OHIO MEDICAL ASSISTANCE PROVIDER AGREEMENT FOR MANAGED CARE PLAN ABD ELIGIBLE POPULATION
Exhibit
10.3
OHIO
DEPARTMENT OF JOB AND FAMILY SERVICES
OHIO
MEDICAL ASSISTANCE PROVIDER AGREEMENT FOR MANAGED CARE PLAN ABD ELIGIBLE
POPULATION
This
provider agreement is entered into this first day of December, 2006, at
Columbus, Franklin County, Ohio, between the State of Ohio, Department of Job
and Family Services, (hereinafter referred to as ODJFS) whose principal offices
are located in the City of Columbus, County of Franklin, State of Ohio, and
WellCare of Ohio, Inc, Managed Care Plan (hereinafter referred to as MCP),
an
Ohio for-profit corporation, whose principal office is located in the city
of
Beechwood, County of Cuyahoga, State of Ohio.
MCP
is
licensed as a Health Insuring Corporation by the State of Ohio, Department
of
Insurance (hereinafter referred to as ODI), pursuant to Chapter 1751. of the
Ohio Revised Code and is organized and agrees to operate as prescribed by
Chapter 5101:3-26 of the Ohio Administrative Code (hereinafter referred to
as
OAC), and other applicable portions of the OAC as amended from time to
time.
MCP
is an
entity eligible to enter into a provider agreement in accordance with 42 CFR
438.6 and is engaged in the business of providing prepaid comprehensive health
care services as defined in 42 CFR 438.2 through the managed care program for
the Aged, Blind or Disabled (ABD) eligible population described in OAC rule
5101:3-26-02 (B).
ODJFS,
as
the single state agency designated to administer the Medicaid program under
Section 5111.02 of the Ohio Revised Code and Title XIX of the Social Security
Act, desires to obtain MCP services for the benefit of certain Medicaid
recipients. In so doing, MCP has provided and will continue to provide proof
of
MCP's capability to provide quality services, efficiently, effectively and
economically during the term of this agreement.
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This
provider agreement is a contract between the ODJFS and the undersigned Managed
Care Plan (MCP), provider of medical assistance, pursuant to the federal
contracting provisions of 42 CFR 434.6 and 438.6 in which the MCP agrees to
provide comprehensive medical services through the managed care program as
provided in Chapter 5101:3-26 of the Ohio Administrative Code, assuming the
risk
of loss, and complying with applicable state statutes, Ohio Administrative
Code,
and Federal statutes, rules, regulations and other requirements, including
but
not limited to title VI of the Civil Rights Act of 1964; title IX of the
Education Amendments of 1972 (regarding education programs and activities);
the
Age Discrimination Act of 1975; the Rehabilitation Act of 1973; and the
Americans with Disabilities Act.
ARTICLE
I
- GENERAL
A.
MCP
agrees to report to the Chief of Bureau of Managed Health Care (hereinafter
referred to as BMHC) or their designee as necessary to assure understanding
of
the responsibilities and satisfactory compliance with this provider
agreement.
B.
MCP
agrees to furnish its support staff and services as necessary for the
satisfactory performance of the services as enumerated in this provider
agreement.
C.
ODJFS
may, from time to time as it deems appropriate, communicate
specific
instructions
and requests to MCP concerning the performance of the services described in
this
provider agreement. Upon such notice and within the designated time frame after
receipt of instructions, MCP shall comply with such instructions and fulfill
such requests to the satisfaction of the department. It is expressly understood
by the parties that these instructions and requests are for the sole purpose
of
performing the specific tasks requested to ensure satisfactory completion of
the
services described in this provider agreement, and are not intended to amend
or
alter this provider agreement or any part thereof.
If
the
MCP previously had a provider agreement with the ODJFS and the provider
agreement terminated more than two years prior to the effective date of any
new
provider agreement, such MCP will be considered a new plan in its first year
of
operation with the Ohio Medicaid managed care program.
ARTICLE
II - TIME OF PERFORMANCE
A.
Upon
approval by the Director of ODJFS this provider agreement shall be in effect
from the date entered through June 30, 2007, unless this provider agreement
is
suspended or terminated pursuant to Article VIII prior to the termination date,
or otherwise amended pursuant to Article IX.
ARTICLE
III -
REIMBURSEMENT
A.
ODJFS
will reimburse MCP in accordance with rule 5101:3-26-09 of the Ohio
Administrative Code and the appropriate appendices of this provider
agreement.
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ARTICLE
IV - MCP INDEPENDENCE
A.
MCP
agrees that no agency, employment, joint venture or partnership has been or
will
be created between the parties hereto pursuant to the terms and conditions
of
this agreement. MCP also agrees that, as an independent contractor, MCP assumes
all responsibility for any federal, state, municipal or other tax liabilities,
along with workers compensation and unemployment compensation, and insurance
premiums which may accrue as a result of compensation received for services
or
deliverables rendered hereunder. MCP certifies that all approvals, licenses
or
other qualifications necessary to conduct business in Ohio have been obtained
and are operative. If at any time during the period of this provider agreement
MCP becomes disqualified from conducting business in Ohio, for whatever reason,
MCP shall immediately notify ODJFS of the disqualification and MCP shall
immediately cease performance of its obligation hereunder in accordance with
OAC
Chapter 5101:3-26.
ARTICLE
V
- CONFLICT OF INTEREST; ETHICS LAWS
A.
In
accordance with the safeguards specified in section 27 of the Office of Federal
Procurement Policy Act (41 LJ.S.C. 423) and other applicable federal
requirements, no officer, member or employee of MCP, the Chief of BMHC, or
other
ODJFS employee who exercises any functions or responsibilities in connection
with the review or approval of this provider agreement or provision of services
under this provider agreement shall, prior to the completion of such services
or
reimbursement, acquire any interest, personal or otherwise, direct or indirect,
which is incompatible or in conflict with, or would compromise in any manner
or
degree the discharge and fulfillment of his or her functions and
responsibilities with respect to the carrying out of such services. For purposes
of this article, "members" does not include individuals whose sole connection
with MCP is the receipt of services through a health care program offered by
MCP.
B.
MCP
hereby covenants that MCP, its officers, members and employees of the MCP have
no interest, personal or otherwise, direct or indirect, which is incompatible
or
in conflict with or would compromise in any manner of degree the discharge
and
fulfillment of his or her functions and responsibilities under this provider
agreement. MCP shall periodically inquire of its officers, members and employees
concerning such interests.
C.
Any
person who acquires an incompatible, compromising or conflicting personal or
business interest shall immediately disclose his or her interest to ODJFS in
writing. Thereafter, he or she shall not participate in any action affecting
the
services under this provider agreement, unless ODJFS shall determine that,
in
the light of the personal interest disclosed, his or her participation in any
such action would not be contrary to the public interest. The written disclosure
of such interest shall be made to: Chief, Bureau of Managed Health Care,
ODJFS.
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D.
No
officer, member or employee of MCP shall promise or give to any ODJFS employee
anything of value that is of such a character as to manifest a substantial
and
improper influence upon the employee with respect to his or her duties. No
officer, member or employee of MCP shall solicit an ODJFS employee to violate
any ODJFS rule or policy relating to the conduct of the parties to this
agreement or to violate sections 102.03, 102.04, 2921.42 or 2921.43 of the
Ohio
Revised Code.
E.
MCP
hereby covenants that MCP, its officers, members and employees are in compliance
with section 102.04 of the Revised Code and that if MCP is required to file
a
statement pursuant to 102.04(D)(2) of the Revised Code, such statement has
been
filed with the ODJFS in addition to any other required filings.
ARTICLE
VI - EQUAL EMPLOYMENT OPPORTUNITY
A.
MCP
agrees that in the performance of this provider agreement or in the hiring
of
any employees for the performance of services under this provider agreement,
MCP
shall not by reason of race, color, religion, sex, sexual orientation, age,
disability, national origin, veteran's status, health status, or ancestry,
discriminate against any citizen of this state in the employment of a person
qualified and available to perform the services to which the provider agreement
relates.
B.
MCP
agrees that it shall not, in any manner, discriminate against, intimidate,
or
retaliate against any employee hired for the performance or services under
the
provider agreement on account of race, color, religion, sex, sexual orientation,
age, disability, national origin, veteran's status, health status, or
ancestry.
C.
In
addition to requirements imposed upon subcontractors in accordance with OAC
Chapter 5101:3-26, MCP agrees to hold all subcontractors and persons acting
on
behalf of MCP in the performance of services under this provider agreement
responsible for adhering to the requirements of paragraphs (A) and (B) above
and
shall include the requirements of paragraphs (A) and (B) above in all
subcontracts for services performed under this provider agreement, in accordance
with rule 5101:3-26-05 of the Ohio Administrative Code.
ARTICLE
VII - RECORDS, DOCUMENTS AND INFORMATION
A.
MCP
agrees that all records, documents, writings or other information produced
by
MCP under this provider agreement and all records, documents, writings or other
information used by MCP in the performance of this provider agreement shall
be
treated in accordance with rule 5101:3-26-06 of the Ohio Administrative Code.
MCP must maintain an appropriate record system for services provided to members.
MCP must retain all records in accordance with 45 CFR 74.
B.
All
information provided by MCP to ODJFS that is proprietary shall be held to be
strictly confidential by ODJFS. Proprietary information is information which,
if
made public, would put MCP at a disadvantage in the market place and trade
of
which MCP is a part
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[see
Ohio
Revised Code Section 1333.61(D)]. MCP is responsible for notifying ODJFS of
the
nature of the information prior to its release to ODJFS. ODJFS reserves the
right to require reasonable evidence of MCP's assertion of the proprietary
nature of any information to be provided and ODJFS will make the final
determination of whether this assertion is supported. The provisions of this
Article are not self-executing.
C.
MCP
shall not use any information, systems, or records made available to it for
any
purpose other than to fulfill the duties specified in this provider agreement.
MCP agrees to be bound by the same standards of confidentiality that apply
to
the employees of the ODJFS and the State of Ohio. The terms of this section
shall be included in any subcontracts executed by MCP for services under this
provider agreement. MCP must implement procedures to ensure that in the process
of coordinating care, each enrollee's privacy is protected consistent with
the
confidentiality requirements in 45 CFR parts 160 and 164.
ARTICLE
VIII - SUSPENSION AND TERMINATION
A.
This
provider agreement may be canceled by the department or MCP upon written notice
in accordance with the applicable rule(s) of the Ohio Administrative Code,
with
termination to occur at the end of the last day of a month.
B.
MCP,
upon receipt of notice of suspension or termination, shall cease provision
of
services on the suspended or terminated activities under this provider
agreement;
suspend,
or terminate all subcontracts relating to such suspended or terminated
activities, take all necessary or appropriate steps to limit disbursements
and
minimize costs, and furnish a report, as of the date of receipt of notice of
suspension or termination describing the status of all services under this
provider agreement.
C.
In the
event of suspension or termination under this Article, MCP shall be entitled
to
reconciliation of reimbursements through the end of the month for which services
were provided under this provider agreement, in accordance with the
reimbursement provisions of this provider agreement.
D.
ODJFS
may, in its judgment, suspend, terminate or fail to renew this provider
agreement if the MCP or MCP's subcontractors violate or fail to comply with
the
provisions of this agreement or other provisions of law or regulation governing
the Medicaid program. Where ODJFS proposes to suspend, terminate or refuse
to
enter into a provider agreement, the provisions of applicable sections of the
Ohio Administrative Code with respect to ODJFS' suspension, termination or
refusal to enter into a provider agreement shall apply, including the MCP's
right to request a public hearing under Chapter 119. of the Revised
Code.
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E.
When
initiated by MCP, termination of or failure to renew the provider agreement
requires written notice to be received by ODJFS at least 75 days in advance
of
the termination or renewal date, provided, however, that termination or
non-renewal must be effective at the end of the last day of a calendar month.
In
the event of non-renewal of the provider agreement with ODJFS, if MCP is unable
to provide notice to ODJFS 75 days prior to the date when the provider agreement
expires, and if, as a result of said lack of notice, ODJFS is unable to
disenroll Medicaid enrollees prior to the expiration date, then the provider
agreement shall be deemed extended for up to two calendar months beyond the
expiration date and both parties shall, for that time, continue to fulfill
their
duties and obligations as set forth herein. If an MCP wishes to terminate or
not
renew their provider agreement for a specific region(s), ODJFS reserves the
right to initiate a procurement process to select additional MCPs to serve
Medicaid consumers in that region(s).
ARTICLE
IX - AMENDMENT AND RENEWAL
A.
This
writing constitutes the entire agreement between the parties with respect to
all
matters herein. This provider agreement may be amended only by a writing signed
by both parties. Any written amendments to this provider agreement shall be
prospective in nature.
B.
This
provider agreement may be renewed one or more times by a writing signed by
both
parties for a period of not more than twelve months for each
renewal.
C.
In the
event that changes in State or Federal law, regulations, an applicable waiver,
or the terms and conditions of any applicable federal waiver, require ODJFS
to
modify this agreement, ODJFS shall notify MCP regarding such changes and this
agreement shall be automatically amended to conform to such changes without
the
necessity for executing written amendments pursuant to this Article of this
provider agreement.
ARTICLE
X
- LIMITATION OF LIABILITY
A.
MCP
agrees to indemnify the State of Ohio for any liability resulting from the
actions or omissions of MCP or its subcontractors in the fulfillment of this
provider agreement.
B.
MCP
hereby agrees to be liable for any loss of federal funds suffered by ODJFS
for
enrollees resulting from specific, negligent acts or omissions of the MCP or
its
subcontractors during the term of this agreement, including but not limited
to
the nonperformance of the duties and obligations to which MCP has agreed under
this agreement.
C.
In the
event that, due to circumstances not reasonably within the control of MCP or
ODJFS, a major disaster, epidemic, complete or substantial destruction of
facilities, war, riot or civil insurrection occurs, neither ODJFS nor MCP will
have any liability or obligation on account of reasonable delay in the provision
or the arrangement of covered services; provided that so long as MCP's
certificate of authority remains in full force and effect, MCP shall be liable
for the covered services required to be provided or arranged for
in
accordance with this agreement.
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ARTICLE
XI - ASSIGNMENT
A.
ODJFS
will not allow the transfer of Medicaid members by one MCP to another MCP unless
this membership has been obtained as a result of an MCP selling their entire
Ohio corporation to another health plan. MCP shall not assign any interest
in
this provider agreement and shall not transfer any interest in the same (whether
by assignment or novation) without the prior written approval of ODJFS and
subject to such conditions and provisions as ODJFS may deem necessary. Any
such
assignments shall be submitted for ODJFS' review 120 days prior to the desired
effective date. No such approval by ODJFS of any assignment shall be deemed
in
any event or in any manner to provide for the incurrence of any obligation
by
ODJFS in addition to the total agreed-upon reimbursement in accordance with
this
agreement.
B.
MCP
shall not assign any interest in subcontracts of this provider agreement and
shall not transfer any interest in the same (whether by assignment or novation)
without the prior written approval of ODJFS and subject to such conditions
and
provisions as ODJFS may deem necessary. Any such assignments of subcontracts
shall be submitted for ODJFS' review 30 days prior to the desired effective
date. No such approval by ODJFS of any assignment shall be deemed in any event
or in any manner to provide for the incurrence of any obligation by ODJFS in
addition to the total agreed-upon reimbursement in accordance with this
agreement.
ARTICLE
XII - CERTIFICATION MADE BY MCP
A.
This
agreement is conditioned upon the full disclosure by MCP to ODJFS of all
information required for compliance with federal regulations as requested by
ODJFS.
B.
By
executing this agreement, MCP certifies that no federal funds paid to MCP
through this or any other agreement with ODJFS shall be or have been used to
lobby Congress or any federal agency in connection with a particular contract,
grant, cooperative agreement or loan. MCP further certifies compliance with
the
lobbying restrictions contained in Section 1352, Title 31 of the U.S. Code,
Section 319 of Public Law 101-121 and federal regulations issued pursuant
thereto and contained in 45 CFR Part 93, Federal Register, Vol. 55, No. 38,
February 26, 1990, pages 6735-6756. If this provider agreement exceeds $100,000,
MCP has executed the Disclosure of Lobbying Activities, Standard Form LLL,
if
required by federal regulations. This certification is material representation
of fact upon which reliance was placed when this provider agreement was entered
into.
C.
By
executing this agreement, MCP certifies that neither MCP nor any principals
of
MCP (i.e., a director, officer, partner, or person with beneficial ownership
of
more than 5% of the MCP's equity) is presently debarred, suspended, proposed
for
debarment, declared ineligible, or otherwise excluded from participation in
transactions by any Federal agency. The MCP also certifies that the MCP has
no
employment, consulting or any other arrangement with any such debarred or
suspended person for the provision of items or services or services that are
significant and material to the MCP's contractual obligation with ODJFS. This
certification is a material representation of fact upon which
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reliance
was placed when this provider agreement was entered into. If it is ever
determined that MCP knowingly executed this certification erroneously, then
in
addition to any other remedies, this provider agreement shall be terminated
pursuant to Article VII, and ODJFS must advise the Secretary of the appropriate
Federal agency of the knowingly erroneous certification.
D.
By
executing this agreement, MCP certifies compliance with Article V as well as
agreeing to future compliance with Article V. This certification is a material
representation of fact upon which reliance was placed when this contract was
entered into.
E.
By
executing this agreement, MCP certifies compliance with the executive agency
lobbying requirements of sections 121.60 to 121.69 of the Ohio Revised Code.
This certification is a material representation of fact upon which reliance
was
placed when this provider agreement was entered into.
F.
By
executing this agreement, MCP certifies that MCP is not on the most recent
list
established by the Secretary of State, pursuant to section 121.23 of the Ohio
Revised Code, which identifies MCP as having more than one unfair labor practice
contempt of court finding. This certification is a material representation
of
fact upon which reliance was placed when this provider agreement was entered
into.
G.
By
executing this agreement MCP agrees not to discriminate against individuals
who
have or are participating in any work program administered by a county
Department of Job and Family Services under Chapters 5101 or 5107 of the Revised
Code.
H.
By
executing this agreement, MCP certifies and affirms that, as applicable to
MCP,
no party listed in Division (I) or (J) of Section 3517.13 of the Ohio Revised
Code or spouse of such party has made, as an individual, within the two previous
calendar years, one or more contributions in excess of $1,000.00 to the Governor
or to his campaign committees. This certification is a material representation
of fact upon which reliance was placed when this provider agreement was entered
into. If it is ever determined that MCP's certification of this requirement
is
false or misleading, and not withstanding any criminal or civil liabilities
imposed by law, MCP shall return to ODJFS all monies paid to MCP under this
provider agreement. The provisions of this section shall survive the expiration
or termination of this provider agreement.
I.
By
executing this agreement, MCP certifies and affirms that HHS, US Comptroller
General or representatives will have access to books, documents, etc. of
MCP.
J.
By
executing this agreement, MCP agrees to comply with the false claims recovery
requirements of Section 6032 of The Deficit Reduction Act of 2005 (also see
Section 5111.101 of the Revised Code).
ARTICLE
XIII - CONSTRUCTION
A.
This
provider agreement shall be governed, construed and enforced in accordance
with
the laws and regulations of the State of Ohio and appropriate federal statutes
and
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regulations.
If any portion of this provider agreement is found unenforceable by operation
of
statute or by administrative or judicial decision, the operation of the balance
of this provider agreement shall not be affected thereby; provided, however,
the
absence of the illegal provision does not render the performance of the
remainder of the provider agreement impossible.
ARTICLE
XIV - INCORPORATION BY REFERENCE
A.
Ohio
Administrative Code Chapter 5101:3-26 (Appendix A) is hereby incorporated by
reference as part of this provider agreement having the full force and effect
as
if specifically restated herein.
B.
Appendices B through P and any additional appendices are hereby incorporated
by
reference as part of this provider agreement having the full force and effect
as
if specifically restated herein.
C.
In the
event of inconsistence or ambiguity between the provisions of OAC 5101:3-26
and
this provider agreement, the provision of OAC 5101:3-26 shall be determinative
of the obligations of the parties unless such inconsistency or ambiguity is
the
result of changes in federal or state law, as provided in Article IX of this
provider agreement, in which case such federal or state law shall be
determinative of the obligations of the parties. In the event OAC 5101:3-26
is
silent with respect to any ambiguity or inconsistency, the provider agreement
(including Appendices B through P and any additional appendices), shall be
determinative of the obligations of the parties. In the event that a dispute
arises which is not addressed in any of the aforementioned documents, the
parties agree to make every reasonable effort to resolve the dispute, in keeping
with the objectives of the provider agreement and the budgetary and statutory
constraints of OD-IFS.
ABD
PROVIDER AGREEMENT INDEX
December
1, 2006
|
APPENDIX
|
TITLE
|
|
APPENDIX
A
|
OCA
RULES 5101 :3-26
|
|
APPENDIX
B
|
SERVICE
AREA SPECIFICAITONS - ABD ELIGIBLE
|
|
APPENDIX
C
|
MCP
RESPONSIBLITIES - ABD ELIGIBLE POPULATION
|
|
APPENDIX
D
|
ODJFS
RESPONSIBILITIES - ABD ELIGIBLE POPULATION
|
|
APPENDIX
E
|
RATE
METHODOLOGY - ABD ELIGIBLE POPULATION
|
|
APPENDIX
F
|
REGIONAL
RATES - ABD ELIGIBLE
POPULATION
|
|
APPENDIX
G
|
COVERAGE
AND SERVICES - ABD ELIGIBLE
POPULATION
|
|
APPENDIX
H
|
PROVIDER
PANEL SPECIFICATIONS - ABD ELIGIBLE
POPULATION
|
|
APPENDIX
I
|
POPULATION
INTEGRITY - ABD ELIGIBLE POPULATION
|
|
APPENDIX
J
|
FINANCIAL
PERFORMANCE - ABD ELIGIBLE POPULATION
|
|
APPENDIX
K
|
QUALITY
ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM AND EXTERNAL QUALITY
REVIEW
- AVD ELIGIBLE POPULATION
|
|
APPENDIX
L
|
DATA
QUALITY - ABD ELIGIBLE POPULATION
|
|
APPENDIX
M
|
PERFORMANCE
EVALUTAION - ABD ELIGIBLE POPULATION
|
|
APPENDIX
N
|
COMPLIANCE
ASSESSMENT SYSTEM - ABD ELGIBLE POPULATION
|
|
APPENDIX
O
|
PAY-FOR-PERFORMANCE
(P4P) - ABD ELIBIBLE POPULATION
|
|
APPENDIX
P
|
MCP
TERMINATIONS/NONRENEWALS/AMENDMENTS - ABD ELIGIBLE
POPULATION
|
APPENDIX
A
OAC
RULES 5101:3-26
The
managed care program rules can be accessed electronically through the BMHC
page
of the ODJFS website.
APPENDIX
B
SERVICE
AREA SPECIFICATIONS
ABD
ELIGIBLE POPULATION
MCP
: WellCare of Ohio, Inc.
The
MCP agrees to provide services to Aged. Blind or Disabled (ABD) members
residing
in the following service area(s):
Service
Area: Northeast Region:
Ashtabula, Cuyahoga, Erie, Geauga, Huron, Lake, Lorain,
▇▇▇▇▇▇
APPENDIX
C
MCP
RESPONSIBILITIES ABD ELIGIBLE POPULATION
The
MCP
must meet on an ongoing basis, all program requirements specified in Chapter
5101:3-26 of the Ohio Administrative Code (OAC) and the Ohio Department of
Job
and Family Services (ODJFS) - MCP Provider Agreement. The following are MCP
responsibilities that are not otherwise specifically stated in OAC rule
provisions or elsewhere in the MCP provider agreement, but are required by
ODJFS.
General
Provisions
1.
The
MCP agrees to implement program modifications as soon as reasonably possible
or
no later than the required effective date, in response to changes in applicable
state and federal laws and regulations.
2.
The
MCP must submit a current copy of their Certificate of Authority (COA) to ODJFS
within 30 days of issuance by the Ohio Department of Insurance.
3
The MCP
must designate the following:
a.
A
primary contact person (the Medicaid Coordinator) who will dedicate a majority
of their time to the Medicaid product line and coordinate overall communication
between ODJFS and the MCP. ODJFS may also require the MCP to designate contact
staff for specific program areas. The Medicaid Coordinator will be responsible
for ensuring the timeliness, accuracy, completeness and responsiveness of all
MCP submissions to ODJFS.
b.
A
provider relations representative for each service area included in their ODJFS
provider agreement. This provider relations representative can serve in this
capacity for only one service area (as specified in Appendix H).
If
an MCP
serves both the CFC and ABD populations, they are not required to designate
a
separate provider relations representative or Medicaid Coordinator for each
population group.
4.
All
MCP employees are to direct all day-to-day submissions and communications to
their ODJFS-designated Contract Administrator unless otherwise notified by
ODJFS.
5.
The
MCP must be represented at all meetings and events designated by ODJFS as
requiring mandatory attendance.
6.
The
MCP must have an administrative office located in Ohio.
Appendix
C
Page
2
7.
Upon
request by ODJFS, the MCP must submit information on the current status of
their
company's operations not specifically covered under this Agreement (for example,
other product lines, Medicaid contracts in other states, NCQA accreditation,
etc.) unless otherwise excluded by law.
8.
The
MCP must have all new employees trained on applicable program requirements,
and
represent, warrant and certify to ODJFS that such training occurs, or has
occurred.
9.
If an
MCP determines that it does not wish to provide, reimburse, or cover a
counseling service or referral service due to an objection to the service on
moral or religious grounds, it must immediately notify ODJFS to coordinate
the
implementation of this change. MCPs will be required to notify their members
of
this change at least thirty (30) days prior to the effective date. The MCP's
member handbook and provider directory, as well as all marketing materials,
will
need to include information specifying any such services that the MCP will
not
provide.
10.
For
any data and/or documentation that MCPs are required to maintain, ODJFS may
request that MCPs provide analysis of this data and/or documentation to ODJFS
in
an aggregate format, such format to be solely determined by ODJFS.
11.
The
MCP is responsible for determining medical necessity for services and supplies
requested for their members as specified in OAC rule 5101:3-26-03.
Notwithstanding such responsibility, ODJFS retains the right to make the final
determination on medical necessity in specific member situations.
12.
In
addition to the timely submission of medical records at no cost for the annual
external quality review as specified in OAC rule 5101:3-26-07, the MCP may
be
required for other purposes to submit medical records at no cost to ODJFS and/or
designee upon request.
13.
The
MCP must notify their Contract Administrator of the termination of an MCP panel
provider that is designated as the primary care physician for ^100 of the MCP's
ABD members. The MCP must provide notification within one working day of the
MCP
becoming aware of the termination.
14.
Upon
request by ODJFS, MCPs may be required to provide written notice to members
of
any significant change(s) affecting contractual requirements, member services
or
access to providers.
15.
MCPs
may elect to provide services that are in addition to those covered under the
Ohio Medicaid fee-for-service program. Before MCPs notify potential or current
members of the availability of these services, they must first notify ODJFS
and
advise ODJFS of such planned services availability. If an MCP elects to provide
additional services, the MCP
Appendix
C
Page
3
must
ensure to the satisfaction of ODJFS that the services are readily available
and
accessible
to members who are eligible to receive them.
a.
MCPs
are required
to make transportation available to any member that
must travel
thirty (30) miles or more from their home to receive a medically-necessary
Medicaid-covered service. If the MCP offers transportation to their members
as
an additional benefit and this transportation benefit only covers a limited
number of trips, the required transportation listed above may not be counted
toward this trip limit.
b.
Additional benefits may not vary by county within a region except out of
necessity for transportation arrangements (e.g., bus versus cab). MCPs approved
to serve consumers in more than one region may vary additional benefits between
regions.
c.
MCPs
must give ODJFS and members ninety (90) days prior notice when decreasing or
ceasing any additional benefit(s). When it is beyond the control of the MCP,
as
demonstrated to ODJFS' satisfaction, ODJFS must be notified within one (1)
working day.
16.
MCPs
must comply with any applicable Federal and State laws that pertain to member
rights and ensure that its staff adhere to such laws when furnishing services
to
its membrs. MCPs shall include a requirement in its contracts with affiliated
providers that such providers also adhere to applicable Federal and State laws
when providing services to members.
17.
MCPs
must comply with any other applicable Federal and State laws (such as Title
VI
of the Civil rights Act of 1964, etc.) and other laws regarding privacy and
confidentiality-;, as such may be applicable to this Agreement.
18.
Upon
request, the MCP will provide members and potential members with a copy of
their
practice guidelines.
19.
The
MCP is responsible for promoting the delivery of services in a culturally
competent manner, as solely determined by ODJFS, to all members, including
those
with limited English proficiency (LEP) and diverse cultural and ethnic
backgrounds.
All
MCPs
must comply with the requirements specified in OAC rules 5101:3-26-03.1,
5101:3-26-05(D), 5101:3-26-05.1(A), 5101:3-26-08 and 5101:3-26-08.2 for
providing assistance to LEP members and eligible individuals. In addition,
MCPs
must provide written translations of certain MCP materials in the prevalent
non-English languages of members and eligible individuals in accordance with
the
following:
Appendix
C
Page
4
| a. |
When
10% or more of the ABD eligible individuals in the MCP's service
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 ABD members in the MCP's service area have a common
primary language other than English, the MCP must translate all ODJFS-approved
member materials into the primary language of that group. The MCP must monitor
their membership and conduct a quarterly assessment to determine which, if
any,
primary language groups meet the 10% threshold. When the 10% threshold is met,
the MCP must report this information to ODJFS, in a format as requested by
ODJFS, translate their member materials, and make these materials available
to
their members. MCPs must submit to ODJFS, upon request, their prevalent
non-English language member analysis and the results of this
analysis.
20.
The
MCP must utilize a centralized database which records the special communication
needs of all MCP members (i.e., those with limited English proficiency, limited
reading proficiency, visual impairment, and hearing impairment) and the
provision of related services (i.e., MCP materials in alternate format, oral
interpretation, oral translation services, written translations of MCP
materials, and sign language services). This database must include all MCP
member primary language information (PLI) as well as all other special
communication needs information for MCP members, as indicated above, when
identified by any source including but not limited to ODJFS, ODJFS selection
services entity, MCP staff, providers, and members. This centralized database
must be readily available to MCP staff and be used in coordinating communication
and services to members, including the selection of a PCP who speaks the primary
language of an LEP member, when such a provider is available. MCPs must share
member specific communication needs information with their providers [e.g.,
PCPs, Pharmacy Benefit Managers (PBMs), and Third Party Administrators (TPAs)],
as applicable. MCPs must submit to ODJFS, upon request, detailed information
regarding the MCP's members with special communication needs, which could
include individual member names, their specific communication need, and any
provision of special services to members (i.e., those special services arranged
by the MCP as well as those services reported to the MCP which were arranged
by
the provider).
Appendix
C
Page
5
Additional
requirements specific to providing assistance to hearing-impaired,
vision-impaired, limited reading proficient (LRP), and LEP members and eligible
individuals are found in OAC rules 5101:3-26-03.1, 5101:3-26-05(D),
5101:3-26-05.1 (A), 5101:3-26-08, and 5101-3-26-08.2.
21.
The
MCP is responsible for ensuring that all member materials use easily understood
language and format. The determination of what materials comply with this
requirement is in the sole discretion of ODJFS.
22.
Pursuant to OAC rules 5101:3-26-08 and 5101:3-26-08.2, the MCP is responsible
for
ensuring
that all MCP marketing and member materials are prior approved by ODJFS before
being used or shared with members. Marketing and member materials are defined
as
follows:
a.
Marketing materials are those items produced in any medium, by or on behalf
of
an MCP, including gifts of nominal value (i.e., items worth no more than
$15.00), which can reasonably be interpreted as intended to market to eligible
individuals.
b.
Member
materials are those items developed, by or on behalf of an MCP, to fulfill
MCP
program requirements or to communicate to all members or a group of members.
Member health education materials that are produced by a source other than
the
MCP and which do not include any reference to the MCP are not considered to
be
member materials.
c.
All
MCP marketing and member materials must represent the MCP in an honest and
forthright manner and must not make statements which are inaccurate, misleading,
confusing, or otherwise misrepresentative, or which defraud eligible individuals
or ODJFS.
d.
All
MCP marketing cannot contain any assertion or statement (whether written or
oral) that the MCP is endorsed by CMS, the Federal or State government or
similar entity.
e.
MCPs
must establish positive working relationships with the CDJFS offices and must
not aggressively solicit from local Directors, MCP County Coordinators, or
or
other staff. Furthermore, MCPs are prohibited from offering gifts of nominal
value (i.e. clipboards, pens, coffee mugs, etc.) to CDJFS offices or SSE staff,
as these may influence an individual's decision to select a particular
MCP.
23.
Advance
Directives
- All
MCPs must comply with the requirements specified in 42 CFR 422.128. At a
minimum, the MCP must:
a.
Maintain written policies and procedures that meet the requirements for advance
directives,
as set forth in 42 CFR Subpart I of part 489.
Appendix
C
Page
6
b.
Maintain written policies and procedures concerning advance directives with
respect to all adult individuals receiving medical care by or through the MCP
to
ensure that the MCP:
i.
Provides written information to all adult members concerning:
a.
the
member's rights under state law to make decisions concerning
their medical care, including the right to accept or refuse medical or surgical
treatment and the right to formulate advance directives. (In meeting this
requirement, MCPs must utilize form JFS 08095 entitled You
Have the Right,
or
include the text from JFS 08095 in their ODJFS-approved member
handbook).
b.
the
MCP's policies concerning the implementation of those rights including a clear
and precise statement of any limitation regarding the implementation of advance
directives as a matter of conscience;
c.
any
changes in state law regarding advance directives as soon as possible but no
later than ninety (90) days after the proposed effective date of the change;
and
d.
the
right to file complaints concerning noncompliance with the advance directive
requirements with the Ohio Department of Health.
ii.
Provides for education of staff concerning the MCP's policies and procedures
on
advance directives;
iii.
Provides for community education regarding advance directives directly or in
concert with other providers or entities;
iv.
Requires that the member's medical record document whether or not the member
has
executed an advance directive; and
v.
Does
not condition the provision of care, or otherwise discriminate against a member,
based on whether the member has executed an advance directive.
Appendix
C
Page
7
24.
New
Member Materials
Pursuant
to OAC rule 5101:3-26-08.2 (B)(3), MCPs must provide to each member an MCP
identification (ID) card, a new member letter, a member handbook, a provider
directory, and information on advance directives.
a.
MCPs
must use the model language specified by ODJFS for the new member
letter.
b.
The ID
card and new member letter must be mailed together to the member via a method
that will ensure its receipt prior to the member's effective date of coverage.
No other materials may be included with this mailing.
c.
The
member handbook, provider directory and advance directives information must
be
mailed separately from the ID card and new member letter. MCPs will meet the
timely receipt requirement for these materials if they are mailed to the member
within twenty-four (24) hours of the MCP receiving the ODJFS-produced monthly
membership roster (MMR). This is provided the materials are mailed via a method
with an expected delivery date of five (5) days. If the MCP is unable to mail
the materials within twenty-four (24) hours, the materials must be mailed via
a
method that will ensure receipt by no later than the effective date of
coverage.
d.
MCPs
must designate two (2) MCP staff members to receive a copy of the new member
materials on a monthly basis in order to monitor the timely receipt of these
materials. At least one of the staff members must receive the materials at
their
home address.
25.
Call
Center Standards
The
MCP
must provide assistance to members through a member services toll-free call-in
system pursuant to OAC rule 5101:3-26-08.2(A)(1). MCP member services staff
must
be available nationwide to provide assistance to members through the toll-free
call-in system every Monday through Friday, at ail times during the hours of
7:00 am to 7:00 pm Eastern Time, except for the following major
holidays:
•
New
Year's Day
•
▇▇▇▇▇▇
▇▇▇▇▇▇ ▇▇▇▇'▇ Birthday
•
Memorial Day
•
Independence Day
•
Labor
Day
•
Thanksgiving Day
•
Christmas Day
•
2
optional closure days: These days can be used independently or in combination
with any of the major holiday closures but cannot both be used within the same
closure period. Before announcing any optional closure dates to members and/or
staff, MCPs must receive ODJFS prior-approval which verifies that the optional
closure days meet the specified criteria.
Appendix
C
Page
8
If
a
major holiday falls on a Saturday, the MCP member services line may be closed
on
the preceding Friday. If a major holiday falls on a Sunday, the member services
line may be closed on the following Monday. MCP member services closure days
must be specified in the MCP's member handbook, member newsletter, or other
some
general issuance to the MCP's members at least thirty (30) days in advance
of
the closure.
The
MCP
must also provide access to medical advice and direction through a centralized
twenty-four-hour, seven day, toll-free call-in system, available nationwide,
pursuant to OAC rule 5101:3-26-03.1(A)(6). The twenty-four (24)/7 hour call-in
system must be staffed by appropriately trained medical personnel. For the
purposes of meeting this requirement, trained medical professionals are defined
as physicians, physician assistants, licensed practical nurses, and registered
nurses.
MCPs
must
meet the current American Accreditation HealthCare Commission/URAC-designed
Health Call Center Standards (HCC) for call center abandonment rate, blockage
rate and average speed of answer. By the 10th
of each
month, MCPs must self-report their prior month performance in these three areas
for their member services and twenty-four (24) hour toll-free call-in systems
to
ODJFS. ODJFS will inform the MCPs of any changes/updates to these URAC call
center standards.
MCPs
are
not permitted to delegate grievance/appeal functions [Ohio Administrative Code
(OAC) rule 5101:3-26-08.4(A)(9)]. Therefore, the member services call center
requirement may not be met through the execution of a Medicaid Delegation
Subcontract Addendum or Medicaid Combined Services Subcontract
Addendum.
26.
Notification
of Optional MCP Membership
In
order
to comply with the terms of the ODJFS State Plan Amendment for the managed
care
program (i.e., 42 CFR 438.50), MCPs in mandatory membership service areas must
inform new members, as applicable, that MCP membership is optional for certain
populations. Specifically, MCPs must inform any applicable pending member or
member that the following ABD population is not required to select an MCP in
order to receive their Medicaid healthcare benefit and what steps they need
to
take if they do not wish to be a member of an MCP:
-
Indians
who are members of federally-recognized tribes, except as permitted under
42 C.F.R
438.50(d)(21).
Appendix
C
Page
9
27.
HIPAA
Privacy Compliance Requirements
The
Health Insurance Portability and Accountability Act (HIPAA) Privacy Regulations
at 45 CFR. § 164.502(e) and § 164.504(e) require ODJFS to have agreements with
MCPs as a means of obtaining satisfactory assurance that the MCPs will
appropriately safeguard all personal identified health information. Protected
Health Information (PHI) is information received from or on behalf of ODJFS
that
meets the definition of PHI as defined by HIPAA and the regulations promulgated
by the United States Department of Health and Human Services, specifically
45
CFR 164.501, and any amendments thereto. MCPs must agree to the
following:
a.
MCPs
shall not use or disclose PHI other than is permitted by this Agreement or
required by law.
b.
MCPs
shall use appropriate safeguards to prevent unauthorized use or disclosure
of
PHI.
c.
MCPs
shall report to ODJFS any unauthorized use or disclosure of PHI of which it
becomes aware. Any breach by the MCP or its representatives of protected health
information (PHI) standards shall be immediately reported to the State HIPAA
Compliance Officer through the Bureau of Managed Health Care. MCPs must provide
documentation of the breach and complete all actions ordered by the HIPAA
Compliance Officer.
d.
MCPs
shall ensure that all its agents and subcontractors agree to these same PHI
conditions and restrictions.
e.
MCPs
shall make PHI available for access as required by law.
f.
MCP
shall make PHI available for amendment, and incorporate amendments as
appropriate as required by law.
g.
MCPs
shall make PHI disclosure information available for accounting as required
by
law.
h.
MCPs
shall make its internal PHI practices, books and records available to the
Secretary of Health and Human Services (HHS) to determine
compliance.
i.
Upon
termination of their agreement with ODJFS, the MCPs, at ODJFS' option, shall
return to ODJFS, or destroy, all PHI in its possession, and keep no copies
of
the information, except as requested by ODJFS or required by law.
j.
ODJFS
will propose termination of the MCP's provider agreement if ODJFS determines
that the MCP has violated a material breach under this section of the agreement,
unless inconsistent with statutory obligations of ODJFS or the MCP.
Appendix
C
Page
10
28.
Electronic
Communications -
MCPs are
required to purchase/utilize Transport Layer
Security
(TLS) for all e-mail communication between ODJFS and the MCP. The MCP's e-mail
gateway must be able to support the sending and receiving of e-mail using
Transport Layer Security (TLS) and the MCP's gateway must be able to enforce
the
sending and receiving of email via TLS.
29.
MCP
Membership acceptance, documentation and reconciliation
a.
Selection
Services Contractor:
The MCP
shall provide to the selection services contractor (SSC) ODJFS prior-approved
MCP materials and directories for distribution to eligible individuals who
request additional information about the MCP.
b.
Monthly
Reconciliation of Membership and Premiums:
The MCP
shall reconcile member data as reported on the SSC-produced consumer contact
record (CCR) with the ODJFS-produced monthly member roster (MMR) and report
to
the ODJFS any difficulties in interpreting or reconciling information received.
Membership reconciliation questions must be identified and reported to the
ODJFS
prior to the first of the month to assure that no member is left without
coverage. The MCP shall reconcile membership with premium payments reported
on
the monthly remittance advice (RA).
The
MCP
shall work directly with the ODJFS, or other ODJFS-identified entity, to resolve
any difficulties in interpreting or reconciling premium information. Premium
reconciliation questions must be identified within thirty (30) days of receipt
of the RA.
c.
Monthly
Premiums:
The MCP
must be able to receive monthly premiums in a method specified by ODJFS. (ODJFS
monthly prospective premium issue dates are provided in advance to the MCPs.)
Various retroactive premium payments and recovery of premiums paid (e.g.,
retroactive terminations of membership, deferments, etc.,) may occur via any
ODJFS weekly remittance.
d.
Hospital
Deferment Requests:
When the
MCP learns of a new member's hospitalization that is eligible for deferment
prior to that member's discharge, the MCP shall notify the hospital and treating
providers of the potential that the MCP may not be the payer. The MCP shall
work
with hospitals, providers and ODJFS to assure that discharge planning assures
continuity of care and accurate payment. Notwithstanding the MCP's right to
request a hospital deferment up to six (6) months following the member's
effective date, when the MCP learns of a
Appendix
C
Page
11
deferment-eligible
hospitalization, the MCP shall make every effort to notify ODJFS and request
the
deferment as soon as possible. When the MCP is notified by ODJFS of a potential
hospital deferment, the MCP must make every effort to respond to ODJFS within
ten (10) business days of the receipt of the deferment information.
e.
Just
Cause Requests:
The MCP
shall follow procedures as specified by ODJFS in assisting the ODJFS in
resolving member requests for member-initiated requests affecting
membership.
f.
Eligible
Individuals:
If an
eligible individual contacts the MCP, the MCP must provide any MCP-specific
managed care program information requested. The MCP must not attempt to assess
the eligible individual's health care needs. However, if the eligible individual
inquires about continuing/transitioning health care services, MCPs shall provide
an assurance that all MCPs must cover all medically necessary Medicaid-covered
health care services and assist members with transitioning their health care
services.
g.
Pending
Member: If
a
pending member (i.e., an eligible individual subsequent to plan selection but
prior to their membership effective date) contacts the selected MCP, the MCP
must provide any membership information requested, including but not limited
to,
assistance in determining whether the current medications require prior
authorization. The MCP must also ensure that any care coordination (e.g., PCP
selection, transition of services) information provided by the pending member
is
logged in the MCP's system and forwarded to the appropriate MCP staff for
processing as required. MCPs may confirm any information provided on the CCR
at
this time. Such communication does not constitute confirmation of membership.
MCPs are prohibited from initiating contact with a pending member.
h.
Transition
of Fee-For-Service Members: Providing
care coordination, access to preventive and specialized care, case management,
member services, and education with minimal disruption to members' established
relationships with providers and existing care treatment plans is critical
for
members transitioning from Medicaid fee-for-service to managed care. MCPs
must:
i.
Develop a transition plan that outlines how the MCP will effectively address
the
unique care coordination issues for members in their first three months of
MCP
membership that includes at a minimum:
Appendix
C
Page
12
ii.
An
effective outreach process to identify each
new
member's existing and/or potential health care needs that results in a new
member profile that includes, but is not limited to identification
of:
a.
Health
care needs, including those services received through state sub-recipient
agencies [e.g., the Ohio Department of Mental Health (ODMH), the Ohio Department
of Mental Retardation and Developmental Disabilities (ODMR/DD), and the Ohio
Department of Alcohol and Drug Addiction Services (ODADAS);
b.
Existing sources of care (i.e., primary physicians, specialists, case
manager(s), ancillary and other care givers); and
c.
Current care therapies for all aspects of health care services, including
scheduled health care appointments, planned and/or approved surgeries (inpatient
or outpatient), ancillary or medical therapies, prescribed drugs, approved
home
health care, scheduled lab/radiology tests, necessary/approved durable medical
equipment, supplies and needed/approved transportation
arrangements.
iii.
Strategies for how each new member will obtain care therapies from appropriate
sources of care as an MCP member including reported scheduled health services
as
described in Section 28.i.(ii-iv) of this Appendix.
iv.
Allow
their new members that are transitioning from Medicaid fee-for-service to
receive services from out-of-panel providers if the members contact the MCP
to
discuss the scheduled health services in advance of the service date and one
of
the following applies:
a.
The
member has appointments within the initial three months of the MCP membership
with a primary physician or specialty physicians that were scheduled prior
to
the effective date of the MCP membership;
b.
The
member has been approved to receive an organ, bone marrow, or hematapoietic
stem
cell transplant pursuant to OAC rule 5101:3-2-07.1;
Appendix
C
Page
13
c.
The
member is in her third trimester of pregnancy and has an established
relationship with an obstetrician and/or delivery hospital;
d.
The
member has been scheduled for an inpatient/outpatient surgery and has been
prior-approved and/or precertified pursuant to OAC rule 5101:3-2-40 (surgical
procedures would also include follow-up care as appropriate);
e.
The
member is receiving ongoing chemotherapy or radiation treatment;
f.
The
member has been released from the hospital within the last thirty (30) days
and
is following a treatment plan;
g. The member has been pre-certified to receive durable medical equipment (DME)
which has not yet been received.
v.
Reimburse out-of-panel providers that agree to provide the transition services
identified in section 28.i.section ii at 100% of the current Medicaid
fee-for-service provider rate for the service(s).
vi.
Document the provision of transition services as follows:
a.
As
expeditiously as the situation warrants, contact the provider's offices via
telephone to confirm that the service(s) meets the above criteria.
b.
For
services that meet the above criteria, inform the provider that the MCP is
sending a form for signature to document that they accept/do not accept the
terms for the provision of the services and copy the member on the
form.
c.
If the
provider agrees to the terms, notify the member and provider of the MCP's
authorization and ensure that the MCP's claims processing system will not deny
the claim payment because the provider is out-of-panel. MCPs must include their
non-contracting provider materials as outlined in Appendix G.4.e with the
provider notice.
d.
If the
provider does not agree to the terms, notify the member and assist the member
with locating a provider as expeditiously as the member's condition
warrants.
Appendix
C
Page
14
e.
Use
the ODJFS-specified model language for the provider and member
notices.
f.
Maintain documentation of all member and/or provider contacts relating to such
out-of-panel services, including but not limited to telephone calls and
letters.
vii.
Not
require prior-authorization of any prescription drug that does not require
prior
authorization by Medicaid fee-for-service for the initial three months of a
member's MCP membership. Additionally, all atypical anti-psychotic drugs must
be
exempted from prior authorization requirements for all MCP ABD members through
December 2007, after which time ODJFS will re-evaluate the continuation of
this
pharmacy utilization strategy.
30.
Health
Information System Requirements
The
ability to develop and maintain information management systems capacity is
crucial to successful plan performance. ODJFS therefore requires MCPs to
demonstrate their ongoing capacity in this area by meeting several related
specifications.
a.
Health
Information System
i.
As
required by 42 CFR 438.242(a), each MCP must maintain a health information
system that collects, analyzes, integrates, and reports data. The system must
provide information on areas including, but not limited to, utilization,
grievances and appeals, and MCP membership terminations for other than loss
of
Medicaid eligibility.
ii.
As
required by 42 CFR 438.242(b)(l), each MCP must collect data on member and
provider characteristics and on services furnished to its members.
iii.
As
required by 42 CFR 438.242(b)(2), each MCP must ensure that data received from
providers is accurate and complete by verifying the accuracy and timeliness
of
reported data; screening the data for completeness, logic, and consistency;
and
collecting service information in standardized formats to the extent feasible
and appropriate.
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).
Appendix
C Page 15
v.
Acceptance testing of any data that is electronically submitted to ODJFS is
required:
a.
Before
an MCP may submit production files
b.
Whenever an MCP changes the method or preparer of the electronic media; and/or
c.
When
the ODJFS determines an MCP's data submissions have
an
unacceptably high error rate.
MCPs
that
change or modify information systems that are involved in producing any type
of
electronically submitted files, either internally or by changing vendors, are
required to submit to ODJFS for review and approval a transition plan including
the submission of test files in the ODJFS-specified formats. Once an acceptable
test file is submitted to ODJFS, as determined solely by ODJFS, the MCP can
return to submitting production files. ODJFS will inform MCPs in writing when
a
test file is acceptable. Once an MCP's new or modified information system is
operational, that MCP will have up to ninety (90) days to submit an acceptable
test file and an acceptable production file.
Submission
of test files can start before the new or modified information system
\s
in
production. ODJFS reserves the right to verify any MCP's capability to report
elements in the minimum data set prior to executing the provider agreement
for
the next contract period. Penalties for noncompliance with this requirement
are
specified in Appendix N, Compliance Assessment System of the Provider
Agreement.
| b. |
Electronic
Data Interchange and Claims Adjudication Requirements
|
Claims
Adjudication
The
MCP
must have the capacity to electronically accept and adjudicate all claims to
final status (payment or denial). Information on claims submission procedures
must be provided to non-contracting providers within thirty (30) days of a
request. MCPs must inform providers of its ability to electronically process
and
adjudicate claims and the process for submission. Such information must be
initiated by the MCP and not only in response to provider requests.
The
MCP
must notify providers who have submitted claims of claims status [paid, denied,
pended (suspended)] within one month of receipt. Such notification may be in
the
form of a claim payment/remittance advice produced on a routine monthly, or
more
frequent, basis.
Appendix
C
Page
16
Electronic
Data Interchange
The
MCP
shall comply with all applicable provisions of HIPAA including electronic data
interchange (EDI) standards for code sets and the following electronic
transactions:
Health
care claims;
Health
care claim status request and response;
Health
care payment and remittance status; and Standard code sets.
Each
EDI
transaction processed by the MCP shall be implemented in conformance with the
appropriate version of the transaction implementation guide, as specified by
applicable federal rule or regulation.
The
MCP
must have the capacity to accept the following transactions from the Ohio
Department of Job and Family services consistent with EDI processing
specifications in the transaction implementation guides and in conformance
with
the 820 and 834 Transaction Companion Guides issued by ODJFS:
ASC
XI 2
820 - Payroll Deducted and Other Group Premium Payment for Insurance Products;
and
ASC
XI 2
834 - Benefit Enrollment and Maintenance.
The
MCP
shall comply with the HIPAA mandated EDI transaction standards and code sets
no
later than the required compliance dates as set forth in the federal
regulations.
Documentation
of Compliance with Mandated EDI Standards The
capacity of the MCP and/or applicable trading partners and business associates
to electronically conduct claims processing and related transactions in
compliance with standards and effective dates mandated by HIPAA must be
demonstrated, to the satisfaction of ODJFS, as outlined below.
Verification
of Compliance with HIPAA (Health Insurance Portability and Accountability Act
of
1995)
MCPs
shall submit written verification to ODJFS for transaction standards and code
sets specified in 45 CFR Part 162 - Health Insurance Reform: Standards
for
Appendix
C
Page
17
Electronic
Transactions (HIPAA regulations), that the MCP has established the capability
of
sending and receiving applicable transactions in compliance with the HIPAA
regulations. The written verification shall specify the date that the MCP has:
1) achieved capability for sending and/or receiving the following transactions,
2) entered into the appropriate trading partner agreements, and 3) implemented
standard code sets. If the MCP has obtained third-party certification of HIPAA
compliance for any of the items listed below, that certification may be
submitted in lieu of the MCP's written verification for the applicable
item(s).
i.
Trading Partner Agreements
ii.
Code
Sets
iii.
Transactions
a.
Health
Care Claims or Equivalent Encounter Information (ASC X12N 837 & NCPDP 5.1)
b.
Eligibility for a Health Plan (ASC X12N 270/271)
c.
Referral Certification and Authorization (ASC X12N 278)
d.
Health
Care Claim Status (ASC X12N 276/277)
e.
Enrollment and Disenrollment in a Health Plan (ASC X12N 834)
f.
Health
Care Payment and Remittance Advice (ASC XI 2N 835)
g.
Health
Plan Premium Payments (ASC X12N 820)
h.
Coordination of Benefits
Trading
Partner Agreement with ODJFS
MCPs
must
complete and submit an EDI trading partner agreement in a format specified
by
the ODJFS. Submission of the copy of the trading partner agreement prior to
entering into this Agreement may be waived at the discretion of
ODJFS;
if
submission prior to entering into the Agreement is waived, the trading partner
agreement must be submitted at a subsequent date determined by
ODJFS.
Noncompliance
with the EDI and claims adjudication requirements will result in the imposition
of penalties, as outlined in Appendix N, Compliance Assessment System, of the
Provider Agreement.
c.
Encounter
Data Submission Requirements
General
Requirements
Each
MCP
must collect data on services furnished to members through an encounter data
system and must report encounter data to the ODJFS. MCPs are required to submit
this data electronically to ODJFS on a monthly basis in the following standard
formats:
Appendix
C
Page
18
•
Institutional Claims - UB92 flat file
•
Noninstitutional Claims - National standard format
•
Prescription Drug Claims - NCPDP
ODJFS
relies heavily on encounter data for monitoring MCP performance. The ODJFS
uses
encounter data to measure clinical performance, conduct access and utilization
reviews, reimburse MCPs for newborn deliveries and aid in setting MCP capitation
rates. For these reasons, it is important that encounter data is timely,
accurate, and complete. Data quality, performance measures and standards are
described in the Agreement.
An
encounter represents all of the services, including medical supplies and
medications, provided to a member of the MCP by a particular provider,
regardless of the payment arrangement between the MCP and the provider. (For
example, if a member had an emergency department visit and was examined by
a
physician, this would constitute two encounters, one related to the hospital
provider and one related to the physician provider. However, for the purposes
of
calculating a utilization measure, this would be counted as a single emergency
department visit. If a member visits their PCP and the PCP examines the member
and has laboratory procedures done within the office, then this is one encounter
between the member and their PCP.)
If
the
PCP sends the member to a lab to have procedures performed, then this is two
encounters; one with the PCP and another with the lab. For pharmacy encounters,
each prescription filled is a separate encounter.
Encounters
include services paid for retrospectively, through fee-for-service payment
arrangements, and prospectively. through capitated arrangements. Only encounters
with services (line items) that are paid by the MCP, fully or in part, and
for
which no further payment is anticipated, are acceptable encounter data
submissions.
All
other
services that are unpaid or paid in part and for which the MCP anticipates
further payment (e.g., unpaid services rendered during a delivery of a 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.
Appendix
C
Page
19
Encounter
Data File Submission Procedures
A
certification letter must accompany the submission of an encounter data file
in
the ODJFS-specified medium. The certification letter must be signed by the
MCP's
Chief Executive Officer (CEO), Chief Financial Officer (CFO), or an individual
who has delegated authority to sign for, and who reports directly to, the MCP's
CEO or CFO.
No
more
than two production files in the ODJFS-specified medium per format (e.g., NSF)
should be submitted each month. If it is necessary for an MCP to submit more
than two production files in the ODJFS-specified medium for a particular format
in a month, they must request and receive permission to do so from their
designated Contract Administrator.
Timing
of Encounter Data Submissions
ODJFS
recommends that MCPs submit encounters no more than thirty-five (35) days after
the end of the month in which they were paid. (For example, claims paid in
January are due March 5.) ODJFS recommends that MCPs submit files in the
ODJFS-specified medium by the 5th of each month. This will help to ensure that
the encounters are included in the ODJFS master file in the same month in which
they were submitted.
d.
Information
Systems Review
Every
two
(2) years, and before ODJFS enters into a provider agreement with a new MCP,
ODJFS or designee may review the information system capabilities of each MCP.
Each MCP must participate in the review, except as specified below. The review
will assess the extent to which MCPs are capable of maintaining a health
information system including producing valid encounter data, performance
measures, and other data necessary to support quality assessment and
improvement, as well as managing the care delivered to its members.
The
following activities, at a minimum, will be carried out during the review.
ODJFS
or its designee will:
i.
Review
the Information Systems Capabilities Assessment (ISCA) forms, as developed
by
CMS; which the MCP will be required to complete.
ii.
Review the completed ISCA and accompanying documents;
Appendix
C
Page
20
iii.
Conduct interviews with MCP staff responsible for completing the ISCA, as well
as staff responsible for aspects of the MCP's information systems
function;
iv.
Analyze the information obtained through the ISCA, conduct follow-up interviews
with MCP staff, and write a statement of findings about the MCP's information
system.
v.
Assess
the ability of the MCP to link data from multiple sources;
vi.
Examine MCP processes for data transfers;
vii.
If
an MCP has a data warehouse, evaluate its structure and reporting
capabilities;
viii.
Review MCP processes, documentation, and data files to ensure that they comply
with state specifications for encounter data submissions; and
ix.
Assess the claims adjudication process and capabilities of the MCP.
As
noted
above, the information system review may be performed every two years. However,
if ODJFS or its designee identifies significant information system problems,
then ODJFS or its designee may conduct, and the MCP must participate in, a
review the following year, or in such a timeframe as ODJFS, in their sole
discretion, deems appropriate to ensure accuracy and efficiency of the MCP
health information system.
If
an MCP
had an assessment performed of its information system through a private sector
accreditation body or other independent entity within the two years preceding
the time when ODJFS or its designee will be conducting its review, and has
not
made significant changes to its information system since that time, and the
information gathered is the same as or consistent with the ODJFS or its
designee's proposed review, as determined by the ODJFS, then the MCP will not
required to undergo the IS review. The MCP must provide ODJFS or its designee
with a copy of the review that was performed so that ODJFS can determine whether
or not the MCP will be required to participate in the IS review. MCPs who are
determined to be exempt from the IS review must participate in subsequent
information system reviews, as determined by ODJFS.
Appendix
C
Page
21
31.
If
the MCP will be using the Internet functions that will allow approved users
to
access member information (e.g., eligibility verification), the MCP must receive
prior written approval from ODJFS that verifies that the proper safeguards,
firewalls, etc., are in place to protect member data.
32.
MCPs
must receive prior written approval from ODJFS before adding any information
to
their website that would require ODJFS prior approval in hard copy form (e.g.,
provider listings, member handbook information).
33.
Pursuant to 42 CFR 438.106(b), the MCP acknowledges that it is prohibited from
holding a member liable for services provided to the member in the event that
the ODJFS fails to make payment to the MCP.
34.
In
the event of an insolvency of an MCP, the MCP, as directed by ODJFS, must cover
the continued provision of services to members until the end of the month in
which insolvency has occurred, as well as the continued provision of inpatient
services until the date of discharge for a member who is institutionalized
when
insolvency occurs.
35.
Franchise
Fee Assessment Requirements
a.
Each
MCP is required to pay a franchise permit fee to ODJFS for each calendar quarter
as required by ORC Section 5111.176. The current fee to be paid is an amount
equal to 4'/2 percent of the managed care premiums, minus Medicare premiums
that
the MCP received from any payer in the quarter to which the fee applies. Any
premiums the MCP returned or refunded to members or premium payers during that
quarter are excluded from the fee.
b.
The
franchise fee is due to ODJFS in the ODJFS-specified format on or before the
30th day following the end of the calendar quarter to which the fee
applies.
c.
At the
time the fee is submitted, the MCP must also submit to ODJFS a completed form
and any supporting documentation pursuant to ODJFS specifications.
d.
Penalties for noncompliance with this requirement are specified in Appendix
N,
Compliance Assessment System of the Provider Agreement and in ORC Section
5111.176.
36.
Information
Required for MCP Websites
a.
On-line
Provider Directory
- MCPs
must have an internet-based provider directory available in the same format
as
their ODJFS-approved provider directory, that allows members to electronically
search for the MCP panel
Appendix
C
Page
22
providers
based on name, provider type, geographic proximity, and population (as specified
in Appendix H). MCP provider directories must include all MCP-contracted
providers [except as specified by ODJFS] as well as certain ODJFS non-contracted
providers.
b.
On-line
Member Website
- MCPs
must have a secure internet-based website which is regularly updated to include
the most current ODJFS approved materials. The website at a minimum must
include: (1) a list of the counties that are covered in their service area;
(2)
the ODJFS-approved MCP member handbook, recent newsletters/announcements, MCP
contact information including member services hours and closures; (3) the MCP
provider directory as referenced in section 36(a) of this appendix; (4) the
MCP's current preferred drug list (PDL), including an explanation of the list,
which drugs require prior authorization (PA), and the PA process; (5) the MCP's
current list of drugs covered only with PA, the PA process, and the MCP's policy
for covering generic for brand-name drugs; and (6) the ability for members
to
submit questions/comments/grievances/appeals/etc. and receive a response
(members must be given the option of a return e-mail or phone call). Responses
regarding questions or comments are expected within one working day of receipt,
whereas responses regarding grievances and appeals must be within the timeframes
specified in OAC rule 5101:3-26-08.4. MCPs must ensure that all member materials
designated specifically for CFC and/or ABD consumers (i.e. the MCP member
handbook) are clearly labeled as such. The MCP's member website cannot be used
as the only means to notify members of new and/or revised MCP information (e.g.,
change in holiday closures, change in additional benefits, revisions to approved
member materials etc.). ODJFS may require MCPs to include additional information
on the member website, as needed.
c.
On-line
Provider Website -
MCPs
must have a secure internet-based website for providers where they will be
able
to confirm a consumer's MCP enrollment and through this website (or through
e-mail process) allow providers to electronically submit and receive responses
to prior authorization requests. This website must also include: (1) a list
of
the counties that are covered in their service area; (2) the MCP's provider
manual;(3) MCP contact information; (4) a link to the MCP's on-line provider
directory as referenced in section 36(a) of this appendix; (5) the MCP's current
PDL list, including an explanation of the list, which drugs require PA, and
the
PA process; and (6) the MCP's current list of drugs covered only with PA, the
PA
process, and the MCP's policy for covering generic for brand-name drugs. MCPs
must ensure that all provider materials designated specifically for CFC and/or
ABD consumers (i.e. The MCP's provider manual) are clearly labeled as such.
ODJFS may require MCPs to include additional information on the provider
website, as needed.
Appendix
C
Page
23
37.
MCPs
must provide members with a printed version of their PDL and PA lists, upon
request.
38.
MCPs
must not use, or propose to use , any offshore programming or call center
services in fulfilling the program requirements.
39.
PCP
Feedback
- The
MCP must have the administrative capacity to offer feedback to individual
providers on their: 1) adherence to evidence-based practice guidelines; and
2)
positive and negative care variances from standard clinical pathways that may
impact outcomes or costs. In addition, the feedback information may be used
by
the MCP for activities such as physician performance improvement projects that
include incentive programs or the development of quality improvement
programs.
APPENDIX
D
ODJFS
RESPONSIBILITIES ABD 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 ofthe eligible population and/or the ODJFS provider panel
specifications.
9.
On a
monthly basis, ODJFS will provide MCPs with an electronic file containing their
MCP's provider panel as reflected in the ODJFS Provider Verification System
(PVS) database.
10.
On a
monthly basis, ODJFS will provide MCPs with an electronic Master Provider File
containing all the Ohio Medicaid fee-for-service providers, which includes
their
Medicaid Provider Number, as well as all providers who have been assigned a
provider reporting number
for current encounter data purposes.
Appendix
D
Page
2
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 hard copy.
The use ofTLS will mean that private health information (PHI) and the
identification of consumers as Medicaid recipients can be shared between ODJFS
and the contracting MCPs via e-mail such as reports, copies of letters, forms,
hospital claims, discharge records, general discussions of member-specific
information, etc. ODJFS may revise data/information exchange policies and
procedures for many functions that are now restricted to FAX, telephone, and
hard copy, including, but not limited to, monthly membership and premium payment
reconciliation requests, newborn reporting, Just Cause disenrollment requests,
information requests etc. (as specified in Appendix C).
12.
ODJFS
will immediately report to Center for Medicare and Medicaid Services (CMS)
any
breach in privacy or security that compromises protected health information
(PHI), when reported by the MCP or ODJFS staff.
13.
Service
Area Designation
Membership
in a service area is mandatory unless ODJFS approves membership in the service
area for consumer initiated selections only. It is ODJFS' 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 will provide MCP eligible individuals, including current MCP
members, with a Consumer Guide. The Consumer Guide will describe the managed
care program and include information on the MCP options in the service area
and
other information regarding the managed care program as specified in 42 CFR
438.10.
b.
ODJFS
will notify members or ask MCPs to notify members about significant changes
affecting contractual requirements, member services or access to
providers.
c.
If an
MCP elects not to provide, reimburse, or cover a counseling service or referral
service due to an objection to the service on moral or religious grounds, ODJFS
will provide coverage and reimbursement for these services for the MCP's
members. ODJFS will provide information on what services the MCP will not cover
and how and where the MCP's members may obtain these services in the applicable
Consumer Guides.
Appendix
D
Page
3
15.
Membership
Selection and Premium Payment
a.
The
Selection Services Entity (SSE) also known as Selection Services Contractor
(SSC): The ODJFS-contracted SSC will provide unbiased education, selection
services, and community outreach for the Medicaid managed care program. The
SSC
shall operate a statewide toll-free telephone center to assist eligible
individuals in selecting an MCP or choosing a health care delivery
option.
The
SSC
shall distribute the most current Consumer Guide that includes the managed
care
program information as specified in 42 CFR 438.10, as well as ODJFS
prior-approved MCP materials, such as solicitation brochures and provider
directories, to consumers who request additional materials.
b.
Auto-Assignment
Limitations -
In order
to promote market and program stability, ODJFS may limit an MCP's
auto-assignments if they meet any of the following enrollment
thresholds:
•
40%
of
statewide
Aged,
Blind, or Disabled (ABD) managed care eligibles; and/or
•
60%
of
the ABD managed care eligibles in
any region with two MCPs; and/or
•
40%
of
the ABD managed care 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, may not impose the auto-assignment limitation
and
auto-assign members to the MCPs in that region as ODJFS deems
appropriate.
c.
Consumer
Contact Record (CCR):
ODJFS or
their designated entity shall forward CCRs to MCPs on no less than a weekly
basis. The CCRs are a record of each consumer-initiated MCP enrollment, change,
or termination, and each SSC-initiated MCP assignment processed through the
SSC.
The CCR contains information that is not included on the monthly member
roster.
d.
Monthly
member roster (MR):
ODJFS
verifies managed care plan enrollment on a monthly basis via the monthly
membership roster. ODJFS or its designated entity provides a full member roster
(F) and a change roster (C) via HIPAA 834 compliant
transactions.
Appendix
D
Page
4
e.
Monthly
Premiums:
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 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, and premium 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 by ODJFS to contact the ODJFS contracting
entity directly.
c.
MCP
delegated entities:
In that
MCPs are ultimately responsible for meeting program requirements, the BMHC
will
not discuss MCP issues
Appendix
D
Page
5
with
the
MCPs' delegated entities unless the applicable MCP is also participating in
the
discussion. MCP delegated entities, with the applicable MCP participating,
should only communicate with the specific CA assigned to that MCP.
▇▇▇▇▇▇
Government
Human Services Consulting
November
17, 2006
▇▇.
▇▇▇
▇▇▇▇▇▇
Bureau
of
Managed Health Care
Ohio
Department of Job and Family Services
▇▇▇
▇▇▇▇
▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇ ▇▇▇▇▇
▇▇▇▇▇▇▇▇,
▇▇ ▇▇▇▇▇-▇▇▇▇
Subject:
ABD
Rate-Setting Methodology & Capitation Rate Certification for the 2007
Contract Period
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
Page
2
November
17, 2006
▇▇.
▇▇▇
▇▇▇▇▇▇
Bureau
of
Managed Health Care
Managed
Care Eligible Population
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 second calendar
month
following the nursing facility admission.
Base
Data Development
Data
Sources
Since
ABD
managed care has not yet been implemented in Ohio, FFS data was the only
available data source for rate-setting. ▇▇▇▇▇▇ used FFS claims and eligibility
data from State Fiscal Year (SFY) 2003 and from SFY 2004 as the basis for rate
development. Once mandatory managed care is implemented and the program becomes
stable, ▇▇▇▇▇▇ will incorporate plan-reported managed care data, including
encounter and cost report data. Other sources of information used, as necessary,
included State enrollment projections. State financial reports, projected
managed care penetration rates and other ad hoc sources.
Validation
Process
▇▇▇▇▇▇'▇
validation process included reviewing SFY 2003 and SFY 2004 dollars, utilization
and member months. ▇▇▇▇▇▇ also performed additional reasonability checks to
ensure the base data was accurate and complete.
FFS
Data
FFS
experience from the base time period of SFY 2003 and SFY 2004 was used as a
direct data source for rate-setting. Adjustments were applied to the FFS data
to
reflect the actuarially equivalent claims experience for the population that
will be enrolled in the managed care
▇▇▇▇▇▇
Government
Human Services Consulting
Page
3
November
17, 2006
▇▇.
▇▇▇
▇▇▇▇▇▇
Bureau
of
Managed Health Care
program.
▇▇▇▇▇▇ excluded claims and eligibility data for the ineligible populations
outlined on the previous page. The State Medicaid Management Information System
(MMIS) includes data for FFS paid claims, which may be net or gross of certain
factors (e.g., gross adjustments or third party liability (TPL)). As a result
of
these conditions, it was necessary to make adjustments to the FFS base data
as
documented in Appendix C and outlined in Appendix A.
Managed
Care Rate Development
This
section explains how ▇▇▇▇▇▇ developed the final capitation rates for each of
the
eight managed care regions, as defined in Appendix B. After the FFS base data
was developed and the two years were blended, ▇▇▇▇▇▇ applied trend, program
changes and managed care adjustments to project the program cost into the
contract year. Next, the MCP administrative component was applied. Appendix
A
outlines the managed care rate development process. Appendix D provides more
detail behind each of the following adjustments.
Blending
Multiple Years of Data
Prior
to
blending the two years of FFS data, the base time period experience was trended
to a common time period ofSFY 2004. ▇▇▇▇▇▇ applied greater credibility to the
most recent year of data to reflect the expectation that the most recent year
may be more reflective of future experience and to reflect that fewer
adjustments are needed to bring the data to the effective contract
period.
Managed
Care Assumptions for the FFS Data Source
In
developing managed care savings assumptions. ▇▇▇▇▇▇ applied generally accepted
actuarial principles that reflect the impact of MCP programs on FFS experience.
▇▇▇▇▇▇ reviewed Ohio's historical FFS experience and other state Medicaid
managed care experience to develop managed care savings assumptions. These
assumptions have been applied to the FFS data to derive managed care cost
levels. The assumptions are consistent with an economic and efficiently operated
Medicaid managed care plan. The managed care savings assumptions vary by region
and Category of Service (COS). Specific adjustments were made in this step
to
reflect the differences between pharmacy contracting for the State and
contracting obtained by the MCPs. ▇▇▇▇▇▇ reviewed information related to
discount rates, dispensing fees, and rebates to make these adjustments. The
rates are reflective of MCP contracting for these services. In addition, ▇▇▇▇▇▇
considered the impact of two pharmacy management restrictions on the MCPs when
determining pharmacy managed care assumptions. These restrictions include the
prohibition to prior
▇▇▇▇▇▇
Government
Human Services Consulting
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4
November
17, 2006
▇▇.
▇▇▇
▇▇▇▇▇▇
Bureau
of
Managed Health Care
authorize
any prescriptions during the first ninety days of managed care implementation
and the restriction on prior authorization of any atypical antipsychotics (as
defined by the State).
Prospective
Policy Changes
CMS
also
requires that the rate-setting methodology incorporates the impact of any
programmatic changes that have taken place, or are anticipated to take place,
between the base period (SFY 2004) and the 2007 contract period.
The
State
staff provided ▇▇▇▇▇▇ with a detailed list of program changes that may have
a
material impact on the cost, utilization, or demographic structure of the
program prior to, or within, the contract period and whose impact was not
included within the base period data. Final programmatic changes approved for
SFY 2006 and SFY 2007 are reflected in the rates, as appropriate. Please refer
to Appendix D for more information on these programmatic changes.
Clinical
Measures/Incentives
As
the
ABD managed care program matures, the State will require MCPs to meet minimum
performance standards for a defined set of clinical measures. The State expects
the first full calendar year of the program will be used as a baseline year
to
determine performance standards and targets. Since the MCPs will not be at
risk
for this period, the rates have not been adjusted to account for improvement
in
performance on the clinical measures.
Caseload
Historically,
the State has experienced significant changes in its Medicaid caseload. These
shifts in caseload have affected the demographics of the remaining Medicaid
population. ▇▇▇▇▇▇ evaluated these caseload variations to determine if an
adjustment was necessary to account for demographic changes. Based on the data
provided by the State, ▇▇▇▇▇▇ determined no adjustments were
necessary.
Selection
Issue
▇▇▇▇▇▇
made an adjustment for voluntary selection, which accounts for the fact that
costs associated with individuals who participate in managed care are generally
lower than the remaining FFS population. Therefore, the voluntary selection
adjustment adjusts for the risk of only those members participating in managed
care. This adjustment is a reduction to paid claims and utilization. Appendix
D
provides more detail around the voluntary selection adjustment.
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5
November
17, 2006
▇▇.
▇▇▇
▇▇▇▇▇▇
Bureau
of
Managed Health Care
Non-State
Plan Services
According
to the CMS Final Medicaid Managed Care Rule that was implemented
August
13, 2003, non-state plan services may not be included in the base data for
rate
setting.
The
FFS
data does not include costs for non-state plan services. Therefore, no
adjustment was necessary.
Prospective
Trend Development
Trend
is
an estimate of the change in the overall cost of providing a specific benefit
service over a finite period of time. A trend factor is necessary to estimate
the expenses of providing health care services in some future year, based on
expenses incurred in prior years. Trend was applied by COS to the blended costs
for SFY 2004 to project the data forward to the 2007 contract
period.
▇▇▇▇▇▇
integrated the FFS trend analysis with a broader analysis of other trend
resources. These resources included health care economic factors (e.g., Consumer
Price Index (CP1) and Data Resource, Inc. (DRI)), trends in neighboring states,
the State FFS trend expectations and any Ohio market changes. Moreover, the
trend component was comprised of both unit cost and utilization
components.
▇▇▇▇▇▇
discussed all trend recommendations with State staff. We reviewed the potential
impact of initiatives targeted to slow or otherwise affect the trends in the
program. Final trend amounts were determined from the many trend resources
and
this additional program information. Appendix D provides more information on
trend.
Administration/Contingencies
Since
ABD
managed care has not yet been implemented, other ABD Medicaid program
administration/contingencies allowances and the State's expectations were
factors that were taken into consideration in determining the final
administration/contingencies percentages. Appendix D provides further detail
on
the allowance.
Risk
Adjustment
The
FFS
data was not categorized by age/sex cohort because the base regional rates
will
undergo risk adjustment. Risk adjustment takes into account the demographics
and
diagnoses of the population. The risk adjusted rates (RAR) will be implemented
into the ABD managed care program using a generally accepted risk adjustment
method to adjust base capitation rates to
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Government
Human Services Consulting
Page
6
November
17, 2006
Mr.
.Ion
Barley
Bureau
of
Managed Health Care
reflect
the different health status of the members enrolled in each MCP's program.
ODJFS
and its actuarial consultant will develop each MCP's risk score to reflect
the
health status of members enrolled in the contractor's program within a
region.
During
the initial months of managed care implementation in each region, it is
anticipated that ODJFS and its actuaries will calculate regional MCP case mix
scores monthly until the enrollment in the region becomes relatively stable.
Because enrollment for these months will not be known until after the start
of
the month, the initial payment will be made assuming the base capitation rates
for all MCPs. An adjustment will be made in the subsequent month to reflect
the
appropriate risk adjustment reimbursement for the prior month. Once regional
enrollment has stabilized, it is anticipated that the MCP case mix scores will
be updated semi-annually. In the event that the ABD implementation is delayed
or
a change in methodology is required, the risk assessment schedule may be
revised.
Certification
of Final Rates
Base
capitation rates were developed for the eight managed care regions, and a rate
summary is provided in Appendix E. Upon receiving final contract period
information for each region, ▇▇▇▇▇▇ will update Appendix E
accordingly.
▇▇▇▇▇▇
certifies the attached rates were developed in accordance with generally
accepted actuarial practices and principles by actuaries meeting the
qualification standards of the American Academy of Actuaries for the populations
and services covered under the managed care contract. Rates developed by ▇▇▇▇▇▇
are actuarial projections of future contingent events. Actual MCP costs will
differ from these projections. ▇▇▇▇▇▇ has developed these rates on behalf of
the
State to demonstrate compliance with the CMS requirements under 42 CFR 438.6(c)
and to demonstrate that rates are in accordance with applicable law and
regulations.
▇▇▇▇▇▇
Government
Human Services Consulting
Page
7
November
17, 2006
▇▇.
▇▇▇
▇▇▇▇▇▇
Bureau
of
Managed Health Care
MCPs
are
advised that the use of these rates may not be appropriate for their particular
circumstance and ▇▇▇▇▇▇ disclaims any responsibility for the use of these rates
by MCPs for any purpose. ▇▇▇▇▇▇ recommends any MCP considering contracting
with
the State should analyze its own projected medical expense, administrative
expense, and any other premium needs for comparison to these rates before
deciding whether to contract with the State. Use of these rates for purposes
beyond that stated may not be appropriate.
Sincerely,
|
/s/
▇▇▇▇▇ ▇▇▇▇▇▇
▇▇▇▇▇
▇▇▇▇▇▇, FSA, MAAA
|
/s/
▇▇▇▇▇▇ ▇▇▇▇▇▇▇
▇▇▇▇▇▇
▇▇▇▇▇▇▇, ASA, MAAA
|
|
Copy:
▇▇▇▇▇
▇▇▇▇▇▇, ▇▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇▇▇ ▇▇▇▇▇▇▇▇ - ODJFS
▇▇▇▇▇▇
▇▇▇▇▇, ▇▇▇▇▇ ▇▇▇▇▇▇ - ▇▇▇▇▇▇
|
|
▇▇▇▇▇▇
Government
Human Services Consulting
Appendix
A - 2007 Contract Period ABD Rate-Setting Methodology
[Flow
Chart]
▇▇▇▇▇▇
Government
Human Services Consulting
Appendix
B - Region Definition
Please
refer to the map below, which defines the counties within each of the eight
managed care regions.
[Medicaid
Managed Care Program Regions for the ABD Population Map]
▇-▇
▇▇▇▇▇▇
Government
Human Services Consulting
Appendix
C - FFS Data Adjustments
This
section lists adjustments made to the FFS claims and eligibility information
received from the State.
Completion
Factors
The
claims data was adjusted to account for the value of claims incurred but unpaid
on a COS basis. ▇▇▇▇▇▇ used claims for SFY 2003 and SPY 2004 that reflect
payments through the dates included in the following table.
|
State
Fiscal
Year
|
Paid
Through
|
|
|
2003
|
03/31/04 | |
|
2004
|
12/31/04 | |
The
value
of the claims incurred during each of these years, but unpaid, was estimated
using completion factor analysis.
Gross
Adjustment File (GAF)
To
account for gross debit and credit amounts not reflected in the FFS data,
adjustments were applied to the FFS paid claims.
Historical
Policy Changes
As
part
of the rate-setting process, ▇▇▇▇▇▇ must account for policy changes that
occurred during the base data time period. Changes only reflected in a portion
of the data must be applied to the remaining data so that the base data reflects
all of the policy changes. All policy changes implemented during SFY 2003 and
SFY 2004 were applied to the FFS data.
▇-▇
▇▇▇▇▇▇
Government
Human Services Consulting
The
following table shows the specified policy changes for which ▇▇▇▇▇▇ adjusted
the
SFY 2003 and SFY 2004 data. ▇▇▇▇▇▇ calculated the adjustments based on the
"History of Policy Changes" document and other information supplied by the
State.
|
Policy
Changes
|
Effective
Date
|
Category
of
Service Affected
|
|
Inpatient
Outlier Payment Methodology - Exceptional cost outlier threshold
increased
from $250,000 to $443,463
|
8/1/2002
|
Inpatient
|
|
Anesthesia
Services -Conversion factor decreased to $8.13
|
9/1/2002
|
Specialists
|
|
Independently-practicing
psychologist services eliminated for adults (s21)
|
1/1/2004
|
PCP,
Specialists
|
|
All
chiropractic services eliminated for adults (>21)
|
1/1/2004
|
Other
|
|
$3.00
Copay on Prior-Authorization Drugs
|
1/1/2004
|
Pharmacy
|
Third
Party Liability Recoveries
TPL
can
be identified with two components: ''cost-avoidance'' and "pay and chase" type
actions. "Cost-avoidance" occurs when the State initially denies paying a claim
because another payer is the primary payer. The State may then pay a residual
portion of the charged amount. Only the residual portion of the claim will
be
included in the FFS data. The portion of the claim paid by another payer has
been avoided and not included in reported claim payments. Participating MCPs
are
expected to pay in a similar fashion and therefore, no adjustment to the FFS
data will be required.
In
a "pay
and chase" scenario, the State pays the claim as though it were the primary
payer. Subsequent to payment, the State makes recovery from a third party.
The
State has indicated the FFS data does not reflect these recoveries. Since MCPs
are also expected to take similar recovery actions, the FFS experience was
adjusted for "pay and chase" recoveries. ▇▇▇▇▇▇ made adjustments to both the
paid claims and utilization for all ▇▇▇▇. Since MCPs do not collect tort
recoveries, the data excludes tort collections.
Hospital
Cost Settlements
The
State
provided ▇▇▇▇▇▇ with SFY 2003 and SFY 2004 interim cost settlements for
Diagnosis Related Group (DRG) and DRG-exempt hospitals. The DRG-exempt hospital
information
C-2
▇▇▇▇▇▇
Government
Human Services Consulting
included
inpatient and outpatient settlements. However, the DRG hospitals only include
capital settlements, which were incorporated into the adjustment. An adjustment
has been applied to inpatient, outpatient, and emergency room (ER) claims to
remove these additional costs.
Fraud
and
Abuse
The
State
does pursue recoveries from fraud and abuse cases. The dollars recovered are
accounted for outside of the State's MMIS system and are not included in the
FFS
data. Therefore, ▇▇▇▇▇▇ applied adjustments to the FFS claims and utilization
data.
Excluded
Time Periods
The
capitation rates paid to the MCPs reflect the risk of serving the eligible
enrollees from the date of health plan enrollment forward. Therefore, the FFS
data has been adjusted to reflect only the time periods for which the MCPs
are
at risk.
Dual
Eligibles
Dual
eligible persons are not enrolled in managed care and are therefore not included
in the managed care rates. Their experience has been excluded from the base
FFS
data used to develop the rates.
Catastrophic
Claims
Since
the
State does not provide reinsurance to the MCPs. the MCPs are expected to
purchase reinsurance on their own. To reflect these costs, all claims, including
claims above the reinsurance threshold, were included in the base FFS data.
The
final rates ▇▇▇▇▇▇ calculated reflect the total risk associated with the covered
population and are expected to be sufficient to cover the cost of the required
stop-loss provision.
DSH
Payments
DSH
payments are made by the State to providers and are not the responsibility
of
the MCPs;
therefore,
the information for these payments was excluded from the FFS data used to
develop the rates. No rate adjustment was necessary.
Spend
Down
Persons
Medicaid eligible due to spend down are not enrolled in managed care and
therefore not included in the managed care rates. The base FFS data is net
of
recipient spend down. Therefore, no additional adjustment was
needed.
Graduate
Medical Education (GME)
The
State
does not make supplemental GME payments for services delivered to individuals
covered under the managed care program. Rather, the MCPs negotiate specific
rates with the individual teaching hospitals for the daily cost of care.
Therefore, the GME payments are included in the capitation rates paid to the
MCPs.
C-3
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Government
Human Services Consulting
Appendix
D - 2007 Contract Period ABD Rate Development
Credibility
By Year
▇▇▇▇▇▇
placed more credibility on the most recent year of FFS data.
FFS
Historical and Prospective Trend
Historical
FFS trend assumptions were used to trend SFY 2003 FFS data to the base period
(SPY 2004). Credibility was then applied to blend together the trended SFY
2003
and the SFY 2004 FFS data. Next, prospective FFS trends were applied to the
base
period FFS data to trend it to the 2007 contract period.
Prospective
Policy Changes
The
following items are considered prospective policy changes. These changes were
not reflected in the base data, but were implemented prior to or within the
contract period. Therefore, ▇▇▇▇▇▇ made the rate-setting adjustments for each
item in the following table.
Adjustments
Affecting Unit Cost
|
Policy
Change
|
Effective
Date
|
Category
of
Service Affected
|
|
Implementation
of $2 copay for trade-name preferred drugs for adults
(^21)
|
1/1/2006
|
Pharmacy
|
|
Implementation
of $3 copay for each dental date of service for adults
(>21)
|
1/1/2006
|
Dental
|
|
Implementation
of $2 copay for vision exams and $1 copay for dispensing services
for
adults (^21)
|
1/1/2006
|
Other
|
|
IP
Recalibration
|
1/1/2006
|
Inpatient
|
|
IP
Rate Freeze
|
1/1/2006
|
Inpatient
|
▇-▇
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Government
Human Services Consulting
Adjustments
Affecting Utilization
|
Policy
Change
|
Effective
Date
|
Category
of
Service Affected
|
|
Reduction
in coverage of dental services for adults (S21)
|
1/1/2006
|
Dental
|
|
Reduction
in coverage of enteral products
|
1/1/2006
|
DME/
Supplies
|
Voluntary
Selection
The
FFS
data reflects the risk of the entire ABD Medicaid program. To solely reflect
the
risk of the managed care program, ▇▇▇▇▇▇ modified the FFS data based on the
projected managed care penetration levels for the 2007 contract period. This
voluntary selection adjustment modifies the FFS data to reflect the risk to
the
MCPs (i.e., only those individuals who enroll in a health plan).
Administration/Contingencies
For
existing managed care plans in Ohio. the MCP administration/contingencies
allowance will be 12% of premium prior to the franchise fee. After the initial
two twelve month contract periods for new and existing plans, 1% of the
pre-franchise fee capitation rate will be put at risk, contingent upon MCPs
meeting performance requirements. The administration schedule will be as follows
for managed care plans currently existing in Ohio:
|
Admin
|
At-Risk
|
|
|
Plan
Year 1 (months 1-12)
|
12%
|
0%
|
|
Plan
Year 2 (months 13-24)
|
12%
|
0%
|
|
Plan
Year 3 (months 25-36)
|
12%
|
1%
|
D-2
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Government
Human Services Consulting
For
managed care plans new to Ohio, the administration schedule will be as
follows:
|
Admin
|
At-Risk
|
|
|
Plan
Year 1 (months 1-12)
|
13%
|
0%
|
|
Plan
Year 2 (months 13-24)
|
12%
|
0%
|
|
Plan
Year 3 (months 25-36)
|
12%
|
1%
|
For
plans
entering Ohio through the acquisition of another Ohio health plan's membership,
the administration schedule will continue as outlined in the chart on the
previous page, based on the plan year of the acquired health plan membership.
The administration schedule will not revert back to the Plan Year 1 schedule
due
to the membership acquisition.
In
addition, the total capitation rate was adjusted to incorporate the 4.5% MCP
franchise fee requirement.
D-3
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Government
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Appendix
E - 2007 Contract Period ABD Regional Rate Summary
State
of
Ohio
Final
& Confidential
Appendix
E 2007 Contact Period ABD Regional Rate Summary
|
Region
|
Contract
Begin Date
|
Contract
End Date
|
Final
Base Rate
|
|
Northeast
|
January
1,2007
|
December
31, 2007
|
$1,088.93
|
Note:
As
the contract periods for the remaining regions are finalized, this exhibit
will
be updated to include the corresponding rates.
E-1
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Government
Human Services Consulting
Appendix
F
PREMIUM
RATES WITHOUT THE AT-RISK PAYMENT AMOUNTS
FOR
01/01/07 THROUGH
06/30/07
MCP's premiums will be at-risk starting the 25th month of the ABD Medicaid
Managed Care Program participation.
MCP:
WellCare of Ohio, Inc.
|
Service
Enrollment Area
|
Base
Rates
|
At-Risk
Amounts
|
|
Northeast
Region
|
$1,101.45
|
$0.00
|
List
of Eligible Assistance Groups (AGs)
Aged,
Blind or Disabled:
MA-A
Aged
MA-B
Blind
MA-D
Disabled
Note:
An
MCP's regional membership for this program must not exceed their Primary Care
Physician capacity for that region as verified by the BMHC provider
database.
Appendix
G
Page
2
APPENDIX
G
COVERAGE
AND SERVICES ABD 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 pertinent to the ABD population
covered by the MCPs:
•
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
•
Family
planning services and supplies
•
Home
health services
•
Podiatry
•
Physical therapy, occupational therapy, and speech therapy
•
Nurse-midwife, certified family nurse practitioner, and certified pediatric
nurse practitioner services
•
Prescription drugs
•
Ambulance and ambulette services
•
Dental
services
•
Durable
medical equipment and medical supplies
•
Vision
care services, including eyeglasses
•
Nursing
facility stays as specified in OAC rule 5101:3-26-03
Appendix
G
Page
2
•
Hospice
care
•
Behavioral health services (see section G.2.b.iii of this appendix).
Note:
Independent
psychologist services not covered for adults age twenty-one (21) and
older.
2.
Exclusions.
Limitations and Clarifications
a.
Exclusions
MCPs
are
not required to pay for Ohio Medicaid FFS program (Medicaid) non-covered
services. For information regarding Medicaid noncovered services, MCPs must
refer to the ODJFS website. The following is a general list of the services
not
covered by the Ohio Medicaid fee-for-service program:
•
Services or supplies that are not medically necessary
•
Experimental services and procedures, including drugs and equipment, not covered
by Medicaid
•
Organ
transplants that are not covered by Medicaid
•
Abortions, except in the case of a reported rape, incest, or when medically
necessary to save the life of the mother
•
Infertility services for males or females
•
Voluntary sterilization if under 21 years of age or legally incapable of
consenting to the procedure
•
Reversal of voluntary sterilization procedures
•
Plastic
or cosmetic surgery that is not medically necessary*
•
Immunizations for travel outside of the United States
•
Services for the treatment of obesity unless medically necessary*
•
Custodial or supportive care
•
Sex
change surgery and related services
•
Sexual
or marriage counseling
Appendix
G
Page
3
•
Court
ordered testing
•
Acupuncture and biofeedback services
•
Services to find cause of death (autopsy)
•
Comfort
items in the hospital (e.g., TV or phone)
•
Paternity testing
MCPs
are
also not required to pay for non-emergency services or supplies received without
members following the directions in their MCP member handbook, unless otherwise
directed by 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 "Annual Opportunity"
month.
Notwithstanding
the preceding paragraph, MCPs must provide an ODJFS-approved notice to all
their
members 90 days in advance of the date that the MCP will impose the co-payment.
With the exception of member co-payments the MCP has elected to implement in
accordance with OAC rules 5101:3-26-05(D) and 5101:3-26-12, the MCP's payment
constitutes payment in full for any covered services and their subcontractors
must not charge members or ODJFS any additional co-payment, cost sharing,
down-payment, or similar charge, refundable or otherwise.
Appendix
G
Page
4
ii.
Abortion
and Sterilization
The
use
of federal funds to pay for abortion and sterilization services is prohibited
unless the specific criteria found in 42 CFR 441 and OAC rules 5101:3-17-01
and
5101:3-21-01 are met. MCPs must verify that all of the information on the
required forms (JFS 03197, 03198, and 03199) is provided and that the service
meets the required criteria before any such claim is paid.
Additionally,
payment must not be made for associated services such as anesthesia, laboratory
tests, or hospital services if the abortion or sterilization itself does not
qualify for payment. MCPs are responsible for educating their providers on
the
requirements;
implementing
internal procedures including systems edits to ensure that claims are only
paid
once the MCP has determined if the applicable forms are completed and the
required criteria are met, as confirmed by the appropriate certification/consent
forms; and for maintaining documentation to justify any such claim
payments.
iii.
Behavioral
Health Services
Coordination
of Services:
MCPs
must have a process to coordinate benefits of and referrals to the publicly
funded community behavioral health system. MCPs must ensure that members have
access to all medically-necessary behavioral health services covered by the
Ohio
Medicaid FFS program and are responsible for coordinating those services with
other medical and support services. MCPs must notify members via the member
handbook and provider directory of where and how to access behavioral health
services, including the ability to self-refer to mental health services offered
through community mental health centers (CMHCs) as well as substance abuse
services offered through Ohio Department of Alcohol and Drug Addiction Services
(ODADAS)-certified Medicaid providers. Pursuant to ORC Section 5111.16, alcohol,
drug addiction and mental health services covered by Medicaid are not to be
paid
by the managed care program when the nonfederal share of the cost of those
services is provided by a board of alcohol, drug addiction, and mental health
services or a state agency other than ODJFS. MCPs must provide behavioral health
services for members who are unable to timely access services or unwilling
to
access services through community providers.
Mental
Health Services:
There
are a number of various Medicaid-covered mental health (MH) services available
through the CMHCs.
Appendix
G
Page
5
Where
an
MCP is responsible for providing MH services for their members, the MCP is
responsible for ensuring access to counseling and psychotherapy,
physician/psychiatrist services, outpatient clinic services, general hospital
outpatient psychiatric services, pre-hospitalization screening, diagnostic
assessment (clinical evaluation), crisis intervention, psychiatric
hospitalization in general hospitals (for all ages), and Medicaid-covered
prescription drugs and laboratory services. MCPs are not required to cover
partial hospitalization, or inpatient psychiatric care in a free-standing
psychiatric hospital.
Substance
Abuse Services:
There
are a number of various Medicaid-covered substance abuse services available
through ODADAS-certified Medicaid providers.
Where
an
MCP is responsible for providing substance abuse services for their members,
the
MCP is responsible for ensuring access to alcohol and other drug (AOD)
urinalysis screening, assessment, counseling, physician/psychiatrist AOD
treatment services, outpatient clinic AOD treatment services, general hospital
outpatient AOD treatment services, crisis intervention, inpatient detoxification
services in a general hospital, and Medicaid-covered prescription drugs and
laboratory services. MCPs are not required to cover outpatient detoxification
and methadone maintenance.
Financial
Responsibility:
MCPs are
responsible for the payment of Medicaid-covered prescription drugs prescribed
by
a CMHC or ODADAS-certified provider when obtained through an MCP's panel
pharmacy. MCPs are also responsible for the payment of Medicaid-covered services
provided by an MCP's panel laboratory when referred by a CMHC or
ODADAS-certified provider. Additionally, MCPs are responsible for the payment
of
all other behavioral health services obtained through providers other than
those
who are CMHC or ODADAS-certified providers when arranged/authorized by the
MCP.
MCPs are not responsible for paying for behavioral health services provided
through CMHCs and ODADAS-certified Medicaid providers. MCPs are also not
required to cover the payment of partial hospitalization (mental health),
inpatient psychiatric care in a free-standing inpatient psychiatric hospital,
outpatient detoxification, or methadone maintenance.
iv.
Pharmacy
Benefit:
In
providing the Medicaid pharmacy benefit to their members, MCPs must cover the
same drugs covered by the Ohio Medicaid fee-for-service program.
Appendix
G
Page
6
MCPs
may
establish a preferred drug list for members and providers which includes a
listing of the drugs that they prefer to have prescribed. Preferred drugs
requiring prior authorization approval must be clearly indicated as such.
Pursuant to ORC §5111.72, ODJFS may approve MCP-specific pharmacy program
utilization management strategies (see appendix G.3.a).
v.
Organ
Transplants:
MCPs
must ensure coverage for organ transplants and related services in accordance
with OAC 5101-3-2-07.1 (B)(4)&(5). Coverage for all organ transplant
services, except kidney transplants, is contingent upon review and
recommendation by the "Ohio Solid Organ Transplant Consortium" based on criteria
established by Ohio organ transplant surgeons and authorization from the ODJFS
prior authorization unit. Reimbursement for bone marrow transplant and
hematapoietic stem cell transplant services, as defined in OAC 3701:84-01,
is
contingent upon review and recommendation by the "Ohio Hematapoietic Stem Cell
Transplant Consortium" again based on criteria established by Ohio experts
in
the field of bone marrow transplant. While MCPs may require prior authorization
for these transplant services, the approval criteria would be limited to
confirming the consumer is being considered and/or has been recommended for
a
transplant by either consortium and authorized by ODJFS. Additionally, in
accordance with OAC 5101:3-2-03 (A)(4) all services related to organ donations
are covered for the donor recipient when the consumer is Medicaid
eligible.
Care
Coordination
a.
Utilization
Management (Modification) Programs
General
Provisions
-
Pursuant to OAC rule 5101:3-26-03.1(A)(7), MCPs must implement the
ODJFS-required emergency department diversion (EDD) utilization management
program to maximize the effectiveness of the care provided to members and may
develop other utilization management programs, subject to prior approval by
ODJFS. For the purposes of this requirement, the specific utilization management
programs which require ODJFS prior-approval are those programs designed by
the
MCP with the purpose of redirecting or restricting access to a particular
service or service location. These programs are referred to as utilization
modification programs. MCP care coordination and disease management activities
which are designed to enhance the services provided to members with specific
health care needs would not be considered utilization management programs nor
would the designation of specific services requiring prior approval by the
MCP
or the member's PCP. MCPs must also implement the ODJFS-required emergency
department
diversion (EDD) program for frequent users. In that ODJFS has developed the
parameters for an MCP's EDD program, it therefore does not require ODJFS
approval.
Pharmacy
Programs
-
Pursuant to ORC Sec. 5111.172 and OAC rule 5101:3-26-03(A) and (B), MCPs subject
to ODJFS prior-approval, may implement strategies, including prior authorization
and limitations on the type of provider and locations where certain medications
may be administered, for the management of pharmacy utilization.
MCPs
must
receive prior approval from ODJFS on the types of medication that they wish
to
cover through prior authorizations. MCPs must establish their prior
authorization system so that it does not unnecessarily impede member access
to
medically-necessary Medicaid-covered services. As outlined in paragraph 29(i)
of
Appendix C, MCPs must adhere to specific prior-authorization limitations to
assist with the transition of new ABD members from FFS Medicaid.
MCPs
must
comply with the provisions of 1927(d)(5) of the Social Security Act, 42 USC
1396r-8(k)(3), and OAC rule 5101:3-26-03.1 regarding the timeframes for prior
authorization of covered outpatient drugs.
MCPs
may
also, with ODJFS prior approval, implement pharmacy utilization modification
programs designed to address members demonstrating high or inappropriate
utilization of specific prescription drugs.
Emergency
Department Diversion (EDD)
- MCPs
must provide access to services in a way that assures access to primary,
specialist and urgent care in the most appropriate settings and that minimizes
frequent, preventable utilization of emergency department (ED) services. OAC
rule 5101:3-26-03.1(A)(7)(d) requires MCPs to implement the ODJFS-required
emergency department diversion (EDD) program for frequent
utilizers.
Each
MCP
must establish an ED diversion (EDD) program with the goal of minimizing
frequent ED utilization. The MCP's EDD program must include the monitoring
of ED
utilization, identification of frequent ED utilizers, and targeted approaches
designed to reduce avoidable ED utilization. MCP EDD programs must, at a
minimum, address those ED visits which could have been prevented through
improved education, access, quality or care management approaches.
Although
there is often an assumption that frequent ED visits are solely the result
of a
preference on the part of the member and education is therefore the standard
remedy, it is also important to ensure that a member's frequent ED utilization
is not due to problems such as their
Appendix
G
Page
8
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.
4.
Case
Management
In
accordance with 5101:3-26-03.1(A)(8), MCPs must offer and provide case
management services which coordinate and monitor the care of members with
specific diagnoses, or who require high-cost and/or extensive
services.
a.
Each
MCP must inform all members and contracting providers of the MCP's case
management services.
b.
The
MCP's case management system must include, at a minimum, the following
components:
i.
Identification -
The
MCP
must have mechanisms in place to identify members potentially eligible for
case
management services. These mechanisms must include an administrative data review
(e.g. diagnosis, cost threshold, and/or service utilization) and may also
include telephone interviews; provider/self-referrals; or home
visits.
ii.
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 to determine the need for case management services. The
goals of the assessment are to identify the member's existing and/or potential
health care needs and assess the member's 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 a
physician.
The
MCP
must have a process to inform members and their PCPs that they have been
identified as meeting the criteria for case management, including their
enrollment into case management services.
iii.
Case
Management-
Risk
Stratification/Levels of Care
The
MCP
must develop a strategy to assign members to risk stratification
levels,
based
on
the member's comprehensive needs assessment. Once the member's
Appendix
G
Page
9
risk
level has been determined, the MCP must, at a minimum:
-develop
a care treatment plan (as described below);
-implement
member-level interventions;
-continuously
monitor the progress of the member;
-identify
gaps between care recommended and actual care provided,
and propose
and implement interventions to address the gaps; and
-implement
a system to monitor the delivery of specific services, including a review of
service utilization, to re-evaluate the member's risk level and adjust the
level
of case management services accordingly.
Care
Treatment Plan
The
MCP
must assure and coordinate the placement of the member into case-management-
including identification of the member's need for services, completion of the
comprehensive health needs assessment, and development of a care treatment
plan
- within ninety (90) days of membership. 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 comorbidities. and the member's psychological, behavioral health
and community support needs. The care treatment plan must also include specific
provisions for periodic reviews 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 physician, 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.
Coordination
of Care and Communication
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 both care and communication with the member, PCP,
and
other service providers and case managers. The MCP must also have a process
to
coordinate care for a member that is receiving services from state sub-recipient
agencies as appropriate [e.g., the Ohio Department of Mental Health (ODMH);
the
Ohio Department of Mental Retardation and Developmental Disabilities (ODMR/DD);
and the Ohio Department of Alcohol and Drug Addiction Services (ODADAS)]. There
should be an accountable point of contact at the MCP for each member in case
management who can help obtain medically necessary care, assist with
health-related services and coordinate care needs, including behavioral health.
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 services.
Appendix
G
Page
10
iv.
ODJFS
Targeted Case Management Conditions
The
MCP
must,
at a
minimum, case manage members with the following physical and behavioral health
conditions:
•
Congestive Heart Failure
•
Coronary Artery Disease
•
Non-Mild Hypertension
•
Diabetes
•
Chronic
Obstructive Pulmonary Disease
•
Asthma
•
Severe
mental illness
•
High
risk or high cost substance abuse disorders
•
Severe
cognitive and/or developmental limitation
The
MCP
should also focus on all members whose health conditions warrant case management
services and should not limit these services only to members with these
conditions (e.g., cystic fibrosis, cerebral palsy and sickle cell
anemia).
Refer
to
Appendix
M for
the
performance measures and standards related to case management.
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
managers, 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 case 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 Strategies
The
MCP
must follow best-practice and/or evidence based clinical guidelines when
devising a member's care treatment plan and coordinating the case management
needs. If an MCP uses a disease management methodology to identify and/or
stratify members in need of case management services, the methods must be
validated by scientific research and/or nationally accepted in the health care
industry.
The
MCP
must develop and implement mechanisms to educate and equip physicians 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.
vii.
Information Technology System for Case Management
The
MCP's
information technology system for its case management program
Appendix
G
Page
11
must
maximize the opportunity for communication between the plan, PCP, the member,
and other service providers and case managers. The MCP must have an integrated
database that allows MCP staff that may be contacted by a member in case
management to have immediate access to, and review of, the most recent
information with the MCP's information systems relevant to the case. The
integrated database may include the following: administrative data, call center
communications, service authorizations, care treatment plans, patient
assessments, case management notes, and PCP notes. The information technology
system must also have the capability to share relevant information with the
member, the PCP, and other service providers and case managers.
viii.
Data Submission
The
MCP
must submit a monthly electronic report to the Case Management System (CAMS)
for
all members that are case managed. In order for a member to be submitted as
case
managed in CAMS, the MCP must 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 the status of cases (e.g., closed, open, and/or active) in CAMS on
an
annual basis with the information contained in the member's case management
record. The CAMS files are due the 10th
business
day of each month.
c.
All MCPs must have an ODJFS-approved case management system which includes
the
items in Section 4(a) and (b) of Appendix G. Each MCP must implement an
evaluation process to review, revise and/or update the case management program.
The MCP must annually submit its case management program for review and approval
by ODJFS. Any subsequent changes to an approved case management system
description must be submitted to ODJFS in writing for review and approval prior
to implementation. Refer to Appendix
K for the
requirements regarding the annual review of the case management
program.
d.
Care Coordination with ODJFS-Designated Providers
Per
OAC
rule 5101:3-26-03.1(A)(4), MCPs are required to share specific information
with
certain ODJFS-designated non-contracting providers in order to ensure that
these
providers have been supplied with specific information needed to coordinate
care
for the MCP's members. Within the first month of operation, after an MCP has
obtained a provider agreement, the MCP must provide to the ODJFS-designated
providers (i.e., ODMH Community Health Centers, ODADAS-certified Medicaid
providers, FQHCs/RHCs, QFPPs, CNMs, CNPs [if applicable], and hospitals) a
quick
reference information packet which includes the following:
i.
A
brief cover letter explaining the purpose of the mailing; and
Appendix
G Page 12
ii.
A
brief summary document that includes the following information:
•
Claims
submission information including the MCP's Medicaid provider number for each
region;
•
The
MCP's prior authorization and referral procedures or the MCP's
website;
•
A
picture of the MCP's member identification card (front and back);
•
Contact
numbers and/or website location for obtaining information for eligibility
verification, claims processing, referrals/prior authorization, and information
regarding the MCP's behavioral health administrator;
•
A
listing of the MCP's major pharmacy chains and the contact number for the MCP's
pharmacy benefit administrator (PBM);
•
A
listing of the MCP's laboratories and radiology providers; and
•
A
listing of the MCP's contracting behavioral health providers and how to access
services through them (this information is only to be provided to
non-contracting community mental health and substance abuse
providers).
The
MCP
must notify ODJFS when this requirement has been fulfilled.
e.
Care
coordination with Non-Contracting Providers
Per
OAC
rule 5101:3-26-05(A)(9), MCPs authorizing the delivery of services from a
provider who does not have an executed subcontract must ensure that they have
a
mutually agreed upon compensation amount for the authorized service and notify
the provider of the applicable provisions of paragraph D of OAC rule
5101:3-26-05. This notice is provided when an MCP authorizes a non-contracting
provider to furnish services on a one-time or infrequent basis to an MCP member
and must include required ODJFS-model language and information. This notice
must
also be included with the transition of services form sent to providers as
outlined in paragraph 28.i.e. of Appendix C.
APPENDIX
H
PROVIDER
PANEL SPECIFICATIONS ABD 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 gastroenterologist
requirement but a member is unable to obtain a timely appointment from a
gastroenterologist on the MCP's provider panel, the MCP will be required to
secure an appointment from a panel gastroenterologist or arrange for an
out-of-panel referral to a gastroenterologist.
MCPs
are required
to make
transportation available to any member that must
travel
30 miles or more from their home to receive a medically-necessary
Medicaid-covered service. If the MCP offers transportation to their members
as
an additional benefit and this transportation benefit only covers a limited
number of trips, the required transportation listed above may
not
be
counted toward this trip limit (as specified in Appendix C).
In
developing the provider panel requirements, ODJFS considered, on a
county-by-county basis, the population size and utilization patterns of the
Aged, Blind or Disabled (ABD) 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
Appendix
H
Page
2
contract
with providers excluded from participation in Federal health care programs
under
either section 1128 or section 1128A of the Social Security Act. As part of
the
prior approval process, MCPs must submit documentation verifying that all
necessary contract documents have been appropriately completed. ODJFS will
verify the approvability of the submission and process this information using
the ODJFS Provider Verification System (PVS). The PVS is a centralized database
system that maintains information on the status of all MCP-submitted
providers.
Only
those providers who meet the applicable criteria specified in this document,
and
as determined by ODJFS, will be approved by ODJFS. MCPs must
credential/recredential providers in accordance with the standards specified
by
the National Committee for Quality Assurance (or receive approval from ODJFS
to
use an alternate industry standard) and must have completed the credentialing
review before submitting any provider to ODJFS for approval. Regardless of
whether ODJFS has approved a provider, the MCP must ensure that the provider
has
met all applicable credentialing criteria before the provider can render
services to the MCP's members.
MCPs
must
notify ODJFS of the addition and deletion of their contracting providers as
specified in OAC rule 5101:3-26-05, and must notify ODJFS within one working
day
in instances where the MCP has identified that they are not in compliance with
the provider panel requirements specified in this appendix.
3.
PROVIDER
PANEL REQUIREMENTS
The
provider network criteria that must be met by each MCP are as
follows:
a.
Primary
Care Physicians fPCPs)
Primary
Care Physicians (PCPs) may be individuals or group practices/clinics [Primary
Care Clinics (PCCs)]. Acceptable specialty types for PCPs are family/general
practice, and internal medicine. Acceptable PCCs include FQHCs, RHCs and the
acceptable group practices/clinics specified by ODJFS. As part of their
subcontract with an MCP, PCPs must stipulate the total Medicaid member capacity
that they can ensure for that individual MCP. Each PCP must have the capacity
and agree to serve at least 50 Medicaid members at each practice site in order
to be approved by ODJFS as a PCP, and to be included in the MCP's total PCP
capacity calculation. The capacity-by-site requirement must be met for all
ODJFS-approved PCPs.
ODJFS
reviews the capacity totals for each PCP to determine if they appear excessive.
ODJFS reserves the right to request clarification from an MCP for any PCP whose
total stated capacity for all MCP networks added together exceeds 2000 Medicaid
members (i.e., 1 FTE). ODJFS may also compare a PCP's capacity against the
number of members assigned to that PCP, and/or the number of patient encounters
attributed to that PCP to determine if the reported capacity number reasonably
reflects a PCP's expected caseload for a specific MCP. Where indicated, ODJFS
may set a cap on the maximum amount of capacity that we will recognize for
a
specific PCP. ODJFS may allow up to an additional 750 member capacity for each
nurse practitioner or physician's assistant that is used to provide clinical
support for a PCP.
Appendix
H
Page
3
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
expects that MCPs will need to utilize specialty physicians to serve as PCPs
for
some special needs members. In these situations it will not be necessary for
the
MCP to submit these specialists to the PVS database as PCPs, however, they
must
be submitted to PVS as the appropriate required provider type. Also, in some
situations (e.g., continuity of care) a PCP may only want to serve a very small
number of members for an MCP. In these situations it will not be necessary
for
the MCP to submit these PCPs to ODJFS for prior approval. These PCPs will not
be
included in the ODJFS PVS database and therefore may not appear as PCPs in
the
MCP's provider directory. Also, no PCP capacity will be counted for these
providers. These PCPs will, however, need to execute a subcontract with the
MCP
which includes the appropriate Model Medicaid Addendum.
The
PCP
requirement is based on an MCP having sufficient PCP capacity to serve 55%
of
the eligibles in the region. Each MCP must meet the PCP minimum FTE requirement
for 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 a PCP with available capacity
in urban counties and 40% of the eligible population within 30 miles of a PCP
with available capacity in rural counties. [Rural areas are defined pursuant
to
42 CFR 412.62(f)(l)(iii).]
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, cardiovascular, dentists, gastroenterology, nephrology,
neurology, oncology, physical medicine, podiatry, psychiatry, urology, vision
care providers, obstetricians/gynecologists (OB/GYNs), allergists, general
surgeons, otolaryngologists, orthopedists, 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).
Appendix
H
Page
4
Although
there are currently no capacity requirements for 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
Aged, Blind or Disabled (ABD) consumers and integrated the existing utilization
patterns into the hospital network requirements to avoid disruption of care.
For
this reason, ODJFS may require that MCPs contract with out-of-state hospitals
(i.e. Kentucky, West Virginia, etc.).
For
each
Ohio hospital, ODJFS utilizes the hospital's most current Annual Hospital
Registration and Planning Report, as filed with the Ohio Department of Health,
in verifying types of services that hospital provides. Although ODJFS has the
authority, under certain situations, to obligate a non-contracting hospital
to
provide non-emergency hospital services to an MCP's members, MCPs must still
contract with the specified number and type of hospitals unless ODJFS approves
a
provider panel exception (see Section 4 of this appendix - Provider Panel
Exceptions).
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. All MCP-contracting OB/GYNs must have current
hospital delivery privileges at a hospital under contract with the MCP in the
region.
Certified
Nurse Midwives (CNMs) and Certified Nurse Practitioners (CNPs)
-
MCPs
must ensure access to CNM and CNP services in the region if such provider types
are present within the region. The MCP may contract directly with the CNM or
CNP
providers, or with a physician or other provider entity who is able to obligate
the participation of a CNM or CNP. If an MCP does not contract for CNM or CNP
services and such providers are present within the region, the MCP will be
required to allow members to receive CNM or CNP services outside of the MCP's
provider network.
Contracting
CNMs must have hospital delivery privileges at a hospital under contract to
the
Appendix
H
Page
5
MCP
in
the region. The MCP must ensure a member's access to CNM and CNP services if
such
providers
are practicing within the region.
Vision
Care Providers -
MCPs
must contract with the specified number of ophthalmologists/optometrists for
each specified county/region, all of whom must maintain a full-time practice
at
a site(s) located in the specified county/region. All ODJFS-approved vision
providers must regularly perform routine eye exams. (MCPs will be expected
to
contract with an adequate number of ophthalmologists as part of their overall
provider panel, but only ophthalmologists who regularly perform routine eye
exams can be used to meet the vision care provider panel requirement.) If
optical dispensing is not sufficiently available in a region through the MCP's
contracting ophthalmologists/optometrists, the MCP must separately contract
with
an adequate number of optical dispensers located in the region.
Dental
Care Providers -
MCPs
must contract with the specified number of dentists.
Federally
Qualified Health Centers/Rural Health Clinics (FQHCs/RHCs) -
MCPs are
required to ensure member access to any federally qualified health center or
rural health clinic (FQHCs/RHCs), regardless of contracting status. Contracting
FQHC/RHC providers must be submitted for ODJFS approval via the PVS process.
Even if no FQHC/RHC is available within the region, MCPs must have mechanisms
in
place to ensure coverage for FQHC/RHC services in the event that a member
accesses these services outside of the region.
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
Appendix
H
Page
6
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 convey pertinent information to the
member's PCP and/or MCP.
Behavioral
Health Providers -
MCPs
must assure member access to all Medicaid-covered behavioral health services
for
members as specified in Appendix G.b.ii. herein. Although ODJFS is aware that
certain outpatient substance abuse services may only be available through
Medicaid providers certified by the Ohio Department of Drug and Alcohol
Addiction Services (ODADAS) in some areas, MCPs must maintain an adequate number
of contracted mental health providers in the region to assure access for members
who are unable to timely access services or unwilling to access services through
community mental health centers. MCPs are advised not to contract with community
mental health centers as all services they provide to MCP members are to be
billed to ODJFS.
Other
Specialty Types {general surgeons, otolaryngologists, orthopedists,
cardiologists, gastroenterologists, nephrologists, neurologists, oncologists,
podiatrists, physialrists, psychiatrists, and urologists ) -
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. Contracting general
surgeons, orthopedists, otolaryngologists, cardiologists,
gastroenterologisis, nephrologists, neurologists, oncologists, podiatrists,
physiatrists, psychiatrists, and urologists
must
have admitting privileges at a hospital under contract with the MCP in the
region.
4.
PROVIDER
PANEL EXCEPTIONS
ODJFS
may
specify provider panel criteria for a service area that deviates from that
specified in this appendix if:
-
the MCP
presents sufficient documentation to ODJFS to verify that they have been unable
to meet or maintain certain provider panel requirements in a particular service
area despite all reasonable efforts on their part to secure such a contract(s),
and
-
if
notified by ODJFS, the provider(s) in question fails to provide a reasonable
argument why they would not contract with the MCP, and
-
the MCP
presents sufficient assurances to ODJFS that their members will have adequate
access to the services in question.
Appendix
H
Page
7
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 approval of
a
provider panel exception request through a variety of data sources, including:
consumer satisfaction surveys; member appeals/grievances/complaints and state
hearing notifications/requests; member just-cause for termination requests;
clinical quality studies;
encounter
data volume; provider complaints, and clinical performance measures. ODJFS
approval of a provider panel exception request does not exempt the MCP from
assuring access to the services in question. If ODJFS determines that an MCP
has
not provided sufficient access to these services, the MCP may be subject to
sanctions.
5.
PROVIDER
DIRECTORIES
MCP
provider directories must include all MCP-contracted providers [except as
specified by ODJFS] as well as certain non-contracted providers. At the time
of
ODJFS' review, the information listed in the MCP's provider directory for all
ODJFS-required provider types specified on the attached charts must exactly
match the data currently on file in the ODJFS PVS.
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 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
Appendix
H
Page
8
deletions
by the MCP without ODJFS prior-approval, however, copies of the revised
directory
(or
inserts) must be submitted to ODJFS prior to distribution to
members.
On
a
quarterly basis, MCPs
must
create
an insert to each printed directory that lists those providers
deleted
from the
MCP's provider panel during the previous three months. Although this insert
does
not need to be prior approved by ODJFS, copies of the insert must be submitted
to ODJFS two weeks prior to distribution to members.
Internet
Provider Directory
MCPs
are
required to have an internet-based provider directory available in the same
format as their ODJFS-approved printed directory. This internet directory must
allow members to electronically search for MCP panel providers based on name,
provider type, and geographic proximity, and population (e.g. CFC and/or ABD).
If an MCP has one internet-based directory for multiple populations, each
provider must include a description of which population they serve.
The
internet directory may be updated at any time to include providers who
are
not
one of
the ODJFS-required provider types listed on the charts included with this
appendix. ODJFS-required providers
must
be added
to the internet directory within one week of the MCP's notification
ofODJFS-approval of the provider via the Provider Verification process.
Providers being deleted from the MCP's panel must be deleted from the internet
directory within one week of notification from the provider to the MCP. 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.
Appendix
H
Page
9
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.
MCPs
are to follow the procedures specified in the current MCP
PVS Instructional Manual, posted
on the ODJFS website. in order to comply with these federal access
requirements.
North
East Central Region - Hospitals
|
Minimum
Provider Panel Requirements
|
||||||||||
|
Total
Required Hospitals
|
Ashtabula
|
Cuyahoga
|
Erie
|
Geauga
|
Huron
|
Lake
|
▇▇▇▇▇▇
|
▇▇▇▇▇▇
|
Additional
Required Hospital In-Region
|
|
|
General
Hospital
|
1
|
1
|
1
|
1
|
1
|
1
|
||||
|
Hospital
System 1
|
1
|
1
|
||||||||
1.
Hospital system includes; physician networks and therefore these physicians
could be considered when fulfilling contracts for PCP and non-PCP provider
panel
requirements
East
Central Region - Hospitals
|
Minimum
Provider Panel Requirements
|
|||||
|
Total
Required Hospitals
|
Columbiana
|
Mahoning
|
Trumbull
|
Additional
Required Hospital In-Region
|
|
|
General
Hospital
|
3
|
1
|
1
|
1
|
|
|
Hospital
System
|
|||||
East
Central Region - Hospitals
|
Minimum
Provider Panel Requirements
|
|||||||||||
|
Total
Required Hospitals
|
Ashland
|
▇▇▇▇▇▇▇
|
▇▇▇▇▇▇
|
Portage
|
Richland
|
▇▇▇▇▇
|
Summit
|
Tuscarawas
|
▇▇▇▇▇
|
Additional
Required Hospital In-Region
|
|
|
General
Hospital
|
7
|
1
|
1
|
1
|
1
|
1
|
2
|
||||
|
Hospital
System 1
|
1
|
1
|
|||||||||
1
Hospital
system includes; physician networks and therefore these physicians could be
considered when fulfilling contracts for PCP and non-PCP provider panel
requirements.
South
East Region - Hospitals
|
Minimum
Provider Panel Requirements
|
||||||||||||||||||
|
Total
Required Hospitals
|
Athens
|
Belmont
|
Coshocton
|
Gallia
|
Guernsey
|
▇▇▇▇▇▇▇▇
|
▇▇▇▇▇▇▇
|
Jefferson
|
▇▇▇▇▇▇▇▇
|
▇▇▇▇▇
|
▇▇▇▇▇▇
|
▇▇▇▇▇▇
|
Muskingum
|
Noble
|
Vintron
|
Washington
|
Additional
Required Hospital: In-Region
|
|
|
General
Hospital
|
8
|
1
|
1
|
1
|
1
|
1
|
|
|
1
|
|
|
|
|
1
|
|
|
1
|
|
|
Hospital
System
|
||||||||||||||||||
Central
Region - Hospitals
|
Minimum
Provider Panel
Requirements
|
||||||||||||||||||||
|
Total
Required Hospitals
|
▇▇▇▇▇▇▇▇
|
Delaware
|
Fairfield
|
Fayette
|
▇▇▇▇▇▇▇▇
|
▇▇▇▇▇▇▇
|
▇▇▇▇
|
Licking
|
Logan
|
Madison
|
▇▇▇▇▇▇
|
▇▇▇▇▇▇
|
▇▇▇▇▇
|
Pickaway
|
▇▇▇▇
|
▇▇▇▇
|
Scioto
|
Union
|
Additional
Required Hospital: In-Region
|
|
|
General
Hospital
|
10
|
1
|
1
|
1
|
1
|
1
|
1
|
1
|
3
|
|||||||||||
|
Hospital
System
|
2
|
2
|
||||||||||||||||||
1
Hospital
system includes; physician networks and therefore these physicians could be
considered when fulfilling contracts for PCP and non-PCP provider panel
requirements.
South
West Region - Hospitals
|
Minimum
Provider Panel Requirements
|
||||||||||
|
Total
Required Hospitals
|
▇▇▇▇▇
|
▇▇▇▇▇
|
▇▇▇▇▇▇
|
▇▇▇▇▇▇▇
|
▇▇▇▇▇▇▇
|
▇▇▇▇▇▇▇▇
|
Highland
|
▇▇▇▇▇▇
|
Additional
Required Hospital In-Region
|
|
|
General
Hospital
|
7
|
|
1
|
1
|
|
1
|
1
|
1
|
|
1
|
|
Hospital
System 1
|
1
|
|
|
|
|
|
2
|
|
||
1
Hospital
system includes; physician networks and therefore these physicians could be
considered when fulfilling contracts for PCP and non-PCP provider panel
requirements.
West
Central Region - Hospitals
|
Minimum
Provider Panel Requirements
|
||||||||||
|
Total
Required Hospitals
|
Champaign
|
▇▇▇▇▇
|
▇▇▇▇▇
|
▇▇▇▇▇▇
|
Miami
|
▇▇▇▇▇▇▇▇▇▇
|
▇▇▇▇▇▇
|
▇▇▇▇▇▇
|
Additional
Required Hospital In-Region
|
|
|
General
Hospital
|
|
|
1
|
|
1
|
|
|
|
|
2
|
|
Hospital
System 2
|
1
|
|||||||||
1
Hospital
system includes; physician networks and therefore these physicians could be
considered when fulfilling contracts for PCP and non-PCP provider panel
requirements.
North
West Region - Hospitals
|
Minimum
Provider Panel Requirements
|
||||||||||||||||||||
|
Total
required Hospitals
|
▇▇▇▇▇
|
Auglaize
|
Defiance
|
▇▇▇▇▇▇
|
▇▇▇▇▇▇▇
|
▇▇▇▇▇▇
|
▇▇▇▇▇
|
▇▇▇▇▇
|
▇▇▇▇▇▇
|
Ottawa
|
Paulding
|
▇▇▇▇▇▇
|
Sandusky
|
Seneca
|
Van
▇▇▇▇
|
▇▇▇▇▇▇▇▇
|
▇▇▇▇
|
Wyandot
|
Additional
Required Hospital: In-Region
|
|
|
General
Hospital
|
1
|
1
|
1
|
1
|
3
|
|||||||||||||||
|
Hospital
System1
|
1
|
|||||||||||||||||||
1
Hospital
system includes; physician networks and therefore these physicians could be
considered when fulfilling contracts for PCP and non-PCP provider panel
requirements.
North
East Region - PCP Capacity
|
Minimum
PCP Capacity Requirements - ABD
|
||||||||||
|
PCPs
|
Total
Required
|
Ashtabula
|
Cuyahoga
|
Erie
|
Geauga
|
Huron
|
Lake
|
▇▇▇▇▇▇
|
▇▇▇▇▇▇
|
Additional
Required: In-Region *
|
|
Capacity
|
14,196
|
799
|
10,587
|
283
|
117
|
228
|
541
|
1,372
|
269
|
|
|
PCPs1
|
31
|
4
|
16
|
2
|
1
|
1
|
2
|
4
|
1
|
|
|
Number
of Eligibles
|
25,810
|
1453
|
19249
|
514
|
212
|
415
|
983
|
2495
|
489
|
|
1
Acceptable
PCP specialty types include Family/General Practice or Internal
Medicine
North
East Central Region - PCP Capacity
|
Minimum
PCP Capacity Requirements - ABD
|
|||||
|
PCPs
|
Total
Required
|
Columbiana
|
Mahoning
|
Trumbull
|
Additional
Required: In-Region
*
|
|
Capacity
|
4,230
|
798
|
2,028
|
1,405
|
|
|
PCPs1
|
11
|
3
|
4
|
4
|
|
|
Number
of Eligibles
|
7,691.00
|
1,450
|
3,687
|
2,554
|
|
1
Acceptable PCP specialty types include Family/General Practice or Internal
Medicine
East
Central Region - PCP Capacity
|
Minimum
PCP Capacit y Requirements - ABD
|
|||||||||||
|
PCPs
|
Total
Required
|
Ashland
|
▇▇▇▇▇▇▇
|
▇▇▇▇▇▇
|
Portage
|
Richland
|
▇▇▇▇▇
|
Summit
|
Tuscarawas
|
▇▇▇▇▇
|
Additional
Required: In-Region *
|
|
Capacity
|
7,415
|
152
|
134
|
83
|
479
|
710
|
1,870
|
3,051
|
458
|
480
|
|
|
PCPs1
|
21
|
1
|
1
|
1
|
2
|
3
|
4
|
5
|
2
|
2
|
|
|
Number
of Eligbles
|
13,482
|
276
|
243
|
150
|
871
|
1,290
|
3,400
|
5,547
|
833
|
872
|
|
1
Acceptable
PCP specialty types include Family/General Practice or Internal
Medicine
▇▇▇▇▇
▇▇▇▇ ▇▇▇▇▇▇ - ▇▇▇ ▇▇▇▇▇▇▇▇
|
▇▇▇▇▇▇
|
Capacity
|
PCPs
1
|
Number
of Eligibles
|
|
Total
Required
|
7,434
|
30
|
13,516
|
|
Athens
|
724
|
2
|
1,317
|
|
Belmont
|
654
|
2
|
1,189
|
|
Coshocton
|
234
|
1
|
426
|
|
Gallia
|
457
|
2
|
830
|
|
Guernsey
|
395
|
2
|
718
|
|
▇▇▇▇▇▇▇▇
|
172
|
1
|
313
|
|
▇▇▇▇▇▇▇
|
483
|
2
|
879
|
|
Jefferson
|
795
|
3
|
1,445
|
|
▇▇▇▇▇▇▇▇
|
1,154
|
4
|
2,098
|
|
Meigs
|
393
|
2
|
714
|
|
Monroe
|
134
|
1
|
244
|
|
Morgon
|
175
|
1
|
319
|
|
Muskingum
|
889
|
3
|
1,617
|
|
Noble
|
86
|
1
|
157
|
|
Vinton
|
197
|
1
|
359
|
|
Washington
|
490
|
2
|
891
|
|
Additional
Required: In-Region *
|
|
||
|
1
Acceptable
PCP specialty types include Family/General Practice or Internal
Medicine
|
|||
Central
Region - PCP Capacity
|
Minimum
PCP Capacity Requirements -ABD
|
|||
|
County
|
Capacity
|
PCPs1
|
Number
of Eligibles
|
|
Total
Required
|
13,660
|
59
|
24,837
|
|
▇▇▇▇▇▇▇▇
|
258
|
2
|
469
|
|
Delaware
|
226
|
2
|
410
|
|
Fairfield
|
528
|
3
|
960
|
|
Fayette
|
207
|
2
|
377
|
|
Franklin
|
6,592
|
17
|
11,985
|
|
Hocking
|
237
|
2
|
431
|
|
▇▇▇▇
|
282
|
2
|
512
|
|
Licking
|
682
|
4
|
1,240
|
|
▇▇▇▇▇
|
168
|
2
|
305
|
|
Madison
|
149
|
1
|
270
|
|
▇▇▇▇▇▇
|
496
|
3
|
902
|
|
▇▇▇▇▇▇
|
133
|
1
|
241
|
|
Perry
|
334
|
3
|
608
|
|
Pickaway
|
306
|
2
|
557
|
|
Pike
|
524
|
3
|
952
|
|
▇▇▇▇
|
741
|
4
|
1,348
|
|
Scioto
|
1,687
|
5
|
3,068
|
|
Union
|
111
|
1
|
202
|
|
Additional
Required: In-Region
|
|||
|
1
Acceptable PCP specialty types include Family/General Practice or
Internal
Medicine
|
|||
South
West Region - PCP Capacity
|
Minimum
PCP Capacity Requirements - ABD
|
||||||||||
|
PCPs
|
Total
Required
|
▇▇▇▇▇
|
▇▇▇▇▇
|
▇▇▇▇▇▇
|
Clermont
|
▇▇▇▇▇▇▇
|
▇▇▇▇▇▇▇▇
|
Highland
|
▇▇▇▇▇▇
|
Additional
Required: In Region *
|
|
Capacity
|
8,615
|
502
|
248
|
1,581
|
717
|
212
|
4,696
|
315
|
344
|
|
|
PCPs1
|
22
|
3
|
1
|
4
|
3
|
1
|
6
|
2
|
2
|
|
|
Number
of Eligibles
|
15,663
|
912
|
451
|
2,875
|
1,303
|
386
|
8,539
|
572
|
625
|
|
1
Acceptable
PCP specialty types include Family/General Practice or Internal
Medicine
West
Central Region - PCP Capacity
|
Minimum
PCP Capacity Requirements - ABD
|
||||||||||
|
PCPs
|
Total
Required
|
Champaign
|
▇▇▇▇▇
|
▇▇▇▇▇
|
▇▇▇▇▇▇
|
Miami
|
▇▇▇▇▇▇▇▇▇▇
|
▇▇▇▇▇▇
|
▇▇▇▇▇▇
|
Additional
Required: In Region *
|
|
Capacity
|
5,965
|
138
|
986
|
171
|
498
|
316
|
3,537
|
147
|
174
|
|
|
PCPs1
|
17
|
1
|
4
|
1
|
2
|
2
|
6
|
1
|
1
|
|
|
Number
of Eligibles
|
10,846
|
250
|
1,793
|
311
|
905
|
574
|
6,430
|
267
|
316
|
|
1
Acceptable
PCP specialty types include Family/General Practice or Internal
Medicine
North
West Region - PCP Capacity
|
Minimum
PCP Capacity Requirements - ABD
|
|||
|
County
|
Capacity
|
PCPs1
|
Number
of Eligibles
|
|
Total
Required
|
6,748
|
33
|
12,269
|
|
Alien
|
591
|
3
|
1,075
|
|
Auglaize
|
105
|
1
|
190
|
|
Defiance
|
150
|
1
|
272
|
|
▇▇▇▇▇▇
|
93
|
1
|
169
|
|
▇▇▇▇▇▇▇
|
212
|
2
|
385
|
|
▇▇▇▇▇▇
|
182
|
2
|
330
|
|
▇▇▇▇▇
|
54
|
1
|
99
|
|
▇▇▇▇▇
|
3,963
|
9
|
7,206
|
|
▇▇▇▇▇▇
|
102
|
1
|
185
|
|
Ottawa
|
103
|
1
|
188
|
|
Paulding
|
90
|
1
|
163
|
|
▇▇▇▇▇▇
|
72
|
1
|
130
|
|
Sandusky
|
240
|
2
|
436
|
|
Seneca
|
243
|
2
|
442
|
|
Van
▇▇▇▇
|
111
|
1
|
202
|
|
▇▇▇▇▇▇▇▇
|
128
|
1
|
233
|
|
Wood
|
253
|
2
|
460
|
|
Wyandot
|
57
|
1
|
104
|
|
Additional
Required:
In-Region *
|
|
|
|
|
1
Acceptable PCP specialty types include family/General Practice or
Internal
Medicine
|
|||
This
chart was finalized 10/14/05 and supercedes the one distributed 9/20/05. The
provider panel charts are a summary of the provider panel requirements. For
the
complete requirements, see RFA - Regional
Provider Panel Specifications.
North
East Region - Practitioners
|
ABD
Provider Panel Requirements
|
||||||||||
|
Provider
Types
|
Total
Required Providers1
|
Ashtabula
|
Cuyahoga
|
Erie
|
Geauga
|
Huron
|
Lake
|
▇▇▇▇▇▇
|
▇▇▇▇▇▇
|
Additional
Required Providers 2
|
|
Cardiovascular
|
6
|
|
3
|
|
|
|
|
1
|
|
2
|
|
Dentists
|
28
|
1
|
20
|
|
|
|
2
|
3
|
1
|
1
|
|
Gastroenterology
|
3
|
|
2
|
|
|
|
|
|
|
1
|
|
General
Surgeons
|
11
|
|
6
|
1
|
|
1
|
1
|
1
|
1
|
|
|
Nephrology
|
2
|
|
1
|
|
|
|
|
|
|
1
|
|
Neurology
|
3
|
|
2
|
|
|
|
|
|
|
1
|
|
OB/GYNs
|
12
|
|
8
|
1
|
|
|
|
1
|
|
2
|
|
Oncology
|
1
|
|
|
|
|
|
|
|
|
1
|
|
Orthopedists
|
7
|
|
4
|
|
|
|
|
1
|
|
2
|
|
Otolaryngologist
|
3
|
|
1
|
|
|
|
|
1
|
|
1
|
|
Physical
Med Rehab
|
3
|
|
2
|
|
|
|
|
|
|
1
|
|
Podiatry
|
8
|
|
4
|
|
|
|
|
2
|
|
2
|
|
Psychiatry
|
11
|
|
5
|
|
|
|
|
3
|
|
3
|
|
Urology
|
4
|
|
2
|
|
|
|
|
|
|
2
|
|
Vision
|
14
|
1
|
7
|
1
|
|
|
1
|
1
|
|
3
|
1
All
required providers must be located within the region.
2
Additional required providers may be located anywhere within the
region.
North
East Central- Practitioners
|
ABD
Provider Panel Requirements
|
|||||
|
Provider
Types
|
Total
Required Providers1
|
Columbiana
|
Mahoning
|
Trumbull
|
Additional
Required Providers 2
|
|
Cardiovascular
|
2
|
|
1
|
|
1
|
|
Dentists
|
7
|
1
|
3
|
3
|
|
|
Gastroenterology
|
1
|
|
|
|
1
|
|
General
Surgeons
|
3
|
1
|
1
|
1
|
|
|
Nephrology
|
1
|
|
|
|
1
|
|
Neurology
|
1
|
|
|
|
1
|
|
OB/GYNs
|
4
|
1
|
1
|
1
|
1
|
|
Oncology
|
1
|
|
|
|
1
|
|
Orthopedists
|
2
|
|
1
|
|
1
|
|
Otolaryngologist
|
1
|
|
1
|
|
|
|
Physical
Med Rehab
|
1
|
|
|
|
1
|
|
Podiatry
|
1
|
|
|
|
1
|
|
Psychiatry
|
6
|
|
3
|
2
|
1
|
|
Urology
|
1
|
|
|
|
1
|
|
Vision
|
5
|
|
2
|
2
|
1
|
1
All
required providers must be located within the region.
2
Additional required providers may be located anywhere within the
region.
East
Central - Practitioners
|
ABD
Provider Panel Requirements
|
|||||||||||
|
Provider
Types
|
Total
Required Providers1
|
Ashland
|
▇▇▇▇▇▇▇
|
▇▇▇▇▇▇
|
Portage
|
Richland
|
▇▇▇▇▇
|
Summit
|
Tuscarawas
|
▇▇▇▇▇
|
Additional
Required Providers 2
|
|
Cardiovascular
|
3
|
|
|
|
|
|
1
|
1
|
|
|
1
|
|
Dentists
|
14
|
1
|
|
|
|
2
|
4
|
6
|
1
|
|
|
|
Gastroenterology
|
2
|
|
|
|
|
|
|
|
|
|
2
|
|
General
Surgeons
|
7
|
|
|
|
|
1
|
1
|
2
|
|
1
|
2
|
|
Nephrology
|
1
|
|
|
|
|
|
|
|
|
|
1
|
|
Neurology
|
2
|
|
|
|
|
|
|
|
|
|
2
|
|
OB/GYNs
|
6
|
|
|
|
|
|
2
|
4
|
|
|
|
|
Oncology
|
1
|
|
|
|
|
|
|
|
|
|
1
|
|
Orthopedists
|
4
|
|
|
|
|
|
1
|
1
|
|
|
2
|
|
Otolaryngologist
|
2
|
|
|
|
|
|
1
|
1
|
|
|
|
|
Physical
Med Rehab
|
2
|
|
|
|
|
|
|
|
|
|
2
|
|
Podiatry
|
4
|
|
|
|
|
|
1
|
2
|
|
|
1
|
|
Psychiatry
|
6
|
|
|
|
|
|
2
|
3
|
|
|
1
|
|
Urology
|
2
|
|
|
|
|
|
|
|
|
|
2
|
|
Vision
|
8
|
|
|
|
|
1
|
2
|
3
|
|
|
2
|
1
All
required providers must be located within the region.
2
Additional required providers may be located anywhere within the
region.
|
South
East - Practitioners
|
||||||||||||||||||
|
ABD
Provider Panel Requirements
|
||||||||||||||||||
|
Provider
Types
|
Total
Required Providers1
|
Athens
|
Belmont
|
Coshocton
|
Gallia
|
Guernsey
|
▇▇▇▇▇▇▇▇
|
▇▇▇▇▇▇▇
|
Jefferson
|
▇▇▇▇▇▇▇▇
|
▇▇▇▇▇
|
▇▇▇▇▇▇
|
▇▇▇▇▇▇
|
Muskington
|
Noble
|
▇▇▇▇▇▇
|
▇▇▇▇▇▇▇▇▇▇
|
Additional
Required Providers2
|
|
Cardiovascular
|
3
|
|
|
|
1
|
|
|
|
|
|
|
|
|
1
|
|
|
|
1
|
|
Dentists
|
8
|
1
|
1
|
|
|
1
|
|
|
|
1
|
|
|
|
1
|
|
|
1
|
2
|
|
Gastroenterology
|
2
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
2
|
|
General
Surgeons
|
5
|
|
1
|
|
1
|
1
|
|
|
1
|
|
|
|
|
1
|
|
|
|
|
|
Nephrology
|
1
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
1
|
|
Neurology
|
2
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
2
|
|
OB/GYNs
|
6
|
1
|
|
|
|
1
|
|
|
1
|
|
|
|
|
1
|
|
|
1
|
1
|
|
Oncology
|
1
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
1
|
|
Orthopedists
|
4
|
|
|
|
1
|
|
|
|
|
|
|
|
|
1
|
|
|
1
|
1
|
|
Otolaryngologist
|
2
|
|
|
|
1
|
|
|
|
|
|
|
|
|
1
|
|
|
|
|
|
Physical
Med Rehab
|
2
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
2
|
|
Podiatry
|
4
|
|
1
|
|
|
|
|
|
|
|
|
|
|
1
|
|
|
|
2
|
|
Psychiatry
|
6
|
2
|
1
|
|
|
|
|
|
|
|
|
|
|
1
|
|
|
|
2
|
|
Urology
|
2
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
2
|
|
Vision
|
8
|
1
|
1
|
|
1
|
1
|
|
1
|
|
1
|
|
|
|
1
|
|
|
1
|
|
1
All
required providers must be located within the region.
2
Additional required providers may be located anywhere within the
region.
|
Central
- Practitioners
|
||||||||||||||||||||
|
ABD
Provider Panel Requirements
|
||||||||||||||||||||
|
Provider
Types
|
Total
Required Providers1
|
▇▇▇▇▇▇▇▇
|
Delaware
|
Fairfield
|
Fayette
|
▇▇▇▇▇▇▇▇
|
▇▇▇▇▇▇▇
|
▇▇▇▇
|
Licking
|
Logan
|
Madison
|
▇▇▇▇▇▇
|
▇▇▇▇▇▇
|
▇▇▇▇▇
|
Pickaway
|
▇▇▇▇
|
▇▇▇▇
|
Scioto
|
Union
|
Additional
Required Providers2
|
|
Cardiovascular
|
5
|
|
|
|
|
2
|
3
|
|||||||||||||
|
Dentists
|
21
|
1
|
1
|
15
|
1
|
1
|
1
|
1
|
||||||||||||
|
Gastroenterology
|
3
|
1
|
2
|
|||||||||||||||||
|
General
Surgeons
|
10
|
1
|
1
|
5
|
1
|
1
|
1
|
|||||||||||||
|
Nephrology
|
2
|
1
|
1
|
|||||||||||||||||
|
Neurology
|
3
|
1
|
|
2
|
||||||||||||||||
|
OB/GYNs
|
10
|
1
|
1
|
6
|
2
|
|||||||||||||||
|
Oncology
|
1
|
|
|
|
|
|
|
|
|
|
|
|
|
1
|
||||||
|
Orthopedists
|
7
|
1
|
3
|
1
|
1
|
1
|
||||||||||||||
|
Otolaryngologist
|
3
|
1
|
2
|
|||||||||||||||||
|
Physical
Med Rehab
|
3
|
1
|
2
|
|||||||||||||||||
|
Podiatry
|
7
|
1
|
3
|
3
|
||||||||||||||||
|
Psychiatry
|
11
|
1
|
1
|
5
|
4
|
|||||||||||||||
|
Urology
|
4
|
|||||||||||||||||||
|
Vision
|
14
|
1
|
1
|
1
|
5
|
1
|
1
|
1
|
1
|
1
|
1
|
|||||||||
1
All
required providers must be located within the region.
2
Additional required providers may be located anywhere within the
region.
Last
Revised May 25, 2006
|
South
West - Practitioners
|
||||||||||
|
ABD
Provider Panel Requirements
|
||||||||||
|
Provider
Types
|
Total
Required Providers1
|
▇▇▇▇▇
|
▇▇▇▇▇
|
▇▇▇▇▇▇
|
▇▇▇▇▇▇▇
|
▇▇▇▇▇▇▇
|
▇▇▇▇▇▇▇▇
|
Highland
|
▇▇▇▇▇▇
|
Additional
Required Providers 2
|
|
Cardiovascular
|
4
|
1
|
1
|
2
|
||||||
|
Dentists
|
15
|
3
|
1
|
8
|
1
|
1
|
1
|
|||
|
Gastroenterology
|
2
|
2
|
||||||||
|
General
Surgeons
|
9
|
1
|
1
|
1
|
3
|
2
|
1
|
|||
|
Nephrology
|
1
|
1
|
||||||||
|
Neurology
|
2
|
2
|
||||||||
|
OB/GYNs
|
7
|
1
|
1
|
4
|
1
|
|||||
|
Oncology
|
1
|
1
|
||||||||
|
Orthopedists
|
5
|
1
|
2
|
2
|
||||||
|
Otolaryngologist
|
2
|
1
|
1
|
|||||||
|
Physical
Med Rehab
|
2
|
2
|
||||||||
|
Podiatry
|
5
|
1
|
2
|
2
|
||||||
|
Psychiatry
|
7
|
3
|
4
|
|||||||
|
Urology
|
3
|
3
|
||||||||
|
Vision
|
8
|
1
|
1
|
3
|
1
|
1
|
1
|
|||
1
All
required providers must be located within the region.
2
Additional
required providers may be located anywhere within the region.
|
West
Central - Practitioners
|
||||||||||
|
ABD
Provider Panel Requirements
|
||||||||||
|
Provider
Types
|
Total
Required Providers1
|
Champaign
|
▇▇▇▇▇▇
|
▇▇▇▇▇
|
▇▇▇▇▇▇
|
Miami
|
▇▇▇▇▇▇▇▇▇▇
|
▇▇▇▇▇▇
|
▇▇▇▇▇▇
|
Additional
Required Providers 2
|
|
Cardiovascular
|
3
|
1
|
2
|
|||||||
|
Dentists
|
5
|
1
|
3
|
1
|
||||||
|
Gastroenterology
|
1
|
1
|
||||||||
|
General
Surgeons
|
5
|
1
|
1
|
1
|
2
|
|||||
|
Nephrology
|
1
|
1
|
||||||||
|
Neurology
|
2
|
2
|
||||||||
|
OB/GYNs
|
5
|
1
|
1
|
3
|
||||||
|
Oncology
|
1
|
1
|
||||||||
|
Orthopedists
|
3
|
1
|
1
|
1
|
||||||
|
Otolaryngologist
|
2
|
1
|
1
|
|||||||
|
Physical
Med Rehab
|
2
|
2
|
||||||||
|
Podiatry
|
4
|
2
|
2
|
|||||||
|
Psychiatry
|
5
|
1
|
2
|
2
|
||||||
|
Urology
|
2
|
2
|
||||||||
|
Vision
|
7
|
1
|
1
|
3
|
2
|
|||||
1
All
required providers must be located within the region.
2
Additional
required roviders may be located anywhere within the region.
Last
Revised May 25, 2006
|
North
West - Practitioners
|
||||||||||||||||||||
|
ABD
Provider Panel Requirements
|
||||||||||||||||||||
|
Provider
Types
|
Total
Required Providers 1
|
▇▇▇▇▇
|
Auglaize
|
Defiance
|
▇▇▇▇▇▇
|
▇▇▇▇▇▇▇
|
▇▇▇▇▇▇
|
▇▇▇▇▇
|
▇▇▇▇▇
|
▇▇▇▇▇▇
|
Ottawa
|
Paulding
|
▇▇▇▇▇▇
|
Sandusky
|
Seneca
|
Van
▇▇▇▇
|
▇▇▇▇▇▇▇▇
|
▇▇▇▇
|
Wyandot
|
Additional
Required Providers 2
|
|
Cardiovascular
|
3
|
|
|
|
|
|
|
|
1
|
|
|
|
|
|
|
|
|
|
|
2
|
|
Dentists
|
11
|
1
|
|
|
1
|
|
|
|
6
|
|
|
|
1
|
1
|
|
|
1
|
|
|
|
|
Gastroenterology
|
2
|
|
|
|
|
|
|
|
1
|
|
|
|
|
|
|
|
|
|
|
1
|
|
General
Surgeons
|
5
|
1
|
|
|
|
|
|
|
2
|
|
|
|
|
|
|
|
|
1
|
|
1
|
|
Nephrology
|
1
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
1
|
|
Neurology
|
2
|
|
|
|
|
|
|
|
1
|
|
|
|
|
|
|
|
|
|
|
1
|
|
OB/GYNs
|
6
|
1
|
|
|
|
|
|
|
2
|
|
|
|
|
1
|
1
|
|
|
1
|
|
|
|
Oncology
|
1
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
1
|
|
Orthopedists
|
4
|
1
|
|
|
|
1
|
|
|
1
|
|
|
|
|
|
|
|
|
1
|
|
|
|
Otolaryngologist
|
2
|
|
|
|
|
|
|
|
1
|
|
|
|
|
|
|
|
|
|
|
1
|
|
Physical
Med Rehab
|
2
|
|
|
|
|
|
|
|
1
|
|
|
|
|
|
|
|
|
|
|
1
|
|
Podiatry
|
4
|
|
|
|
|
|
|
|
2
|
|
|
|
|
|
|
|
|
1
|
|
1
|
|
Psychiatry
|
6
|
1
|
|
|
|
|
|
|
3
|
|
|
|
|
|
|
|
|
1
|
|
1
|
|
Urology
|
2
|
|
|
|
|
|
|
|
1
|
|
|
|
|
|
|
|
|
|
|
1
|
|
Vision
|
7
|
1
|
|
1
|
|
|
|
|
2
|
1
|
|
|
|
1
|
|
1
|
|
|
|
|
1
All
required providers must be located within the region.
2
Additional required
APPENDIX
I
PROGRAM
INTEGRITY ABD ELIGIBLE POPULATION
MCPs
must
comply with all applicable program integrity requirements, including those
specified in 42 CFR 455 and Subpart H.
1.
Fraud
and Abuse Program:
In
addition to the specific requirements ofOAC rule 5101:3-26-06, MCPs must have
a
program that includes administrative and management arrangements or procedures,
including a mandatory compliance plan, to guard against fraud and abuse. The
MCP's compliance plan must designate staff responsibility for administering
the
plan and include clear goals, milestones or objectives, measurements, key dates
for achieving identified outcomes, and explain how the MCP will determine the
compliance plan's effectiveness.
a.
Monitoring
for fraud and abuse:
In
addition to the requirements in OAC rule 5101:3-26-06, the MCP's program which
safeguards against fraud and abuse must specifically address the MCP's
prevention, detection, investigation, and reporting strategies in at least
the
following areas:
i.
Embezzlement and theft - MCPs must monitor activities on an ongoing basis to
prevent and detect activities involving embezzlement and theft (e.g., by staff,
providers, contractors, etc.) and respond promptly to such
violations.
ii.
Underutilization of services - MCPs must monitor for the potential
underutilization of services by their members in order to assure that all
Medicaid-covered services are being provided, as required. If any underutilized
services are identified, the MCP must immediately investigate and, if indicated,
correct the problem(s) which resulted in such underutilization of
services.
The
MCP's
monitoring efforts must, at a minimum, include the following activities: a)
an
annual review of their prior authorization procedures to determine that they
do
not unreasonably limit a member's access to Medicaid-covered services; b) an
annual review of the procedures providers are to follow in appealing the MCP's
denial of a prior authorization request to determine that the process does
not
unreasonably limit a member's access to Medicaid-covered services; and c)
ongoing monitoring of MCP service denials and utilization in order to identify
services which may be underutilized.
Appendix
I
Page
2
iii.
Claims submission and billing - On an ongoing basis, MCPs must identify and
correct claims submission and billing activities which are potentially
fraudulent including, at a minimum, double-billing and improper coding, such
as
upcoding and bundling, to the satisfaction ofODJFS.
b.
Reporting
MCP fraud and abuse activities:
Pursuant
to OAC rule 5101:3-26-06, MCPs are required to submit annually to ODJFS a report
which summarizes the MCP's fraud and abuse activities for the previous year
in
each of the areas specified above. The MCP's report must also identify any
proposed changes to the MCP's compliance plan for the coming year.
c.
Reporting
fraud and abuse:
MCPs are
required to promptly report all instances of provider fraud and abuse to ODJFS
and member fraud to the CDJFS. The MCP, at a minimum, must report the following
information on cases where the MCP's investigation has revealed that an incident
of fraud and/or abuse has occurred:
i.
provider's name and Medicaid provider number or provider reporting number
(PRN);
ii.
source of complaint;
iii.
type
of provider;
iv.
nature of complaint;
v.
approximate range of dollars involved, if applicable;
vi.
results of MCP's investigation and actions taken;
vii.
name(s) of other agencies/entities (e.g., medical board, law enforcement)
notified by MCP; and viii. legal and administrative disposition of case,
including actions taken by law enforcement officials to whom the case has been
referred.
2.
Data
Certification:
Pursuant
to 42 CFR 438.604 and 42 CFR 438.606, MCPs are required to provide certification
as to the accuracy, completeness, and truthfulness of data and documents
submitted to ODJFS which may affect MCP payment.
a.
MCP
Submissions:
MCPs
must submit the appropriate ODJFS-developed certification concurrently with
the
submission of the following data or documents:
i.
Encounter Data [as specified in the Data Quality Appendix (Appendix
L)]
Appendix
I
Page
3
ii.
Prompt Pay Reports [as specified in the Fiscal Performance Appendix (Appendix
J)]
iii.
Cost
Reports [as specified in the Fiscal Performance Appendix (Appendix
J)]
b.
Source
of Certification:
The
above MCP data submissions must be certified by one of the
following:
i.
The
MCP's Chief Executive Officer;
ii.
The
MCP's Chief Financial Officer, or
iii.
An
individual who has delegated authority to sign for, or who reports directly
to,
the MCP's Chief Executive Officer or Chief Financial Officer.
ODJFS
may
also require MCPs to certify as to the accuracy, completeness, and truthfulness
of additional submissions.
3.
Prohibited
Affiliations:
Pursuant
to 42 CFR 438.610, MCPs must not knowingly have a relationship with individuals
debarred by Federal Agencies, as specified in Article XII of the
Agreement.
APPENDIX
J
FINANCIAL
PERFORMANCE ABD 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(8). The Financial
Statements must include all required Health Statement filings, schedules and
exhibits as stated in the NAIC Annual Health Statement Instructions including,
but not limited to, the following sections: Assets, Liabilities, Capital and
Surplus Account, Cash Flow, Analysis of Operations by Lines of Business,
Five-Year Historical Data, and the Exhibit of Premiums, Enrollment and
Utilization. The Financial Statements must be submitted to BMHC even if the
Ohio
Department of Insurance (ODI) does not require the MCP to submit these
statements to ODI. A signed hard copy and an electronic copy of the reports
in
the NAIC-approved format must both be provided to ODJFS;
b.
Hard
copies of annual financial statements for those entities who have an ownership
interest totaling five percent or more in the MCP or an indirect interest of
five percent or more, or a combination of direct and indirect interest equal
to
five percent or more in the MCP;
c.
Annual
audited Financial Statements prepared by a licensed independent external auditor
as submitted to the ODI, as outlined in OAC rule 5101:3-26-09(B);
d.
Medicaid Managed Care Plan Annual Ohio Department of Job and Family Services
(ODJFS) Cost Report and the auditor's certification of the cost report, as
outlined in OAC rule 5101:3-26-09(B);
e.
Annual
physician incentive plan disclosure statements and disclosure of and changes
to
the MCP's physician incentive plans, as outlined in OAC rule
5101:3-26-09(B);
f.
Reinsurance agreements, as outlined in OAC rule 5101:3-26-09(C);
g.
Prompt
Pay Reports, in accordance with OAC rule 5101:3-26-09(B). A hard copy and an
electronic copy of the reports in the ODJFS-specified format must be provided
to
ODJFS;
Appendix
J
Page
2
h.
Notification of requests for information and copies of information released
pursuant to a tort action (i.e., third party recovery), as outlined in OAC
rule
5101:3-26-09.1;
i.
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);
j.
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 2006, a minimum net worth per member
of $156.00, as determined from the annual Financial Statement submitted to
ODI
and the ODJFS.
The
Net
Worth Per Member (NWPM) standard is the Medicaid Managed Care Capitation amount
paid to the MCP during the preceding calendar year, excluding the at-risk
amount, expressed as a per-member per-month figure, multiplied by the applicable
proportion below:
0.75
if
the MCP had a total membership of 100,000 or more during that calendar
year
0.90
if
the MCP had a total membership of less than 100,000 for that calendar
year
Appendix
J
Page
3
If
the
MCP did not receive Medicaid Managed Care Capitation payments during the
preceding calendar year, then the NWPM standard for the MCP is the average
Medicaid Managed Care capitation amount paid to Medicaid-contracting MCPs during
the preceding calendar year, 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 minus Franchise Fees 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.
Appendix
J
Page
4
Failure
to submit complete quarterly and annual Financial Statements on a timely basis
will be deemed a failure to meet the standards and will be subject to the
noncompliance penalties listed for indicators 2.a., 2.b., and 2.c., including
the imposition of a new membership freeze. The new membership freeze will take
effect at the first of the month following the month in which the determination
was made that the MCP was 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.
Appendix
J
Page
4
The
annual deductible or retention amount for such insurance must be specified
in
the reinsurance agreement and must not exceed $75,000.00, except as provided
below. Except for transplant services, and as provided below, this reinsurance
must cover, at a minimum, 80% of inpatient costs incurred by one member in
one
year, in excess of $75,000.00.
For
transplant services, the reinsurance must cover, at a minimum, 50% of transplant
related costs incurred by one member in one year, in excess of
$75,000.00.
An
MCP
may request a higher deductible amount and/or that the reinsurance cover 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 of 2.5 or higher calculated from the last annual ODI
financial statement;
f.
graph/chart showing the claims history for reinsurance above the previously
approved deductible from the last calendar year.
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/or
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,
Appendix
J
Page
6
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 ▇▇▇▇ 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 ▇▇▇▇ for services; (2) a line item
of
services; or (3) all services for one recipient within a ▇▇▇▇. A "clean claim"
is a claim that can be processed without obtaining additional information from
the provider of a service or from a third party.
Clean
claims do not include payments made to a provider of service or a third party
where the timing of payment is not directly related to submission of a completed
claim by the provider of service or third party (e.g., capitation). A clean
claim also does not include a claim from a provider who is under investigation
for fraud or abuse, or a 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.
Upon
request by a member or a potential member and no later than 14 calendar days
after the request, the MCP must provide the following information to the member:
(1) whether the MCP uses a physician incentive plan that affects the use of
referral services; (2) the type of incentive arrangement; (3) whether stop-loss
protection is provided; and
Appendix
J Page 8
(4)
a
summary of the survey results if the MCP was required to conduct a survey.
The
information provided by the MCP must adequately address the member's
request.
6.
NOTIFICATION OF REGULATORY ACTION
Any
MCP
notified by the ODI of proposed or implemented regulatory action must report
such notification and the nature of the action to ODJFS no later than one
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 ABD 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.
ODJFS
will identify the clinical and/or non-clinical study topics for the SPY 2008
Provider Agreement. Initiation of the PIPs will begin in the second year
of
participation in the ABD Medicaid managed care program.
In
addition, as noted in Appendix M, if an MCP fails to meet the Minimum
Performance Standard for selected Clinical Performance Measures, the MCP
will be
required to complete a PIP.
b.
UNDER-
AND OVER-UTILIZATION
Each
MCP
must have mechanisms in place to detect under- and over-utilization of health
care services. The MCP must specify the mechanisms used to monitor utilization
in its annual submission of the QAPI program to ODJFS.
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.
Appendix
K
Page
2
In
addition, beginning in SFY 2005, the MCP must conduct an ongoing review of
service denials and must monitor utilization on an ongoing basis in order
to
identify services which may be under-utilized.
c.
SPECIAL
HEALTH CARE NEEDS
Each
MCP
must have mechanisms in place to assess the quality and appropriateness of
care
furnished to members with special health care needs. The MCP must specify
the
mechanisms used in its annual submission of the QAP1 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 will be required to submit
Health Employer Data Information Set (HEDIS) audited data for measures that
.
will be identified by ODJFS for the SFY 2008 Provider Agreement.
The
measures must have received a "report" designation from the HEDIS certified
auditor and must be specific to the Medicaid population. Data must be submitted
annually and in an electronic format. Data will be used for MCP clinical
performance monitoring and will be incorporated into comparative reports
developed by the EQRO.
Initiation
of submission of performance data will begin in the second year of participation
in the Medicaid managed care program.
2.
EXTERNAL QUALITY REVIEW
In
addition to the following requirements, MCPs must participate in external
quality review activities as outlined in OAC 5101:3-26-07.
a.
EORO
ADMINISTRATIVE REVIEW AND NON-DUPLICATION OF MANDATORY
ACTIVITIES
The
EQRO
will conduct administrative compliance assessments for each MCP every three
(3)
years. The review will include, but not be limited to, the following domains
as
specified by ODJFS: member rights and services, QAPI program, access standards,
provider network, grievance system, case management, coordination and continuity
of care, and utilization management. In accordance with 42 CFR 438.360 and
438.362, MCPs with accreditation from a national accrediting organization
approved by the Centers for Medicare and Medicaid Services (CMS) may request
a
non-duplication exemption
from certain specified components of the administrative review. Non-duplication
exemptions may not be requested for SFY 07.
b.
ANNUAL
REVIEW OF OAPI AND CASE MANAGEMENT PROGRAM
Each
MCP
must implement an evaluation process to review, revise, and/or update the
QAPI
program. The MCP must annually submit its QAPI program for review and approval
by ODJFS.
The
annual QAPI and case management (refer to Appendix G) program submissions
are
subject to an administrative review by the EQRO. If the EQRO identifies
deficiencies during its review, the MCP must develop and implement Corrective
Action Plan(s) that are prior approved by ODJFS. Serious deficiencies may
result
in immediate termination or non-renewal of the provider agreement.
c.
EXTERNAL
QUALITY REVIEW PERFORMANCE
In
accordance with OAC rule 5101:3-26-07, each MCP must participate in clinical
or
non-clinical focused quality of care studies as part of the annual external
quality review survey. If the EQRO cites a deficiency in clinical or
non-clinical performance, the MCP will be required to complete a Corrective
Action Plan (e.g., ODJFS technical assistance session). Quality Improvement
Directives or Performance Improvement Projects depending on the severity
of the
deficiency. (An example of a deficiency is if an MCP fails to meet certain
clinical or administrative standards as supported by national evidence-based
guidelines or best practices.) Serious deficiencies may result in immediate
termination or non-renewal of the provider agreement. These quality improvement
measures recognize the importance of ongoing MCP performance improvement
related
to clinical care and service delivery.
APPENDIX
L
DATA
QUALITY ABD 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 Aged, Blinded or Disabled (ABD) 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 ABD
membership, if applicable): Encounter Data Omissions, 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 the ABD and CFC Medicaid Managed Care Programs Data Quality
Measures.
l.a.
Encounter Data Completeness
Each
MCP's encounter data submissions will be assessed for completeness. The MCP
is
responsible for collecting information from providers and reporting the data
to
ODJFS in accordance with program requirements established in Appendix C,
MCP
Responsibilities.
Failure
to do so jeopardizes the MCP's ability to demonstrate compliance with other
performance standards.
l.a.i.
Encounter Data Volume
Measure:
The
volume measure for each service category, as listed in Table 2 below, is
the
rate of utilization (e.g., discharges, visits) per 1.000 member months (MM)
for
the ABD program. The measure will be calculated per MCP (i.e., to include
all
counties with ABD memberships served by the MCP).
Report
Period:
The
report periods for the SFY 2007 and SPY 2008 contract periods are listed
in the
table below.
Appendix
L
Page
2
Table
1. Report Periods for the SFY 2007 and 2008 Contract
Periods
|
Report
Period
|
Data
Source:
Estimated
Encounter Data
File Update
|
Quarterly
Report Estimated Issue Date
|
Contract
Period
|
|
Qtr
1 2007
|
July
2007
|
August
2007
|
SFY
2007
|
|
Qtr
l, Qtr 2 2007
|
October
2007
|
November
2007
|
SFY
2007
|
|
Qtr
1 thru Qtr 3 2007
|
January
2008
|
February
2008
|
SFY
2008
|
|
Qtr
1 thru Qtr 4 2007
|
April
2007
|
May
2007
|
SFY
2008
|
|
Qtr
1 thru Qtr 4 2007, Qtr 1 2008
|
July
2008
|
August
2008
|
SFY
2008
|
|
Qtr
1 thru Qtr 4 2007, Qtr 1, Qtr 2 2008
|
October
2008
|
November
2008
|
SFY
2008
|
Qtrl
=
January to March Qtr2
=
April to June Qtr3
=
July to September Qtr
4 =
October to December
Data
Quality Standard:
The
utilization rate for all service categories listed in Table 2 must be equal
to
or greater than the interim standards established in Table 2 (see below.
Table 2
-Encounter Data Volume Standards).
Statewide
Approach:
Prior to
establishment of statewide minimum performance standards, ODJFS will evaluate
MCP performance using the interim standards for Encounter data volume. ODJFS
will use the first four quarters of data (i.e., full calendar year quarters)
from all MCPs serving ABD program membership to determine statewide minimum
encounter volume data quality standards.
Appendix
L
Page
3
Table
2. Interim Standards
Encounter
Data Volume
|
Category
|
Measure
per 1,000/MM
|
Standard
for Dates of Service on or after 1/1/2007
|
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
|
Visits
|
25.5
|
Non-institutional
and hospital dental visits
|
|
Vision
|
Visits
|
5.3
|
Non-institutional
and hospital outpatient optometry and ophthalmology
visits
|
|
Primary
and Specialist Care
|
Visits
|
116.6
|
Physician/practitioner
and hospital outpatient visits
|
|
Ancillary
Services
|
Visits
|
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, 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.
Appendix
L
Page
4
l.a.ii.
Encounter Data Omissions
Omission
studies will evaluate the completeness of the encounter data.
Measure:
This
study will compare the medical records of members during the time of membership
to the encounters submitted. Omission rates will be calculated per MCP (i.e.,
to
include all counties serviced by the MCP).
The
encounters documented in the medical record that do not appear in the encounter
data will be counted as omissions.
Report
Period:
In order
to provide timely feedback on the omission rate of encounters, the report
period
will be the most recent from when the measure is initiated. This measure
is
conducted annually.
Medical
records retrieval from the provider and submittal to ODJFS or its designee
is an
integral component of the omission measure. ODJFS has optimized the sampling
to
minimize the number of records required. This methodology requires a high
record
submittal rate. To aid MCPs in achieving a high submittal rate, ODJFS will
give
at least an 8 week period to retrieve and submit medical records as a part
of
the validation process. A record submittal rate will be calculated as a
percentage of all records requested for the study.
Data
Quality Standard:
The data
quality standard is a maximum omission rate of 15% for studies with time
periods
ending in CY 2008.
Penalty
for Noncompliance:
The
first time an MCP is noncompliant with a standard for this measure, ODJFS
will
issue a Sanction Advisory informing the MCP that any future noncompliance
instances with the standard for this measure will result in ODJFS imposing
a
monetary sanction.
Upon
all
subsequent measurements of performance, if an MCP is again determined to
be
noncompliant with the standard, ODJFS will impose a monetary sanction (see
Section 6) of one percent of the current month's premium payment. Once the
MCP
is performing at standard levels and violations/deficiencies are resolved
to the
satisfaction of ODJFS, the money will be refunded.
l.a.iii.
Incomplete Outpatient Hospital Data
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 (i.e., to include all counties serviced
by the MCP).
Appendix
L
Page
5
Report
Period:
For the
SFY 2007 contract period, performance will be evaluated using the following
report periods: January - March 2007; April - June 2007. For the SFY 2008
contract period, performance will be evaluated using the following report
periods: January - March 2007; April - June 2007; July-September 2007; October
-
December 2007; January - March 2008; April -June 2008.
Data
Quality Standard:
The
data
quality standard is a minimum rate of 95%.
Determination
of Compliance:
Performance is monitored once every quarter. If the standard is not met in
all
report periods, then the MCP will be determined to be noncompliant.
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.
l.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 (i.e., to include all counties serviced by the
MCP).
Report
Period:
For the
SFY 2007 contract period, performance will be evaluated using the following
report periods: January - March 2007; April - June 2007. For the SFY 2008
contract period, performance will be evaluated using the following report
periods July - September 2007;
October
-
December 2007; January - March 2008; April - June 2008.
Data
Quality Standard 1:
Data
Quality Standard 1 is a maximum encounter data rejection rate of 10% for
each
file in
the ODJFS-specified medium per format. The measure will be calculated per
MCP
(i.e., to include all counties serviced by the MCP).
Determination
of Compliance:
Performance is monitored once every quarter. Compliance determination with
the
standard applies only to the quarter under consideration and does not include
performance in previous quarters.
Appendix
L
Page
6
Penalty
for noncompliance with Data Quality Standard 1:
The
first time an MCP is noncompliant with a standard for this measure, ODJFS
will
issue a Sanction Advisory informing the MCP that any future noncompliance
instances with the standard for this measure will result in ODJFS imposing
a
monetary sanction. Upon all subsequent measurements of performance, if an
MCP is
again determined to be noncompliant with the standard, ODJFS will impose
a
monetary sanction (see Section 6.) of one percent of the current month's
premium
payment. The monetary sanction will be applied for each file in the
ODJFS-specified medium per format that is determined to be out of
compliance.
Once
the
MCP is performing at standard levels and violations/deficiencies are resolved
to
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 (i.e., to include all counties serviced by the
MCP).
Report
Period:
The
report period for Measure 2 is monthly. Results are calculated and performance
is monitored monthly. The first reporting month begins with the third month
of
enrollment.
Data
Quality Standard 2:
The data
quality standard is a maximum encounter data rejection rate for each file
in the
ODJFS-specified medium per format as follows:
Third
through sixth months with membership: 50%
Seventh
through twelfth month with membership: 25%
Files
in
the ODJFS-specified medium per format that are totally rejected will not
be
considered in the determination of noncompliance.
Determination
of Compliance:
Performance is monitored once every month. Compliance determination with
the
standard applies only to the month under consideration and does not include
performance in previous quarters.
Penalty
for Noncompliance with Data Quality Standard 2:
If the
MCP is determined to be noncompliant for either standard, ODJFS will impose
a
monetary sanction of one percent of the MCP's current month's premium payment.
The monetary sanction will be applied only once per measure per compliance
determination period and will not exceed a total of two percent of the MCP's
current month's premium payment. Once the MCP is performing at standard levels
and violations/deficiencies are resolved to the satisfaction of ODJFS, the
money
will be refunded. Special consideration will be made for MCPs with less than
1,000 members.
Appendix
L
Page
7
l.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 ODJFS and accepted (i.e. accepted encounters
per 1,000 member months). The measure will be calculated per MCP (i.e., to
include all counties serviced by the MCP).
Report
Period:
The
report period for this measure is monthly. Results are calculated and
performance is monitored monthly. The first reporting month begins with the
third month of enrollment.
Data
Quality Standard:
The data
quality standard is a monthly minimum accepted rate of encounters for each
file
in the ODJFS-specified medium per format as follows:
Third
through sixth month with membership:
50
encounters per 1,000 MM for NCPDP
65
encounters per 1,000 MM forNSF
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 only once per measure per compliance
determination period and will not exceed a total of two percent of the MCP's
current month's premium payment. Once the MCP is performing at standard levels
and violations/deficiencies are resolved to the satisfaction of ODJFS, the
money
will be refunded.
Appendix
L
Page
8
▇.▇.▇▇. Informational
Encounter Data Completeness Measures
The
encounter data quality measures listed below (section 1 .▇.▇▇. (1) -(2))
are
informational only for the ABD population. Although there are no minimum
performance standards for these measures, results will be reported and used
as
one component in monitoring the quality of data submitted to ODJFS by the
MCPs.
(1)
Incomplete Data For Last Menstrual Period
(2)
Incomplete Birth Weight Data
l.b.
Encounter Data Accuracy
As
with
data completeness, MCPs are responsible for assuring the collection and
submission of accurate data to ODJFS. Failure to do so jeopardizes MCPs'
performance, credibility and, if not corrected, will be assumed to indicate
a
failure in actual performance.
l.b.i.
Encounter Data Accuracy Study
Measure:
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 (i.e., to include
all
counties serviced by the MCP).
Payment
information found in MCPs' claims systems for paid claims that does not match
payment information found on a corresponding encounter will be counted as
omissions.
Report
Period:
In order
to provide timely feedback on the omission rate of encounters, the report
period
will be the most recent from when the measure is initiated. This measure
is
conducted annually.
Data
Quality Standard/or Measure:TBD
for SFY
2008.
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.
▇.▇.▇▇.
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
Appendix
L
Page
9
submitted
to ODJFS with the generic provider number 9111115. The measure will be
calculated per
MCP
(i.e., to include all counties serviced by the MCP).
All
other
encounters are required to have the MMIS provider number of the servicing
provider. The report period for this measure is quarterly.
Report
Period:
For the
SPY 2007 contract period, performance will be evaluated using the following
report periods: January - March 2007; April - June 2007. For the SFY 2008
contract period, performance will be evaluated using the following report
periods: January - March 2007;
April
-
June 2007; July-September 2007; October - December 2007; January - March
2008;
April -June 2008.
Data
Quality Standard:
A
maximum generic provider usage rate of 10%.
Determination
of Compliance:
Performance is monitored once every quarter. If the standard is not met in
all
report periods, then the MCP will be determined to be noncompliant
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
l.c.i.
Timeliness
ODJFS
recommends submitting encounters no later than thirty-five days after the
end of
the month in which they were paid. ODJFS does not monitor standards specifically
for timeliness, but the minimum claims volume (Section l.a.i.) and the rejected
encounter (Section l.a.v.) standards are based on encounters being submitted
within this time frame.
▇.▇.▇▇.
Submission ofEncounter Data
Files in the ODJFS-specified medium per format
MCP
submissions of encounter data files in the ODJFS-specified medium per format
to
ODJFS are limited to two per format per month. Should an MCP wish to send
additional files in the ODJFS-specified medium per format, permission to
do so
must be obtained by contacting BMHC. 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.
Appendix
L
Page
10
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 case management requirements. For detailed descriptions of the case
management measures below, see ODJFS
Methods for theABD andCFC Medicaid Managed Care Programs Data Quality
Measures.
2.a.
Case Management System Data Accuracy
2.a.i.
Open Case Management Spans for Disenrolled Members
Measure:
The
percentage of the MCP's case management records in CAMS for the ABD program
that
have open case management date spans for members who have disenrolled from
the
MCP.
Report
Period:
January
- March 2007, and April - June 2007 report periods. For the SFY 2008 contract
period, July — September 2007, October — December 2007, January - March 2008,
and April - June 2008 report periods.
Data
Quality Standard:
A rate
of open case management spans for disenrolled members of no more than
1.0%.
Statewide
Approach:
MCPs
will be evaluated using a statewide result specific for the ABD program,
including all regions in which an MCP has ABD membership. An MCP will not
be
evaluated until the MCP has at least 3,000 ABD members statewide who have
had at
least three months of continuous enrollment during each month of the entire
report period. As the ABD Medicaid managed care program expands statewide
and
regions become active in different months, statewide results will include
every
region in which an MCP has membership [Example: MCP AAA has: 6,000 members
in
the South West region beginning in January 2007; 7,000 members in the West
Central region beginning in February 2007; and 8,000 members in the South
East
region beginning in March 2007. MCP AAA's statewide results for the April-June
2007 report period will include data for the ▇▇▇▇▇ ▇▇▇▇, ▇▇▇▇ ▇▇▇▇▇▇▇, ▇▇▇
▇▇▇▇▇
▇▇▇▇ regions.]
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.
Appendix
L
Page
11
Once
the
MCP is performing at standard levels and violations/deficiencies are resolved
to
the
satisfaction
ofODJFS, the money will be refunded.
2.b.
Timely Submission of Case Management Files
Data
Quality Submission Requirement:
The MCP
must submit Case Management files on a monthly basis according to the
specifications established in ODJFS'
Case Management File and Submission Specifications.
Penalty/or
noncompliance:
See
Appendix N, Compliance
Assessment System,
for the
penalty for noncompliance with this requirement.
3.
EXTERNAL QUALITY REVIEW DATA
In
accordance with federal law and regulations, ODJFS is required to conduct
an
independent quality review of contracting managed care plans. 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 the clinical
studies, quality must be sufficient to ensure valid sampling.
An
adequate number of medical records must then be retrieved from providers
and
submitted to ODJFS or its designee in order to generalize results to all
applicable members. To aid MCPs in achieving the required medical record
submittal rate, ODJFS will give at least an eight week period to retrieve
and
submit medical records.
If
an MCP
does not complete a study because either their encounter data is of insufficient
quality or too few medical records are submitted, accurate evaluation of
clinical quality in the study area cannot be determined for the individual
MCP
and the assurance of adequate clinical quality for the program as a whole
is
jeopardized.
3.a.
Independent External Quality Review
Measure:
The
independent external quality review covers both administrative and clinical
focus areas of study.
Report
Period:
The
report period is one year. Results are calculated and performance is monitored
annually. Performance is measured with each review.
Data
Quality Standard 1:
Sufficient encounter data quality in each study area to draw a sample as
determined by the external quality review organization
Appendix
L
Page
12
Penalty
for noncompliance with Data Quality Standard 1:
For each
study that is completed during this contract period, if an MCP is noncompliant
with the standard, ODJFS will impose a non-refundable $10,000 monetary
sanction.
Data
Quality Standard 2:
A
minimum record submittal rate of 85% for each clinical measure.
Penalty
for noncompliance for Data Quality Standard 2:
For each
study that is completed during this contract period, if an MCP is noncompliant
with the standard, ODJFS will impose a non-refundable $10,000 monetary
sanction.
4.
MEMBERS' PCP DATA
The
designated PCP is the physician who will manage and coordinate the overall
care
for ABD members including those who have case management needs. The MCP must
submit a Members' Designated PCP file every month. Specialists may and should
be
identified as the PCP as appropriate for the member's condition; however,
no ABD
member may have more than one PCP identified.
4.a.
Timely submission of Member's PCP Data
Data
Quality Submission Requirement:
The MCP
must submit a Members' Designated PCP Data files on a monthly basis according
to
the specifications established in ODJFS
Member's PCP Data File and Submission Specifications.
Penalty
for noncompliance:
See
Appendix N, Compliance Assessment System, for the penalty for noncompliance
with
this requirement.
4.b.
Designated PCP for newly enrolled members
Measure:
The
percentage ofMCP's newly enrolled members who were designated a PCP by their
effective date of enrollment.
Report
Periods:
For the
SFY 2007 contract period, performance will be evaluated quarterly using the
January - March 2007 and April - June 2007 report periods. For the SFY 2008
contract period, performance will be evaluated quarterly using the
July-September 2007, October - December 2007, January - March 2008 and April
-
June 2008 report periods.
Data
Quality Standard:
A
minimum rate of 65% of new members with PCP designation by their effective
date
of enrollment for quarter 3 and quarter 4 of SFY 2007. A minimum rate of
75% of
new members with PCP designation by their effective date of enrollment for
quarter 1 and quarter 2 of SFY 2008. A minimum rate of 85% of new members
with
PCP designation by their effective date of enrollment for quarter 3 and quarter
4 of SFY 2008.
Statewide
Approach:
MCPs
will be evaluated using a statewide result, including all regions in which
an
MCP has ABD membership. An MCP will not be evaluated until the MCP has at
least
Appendix
L
Page
13
3,000
ABD
members statewide who have had at least three months of continuous
enrollment
during
each month of the entire report period.
Penalty
for noncompliance:
If an
MCP is noncompliant with the standard, ODJFS will impose a monetary sanction
of
one-half of one percent the current month's premium payment. Once the MCP
is
performing at standard levels and violations/deficiencies are resolved to
the
satisfaction of ODJFS, the money will be refunded. As stipulated in OAC rule
5101:3-26-08.2, each new member must have a designated primary care physician
(PCP) prior to their effective date of coverage. Therefore, MCPs are subject
to
additional corrective action measures under Appendix N, Compliance Assessment
System, for failure to meet this requirement.
5.
APPEALS AND GRIEVANCES DATA
Pursuant
to OAC rule 5101:3-26-08.4, MCPs are required to submit information at least
monthly to ODJFS regarding appeal and grievance activity. ODJFS requires
these
submissions to be in an electronic data file format pursuant to the Appeal
File and Submission Specifications
and
Grievance
File and Submission Specifications.
The
appeal data file and the grievance data file must include all appeal and
grievance activity, respectively, for the previous month, and must be submitted
by the ODJFS-specified due date, These data files must be submitted in the
ODJFS-specified format and with the ODJFS-specified filename in order to
be
successfully processed.
Penalty/or
noncompliance:
MCPs who
fail to submit their monthly electronic data files to the ODJFS by the specified
due date or who fail to resubmit, by no later than the end of that month,
a file
which meets the data quality requirements will be subject to penalty as
stipulated under the Compliance Assessment System (Appendix N).
6.
NOTES
6.a.
Penalties, Including Monetary Sanctions, for Noncompliance
Penalties
for noncompliance with standards outlined in this appendix, including monetary
sanctions, will be imposed as the results are finalized. With the exception
of
Sections 1 .a.i., 1 .a.v., and 1 .a.v.i., no monetary sanctions described
in
this appendix will be imposed if the MCP is in its first contract year
ofMedicaid 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.
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.
Appendix
L
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14
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 ofnoncompliance,
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
for
the Ohio Medicaid program.
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 ABD ELIGIBLE POPULATION
This
appendix establishes minimum performance standards for managed care plans
(MCPs)
in key program areas, under the Agreement. Standards are subject to change
based
on the revision or update of applicable national standards, methods, benchmarks,
or other factors as deemed relevant. 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. All performance measures, as
specified in this appendix, will be calculated per MCP and include only members
in the ABD Medicaid managed care program
Selected
measures in this appendix will be used to determine incentives as specified
in
Appendix
0, Pay for Performance (P4P).
1.
QUALITY OF CARE
l.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 both an administrative review
and
focused quality of care studies as outlined in Appendix K.
Report
Period: Performance will be evaluated using the reviews conducted during
SFY
2008.
Action
Required for Deficiencies: For all reviews conducted during the contract
period,
if the EQRO cites a deficiency in the administrative review or quality of
care
studies, the MCP will be required to complete a Corrective Action Plan, Quality
Improvement Directive, or Performance Improvement Project as outlined in
Appendix K of the Agreement. Serious deficiencies may result in immediate
termination or non-renewal of the Agreement.
l.b.
Members with Special Health Care Needs (MSHCN)
Given
the
substantial proportion of members with chronic conditions and co-morbidities
in
the ABD population, one of the quality of care initiatives of the ABD Medicaid
managed care program focuses on case management. In order to ensure state
compliance with the provisions of 42 CFR 438.208, the Bureau of Managed Health
Care established Members with Special Health Care Needs (MSHCN) basic program
requirements as set forth in Appendix G, Coverage
and Services
of the
Agreement, and corresponding minimum performance standards as described below.
The purpose of
Appendix
M
Page
2
these
measures is to provide appropriate and targeted case management services
to
MSHCN who have specific diagnoses and/or who require high-cost or extensive
services. Given the expedited schedule for implementing the ABD Medicaid
managed
care program, coupled with the challenges facing a new Medicaid program in
the
State of Ohio, the minimum performance standards for the case management
requirements for MSHCN are phased in throughout SFY 2007 and SFY 2008. The
minimum standards for these performance measures will be fully phased in
by no
later than SPY 2009. For detailed methodologies of each measure, see
ODJFS
Methods/or the ABD Medicaid Managed Care Program's Case Management Performance
Measures.
▇.▇.▇▇.
Case Management of Members
Measure:
The
average monthly case management rate for members who have at least three
months
of consecutive enrollment in one MCP.
Report
Period:
For the
SFY 2007 contract period, April - June 2007 report period. For the SFY 2008
contract period, July - September 2007, October - December 2007, January
- March
2008, and April - June 2008 report periods.
Statewide
Approach:
MCPs
will be evaluated using a statewide result, including all regions in which
an
MCP has membership. An MCP will not be evaluated until the MCP has at least
3,000 members statewide who have had at least three months of continuous
enrollment during each month of the entire report period. As the ABD Medicaid
managed care program expands statewide and regions become active in different
months, statewide results will include every region in which an MCP has
membership [Example: MCP AAA has: 6,000 members in the South West region
beginning in January 2007; 7,000 members in the West Central region beginning
in
February 2007;
and
8,000
members in the South East region beginning in March 2007. MCP AAA's statewide
results for the April-June 2007 report period will include case management
rates
for all members who meet minimum continuous enrollment criteria for this
measure
in: the South West region for April 2007's monthly rate calculation; the
South
West and West Central regions for May 2007's monthly rate calculation; and
the
▇▇▇▇▇ ▇▇▇▇, ▇▇▇▇ ▇▇▇▇▇▇▇, ▇▇▇ ▇▇▇▇▇ ▇▇▇▇ regions for June 2007's monthly
rate
calculation.]
Minimum
Performance Standard:
For the
fourth quarters of SFY 2007, a case management rate of 30%. For the first
and
second quarters of SFY 2008, a case management rate of 35%. For the third
and
fourth quarters of SFY 2008, a case management rate of 40%. ODJFS expects
the
minimum standard for this measure to increase to 50% by the fourth quarter
of
SFY 2009.
Penalty
for Noncompliance:
The
first time an MCP is noncompliant with the standard for this measure, ODJFS
will
issue a Sanction Advisory informing the MCP that any future noncompliance
instances with the standard for this measure will result in new member selection
freezes or a reduction of assignments will occur as outlined in Appendix
N of
the Provider Agreement. Once the MCP is performing at standard levels and
the
violations/deficiencies are resolved to the satisfaction of ODJFS, the new
member selection freeze/reduction of assignments will be lifted.
▇.▇.▇▇.
Case Management of Members with an ODJFS-Mandated
Condition
Appendix
M
Page
3
Measure
1:
The
percent of members with a positive identification through an ODJFS
administrative review of data for the ODJFS-mandated case management condition
of asthma
who have
had at least three consecutive months of enrollment in one MCP that are case
managed.
Measure
2:
The
percent of members with a positive identification through an ODJFS
administrative review of data for the ODJFS-mandated case management condition
of chronic
obstructive pulmonary disease
who have
had at least three consecutive months of enrollment in one MCP that are case
managed.
Measure
3:
The
percent of members with a positive identification through an ODJFS
administrative review of data for the ODJFS-mandated case management condition
of congestive
heart failure who
have
had at least three consecutive months of enrollment in one MCP that are case
managed.
Measure
4:
The
percent of members with a positive identification through an ODJFS
administrative review of data for the ODJFS-mandated case management condition
of severe
mental illness
who have
had at least three consecutive months of enrollment in one MCP that are case
managed.
Measure
5:
The
percent of members with a positive identification through an ODJFS
administrative review of data for the ODJFS-mandated case management condition
of high
risk or high cost substance abuse disorders
who have
had at least three consecutive months of enrollment in one MCP that are case
managed.
Measure
6:
The
percent of members with a positive identification through an ODJFS
administrative review of data for the ODJFS-mandated case management condition
of severe
cognitive and/or developmental limitation
who have
had at least three consecutive months of enrollment in one MCP that are case
managed.
Measure
7:
The
percent of members with a positive identification through an ODJFS
administrative review of data for the ODJFS-mandated case management condition
of diabetes
who have
had at least three consecutive months of enrollment in one MCP that are case
managed.
Measure
8:
The
percent of members with a positive identification through an ODJFS
administrative review of data for the ODJFS-mandated case management condition
of non-mild
hypertension
who have
had at least three consecutive months of enrollment in one MCP that are case
managed.
Measure
9:
The
percent of members with a positive identification through an ODJFS
administrative review of data for the ODJFS-mandated case management condition
of coronary
arterial disease who
have
had at least three consecutive months of enrollment in one MCP that are case
managed.
Report
Periods/or Measures 1- 9: For the SFY 2007 contract period April - June 2007
report periods. For the SFY 2008 contract period, July - September 2007,
October
- December 2007, January - March 2008, and April - June 2008 report
periods.
Appendix
M
Page
4
Statewide
Approach:
MCPs
will be evaluated using a statewide result, including all regions in which
an
MCP has membership. An MCP will not be evaluated until the MCP has at least
3,000 members statewide who have had at least three months of continuous
enrollment during each month of the entire report period. As the ABD Medicaid
managed care programs expands statewide and regions become active in different
months, statewide results will include every region in which an MCP has
membership [Example: MCP AAA has: 6,000 members in the South West region
beginning in January 2007; 7,000 members in the West Central region beginning
in
February 2007;
and
8,000
members in the South East region beginning in March 2007. MCP AAA's statewide
results for the April-June 2007 report period will include case management
rates
for all members in the ▇▇▇▇▇ ▇▇▇▇, ▇▇▇▇ ▇▇▇▇▇▇▇, ▇▇▇ ▇▇▇▇▇ ▇▇▇▇ regions who
are
identified through the administrative data review as having a mandated condition
and are continuously enrolled for at least three consecutive months in one
MCP.]
Minimum
Performance Standard/or Measures 1-9:
For the
fourth quarter of SFY 2007, a case management rate of 60%. For the first
and
second quarters of SFY 2008, a case management rate of 65%. For the third
and
fourth quarters of SFY 2008, a case management rate of 70%. ODJFS expects
the
minimum standard for this measure to increase to 80% by the fourth quarter
of
SFY 2009.
Penalty
for Noncompliance for Measures 1-9:
The
first time an MCP is noncompliant with the standard for this measure, ODJFS
will
issue a Sanction Advisory informing the MCP that any future noncompliance
instances with the standard for this measure will result in new member selection
freezes or a reduction of assignments will occur as outlined in Appendix
N of
the Provider Agreement. Once the MCP is performing at standard levels and
the
violations/deficiencies are resolved to the satisfaction of ODJFS the new
member
selection freeze/reduction of assignments will be lifted.
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 (NCQA) Health Plan Employer Data and
Information Set (HEDIS). 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 are used to calculate
calendar year 2008 results (the baseline period) and calendar year 2009 results.
The methods will be updated and a new baseline will be created during 2009
for
calendar year 2010 results. These results will then serve as the baseline
to
evaluate whether improvement occurred from calendar year 2009 to calendar
year
2010. 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
Appendix
M
Page
5
comprehensive
description of the clinical performance measures below, see ODJFS
Methods for Clinical Performance Measures, ABD Medicaid Managed Care
Program.
Performance standards are subject to change, based on the revision or update
ofNCQA methods or other national standards, methods or benchmarks.
MCPs
will
be evaluated using a statewide result, including all regions in which an
MCP has
membership. ODJFS will use the first calendar year of an MCP's ABD managed
care
program membership as the baseline year (i.e., CY2007). The baseline year
will
be used to determine performance standards and targets; baseline data will
come
from a combination ofFFS claims data and MCP encounter data. For those
performance measures that require two calendar years of baseline data, the
additional calendar year (i.e., the calendar year prior to the first calendar
year of ABD managed care program membership, i.e., CY2006) data will come
from
FFS claims data.
An
MCP's
second calendar year of ABD managed care program membership (i.e., CY2008)
will
be the initial report period of evaluation for performance measures that
require
one calendar year of baseline data (i.e., CY2007), and for performance measures
that require two calendar years of baseline data (i.e., CY2006 and
CY2007).
Report
Period:
For the
SFY 2008 contract period, performance will be evaluated using the January
-December 2007 report period and may be adjusted based on the number of months
of ABD managed care membership. For the SFY 2009 contract period, performance
will be evaluated using the January - December 2008 report period.
l.c.i.
Congestive Heart Failure (CHF) - Inpatient Hospital Discharge
Rate
Measure:
The
number of acute inpatient hospital discharges in the reporting year where
the
principal diagnosis was CHF, per thousand member months, for members who
had a
diagnosis of CHF in the year prior to the reporting year.
Target:
TBD
Minimum
Performance Standard:
The
level of improvement must result in at least a TBD% decrease in the difference
between the target and the previous report period's results. (For example,
if
last year's results were TBD%, then the difference between the target and
last
year's results is TBD%. In this example, the standard is an improvement in
performance of TBD% of this difference or TBD%. In this example, results
of TBD%
or better would be compliant with the standard.)
Action
Required for Noncompliance:
If the
standard is not met and the results are below TBD%, then the MCP is required
to
complete a Performance Improvement Project, as described in Appendix K,
Quality
Assessment and Performance Improvement Program,
to
address the area of noncompliance. If the standard is not met and the results
are at or above TBD%, then ODJFS will issue a Quality Improvement Directive
which will notify the MCP of noncompliance and may outline the steps that
the
MCP must take to improve the results.
▇.▇.▇▇.
Congestive Heart Failure (CHF) - Emergency Department (ED) Utilization
Rate
Appendix
M
Page
6
Measure:
The
number of emergency department visits in the reporting year where the primary
diagnosis was CHF, per thousand member months, for members who had a diagnosis
ofCHF in the year prior to the reporting year.
Target:
TBD
Minimum
Performance Standard:
The
level of improvement must result in at least a TBD% decrease in the difference
between the target and the previous report period's results.
Action
Required for Noncompliance:
If the
standard is not met and the results are below TBD%, then the MCP is required
to
complete a Performance Improvement Project, as described in Appendix K,
Quality
Assessment and Performance Improvement Program,
to
address the area of noncompliance. If the standard is not met and the results
are at or above TBD%, then ODJFS will issue a Quality Improvement Directive
which will notify the MCP of noncompliance and may outline the steps that
the
MCP must take to improve the results.
l.c.iii.
Congestive Heart Failure (CHF) - ACE Inhibitor/Angiotensin Receptor
Blocker
Measure:
The
percentage of members who had a diagnosis of CHF in the year prior to the
reporting year, who were enrolled for six or more months in the reporting
year,
who received one or more prescriptions for an ACE Inhibitor or Angiotensin
Receptor Blocker during the reporting year.
Target:
TBD.
Minimum
Performance Standard:
The
level of improvement must result in at least a TBD% decrease in the difference
between the target and the previous year's results.
Action
Required for Noncompliance:
If the
standard is not met and the results are below TBD%, then the MCP is required
to
complete a Performance Improvement Project, as described in Appendix K,
Quality
Assessment and Performance Improvement Program,
to
address the area of noncompliance. If the standard is not met and the results
are at or above TBD%, then ODJFS will issue a Quality Improvement Directive
which will notify the MCP of noncompliance and may outline the steps that
the
MCP must take to improve the results.
▇.▇.▇▇.
Congestive Heart Failure (CHF) - Cardiac Related Hospital
Readmission
Measure:
The rate
of cardiac related readmissions during the reporting period for members who
had
a diagnosis of CHF in the year prior to the reporting period. A readmission
is
defined as a cardiac related admission that occurs within 30 days of a prior
cardiac related admission. Target:
TBD.
Minimum
Performance Standard:
The
level of improvement must result in at least a TBD% decrease in the difference
between the target and the previous year's results.
Action
Required for Noncompliance:
If the
standard is not met and the results are below TBD%, then the MCP is required
to
complete a Performance Improvement Project, as described in
Appendix
M
Page
7
Appendix
K., Quality
Assessment and Performance Improvement Program,
to
address the area of noncompliance. If the standard is not met and the results
are at or above TBD%, then ODJFS will issue a Quality Improvement Directive
which w'ill notify the MCP of noncompliance and may outline the steps that
the
MCP must take to improve the results.
l.c.v. Coronary
Artery Disease (CAD) - Inpatient Hospital Discharge Rate
Measure:
The
number of acute inpatient hospital discharges in the reporting year where
the
primary diagnosis was CAD, per thousand member months, for members who had
diagnosis of CAD in the year prior to the reporting year.
Target:
TBD
Minimum
Performance Standard:
The
level of improvement must result in at least a TBD% decrease in the difference
between the target and the previous report period's results.
Action
Required for Noncompliance:
If the
standard is not met and the results are below TBD%, then the MCP is required
to
complete a Performance Improvement Project, as described in Appendix K,
Quality
Assessment and Performance Improvement Program,
to
address the area of noncompliance. If the standard is not met and the results
are at or above TBD%, then ODJFS will issue a Quality Improvement Directive
which will notify the MCP of noncompliance and may outline the steps that
the
MCP must take to improve the results.
▇.▇.▇▇.
Coronary Artery Disease (CAD) - Emergency Department (ED) Utilization
Rate
Measure:
The
number of emergency department visits in the reporting year where the principal
diagnosis was CAD, per thousand member months, for members who had a diagnosis
of CAD in the year prior to the reporting year.
Target:
TBD
Minimum
Performance Standard:
The
level of improvement must result in at least a TBD% decrease in the difference
between the target and the previous report period's results.
Action
Required for Noncompliance:
If the
standard is not met and the results are below TBD%, then the MCP is required
to
complete a Performance Improvement Project, as described in Appendix K,
Quality
Assessment and Performance Improvement Program,
to
address the area of noncompliance. If the standard is not met and the results
are at or above TBD%, then ODJFS will issue a Quality Improvement Directive
which will notify the MCP of noncompliance and may outline the steps that
the
MCP must take to improve the results.
l.c.vii.
Coronary Artery Disease (CAD) - Cardiac Related Hospital
Readmission
Measure:
The rate
of cardiac related readmissions in the reporting year for members who had
a
diagnosis of CAD in the year prior to the reporting year. A readmission is
defined as a cardiac related admission that occurs within 30 days of a prior
cardiac related admission.
Appendix
M
Page
8
Target:
TBD.
Minimum
Performance Standard:
The
level of improvement must result in at least a TBD% decrease in the difference
between the target and the previous year's results.
Action
Required for Noncompliance:
If the
standard is not met and the results are below TBD%, then the MCP is required
to
complete a Performance Improvement Project, as described in Appendix K,
Quality
Assessment and Performance Improvement Program,
to
address the area of noncompliance. If the standard is not met and the results
are at or above TBD%, then ODJFS will issue a Quality Improvement Directive
which will notify the MCP of noncompliance and may outline the steps that
the
MCP must take to improve the results.
l.c.viii.
Beta Blocker Treatment after Heart Attack
Measure:
The
percentage of members 35 years and older as of December 31st
of the
reporting year who were hospitalized from January 1 - December 241
of the
reporting year with a diagnosis of acute myocardial infarction (AMI) and
who
received an ambulatory prescription for beta blockers within seven days of
discharge. Target:
TBD.
Minimum
Performance Standard:
The
level of improvement must result in at least a TBD% decrease in the difference
between the target and the previous year's results.
Action
Required for Noncompliance:
If the
standard is not met and the results are below TBD%, then the MCP is required
to
complete a Performance Improvement Project, as described in Appendix K,
Quality
Assessment and Performance Improvement Program,
to
address the area of noncompliance. If the standard is not met and the results
are at or above TBD%, then ODJFS will issue a Quality Improvement Directive
which will notify the MCP of noncompliance and may outline the steps that
the
MCP must take to improve the results.
l.c.ix.
Coronary Artery Disease (CAD) - Cholesterol Management for Patients with
Cardiovascular Conditions/LDL-C Screening Performed
Measure:
The
percentage of members who had a diagnosis of CAD in the year prior to the
reporting year, who were enrolled for at least 11 months in the reporting
year,
and who received a lipid profile during the reporting year.
Target:
TBD.
Minimum
Performance Standard:
The
level of improvement must result in at least a TBD% decrease in the difference
between the target and the previous year's results.
Action
Required for Noncompliance:
If the
standard is not met and the results are below TBD%, then the MCP is required
to
complete a Performance Improvement Project, as described in Appendix K,
Quality
Assessment and Performance Improvement Program,
to
address the area of
Appendix
M
Page
9
noncompliance.
If the standard is not met and the results are at or above TBD%, then ODJFS
will
issue a Quality Improvement Directive which will notify the MCP of noncompliance
and may outline the steps that the MCP must take to improve the
results.
l.c.x. Hypertension
- Inpatient Hospital Discharge Rate
Measure:
The
number of acute inpatient hospital discharges in the reporting year where
the
primary diagnosis was non-mild hypertension, per thousand member months,
for
members who had a diagnosis of non-mild hypertension in the year prior to
the
reporting year.
Target:
TBD
Minimum
Performance Standard:
The
level of improvement must result in at least a TBD% decrease in the difference
between the target and the previous report period's results.
Action
Required/or Noncompliance:
If the
standard is not met and the results are below TBD%, then the MCP is required
to
complete a Performance Improvement Project, as described in Appendix K,
Quality
Assessment and Performance Improvement Program,
to
address the area of noncompliance. If the standard is not met and the results
are at or above TBD%, then ODJFS will issue a Quality Improvement Directive
which will notify the MCP of noncompliance and may outline the steps that
the
MCP must take to improve the results.
l.c.xi.
Hypertension - Emergency Department (ED) Utilization Rate
Measure:
The
number of emergency department visits in the reporting year where the principal
diagnosis was non-mild hypertension, per thousand member months, for members
who
had a diagnosis of non-mild hypertension in the year prior to the reporting
year.
Target:
TBD
Minimum
Performance Standard:
The
level of improvement must result in at least a TBD% decrease in the difference
between the target and the previous report period's results.
Action
Required for Noncompliance:
If the
standard is not met and the results are below TBD%, then the MCP is required
to
complete a Performance Improvement Project, as described in Appendix K,
Quality
Assessment and Performance Improvement Program,
to
address the area of noncompliance. If the standard is not met and the results
are at or above TBD%, then ODJFS will issue a Quality Improvement Directive
which will notify the MCP of noncompliance and may outline the steps that
the
MCP must take to improve the results.
l.c.xii.
Diabetes - Inpatient Hospital Discharge Rate
Measure:
The
number of acute inpatient hospital discharges in the reporting year where
the
principal diagnosis was diabetes, per thousand member months, for members
identified as diabetic in the year prior to the reporting year.
Target:
TBD
Appendix
M
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10
Minimum
Performance Standard:
The
level of improvement must result in at least a TBD% decrease in the difference
between the target and the previous report period's results.
Action
Required/or Noncompliance:
If the
standard is not met and the results are below TBD%, then the MCP is required
to
complete a Performance Improvement Project, as described in Appendix K,
Quality
Assessment and Performance Improvement Program,
to
address the area of noncompliance. If the standard is not met and the results
are at or above TBD%, then ODJFS will issue a Quality Improvement Directive
which will notify the MCP of noncompliance and may outline the steps that
the
MCP must take to improve the results.
l.c.xiii.
Diabetes - Emergency Department (ED) Utilization Rate
Measure:
The
number of emergency department visits in the reporting year where the primary
diagnosis was diabetes, per thousand member months, for members identified
as
diabetic in the year prior to the reporting year.
Target:
TBD
Minimum
Performance Standard:
The
level of improvement must result in at least a TBD% decrease in the difference
between the target and the previous report period's results.
Action
Required for Noncompliance:
If the
standard is not met and the results are below TBD%, then the MCP is required
to
complete a Performance Improvement Project, as described in Appendix K,
Quality/Assessment
and Performance Improvement Program,
to
address the area of noncompliance. If the standard is not met and the results
are at or above TBD%, then ODJFS will issue a Quality Improvement Directive
which will notify the MCP of noncompliance and may outline the steps that
the
MCP must take to improve the results.
l.c.xiv. Diabetes
- Eye Exam
Measure:
The
percentage of diabetic members who were enrolled for at least 11 months during
the reporting year, who received one or more retinal or dilated eye exams
from
an ophthalmologist or optometrist during the reporting year.
Target:
TBD.
Minimum
Performance Standard:
The
level of improvement must result in at least a TBD% increase in the difference
between the target and the previous year's results.
Action
Required for Noncompliance:
If the
standard is not met and the results are below TBD%, then the MCP is required
to
complete a Performance Improvement Project, as described in Appendix K,
Quality
Assessment and Performance Improvement Program,
to
address the area of noncompliance. If the standard is not met and the results
are at or above TBD%, then ODJFS will issue a Quality Improvement Directive
which will notify the MCP of noncompliance and may outline the steps that
the
MCP must take to improve the results.
Appendix
M
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11
l.c.xv. Chronic
Obstructive Pulmonary Disease (COPD) - Inpatient Hospital Discharge
Rate
Measure:
The
number of acute inpatient hospital discharges in the reporting year where
the
primary diagnosis was COPD, per thousand member months, for members who had
a
diagnosis of COPD in the year prior to the reporting year.
Target:
TBD
Minimum
Performance Standard:
The
level of improvement must result in at least a TBD% decrease in the difference
between the target and the previous report period's results.
Action
Required/or Noncompliance:
If the
standard is not met and the results are below TBD%, then the MCP is required
to
complete a Performance Improvement Project, as described in Appendix K,
Quality
Assessment and Performance Improvement Program,
to
address the area of noncompliance. If the standard is not met and the results
are at or above TBD%, then ODJFS will issue a Quality Improvement Directive
which will notify the MCP of noncompliance and may outline the steps that
the
MCP must take to improve the results.
▇.▇.▇▇▇.
Chronic Obstructive Pulmonary Disease (COPD) - Emergency Department (ED)
Utilization Rate
Measure:
The
number of emergency department visits in the reporting year where the principal
diagnosis was COPD, per thousand member months, for members who had a diagnosis
of COPD in the year prior to the reporting year.
Target:
TBD
Minimum
Performance Standard:
The
level of improvement must result in at least a TBD% decrease in the difference
between the target and the previous report period's results.
Action
Required for Noncompliance:
If the
standard is not met and the results are below TBD%, then the MCP is required
to
complete a Performance Improvement Project, as described in Appendix K,
Quality
Assessment and Performance Improvement Program,
to
address the area of noncompliance. If the standard is not met and the results
are at or above TBD%, then ODJFS will issue a Quality Improvement Directive
which will notify the MCP of noncompliance and may outline the steps that
the
MCP must take to improve the results.
l.c.xvii.
Asthma - Inpatient Hospital Discharge Rate
Measure:
The
number of acute inpatient hospital discharges in the reporting year where
the
primary diagnosis was asthma, per thousand member months, for members with
persistent asthma.
Target:
TBD
Appendix
M
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12
Minimum
Performance Standard:
The
level of improvement must result in at least a TBD% decrease in the difference
between the target and the previous report period's results.
Action
Required/or Noncompliance:
If the
standard is not met and the results are below TBD%,
then
the
MCP is required to complete a Performance Improvement Project, as described
in
Appendix
K, Quality
Assessment and Performance Improvement Program,
to
address the area of
noncompliance.
If
the
standard is not met and the results are at or above TBD%, then ODJFS will
issue
a Quality
Improvement
Directive which will notify the MCP of noncompliance and may outline the
steps
that
the
MCP
must take to improve the results.
l.c.xviii.
Asthma -
Emergency Department (ED) Utilization Rate
Measure:
The
number of emergency department visits in the reporting year where the principal
diagnosis was asthma, per thousand member months, for members with persistent
asthma.
Target:
TBD
Minimum
Performance Standard:
The
level of improvement must result in at least a TBD% decrease in the difference
between the target and the previous report period's results.
Action
Required for Noncompliance:
If the
standard is not met and the results are below TBD%, then the MCP is required
to
complete a Performance Improvement Project, as described in Appendix K-,
Quality
Assessment and Performance Improvement Program,
to
address the area of noncompliance. If the standard is not met and the results
are at or above TBD%, then ODJFS will issue a Quality Improvement Directive
which will notify the MCP of noncompliance and may outline the steps that
the
MCP must take to improve the results.
l.c.xix. Asthma
- Use of Appropriate Medications for People with Asthma
Measure:
The
percentage of members with persistent asthma who received prescribed medications
acceptable as primary therapy for long-term control of asthma.
Target:
TBD
Minimum
Performance Standard:
The
level of improvement must result in at least a TBD% decrease in the difference
between the target and the previous report period's results.
Action
Required for Noncompliance:
If the
standard is not met and the results are below TBD%, then the MCP is required
to
complete a Performance Improvement Project, as described in Appendix K,
Quality
Assessment and Performance Improvement Program,
to
address the area of noncompliance. If the standard is not met and the results
are at or above TBD%, then ODJFS will issue a Quality Improvement Directive
which will notify the MCP of noncompliance and may outline the steps that
the
MCP must take to improve the results.
l.c.xx.
Mental Health, Severely Mentally Disabled (SMD) - Inpatient Hospital Discharge
Rate
Appendix
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Page
13
Measure:
The
number of acute inpatient hospital discharges in the reporting year where
the
primary diagnosis was SMD, per thousand member months, for members who had
a
primary diagnosis of SMD in the year prior to the reporting year.
Target:
TBD
Minimum
Performance Standard:
The
level of improvement must result in at least a TBD% decrease in the difference
between the target and the previous report period's results.
Action
Required/or Noncompliance:
If the
standard is not met and the results are below TBD%, then the MCP is required
to
complete a Performance Improvement Project, as described in Appendix K,
Quality
Assessment and Performance Improvement Program,
to
address the area of noncompliance. If the standard is not met and the results
are at or above TBD%, then ODJFS will issue a Quality Improvement Directive
which will notify the MCP of noncompliance and may outline the steps that
the
MCP must take to improve the results.
l.c.xxi.
Mental Health, Severely Mentally Disabled (SMD) - Emergency Department
Utilization Rate
Measure:
The
number of emergency department visits in the reporting year where the primary
diagnosis was SMD, per thousand member months, for members who had a primary
diagnosis of SMD in the year prior to the reporting year.
Target:
TBD
Minimum
Performance Standard:
The
level of improvement must result in at least a TBD% decrease in the difference
between the target and the previous report period's results.
Action
Required for Noncompliance:
If the
standard is not met and the results are below TBD%, then the MCP is required
to
complete a Performance Improvement Project, as described in Appendix K,
Quality
Assessment and Performance Improvement Program,
to
address the area of noncompliance. If the standard is not met and the results
are at or above TBD%, then ODJFS will issue a Quality Improvement Directive
which will notify the MCP of noncompliance and may outline the steps that
the
MCP must take to improve the results.
l.c.xxii.
Follow-up After Hospitalization for Mental Illness
Measure:
The
percentage of discharges for members enrolled from the date of discharge
through
30 days after discharge, who were hospitalized for treatment of selected
mental
health disorders and who had a follow-up visit (i.e., were seen on an outpatient
basis or were in intermediate treatment with a mental health provider)
within:
1)
30
Days of discharge, and
2)
7 Days
of discharge.
Target:
TBD.
Appendix
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14
Minimum
Performance Standard For Each Measure:
The
level of improvement must result in at least a TBD% decrease in the difference
between the target and the previous year's results.
Action
Required/or Noncompliance (Follow-up visits within 30 days of
discharge):
If the
standard is not met and the results are below TBD%, then the MCP is required
to
complete a Performance Improvement Project, as described in Appendix K,
Quality
Assessment and Performance Improvement Program,
to
address the area of noncompliance. If the standard is not met and the results
are at or above TBD%, then ODJFS will issue a Quality Improvement Directive
which will notify the MCP of noncompliance and may outline the steps that
the
MCP must take to improve the results.
Action
Required for Noncompliance (Follow-up visits within 7 days of
discharge):
If the
standard is not met and the results are below TBD%, then the MCP is required
to
complete a Performance Improvement Project, as described in Appendix K-,
Quality
Assessment and Performance Improvement Program,
to
address the area of noncompliance. If the standard is not met and the results
are at or above TBD%, then ODJFS will issue a Quality Improvement Directive
which will notify the MCP of noncompliance and may outline the steps that
the
MCP must take to improve the results.
l.c.xxiii.
Mental Health, Severely Mentally Disabled (SMD) - SMD Related Hospital
Readmission
Measure:
The
number of SMD related readmissions for members for members who had a diagnosis
of SMD in the year prior to the reporting year. A readmission is defined
as a
SMD related admission that occurs within 30 days of a prior SMD related
admission.
Target:
TBD.
Minimum
Performance Standard:
The
level of improvement must result in at least a TBD% decrease in the difference
between the target and the previous year's results.
Action
Required for Noncompliance:
If the
standard is not met and the results are below TBD%, then the MCP is required
to
complete a Performance Improvement Project, as described in Appendix K,
Quality
Assessment and Performance Improvement Program,
to
address the area of noncompliance. If the standard is not met and the results
are at or above TBD%, then ODJFS will issue a Quality Improvement Directive
which will notify the MCP of noncompliance and may outline the steps that
the
MCP must take to improve the results.
l.c.xxiv.
Substance Abuse - Inpatient Hospital Discharge Rate
Measure:
The
number of acute inpatient hospital discharges in the reporting year where
the
primary diagnosis was alcohol and other drug abuse or dependence (AOD), per
thousand member months, for members who had, in the year prior to the reporting
year, a diagnosis of AOD and
one of
the following: AOD-related acute inpatient admission or two AOD related
Emergency Department visits.
Appendix
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15
Target:
TBD
Minimum
Performance Standard:
The
level of improvement must result in at least a TBD% decrease in the difference
between the target and the previous report period's results.
Action
Required for Noncompliance:
If the
standard is not met and the results are below TBD%, then the MCP is required
to
complete a Performance Improvement Project, as described in Appendix K.,
Quality
Assessment and Performance Improvement Program,
to
address the area of noncompliance. If the standard is not met and the results
are at or above TBD%, then ODJFS will issue a Quality Improvement Directive
which will notify the MCP of noncompliance and may outline the steps that
the
MCP must take to improve the results.
l.c.xxv. Substance
Abuse - Emergency Department Utilization Rate
Measure:
The
number of emergency department visits in the reporting year where the principal
diagnosis was AOD, per thousand member months, for members who had, in the
year
prior to the reporting year, a diagnosis of AOD and
one of
the following: AOD-related acute inpatient admission or two AOD related
Emergency Department visits .
Target:
TBD
Minimum
Performance Standard:
The
level of improvement must result in at least a TBD% decrease in the difference
between the target and the previous report period's results.
Action
Required for Noncompliance:
If the
standard is not met and the results are below TBD%, then the MCP is required
to
complete a Performance Improvement Project, as described in Appendix K,
Quality
Assessment and Performance Improvement Program,
to
address the area of noncompliance. If the standard is not met and the results
are at or above TBD%, then ODJFS will issue a Quality Improvement Directive
which will notify the MCP of noncompliance and may outline the steps that
the
MCP must take to improve the results.
l.c.xxvi. Substance
Abuse - Inpatient Hospital Readmission Rate
Measure:
The
number of AOD related readmissions in the reporting year for members who
had, in
the year prior to the reporting year, a diagnosis of AOD and
one of
the following: AOD-related acute inpatient admission or two AOD related
Emergency Department visits. A readmission is defined as an AOD-related
admission that occurs within 30 days of a prior AOD-related
admission.
Target:
TBD.
Minimum
Performance Standard:
The
level of improvement must result in at least a TBD% decrease in the difference
between the target and the previous year's results.
Action
Required for Noncompliance:
If the
standard is not met and the results are below TBD%, then the MCP is required
to
complete a Performance Improvement Project, as described in
Appendix
M
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16
Appendix
K, Quality
Assessment and Performance Improvement Program,
to
address the area of noncompliance. If the standard is not met and the results
are at or above TBD%, then ODJFS will issue a Quality Improvement Directive
which will notify the MCP of noncompliance and may outline the steps that
the
MCP must take to improve the results.
l.c.xxvii.
Informational Clinical Performance Measures
The
clinical performance measures listed in Table 1 are informational only. Although
there are no performance targets or minimum performance standards for these
measures, results will be reported and used as one component in assessing
the
quality of care provided by MCPs to the ABD managed care
population.
Table
1. Informational Clinical Performance Measures
|
Condition
|
Informational
Performance Measure
|
|
CHF
|
Discharge
rate with age group breakouts
|
|
CAD
|
Discharge
rate with age group breakouts
|
|
Hypertension
|
Discharge
rate with age group breakouts
|
|
Diabetes
|
Discharge
rate with age group breakouts
|
|
Comprehensive
Diabetes Care (CDC)/HbAlc testing
|
|
|
CDC/kidney
disease monitored
|
|
|
CDC/LDL-C
screening performed
|
|
|
COPD
|
Discharge
rate with age group breakouts
|
|
Use
of Spirometry Testing in the Assessment and Diagnosis of
COPD
|
|
|
Asthma
|
Discharge
rate with age group breakouts
|
|
Mental
Health (SMD)
|
Discharge
rate with age group breakouts
|
|
Antidepressant
Medication Management
|
|
|
Substance
Abuse
|
Discharge
rate with age group breakouts
|
|
Initiation
and Engagement of Alcohol and Other Drug Dependence
Treatment
|
2.
ACCESS
Performance
in the Access category will be determined by the following measures: Primary
Care Physician (PCP) Turnover, Adults' Access to Preventive/Ambulatory Health
Services, and Adults' Access to Designated PCP. For a comprehensive description
of the access performance measures below, see ODJFS
Methods/or the ABD Medicaid Managed Care Program Access Performance
Measures.
2.a.
PCP Turnover
A
high
PCP turnover rate may affect continuity of care and may signal poor management
of providers. However, some turnover may be expected when MCPs end contracts
with physicians who are not adhering to the MCP's standard of care. Therefore,
this measure is used in conjunction with the adult access and designated
PCP
measures to assess performance in the access category.
Appendix
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17
Measure:
The
percentage of primary care physicians affiliated with the MCP as of the
beginning of the measurement year who were not affiliated with the MCP as
of the
end of the year.
Statewide
Approach:
MCPs
will be evaluated using a statewide result, including all regions in which
an
MCP has membership. ODJFS will use the first calendar year ofABD managed
care
program membership as the baseline year (i.e., CY2007). The baseline year
will
be used to determine a minimum statewide performance standard. An MCP's second
calendar year ofABD managed care program membership (i.e., CY2008) will be
the
initial report period of evaluation, and penalties will be applied for
noncompliance.
Report
Period:
For the
SFY 2008 contract period, a baseline level of performance will be established
using the CY2007 report period (and may be adjusted based on the number of
months ofABD managed care membership). For the SFY 2009 contract period,
performance will be evaluated using the January - December 2008 report period.
The first reporting period in which MCPs will be held accountable to the
performance standards will be the CY2008 reporting period.
Minimum
Performance Standard:
A
maximum PCP Turnover rate of 18%.
Action
Required for Noncompliance:
MCPs are
required to perform a causal analysis of the high PCP turnover rate and assess
the impact on timely access to health services, including continuity of care.
If
access has been reduced or coordination of care affected, then the MCP must
develop and implement an action plan to address the findings.
2.b.
Adults' Access to Designated PCP
The
MCP
must encourage and assist ABD members without a designated primary care
physician (PCP) to establish such a relationship, so that a designated PCP
can
coordinate and manage member's health care needs. This measure is used to
assess
MCPs' performance in the access category.
Measure:
The
percentage of members who had a visit through member's designated
PCPs.
Statewide
Approach:
MCPs
will be evaluated using a statewide result, including all regions in which
an
MCP has membership. ODJFS will use the first calendar year ofABD managed
care
program membership as the baseline year (i.e., CY2007). The baseline year
will
be used to determine a minimum statewide performance standard. An MCP's second
calendar year ofABD managed care program membership (i.e., CY2008) will be
the
initial report period of evaluation, and penalties will be applied for
noncompliance.
Report
Period:
For the
SFY 2008 contract period, performance will be evaluated using the January
-
December 2007 report period (and may be adjusted based on the number of months
of ABD managed care membership). For the SFY 2009 contract period, performance
will be evaluated using the January - December 2008 report period. The first
reporting period in which MCPs will be held accountable to the performance
standards will be the SFY 2009 contract period.
Appendix
M
Page
18
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 21 and older who had an ambulatory or preventive-care
visit.
Statewide
Approach:
MCPs
will be evaluated using a statewide result, including all regions in which
an
MCP has membership. ODJFS will use the first calendar year ofABD managed
care
program membership as the baseline year (i.e., CY2007). The baseline year
will
be used to determine a minimum statewide performance standard. An MCP's second
calendar year ofABD managed care program membership (i.e., CY2008) will be
the
initial report period of evaluation, and penalties will be applied for
noncompliance.
Report
Period:
For the
SPY 2008 contract period, performance will be evaluated using the January
-
December 2007 report period (and may be adjusted based on the number of months
of ABD managed care membership). For the SFY 2009 contract period, performance
will be evaluated using the January - December 2008 report period. The first
reporting period in which MCPs will be held accountable to the performance
standards will be the CY2008 reporting period.
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.
3.
CONSUMER SATISFACTION
MCPs
will
be evaluated using a statewide result, including all regions in which an
MCP has
membership.
In
accordance with federal requirements and in the interest of assessing enrollee
satisfaction with MCP performance, ODJFS periodically conducts independent
consumer satisfaction surveys. Results are used to assist in identifying
and
correcting MCP performance overall and in the areas of access, quality of
care,
and member services. Performance in this category will be determined by the
overall satisfaction score. For a comprehensive description of the Consumer
Satisfaction performance measure below, see ODJFS
Methods for ABD Medicaid Managed Care Program Consumer Satisfaction Performance
Measures,
which
are incorporated in this Appendix.
Appendix
M
Page
19
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.
Report
Period:
For the
SFY 2008 contract period, the measure is under review and the report period
has
not been determined.
Minimum
Performance Standard:
An
average score of no less than 7.0.
Penalty/or
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 ABD Medicaid Managed Care Program Administrative Capacity
Performance Measures,
which
are incorporated in this Appendix.
4.b.
Emergency Department Diversion
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 TBD ED visits during a twelve month reporting
period.
Statewide
Approach:
MCPs
will be evaluated using a statewide result, including all regions in which
an
MCP has membership. ODJFS will use the first calendar year of ABD managed
care
membership as the baseline year (i.e., CY2007). The baseline year will be
used
to determine a minimum statewide performance standard and a target. The number
of members with an ED visit used to calculate the measure for the baseline
year
will be adjusted based on the number of months of ABD managed care membership
in
the baseline year. An MCP's second calendar year of ABD managed care program
membership (i.e., CY2008) will be the initial report period of evaluation,
and
penalties will be applied for noncompliance.
Report
Period:
For the
SFY 2008 contract period, a baseline level of performance will be established
using the CY2007 report period (and may be adjusted based on the number of
months of ABD managed care membership). For the SFY 2009 contract period,
results will be calculated for
Appendix
M
Page
20
the
reporting period ofCY2008 and compared to the CY2007 baseline results to
determine if the minimum performance standard is met.
Target:
TBD
Minimum
Performance Standard:
TBD
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.
APPENDIX
N
COMPLIANCE
ASSESSMENT SYSTEM (CAS) ABD ELIGIBLE POPULATION
The
Compliance Assessment System (CAS) is designed to improve the quality of
each
MCP's performance through actions taken by ODJFS to address identified failures
to meet certain program requirements. The CAS assesses progressive remedies
with
specified values (occurrences or points) assigned for certain documented
failures to satisfy the deliverables required by the Agreement. Remedies
are
progressive based upon the severity of the violation, or a repeated pattern
of
violations. The CAS does not include categories which require subjective
assessments or which are not within the MCPs' control. CAS allows the
accumulated point total to reflect both patterns of less serious violations
as
well as less frequent, more serious violations.
The
CAS
focuses on clearly identifiable deliverables, and occurrences/points are
only
assessed in documented and verified instances ofnoncompliance. The CAS does
not
replace ODJFS' ability to require corrective action plans (CAPs) and program
improvements, or to impose any of the sanctions specified in Ohio Administrative
Code (OAC) rule 5101:3-26-10, including the proposed termination, amendment,
or
nonrenewal of the MCP's provider agreement.
As
stipulated in OAC rule 5101:3-26-10(F). regardless of whether ODJFS imposes
a
sanction, MCPs are required to initiate corrective action for any MCP program
violations or deficiencies as soon as they are identified by the MCP or
ODJFS.
Corrective
Action Plans (CAPs)
- MCPs
may be required to develop CAPs for any instance of noncompliance, and CAPs
are
not limited to actions taken under the CAS. All CAPs requiring ongoing activity
on the part of an MCP to ensure their compliance with a program requirement
remain in effect for the next provider agreement period. In situations where
ODJFS has already determined the specific action which must be implemented
by
the MCP or if the MCP has failed to submit an ODJFS-approvable CAP, ODJFS
may
require the MCP to comply with an ODJFS-developed or "directed''
CAP.
Appendix
N
Page
2
Occurrences
and Points
-
Occurrences and points are defined and applied as follows:
Occurrences
— Failures to meet program requirements, including but not limited to,
noncompliance with administrative requirements.
Examples
include:
-
Use of
unapproved marketing materials.
-
Failure
to attend a required meeting.
-
Second
failure to meet a call center standard.
5
Points
— Failures to meet program requirements, including but not limited to, actions
which could impair the member's ability to access information regarding services
in a timely manner or which could impair a member's rights.
Examples
include:
-
24-hour
call-in system is not staffed by medical personnel.
-
Failure
to notify a member of their right to a state hearing when the MCP proposes
to
deny, reduce, suspend or terminate a Medicaid-covered service.
-
Failure
to appropriately notify ODJFS of provider panel terminations.
10
Points
— Failures to meet program requirements, including but not limited to, actions
which could affect the ability of the MCP to deliver or the member to access
covered services.
Examples
include:
-
Failure
to comply with the minimum provider panel requirements specified in Appendix
H
of the Agreement.
-
Failure
to provide medically-necessary Medicaid covered services to
members.
-
Failure
to meet the electronic claims adjudication requirements.
-
Failure
to submit or comply with CAPs will result in the assessment of occurrences
or
points based on the nature of the violation under correction.
Appendix
N
Page
3
Notwithstanding
the assessment of occurrences and/or points as a result of individual events,
the
following
cumulative actions will be imposed for repeated violations.
•
After
accumulating a total of three occurrences within a contract term, all subsequent
occurrences during the period will be assessed as 5-point violations, regardless
of the number of 5-point violations which have been accrued by the
MCP.
•
After
accumulating a total of three 5-point violations within a contract term,
all
subsequent 5-point violations during the period will be assessed as 8-point
violations, except as specified above.
•
After
accumulating a total of two 10-point violations within a contract term, all
subsequent 10-point violations during the period will be assessed as 15-point
violations.
Occurrences
and points will accumulate over the contract term of the Agreement. Upon
the
beginning of a new Agreement, the MCP will begin a new contract term with
a
score of zero unless the MCP has accrued a total of 55 points or more during
the
prior provider agreement period. Those MCPs who have accrued a total of 55
points or more during the contract term of a prior provider agreement will
carry
these points over for the first three (3) months of their next provider
agreement. If the MCP does not accrue any additional points during this three
(3) month period the MCP will then have their point total reduced to zero
and
continue on in the new contract term. If the MCP does accrue additional points
during this three-month period, the MCP will continue to carry the points
accrued from the prior provider agreement plus any additional points accrued
during the new provider agreement contract term.
For
purposes of the CAS, the date that ODJFS first becomes aware of an MCP's
program
violation is considered the date on which the violation occurred. Therefore,
program violations that technically reflect noncompliance from the previous
provider agreement period will be subject to remedial action under CAS at
the
time that ODJFS first becomes aware of this noncompliance.
In
cases
where an MCP subcontracting provider is found to have violated a program
requirement (e.g., failing to provide adequate contract termination notice,
marketing to potential members, unapprovable billing of members, etc.), ODJFS
will not assess occurrences or points if: (1) the MCP can document that they
provided sufficient notification/education to providers of applicable program
requirements and prohibited activities; and (2) the MCP takes immediate and
appropriate action to correct the problem and to ensure that it does not
happen
again to the satisfaction of ODJFS. Repeated incidents will be reviewed to
determine if the MCP has a systemic problem in this area, and if so, occurrences
or points may be assessed, as determined by ODJFS.
Appendix
N
Page
4
All
required submissions are to be received by their specified deadline. Unless
otherwise
specified,
late submissions will initially be addressed through CAPs, with repeated
instances of
untimely
submissions resulting in escalating penalties, as may be determined by
ODJFS.
If
an MCP
determines that they will be unable to meet a program deadline, the MCP must
verbally inform the designated ODJFS contact person (or their supervisor)
of
such and submit a written request (by facsimile transmission) for an extension
of the deadline as soon as possible, but no later than 3 PM Eastern Time
(ET) on
the date of the deadline in question. Extension requests should only be
submitted in situations where unforeseeable circumstances have arisen which
make
it impossible for the MCP to meet an ODJFS-stipulated deadline and all such
requests will be evaluated upon that basis and with that in mind. Only written
approval as may be granted by ODJFS of a deadline extension will preclude
the
assessment of a CAP, occurrence or points for untimely submissions.
No
points
or occurrences will be assigned for any violation where an MCP is able to
document that the precipitating circumstances were completely beyond their
control and could not have been foreseen (e.g., a construction crew ▇▇▇▇▇▇
a
phone line, a lightning strike blows a computer system, etc.).
REMEDIES
Progressive
remedies will be based on the number of points accumulated at the time of
the
most recent incident. Unless specifically otherwise indicated in this appendix,
all fines issued under the CAS are nonrefundable.
1
-9
Points Corrective Action Plan (CAP)
10-19
Points CAP + $5,000 fine
20-29
Points CAP + $ 10,000 fine
30-39
Points CAP + $20,000 fine
40-69
Points CAP + $30,000 fine
70+
Points Proposed Contract Termination
Appendix
N Page 5
New
Member Selection Freezes:
Notwithstanding
any other penalty- occurrence or point assessment that ODJFS may impose on
an
MCP under this Appendix, ODJFS may prohibit an MCP from receiving new membership
through consumer initiated selection or the assignment process (selection
freeze) in one or more counties if: (1) the MCP has accumulated a total of
20 or
more points during a contract term;
(2)
or
the MCP fails to fully implement a CAP within the designated time frame;
or (3)
circumstances exist which potentially jeopardize the MCP's members' access
to
care. [Examples of circumstances that ODJFS may consider as jeopardizing
member
access to care include:
-
the MCP
has been found by ODJFS to be noncompliant with the prompt payment or the
non-contracting provider payment requirements;
-
the MCP
has been found by ODJFS to be noncompliant with the provider panel requirements
specified in Appendix H of the Agreement;
-
the
MCP's refusal to comply with a program requirement after ODJFS has directed
the
MCP to comply with the specific program requirement; or
-
the MCP
has received notice of proposed or implemented adverse action by the Ohio
Department of Insurance.]
Payments
provided for under the Agreement will be denied for new enrollees, when and
for
so long as, payments for those enrollees is denied by CMS in accordance with
the
requirements in 42 CFR 438.730.
Reduction
of Assignments
ODJFS
may
reduce the number of assignments an MCP receives if ODJFS, in its sole
discretion, determines that the MCP lacks sufficient administrative capacity
to
meet the needs of the increased volume in membership. Examples of circumstances
which ODJFS may determine demonstrate a lack of sufficient administrative
capacity include, but are not limited to, an MCP's failure to: repeatedly
provide new member materials by the member's effective date; meet the minimum
call center requirements; meet the minimum performance standards for identifying
and assessing children with special health care needs and members needing
case
management services; and/or provide complete and accurate appeal/grievance,
member's PCP and CAMS data files.
Noncompliance
with Claims Adjudication Requirements:
If
ODJFS
finds that an MCP is unable to (1) electronically accept and adjudicate claims
to final status and/or (2) notify providers of the status of their submitted
claims, as stipulated in
Appendix
N
Page
6
Appendix
C of the Agreement, ODJFS will assess the MCP with a 10-point penalty and
a
monetary sanction of $20,000 per day for the period of noncompliance. ODJFS
may
assess additional penalty points based on the length of noncompliance, as
it may
determine in its sole discretion.
If
ODJFS
has identified specific instances where an MCP has failed to take the necessary
steps to comply with the requirements specified in Appendix C of the Agreement,
for (1) failing to notify non-contracting providers of procedures for claims
submissions when requested and/or (2) failing to notify contracting and
non-contracting providers of the status of their submitted claims, the MCP
will
be assessed 5 points per incident of noncompliance.
Noncompliance
with Prompt Payment:
Noncompliance
with the prompt pay requirements as specified in Appendix J of the Agreement,
will result in progressive penalties. The first violation during the contract
term will result in the assessment of 5 points, quarterly prompt pay reporting,
and submission of monthly status reports to ODJFS until the next quarterly
report is due. The second and any subsequent violation during the contract
term
will result in the submission of monthly status reports, assessment of 10
points
and a refundable fine equal to 5% of the MCP's monthly premium payment or
$300,000, whichever is less. The refundable fine will be applied in lieu
of a
nonrefundable fine and the money will be refunded by ODJFS only after the
MCP
complies with the required standards for two (2) consecutive
quarters.
If
an MCP
is found to have not been in compliance with the prompt pay requirements
for any
time period for which a report and signed attestation have been submitted
representing the MCP as being in compliance, the MCP will be subject to a
selection freeze of not less than three (3) months duration.
Noncompliance
with Franchise Fee Assessment Requirements
In
accordance with ORC Section 5111.176, and in addition to the imposition of
any
other penalty, occurrence or points under this Appendix, an MCP that does
not
pay the franchise permit fee in full by the due date is subject to any or
all of
the following. :
•
A
monetary penalty in the amount of $500 for each day any part of the fee remains
unpaid, except the penalty will not exceed an amount equal to 5 % of the
total
fee that was due for the calendar quarter for which the penalty was
imposed;
•
Withholdings from future ODJFS capitation payments. If an MCP fails to pay
the
full amount of its franchise fee when due, or the full amount of the imposed
penalty, ODJFS may withhold an amount equal to the remaining amount due from
any
future ODJFS capitation payments. ODJFS will return all withheld capitation
payments when the franchise fee amount has been paid in full.
•
A
10
point penalty assessment for the period of noncompliance.
Appendix
N Page 7
•
Proposed termination or non-renewal of the MCP's Medicaid provider agreement
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.
Noncompliance
with Clinical Laboratory Improvement Amendments:
Noncompliance
with CLIA requirements as specified by ODJFS will result in the assessment
of a
nonrefundable $1,000 fine for each violation.
'Noncompliance
with Encounter Data Submissions:
Submission
of unpaid encounters (except for immunization services as specified in Appendix
L) will result in the assessment of a nonrefundable $1,000 fine for each
violation.
Noncompliance
with Abortion and Sterilization Payment
Noncompliance
with abortion and sterilization requirements as specified by ODJFS will result
in the assessment of a nonrefundable $1,000 fine for each documented violation.
Additionally, MCPs must take all appropriate action to correct each such
ODJFS-documented violation.
'Negligent
Breach of Protected Health Information (PHI) Standards
Non-compliance
with the HIPAA Privacy Regulations and negligent breach of protected health
information (PHI) standards will be assessed in accordance with Appendix
C.
Therefore, the progressive remedies specified under Appendix N, Compliance
Assessment System will not be utilized for assessing non-compliance with
the
HIPAA Privacy Regulations and negligent breach of PHI.
Refusal
to Comply with Program Requirements
If
ODJFS
has instructed an MCP that they must comply with a specific program requirement
and the MCP refuses, such refusal constitutes documentation that the MCP
is no
longer operating in the best interests of the MCP's members or the state
of Ohio
and ODJFS will move to terminate or nonrenew the MCP's provider
agreement.
General
Provisions:
All
notifications of the imposition by ODJFS of a fine or freeze will be made
via
certified or overnight mail to the identified MCP Medicaid
Coordinator.
Appendix
N
Page
8
Pursuant
to procedures as may be 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.
Refundable
monetary sanctions/assurances applied by ODJFS will be based on the premium
payment for the month in which the MCP was cited for the deficiency. Any
monies
collected through the imposition of such a fine will be returned to the MCP
(minus any applicable collection fees owed to the Attorney General's Office
if
the MCP has been delinquent in submitting payment) after they have demonstrated
full compliance, as determined by ODJFS, with the particular program
requirement.
If
an MCP
does not comply within one (1) year of the date of notification of noncompliance
involving issues of case management and two (2) years of the date of
notification of noncompliance in issues involving encounter data, then the
monies will not be refunded. MCPs are required to submit a written request
for
refund to ODJFS at the time they believe is appropriate before a refund of
monies will be considered.
Notwithstanding
any other action ODJFS may take under this Appendix, ODJFS may impose a combined
remedy which will address multiple areas of noncompliance if ODJFS determines,
in its sole discretion, that (1) one systemic problem is responsible for
multiple areas of noncompliance and/or (2) that there are a number of repeated
instances of noncompliance with the same program requirement.
In
addition, ODJFS can at any time move to terminate, amend or deny renewal
of a
provider agreement.
Upon
such
termination, nonrenewal or denial of an MCP provider agreement, all previously
collected monetary sanctions will be retained by ODJFS.
In
addition to the remedies imposed under the CAS, remedies related to areas
of
data quality and financial performance may also be imposed pursuant to
Appendices J, L, and M respectively, of the Agreement.
If
ODJFS
determines that an MCP has violated any of the requirements of sections 1903(m)
or 1932 of the Social Security Act which are not specifically identified
within
the CAS, the ODJFS may, pursuant to the provisions of OAC rule 5101:3-26-10(A):
(1) notify the MCP's members that they may terminate from the MCP without
cause;
and/or (2) suspend any further new member selections.
Appendix
N Page 9
REQUESTS
FOR RECONSIDERATIONS
Requests
for reconsiderations of remedial action taken under the CAS shall be submitted
to ODJFS as follows:
•
MCPs
notified of ODJFS' imposition of remedial action taken under the CAS (i.e.,
occurrences, points, fines, assignment reductions and selection freezes),
will
have five (5) working days from the date of receipt to request reconsideration,
although ODJFS will impose selection freezes based on an access to care concern
concurrent with initiating notification to the MCP. (All notifications of
the
imposition of a fine or a freeze will be made via certified or overnight
mail to
the identified MCP Contact.) Any information that the MCP would like reviewed
as
part of the reconsideration request must be submitted at the time of submission
of the reconsideration request, unless ODJFS extends the timeframe in
writing.
•
All
requests for reconsideration must be submitted by either facsimile transmission
or overnight mail to the Chief, Bureau of Managed Health Care, and received
by
ODJFS by the fifth business day after receipt of notification of the imposition
of the remedial action by ODJFS.
The
MCP
will be responsible for verifying timely receipt of all reconsideration
requests. All requests for reconsideration must explain in detail why the
specified remedial action should not be imposed. The MCP's justification
for
reconsideration will be limited to a review of the written material submitted
by
the MCP. The Bureau Chief will review all correspondence and materials related
to the violation in question in making the final reconsideration
decision.
•
Final
decisions or requests for additional information will be made by ODJFS within
five (5) business days of receipt of the request for
reconsideration.
If
additional information is requested by ODJFS, a final reconsideration decision
will be made within three (3) business days of the due date for the submission.
Should ODJFS require additional time in rendering the final reconsideration
decision, the MCP will be notified of such in writing.
If
a
reconsideration request is decided, in whole or in part, in favor of the
MCP,
both the penalty and the points associated with the incident, will be rescinded
or reduced, in the sole discretion of ODJFS. The MCP may still be required
to
submit a CAP if ODJFS, in its sole discretion, believes that a CAP is still
warranted under the circumstances.
Appendix
N
Page
10
POINT
COMPLIANCE SYSTEM - POINT VALUES
OCCURRENCES:
Failures
to meet program requirements, including but not limited to, noncompliance
with
administrative requirements, as determined by ODJFS. Examples include, but
are
not limited to, the following:
•
Unapproved use of marketing/member materials.
•
Failure
to attend ODJFS-required meetings or training sessions.
•
Failure
to maintain ODJFS-required documentation.
•
Use
ofunapproved subcontracting providers where prior approval is required by
ODJFS.
•
Use
of
unapprovable subcontractors (e.g., not in good standing with Medicaid and/or
Medicare programs, provider listed in directory but no current contract,
etc.)
where prior-approval is not required by ODJFS.
•
Failure
to provide timely notification to members, as required by ODJFS (e.g., notice
of
PCP or hospital termination from provider panel).
•
Participation in a prohibited or unapproved marketing activity.
•
Second
failure to meet the monthly call-center requirements for either the member
services or 24-hour call-in system lines.
•
Failure
to submit and/or comply with a Corrective Action Plan (CAP) requested by
ODJFS
as the result of an occurrence, or when no occurrence was designated for
the
precipitating violation of OAC rules or provider agreement
•
Failure
to comply with the physician incentive plan requirements, except for
noncompliance where member rights are violated (i.e., failure to complete
required patient satisfaction surveys or to provide members with requested
physician incentive information) or where false, misleading or inaccurate
information is provided to ODJFS.
Appendix
N
Page
11
5
POINTS:
Failures
to meet program requirements, including but not limited to, actions which
could
impair the member's ability to access information regarding services in a
timely
manner or which could impair a consumer's or member's rights, as determined
by
ODJFS. Examples include, but are not limited to, the following:
•
Violations which result in selection or termination counter to the recipient's
preference (e.g., a recipient makes a selection decision based on inaccurate
provider panel information from the MCP).
•
Any
violation of a member's rights.
•
Failure
to provide member materials to new members in a timely manner.
•
Failure
to comply with appeal, grievance, or state hearing requirements, including
timely submission to ODJFS.
•
Failure
to staff 24-hour call-in system with appropriate trained medical
personnel.
•
Third
failure to meet the monthly call-center requirements for either the member
services or the 24-hour call-in system lines.
•
Failure
to submit and/or comply with a CAP as a result of a 5-point
violation.
•
Failure
to meet the prompt payment requirements (first violation).
•
Provision of false, inaccurate or materially misleading information to health
care providers, the MCP's members, or any eligible individuals.
•
Failure
to submit a required monthly CAMS file (as specified in Appendix L of the
Agreement) by the end of the month the submission was required.
•
Failure
to submit a required monthly Members' Designated PCP file (as specified in
Appendix L of the Agreement) by the end of the month the submission was
required.
Appendix
N Page 12
10
POINTS:
Failures
to meet program requirements, including but not limited to, actions which
could
affect the ability of the MCP to deliver or the consumer to access covered
services as determined by ODJFS. Examples include, but are not limited
to:
•
Failure
to meet any of the provider panel requirements as specified in Appendix H
of the
Agreement.
•
Discrimination among members on the basis of their health status or need
for
health care services (this includes any practice that would reasonably be
expected to encourage termination or discourage selection by individuals
whose
medical condition indicates probable need for substantial future medical
services).
•
Failure
to assist a member in accessing needed services in a timely manner after
request
from the member.
•
Failure
to process prior authorization requests within prescribed time
frame.
•
Failure
to remit any ODJFS-required payments within the specified time
frame.
•
Failure
to meet the electronic claims adjudication requirements.
•
Failure
to submit and/or comply with a CAP as a result of a 10-point
violation.
•
Failure
to meet the prompt payment requirements (second and subsequent
violations).
•
Fourth
and any subsequent failure to meet the monthly call-center requirements for
either the member services or the 24-hour call-in system lines.
•
Failure
to provide ODJFS with a required submission after ODJFS has notified the
MCP
that the prescribed deadline for that submission has passed.
•
Failure
to submit a required monthly appeal or grievance file (as specified in Appendix
L of the Agreement) by the end of the month the submission was
required.
•
Misrepresentation or falsification of information that the MCP furnishes
to the
ODJFS or to the Centers for Medicare and Medicaid Services.
APPENDIX
0
PAY-FOR-PERFORMANCE
(P4P) ABD ELIGIBLE POPULATION
This
Appendix establishes a Pay-for-performance (P4P) incentive system for managed
care plans (MCPs) to improve performance in specific areas important to the
Medicaid MCP members. P4P includes the at-risk amount included with the monthly
premium payments (see Appendix F, Rate
Chart),
and
possible additional monetary rewards up to $250,000.
To
qualify for consideration of any P4P, MCPs must meet minimum performance
standards established in Appendix M, Performance
Evaluation
on
selected measures, and achieve P4P standards established for selected Clinical
Performance Measures, as set forth herein below. 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). 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 2).
ODJFS
will use the first calendar year of an MCP's ABD managed care program membership
as the baseline year (i.e., CY2007). The baseline year will be used to determine
performance standards and targets; baseline data may come from a combination
ofFFS claims data and MCP encounter data. As many of the performance measures
used in the determination of P4P require two calendar years of baseline data,
the additional calendar year (i.e., the calendar year prior to the first
calendar year of ABD managed care program membership, i.e., CY2006) data
will
come from FFS claims.
An
MCP's
second calendar year of ABD managed care program membership (i.e., CY2008)
will
be the initial report period of evaluation for performance measures that
require
one calendar year of baseline data (i.e., CY2007), and for performance measures
that require two calendar years of baseline data (i.e., CY2006 and CY2007).
CY2008 will be the initial report period upon which compliance with the
performance standards will be determined. SFY2009 will become the first year,
an
MCP's performance level for P4P can be determined.
1.
SFY 2009 P4P
l.a.
Qualifying Performance Levels
To
qualify for consideration of the SFY 2009 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 Clinical Performance Measures
below.
Appendix
0 Page 2
•
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 2009 established in Appendix
M, Performance
Evaluation,
must be
met to qualify for consideration of incentives are as follows:
1.
PCP
Turnover (Appendix M, Section 2.a.)
Report
Period:
CY
2008
2.
Adults' Access to Preventive/Ambulatory Health Services (Appendix M, Section
2.c.)
Report
Period:
CY
2008
3.
Satisfaction with MCP Customer Service (Appendix M, Section 3.)
Report
Period:
The most
recent consumer satisfaction survey completed prior to the end of the SFY
2009
contract period.
For
each
clinical performance measure listed below, the MCP must meet the P4P standard
to
be considered for SFY 2009 P4P. The MCP meets the P4P standard if one of
two
criteria is met. The P4P standard is a performance level of either:
1)
The
minimum performance standard established in Appendix M, Performance
Evaluation,
for five
of eight clinical performance measures listed below; or
2)
The
Medicaid benchmarks for five of eight 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.
CHF:
ACE Inhibitor/Angiotensin Receptor B locker TBD
2.
CAD:
Beta-Blocker Treatment after Heart Attack (AMI -related TBD
admission)
3.
CAD:
Cholesterol Management for Patients with Cardiovascular TBD Conditions/LDL-C
screening performed
4.
Hypertension: Inpatient Hospital Discharge Rate TBD
5.
Diabetes: Comprehensive Diabetes Care (CDC)/Eye exam TBD
6.
COPD:
Inpatient Hospital Discharge Rate TBD
7.
Asthma: Use of Appropriate Medications for People with Asthma TBD
8.
Mental
Health: Follow-up After Hospitalization for Mental Illness TBD
Appendix
0
Page
3
l.b.
Excellent and Superior Performance Levels
For
qualifying MCPs as determined by Section 1 .a.. herein, 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 Members (Appendix M, Section l.b.i) Report
Period:
April - June 2008
Excellent
Standard: TBD
Superior
Standard:
TBD
2.
Comprehensive Diabetes Care (CDC)/Eye exam (Appendix M, Section l.c.xiv.)
Report
Period:
CY 2008
Excellent
Standard:
TBD
Superior
Standard:
TBD
3.
Adults' Access to Preventive/Ambulatory Health Services (Appendix M, Section
2.c.)
Report
Period: CY 2008
Excellent
Standard: TBD
Superior
Standard: TBD
1.c.
Determining SFY 2009 P4P
MCP's
reaching the minimum performance standards described in Section l.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 l.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
l.b.
herein, additional P4P may be awarded as determined by ODJFS. For MCPs receiving
additional P4P, the amount in the P4P fund (see section 2.) will be divided
equally, up to the maximum amount, among all MCPs'ABD and/or CFC programs
receiving additional P4P. The maximum amount to be awarded to a single plan
in
P4P additional to the at
Appendix
0
Page
4
risk
amount is $250,000 per contract year. An MCP may receive up to $500,000 should
both of the MCP's ABD and CFC programs achieve the Superior Performance
Levels.
2.
NOTES
2.a.
Initiation of the P4P System
For
MCPs
in their first twenty-four (24) months of Ohio Medicaid ABD Managed Care
Program
participation, the status of the at-risk amount will not be determined because
compliance with many of the standards in the ABD program cannot be determined
in
an MCP's first two contract years (see Appendix F., Rate
Chart).
In
addition, MCPs in their first two (2) contract years in the ABD program are not
eligible for the additional P4P amount awarded for superior
performance.
Starting
with the twenty-fifth (25* ) month of participation in the ABD program, the
MCP's at-risk amount will be included in the P4P system. The determination
of
the status of this at-risk amount will occur after two (2) calendar years
of ABD
membership as compliance with many performance standards requires two (2)
calendar years to determine. Because of this requirement, the number of months
of at-risk dollars to be included in an MCP's first at-risk status determination
may vary depending on when an MCP starts with the ABD program relative to
the
calendar year.
2.b.
Determination of at-risk amounts and additional P4P
payments
For
MCPs
that have participated in the Ohio Medicaid ABD 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 (6) 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.
2.c.
Statewide P4P system
All
MCPs
will be included in a statewide P4P system for the ABD program. The at-risk
amount will be determined using a statewide result for all regions in which
an
MCP serves ABD membership.
2.d.
Contract Termination, Nonrenewals, or Denials
Upon
termination, nonrenewal or denial of an MCP contract, the at-risk amount
paid to
the MCP under the current provider agreement 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.
Appendix
0
Page
5
2.e.
Report Periods
The
report period used in determining the MCP's performance levels varies for
each
measure depending on the frequency of the report and the data source. Unless
otherwise noted, the most recent report or study finalized prior to the end
of
the contract period will be used in determining the MCP's overall performance
level for that contract period.
APPENDIX
P
MCPTERMINATIONS/NONRENEWALS/AMENDMENTS
ABD ELIGIBLE POPULATION
Upon
termination either by the MCP or ODJFS, nonrenewal or denial of an MCP's
provider agreement, all previously collected refundable monetary sanctions
will
be retained by ODJFS.
MCP-INITIATEDTERMINATIONS/NONRENEWALS
If
an MCP
provides notice of the termination/nonrenewal of their provider agreement
to
ODJFS, pursuant to Article VIII of the agreement, the MCP will be required
to
submit a refundable monetary assurance. This monetary assurance will be held
by
ODJFS until such time that the MCP has submitted all outstanding monies owed
and
reports, including, but not limited to, grievance, appeal, encounter and
cost
report data related to time periods through the final date of service under
the
MCP's provider agreement. The monetary assurance must be in an amount of
either
$50,000 or 5 % of the capitation amount paid by ODJFS in the month the
termination/nonrenewal notice is issued, whichever is greater.
The
MCP
must also return to ODJFS the at-risk amount paid to the MCP under the current
provider agreement. The amount to be returned will be based on actual MCP
membership for preceding months and estimated MCP membership through the
end
date of the contract. MCP membership for each month between the month the
ten-ninatioi-i/noni-enewal is issued and the end date of the provider agreement
will be estimated as the MCP membership for the month the termination/nonrenewal
is issued. Any over payment will be determined by comparing actual to estimated
MCP membership and will be returned to the MCP following the end date of
the
provider agreement.
The
MCP
must remit the monetary assurance and the at-risk amount in the specified
amounts via separate electronic fund transfers (EFT) payable to Treasurer
of State, State of Ohio (ODJFS).
The MCP
should contact their Contract Administrator to verify the correct amounts
required for the monetary assurance and the at-risk amount and obtain an
invoice
number prior to submitting the monetary assurance and the at-risk amount.
Information from the invoices must be included with each EFT to ensure monies
are deposited in the appropriate ODJFS Fund account. In addition, the MCP
must
send copies of the EFT bank confirmations and copies of the invoices to their
Contract Administrator.
If
the
monetary assurance and the at-risk amount are not received as specified above,
ODJFS will withhold the MCP's next month's capitation payment until such
time
that ODJFS receives documentation that the monetary assurance and the at-risk
amount are received by the Treasurer of State. If within one year of the
date of
issuance of the invoice, an MCP does not submit all outstanding monies owed
and
required submissions, including, but not limited to, grievance, appeal,
encounter and cost report data related to time periods through the final
date of
service under the MCP's provider agreement, the monetary assurance will not
be
refunded to the MCP.
Appendix
▇
▇▇▇▇
2
ODJFS-INITIATED
TERMINATIONS
If
ODJFS
initiates the proposed termination, nonrenewal or amendment of an MCP's provider
agreement pursuant to OAC rule 5101:3-26-10 and the MCP appeals that proposed
action, the MCP's provider agreement will be extended through the duration
of
the appeals process.
During
this time, the MCP will continue to accrue points and be assessed penalties
for
each subsequent compliance assessment occurrence/violation under Appendix
N of
the provider agreement. If the MCP exceeds 69 points, each subsequent point
accrual will result in a $15,000 nonrefundable fine.
Pursuant
to OAC rule 5101:3-26-10(H), if ODJFS has proposed the termination, nonrenewal,
denial or amendment of a provider agreement, ODJFS may notify the MCP's members
of this proposed action and inform the members of their right to immediately
terminate their membership with that MCP without cause. IfODJFS has proposed
the
termination, nonrenewal, denial or amendment of a provider agreement and
access
to medically-necessary covered services is jeopardized, ODJFS may propose
to
terminate the membership of all of the MCP's members. The appeal process
for
reconsideration of either of these proposed actions is as follows:
•
All
notifications of such a proposed MCP membership termination will be made
by
ODJFS via certified or overnight mail to the identified MCP
Contact.
•
MCPs
notified by ODJFS of such a proposed MCP membership termination will have
three
working days from the date of receipt to request reconsideration.
•
All
reconsideration requests must be submitted by either facsimile transmission
or
overnight mail to the Deputy Director, Office of Ohio Health Plans, and received
by 3PM Eastern Time (ET) on the third working day following receipt of the
ODJFS
notification of termination. The address and fax number to be used in making
these requests will be specified in the ODJFS notification of termination
document.
•
The
MCP
will be responsible for verifying timely receipt of all reconsideration
requests. All requests must explain in detail why the proposed MCP membership
termination is not justified. The MCP's justification for reconsideration
will
be limited to a review of the written material submitted by the
MCP.
•
A
final
decision or request for additional information will be made by the Deputy
Director within three working days of receipt of the request for
reconsideration. Should the Deputy Director require additional time in rendering
the final reconsideration decision, the MCP will be notified of such in
writing.
•
The
proposed MCP membership termination will not occur while an appeal is under
review and pending the Deputy Director's decision. If the Deputy Director
denies
the appeal, the MCP
membership termination will proceed at the first possible effective date.
The
date may be retroactive if the ODJFS determines that it would be in the best
interest of the members.