
the nine clinical performance measures listed below; or
2)
The Medicaid benchmarks for seven of
the nine clinical performance measures listed below. The Medicaid
benchmarks are subject to change based on the revision or update of applicable
national standards, methods or benchmarks.
|
Clinical
Performance Measure
|
Medicaid
Benchmark
|
|
1.
Perinatal Care - Frequency of
Ongoing Prenatal Care
|
42%
|
|
2.
Perinatal Care - Initiation of
Prenatal Care
|
71%
|
|
3.
Perinatal Care - Postpartum
Care
|
48%
|
|
4.
Well-Child Visits – Children
who turn 15 months old
|
34%
|
|
5.
Well-Child Visits - 3, 4, 5, or
6, years old
6.
Well-Child Visits - 12 through
21 years old
7.
Use of Appropriate Medications
for People with Asthma
8.
Annual Dental
Visits
9.
Blood Lead – 1 year
olds
|
50%
30%
83%
40%
45%
|
2.b.
Excellent and Superior Performance
Levels
For
qualifying MCPs as determined by
Section 2.a., performance will be evaluated on the measures below to determine
the status of the at-risk amount or any additional P4P that
may be
awarded. Excellent and Superior standards
are set for the three measures
described below. The standards are subject to change based on the
revision or update of applicable national standards, methods or
benchmarks.
A
brief description of these measures is
provided in Appendix M, Performance
Evaluation. A
detailed description of the methodologies for each measure can be found on
the
BMHC page of the ODJFS website.
1.
Case Management of Children (Appendix
M, Section 1.b.i.)
Report
Period: April - June
2008
Excellent
Standard:
5.5%
Superior
Standard:
6.5%
2.
Use of Appropriate Medications for
People with Asthma (Appendix M, Section 1.c.v.)
Report
Period: CY
2007
Excellent
Standard:
86%
Superior
Standard:
88%
3.
Adults’ Access to
Preventive/Ambulatory Health Services (Appendix M, Section
2.c.)
Report
Period: CY
2007
Excellent
Standard:
76%
Superior
Standard:
84%
2.c.
Determining SFY 2008
P4P
MCP’s
reaching the minimum performance
standards described in Section 2.a. herein, will be considered for P4P including
retention of the at-risk
amount and any additional P4P. For
each Excellent standard
established in Section 2.b. herein, that an MCP meets, one-third of the at-risk
amount may be retained. For MCPs meeting all of the Excellent and
Superiorstandards
established in Section 2.b.
herein, additional P4P
may
be
awarded. For MCPs receiving additional P4P,
the amount in the P4P fund (see
Section 3.) will be divided equally, up to the maximum additional amount,
among
all MCPs’ ABD and/or CFC programs receiving additional P4P. The
maximum additional
amount to be awarded per plan, per program, per contract year is
$250,000. An MCP may receive up to $500,000 should both of the MCP’s
ABD and CFC programs achieve the Superior Performance
Levels.
3.
NOTES
3.a.
Transition from a county-based statewide to a regional-based statewide P4P
system.
The
current county-based statewide P4P system will transition to a regional-based
statewide system as managed care expands statewide. The
regional-based statewide approach will be fully phased in no later than SFY
2010. The regional-based statewide P4P system will be modeled after
the county-based statewide system with adjustments to performance standards
where appropriate.
3.a.i.
County-based statewide P4P system
For
MCPs
in their first twenty-four months of Ohio Medicaid CFC Managed Care Program
participation, the status of the at-risk amount will not be determined because
compliance with many of the standards cannot be determined in an MCP’s first two
contract years (see Appendix F., Rate Chart). In addition,
MCPs in their first two contract years are not eligible for the additional
P4P
amount awarded for superior performance.
Starting
with the twenty-fifth month of participation in the program, a new MCP’s at-risk
amount will be included in the P4P system. The determination of the status
of
this at-risk amount will be after at least three full calendar years of
membership as many of the performance standards require three full calendar
years to determine an MCP’s performance level. Because of this
requirement, more than 12 months of at-risk dollars may be included in an
MCP’s
first at-risk status determination depending on when an MCP starts with the
program relative to the calendar year.
During
the transition to a regional-based statewide system (SFY 2006 through SFY
2009),
MCPs with membership as of February 1, 2006 will continue in the
county-based statewide P4P system until the transition is
complete. These MCPs will be put at-risk for a portion of the
premiums received for members in counties they are serving as of February
1,
2006.
3.a.ii.
Regional-based statewide P4P system
All
MCPs will be included in the
regional-based statewide P4P system. The at-risk amount will
be determined separately for each region an MCP serves.
The
status of the at-risk amount for counties not included in the county-based statewide
P4P
system will not be determined for the first twenty-four months of regional
membership. Starting with the twenty-fifth month of regional
membership, the MCP’s at-risk amount will be included in the P4P system. The
determination of the status of this at-risk amount will be after at least
three
full calendar years of regional membership as many of the performance standards
require three full calendar years to determine an MCP’s performance level. Given
that statewide expansion was not complete by December 31, 2006, ODJFS may
adjust
performance measure reporting periods based on the number of months an MCP
has
had regional membership. Because of this requirement, more than 12 months
of
at-risk dollars may be included in an MCP’s first regional at-risk status
determination depending on when regional membership starts relative to the
calendar year. Regional premium payments for months prior to July
2009 for members in counties included in the county-based statewide P4P system
for the SFY 2009 P4P determination, will be excluded from the at-risk dollars
included in the first regional-based statewide
P4P determination.
3.b.
Determination of at-risk amounts and additional P4P payments
For
MCPs
that have participated in the Ohio Medicaid Managed Care Program long enough
to
calculate performance levels for all of the performance measures included
in the
P4P system, determination of the status of an MCP’s at-risk amount will occur
within six months of the end of the contract period. Determination of
additional P4P payments will be made at the same time the status of an MCP’s
at-risk amount is determined.
3.c.
Contract Termination, Nonrenewals, or Denials
Upon
termination, nonrenewal or denial of an MCP contract, the at-risk amount
paid to
the MCP under the current provider agreement will be returned to
ODJFS in accordance with Appendix P., Terminations/Nonrenewals/Amendments,
of the provider agreement.
Additionally,
in accordance with Article XI of the provider agreement, the return of the
at-risk amount paid to the MCP under the current provider agreement will
be a
condition necessary for ODJFS’ approval of a provider agreement
assignment.
3.d.
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.
