MCP delegated entities Clause Samples

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. 3▇▇ ▇▇▇▇▇ ▇▇▇ ▇▇▇▇▇▇, ▇▇▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇ w▇▇.▇▇▇▇▇▇▇▇.▇▇▇ November 17, 2006 M▇. ▇▇▇ ▇▇▇▇▇▇ Bureau of Managed Health Care Ohio Department of Job and Family Services 2▇▇ ▇▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇ Subject: ABD Rate-Setting Methodology & Capitation Rate Certification for the 2007 Contract Period Dear J▇▇: The Ohio Department of Job and Family Services (State) contracted with M▇▇▇▇▇ Government Human Services Consulting (M▇▇▇▇▇) to develop actuarially sound regional capitation rates for the Aged, Blind or Disabled (ABD) managed care population. During calendar year (CY) 2007, the State will roll out statewide ABD mandatory managed care on a regional basis. It is anticipated that managed care will be implemented in all eight regions by May 2007. The specific contract period and effective dates vary by region. A summary of the regional rates for each region is included in Appendix E. This summary will be updated each time the contract period for a new region is determined. This methodology letter outlines the rate-setting process, provides information on the data adjustments and provides a final rate summary. The key components in the rate-setting process are: • Base data development, • Managed care rate development, and • Centers for Medicare and Medicaid Services (CMS) documentation requirements. Each of these components is described further throughout the document and is depicted in the flowchart included as Appendix A. The following ABD individuals are not eligible to enroll in the managed care program. • Children under twenty-one years of age, • Individuals who are dually eligible under both the Medicaid and Medicare programs, • Institutionalized individuals, • Individuals eligible for Medicaid by spending down their income or resources to a level that meets the Medicaid program’s financial eligibility requirements, or • Individuals receiving Medicaid services through a Medicaid Waiver. In addition, for managed care eligible individuals who enter a nursing facility, managed care plans (MCPs) are responsible for nursing facility payment and payment for all covered services until t...

MCP delegated entities. In that MCPs are ultimately responsible for meeting program requirements, the BMHC will not discuss MCP issues Appendix D 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. Government Human Services Consulting November 17, 2006 ▇▇. ▇▇▇ ▇▇▇▇▇▇ Bureau of Managed Health Care Ohio Department of Job and Family Services ▇▇▇ ▇▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇ Subject: Dear ▇▇▇: The Ohio Department of Job and Family Services (State) contracted with ▇▇▇▇▇▇ Government Human Services Consulting (▇▇▇▇▇▇) to develop actuarially sound regional capitation rates for the Aged, Blind or Disabled (ABD) managed care population. During calendar year (CY) 2007, the State will roll out statewide ABD mandatory managed care on a regional basis. It is anticipated that managed care will be implemented in all eight regions by May 2007. The specific contract period and effective dates vary by region. A summary of the regional rates for each region is included in Appendix E. This summary will be updated each time the contract period for a new region is determined. This methodology letter outlines the rate-setting process, provides information on the data adjustments and provides a final rate summary. The key components in the rate-setting process are: • Base data development, • Managed care rate development, and • Centers for Medicare and Medicaid Services (CMS) documentation requirements. Each of these components is described further throughout the document and is depicted in the flowchart included as Appendix ▇. Government Human Services Consulting November 17, 2006 ▇▇. ▇▇▇ ▇▇▇▇▇▇ Bureau of Managed Health Care The following ABD individuals are not eligible to enroll in the managed care program. • Children under twenty-one years of age, • Individuals who are dually eligible under both the Medicaid and Medicare programs, • Institutionalized individuals, • Individuals eligible for Medicaid by spending down their income or resources to a level that meets the Medicaid program's financial eligibility requirements, or • Individuals receiving Medicaid services through a Medicaid Waiver. In addition, for managed care eligible individuals who enter a nursing facility, managed care plans (MCPs) are responsible for nursing facility payment and payment for all covered services until the last day of the ...

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. Chase Center/Circle ▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇ ▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇ USA Tel +▇ ▇▇▇ ▇▇▇ ▇▇▇▇ Fax +▇▇▇▇ ▇▇▇ ▇▇▇▇ June 5, 2008

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. 1. PREMIUM RATES WITHOUT THE AT-RISK PAYMENT AMOUNTS FOR 01/01/09 THROUGH 06/30/09 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. List of Eligible Assistance Groups (AGs) 2. AT-RISK AMOUNTS FOR 01/01/09 THROUGH 06/30/09 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 ENROLLMENT AREA REGIONAL STATUS HF/HST Age < 1 HF/HST Age 1 HF/HST Age 2-13 HF/HST Age 14-18 Male HF/HST Age 14-18 Female HF Age 19-44 Male HF Age 19-44 Female HF Age 45 and over HST Age 19-64 Female Delivery Payment List of Eligible Assistance Groups (AGs) 3. PREMIUM RATES FOR 01/01/09 THROUGH 06/30/09 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 ENROLLMENT AREA REGIONAL STATUS HF/HST Age < 1 HF/HST Age 1 HF/HST Age 2-13 HF/HST Age 14-18 Male HF/HST Age 14-18 Female HF Age 19-44 Male HF Age 19-44 Female HF Age 45 and over HST Age 19-64 Female Delivery Payment List of Eligible Assistance Groups (AGs) 1. Basic Benefit Package

MCP delegated entities. In that MCPs are ultimately responsible for meeting program requirements, the BMHC will not discuss MCP issues Appendix D 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. October 20, 2006 ▇▇. ▇▇▇ ▇▇▇▇▇▇ State of Ohio Bureau of Managed Health Care Ohio Department of Job and Family Services ▇▇▇ ▇▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇ ▇▇▇▇▇ Columbus.OH43215.5222 Subject: Dear ▇▇▇: The Ohio Department of Job and Family Services (State) contracted with ▇▇▇▇▇▇ Government Human Services Consulting (▇▇▇▇▇▇) to develop actuarially sound capitation rates for Calendar Year (CY) 2007 for the Healthy Families and Healthy Start (CFC) managed care populations. ▇▇▇▇▇▇ developed CY 2007 capitation rates for the following seven managed care regions: Central, East Central. Northeast, Northwest. Southeast. Southwest, and West Central. At this time, ▇▇▇▇▇▇ has not developed rates for the eighth region, Northeast Central, because managed care implementation has been put on hold for this region. Once the implementation date is determined for Northeast Central, a supplemental certification with the Northeast Central rates will be provided. The basic rate-setting methodology is similar to the county-specific rate methodology used in previous years. This methodology letter outlines the rate-setting process, provides information on data adjustments, and includes a final rate summary. The key components in the CY 2007 rate-setting process are: • Base data development, • Managed care rate development, and • Centers for Medicare and Medicaid Services (CMS) documentation requirements. Each of these components is described further throughout the document and is depicted in the flowchart included as Appendix ▇. October 20, 2006 ▇▇. ▇▇▇ ▇▇▇▇▇▇ Ohio Department of Job and Family Services The major steps in the development of the base data are similar to previous years. ▇▇▇▇▇▇ and the State have discussed the available data sources for rate development and the applicability of these data sources for each region. The data sources used for CY 2007 rate setting were: • Ohio historical FFS data, • MCP encounter data, and • MCP financial cost report data. Validation Process As part of the rate-setting process. ▇▇▇▇▇▇ validated each of the data sources that were used to develop rates. The validations included a review of the data to be u...

MCP delegated entities. In that MCPs are ultimately responsible for meeting program requirements, the BMHC will not discuss MCP issues Appendix D 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 G Page 1 1. Basic Benefit Package