Common use of Subcontractual Relationships and Delegation Clause in Contracts

Subcontractual Relationships and Delegation. An MCOP that delegates to any first tier, downstream and related entity (FDRs) as defined in 42 CFR 423.4, must ensure that it has an arrangement with the FDR to perform administrative services as defined below on the MCOP’s behalf. a. Unless otherwise specified by ODM, administrative services include: care management, marketing, utilization management, quality improvement, enrollment, disenrollment, membership functions, claims administration, licensing and credentialing, provider network management, and coordination of benefits. b. Before an MCOP enters into an arrangement with an FDR to perform an administrative function not listed above that could impact a member’s health, safety, welfare or access to Medicaid covered services, the MCOP must contact ODM to request a determination of whether or not the function should be included as an administrative service that complies with the provisions listed herein. c. An MCOP that enters into a written arrangement with an FDR shall include the following enforceable provisions: i. A description of the administrative services to be provided by the FDR and any requirements for the FDR to report information to the MCOP. ii. The beginning date and expiration date or automatic renewal clause for the arrangement, as well as applicable methods of extension, renegotiation and termination. iii. Identification of the service area and Medicaid population, either “dual” or “dual and non-dual” the FDR will serve. iv. A provision stating that the FDR shall release to the MCOP and ODM any information necessary for the MCOP to perform any of its obligations under the MCOP’s provider agreement with ODM, including but not limited to compliance with reporting and quality assurance requirements. v. A provision that the FDR’s applicable facilities and records will be open to inspection by the MCOP, ODM, its designee or other entities as specified in OAC rule. vi. A provision that the arrangement is governed by, and construed in accordance with all applicable state or federal laws, regulations and contractual obligations of the MCOP. The arrangement shall be automatically amended to conform to any changes in laws, regulations and contractual obligations without the necessity for written amendment. vii. A provision that Medicaid eligible individuals and ODM are not liable for any cost, payment, copayment, cost-sharing, down payment, or similar charge, refundable or otherwise for services performed, including in the event the FDR or MCOP cannot or will not pay for the administrative services. This provision does not prohibit waiver entities from collecting patient liability payments from MCOP members as specified in OAC rule 5160:1-3-04.3. viii. The procedures to be employed upon the ending, nonrenewal or termination of the arrangement including at a minimum to promptly supply any documentation necessary for the settlement of any outstanding claims or services. ix. A provision that the FDR will abide by the MCOP’s written policies regarding the False Claims Act and the detection and prevention of fraud, waste and abuse. x. A provision that the FDR, and all employees of the FDR, are subject to the applicable provider qualifications in OAC rule 5160-26-05. xi. For an FDR providing administrative services that result in direct contact with a Medicaid eligible individual, a provision that the FDR will identify, and where indicated, arrange pursuant to the mutually agreed upon policies and procedures between the MCOP and FDR for the following at no cost to the individual or ODM: 1. Sign language services; and 2. Oral interpretation and oral translation services. xii. For an FDR providing licensing and credentialing services of medical providers an provision that: 1. The credentials of medical professionals affiliated with the party or parties will be reviewed by the MCOP; or 2. The credentialing process will be reviewed and approved by the MCOP and the MCOP will audit the credentialing process on an ongoing basis. xiii. For an FDR providing administrative services that result in the selection of providers, a provision that the MCOP retains the right to approve, suspend, or terminate any such selection. xiv. A provision that permits ODM or the MCOP to seek revocation or other remedies, as applicable, if ODM or the MCOP determine that the FDR has not performed satisfactorily or the arrangement is not in the best interest of the MCOP’s members. d. The MCOP is ultimately responsible for meeting all contractual obligations under the MCOP’s provider agreement with ODM. The MCOP must: i. Ensure that the performance of FDR is monitored on an ongoing basis to identify any deficiencies or areas for improvement; ii. Impose corrective action on the FDR as necessary; and iii. Maintain policies and procedures that ensure there is no disruption in meeting their contractual obligations to ODM, if the FDR or MCOP terminates the arrangement between the FDR and the MCOP. e. Unless otherwise specified by ODM, all information required to be submitted to ODM must be submitted directly by the MCOP. f. Information regarding new, changes to, or termination of FDR arrangements must be reported to ODM no less than 15 days prior to it taking effect. g. Delegation requirements do not apply to care management arrangements between an MCOP and a Recovery Management entity as cited in appendix K.

Subcontractual Relationships and Delegation. An MCOP that delegates to any first tier, downstream and related entity (FDRs) as defined in 42 CFR 423.4, must ensure that it has an arrangement with the FDR to perform administrative services as defined below on the MCOP’s behalf. a. Unless otherwise specified by ODM, administrative services include: care management, marketing, utilization management, quality improvement, enrollment, disenrollment, membership functions, claims administration, licensing and credentialing, provider network management, and coordination of benefits. b. Before an MCOP enters into an arrangement with an FDR to perform an administrative function not listed above that could impact a member’s health, safety, welfare or access to Medicaid covered services, the MCOP must contact ODM to request a determination of whether or not the function should be included as an administrative service that complies with the provisions listed herein. c. An MCOP that enters into a written arrangement with an FDR shall include the following enforceable provisions: i. A description of the administrative services to be provided by the FDR and any requirements for the FDR to report information to the MCOP. ii. The beginning date and expiration date or automatic renewal clause for the arrangement, as well as applicable methods of extension, renegotiation and termination. iii. Identification of the service area and Medicaid population, either “dual” or “dual and non-dualnon‐dual” the FDR will serve. iv. A provision stating that the FDR shall release to the MCOP and ODM any information necessary for the MCOP to perform any of its obligations under the MCOP’s provider agreement with ODM, including but not limited to compliance with reporting and quality assurance requirements. v. A provision that the FDR’s applicable facilities and records will be open to inspection by the MCOP, ODM, its designee or other entities as specified in OAC rule. vi. A provision that the arrangement is governed by, and construed in accordance with all applicable state or federal laws, regulations and contractual obligations of the MCOP. The arrangement shall be automatically amended to conform to any changes in laws, regulations and contractual obligations without the necessity for written amendment. vii. A provision that Medicaid eligible individuals and ODM are not liable for any cost, payment, copayment, cost-sharingcost‐sharing, down payment, or similar charge, refundable or otherwise for services performed, including in the event the FDR or MCOP cannot or will not pay for the administrative services. This provision does not prohibit waiver entities from collecting patient liability payments from MCOP members as specified in OAC rule 5160:1-3-04.3.the viii. The procedures to be employed upon the ending, nonrenewal or termination of the arrangement including at a minimum to promptly supply any documentation necessary for the settlement of any outstanding claims or services. ix. A provision that the FDR will abide by the MCOP’s written policies regarding the False Claims Act and the detection and prevention of fraud, waste and abuse. x. A provision that the FDR, and all employees of the FDR, are subject to the applicable provider qualifications in OAC rule 5160-26-055160‐26‐05. xi. For an FDR providing administrative services that result in direct contact with a Medicaid eligible individual, a provision that the FDR will identify, and where indicated, arrange pursuant to the mutually agreed upon policies and procedures between the MCOP and FDR for the following at no cost to the individual or ODM: 1. Sign language services; and 2. Oral interpretation and oral translation services. xii. For an FDR providing licensing and credentialing services of medical providers an provision that: 1. The credentials of medical professionals affiliated with the party or parties will be reviewed by the MCOP; or 2. The credentialing process will be reviewed and approved by the MCOP and the MCOP will audit the credentialing process on an ongoing basis. xiii. For an FDR providing administrative services that result in the selection of providers, a provision that the MCOP retains the right to approve, suspend, or terminate any such selection. xiv. A provision that permits ODM or the MCOP to seek revocation or other remedies, as applicable, if ODM or the MCOP determine that the FDR has not performed satisfactorily or the arrangement is not in the best interest of the MCOP’s members. d. The MCOP is ultimately responsible for meeting all contractual obligations under the MCOP’s provider agreement with ODM. The MCOP must:obligations i. Ensure that the performance of FDR is monitored on an ongoing basis to identify any deficiencies or areas for improvement; ii. Impose corrective action on the FDR as necessary; and iii. Maintain policies and procedures that ensure there is no disruption in meeting their contractual obligations to ODM, if the FDR or MCOP terminates the arrangement between the FDR and the MCOP. e. Unless otherwise specified by ODM, all information required to be submitted to ODM must be submitted directly by the MCOP. f. Information regarding new, changes to, or termination of FDR arrangements must be reported to ODM no less than 15 days prior to it taking effect. g. Delegation requirements do not apply to care management arrangements between an MCOP and a Recovery Management entity as cited in appendix K.

Subcontractual Relationships and Delegation. An MCOP that delegates to any first tier, downstream and related entity (FDRs) as defined in 42 CFR 423.4, must ensure that it has an arrangement with the FDR to perform administrative services as defined below on the MCOP’s behalf. a. Unless otherwise specified by ODM, administrative services include: care management, marketing, utilization management, quality improvement, enrollment, disenrollment, membership functions, claims administration, licensing and credentialing, provider network management, and coordination of benefits. b. Before an MCOP enters into an arrangement with an FDR to perform an administrative function not listed above that could impact a member’s health, safety, welfare or access to Medicaid covered services, the MCOP must contact ODM to request a determination of whether or not the function should be included as an administrative service that complies with the provisions listed herein. c. An MCOP that enters into a written arrangement with an FDR shall include the following enforceable provisions: i. A description of the administrative services to be provided by the FDR and any requirements for the FDR to report information to the MCOP. ii. The beginning date and expiration date or automatic renewal clause for the arrangement, as well as applicable methods of extension, renegotiation and termination. iii. Identification of the service area and Medicaid population, either “dual” or “dual and non-dual” the FDR will serve. iv. A provision stating that the FDR shall release to the MCOP and ODM any information necessary for the MCOP to perform any of its obligations under the MCOP’s provider agreement with ODM, including but not limited to compliance with reporting and quality assurance requirements. v. A provision that the FDR’s applicable facilities and records will be open to inspection by the MCOP, ODM, its designee or other entities as specified in OAC rule. vi. A provision that the arrangement is governed by, and construed in accordance with all applicable state or federal laws, regulations and contractual obligations of the MCOP. The arrangement shall be automatically amended to conform to any changes in laws, regulations and contractual obligations without the necessity for written amendment. vii. A provision that Medicaid eligible individuals and ODM are not liable for any cost, payment, copayment, cost-sharing, down payment, or similar charge, refundable or otherwise for services performed, including in the event the FDR or MCOP cannot or will not pay for the administrative services. This provision does not prohibit waiver entities from collecting patient liability payments from MCOP members as specified in OAC rule 5160:1-3-04.3.the viii. The procedures to be employed upon the ending, nonrenewal or termination of the arrangement including at a minimum to promptly supply any documentation necessary for the settlement of any outstanding claims or services. ix. A provision that the FDR will abide by the MCOP’s written policies regarding the False Claims Act and the detection and prevention of fraud, waste and abuse. x. A provision that the FDR, and all employees of the FDR, are subject to the applicable provider qualifications in OAC rule 5160-26-05. xi. For an FDR providing administrative services that result in direct contact with a Medicaid eligible individual, a provision that the FDR will identify, and where indicated, arrange pursuant to the mutually agreed upon policies and procedures between the MCOP and FDR for the following at no cost to the individual or ODM: 1. Sign language services; and 2. Oral interpretation and oral translation services. xii. For an FDR providing licensing and credentialing services of medical providers an provision that: 1. The credentials of medical professionals affiliated with the party or parties will be reviewed by the MCOP; or 2. The credentialing process will be reviewed and approved by the MCOP and the MCOP will audit the credentialing process on an ongoing basis. xiii. For an FDR providing administrative services that result in the selection of providers, a provision that the MCOP retains the right to approve, suspend, or terminate any such selection. xiv. A provision that permits ODM or the MCOP to seek revocation or other remedies, as applicable, if ODM or the MCOP determine that the FDR has not performed satisfactorily or the arrangement is not in the best interest of the MCOP’s members. d. The MCOP is ultimately responsible for meeting all contractual obligations under the MCOP’s provider agreement with ODM. The MCOP must:obligations i. Ensure that the performance of FDR is monitored on an ongoing basis to identify any deficiencies or areas for improvement; ii. Impose corrective action on the FDR as necessary; and iii. Maintain policies and procedures that ensure there is no disruption in meeting their contractual obligations to ODM, if the FDR or MCOP terminates the arrangement between the FDR and the MCOP. e. Unless otherwise specified by ODM, all information required to be submitted to ODM must be submitted directly by the MCOP. f. Information regarding new, changes to, or termination of FDR arrangements must be reported to ODM no less than 15 days prior to it taking effect. g. Delegation requirements do not apply to care management arrangements between an MCOP and a Recovery Management entity as cited in appendix K.K. The following are the Ohio Department of Medicaid (ODM) responsibilities or clarifications that are not otherwise specifically stated in OAC Chapters 5160-26, 5160-58 or elsewhere in the Provider Agreement. 1. ODM will provide MCOPs with an opportunity to review and comment on the rate- setting time line, proposed rates, proposed changes to the OAC program rules, and the provider agreement. 2. ODM will notify MCOPs of managed care program policy and procedural changes and, whenever possible, offer sufficient time for comment and implementation. 3. ODM will provide regular opportunities for MCOPs to receive program updates and discuss program issues with ODM staff. 4. ODM will provide technical assistance sessions where MCOP attendance and participation is required. ODM will also provide optional technical assistance sessions to MCOPs, individually or as a group. 5. ODM will provide MCOPs with linkages to organizations that can provide guidance on the development of effective strategies to eliminate health disparities. 6. ODM will conduct an annual analysis of Medicaid eligible individuals to identify whether there are any prevalent common primary languages, other than English, in an MCOP’s service area. ODM will notify the MCOP of any languages that are identified as prevalent for the purpose of translating marketing and member materials. 7. ODM will provide each MCOP with an annual MCOP Calendar of Submissions outlining major submissions and due dates. 8. ODM will identify contact staff, including the Contract Administrator (CA), selected for each MCOP. 9. ODM will provide each MCOP with an electronic Provider Master File containing all the Ohio Medicaid fee-for-service (FFS) providers, which includes their Medicaid Provider Numbers, as well as all providers who have been assigned a provider reporting number for current encounter data purposes. This file will also include NPI information when available.