OHIO MEDICAL ASSISTANCE PROVIDER AGREEMENT FOR MANAGED CARE PLAN
Exhibit
10.17
OHIO
DEPARTMENT OF JOB AND FAMILY SERVICES
OHIO
MEDICAL ASSISTANCE PROVIDER AGREEMENT FOR MANAGED CARE
PLAN
This
provider agreement is entered into this first day of November, 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 tor-profit corporation, whose principal office is located in the city
ofBeechwood, County ofCuyahoga, State of Ohio.
MCP
is
licensed as a Health Insuring Corporation by the State of Ohio, Department
of
Insurance (hereinafter referred to as OD1), pursuant to Chapter 1751. of the
Ohio Revised Code and is organized and agrees to operate as prescribed by
Chapter 5101:3-26 of the Ohio Administrative Code (hereinafter referred to
as
OAC), and other applicable portions of the OAC as amended from time to
time.
MCP
is an
entity eligible to enter into a provider agreement in accordance with 42 CFR
438.6 and is engaged in the business of providing prepaid comprehensive health
care services as defined in 42 CFR 438.2 through the managed care program for
the Covered Families and Children (CFC) eligible population described in OAC
rule 5101:3-26-02 (B).
ODJFS,
as
the single state agency designated to administer the Medicaid program under
Section 5111.02 of the Ohio Revised Code and Title XIX of the Social Security
Act, desires to obtain MCP services for the benefit of certain Medicaid
recipients. In so doing, MCP has provided and will continue to provide proof
of
MCP's capability to provide quality services, efficiently, effectively and
economically during the term of this agreement.
Page
2 of
10
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 comprehensive 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.
Page
3 of
10
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 U.S.C. 423) and other applicable federal
requirements, no officer, member or employee of MCP. the Chief of BMHC, or
other
ODJFS employee who exercises any functions or responsibilities in connection
with the review or approval of this provider agreement or provision of services
under this provider agreement shall, prior to the completion of such services
or
reimbursement, acquire any interest, personal or otherwise, direct or indirect,
w'hich 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.
Page
4 of
10
D.
No
officer, member or employee ofMCP shall promise or give to any ODJFS employee
anything of value that is of such a character as to manifest a substantial
and
improper influence upon the employee with respect to his or her duties. No
officer, member or employee ofMCP shall solicit an ODJFS employee to violate
any
ODJFS rule or policy relating to the conduct of the parties to this agreement
or
to violate sections 102.03, 102.04, 2921.42 or 2921.43 of the Ohio Revised
Code.
E.
MCP
hereby covenants that MCP. its officers, members and employees are in compliance
with section 102.04 of the Revised Code and that if MCP is required to file
a
statement pursuant to 102.04(D)(2) of the Revised Code, such statement has
been
filed with the ODJFS in addition to any other required filings.
ARTICLE
VI - EQUAL EMPLOYMENT OPPORTUNITY
A.
MCP
agrees that in the performance of this provider agreement or in the hiring
of
any employees for the performance of services under this provider agreement,
MCP
shall not by reason of race, color, religion, sex, sexual orientation, age,
disability, national origin, veteran's status, health status, or ancestry,
discriminate against any citizen of this state in the employment of a person
qualified and available to perform the services to which the provider agreement
relates.
B.
MCP
agrees that it shall not, in any manner, discriminate against, intimidate,
or
retaliate against any employee hired for the performance or services under
the
provider agreement on account of race, color, religion, sex, sexual orientation,
age, disability, national origin, veteran's status, health status, or
ancestry.
C.
In
addition to requirements imposed upon subcontractors in accordance with OAC
Chapter 5101:3-26, MCP agrees to hold all subcontractors and persons acting
on
behalf of MCP in the performance of services under this provider agreement
responsible for adhering to the requirements of paragraphs (A) and (B) above
and
shall include the requirements of paragraphs (A) and (B) above in all
subcontracts for services performed under this provider agreement, in accordance
with rule 5101:3-26-05 of the Ohio Administrative Code.
ARTICLE
VII - RECORDS, DOCUMENTS AND INFORMATION
A.
MCP
agrees that all records, documents, writings or other information produced
by
MCP under this provider agreement and all records, documents, writings or other
information used by MCP in the performance of this provider agreement shall
be
treated in accordance with rule 5101:3-26-06 of the Ohio Administrative Code.
MCP must maintain an appropriate record system for services provided to members.
MCP must retain all records in accordance with 45 CFR 74.
B.
All
information provided by MCP to ODJFS that is proprietary shall be held to be
strictly 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
Page
5 of
10
[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.
Page
6 of
10
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
Page
7 of
10
effect,
MCP shall be liable for the covered services required to be provided or arranged
for in accordance with this agreement.
ARTICLE
XI - ASSIGNMENT
A.
ODJFS
will not allow the transfer of Medicaid members by one MCP to another MCP unless
this membership has been obtained as a result of an MCP selling their entire
Ohio corporation to another health plan. MCP shall not assign any interest
in
this provider agreement and shall not transfer any interest in the same (whether
by assignment or novation) without the prior written approval of ODJFS and
subject to such conditions and provisions as ODJFS may deem necessary. Any
such
assignments shall be submitted for ODJFS' review 120 days prior to the desired
effective date. No such approval by ODJFS of any assignment shall be deemed
in
any event or in any manner to provide for the incurrence of any obligation
by
ODJFS in addition to the total agreed-upon reimbursement in accordance with
this
agreement.
B.
MCP
shall not assign any interest in subcontracts of this provider agreement and
shall not transfer any interest in the same (whether by assignment or novation)
without the prior written approval of ODJFS and subject to such conditions
and
provisions as ODJFS may deem necessary. Any such assignments of subcontracts
shall be submitted for ODJFS' review 30 days prior to the desired effective
date. No such approval by ODJFS of any assignment shall be deemed in any event
or in any manner to provide for the incurrence of any obligation by ODJFS in
addition to the total agreed-upon reimbursement in accordance with this
agreement.
ARTICLE
XII - CERTIFICATION MADE BY MCP
A.
This
agreement is conditioned upon the full disclosure by MCP to ODJFS of all
information required for compliance with federal regulations as requested by
ODJFS.
B.
By
executing this agreement. MCP certifies that no federal funds paid to MCP
through this or any other agreement with ODJFS shall be or have been used to
lobby Congress or any federal agency in connection with a particular contract,
grant, cooperative agreement or loan. MCP further certifies compliance with
the
lobbying restrictions contained in Section 1352, Title 31 of the U.S. Code.
Section 319 of Public Law 101-121 and federal regulations issued pursuant
thereto and contained in 45 CFR Part 93, Federal Register, Vol. 55, No. 38,
February 26, 1990, pages 6735-6756. If this provider agreement exceeds $100,000,
MCP has executed the Disclosure of Lobbying Activities, Standard Form LLL,
if
required by federal regulations. This certification is material representation
of fact upon which reliance was placed when this provider agreement was entered
into.
C.
By
executing this agreement, MCP certifies that neither MCP nor any principals
of
MCP (i.e., a director, officer, partner, or person with beneficial ownership
of
more than 5% of the MCP's equity) is presently debarred, suspended, proposed
for
debarment, declared ineligible, or otherwise excluded from participation in
transactions by any Federal 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
Page
8 of
10
obligation
with ODJFS. This certification is a material representation of fact upon which
reliance was placed when this provider agreement was entered into. If it is
ever
determined that MCP knowingly executed this certification erroneously, then
in
addition to any other remedies, this provider agreement shall be terminated
pursuant to Article VII, and ODJFS must advise the Secretary of the appropriate
Federal agency of the knowingly erroneous certification.
D.
By
executing this agreement, MCP certifies compliance with Article V as well as
agreeing to future compliance with Article V. This certification is a material
representation of fact upon which reliance was placed when this contract was
entered into.
E.
By
executing this agreement, MCP certifies compliance with the executive agency
lobbying requirements of sections 121.60 to 121.69 of the Ohio Revised Code.
This certification is a material representation of fact upon which reliance
was
placed when this provider agreement was entered into.
F.
By
executing this agreement, MCP certifies that MCP is not on the most recent
list
established by the Secretary of State, pursuant to section 121.23 of the Ohio
Revised Code, which identifies MCP as having more than one unfair labor practice
contempt of court finding. This certification is a material representation
of
fact upon which reliance was placed when this provider agreement was entered
into.
G.
By
executing this agreement MCP agrees not to discriminate against individuals
who
have or are participating in any work program administered by a county
Department of Job and Family Services under Chapters 5101 or 5107 of the Revised
Code.
H.
By
executing this agreement. MCP certifies and affirms that. as applicable to
MCP,
no party listed in Division (1) 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 1902(a)(68) of the Social Security Act.
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
Page
9 of
10
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 ofinconsistence or ambiguity between the provisions ofOAC 5101:3-26 and
this provider agreement, the provision of OAC 5101:3-26 shall be determinative
of the obligations of the parties unless such inconsistency or ambiguity is
the
result of changes in federal or state law, as provided in Article IX of this
provider agreement, in which case such federal or state law shall be
determinative of the obligations of the parties. In the event OAC 5101:3-26
is
silent with respect to any ambiguity or inconsistency, the provider agreement
(including Appendices B through P and any additional appendices), shall be
determinative of the obligations of the parties. In the event that a dispute
arises which is not addressed in any of the aforementioned documents, the
parties agree to make every reasonable effort to resolve the dispute, in keeping
with the objectives of the provider agreement and the budgetary and statutory
constraints ot'ODJFS.
Page
10
of 10
The
parties have executed this agreement the date first written above. The agreement
is hereby accepted and considered binding in accordance with the terms and
conditions set forth in the preceding statements.
WELLCARE
OF OHIO, INC.:
|
WELLCARE
OF OHIO, INC.
BY:
/s/
▇▇▇▇ ▇. ▇▇▇▇▇
▇▇▇▇
▇. ▇▇▇▇▇
|
DATE:
10/23/06
|
|
DEPARTMENT
OF JOB AND FAMILY SERVICES:
BY:
/s/
▇▇▇▇▇▇▇
▇▇▇▇▇
▇▇▇▇▇▇▇
▇. ▇▇▇▇▇, DIRECTOR
|
DATE:
10/27/06
|
|
PROVIDER
AGREEMENT INDEX
JULY
1, 2006
|
|
|
APPENDIX
|
TITLE
|
|
APPENDIX
A
|
OAC
RULES 101:3-26
|
|
APPENDIX
B
|
SERVICE
AREA SPECIFICATIONS
|
|
APPENDIX
C
|
MCP
RESPONSIBILITIES
|
|
APPENDIX
D
|
ODJFS
RESPONSIBILITIES
|
|
APPENDIX
E
|
RATE
METHODOLOGY
|
|
APPENDIX
F
|
COUNTY
AND REGIONAL RATES
|
|
APPENDIX
G
|
COVERAGE
AND SERVICES
|
|
APPENDIX
H
|
PROVIDER
PANEL SPECIFICATIONS
|
|
APPENDIX
I
|
PROGRAM
INTEGRITY
|
|
APPENDIX
J
|
FINANCIAL
PERFORMANCE
|
|
APPENDIX
K
|
QUALITY
ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM
|
|
APPENDIX
L
|
DATA
QUALITY
|
|
APPENDIX
M
|
PERFORMANCE
EVALUATION
|
|
APPENDIX
N
|
COMPLIANCE
ASSESSMENT SYSTEM
|
|
APPENDIX
0
|
PERFORMANCE
INCENTIVES
|
|
APPENDIX
P
|
MCP
TERM1NATIONS/NONRENEWALS/
AMENDMENTS
|
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
MCP
: WellCare of Ohio, Inc.
The
MCP agrees to provide services to Covered Families and Children (CFC) members
residing in the following service area(s):
Service
Area: Northeast Region
-
Ashtabula, Cuyahoga, Erie, Geauga, Huron, Lake, Lorain, and ▇▇▇▇▇▇
counties.
APPENDIX
C
MCP
RESPONSIBILITIES
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.
General
Provisions
1.
The
MCP agrees to implement program modifications 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).
4.
All
MCP employees are to direct all day-to-day submissions and communications to
their ODJFS-designated Contract Administrator unless otherwise notified by
ODJFS.
5.
The
MCP must be represented at all meetings and events designated by ODJFS as
requiring mandatory attendance.
6.
The
MCP must have an administrative office located in Ohio.
7.
Upon
request by ODJFS, the MCP must submit information on the current status of
their
company's operations not specifically covered under this provider agreement
(for
example, other product lines, Medicaid contracts in other states, NCQA
accreditation, etc.)
8.
The
MCP must assure that all new employees are trained on applicable program
requirements
Appendix
C
Page
2
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 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.
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.
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.
14.
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.
If
an MCP elects to provide additional services, the MCP must ensure 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
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.
Appendix
C
Page
3
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 90 days prior notice when decreasing or ceasing
any
additional benefit(s). When it is beyond the control of the MCP, ODJFS must
be
notified within 1 working day.
15.
MCPs
must comply with any applicable Federal and State laws that pertain to member
rights and ensure that its staff and affiliated providers take those rights
into
account w'hen furnishing services to members.
16.
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.
17.
Upon
request, the MCP will provide members and potential members with a copy of
their
practice guidelines.
18.
The
MCP is responsible for promoting the delivery of services in a culturally
competent manner to all members, including those with limited English
proficiency (LEP) and diverse cultural and ethnic backgrounds.
All
MCPs
must comply with the requirements specified in OAC rules 5101:3-26-03.1,
5101:3-26-05(D). 5101:3-26-05.1(A). 5101:3-26-08 and 5101:3-26-08.2 for
providing assistance to LEP members and eligible individuals. In addition,
MCPs
must provide written translations of certain MCP materials in the prevalent
non-English languages of members and eligible individuals in accordance with
the
following:
a.
When
10% or more of the 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, 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 members in the MCP's service area have
Appendix
C
Page
4
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. 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.
19.
The
MCP must utilize a centralized database which records the special 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 needs information for MCP
members, as indicated above, when identified by a 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 special 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 needs, which
could
include individual member names, their specific special need, and any provision
of special services to members (i.e., those special services arranged by the
MCP
as well as those services reported to the MCP which were arranged by the
provider).
Additional
requirements specific to providing assistance to hearing-impaired,
vision-impaired, limited reading proficient (LRP). and LEP members and eligible
individuals are found in OAC rules 5101:3-26-03.1,5101:3-26-05(D),
5101:▇-▇▇-▇▇.▇▇), 5101:3-26-08, and 5101-3-26-08.2.
20.
The
MCP is responsible for ensuring that all member materials use easily understood
language and format.
21.
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. 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.
Appendix
C
Page
5
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 ODJFsT.
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.
22.
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 1 of part 489.
b.
Maintain written policies and procedures concerning advance directives with
respect to all adult individuals receiving medical care by or through the MCP
to
ensure that the MCP:
i.
Provides written information to all adult members concerning:
a.
the
member's rights under state law to make decisions concerning their medical
care.
including the right to accept or refuse medical or surgical treatment and the
right to formulate advance directives. (In meeting this requirement, MCPs must
utilize form JFS 08095 entitled You
Have the Right,
or
include the text from JFS 08095 in their ODJFS-approved member
handbook).
b.
the
MCP's policies concerning the implementation of those rights including a clear
and precise statement of any limitation regarding the implementation of advance
directives as a matter of conscience;
Appendix
C
Page
6
c.
any
changes in state law regarding advance directives as soon as possible but no
later than 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.
23.
New
Member Materials
Pursuant
to OAC rule 5101:3-26-08.2 (B)(3), MCPs must provide to each member or
assistance group, as applicable, an MCP identification (ID) card, a new member
letter, a member handbook, a provider directory, and information on advance
directives.
(a)
MCPs
must use the model language specified by OD.IFS 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 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 5 days.
(d)
MCPs
must designate two MCP staff 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.
Appendix
C
Page
7
24.
Call
Center Standards
The
MCP
must provide assistance to members through a member services toll-free call-in
system pursuant to OAC rule 5101:3-26-08.2(A)(1). MCP member services staff
must
be available nationwide to provide assistance to members through the toll-free
call-in system every Monday through Friday, at all times during the hours of
7:00 a.m to 7:00 p.m Eastern Time, except for the following major
holidays:
•
New
Year's Day
•
▇▇▇▇▇▇
▇▇▇▇▇▇ ▇▇▇▇'▇ Birthday
•
Memorial Day
•
Independence Day
•
Labor
Day
•
Thanksgiving Day
•
Christmas Day
•
2
optional closure days: These days can be used independently or in
combination
with any of the major holiday closures but cannot both be
used
within the same closure period.
Before
announcing any optional closure dates to members and/or staff, MCPs must receive
ODJFS prior-approval which verifies that the optional closure days meet the
specified criteria.
If
a
major holiday falls on a Saturday, the MCP member services line may be closed
on
the preceding Friday. If a major holiday falls on a Sunday, the member services
line may be closed on the following Monday. MCP member services closure days
must be specified in the MCP's member handbook, member newsletter, or other
some
general issuance to the MCP's members at least 30 days in advance of the
closure.
The
MCP
must also provide access to medical advice and direction through a centralized
twenty-four-hour toll-free call-in system pursuant to OAC rule
5101:3-26-03.1(A)(6). The twenty-four 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-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
Appendix
C
Page
8
requirement
may not be met through the execution of a Medicaid Delegation Subcontract
Addendum or Medicaid Combined Services Subcontract Addendum.
25.
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 counties must notify
their new members that MCP membership is optional for certain populations.
Specifically. MCPs must include information in their new member letter that
the
following CFC populations are not required to select an MCP in order to receive
their Medicaid healthcare benefit and what steps they need to take if they
do
not wish to be a member of an MCP:
-
Indians
who are members of federally-recognized tribes.
-
Children under 19 years of age who are:
o
Eligible for Supplemental Security Income under title XVI;
o
In
▇▇▇▇▇▇ care or other out-of-home placement;
o
Receiving ▇▇▇▇▇▇ care of adoption assistance;
o
Receiving services through the Ohio Department of Health's Bureau for Children
with Medical Handicaps (BCMH) or any other family-centered. community-based,
coordinated care system that receives grant funds under section 501(a)(l)(D)
of
title V. and is defined by the State in terms of either program participation
or
special health care needs.
26.
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
ofPHI.
c.
MCPs
shall report to ODJFS any unauthorized use or disclosure of PHI of which it
becomes aware.
Appendix
C
Page
9
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.
27.
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.
28.
MCP
Membership acceptance, documentation and reconciliation
a.
Selection
Services Contractor:
The MCP
shall provide to the selection services contractor (SSC) ODJFS prior-approved
MCP materials and directories for distribution to eligible individuals who
request additional information about the MCP.
b.
Monthly
Reconciliation of Membership and Premiums:
The MCP
shall reconcile member data as reported on the SSC-produced consumer contact
record (CCR) with the ODJFS-produced monthly member roster (MMR) and report
to
the ODJFS any difficulties in interpreting or reconciling information received.
Membership reconciliation questions must be identified and reported to the
ODJFS
prior to the first of the month to assure that no member is left without
coverage. The MCP shall reconcile membership with premium payments and delivery
payments as reported on the monthly remittance advice (RA).
Appendix
C
Page
10
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 30 days of receipt of
theRA.
c.
Monthly
Premiums and Delivery Payments:
The MCP
must be able to receive monthly premiums and delivery payments in a method
specified by ODJFS. (ODJFS monthly prospective premium and delivery payment
issue dates are provided in advance to the MCPs.) Various retroactive premium
payments (e.g., newborns), and recovery of premiums paid (e.g., retroactive
terminations of membership for children in custody, deferments, etc..) may
occur
via any ODJFS weekly remittance.
d.
Hospital
Deferment Requests:
When the
MCP learns of a new member's hospitalization that is eligible for deferment
prior to that member's discharge, the MCP shall notify the hospital and treating
providers of the potential that the MCP may not be the payer. The MCP shall
work
with hospitals, providers and the ODJFS to assure that discharge planning
assures continuity of care and accurate payment. Notwithstanding the MCP's
right
to request a hospital deferment up to six months following the member's
effective date, when the MCP learns of a deferment-eligible hospitalization.
the
MCP shall make every effort to notify the ODJFS and request the deferment as
soon as possible. When the MCP is notified by ODJFS of a potential hospital
deferment, the MCP must make every effort to respond to ODJFS within 10 business
days of the receipt of the deferment information.
e.
Just
Cause Requests:
The MCP
shall follow procedures as specified by ODJFS in assisting the ODJFS in
resolving member requests for member-initiated requests affecting
membership.
f.
Newborn
Notifications:
The MCP
is required to submit newborn notifications to ODJFS in accordance with the
ODJFS Newborn Notification File and Submissions Specifications.
g.
Eligible
Individuals:
If an
eligible individual contacts the MCP, the MCP must provide any MCP-specific
managed care program information requested. The MCP must not attempt to assess
the eligible individual's health care needs. However, if the eligible individual
inquires about continuing/transition ing health care services, MCPs must 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.
Appendix
C
Page
11
h.
Pending
Member
If
a
pending member (i.e., an eligible individual subsequent to plan selection but
prior to their membership effective date) contacts the selected MCP. the MCP
must provide any membership information requested, including but not limited
to.
assistance in determining whether the current medications require prior
authorization. The MCP must also ensure that any care coordination (e.g., PCP
selection, transition of services) information provided by the pending member
is
logged in the MCP's system and forwarded to the appropriate MCP staff for
processing as required. MCPs may confirm any information provided on the CCR
at
this time. Such communication does not constitute confirmation of membership.
MCPs are prohibited from initiating contact with a pending member.
i.
Transition
ofFee-For-Service Members
(i)
MCPs
must 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 the services relate to one of the following:
(a)
The
member has been approved to receive an organ, bone marrow, or hematapoietic
stem
cell transplant pursuant to OAC rule 5101:3-2-07.1.
(b)
The
member is in her third trimester of pregnancy and has an established
relationship with an obstetrician and/or delivery hospital;
(c)
The
member has been scheduled for an inpatient/outpatient surgery and has been
prior-approved and/or precertified pursuant to OAC rule 5101:3-2-40 (surgical
procedures would also include follow-up care as appropriate);
(d)
The
member has appointments within the initial month of MCP membership with
specialty physicians that were scheduled prior to the effective date of
membership; or
(e)
The
member is receiving ongoing chemotherapy or radiation treatment.
(ii)
MCPs
must reimburse these out-of-panel providers at 100% of the current Medicaid
fee-for-service provider rate for the service(s).
Appendix
C
Page
12
(a)
As
expeditiously as the situations warrant, MCPs must contact the providers'
offices via telephone to confirm that the services meet the above
criteria.
(b)
For
services that meet the above criteria, MCPs must inform the providers that
they
are sending a form for signature to document that they accept/do not accept
the
terms for the provision of the services and copy members on the
forms.
(c)
If
the providers agree to the terms, MCPs must notify the members and providers
of
the authorization and ensure that the claims processing system will not deny
the
claim payment because the providers are out-of-panel.
(d)
If
the providers do not agree to the terms. MCPs must notify the members and assist
the embers with locating a provider as expeditiously as the members' conditions
warrant.
(e)
MCPs
must use the ODJFS-specified model language for the provider and member
notices.
(f)
MCPs
must 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.
29.
Health
Information System Requirements
The
ability to develop and maintain information management systems capacity is
crucial to successful plan performance. OD.IFS therefore requires MCPs to
demonstrate their ongoing capacity in this area by meeting several related
specifications.
a.
Health
Information System
(i)
As
required by 42 CFR 438.242(a), each MCP must maintain a health information
system that collects, analyzes, integrates, and reports data. The system must
provide information on areas including, but not limited to, utilization,
grievances and appeals, and MCP membership terminations for other than loss
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.
Appendix
C
Page
13
(iii)
As
required by 42 CFR 438.242(b)(2), each MCP must ensure that data received from
providers is accurate and complete by verifying the accuracy and timeliness
of
reported data: screening the data for completeness, logic, and consistency;
and
collecting service information in standardized formats to the extent feasible
and appropriate.
(iv)
As
required by 42 CFR 438.242(b)(3), each MCP must make all collected data
available upon request by ODJFS or the Center for Medicare and Medicaid Services
(CMS).
(v)
Acceptance testing of any data that is electronically submitted to ODJFS is
required:
(a)
Before an MCP may submit production files
(b)
Whenever an MCP changes the method or prepare!" 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 flies in the ODJFS-specified formats. Once an acceptable
test file is submitted to 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 w'ill have
up
to 90 days to submit an acceptable test file and an acceptable production
file.
Submission
of test files can start before the new or modified information system is in
production. ODJFS reserves the right to verify any MCP's capability to report
elements in the minimum data set prior to executing the provider agreement
for
the next contract period. Penalties for noncompliance with this requirement
are
specified in Appendix "N, Compliance Assessment System of the Provider
Agreement.
b.
Electronic Data Interchange and Claims Adjudication Requirements
Claims
Adjudication
Appendix
C
Page
14
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 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)] w ithin one month of receipt. Such notification may be
in
the form of a claim payment/remittance advice produced on a routine monthly,
or
more frequent, basis.
Electronic
Data Interchange
The
MCP
shall comply with all applicable provisions of HIPAA including electronic data
interchange (EDI) standards for code sets and the following electronic
transactions:
Health
care claims;
Health
care claim status request and response:
Health
care payment and remittance status; and Standard code sets.
Each
EDI
transaction processed by the MCP shall be implemented in conformance with the
appropriate version of the transaction implementation guide, as specified by
federal 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 as outlined below.
Appendix
C
Page
15
Verification
of Compliance with HIPAA (Health Insurance Portability and Accountability Act
of
1995)
MCPs
shall submit written verification for transaction standards and code sets
specified in 45 CFR Part 162 - Health Insurance Reform: Standards for Electronic
Transactions (HIPAA regulations), that the MCP has established the capability
of
sending and receiving applicable transactions in compliance with the HIPAA
regulations. The written verification shall specify the date that the MCP has:
1) achieved capability for sending and/or receiving the following transactions,
2) entered into the appropriate trading partner agreements, and 3) implemented
standard code sets. If the MCP has obtained third-party certification of HIPAA
compliance for any of the items listed below, that certification may be
submitted in lieu of the MCP's written verification for the applicable
item(s).
1.
Trading Partner Agreements
2.
Code
Sets
3.
Transactions
a.
Health
Care Claims or Equivalent Encounter Information (ASCX12N837&NCPDP5.1)
b.
Eligibility fora Health Plan (ASC X12N 270/271)
c.
Referral Certification and Authorization (ASC X12N 278)
d.
Health
Care Claim Status (ASC X 12N 276/277)
e.
Enrollment and Disenrollment in a Health Plan (ASC X12N 834)
f.
Health
Care Payment and Remittance Advice (ASC X 12N 835)
g.
Health
Plan Premium Payments (ASC X12N 820)
h.
Coordination of Benefits
Trading
Partner Agreement with OD.1FS
MCPs
must
complete and submit an ED1 trading partner agreement in a format specified
by
the ODJFS. Submission of the copy of the trading partner agreement prior to
entering into the provider agreement may be waived at the discretion of ODJFS;
if submission prior to entering into the provider 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. ODJFS is required to collect
this data pursuant to federal requirements. MCPs are required to submit this
data electronically to ODJFS on a monthly basis in the following standard
formats:
Appendix
C
Page
16
•
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 and performance measures and standards
are
described in the MCP Provider 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 betw een 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. How'ever, 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 POP examines
the member and has laboratory procedures done within the office, then this
is
one encounter between the member and their PCP.
If
the
PCP sends the member to a lab to have procedures performed, then this is two
encounters; one with the PCP and another with the lab. For pharmacy encounters,
each prescription filled is a separate encounter.
Encounters
include services paid for retrospectively through fee-for-service payment
arrangements, and prospectively through capitated arrangements. Only encounters
with services (line items) that are paid by the MCP, fully or in part, and
for
which no further payment is anticipated, are acceptable encounter data
submissions, except for immunization services. Immunization services submitted
to the MCP must be submitted to ODJFS if these services were paid for by another
entity (e.g., free vaccine program).
All
other
services that are unpaid or paid in part and for which the MCP anticipates
further payment (e.g.. unpaid services rendered during a delivery of a newborn)
may not be submitted to ODJFS until they are paid. Penalties for noncompliance
with this requirement are specified in Appendix N, Compliance Assessment Svstem
of the Provider Agreement.
Appendix
C
Page
17
Acceptance
Testing
The
MCP
must have the capability to report all elements in the Minimum Data Set as
set
forth in the ODJFS Encounter Data Specifications and must submit a test file
in
the ODJFS-specified medium in the required formats prior to contracting or
prior
to an information systems replacement or update.
Acceptance
testing of encounter data is required as specified in Section 29(a)(v) of this
Appendix.
Encounter
Data File Submission Procedures
A
certification letter must accompany the submission of an encounter data file
in
the ODJFS-specified medium. The certification letter must be signed by the
MCP's
Chief Executive Officer (CEO), Chief Financial Officer (CFO). or an individual
who has delegated authority to sign for. and who reports directly to, the MCP's
CEO or CFO.
No
more
than two production files in the ODJFS-specified medium per format (e.g., NSF)
should be submitted each month. If it is necessary for an MCP to submit more
than two production files in the ODJFS-specified medium for a particular format
in a month, they must request permission to do so through their Contract
Administrator.
Timing
of Encounter Data Submissions
ODJFS
recommends that MCPs submit encounters no more than thirty-five 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
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 will be
carried out during the review. ODJFS or its desianee will:
Appendix
C
Page
18
(i)
Review the Information Systems Capabilities Assessment (ISCA) forms, as
developed by CMS; which the MCP will be required to complete.
(ii)
Review the completed ISCA and accompanying documents;
(iii)
Conduct interviews with MCP staff responsible for completing the ISCA, as well
as staff responsible for aspects of the MCP's information systems
function;
(iv)
Analyze the information obtained through the ISCA, conduct follow-up interviews
with MCP staff, and write a statement of findings about the MCP's information
system.
(v)
Assess the ability of the MCP to link data from multiple sources;
(vi)
Examine MCP processes for data transfers:
(vii)
If
an MCP has a data warehouse, evaluate its structure and reporting
capabilities;
(viii)
Review MCP processes, documentation, and data files to ensure that they comply
with state specifications for encounter data submissions; and
(ix)
Assess the claims adjudication process and capabilities of the MCP.
As
noted
above, the information system review may be performed every two years. However,
if ODJFS or its designee identifies significant information system problems.
then ODJFS or its designee may conduct, and the MCP must participate in, a
review the following year.
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
when the 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 w ith 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 w'ho
are
determined to be exempt from the IS review must participate in subsequent
information system reviews.
Appendix
C
Page
19
30.
Delivery
Payments
MCPs
will
be reimbursed for paid deliveries that are identified in the
submitted
encounters
using the methodology outlined in the ODJFS
Methods for Reimbursing for Deliveries
(as
specified in Appendix L). The delivery payment represents the facility and
professional service costs associated with the delivery event and postpartum
care that is rendered in the hospital immediately following the delivery event;
no prenatal or neonatal experience is included in the delivery
payment.
If
a
delivery occurred, but the MCP did not reimburse providers for any costs
associated with the delivery, then the MCP shall not submit the delivery
encounter to ODJFS and is not entitled to receive payment for the delivery.
MCPs
are required to submit all delivery encounters to ODJFS no later than one year
after the date of the delivery. Delivery encounters which are submitted after
this time will be denied payment. MCPs will receive notice of the payment denial
on the remittance advice.
If
an MCP
is denied payment through ODJFS' automated payment system because the delivery
encounter was not submitted within a year of the delivery date, then it will
be
necessary for the MCP to contact BMHC staff to receive payment. Payment will
be
made for the delivery, at the discretion of ODJFS if a payment had not been
made
previously for the same delivery.
To
capture deliveries outside of institutions (e.g., hospitals) and deliveries
in
hospitals without an accompanying physician encounter, both the institutional
encounters (UB-92) and the noninstitutional encounters (NSF) are searched for
deliveries.
If
a
physician and a hospital encounter is found for the same delivery, only one
payment will be made. The same is true for multiple births: if multiple delivery
encounters are submitted, only one payment will be made. The method for
reimbursing for deliveries includes the delivery ofstillboms where the MCP
incurred costs related to the delivery.
Rejections
If
a
delivery encounter is not submitted according to ODJFS specifications, it will
be
rejected
and MCPs will receive this information on the exception report (or error
report)
that
accompanies every file in the ODJFS-specified format. Tracking, correcting
and
resubmitting
all rejected encounters is the responsibility of the MCP and is required
by
ODJFS.
Timing
of Delivery Payments
MCPs
will
be paid monthly for deliveries. For example, payment for a delivery encounter
submitted with the required encounter data submission in March, will be
reimbursed in March. The delivery payment w'ill cover any encounters submitted
with the monthly encounter data submission regardless of the date of the
encounter, but will not cover encounters that occurred over one year
ago.
Appendix
C
Page
20
This
payment will be a part of the weekly update (adjustment payment) that is in
place currently. The third weekly update of the month will include the delivery
payment. The remittance advice is in the same format as the capitation
remittance advice.
Updating
and Deleting Delivery Encounters
The
process for updating and deleting delivery encounters is handled differently
from all other encounters. See the ODJFS
Encounter Data Specifications
for
detailed instructions on updating and deleting delivery encounters.
The
process for deleting delivery encounters can be found on page 35 of the LJB-92
technical specifications (record/field 20-7) and page 111-47 of the NSF
technical specifications (record/field CAO-31.0a).
Auditing
of Delivery Payments
A
delivery payment audit will be conducted periodically. If medical records do
not
substantiate that a delivery occurred related to the payment that was made,
then
ODJFS will recoup the delivery payment from the MCP. Also, if it is determined
that the encounter which triggered the delivery payment was not a paid
encounter, then ODJFS will recoup the delivery payment.
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 approval from ODJFS that verifies that the proper safeguards, firewalls,
etc.. are in place to protect member data.
32.
MCPs
must receive prior 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 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 ofinpatient
services until the date of discharge for a member who is institutionalized
when
insolvency occurs.
Appendix
C
Page
21
35.
Franchise
Fee Assessment Requirements
a.
Each
MCP is required to pay a franchise permit fee to ODJFS for each calendar quarter
in compliance with ORC Section 5111.176. The fee to be paid is an amount equal
to 4!/z percent of the managed care premiums, minus Medicare premiums that
the
MCP received from any payer in the quarter to \\hich 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
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.
Provider
Directory
- MCPs
must have an internet-based provider directory available in the same format
as
their ODJFS-approved provider directory, that allow's members to electronically
search for the MCP panel providers based on name. provider type, and geographic
proximity (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.
Member
Websitc - MCPs must have a secure internet-based website which is updated to
include the most current ODJFS approved materials. The website at a minimum
must
include: (1) a list of the counties that are covered in their service area;
(2)
the ODJFS-approved MCP member handbook, recent newsletters/announcements, MCP
contact information including member services hours and closures: (3) the MCP
provider directory as referenced in section 36(a) of this appendix; (4) the
MCP's current preferred drug list (PDL), including an explanation of the list,
which drugs require prior authorization (PA), and the PA process; (5) the MCP's
current list of drugs covered only with PA, the PA process, and the MCP's policy
for covering generic for brand-name drugs; and (6) the ability for members
to
submit questions/comments/grievances/appeals/etc, and receive a response
(members must be given the option of a return e-mail or phone call) within
one
working day of receipt.
Appendix
C
Page
22
c.
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.
37.
MCPs
must provide members w'ith 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.
APPENDIX
D
ODJFS
RESPONSIBILITIES
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 (G1S) software, if ODJFS determines that significant changes
have occurred in the availability of specific provider!} pes 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.
Appendix
D
Page
2
10.
On a
monthly basis. ODJFS will provide MCPs with an electronic Master Provider File
containing all the Ohio Medicaid fee-for-service providers, w'tiich includes
their Medicaid Provider Number, as well as all providers who have been assigned
a provider reporting number for encounter data purposes.
11.
It is
the intent of ODJFS to utilize electronic commerce for many processes
and
procedures
that are now limited by HIPAA privacy concerns to FAX, telephone, or 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 will 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.
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' 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.
13.
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
14. 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-Assigment
Limitations -
In order
to ensure market and program stability, ODJFS will limit an MCP's
auto-assignments if they meet any of the following enrollment
thresholds;
•
40%
of statewide
Covered
Families and Children (CFC) eligible population; and/or
•
60%
of
the CFC eligibles in
any region with two MCPs;
and/or
•
40%
of
the CFC eligibles in
any region with three MCPs.
Once
an
MCP meets one of these enrollment thresholds, the MCP will only be permitted
to
receive the additional new membership (in the region or statewide, as
applicable) through: (1) consumer-initiated enrollment; and (2) auto-assignments
which are based on previous enrollment in that MCP or an historical provider
relationship w ith a provider w ho is not on the panel of any other MCP in
that
region. In the event that all MCPs in a region meet one or more of these
enrollment thresholds, ODJFS reserves the right to not impose the
auto-assignment limitation and to 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 ccr.s
to
MCPs
on no less than a weekly basis. The CCRs are a record of each consumer-initiated
MCP enrollment, change, or termination, and each SSC-initiated MCP assignment
processed through the SSC. The CCR contains information that is not included
on
the monthly member roster.
d.
Monthly
member roster (MR):
ODJFS
verifies managed care plan enrollment on a monthly basis via the monthly
membership roster. ODJFS or its designated entity provides a full member roster
(F) and a change roster (C) via HIPAA 834 compliant transactions.
e.
Monthly
Premiums and Delivery Payments:
ODJFS
will remit payment to the MCPs via an electronic funds transfer (EFT), or at
the
discretion of ODJFS, by paper warrant.
Appendix
D
Page
4
f.
Remittance
Advice:
ODJFS
will confirm all premium payments and delivery payments paid to the MCP during
the month via a monthly remittance advice (RA), which is sent to the MCP the
week following state cut-off. ODJFS or its designated entity provides a record
of each payment via HIPAA 820 compliant transactions.
g.
MCP
Reconciliation Assistance:
ODJFS
will work with an MCP-designated contact(s) to resolve the MCP's member and
newborn eligibility inquiries, premium and delivery payment
inquiries/discrepancies and to review/approve hospital deferment
requests.
15.
ODJFS
will make available a website which includes current program
information.
16.
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.
17.
ODJFS
will periodically review a random sample of online and printed directories
to
ensure that MCP information is both accessible and updated.
18.
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
Contract Administrator (CA) has been assigned to each MCP. Unless specifically
directed otherwise. MCPs are to 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 w ithin the
Contract Administration Section.
b.
ODJFS
contracting-entities:
ODJFS-contracting entities should never be contacted by the MCPs unless the
MCPs
have been specifically informed to contact the ODJFS contracting entity
directly. Ensuring that MCP staff know to contact their CA will help ensure
that
the MCP does not receive conflicting, inaccurate, or incomplete information
as a
result of conversing with ODJFS staff (and ODJFS-contracting entities) w'ho
do
not have the full context and/or understanding of the managed care program.
Because MCPs are ultimately responsible for meeting program requirements, the
BMHC will not discuss MCP issues with the
Appendix
D
Page
5
MCPs'
delegated entities unless the applicable MCP is also participating in the
discussion.
|
▇▇▇▇▇▇
|
|
|
Government
Human Services Consulting
|
▇▇▇
▇▇▇▇▇ ▇▇▇ ▇▇▇▇▇▇, ▇▇▇▇▇ ▇▇▇▇
▇▇▇▇▇▇▇▇▇▇▇.
▇▇ ▇▇▇▇▇
▇▇▇.▇▇▇▇▇▇▇▇.▇▇▇
|
October
12, 2006
▇▇.
▇▇▇
▇▇▇▇▇▇
Bureau
of
Managed Health Care
Ohio
Department of Job and Family Services
▇▇▇
▇▇▇▇
▇▇▇▇ ▇▇▇▇▇▇. ▇▇▇ ▇▇▇▇▇
▇▇▇▇▇▇▇▇,
▇▇ ▇▇▇▇▇-▇▇▇▇
Subject:
Supplemental
Certification for Contract Period 2006 Regional Rates - Final &
Confidential
Dear
▇▇▇:
▇▇▇▇▇▇
Government Human Services Consulting (▇▇▇▇▇▇) provided the Ohio Department
of
Job and Family Services (ODJFS) with a rate certification letter dated June
14.
2006. The letter described the analysis and methodology used by ▇▇▇▇▇▇ in
developing regional capitation rates for the Healthy Families and Healthy Start
managed care populations.
At
that
time, the contract period and effective date were known for only one of the
eight regions, East-Central. The contract period for the East-Central region
w
'as July 1, 2006 - December 31, 2006. Effective August 1, 2006, ODJFS expanded
managed care for these populations into two more regions, Southwest and
West-Central. ▇▇▇▇▇▇ provided ODJFS with a supplemental certification for these
regions dated July 12, 2006. ▇▇▇▇▇▇ also provided ODJFS with supplemental
certifications dated August 11, 2006 and September 12, 2006 for rates developed
for the Southeast and Northwest regions, respectively, with an effective period
of October 1. 2006 - December 31, 2006.
ODJFS
is
now set to expand managed care for the Healthy Families and Health Start
populations into the sixth region (Northeast) starting November 1. 2006. This
supplemental certification presents the rates developed for the Northeast region
with an effective period of November 1, 2006 - December 31, 2006.
The
June
14, 2006 certification is still applicable and valid, as the overall rating
methodology has not changed. ▇▇▇▇▇▇ made two modifications to the rating
methodology due to the change in the effective date and ramp-up schedule. The
first change was the inclusion of two additional months of trend to reflect
the
November 1, 2006 start date. instead of July 1, 2006. The second and only other
change made was an update to the voluntary selection factors based on the new
effective date and the current
▇▇▇▇▇▇
Government
Human Services Consulting
Page
2
October
12,2006
▇▇.
▇▇▇
▇▇▇▇▇▇
Bureau
of
Managed Health Care
penetration
level within the Northeast region. The voluntary selection factors for this
region are displayed in the following table.
|
Region
|
Projected
Penetration
|
Voluntary
Selection Adjustment
|
||
|
FFS
|
Encounter
|
Cost
Report
|
||
|
Northeast
|
76%
|
-9.2%
|
0.9%
|
0.9%
|
All
other
steps in the rate development process are consistent with the methodology
presented in the June 14 letter. A summary of the Northeast rates for November
1, 2006 - December 31, 2006 is presented in Appendix ▇.
▇▇▇▇▇▇
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. ▇▇▇▇▇▇ has developed
these
rates on behalf of ODJFS to demonstrate compliance with the Centers for Medicare
and Medicaid Services (CMS) requirements under 42 CFR 438.6(c) and to
demonstrate that the rates are in accordance with applicable law and
regulations.
MCPs
are
advised that the use of these rates may not be appropriate for their particular
circumstance and ▇▇▇▇▇▇ disclaims any responsibility for the use of these rates
by MCPs for any purpose. ▇▇▇▇▇▇ recommends any MCP considering contracting
with
ODJFS 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 ODJFS. Use of these rates for purposes beyond that
stated may not be appropriate.
If
you
have any questions, please contact ▇▇▇▇▇ ▇▇▇▇▇▇▇ at ▇▇▇ ▇▇▇ ▇▇▇▇ or ▇▇▇▇▇ ▇▇▇▇▇▇
at ▇▇▇ ▇▇▇▇▇▇▇.
Sincerely,
|
/s/
▇▇▇▇▇▇ ▇▇▇▇▇▇▇
|
/s/
▇▇▇▇▇ ▇▇▇▇▇▇
|
|
▇▇▇▇▇▇
▇▇▇▇▇▇▇, ASA, MAAA
|
▇▇▇▇▇
▇▇▇▇▇▇, FSA, MAAA
|
Copy:
▇▇▇▇▇▇
▇▇▇▇▇▇, ▇▇▇▇▇ ▇▇▇▇▇▇ - ODJFS ▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇ ▇▇▇▇▇▇▇▇▇ - ▇▇▇▇▇▇
State
of
Ohio
Final
& Confidential
Appendix
A
November
1, 2006 - December 31, 2006 Regional Rates
|
Region
|
Rate
Cohort
|
Annualized
April 2006 Managed Care
MM/Delv
|
%
of Member
Months
|
November
1, 2006 - December 31, 2006
Guaranteed
Rate
|
November
1, 2006
December
31, 2006 Rate At Risk
|
November
1, 2006 -
December
31, 2006
Rate
w/ Admin and 2006
Franchise
Fee
|
|
Northeast
|
HF/HST,
Age 0, M & F
|
123,246
|
5.2%
|
$
577.16
|
$
5.57
|
$
582.73
|
|
Northeast
|
HF/HST,
Age 1, M &F
|
107,766
|
4.5%
|
$
147.25
|
$
1.42
|
$
148.67
|
|
Northeast
|
HF/HST,
Age 2-13, M &F
|
1,112,861
|
46.7%
|
$
92.71
|
$
0.89
|
$
93.60
|
|
Northeast
|
HF/HST,
Age 14-18, M
|
179,728
|
7.5%
|
$
99.79
|
$
0.96
|
$
100.75
|
|
Northeast
|
HF/HST,
Age 14-18, F
|
190,200
|
8.0%
|
$
158.21
|
$
1.53
|
$
159.73
|
|
Northeast
|
HF,Age
19-44, M
|
110,384
|
4.6%
|
$
175.50
|
$
1.69
|
$
177.19
|
|
Northeast
|
HF,Age
19-44, F
|
463,912
|
19.5%
|
$
265.95
|
$
2.56
|
$
268.51
|
|
▇▇▇▇▇▇▇▇▇
|
▇▇,▇▇▇▇▇▇,
M&F
|
60,998
|
2.6%
|
$
401.44
|
$
3.87
|
$
405.31
|
|
Northeast
|
HST.Age
19-64, F
|
33,295
|
1.4%
|
$
351.88
|
$
3.39
|
$
355.27
|
|
Northeast
|
Subtotal
|
2,382,389
|
100.0%
|
$
175.10
|
$
1.69
|
$
176.78
|
|
Northeast
|
Delivery
Payment
|
7,377
|
0.3%
|
$
5,168.45
|
$
49.83
|
$
5,218.29
|
|
Northeast
|
Total
|
2,382,389
|
100.0%
|
$
191.10
|
$
1.84
|
$192.94
|
▇▇▇▇▇▇
Government Human Services Consulting
A-1
APPENDIX
F
REGIONAL
RATES
1.
PREMIUM RATES WITHOUT THE AT-RISK PAYMENT AMOUNTS FOR 11/01/06, THROUGH
12/31/06, SHALL BE AS FOLLOWS;
An
at-risk amount of 1% is applied to the MCP rates. The status of the at-risk
amount is determined in accordance with Appendix 0, performance
incentives.
MCP:
WellCare of Ohio, lnc.
|
SERVICE
ENROLLMENT AREA
|
VOLUNTARY/
MANDATORY**
|
HF/HST
Age
< 1
|
HF/HST
Age
1
|
HF/HST
Age
2-13
|
HF/HST
Age
14-18 Male
|
HF/HST
Age
14-18 Female
|
HF
Age
19-44 Male
|
HF
Age
19-44 Female
|
HF
Age
45 and over
|
HST
Age
19-64 Female
|
Delivery
Payment
|
|
Northeast
|
Mandatory
|
S589.42
|
$150.38
|
$94.68
|
$101.91
|
$161.57
|
$179.22
|
$271.60
|
$409.97
|
$359.36
|
$5,278.27
|
|
|
|
|
|
|
|||||||
List
of Eligible Assistance Groups (AGs)
|
Healthy
Families:
|
-
MA-C Categorically eligible due to ADC cash
-
MA-T Children under 21
-
MA-Y Transitional Medicaid
|
|
Healthy
Start:
|
-
MA-P Pregnant Women and Children
|
Note:
An
MCP's county membership for this program must not exceed their Primary Care
Physician (PCP) capacity for that county as verified by the ODJFS provider
database.
For
the
SPY 2007 contract period. MCPs will be put al-risk for a portion of the premiums
received for members in counties they served as of January 1, 2006, provided
the
MCP has participated in the program for more than twenty-four
months.
MCPs
will
be put at-risk for a portion of the premiums received for members in counties
they began serving after January 1, 2006, beginning with the MCP's twenty-fifth
month of membership in each county's region.
Page
1 of
3
APPENDIX
F
REGIONAL RATES
2.
AT-R1SK AMOUNTS FOR 11/01/06, THROUGH 12/31/06, SHALL BE AS
FOLLOWS:
An
at-risk amount of 1% is applied to the MCP rates. The status of the at-risk
amount is determined in accordance with Appendix 0, performance
incentives.
MCP:
WellCare of Ohio, Inc.
AT-RISK
AMOUNTS*
|
SERVICE
ENROLLMENT AREA
|
VOLUNTARY/
MANDATORY**
|
HF/HST
Age<
1
|
HF/HST
Age
1
|
HF/HST
Age
2-13
|
HF/HST
Age
14-18 Male
|
HF/HST
Age
14-18 Female
|
HF
Age
19-44 Male
|
HF
Age
19-44 Female
|
HF
Age
45 and over
|
HST
Age
19-64 Female
|
Delivery
Payment
|
|
Northeast
|
Mandatory
|
$0.00
|
$0.00
|
$0.00
|
$0.00
|
$0.00
|
$0.00
|
$0.00
|
$0.00
|
$0.00
|
$0.00
|
|
List
of Eligible Assistance Groups (AGs)
|
|
|
Healthy
Families:
|
-
MA-C Categorically eligible due to ADC cash
-
MA-T Children under 21
-
MA-Y Transitional Medicaid
|
|
Healthy
Start:
|
-
MA-P Pregnant Women and Children
|
Note:
An
MCP's county membership for this program must not exceed their Primary Care
Physician (PCP) capacity for that county as verified by the ODJFS provider
database.
For
the
SFY 2007 contract period, MCPs will be put at-risk for a portion of the premiums
received for members in counties they served as of January 1, 2006, provided
the
MCP has participated in the program for more than twenty-four
months.
MCPs
will
be put at-risk for a portion of the premiums received for members in counties
they began serving after January 1, 2006, beginning with the MCP's twenty-fifth
month of membership in each county's region.
Page
2 of
3
APPENDIX
F
REGIONAL
RATES
3.
PREMIUM RATES* FOR 11/01/06, THROUGH 12/31/06, SHALL BE AS FOLLOWS:
An
at-risk amount of 1% is applied to the MCP rates. The status of the at-risk
amount is determined in accordance with Appendix 0, performance
incentives.
MCP:
WellCareofOhio.lnc.
|
SERVICE
ENROLLMENT AREA
|
VOLUNTARY/
MANDATORY**
|
HF/HST
Age<
1
|
HF/HST
Age
1
|
HF/HST
Age
2-13
|
HF/HST
Age
14-18 Male
|
HF/HST
Age
14-18 Female
|
HF
Age
19-44 Male
|
HF
Age
19-44
Female
|
HF
Age
45 and over
|
HST
Age
19-64 Female
|
Delivery
Payment
|
|
Northeast
|
Mandatory
|
$589.42
|
$150.38
|
$94.68
|
$101.91
|
$161.57
|
$179.22
|
$271.60
|
$409.97
|
$359.36
|
$5,278.27
|
List
of Eligible Assistance Groups (AGs)
|
Healthy
Families:
|
-
MA-C Categorically eligible due to ADC cash
-
MA-T Children under 21
-
MA-Y Transitional Medicaid
|
|
Healthy
Start:
|
-
MA-P Pregnant Women and Children
|
Note:
An
MCP's county membership for this program must not exceed their Primary Care
Physician (PCP) capacity for that county as verified by the ODJFS provider
database.
For
the
SFY 2007 contract period, MCPs will be put at-risk for a portion of the premiums
received for members in counties they served as of January 1, 2006, provided
the
MCP has participated in the program for more than twenty-four
months.
MCPs
will
be put at-risk for a portion of the premiums received for members in counties
they began serving after January 1. 2006, beginning with the MCP's twenty-fifth
month of membership in each county's region.
Page
3 of
3
APPENDIX
G
COVERAGE
AND SERVICES
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 BMHC page
of
the ODJFS website. The following is a general list of the benefits covered
by
the Ohio Medicaid fee-for-service program:
•
Inpatient hospital services
•
Outpatient hospital services
•
Rural
health clinics (RHCs) and Federally qualified health centers
(FQHCs)
•
Physician services whether furnished in the physician's office, the covered
person's home, a hospital, or elsewhere
•
Laboratory and x-ray services
•
Screening, diagnosis, and treatment services to children under the age of
twenty-one (21) under the HealthChek (EPSDT) program
•
Family
planning services and supplies
•
Home
health services
•
Podiatry
•
Chiropractic services [not covered for adults age twenty-one (21) and
older]
•
Physical therapy, occupational therapy, and speech therapy
•
Nurse-midwife, certified family nurse practitioner, and certified pediatric
nurse practitioner services
•
Prescription drugs
•
Ambulance and ambulette services
•
Dental
services
•
Durable
medical equipment and medical supplies
•
Vision
care services, including eyeglasses
Appendix
G
Page
2
•
Short-term rehabilitative stays in a nursing facility
•
Hospice
care
•
Behavioral health services (see section G.2.b.iii of this appendix). Note:
Independent psychologist services not covered for adults age twenty-one (21)
and
older.
2.
Exclusions.
Limitations and Clarifications
a.
Exclusions
MCPs
are
not required to pay for Ohio Medicaid FFS program (Medicaid) non-covered
services. For information regarding Medicaid noncovered services. MCPs must
refer to the BMHC page of 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(0) and 5101:3-26-12. MCPs are permitted
to
impose the applicable member co-payment amount(s) for dental services, vision
services, non-emergency emergency department services, or prescription drugs,
other than generic drugs. MCPs must notify 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 ofw'hen 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 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/psychologist/psychiatrist services, outpatient clinic services,
general hospital outpatient psychiatric services, pre-hospitalization screening,
diagnostic assessment (clinical evaluation), crisis intervention, psychiatric
hospital ization in general hospitals (for all ages), and Medicaid-covered
prescription drugs and laboratory services. MCPs are not required to cover
partial hospitalization, or inpatient psychiatric care in a free-standing
psychiatric hospital.
Substance
Abuse Services:
There
are a number of various Medicaid-covered substance abuse services available
through ODADAS-certified Medicaid providers.
Where
an
MCP is responsible for providing substance abuse services for their members,
the
MCP is responsible for ensuring access to alcohol and other drug (AOD)
urinalysis screening, assessment, counseling,
physician/psychologist/psychiatrist AOD treatment services, outpatient clinic
AOD treatment services, general hospital outpatient AOD treatment services,
crisis intervention, inpatient detoxification services in a general hospital,
and Medicaid-covered prescription drugs and laboratory services. MCPs are not
required to cover outpatient detoxification and methadone
maintenance.
Financial
Responsibility: MCPs are responsible for the payment .of Medicaid-covered
prescription drugs prescribed by a CMHC or ODADAS-certified provider when
obtained through an MCP's panel pharmacy. MCPs are also responsible for the
payment of Medicaid-covered services provided by an MCP's panel laboratory
when
referred by a CMHC or ODADAS-certified provider. Additionally, MCPs are
responsible for the payment of all other behavioral health services obtained
through providers other than those who are CMHC or ODADAS-certified providers
when 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 use the
same
fundamental drug formulary as the Ohio Medicaid fee-for-service
program.
Appendix
G
Page
6
MCPs
may
establish a preferred drug list for members and providers which includes a
listing of the drugs that they prefer to have prescribed. Preferred drugs
requiring prior authorization approval must be clearly indicated as such.
Pursuant to ORC §5111.72. ODJFS may approve MCP-specific pharmacy program
utilization management strategies (see appendix G.3.a).
v.
Organ
Transplants:
MCPs
must ensure coverage for organ transplants and related services in accordance
with OAC 5101-3-2-07.1 (B)(4)&(5). Coverage for all organ transplant
services, except kidney transplants, is contingent upon review and
recommendation by the "Ohio Solid Organ Transplant Consortium" based on criteria
established by Ohio organ transplant surgeons and authorization from the ODJFS
prior authorization unit. Reimbursement for bone marrow transplant and
hematapoietic stem cell transplant services, as defined in OAC 3701:84-01.
is
contingent upon review and recommendation by the "Ohio Hematapoietic Stem Cell
Transplant Consortium" again based on criteria established by Ohio experts
in
the field of bone marrow transplant. While MCPs may require prior authorization
for these transplant services, the approval criteria would be limited to
confirming the consumer is being considered and/or has been recommended for
a
transplant by either consortium and authorized by ODJFS. Additionally, in
accordance with OAC 5101:3-2-03 (A)(4) all services related to organ donations
are covered for the donor recipient when the consumer is Medicaid
eligible.
3. Care
Coordination
a.
Utilization
Management (Modification) Programs
General
Provisions - Pursuant to OAC rule 5101:3-26-03.1(A)(7). MCPs must implement
the
ODJFS-required emergency department diversion (EDD) utilization management
program to maximize the effectiveness of the care provided to members and may
develop other utilization management programs, subject to prior approval by
ODJFS. For the purposes of tills 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
Appendix
G
Page
7
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.
Prior
Authorizations:
MCPs
must receive prior approval from ODJFS on the types of medication that they
wish
to cover through prior authorizations. MCPs must establish their prior
authorization system so that it does not unnecessarily impede member access
to
medically-necessary medicaid-covered services.
MCPs
must
comply with the provisions of 1927(d)(5) of the Social Security Act. 42 USC
1396r-8(k)(3), and OAC rule 5101:3-26-03.1 regarding the timeframes for prior
authorization of covered outpatient drugs.
MCPs
may
also, w ith ODJFS prior approval, implement pharmacy utilization modification
programs designed to address members demonstrating high or inappropriate
utilization of specific prescription
drugs.
Emergency
Department Diversion (EDD)
- MCPs
must provide access to services in a way that assures access to primary,
specialist and urgent care in the most appropriate settings and that minimizes
frequent, preventable utilization of emergency department (ED) services. OAC
rule 5101:3-26-03.1(A)(7)(d) requires MCPs to implement the ODJFS-required
emergency department diversion (EDD) program for frequent
utilizers.
Each
MCP
must establish an ED diversion (EDD) program with the goal of minimizing
frequent ED utilization. The MCP's EDD program must include the monitoring
of ED
utilization, identification of frequent ED utilizers, and targeted approaches
designed to reduce avoidable ED utilization. MCP EDD programs must. at a
minimum, address those ED visits which could have been prevented through
improved education, access, quality or care management approaches.
Although
there is often an assumption that frequent ED visits are solely the result
of a
preference on the part of the member and education is therefore the standard
remedy, it is also important to ensure that a member's frequent ED utilization
is not due to problems such as their PCP's lack of accessibility or failure
to
make appropriate specialist referrals. The MCP's EDD program must therefore
also
include the identification of providers who serve as PCPs for a substantial
number of frequent ED utilizers and the implementation of corrective action
with
Appendix
G
Page
8
these
providers as so indicated.
This
requirement does not replace the MCP's responsibility to inform and educate
all
members regarding the appropriate use of the ED.
b.
Case
Management
In
accordance with 5101:3-26-03.1(A)(8), MCPs must offer and provide case
management services which coordinate and monitor the care of members with
specific diagnoses, or who require high-cost and/or extensive
services.
i.
Each
MCP must inform all members and contracting providers of the MCP's case
management services.
ii..
The
MCP's case management system must include, at a minimum, the follow'ing
components:
a.
specification of the criteria used by the MCP to identify those potentially
eligible for case management services, including diagnosis. cost threshold
and/or amount of service utilization, and the methodology or process (e.g.
administrative data, provider referrals, self-referrals) used to identify the
members who meet the criteria for case management;
b.
a
process for comprehensive assessment of the member's health condition to confirm
the results of a positive identification, and determine the need for case
management, including information regarding the credentials of the staff
performing the assessments of CSHCN;
c.
a
process
to inform members and their PCPs in writing that they have been identified
as
meeting the criteria for case management^ including their enrollment into case
management services;
d.
the
procedure by which the MCP will assure the timely development of a care
treatment plan for any member receiving case management services; offer both
the
member and the member's PCP/specialist the opportunity to participate in the
care treatment plan's development based on the
Appendix
G
Page
9
health
needs assessment; and provide for the periodic review of the member's need
for
case management and updating of the care treatment plan;
e.
a
process
to facilitate, maintain, and coordinate communication between service providers,
and member/family, including an accountable point of contact to help obtain
medically necessary care. and assist with health-related services and coordinate
care needs.
iii.
MCPs
must submit a monthly electronic report to the Case Management System (CAMS)
for
all members who are case managed by the MCP as outlined in the ODJFS
"Case
Management File and Submission Specifications."
The CAMS
tiles are due the 1011
business
day of each month.
iv.
MCPs
must have an ODJFS-approved case management system which includes the items
in
Section G.3.b.i. and Section G.3.b.ii. of this Appendix. Each MCP must implement
an evaluation process to review, revise and/or update the case management
program. The MCP must annually submit its case management program for review
and
approval by ODJFS. Any subsequent changes to an approved case management system
description must be submitted to ODJFS in writing for review and approval prior
to implementation.
c.
Children
with Special Health Care Needs
Children
with special health care needs (CSHCN) are a particularly vulnerable population
which often have chronic and complex medical health care conditions. In order
to
ensure state compliance with the provisions of 42 CFR 438.208. ODJFS has
implemented program requirements for the identification, assessment, and case
management of CSHCN.
Each
MCP
must establish a CSHCN program with the goal of conducting timely identification
and screening, assuring a thorough and comprehensive assessment, and providing
appropriate and targeted case management services for any CSHCN.
Appendix
G
Page
10
i.
Definition of CSHCN
CSHCN
are
defined as children age 17 and under who are pregnant, and members under 21
years of age with one or more of the following:
| · |
Asthma
|
| · |
HIV/AIDS
|
| · |
A
chronic physical, emotional, or mental condition for which they need
or
are receiving treatment or
counseling
|
| · |
Supplemental
security income (SS1) for a health-related
condition
|
| · |
A
current letter of approval from the Bureau of Children with Medical
Handicaps (BCMH). Ohio Department of
Health
|
ii.
Identification of CSHCN
All
MCPs
must implement mechanisms to identify CSHCN.
MCPs
are
expected to use a variety of mechanisms to identify children that meet the
definition of CSHCN and are in need of a follow-up assessment including: MCP
administrative review; information as reported by the SSC during membership
selection; PCP referrals; outreach; and contacting newly-enrolled children.
The
MCP must annually submit the process used to identify and assess CSHCN for
review and approval by OD.IFS as part of their CSHCN program.
iii.
Assessment of CSHCN
All
MCPs
must implement mechanisms to assess children with a positive identification
as a
CSHCN. A positive assessment confirms the results of the positive identification
and should assist the MCP in determining the need for case
management.
This
assessment mechanism must include, at a minimum:
•
The
use
of the ODJFS
CSHCN Standard Assessment Tool
to
assess all children with a positive identification using the methods described
in Section 2.c., Children with Special Health Care Needs, of this appendix
as
having a
Appendix
G
Page
11
condition
that may warrant case management. See ODJFS CSHCN Program Requirements for
a
description of the ODJFS
CSHCN Standard Assessment Tool.
•
Completion of the assessment by a physician, physician assistant, RN, LPN,
licensed social worker, or a graduate of a two or four year allied health
program.
•
The
oversight and monitoring by either a registered nurse or a physician, if the
assessment is completed by another medical professional.
iv.
Case
Management of CSHCN
All
MCPs
must implement mechanisms to provide case management services for all CSHCN
with
a positive assessment, including those children with an ODJFS mandated
condition. The ODJFS mandated conditions for case management are HIV/A1DS,
asthma, and pregnant teens as specified by the ODJFS methods outlined in
Appendix M Case Management System Performance Measures. This case management
mechanism must include, at a minimum:
•
The
components required in Section 3. b., Case Management, of this
Appendix.
•
Case
management of CSHCN must include at a minimum, the elements listed in the
Minimum
Case Management Components
document. See ODJFS
CSHCN Program Requirements
for a
description of the Minimum
Case ^Management Components.
v.
Access
to Specialists for CSHCN
All
MCPs
must implement mechanisms to notify all CSHCN with a positive assessment and
determined to need case management of their right to directly access a
specialist. Such access may be assured through, for example, a standing referral
or an approved number of visits, and documented in the care treatment
plan.
Appendix
G
Page
12
vi.
Submission of Data on CSHCN
MCPs
must
submit to ODJFS all case management records as specified by the ODJFS
Case Management File and Submission Specifications.
vii.
MCPs
must have an ODJFS-approved CSHCN system which includes the items specified
in
Section G.3.c.ii-vi of this Appendix. Each MCP should implement an evaluation
process to review, revise and/or update the CSHCN program. The MCP must annually
submit its CSHCN program for review and approval by ODJFS. Any subsequent
changes to an approved CSHCN system description must be submitted to ODJFS
in
writing for review and approval prior to implementation.
d.
Care
Coordination with ODJFS-Designated Providers
Per
OAC
rule 5101:3-26-03.1(A)(4). MCPs are required to share specific information
with
certain ODJFS-designated non-contracting providers in order to ensure that
these
providers have been supplied with specific information needed to coordinate
care
for the MCP's members. Within the first month of operation, after an MCP has
obtained a provider agreement, the MCP must provide to the ODJFS-designated
providers (i.e., ODMH Community Health Centers. ODADAS-certified Medicaid
providers. FQHCs/RHCs. QFPPs. CNMs. CNPs [if applicable]. and hospitals) a
quick
reference information packet which includes the following:
i.
A
brief cover letter explaining the purpose of the mailing; and
ii.
A
brief summary document that includes the following information:
•
Claims
submission information including the MCP's Medicaid provider number for each
region;
•
The
MCP's prior authorization and referral procedures or the MCP's website which
includes this information;
•
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
Appendix
G
Page
13
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.
APPENDIX
H
PROVIDER
PANEL SPECIFICATIONS
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 minimum pediatrician
requirement but a member is unable to obtain a timely appointment from a
pediatrician on the MCP's provider panel in that, the MCP will be required
to
secure an appointment from a panel pediatrician or arrange for an out-of-panel
referral to a pediatrician.
MCPs
are required
to make
transportation available to any member that must
travel
30 miles or more from their home to receive a medically-necessary
Medicaid-covered service. If the MCP offers transportation to their members
as
an additional benefit and this transportation benefit only covers a limited
number of trips, the required transportation listed above may
not
be
counted toward this trip limit (as specified in Appendix C).
In
developing these minimum provider panel requirements. ODJFS considered, on
a
county-by-county basis, the population size and utilization patterns of the
Covered Families and Children (CFC) consumers, as well a.s the potential
availability of the designated provider types. ODJFS has tried to integrate
existing utilization patterns into the minimum provider network requirements
to
avoid disruption of care. Most provider panel requirements, therefore, 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.
Although
ODJFS does offer some latitude in where the minimum required provider panel
members may be located, MCPs are strongly urged to consider the importance
of
geographic accessibility and existing utilization patterns in developing their
entire provider panel.
Available and accessible providers have been found to be the essential element
in attracting and retaining members.
2.
PROVIDER SUBCONTRACTING
Unless
otherwise specified in this appendix or OAC rule 5101:3-26-05, all MCPs will
be
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
Appendix
H
Page
2
Medicaid
Addendum. The Model Medicaid Addendums incorporate all applicable Ohio
Administrative Code rule requirements specific to provider subcontracting and
therefore cannot be modified except to add personalizing information such as
the
MCP's name.
ODJFS
must prior approve all MCP providers in the ODJFS- required provider type
categories before they can begin to provide services to that MCP's members.
MCPs
may not employ or contract with providers excluded from participation in Federal
health care programs under either section 1128 or section 1128A of the Social
Security Act. As part of the prior approval process, MCPs must submit
documentation verifying that all necessary contract documents have been
appropriately completed. ODJFS will verify the approvability of the submission
and process this information using the ODJFS Provider Verification System (PVS).
The PVS is a 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
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
initiated 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. If an MCP determines
that
an ODJFS-approved provider does not meet credentialing requirements they must
notify ODJFS within one working day of this determination.
MCPs
must
notify ODJFS of the addition and deletion of their contracting providers as
specified in OAC rule 5101:3-26-05. and must notify ODJFS within one working
day
in instances where the MCP has identified that they are not in compliance with
the provider panel requirements specified in this appendix.
3.
PROVIDER
PANEL REQUIREMENTS
The
provider network criteria that must be met by each MCP are as
follows:
a.
Primary
Care Physicians (PCPs)
Primary
Care Physicians (PCPs) may be individuals or group practices/clinics [Primary
Care Clinics (PCCs)]. Acceptable specialty types for PCPs are family/general
practice, internal medicine, pediatrics and obstetrics/gynecology(OB/GYMs).
As
part of their subcontract w'ith 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.
Appendix
H
Page
3
In
determining whether an MCP has sufficient PCP capacity for a region, ODJFS
considers a physician who can serve as a PCP for 2000 Medicaid MCP members
as
one full-time equivalent (FTE).
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 will allow up to an additional 750 member capacity for
each
nurse practitioner or physician's assistant that is used to provide clinical
support for a PCP.
For
PCPs
contracting with more than one MCP. the MCP must ensure that the capacity figure
stated by the PCP in their subcontract reflects only the capacity the PCP
intends to provide for that one MCP. ODJFS utilizes each approved PCP's capacity
figure to determine if an MCP meets the minimum 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. 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
minimum PCP requirement is based on an MCP having sufficient PCP capacity to
serve 55% of the eligibles in the region. At a minimum, each MCP must meet
both
the PCP minimum FTE requirement for that region, and a minimum ratio of one
PCP
FTE for each 2,000 of their Medicaid members in that region. MCPs must also
satisfy a PCP geographic accessibility standard. ODJFS will match the PCP
practice sites and the stated PCP capacity with the geographic location of
the
eligible population in that region (on a county-specific basis) and perform
analysis using Geographic Information Systems (GIS) software. The analysis
will
be used to determine if at least 40% of the eligible population is located
within 10 miles of PCP with available capacity in urban counties and 40% of
the
eligible population within 30 miles of a PCP with available capacity in rural
counties. [Rural areas are defined pursuant to 42 CFR
412.62(t)(l)(iii).]
In
addition to the PCP FTE capacity requirement. MCPs must also contract with
the
specified number
of
pediatric PCPs for each region. These pediatric PCPs will have their stated
capacity counted toward the PCP FTE requirement.
A
pediatric PCP must maintain a general pediatric practice (e.g.. a pediatric
neurologist would not meet this definition unless this physician also operated
a
practice as a general pediatrician) at a site(s) located within the
county/region and be listed as a pediatrician with the Ohio State Medical Board.
In addition, half of the minimum required number of pediatric PCPs must also
be
certified by the American Board of Pediatrics. The minimum provider panel
requirements for pediatricians are included in the practitioner charts in this
appendix.
b.
Non-PCP
Minimum Provider Network
In
addition to the PCP capacity requirements, each MCP is also required to maintain
adequate capacity in the remainder of its provider network within the following
categories: hospitals, dentists, pharmacies, vision care providers,
obstetricians/gynecologists (OB/GYNs), allergists. general surgeons,
otolaryngologists. orthopedists, certified nurse midwives (CNMs). certified
nurse practitioners (CNPs), federally qualified health centers (FQHCs)/rural
health centers (RHCs) and qualified family planning providers (QFPPs), CNMs,
CNPs, FQHCs/RHCs and QFPPs are federally-required provider types.
All
Medicaid-contracting MCPs must provide all medically-necessary Medicaid-covered
services to their members and therefore their complete provider network will
include many other additional specialists and provider types. MCPs must ensure
that all non-PCP network providers follow community standards in the scheduling
of routine appointments (i.e.. the amount of time members must wait from the
time of their request to the first available time when the visit can
occur).
Although
there are currently no FTE capacity requirements for any of the non-PCP required
provider types, MCPs are required to ensure that adequate access is available
to
members for all required provider types. Additionally, for certain non-PCP
required provider types, MCPs must ensure that these providers maintain a
full-time practice at a site(s) located in the specified county/region (i.e.,
the ODJFS-specified county within the region or anywhere within the region
if no
particular county is specified). A full-time practice is defined as one where
the provider is available to patients at their practice site(s) in the specified
county/region for at least 25 hours a week. ODJFS will monitor access to
services through a variety of data sources, including:
consumer
satisfaction surveys; member appeals/grievances/complaints and state hearing
notifications/requests; clinical quality studies; encounter data volume;
provider complaints, and clinical performance measures.
Appendix
H
Page
5
Hospitals
-
MCPs
must contract with the number and type of hospitals specified by ODJFS for
each
county/region. In developing these minimum hospital requirements, ODJFS
considered, on a county-by-county basis, the population size and utilization
patterns of the Covered Families and Children (CFC) consumers and integrated
the
existing utilization patterns into the minimum hospital network requirements
to
avoid disruption of care. For this reason, ODJFS may require that MCPs contract
w ith 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, then 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. For this provider panel requirement, the MCP
may
contract directly with the CNM or CNP providers, or with a physician or other
provider entity who is able to obligate the participation of a CNM or CNP.
If an
MCP does not contract for CNM or CNP services and such providers are present
within the region, the MCP will be required to allow members to receive CNM
or
CNP services outside of the MCP's provider network.
Contracting
CNMs must have hospital delivery privileges at a hospital under contract to
the
MCP in the region. The MCP must ensure a member's access to CNM and CNP services
if such providers are practicing within the region.
Vision
Care Providers -
MCPs
must contract with the specified number of ophthalmologists/optometrists for
each specified county/region , all of whom must maintain a full-time practice
at
a site(s) located in the specified county/region. All ODJFS-approved vision
providers must regularly perform routine eye exams. (MCPs w'ill be expected
to
contract with an adequate number of opthalmologists as part of their overall
provider panel, but only opthalmologists who regularly perform routine eye
exams
can be used to meet the minimum 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
Appendix
H
Page
6
contract
with an adequate number of optical dispensers located in the
region.
Denial
Care Providers -
MCPs
must contract with the specified number of dentists. In order to assure
sufficient access to adult MCP members, no more than two-thirds of the dentists
used to meet the minimum provider panel requirement may be pediatric
dentists.
Federally
Qualified Health Centers/Rural Health Clinics (FQHCs/RHCs) -
MCPs are
required to ensure member access to any federally qualified health center or
rural health clinic (FQHCs/RHCs). regardless of contracting status. Contracting
FQHC/RHC providers must be submitted for ODJFS approval via the PVS process.
(ODJFS maintains a list of FQHCs/RHCs on our website). 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 assure FQHC/RHC access to members, MCPs may require that their members
request a referral from their PCP in order to access FQHC/RHC providers;
however, such referral requests must be approved.
In
order
to ensure that any FQHC/RHC has the ability to submit a claim to ODJFS for
the
state's supplemental payment, MCPs must offer FQHCs/RHCs reimbursement pursuant
to the following:
•
MCPs
must provide expedited reimbursement on a service-specific basis in an amount
no
less than the payment made to other providers for the same or similar
service.
•
If
the
MCP has no comparable service-specific rate structure, the MCP must use the
regular Medicaid fee-for-service payment schedule for non-FQHC/RHC
providers.
•
MCPs
must make all efforts to pay FQHCs/RHCs as quickly as possible and not just
attempt to pay these claims within the prompt pay time frames.
MCPs
are
required to educate their staff and providers on the need to assure member
access to FQHC/RHC services.
Qualified
Family Planning Providers (QFPPs) -
All MCP
members must be permitted to self-refer to family planning services provided
by
a QFPP. A QFPP is defined as any public or not-for-profit health care provider
that complies with Title X guidelines/standards, and receives either Title
X
funding or family planning funding from the Ohio Department of Health. MCPs
must
reimburse all medically-necessary Medicaid-covered family planning services
provided to eligible members by a QFPP provider (including on-site pharmacy
and
diagnostic services) on a patient self-referral basis, irrespective 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
policies
Appendix
H
Page
7
and
procedures to preserve patient/provider confidentiality, and convey pertinent
information to the member's PCP and/or MCP.
Behavioral
Health Providers -
MCPs
must assure member access to all Medicaid-covered behavioral health services
for
members as specified in Appendix G.b.ii. Although ODJFS is aware that certain
outpatient substance abuse services may only be available through Medicaid
providers certified by the Ohio Department of Drug and Alcohol Addiction
Services (ODADAS) in some areas, MCPs must maintain an adequate number of
contracted mental health providers in the region to assure access for members
who are unable to timely access services or unwilling to access services through
community mental health centers. MCPs are advised not to contract with community
mental health centers as all services they provide to MCP members are to be
billed to ODJFS.
Other
Specialty Types (pediatricians, general surgeons, otolaryngologists, allergists,
and orthopedists) -
MCPs
must contract with the specified number of all other ODJFS designated specialty
provider types. In order to be counted toward meeting the minimum 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 and otolaryngologists must have admitting privileges
at a
hospital under contract with the MCP in the region.
4.
PROVIDER
PANEL EXCEPTIONS
ODJFS
may
specify minimum 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
1:0 meet or maintain certain minimum provider panel requirements in a particular
service area despite all reasonable efforts on their part to secure such
a
contract(s), and
·
when
notified by ODJFS. the provider(s) in question fails to provide a reasonable
argument why they would not contract with the MCP, and
·
the
MCP
presents sufficient assurances to ODJFS that their members will have adequate
access to the services in question.
If
an MCP
is unable to contract with or maintain a sufficient number of providers to
meet
the ODJFS-specified minimum provider panel criteria, the MCP may request an
exception to these criteria by submitting a provider panel exception request
as
specified by ODJFS. ODJFS w'ill review the exception request and determine
w
hether 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.
MCPs are
strongly
Appendix
H
Page
8
cautioned
against ceasing their recruitment efforts and submitting a provider panel
exception request unless they are confident that they can document that they
have truly exhausted all reasonable efforts to contract with the needed
provider(s). ODJFS' approval of a provider panel exception request does not
preclude the MCP from continuing to obtain contracts with providers of the
type(s) in question.
ODJFS
will aggressively monitor access to any services provided pursuant 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 ODJFS 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 with 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.
Appendix
H
Page
9
Printed
Provider Directory
Prior
to
receiving a provider agreement, all MCPs must develop a printed provider
directory that must be prior-approved by ODJFS. Once approved, this directory
may be regularly updated with provider additions or deletions by the MCP without
ODJFS prior-approval, however, copies of the revised directory (or inserts)
must
be submitted to ODJFS prior to distribution to members.
On
a
quarterly basis, MCPs
must
create
an insert to their 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.
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 posted to the internet directory within one week of notification from
the provider to the MCP of the deletion. These deleted providers must be
included in the inserts to the MCP's provider directory referenced
above.
Note:
MCPs
currently functioning under a county specific Provider Agreement may choose
to
develop either regional or county based Provider Directory(ies) for their
existing counties.
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 furnish 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
Appendix
H
Page
10
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 w ith the applicable requirements.
Contracting
panel 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
w'ith these timely access requirements. MCPs are required to regularly monitor
their provider panels to determine compliance and if necessary 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 OD.IFS. 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
in
order to comply with these federal access requirements.
North
East Region
-
Hospitals
|
Minimum
Provider Panel Requirements
|
Preferred
Providers 1
|
|||||||||||
|
Total
Required Hospitals
|
Ashtabula
|
Cuyahoga
|
Erie
|
Geauga
|
Huron
|
Lake
|
▇▇▇▇▇▇
|
▇▇▇▇▇▇
|
Additional
Required Hospitals: Out-of-Region
|
Preferred
Hospitals: In-Region2
|
Preferred
Hospitals: Out-of Region
|
|
|
General
Hospital3
|
84
|
1
|
14
|
1
|
1
|
1
|
1
|
1
|
1
|
|
+3
|
Childrens
Hospital of Akron
|
|
Hospital
System
|
1
|
|
1
|
|
|
|
|
|
|
|
+1
|
|
|
1
|
Preferred
Providers are the additional provider contracts that must be secured
in
order for the MCP to receive bonus points.
|
|
2
|
These
hospitals cannot be included under any subcontract used to meet the
minimum required provider panel requirements.
|
|
3
|
These
hospitals must provide obstetrical services if such a hospital is
available in the county/region.
|
|
4
|
The
Cuyahoga hospital requirement may be met by either contracting with
(1) a
single hospital that includes fifty (50) pediatric beds and five
(5)
pediatric intensive care unit (PICU) beds OR
(2) a single general hospital that includes fifty (50) pediatric
beds and
five (5) pediatric intensive care unit (PICU) beds and a hospital
system.
|
NORTHEAST
REGION
|
Minimum
PCP Capacity Requirements
|
|||||||||||
|
PC
Ps
|
Total
Required
|
Ashtabula
|
Cuyahoga
|
Erie
|
Geauga
|
Huron
|
Lake
|
▇▇▇▇▇▇
|
▇▇▇▇▇▇
|
Additional
Required:
In-Region *
|
Additional
Preferred:
In-Region
|
|
Capacity
1
|
146,000
|
6,560
|
111,520
|
3,680
|
2,080
|
3,960
|
3,680
|
11,320
|
3,200
|
|
+36,500
|
|
FTEs
|
73.00
|
3.28
|
55.76
|
1.84
|
1.04
|
1.98
|
1.84
|
5.66
|
1.60
|
|
+
18,25
|
1
Based
on
an FTE of 2000 members
*
Must be
located within the region.
NORTHEAST
REGION
|
Minimum
Provider Panel Requirements
|
Preferred
Providers (In Region)
|
||||||||||
|
Provider
Types
|
Total
Required Providers1
|
Ashtabula
|
Cuyahoga
|
Erie
|
Geauga
|
Huron
|
Lake
|
▇▇▇▇▇▇
|
▇▇▇▇▇▇
|
Additional
Require Providers2
|
Total
Preferred
Providers3
|
|
Pediatricians4
|
90
|
1
|
66
|
2
|
3
|
8
|
3
|
7
|
+23
|
||
|
OB/GYNs
|
25
|
1
|
16
|
1
|
1
|
1
|
2
|
1
|
2
|
+7
|
|
|
Vision
|
33
|
1
|
25
|
1
|
1
|
2
|
1
|
2
|
+9
|
||
|
General
Surgeons
|
20
|
12
|
1
|
1
|
1
|
2
|
1
|
2
|
+5
|
||
|
Otolaryngologist
|
6
|
2
|
1
|
3
|
+2
|
||||||
|
Allergists
|
5
|
2
|
1
|
2
|
+1
|
||||||
|
Orthopedists
|
16
|
8
|
1
|
1
|
2
|
1
|
3
|
+4
|
|||
|
Dentists5
|
90
|
3
|
65
|
1
|
1
|
1
|
5
|
10
|
3
|
1
|
+
23
|
|
1
|
All
required providers must be located within the region.
|
|
2
|
Additional
required providers may be located anywhere within the
region.
|
|
3
|
Preferred
Providers are the additional provider contracts that must be secured
in
order for the MCP to receive bonus points.
|
|
4
|
Half
of this number must be certified by the American Board of
Pediatrics.
|
|
5
|
No
more than two-thirds of this number can be pediatric
dentists.
|
APPENDIX
I
PROGRAM
INTEGRITY
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
order
to comply with OAC rule 5101:3-26-06, MCPs must have a program that includes
administrative and management arrangements or procedures, including a mandatory
compliance plan, to guard against fraud and abuse. The MCP's compliance plan
must designate staff responsibility for administering the plan and include
clear
goals, milestones or objectives, measurements, key dates for achieving
identified outcomes, and explain how the MCP will determine the compliance
plan's effectiveness.
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.
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 CD.IFS. The MCP must report the following information
on
cases w'here 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 (Apendix
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
•I)]
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,
theCP'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 Baseline
Provider Agreement.
APPENDIX
J
FINANCIAL
PERFORMANCE
1.
SUBMISSION OF FINANCIAL STATEMENTS AND REPORTS
MCPs
must
submit the following financial reports to ODJFS:
a.
The
National Association of Insurance Commissioners (NAIC) quarterly and annual
Health Statements (hereafter referred to as the "Financial Statements"), as
outlined in Ohio Administrative Code (OAC) rule 5101:3-26-09(8). The Financial
Statements must include all required Health Statement filings, schedules and
exhibits as stated in the NAIC Annual Health Statement Instructions including,
but. not limited to. the following sections: Assets. Liabilities. Capital and
Surplus Account. Cash Flow, Analysis of Operations by Lines of Business,
Five-Year Historical Data. and the Exhibit of Premiums, Enrollment and
Utilization. The Financial Statements must be submitted to BMHC even if the
Ohio
Department of Insurance (ODI) does not require the MCP to submit these
statements to ODI. A signed hard copy and an electronic copy of the reports
in
the NAIC-approved format must both be provided to ODJFS:
b.
Hard
copies of annual financial statements for those entities who have an ownership
interest totaling five percent or more in the MCP or an indirect interest of
five percent or more. or a combination of direct and indirect interest equal
to
five percent or more in the MCP;
c.
Annual
audited Financial Statements prepared by a licensed independent external auditor
as submitted to the ODI. as outlined in OAC rule 5101:3-26-09(8);
d.
Medicaid Managed Care Plan Annual Ohio Department of Job and Family Services
(ODJFS) Cost Report and the auditor's certification of the cost report- as
outlined in OAC rule 5101:3-26-09(B);
e.
Annual
physician incentive plan disclosure statements and disclosure of and changes
to
the MCP's physician incentive plans, as outlined in OAC rule
5101:3-26-09(B);
f.
Reinsurance agreements, as outlined in OAC rule 5101:3-26-09(C);
g.
Prompt
Pay Reports, in accordance with OAC rule 5101:3-26-09(B). A hard copy and an
electronic copy of the reports in the ODJFS-specified format must be provided
to
ODJFS;
Appendix
J
Page
2
|
h.
|
Notification
of requests for information and copies of information released pursuant
to
a tort action (i.e., third party recovery), as outlined in OAC rule
5101:3-26-09.1;
|
Financial,
utilization, and statistical reports, when ODJFS requests such reports, based
on
a concern regarding the MCP's quality of care, delivery of services, fiscal
operations or solvency, in accordance with OAC rule
5101:3-26-06(0);
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 OD1 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
OD1
and the OD.IFS.
The
Net
Worth Per Member (NWPM) standard is the M'edicaid Managed Care Capitation amount
paid to the MCP during the preceding calendar year, including delivery payments,
but excluding the at-risk amount, expressed as a per-member per-month figure,
multiplied by the applicable proportion below:
0.75
if
the MCP had a total membership of 100,000 or more during that calendar
year
0.90
if
the MCP had a total membership of less than 100.000 for that calendar
year
Appendix
J
Page
3
If
the
MCP did not receive Medicaid Managed Care Capitation payments during the
preceding calendar year, then the NWPM standard for the MCP is the average
Medicaid Managed Care capitation amount paid to Medicaid-contracting MCPs during
the preceding calendar year, including delivery payments, but excluding the
at-risk amount, multiplied by the applicable proportion above.
b.
Indicator: Administrative Expense Ratio
Definition:
Administrative Expense Ratio = Administrative Expenses divided by Total
Revenue
Standard:
Administrative Expense Ratio not to exceed 15%, as determined from the annual
Financial Statement submitted to ODI and ODJFS.
c.
Indicator: Overall Expense Ratio
Definition:
Overall
Expense Ratio = The sum of the Administrative Expense Ratio and the Medical
Expense Ratio
Administrative
Expense Ratio = Administrative Expenses divided by Total Revenue
Medical
Expense Ratio = Medical Expenses divided by Total Revenue
Standard:
Overall
Expense Ratio not to exceed 100% as determined 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
OD1
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
DJFS.
3.
REINSURANCE REQUIREMENTS
Pursuant
to the provisions of OAC rule 5101:3-26-09 (C), each MCP must carry reinsurance
coverage from a licensed commercial carrier to protect against inpatient-related
medical expenses incurred by Medicaid members.
Appendix
J
Page
5
The
annual deductible or retention amount for such insurance must be specified
in
the reinsurance agreement and must not exceed $75,000.00, except as provided
below. Except for transplant services, and as provided below, this reinsurance
must cover, at a minimum. 80% of inpatient costs incurred by one member in
one
year, in excess of
$75,000.00.
For
transplant services, the reinsurance must cover, at a minimum, 50% of transplant
related costs incurred by one member in one year, in excess of
$75,000.00.
An
MCP
may request a higher deductible amount and/or that the reinsurance cover 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.
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.
Penally/or
noncompliatice:
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 betw'een the estimated amount,
as determined by ODJFS, of what the MCP would have paid in premiums for the
reinsurance policy if it had been in compliance and what the MCP did actually
pay while it was out of compliance plus 5%. For example, if the MCP paid
$3.000,000.00 in premiums during the period of non-compliance and would have
paid $5,000.000.00 if the requirements had been met, then the penalty would
be
$2,100,000.00.
Appendix
J
Page
6
If
it is
determined that an MCP's reinsurance for transplant services covers less than
50% of inpatient costs incurred by one member for one year, the MCP will be
required to develop a corrective action plan (CAP).
4.
PROMPT PAY REQUIREMENTS
In
accordance with 42 CFR 447.46, MCPs must pay 90% of all submitted clean claims
within 30 days of the date of receipt and 99% of such claims within 90 days
of
the date of receipt, unless the MCP and its contracted pi-ovider(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.
Penally/or
noncompliance:
Noncompliance with prompt pay requirements will result in progressive penalties
to be assessed on a quarterly basis, as outlined in Appendix N of the Provider
Agreement.
5.
PHYSICIAN INCENTIVE PLAN DISCLOSURE REQUIREMENTS
MCPs
must
comply with the physician incentive plan requirements stipulated in 42 CFR
438.6(h). If the MCP operates a physician incentive plan, no specific payment
can be made directly or indirectly under this physician incentive plan to a
physician or physician group as an inducement to reduce or limit medically
necessary services furnished to an individual.
If
the
physician incentive plan places a physician or physician group at substantial
financial risk [as determined under paragraph (d) of 42 CFR 422.208] for
services that the physician or physician group does not furnish itself, the
MCP
must assure that all physicians and physician groups at substantial financial
risk have either aggregate or per-
Appendix
J
Page
7
patient
stop-loss protection in accordance with paragraph (f) of 42 CFR 422.208, and
conduct periodic surveys in accordance with paragraph (h) of 42 CFR
422.208.
In
accordance with 42 CFR 417.479 and 42 CFR 422.210, MCPs must maintain copies
of
the following required documentation and make this information available to
OD.IFS upon request:
a.
A
description of the types of physician incentive arrangements the MCP has in
place which indicates whether they involve a withhold, bonus, capitation, or
other arrangement. If a physician incentive arrangement involves a withhold
or
bonus, the percent of the withhold or bonus must be specified.
b.
A
description of the panel size for each physician incentive plan. If patients
are
pooled, then the pooling method used to determine if substantial financial
risk
exists must also be specified.
c.
If
more than 25% of the total potential payment of a physician/group is at risk
for
referral services, the MCP must maintain a copy of the 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 (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
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 (EQR.O) process, the EQRO will assist MCPs with
conducting PIPs by providing technical assistance and will annually validate
the
PIPs. In addition, the MCP must annually submit to ODJFS the status and results
of each PIP.
MCPs
must
initiate the following PIPs:
i.
Non-clinical
Topic:
Identifying children/members with special health care needs.
ii.
Clinical
Topic:
Well-child visits during the first 15 months of life.
iii.
Clinical
Topic:
Percentage of members aged 2-21 years that access dental care
services.
Initiation
of PIPs will begin in the second year of participation in the Medicaid managed
care program.
In
addition, as noted in Appendix M, if an MCP fails to meet the Minimum
Performance Standard for selected Clinical Performance Measures, the MCP will
be
required to complete a PIP.
b.
UNDER-
AND OVER-UTILIZATION
Each
MCP
must have mechanisms in place to detect under- and over-utilization of health
care services. The MCP must specify the mechanisms used to monitor utilization
in its annual submission of the QAPI program to ODJFS.
Appendix
K
Page
2
It
should
also be noted that pursuant to the program integrity provisions outlined in
Appendix I, MCPs must monitor for the potential under-utilization of services
by
their members in order to assure that all Medicaid-covered services are being
provided, as required. If any under-utilized services are identified, the MCP
must immediately investigate and correct the problem(s) which resulted in such
under-utilization of services.
In
addition, beginning in 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 children/members with special health care needs. The MCP must
specify the mechanisms used in its annual submission of the QAPI program to
OD.IFS.
d.
SUBMISSION
OF PERFORMANCE MEASUREMENT DATA
Each
MCP
must submit clinical performance measurement data as required by ODJFS that
enables ODJFS to calculate standard measures. Refer to Appendix M "Performance
Evaluation" for a more comprehensive description of the clinical performance
measures.
Each
MCP
must also submit clinical performance measurement data as required by ODJFS
that
uses standard measures as specified by ODJFS. MCPs are required to submit Health
Employer Data Information Set (HEDIS) audited data for the following
measures:
i.
Comprehensive Diabetes Care
ii.
Child
Immunization Status
iii.
Adolescent Immunization Status
The
measures must have received a "report" designation from the HEDIS certified
auditor and must be specific to the Medicaid population. Data must be submitted
annually and in an electronic format. Data will be used for MCP clinical
performance monitoring and will be incorporated into comparative reports
developed by the EQRO.
Initiation
of submission of performance data will begin in the second year of participation
in the Medicaid managed care program.
2.
EXTERNAL QUALITY REVIEW
In
addition to the following requirements, MCPs must participate in external
quality review activities as outlined in OAC 5101:3-26-07.
Appendix
K
Page
3
a.
EORO
ADMINISTRATIVE REVIEW AND NON-DUPLICATION OF MAMDATORY
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 QAPI AND CASE MANAGEMENT PROGRAM
Each
MCP
must implement an evaluation process to review, revise, and/or update the QAPI
program. The MCP must annually submit its QAPI program for review and approval
by ODJFS.
The
annual QAPI and case management/CSHCN (refer to Appendix G) program submissions
are subject to an administrative review by the EQRO. If the EQRO identifies
deficiencies during its review, the MCP must develop and implement Corrective
Action Plan(s) that are prior approved by ODJFS. Serious deficiencies may result
in immediate termination or non-renewal of the provider agreement.
c.
EXTERNAL
QUALITY REVIEW PERFORMANCE
In
accordance with OAC rule 5101:3-26-07. each MCP must participate in clinical
or
non-clinical focused quality of care studies as part of the annual external
quality review survey. If the EQRO cites a deficiency in clinical or
non-clinical performance, the MCP will be required to complete a Corrective
Action Plan (e.g., ODJFS technical assistance session), Quality Improvement
Directives or Performance Improvement Projects depending on the severity of
the
deficiency. (An example of a deficiency is if an MCP fails to meet certain
clinical or administrative standards as supported by national evidence-based
guidelines or best practices.) Serious deficiencies may result in immediate
termination or non-renewal of the provider agreement. These quality improvement
measures recognize the importance of ongoing MCP performance improvement related
to clinical care and service delivery.
APPENDIX
L
DATA
QUALITY
A
high
level of performance on the data quality measures established in this appendix
is crucial in order for the Ohio Department of Job and Family Services (ODJFS)
to determine the value of the Medicaid Managed Health Care Program and to
evaluate Medicaid consumers' access to and quality of services. Data collected
from MCPs are used in key performance assessments such as the external quality
review, clinical performance measures, utilization review, care coordination
and
case management, and in determining incentives. The data will also be used
in
conjunction with the cost reports in setting the premium payment
rates.
Data
sets
collected from MCPs with data quality standards include: encounter data; case
management data; data used in the external quality review; members' PCP data;
and appeal and grievance data.
1.
ENCOUNTER DATA
For
detailed descriptions of the encounter data quality measures below, see
ODJFS
Methods for Encounter Data Quality Measures.
l.a.
Encounter Data Completeness
Each
MCP's encounter data submissions will be assessed for completeness. The MCP
is
responsible for collecting information from providers and reporting the data
to
ODJFS in accordance with program requirements established in Appendix C.
MCP
Responsibilities.
Failure
to do so jeopardizes the MCP's ability to demonstrate compliance with other
performance standards.
l.a.i.
Encounter Data Volume
Measure:
The
volume measure for each service category, as listed in Table 1 below, is the
rate of utilization (e.g., discharges, visits) per 1.000 member months
(MM).
Report
Period:
The
report periods for the SFY 2007 and SFY 2008 contract periods are listed in
the
table below.
Appendix
L
Page
2
Table
1. Report Periods for the SFY 2007 and 2008 Contract
Periods
|
Quarterly
Report Periods
|
Data
Source: Estimated Encounter Data File Update
|
Quarterly
Report Estimated Issue Date
|
Contract
Period
|
|
Qtr
3& Qtr4 2003, 2004, 2005
Qtrl
2006
|
July
2006
|
August
2006
|
SFY
7007
|
|
Qtr
3 & Qtr 4 2003, 2004, 2005 Qtrl, Qtr 2 2006
|
October
2006
|
November
2006
|
|
|
Qtr
3 & Qtr 4 2003, 2004, 2005 Qtr 1 thru Qtr 3 2006
|
January
2007
|
February
2007
|
|
|
Qtr
3 & Qtr 4 2003, 2004, 2005 Qtr 1 thru Qtr 4 2006
|
April
2007
|
May
2007
|
|
|
Qtr
3 & Qtr 4 2003, 2004,2005,2006 Qtrl 2007
|
July
2007
|
August
2007
|
SFY
2008
|
|
Qtr
3 & Qtr 4 2003, 2004,2005.2006 Qtr 1, Qtr 2 2007
|
October
2007
|
November
2007
|
|
|
Qtr
3 & Qtr 4 2003. 2004,2005,2006 Qtr 1 ihru Qtr 3 2007
|
January
2008
|
February
2008
|
|
|
Qtr
3 & Qtr 4 2003, 2004,2005,2006 Qtr 1 thru Qtr 4 2007
|
April
2008
|
May
2008
|
Appendix
L
Page
3
Table
2. Standards - Encounter Data Volume (County-Based
Approach)
|
Category
|
Measure
per 1,000/MM
|
Standard
for Dates of Service 7/1/2003 thru 6/30/2004
|
Standard
for Dates of Service 7/1/2004 thru 6/30/2006
|
Standard
for Dates of Service on or after 7/1/2006
|
Description
|
|
Inpatient
Hospital
|
Discharges
|
5.4
|
5.0
|
5.4
|
General/acute
care, excluding newborns and mental health and chemical dependency
services
|
|
Emergency
Department
|
Visits
|
51.6
|
51.4
|
50.7
|
Includes
physician and hospital emergency department encounters
|
|
Dental
|
38.2
|
41.7
|
50.9
|
Non-institutional
and hospital dental visits
|
|
|
Vision
|
11.6
|
11.6
|
10.6
|
Non-institutional
and hospital outpatient optometry and ophthalmology
visits
|
|
|
Primary
and Specialist Care
|
220.1
|
225.7
|
233.2
|
Physician/practitioner
and hospital outpatient visits
|
|
|
Ancillary
Services
|
144.7
|
123.0
|
133.6
|
Ancillary
visits
|
|
|
Behavioral
Health
|
Service
|
7.6
|
8.6
|
10.5
|
Inpatient
and outpatient behavioral encounters
|
|
Pharmacy
|
Prescriptions
|
388.5
|
457.6
|
492.2
|
Prescribed
drugs
|
County-Based
Approach:
All
counties with managed care membership as of January 1. 2006, will be included
in
a county-based encounter data volume measure until regional evaluation is
implemented for the county's applicable region.. Upon implementation of
regional-based evaluation fora particular county's region, the county will
be
included in the MCP's regional-based results and will no longer be included
in
the MCP's county-based results. County-based results w'ill be determined by
MCP
(i.e., one utilization rate per service category for all applicable counties)
and must be equal to or greater than the standards established in Table 2 above.
[Example: The county-based result for MCP AAA, which has contracts in the
Central and West Central regions, will include Franklin, Pickaway, ▇▇▇▇▇▇▇▇▇▇.
▇▇▇▇▇▇ and dark counties (i.e., counties with managed care membership as of
January 1,2006). When the regional-based evaluation is implemented for the
Central region. Franklin and Pickaway counties, along with all other counties
in
the region, will then be included in the Central region results for MCP AAA;
▇▇▇▇▇▇▇▇▇▇. ▇▇▇▇▇▇, and dark counties will remain in the county-based results
for MCP AAA until the West Central regional measure is
implemented.]
Da/a
Quality Standard. County-Based Approach:
The
standards in Table 2 apply to the MCP's county-based results (see County-Based
Approach
above).
The utilization rate for all service
Appendix
L
Page
4
categories
listed in Table 2 must be equal to or greater than the standard established
in
Table 2 below.
Interim
Regional-Based Approach:
Prior
to
the transition to the regional-based approach, encounter data volume will be
evaluated by MCP, by region, using an interim approach. All regions with managed
care membership will be included in results for an interim regional-based
encounter data volume measure until regional evaluation is implemented for
the
applicable region (see Regional-Based Approach below). Encounter data volume
will be evaluated by MCP (i.e., one utilization rate per service category for
all counties in the region). The utilization rate for all service categories
listed in Table 3 must be equal to or greater than the standard established
in
Table 3 below. The standards listed in Table 3 below are based on utilization
data for counties with managed care membership as of January 1, 2006, and have
been adjusted to accommodate estimated differences in utilization for all
counties in a region, including counties that did not have membership as of
January 1, 2006.
Prior
to
implementation of the regional-based approach, an MCP's encounter data volume
will be evaluated using the county-based approach and the interim regional-based
approach. A county with managed care membership as of January 1. 2006. w'ill
be
included in both the County-Based approach and the Interim Regional-Based
approach until regional evaluation is implemented for the county's applicable
region.
Data
Qualify Standard. Interim Regional-Bawd Approach:
The
standards in Table 3 apply to the MCP's interim regional-based results. The
utilization rate for all service categories listed in Table 3 must be equal
to
or greater than the standard established in Table 3 below.
Table
3. Standards - Encounter Data Volume (Interim Regional-Based
Approach)
|
Category
|
Measure
per 1,000/MM
|
Standard
for Dates of Service on or after
7/1/2006
|
Description
|
|
Inpatient
Hospital
|
Discharges
|
2.7
|
General/acute
care. excluding newborns and mental health and chemical dependency
services
|
|
Emergency
Department
|
Visits
|
25.3
|
Includes
physician and hospital emergency
department
encounters
|
|
Dental
|
25.5
|
Non-institutional
and hospital dental visits
|
|
|
Vision
|
5.3
|
Non-institutional
and hospital outpatient optometry and ophthalmology
visits
|
|
|
Primary
and Specialist Care
|
116.6
|
Physician/practitioner
and hospital outpatient visits
|
|
|
Ancillary
Services
|
66.8
|
Ancillary
visits
|
|
|
Behavioral
Health
|
Service
|
5.2
|
Inpatient
and outpatient behavioral encounters
|
|
Pharmacy
|
Prescriptions
|
246.1
|
Prescribed
drugs
|
Appendix
L
Page
5
Determination
of Compliance:
Performance is monitored once every quarter for the entire report
period.
If the standard is not met for every service category in all quarters of the
report period in
either
the county-based or interim regional-based approach, or both, then the MCP
will
be
determined
to be noncompliant for the report period.
Penalty/or
noncompliance:
The
first time an MCP is noncompliant with a standard for this measure, ODJFS will
issue a Sanction Advisory informing the MCP that any future noncompliance
instances with the standard for this measure will result in ODJFS imposing
a
monetary sanction. Upon all subsequent measurements of performance, if an MCP
is
again determined to be noncompliant with the standard, ODJFS 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
Appendix
L
Page
6
determined
to be compliant with the standard and the violations/deficiencies are resolved
to the satisfaction of ODJFS, the penalties will be lifted, if applicable,
and
monetary sanctions will be returned.
Regional-Based
Approach:
Transition to the regional-based approach will occur by region, after the first
four quarters (i.e., full calendar year quarters) of regional membership.
Encounter data volume will be evaluated by MCP- by region, after determination
of the regional-based data quality standards. ODJFS will use the first four
quarters of data (i.e., full calendar year quarters) from all MCPs serving
in an
active region to determine minimum encounter volume data quality standards
for
that region.
l.a.ii.
Encounter Data Omissions
Omission
studies will evaluate the completeness of the encounter data.
Measure:
This
study will compare the medical records of members during the time of membership
to the encounters submitted. Omission rates will be calculated per MCP (i.e.,
to
include all counties serviced by the MCP).
The
encounters documented in the medical record that do not appear in the encounter
data will be counted as omissions.
Report
Period:
In order
to provide timely feedback on the omission rate of encounters, the report period
will be the most recent from when the measure is initiated. This measure is
conducted annually.
Medical
records retrieval from the provider and submittal to ODJFS or its designee
is an
integral component of the omission measure. ODJFS has optimized the sampling
to
minimize the number of records required. This methodology requires a high record
submittal rate. To aid MCPs in achieving a high submittal rate, ODJFS will
give
at least an 8 week period to retrieve and submit medical records as a part
of
the validation process. A record submittal rate will be calculated as a
percentage of all records requested for the study.
Appendix
L
Page
6
Data
Quality Standard:
The data
quality standard is a maximum omission rate of 15% for studies
with
time
periods ending in the CY 2007 contract 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 one percent of the current month's premium payment. Once the
MCP
is performing at standard levels and violations/deficiencies are resolved to
the
satisfaction of ODJFS, the money will be refunded.
l.a.iii.
Incomplete Outpatient Hospital Data
Since
July 1,1997, MCPs have been required to provide both the revenue code and the
HCPCS code on applicable outpatient hospital encounters. ODJFS will be
monitoring, on a quarterly basis, the percentage of hospital encounters which
contain a revenue code and CPT/HCPCS code. A CPT/HCPCS code must accompany
certain revenue center codes. These codes are listed in Appendix B of Ohio
Administrative Code rule 5101:3-2-21 (fee-for-service outpatient hospital
policies) and in the methods for calculating the completeness
measures.
Measure:
The
percentage of outpatient hospital line items with certain revenue center codes,
as explained above, which had an accompanying valid procedure (CPT/HCPCS) code.
The measure will be calculated per MCP (i.e.. to include all counties serviced
by the MCP).
Report
Period:
For the
SPY 2007 contract period, performance will be evaluated using the following
report periods: January - March 2006; April - June 2006; July-September 2006;
October -December 2006. 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.
Data
Quality Standard:
The data
quality standard is a minimum rate of 95%.
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.
Appendix
L
Page7
l.a.iv.
Incomplete Data For Last Menstrual Period
As
outlined in ODJFS
Encounter Data Specifications,
the last
menstrual period (LMP) field is a required encounter data field. It is discussed
in Item 14 of the "HCFA 1500 Billing Instructions." The date of the LMP is
essential for calculating the clinical performance measures and allows the
ODJFS
to adjust performance expectations for the length of a pregnancy.
The
occurrence code and date fields on the UB-92, which are "optional" fields,
can
also be used to submit the date of the LMP. These fields are described in Items
32a & b, 33a & b, 34a & b, 35a & b of the "Inpatient Hospital"
and "Outpatient Hospital UB-92 Claim Form Instructions."
An
occurrence code value of ' 10" indicates that a LMP date was provided. The
actual date of the LMP would be given in the 'Occurrence Date'
field.
Measure:
The
percentage of recipients with a live birth during the report period where a
''valid" LMP date was given on one or more of the recipient's perinatal claims.
If the LMP date is before the date of birth and there is a difference of between
119 and 315 days between the date the recipient gave birth and the LMP date.
then the LMP date will be considered a valid date. The measure will be
calculated per MCP (i.e.. to include all counties serviced by the
MCP).
Report
Period:
For the
SFY 2007 contract period, performance will be evaluated using the January -
December 2006 report period. For the SFY 2008 contract period, performance
will
be evaluated using the January - December 2007 report period.
Data
Quality Standard:
The data
quality standard is 80%.
Penalty/or
noncompliance:
The
first time an MCP is noncompliant with a standard for this measure, ODJFS will
issue a Sanction Advisory informing the MCP that any future noncompliance
instances with the standard for this measure will result in ODJFS imposing
a
monetary sanction. Upon all subsequent measurements of performance, if an MCP
is
again determined to be noncompliant with the standard, ODJFS will impose a
monetary sanction (see Section 6.) of one percent of the current month's premium
payment. Once the MCP is performing at standard levels and
violations/deficiencies are resolved to the satisfaction of ODJFS, the money
will be refunded.
l.a.v.
Rejected Encounters
Encounters
submitted to ODJFS that are incomplete or inaccurate are rejected and reported
back to the MCPs on the Exception Report. If an MCP does not resubmit rejected
encounters, ODJFS' encounter data set will be incomplete.
Measure
1 only applies to MCPs that have had Medicaid membership for more than one
year.
Measure
1:
The
percentage of encounters submitted to ODJFS that are rejected. The measure
will
be calculated per MCP (i.e., to include all counties serviced by the
MCP).
Appendix
L
Page
8
Report
Period'.
For the
SFY 2007 contract period, performance will be evaluated using the following
report periods: April - June 2006; July - September 2006; October - December
2006 and January - March 2007. For the SFY 2008 contract period, performance
will be evaluated using the following report periods: April - June 2007; July
-
September 2007; October - December 2007 and January - March 2008.
Data
Quality Standard I:
Data
Quality Standard 1 is a maximum encounter data rejection rate of 10% for each
file in the ODJFS-specified medium per format for encounters submitted in SFY
2004 and thereafter. The measure will be calculated per MCP (i.e., to include
all counties serviced by the MCP).
Determination
of Compliance'.
Performance is monitored once every quarter. Compliance determination with
the
standard applies only to the quarter under consideration and does not include
performance in previous quarters.
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 w'ill 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%
Appendix
L
Page
9
Files
in
the ODJFS-specified medium per format that are totally rejected will not be
considered in the determination ofnoncompliance.
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.
1.a.vi.Acceptance
Rate
This
measure only applies to MCPs that have had Medicaid membership for one year
or
less.
Measure:
The rate
of encounters (encounters per 1.000 member months (MM)) submitted to ODJFS.
The
measure will be calculated per MCP (i.e.. to include all counties serviced
by
the MCP).
Report
Period'.
The
report period for this measure is monthly. Results are calculated and
performance is monitored monthly. The first reporting month begins with the
third month of enrollment.
Data
Quality Standard:
The data
quality standard is a monthly minimum accepted rate of encounters for each
file
in the ODJFS-specified medium per format as follows:
Third
through sixth month with membership: 50 encounters per 1,000 MM for NCPDP 65
encounters per 1,000 MM for NSF
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.
Penally
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
Appendix
L
Page
10
premium
payment. Once the MCP is performing at standard levels and
violations/deficiencies are resolved
to the satisfaction of ODJFS- the monev will be refunded.
l.a.vii.
Incomplete Birth Weight Data
Measure:
The
percentage of newborn delivery inpatient encounters during the report period
which contained a birth weight. If a value of "88" through "96" is found on
any
of the five condition code fields on the UB-92 inpatient claim format, then
the
encounter will be considered to have a birth weight. The condition code fields
are described in Items 24-30 of the "Inpatient Hospital. UB-92 Claim Form
Instructions." The measure will be calculated per MCP (i.e., to include all
counties serviced by the MCP).
Report
Period:
For the
SFY 2007 contract period, performance will be evaluated using the January
-December 2006 report period. For the SFY 2008 contract period, performance
will
be evaluated using the January - December 2007 report period.
Data
Quality Standard:
The data
quality standard is 90%.
Penalty/or
noncompliance:
If an
MCP is determined to be noncompliant with the standard, ODJFS will impose a
monetary sanction (see Section 6.) of one percent of the current month's premium
payment. Once the MCP is performing at standard levels and
violations/deficiencies are flB resolved to the satisfaction of ODJFS. the
money
will be refunded.
l.b.
Encounter Data Accuracy
As
with
data completeness. MCPs are responsible for assuring the collection and
submission of accurate data to ODJFS. Failure to do so jeopardizes MCPs'
performance, credibility and, if not corrected, will be assumed to indicate
a
failure in actual performance.
l.b.i.
Encounter Data Accuracy Studies
Measure
1:
The
focus of this accuracy study will be on delivery encounters. Its primary purpose
will be to verify that MCPs submit encounter data accurately and to ensure
only
one payment is made per delivery. The rate of appropriate payments will be
determined by comparing a sample of delivery payments to the medical record.
The
measure will be calculated per MCP (i.e., to include all counties serviced
by
the MCP).
Report
Period:
In order
to provide timely feedback on the accuracy rate of encounters, the report period
will be the most recent from when the measure is initiated. This measure is
conducted annually.
Medical
records retrieval from the provider and submittal to ODJFS or its designee
is an
integral component of the validation process. ODJFS has optimized the sampling
to minimize the number of
Appendix
L
Page
11
records
required. This methodology requires a high record submittal rate. To aid MCPs
in
achieving
a
high
submittal rate, ODJFS will give at least an 8 week period to retrieve and submit
medical records as a part of the validation process. A record submittal rate
will be calculated as a percentage of all records requested for the
study.
Data
Quality Standard 1:
For
results that are finalized during the contract year, the accuracy rate for
encounters generating delivery payments is 100%.
Penalty
for noncompliance:
The MCP
must participate in a detailed review of delivery payments made for deliveries
during the report period. Any duplicate or unvalidated delivery payments must
be
returned to ODJFS.
Data
Quality Standard for Measure 2:
A
minimum record submittal rate of 85%.
Penalty/or
noncompliance:
For all
encounter data accuracy studies that are completed during this contract period,
if an MCP is noncompliant with the standard, ODJFS will impose a non-refundable
$10,000 monetary sanction.
Measure
2:
This
accuracy study will compare the accuracy and completeness of payment 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 for Measure 2:
TBD for
SFY 2008 based on study conducted in SFY 2007
Penalty/or
Noncompliance:
Does not
apply for SFY 2006 or SFY 2007. The first time an MCP is noncompliant with
a
standard for this measure. ODJFS will issue a Sanction Advisory informing the
MCP that any future noncompliance instances with the standard for this measure
will result in ODJFS imposing a monetary sanction.
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.
Appendix
L
Page
12
▇.▇.▇▇.
Generic Provider Number Usage
Measure:
This
measure is the percentage of non-pharmacy encounters with the generic provider
number. Providers submitting claims which do not have an MMIS provider number
must be submitted to OD.IFS with the generic provider number 9111115. The
measure will be calculated per MCP (i.e., to include all counties serviced
by
the MCP).
All
other
encounters are required to have the MMIS provider number of the servicing
provider. The report period for this measure is quarterly.
Report
Period'.
For the
SFY 2007 contract period, performance will be evaluated using the following
periods: January - March 2006; April - June 2006; July - September 2006: October
-December 2006. For the SFY 2008 contract period, performance will be evaluated
using the following periods: January - March 2007; April - June 2007; July
-
September 2007; October -December 2007.
Data
Quality Standard:
A
maximum generic provider usage rate of 10%.
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.
I.c.
Timely Submission of Encounter Data
l.c.i.
Timeliness
ODJFS
recommends submitting encounters no later than thirty-five days after the end
of
the month in which they were paid. ODJFS does not monitor standards specifically
for timeliness, but the minimum claims volume (Section l.a.i.) and the rejected
encounter (Section l.a.v.) standards are based on encounters being submitted
within this time frame.
▇.▇.▇▇.
Submission of Encounter Data
Files in
the ODJFS-specified medium per format
MCP
submissions of encounter data files in the ODJFS-specified medium per format
to
ODJFS are limited to two per format per month. Should an MCP wish to send
additional files in the ODJFS-specified medium per format, permission to do
so
must be obtained by contacting BMHC.
Appendix
L
Page
13
Information
concerning the proper submission of encounter data may be obtained from the
ODJFS
Encounter
Data File and Submission Specifications
document. The MCP must submit a letter of
certification,
using the form required by ODJFS, with each encounter data file in the
OD.IFS-
specified
medium per format.
The
letter of certification must be signed by the MCP's Chief Executive Officer
(CEO), Chief Financial Officer (CFO), or an individual who has delegated
authority to sign for, and who reports directly to, the MCP's CEO or
CFO.
2.
CASEMANAGEMENT
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 w'ill be assessed for completeness and
accuracy. The MCP is responsible for submitting a a case management file every
month. Failure to do so jeopardizes the MCP's ability to demonstrate compliance
w ith CSF1CN requirements. For detailed descriptions of the case management
measures below, see ODJFS
Methods/or Case Management 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 adult and children case management records in the
Screening, Assessment, and Case Management System that have open case management
date spans for members who have disenrolled from the MCP.
Report
Period:
For the
SFY 2007 contract period, performance will be evaluated using the January -June
2006 and July - December 2006 report periods. For the SFY 2007 contract period,
July -September 2006. October - December 2006. January - March 2007, and April
-
June 2007 report periods. For the SFY 2008 contract period. July - September
2007, October - December 2007, January - March 2008, and April - June 2008
report periods.
Da/a
Quality Standard:
A rate
of open case management spans for disenrolled members of no more than
L0%.
For
an MCP which had membership as of January 1, 2006:
Performance will be evaluated using: 1) region-based results for any active
region in which all selected MCPs had at least 10,000 members during each month
of the entire report period; and/or 2) the statew ide result for all counties
that were not included in the region-based results, but had managed care
membership as of January 1, 2006.
For
any MCP which did not have membership as a/January 1, 2006:
Performance will begin to be evaluated using region-based results for any active
region in which all selected MCPs had at least 10,000 members during each month
of the entire report period.
Appendix
L
Page
14
Regional-Based
Approach:
MCPs
will be evaluated by region, using results for all counties
included
in
the
region.
Penally
for nonconipliance:
[fan MCP
is noncompliant with the standard, then the ODJFS will issue a Sanction Advisory
informing the MCP that a monetary sanction will be imposed if the MCP is
noncompliant for any future report periods. Upon all subsequent semi-annual
measurements of performance, if an MCP is again determined to be noncompliant
with the standard, ODJFS will impose a monetary sanction of one-half of one
percent of the current month's premium payment. Once the MCP is performing
at
standard levels and violations/deficiencies are resolved to the satisfaction
of
ODJFS, the money will be refunded.
2.b.
Timely Submission of Case Management Files
Data
Quality Submission Requirement:
The MCP
must submit Case Management files on a monthly basis according to the
specifications established in ODJFS'
Case Management File and Submission Specifications.
Penalty/or
nonconipliance:
See
Appendix N, Compliance
Assessment System,
for the
penalty for noncompliance with this requirement.
3.
EXTERNAL QUALITY REVIEW DATA
In
accordance with federal law and regulations, ODJFS is required to conduct an
independent
quality
review of contracting managed care plans. TheOAC rule 5101:3-26-07(C) requires
MCPs to submit data and information as requested by ODJFS or its designee for
the annual external quality review.
Two
information sources are integral to these studies: encounter data and medical
records. Because encounter data is used to draw samples for the clinical
studies, quality must be sufficient to ensure valid sampling.
An
adequate number of medical records must then be retrieved from providers and
submitted to ODJFS or its designee in order to generalize results to all
applicable members. To aid MCPs in achieving the required medical record
submittal rate. ODJFS will give at least an eight week period to retrieve and
submit medical records.
If
an MCP
does not complete a study because either their encounter data is of insufficient
quality or too few medical records are submitted, accurate evaluation of
clinical quality in the study area cannot be determined for the individual
MCP
and the assurance of adequate clinical quality for the program as a whole is
jeopardized.
3.a.
Independent External Quality Review
Appendix
L
Page
15
Measure:
The
independent external quality review covers both administrative and clinical
focus
areas
of
study.
Report
Period:
The
report period is one year. Results are calculated and performance is monitored
annually. Performance is measured with each review.
Data
Quality Standard 1:
Sufficient encounter data quality in each study area to draw a sample as
determined by the external quality review organization
Penalty
for noncompliance with Data Quality Standard 1:
For each
study that is completed during this contract period, if an MCP is noncompliant
with the standard, OD.IFS will impose a non-refundable $10,000 monetary
sanction.
Data
Quality Standard 2:
A
minimum record submiltal 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
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
Members' PCP Data File and Submission Specifications.
Penalty
for noncompliance:
See
Appendix N, Compliance
Assessment System,
for the
penalty for noncompliance with this requirement.
5.
APPEALS AND GRIEVANCES DATA
Pursuant
to OAC rule 5101:3-26-08.4, MCPs are required to submit information at least
monthly to ODJFS regarding appeal and grievance activity. ODJFS requires these
submissions to be in an electronic data file format pursuant to the Appeal
File and Submission Specifications
and
Grievance
File and Submission Specifications.
The
appeal data file and the grievance data file must include all appeal and
grievance activity, respectively, for the previous month, and must be submitted
by the ODJFS-specified due date. These data files must be submitted in the
ODJFS-specified format and with the ODJFS-specified filename in order to be
successfully processed.
Penalty
for noncompliance:
MCPs who
fail to submit their monthly electronic data files to the ODJFS by the specified
due date or who fail to resubmit, by no later than the end of that month,
a
Appendix
L
Page
16
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 l.a.i. and l.a.v., no monetary sanctions described in this appendix
will be imposed if the MCP is in its first contract year of Medicaid program
participation. Notwithstanding the penalties specified in this Appendix, ODJFS
reserves the right to apply the most appropriate penalty to the area of
deficiency identified
when
an
MCP is determined to be noncompliant with a standard. Monetary penalties for
noncompliance with any individual measure, as determined in this appendix,
shall
not exceed $300,000 during each evaluation period.
Refundable
monetary sanctions will
be
based on
the premium payment in the month of the cited deficiency and due within 30
days
of notification by ODJFS to the MCP of the amount.
Any
monies collected through the imposition of such a sanction will be returned
to
the MCP (minus any applicable collection P;es 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 w ithin two years of the date of notification of noncompliance.
then the monies will not be refunded.
6.b.
Combined Remedies
If
ODJFS
determines that one systemic problem is responsible for multiple deficiencies,
ODJFS may impose a combined remedy which will address all areas of deficient
performance. The total fines assessed in any one month will not exceed 15%
of
the MCP's monthly premium payment.
6.c.
Membership Freezes
MCPs
found to have a pattern of repeated or ongoing noncompliance may be subject
to a
membership freeze.
6.d.
Reconsideration
Requests
for reconsideration of monetary sanctions and enrollment freezes may be
submitted as
provided
in Appendix N, Compliance
Assessment System.
Appendix
L
Page
17
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
This
appendix establishes minimum performance standards for managed care plans (MCPs)
in key program areas. The intent is to maintain accountability for contract
requirements. Standards are subject to change based on the revision or update
of
applicable national standards, methods or benchmarks. Performance will be
evaluated in the categories of Quality of Care, Access, Consumer Satisfaction,
and Administrative Capacity. Each performance measure has an accompanying
minimum performance standard. MCPs with performance levels below the minimum
performance standards will be required to take corrective action. The Ohio
Medicaid managed care program will transition to a regional-based system as
managed care expands statewide, beginning in SPY 2007. Evaluation of performance
will transition to a regional-based approach after completion of the statewide
expansion. Due to differences in data and reporting requirements, transition
to
the regional-based approach will vary by performance measure. Unless otherwise
noted, performance measures and standards (see Sections 1. 2, 3 and 4) will
be
applicable for all counties in which the MCP has membership as of January 1.
2006, until the regional-based approach is developed.
Selected
measures in this appendix will be used to determine incentives as specified
in
Appendix
0, Performance
Incentives.
1.
QUALITY OF CARE
l.a.i
Independent External Quality Review [Only use in SFY2006 Incentive System;
only
applicable for MCPs with membership as ofJanuary I,
2006}
In
accordance with federal law. and regulations state Medicaid agencies must
annually provide for an external review of the quality outcomes and timeliness
of, and access to, services provided by Medicaid-contracting MCPs [(42 CFR
438.204(d)]. The external review assists the state in assuring MCP compliance
w'ith program requirements and facilitates the collection of accurate and
reliable information concerning, MCP performance.
Measure:
The
independent external quality review covers both an administrative component
and
clinical focus areas of study. The overall score is weighted to emphasize
clinical performance.
Report
Period:
For the
SFY 2006 contract period, performance will be evaluated using the reviews that
are finalized during SFY 2006.
Minimum
Performance Standard 1:
A
minimum score of 75% for each clinical study and the administrative
component.
Action
Required for Noncompliance with the Minimum Performance Standard
1:
For all
studies that are finalized during this contract period, if an MCP is
noncompliant with the standard, then the MCP is required to complete a
Performance Improvement Project, as described in Appendix K, Quality
Assessment and Performance Improvement Program,
to
address the area(s) of noncompliance.
Appendix
M
Page
3
Minimum
Performance Standard:
For
results that are below the performance target the performance standard is an
improvement level that results in a 20% decrease between the target and the
previous reporting period's results. For MCPs that reach or surpass the
performance target, then the standard is to keep the results at or above the
performance target.
Penalty
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 w'ill result in ODJFS imposing
a
monetary sanction. Upon all subsequent semi-annual measurements of performance,
if an MCP is again determined to be noncompliant with the standard for this
measure. ODJFS will impose a monetary sanction (see Section 5) of one half
of
one percent of the current month's premium payment. Once the MCP is performing
at standard levels and the violations/deficiencies are resolved to the
satisfaction of ODJFS, the money will be refunded.
▇.▇.▇▇.
Case Management of Children
Measure:
The
average monthly case management rate for children under 21 years of
age.
Report
Period:
For the
SFY 2007 contract period. July - September 2006. October - December 2006,
January - March 2007. and April - June 2007 report periods. For the SFY 2008
contract period, July-September 2007. October-December 2007.
January-March2008.andApril-.Iune 2008 report periods.
County-Based
Approach:
MCPs
with managed care membership as of January 1. 2006 will be evaluated using
their
county-based statewide result until regional evaluation is implemented for
the
county's applicable region. The county-based statew ide result will include
data
for all counties with membership as of January 1. 2006 that are not included
in
any regional-based result. Regional-based results will not be used for
evaluation until all selected MCPs in a active region have at least 10.000
members during each month of the entire report period. Upon implementation
of
regional-based evaluation for a particular county's region, the county will
be
included in the MCP's regional-based result and will no longer be included
in
the MCP's county-based statew ide result. [Example: The county-based statewide
result for MCP AAA. which has contracts in the Central and West Central regions,
will include Franklin. Pickaway. ▇▇▇▇▇▇▇▇▇▇. ▇▇▇▇▇▇ and dark counties (i.e.,
counties with managed care membership as of January 1, 2006). When
regional-based evaluation is implemented for the Central region. Franklin and
Pickaway counties, along with all other counties in the region, will then be
included in the Central region results for MCP AAA; Montgomery, Greene, and
dark
counties will remain in the county-based statewide result for evaluation of
MCP
AAA until the West Central regional-based approach is implemented.]
Regional-Based
Approach:
MCPs
will be evaluated by region, using results for all counties included in the
region. Performance will begin to be evaluated using regional-based results
for
any active region in which all selected MCPs had at least 10.000 members during
each month of the entire report period.
Appendix
M
Page
4
Minimum
Performance Standard:
For the
first and second quarters of SPY 2007, a case management rate of 4.5%. For
the
third and fourth quarters ofSFY 2007, a case management rate of 5.0%. For SFY
2008, a case management rate of 6.0%.
Penally
for Noncompliance:
The
first time an MCP is noncompliant with the standard for this measure, ODJFS
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.
l.b.iii.
Case Management oFChiIdren with an ODJFS-Mandated Condition
(only
applicable for MCPs with membership as of January 1,
2006)
Measure
1:
The
percent of children 6 months and over and under 21 years of age with a positive
identification through an ODJFS administrative review of data for the
ODJFS-mandated case management condition of asthma that are case
managed.
Report
Period:
For the
SFY 2006 contract period, performance will be evaluated using the July
-September 2005 and January - March 2006 report periods. Measure
2:
The
percent of children age 17 and under with a positive identification through
an
ODJFS administrative review of data for the ODJFS-mandated case management
condition of teenage
pregnancy
that are
case managed.
Report
Period:
For the
SFY 2006 contract period, performance will be evaluated using the -January
-
June 2005 and July - December 2005 report periods. For the SFY 2007 contract
period, performance will be evaluated using the January - June 2006 report
period.
Measure
3:
The
percent of children 6 months and over and under 21 years of age with a positive
identification through an ODJFS administrative review of data for the
ODJFS-mandated case management condition of HIV/A1DS that are case
managed.
Report
Period:
For the
SFY 2006 contract period, performance will be evaluated using the July
-September 2005 and January - March 2006 report periods.
Performance
Target for Measures I, 2, and 3:
A
minimum case management rate of 80%.
Minimum
Performance Standard for Measures
7,
2,
and 3:
For
results that are below the performance target the performance standard is an
improvement level that results in a 20% decrease between the target and the
previous reporting period's results. For MCPs that reach or surpass the
performance target, then the standard is to keep the results at or above the
performance target.
Penalty
for Noncompliance for Measures 1 and 2:
The
first time an MCP is noncompliant with the standard for this measure. ODJFS
will
issue a Sanction Advisory informing the MCP that any future noncompliance
instances with the standard for this measure will result in ODJFS imposing
a
monetary sanction . Upon all subsequent semi-annual measurements of performance,
if an MCP is
Appendix
M
Page
5
again
determined to be noncompliant with the standard (see Section 5) for measures
1
or 2, ODJFS will impose a monetary sanction of one half of one percent of the
current month's premium payment. Once the MCP is performing at standard levels
and the violations/deficiencies are resolved to the satisfaction of ODJFS,
the
money will be refunded. Note: For SFY 2006, measure 3 is a reporting-only
measure.
▇.▇.▇▇.
Case Management of Children with an ODJFS-Mandated
Condition
Measure
1:
The
percent of children under 21 years of age with a positive identification through
an ODJFS administrative review of data for the ODJFS-mandated case management
condition of asthma
that are
case managed.
Measure
2:
The
percent of children age 17 and under with a positive identification through
an
ODJFS administrative review of data for the ODJFS-mandated case management
condition of teenage
pregnancy
that are
case managed.
Measure
3:
The
percent of children under 21 years of age with a positive identification through
an ODJFS administrative review of data for the ODJFS-mandated case management
condition of H1V/A1DS
that are
case managed.
Report
Periods/or Measures 1, 2, and 3:
For the
SFY 2007 contract period. July - September 2006, October-December 2006, January
-March 2007. and April -June 2007 report periods. For
the
SFY
2008 contract period. July-September 2007, October-December 2007, January-March
2008, and April - June 2008 report periods.
County-Based
Approach:
MCPs
with managed care membership as of January 1, 2006 will be evaluated using
their
county-based statewide result until regional evaluation is implemented forthe
county's applicable region. The county-based statewide result will include
data
for all counties with membership as of January 1, 2006 that are not included
in
any regional-based result. Regional-based results will not be used for
evaluation until all selected MCPs in an active region have at least 10,000
members during each month of the entire report period. Upon implementation
of
regional-based evaluation fora particular county's region, the county will
be
included in the MCP's regional-based result and will no longer be included
in
the MCP's county-based statewide result. [Example:
The
county-based statewide result for MCP AAA, which has contracts in the Central
and West Central regions, will include Franklin, Pickaway, ▇▇▇▇▇▇▇▇▇▇, ▇▇▇▇▇▇
and dark counties (i.e., counties with managed care membership as of January
1.2006). When regional-based evaluation is implemented forthe Central region.
Franklin and Pickaway counties, along with all other counties in the region,
will then be included in the Central region results for MCP AAA; Montgomery,
Greene, and dark counties will remain in the county-based statewide result
for
evaluation of MCP AAA until the West Central regional-based approach is
implemented.]
Regional-Based
Approach:
MCPs
will be evaluated by region, using results for all counties included in the
region. Performance will begin to be evaluated using regional-based results
for
any active region in which all selected MCPs had at least 10,000 members during
each month of the entire report period.
Appendix
M
Page
6
Minimum
Performance Standard for Measures 1 and 3:
For the
first and second quarters of SPY 2007, a case management rate of 65%. For the
third and fourth quarters of SFY 2007. a case management rate of 70%. For SFY
2008. a case management rate of 80%.
Minimum
Performance Standard for .Measure 2:
For the
first and second quarters of SFY 2007, a case management rate of 55%. For the
third and fourth quarters of SFY 2007. a case management rate of 60%. For SFY
2008. a case management rate of 70%.
Penalty
for Noncompliance for Measures 1 and 2:
The
first time an MCP is noncompliant with the standard for this measure. 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. Note: For the first
reporting period during w hich regional results are used to evaluate
performance, measures 1, 2. and 3 are reporting-only measures. For both SFY
2007
and 2008, measure 3 is a reporting-only measure.
1.c.
Clinical Performance Measures
MCP
performance will be assessed based on the analysis of submitted encounter data
for each year. For certain measures, standards are established; the
identification of these standards is not intended to limit the assessment of
other indicators for performance improvement activities. Performance on multiple
measures will be assessed and reported to the MCPs and others, including
Medicaid consumers.
The
clinical performance measures described below closely follow the National
Committee for Quality Assurance's Health Plan Employer Data and Information
Set(HEDIS). Minor adjustments to HEDIS measures were required to account for
the
differences between the commercial population and the Medicaid population such
as shorter and interrupted enrollment periods. NCQA may annually change its
method for calculating a measure. These changes can make it difficult to
evaluate whether improvement occurred from a prior year. For this reason, ODJFS
will use the same methods to calculate the baseline results and the results
for
the period in which the MCP is being held accountable. For example, the same
methods were being used to calculate calendar year 2003 results (the baseline
period) and calendar year 2004 results. The methods will be updated and a new
baseline will be created during 2005 for calendar year 2004 results. These
results will then serve as the baseline to evaluate whether improvement occurred
from calendar year 2004 to calendar year 2005. Clinical performance measure
results will be calculated after a sufficient amount of time has passed after
the end of the report period in order to allow for claims runout. For a
comprehensive description of the clinical performance measures below, see
ODJFS
Methods for Clinical Performance Measures.
Performance standards are subject to change based on the revision or update
of
NCQA methods or other national standards, methods or benchmarks.
For
an MCP which had membership as of January 1, 2006:
Prior to
the transition to the regional-based approach. MCP performance will be evaluated
using an MCP's statewide result for the counties in which the MCP had membership
as of January 1.2006. For reporting periods CY ▇▇▇▇
▇▇▇▇▇▇▇▇
M
Page
7
and
CY
2008, targets and performance standards for Clinical
Performance Measures in this Appendix (l.c.i - l.c.vii)
will be
applicable to all counties in which MCPs had membership as of January 1, 2006.
The final reporting year for the counties in which an MCP had membership as
of
January 1, 2006, will be CY 2008. ^
For
any MCP which did not have membership as of January 3. 2006:
Performance will be evaluated using a regional-based approach for any active
region in which the MCP had membership.
Regional-Based
Approach:
MCPs
will be evaluated by region, using results for all counties included in the
region. CY 2008 will be the first reporting year that MCPs will be held
accountable to the performance standards for an active region, and penalties
will be applied for noncompliance. CY 2007 will be the first baseline reporting
year for an active region.
ODJFS
will use a sufficient amount of data needed per performance measure from all
MCPs serving an active region to determine performance standards and targets
for
that region. For example, should a measure call for one calendar year of
baseline data. the first full calendaryearofdata will be used. CY 2008 will
be
the first reporting year for measures that call for one year of baseline data.
Should a measure call for two calendar years of baseline data, the first two
full calendar years of data will be used. CY 2009 will be the first reporting
year for measures that call for two years of baseline data.
Report
Period:
For the
SPY 2006 contract period, performance will be evaluated using the January
-December 2005 report period. For the SFY 2007 contract period, performance
will
be evaluated using the January - December 2006 report period. For the SFY 2008
contract period, performance will be evaluated using the January - December
2007
report period.
l.c.i.
Perinatal Care- Frequency of Ongoing Prenatal Care
Measure:
The
percentage of enrolled women with a live birth during the year who received
the
expected number of prenatal visits. The number of observed versus expected
visits will be adjusted for length of enrollment.
Target:
80% of
the eligible population must receive 81% or more of the expected number of
prenatal visits.
Minimum
Performance Standard:
The
level of improvement must result in at least a 10% decrease in the difference
between the target and the previous report period's results. (For example,
if
last year's results were 20%. then the difference between the target and last
year's results is 60%. In this example, the standard is an improvement in
performance of 10% of this difference or 6%. In this example, results of 26%
or
better would be compliant with the standard.)
Action
Required for Noncompliance:
If the
standard is not met and the results are below 42%, then the MCP is required
to
complete a Performance Improvement Project, as described in Appendix K,
Quality
Assessment and Performance Improvement Program,
to
address the area of noncompliance.
Appendix
M
Page
8
If
the
standard is not met and the results are at or above 42%, then OD.IFS will issue
a Quality Improvement Directive which will notify the MCP ofnoncompliance and
may outline the steps that the MCP must take to improve the
results.
▇.▇.▇▇.
Perinatal Care - Initiation of Prenatal Care
Measure:
The
percentage of enrolled women with a live birth during the year who had a
prenatal visit within 42 days of enrollment or by the end of the first trimester
forthose women who enrolled in the MCP during the early stages of
pregnancy.
Target:
90% of
the eligible population initiate prenatal care within the specified
time.
Minimum
Performance Standard:
The
level of improvement must result in at least a 10% decrease in the difference
between the target and the previous year's results.
Action
Required for Noncompliance:
If the
standard is not met and the results are below 71 %, then the MCP is required
to
complete a Performance Improvement Project, as described in Appendix K,
Quality
Assessment and Performance Improvement Program,
to
address the area ofnoncompliance. If the standard is not met and the results
are
at or above 71%, then ODJFS will issue a Quality Improvement Directive which
will notify the MCP ofnoncompliance and may outline the steps that the MCP
must
take to improve the results.
l.c.iii.
Perinatal Care - Postpartum Care
Measure:
The
percentage of women who delivered a live birth who had a postpartum visit on
or
between 21 days and 56 days after delivery.
Target:
At least
80% of the eligible population must receive a postpartum visit.
Minimum
Performance Standard:
The
level of improvement must result in at least a 5% decrease in the difference
between the target and the previous year's results.
Action
Required for Noncompliance:
If the
standard is not met and the results are below 48%, then the MCP is required
to
complete a Performance Improvement Project, as described in Appendix K,
Quality/Assessment
and Performance Improvement Program,
to
address the area of noncompliance. If the standard is not met and the results
are at or above 48%, then ODJFS will issue a Quality Improvement Directive
which
will notify the MCP of noncompliance and may outline the steps that the MCP
must
take to improve the results.
▇.▇.▇▇.
Preventive Care for Children - Well-Child Visits
Measure:
The
percentage of children who received the expected number of well-child visits
adjusted by age and enrollment. The expected number of visits is as
follows:
Children
who turn 15 months old: six or more well-child visits.
Appendix
M
Page
9
Children
who were 3, 4, 5, or 6, years old: one or more well-child visits.
Children
who were 12 through 21 years old: one or more well-child visits.
Target:
At least
80% of
the eligible children receive the expected number of well-child
visits.
Minimum
Performance Standard for Each of the Age Groups:
The
level of improvement must result in at least a 10% decrease in the difference
between the target and the previous year's results.
Action
Required for Noncompliance (15 month old age group):
If the
standard is not met and the results are below 34%, then the MCP is required
to
complete a Performance Improvement Project, as described in Appendix K.
Quality
Assessment and Performance Improvement Program,
to
address the area of noncompliance. If the standard is not met and the results
are at or above 34%. 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 (3-6 year old age group):
If the
standard is not met and the results are below 50%. then the MCP is required
to
complete a Performance Improvement Project, as described in Appendix K,
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 50%. 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 (12-21 year old age group):
If the
standard is not met and the results are below 30%. then the MCP is required
to
complete a Performance Improvement Project, as described in Appendix K.
Quality
Assessment and Performance Improvement Program,
to
address the area of noncompliance. If the standard is not met and the results
are at or above 30%, then ODJFS will issue a Quality Improvement Directive
which
will notify the MCP of noncompliance and may outline the steps that the MCP
must
take to improve the results.
l.c.v.
Use of Appropriate Medications for People with Asthma
Measure:
The
percentage of members w-ith persistent asthma who were enrolled for at least
11
months with the plan during the year and who received prescribed medications
acceptable as primary therapy for long-term control of asthma.
Target:
95% of
the eligible population must receive the recommended medications.
Minimum
Performance Standard:
The
level of improvement must result in at least a 10% decrease in the difference
between the target and the previous year's results.
Action
Required for Noncompliance:
If the
standard is not met and the results are below 83%, then the MCP is required
to
complete a Performance Improvement Project, as described in Appendix K.
Quality
Assessment and Performance Improvement Program,
to
address the area of noncompliance. If the standard is not met and the results
are at or above 83%, then ODJFS will
Appendix
M
Page
10
issue
a
Quality Improvement Directive which will notify the MCP ofnoncompliance and
may
outline the steps that the MCP must take to improve the results.
▇.▇.▇▇.
Annual Dental Visits
Measure:
The
percentage of enrolled members age 4 through 21 who were enrolled for at least
11 months with the plan during the year and who had at least one dental visit
during the year.
Target:
At least
60% of the eligible population receive a dental visit.
Minimum
Performance Standard:
The
level of improvement must result in at least a 10% decrease in the difference
between the target and the previous year's results.
Action
Required for Noncompliance:
If the
standard is not met and the results are below 40%, then the MCP is required
to
complete a Performance Improvement Project, as described in Appendix K,
Quality
Assessment and
Performance
Improvement Program,
to
address the area ofnoncompliance. If the standard is not met and the results
are
at or above 40%. then ODJFS will issue a Quality Improvement Directive which
will notify the MCP ofnoncompliance and may outline the steps that the MCP
must
take to improve the results.
l.c.vii.
Lead Screening
Measure:
The
percentage of one and two year olds who received a blood lead screening by
age
group.
Target:
At least
80% of the eligible population receive a blood lead screening.
Minimum
Performance Standard for Each of the Age Groups:
The
level of improvement must result in at least a 10% decrease in the difference
between the target and the previous year's results.
Action
Required for Noncompliance (I year olds):
If the
standard is not met and the results are below 45% then
the
MCP
is required to complete a Performance Improvement Project, as described in
Appendix K. Quality
Assessment and Performance Improvement Program,
to
address the area of noncompliance. If the standard is not met and the results
are at or above 45%, then OD.IFS will issue a Quality Improvement Directive
which will notify the MCP ofnoncompliance and may outline the steps that the
MCP
must take to improve the results.
Action
Required for Noncompliance (2 year olds):
If the
standard is not met and the results are below 28% then the MCP is required
to
complete a Performance Improvement Project, as described in Appendix K,
Quality
Assessment and Performance Improvement Program,
to
address the area of noncompliance.
If
the
standard is not met and the results are at or above 28%, then ODJFS will issue
a
Quality Improvement Directive which will notify the MCP ofnoncompliance and
may
outline the steps that the MCP must take to improve the results.
Appendix
M
Page
11
2.
ACCESS
Performance
in the Access category will be determined by the following measures: Primary
Care Physician (PCP) Turnover. Children's Access to Primary Care. and Adults'
Access to Preventive/Ambulatory Health Services. For a comprehensive description
of the access performance measures below, see ODJFS
Methods for Access Performance Measures.
2.a.
PCP Turnover
A
high
PCP turnover rate may affect continuity of care and may signal poor management
of providers. However, some turnover may be expected when MCPs end contracts
with physicians who are not adhering to the MCP's standard of care. Therefore,
this measure is used in conjunction with the children and adult access measures
to assess performance in the access category.
Measure:
The
percentage of primary care physicians affiliated with the MCP as of the
beginning of the measurement year who were not affiliated with the MCP as of
the
end of the year.
For
an MCP which had membership as of January J, 2006:
Prior to
the transition to the regional-based approach, MCP performance will be evaluated
using an MCP's statewide result for the counties in which the MCP had membership
as of January 1. 2006. The minimum performance standard in the Appendix
(2.a)
will be
applicable to the MCP's statewide result for the counties in which the MCP
had
membership as of January 1. 2006. The last reporting year using the MCP's
statewide result for the counties in which the MCP had membership as of January
1, 2006 for performance
evaluation
is
CY2007: the last reporting year using the MCP's statew'ide result for the
counties in which the MCP had membership as of January 1. 2006 for performance
incentives {Appendix
0)
is
CY2008.
For
any MCP which did not have membership as of January 1. 2006:
Performance w i 11 be evaluated using a regional-based approach for any active
region in which the MCP had membership.
Regional-Based
Approach:
MCPs
will be evaluated by region, using results for all counties included in the
region. ODJFS will use the first full calendar year of data (i.e.. CY2007)
from
all MCPs serving an active region to determine a minimum performance standard
for that region. CY 2008 will be the first reporting year that MCPs will be
held
accountable to the performance standards for an active region, and penalties
will be applied for noncompliance.
Report
Period:
For the
SFY 2006 contract period, performance will be evaluated using the January
-December 2005 report period. For the SFY 2007 contract period, performance
will
be evaluated using the January - December 2006 report period. For the SFY 2008
contract period, performance will be evaluated using the January - December
2007
report period.
Minimum
Performance Standard:
A
maximum PCP Turnover rate of 18%.
Action
Required/or 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
Appendix
M
Page
12
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.
Children's Access to Primary Care
This
measure indicates whether children aged 12 months to 11 years are accessing
PCPs
for sick or well-child visits.
Measure:
The
percentage of members age 12 months to 11 years who had a visit with an MCP
PCP-type provider.
For
an MCP which had membership as of January 1, 2006:
Prior to
the transition to the regional-based approach. MCP performance will be evaluated
using an MCP's statewide result for the counties in which the MCP had membership
as of January 1, 2006. The minimum performance standard in the Appendix
(2.b)
will be
applicable to the MCP's statewide result for the counties in which the MCP
had
membership as of January 1, 2006. The last reporting year using the MCP's
statewide result for the counties in which the MCP had membership as of January
1, 2006 is CY2008.
For
any MCP which did not have membership as of January 1. 2006:
Performance will be evaluated using a regional-based approach for any active
region in which the MCP had membership.
Regional-Based
Approach:
MCPs
will be evaluated by region, using results for all counties included in the
region. ODJFS will use the first two full calendar years of data (i.e., CY2007
and CY2008) from all MCPs serving an active region to determine a minimum
performance standard for that region. CY 2009 will be the first reporting year
that MCPs will be held accountable to the performance standards for an active
region, and penalties will be applied for noncompliance. Performance measure
results for that region will be calculated after a sufficient amount of time
has
passed after the end of the report period in order to allow for claims
runout.
Report
Period:
For the
SFY 2006 contract period, performance will be evaluated using the January -
December 2005 report period. For the SFY 2007 contract period, performance
will
be evaluated using the January - December 2006 report period. For the SFY 2008
contract period, performance will be evaluated using the January - December
2007
report period.
Minimum
Performance Standards:
CY
2005
report period - 70% of the children must receive a visit. CY 2006 report period
- 70% of the children must receive a visit. CY 2007 report period - 71% of
the
children must receive a visit.
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
Appendix
M
Page
13
This
measure indicates whether adult members are accessing health
services.
Measure:
The
percentage of members age 20 and older who had an ambulatory or preventive-care
visit.
For
an MCP which had membership as of January 1, 2006:
Prior to
the transition to the regional-based approach, MCP performance will be evaluated
using an MCP's statewide result for the counties in which the MCP had membership
as of January 1. 2006. The minimum performance standard in the Appendix
(2.c)
will be
applicable to the MCP's statewide result for the counties in which the MCP
had
membership as of January 1, 2006. The last reporting year using the MCP's
statewide result for the counties in which the MCP had membership as of January
1, 2006 for performance evaluation is CY2007: the last reporting year using
the
MCP's statewide result for the counties in which the MCP had membership as
of
January 1. 2006 for performance
incentives (Appendix
0)
is
CY2008.
For
any MCP which did not have membership as of January 1. 2006:
Performance will be evaluated using a regional-based approach for any active
region in which the MCP had membership.
Regional-Based
Approach:
MCPs
will be evaluated by region, using results for all counties included in the
region. OD.IFS will use the first full calendar year of data (i.e., CY2007)
from
all MCPs serving an active region to determine a minimum performance standard
for that region. CY 2008 will be the first reporting year that MCPs will be
held
accountable to the performance standards for an active region, and penalties
will be applied for noncompliance. Performance measure results for that region
will be calculated after a sufficient amount of time has passed after the end
of
the report period in order to allow for claims runout.
Report
Period:
For the
SFY 2006 contract period, performance will be evaluated using the January -
December 2005 report period. For the SFY 2007 contract period, performance
will
be evaluated using the January - December 2006 report period. For the SFY 2008
contract period, performance will be evaluated using the January - December
2007
report period.
Minimum
Performance Standards:
63% of
the adults must receive a visit.
Penally
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
The
regional approach for this measure is to be determined for SFY 2008. The
county-based approach remains effective in SFY 2007; the county-based approach
is only applicable for MCPs with membership as of January 1, 2006 and for the
counties in which the MCPs had membership as of January 1,2006.
Appendix
M
Page
14
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 Consumer Satisfaction Performance Measures.
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 2006 contract period, performance will be evaluated using the results from
the most recent consumer satisfaction survey completed prior to the end of
the
SFY 2006. For the SFY 2007 contract period, performance will be evaluated using
the results from the most recent consumer satisfaction survey completed prior
to
the end of the SFY 2007. For the SFY 2008 contract period, the measure is under
review and the report period has not been determined.
Minimum
Performance Standard:
An
average score of no less than 7.0.
Penalty
for noncompliance:
If an
MCP is determined noncompliant with the Minimum Performance Standard, then
the
MCP must develop a corrective action plan and provider agreement renewals may
be
affected.
4.
ADMINISTRATIVE CAPACITY
The
ability of an MCP to meet administrative requirements has been found to be
both
an indicator of current plan performance and a predictor of future performance.
Deficiencies in administrative capacity make the accurate assessment of
performance in other categories difficult, with findings uncertain. Performance
in this category will be determined by the Compliance Assessment System, and
the
emergency department diversion program. For a comprehensive description of
the
Administrative Capacity performance measures below, see ODJFS
Methods for Administrative Capacity Performance Measures.
4.a.
Compliance Assessment System
Measure:
The
number of points accumulated for one contract year (one state fiscal year)
through the Compliance Assessment System.
Report
Period:
For the
SFY 2005 contract period, performance will be evaluated using the July 2004
-
June 2005 report period. For the SFY 2006 contract period, performance will
be
evaluated using the July 2005 - June 2006 report period.
Minimum
Performance Standard:
No more
than 25 points
Appendix
M
Page
15
Penalty/or
Noncompliance:
Penalties for points are established in Appendix N, Compliance
Assessment System.
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 four or more ED visits during the six month
reporting period.
For
an MCP which had membership as of January 1, 2006:
Prior to
the transition to the regional-based approach, MCP performance w'ill be
evaluated using an MCP's statewide result for the counties in which the MCP
had
membership as of January 1. 2006. The minimum performance standard and the
target in the Appendix
(4.b)
will be
applicable to the MCP's statewide result for the counties in which the MCP
had
membership as of January 1, 2006. The last reporting period using the MCP's
statewide result for the counties in which the MCP had membership as of January
1, 2006 for performance evaluation is July-December 2007; the last reporting
period using the MCP's statewide result for the counties in which the MCP had
membership as of January 1, 2006 for performance
incentives {Appendix
0)
is
July-December 2008.
For
any MCP which did not Have membership as of January 1, 2006:
Performance wi 11 be evaluated using a regional-based approach for any active
region in which the MCP had membership.
Regional-Based
Approach:
MCPs
w'ill be evaluated by region, using results for all counties included in the
region. The reporting period will be a full calendar year. ODJFS will use the
first full calendar year of data (i.e.. CY2007) as a baseline from all MCPs
serving an active region to determine a minimum performance standard and a
target for that region. CY 2008 will be the first reporting year that MCPs
will
be held accountable to the performance standards for an active region, and
penalties will be applied for noncompliance. Performance measure results for
that region will be calculated after a sufficient amount of time has passed
after the end of the report period in order to allow for claims
runout.
Report
Period:
For the
SFY 2006 contract period, a baseline level of performance will be set using
the
January - June 2005 report period. Results will be calculated for the reporting
period of July-December 2005 and compared to the baseline results to determine
if the minimum performance standard is met. For the SFY 2007 contract period,
a
baseline level of performance will be set using the January - June 2006 report
period. Results will be calculated for the reporting period of July -December
2006 and compared to the baseline results to determine if the minimum
performance standard is met. For the SFY 2008 contract period, a baseline level
of performance will be set using the January - June 2007 report period. Results
will be calculated for the reporting period of July -December 2007 and compared
to the baseline results to determine if the minimum performance standard is
met.
SFY2008 is also the first year for regional based reporting, using January
-December 2007 as a baseline.
Appendix
M
Page
16
Target:
A
maximum of 0.70% of the eligible population will have four or more ED visits
during the reporting period.
Minimum
Performance Standard:
The
level of improvement must result in at least a 10% decrease in the difference
between the target and the baseline period results.
Penalty
for Noncompliance:
If the
standard is not met and the results are above 1.1 %. then the MCP must
develop
a
corrective action plan. for which ODJFS may direct the MCP to develop the
components of their EDD program as specified by ODJFS. If the standard is not
met and the results are at or below 1.1%, then the MCP must develop a Quality
Improvement Directive.
5.
NOTES
5.a.
Report Periods
Unless
otherwise noted, the most recent report or study finalized prior to the end
of
the contract period will be used in determining the MCP's performance level
for
that contract period.
5.b.
Monetary Sanctions
Penalties
for noncompliance with individual standards in this appendix will be imposed
as
the results are finalized. Penalties for noncompliance with individual standards
for each period compliance is determined in this appendix will not exceed
$250.000.
Refundable
monetary sanctions will be based on the capitation payment in the month of
the
cited deficiency and due within 30 days of notification by ODJFS to the MCP
of
the amount. Any monies collected through the imposition of such a sanction
would
be returned to the MCP (minus any applicable collection fees owed to the
Attorney General's Office, ifthe MCP has been delinquent in submitting payment)
after they have demonstrated improved performance in accordance with this
appendix. If an MCP does not comply within two years of the date of notification
of noncompliance, then the monies will not be refunded.
5.c.
Combined Remedies
If
ODJFS
determines that one systemic problem is responsible for multiple deficiencies,
ODJFS may impose a combined remedy which will address all areas of deficient
performance. The total fines assessed in any one month will not exceed 15%
of
the MCP's monthly capitation.
5.d.
Enrollment Freezes
MCPs
found to have a pattern of repeated or ongoing noncompliance may be subject
to
an enrollment freeze.
5.e.
Reconsideration
Appendix
M
Page
17
Requests
for reconsideration of monetary sanctions and enrollment freezes may be
submitted as provided in Appendix N, Compliance
Assessment System.
S.f.
Contract Termination, Nonrenewals or Denials
Upon
termination, nonrenewal or denial of an MCP contact, all monetary sanctions
collected under this appendix will be retained by ODJFS. The at-risk amount
paid
to the MCP under the current provider agreement will be returned to ODJFS in
accordance with Appendix P, Terminations,
of the
provider agreement.
APPENDIX
N
COMPLIANCE
ASSESSMENT SYSTEM (CAS)
The
compliance assessment system (CAS) is designed to improve the quality of each
MCP's performance through a progressive series of 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 provider agreement. Remedies are progressive based upon the severity of
the
violation, or a repeated pattern of violations. Progressive measures that
recognize and monitor continuous quality improvement efforts enable both ODJFS
and the MCPs to determine performance consistently across MCPs over
time.
The
CAS
focuses on noncompliance with clearly identifiable deliverables and
occurrences/points are only assessed in documented and verified instances of
noncompliance. 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
in certain circumstances.
The
CAS
does not include categories which require subjective assessments or which are
not under the MCP's control. Documented violations in the categories specified
in this appendix will ^^ result in the assessment of occurrences and points,
with point values proportional to the severity alat
of the
violation. This approach allows the accumulated point total to reflect both
patterns of less serious violations as well as less frequent, more serious
violations.
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:
-
Use
ofunapproved/unapprovable 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:
-
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:
-
Failure
to comply with the minimum provider panel requirements specified in Appendix
H.
-
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 be assessed occurrences or points based
on
the nature of the violation under correction.
In
order
to reflect appropriately the impact of repeated violations, the following also
applies:
Appendix
N
Page
3
After
accumulating a total of three occurrences within the accumulation period, 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 the accumulation period,
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 the accumulation period,
all subsequent 10-point violations during the period will be assessed as
15-point violations.
Occurrences
and points will accumulate over the duration of the provider agreement. With
the
beginning of a new provider agreement, the MCP will begin the new accumulation
period 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 provider agreement will carry these points
over for the first three months of their next provider agreement. If the MCP
does not accrue any additional points during this three-month period the MCP
will then have their point total reduced to zero and continue on in the new
accumulation period. 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 accumulation period.
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. 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.
ODJFS
expects all required submissions to be received by their specified deadline.
Unless otherwise specified, late submissions will initially be addressed through
CAPs, with repeated instances of untimely submissions resulting in escalating
penalties.
Appendix
N
Page
4
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 by no later than 3 PM 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. Only written approval 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 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:
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 the accrual
period; (2) 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 out of compliance with the provider
panel requirements specified in Appendix
H;
|
| § |
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 this provider 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 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 failing 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, designated PCP and SACMS 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 C, ODJFS will assess the MCP with a 10-point
penalty and a monetary sanction of $20,000 per day for the period
ofnoncompliance. ODJFS may assess additional penalty points based on the length
ofnoncompliance.
Appendix
N
Page
6
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 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 ofnoncompliance.
Noncompliance
with Prompt Payment:
Noncompliance
with the prompt pay requirements as specified in Appendix J 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 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 months duration.
Noncompliance
with Franchise Fee Assessment Requirements
In
accordance with ORC Section 5111.176. 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.
•
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;
Appendix
N
Page
7
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 documented 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
documented 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.
Refusal
to Comply w'ith Program Requirements
If
ODJFS
has instructed an MCP that they must comply with a specific program requirement
and the MCP refuses, ODJFS v»'ill consider this to mean that the MCP is no
longer operating in the best interests of the MCP's members or the state of
Ohio
and will move to terminate or nonrenew the MCP's provider agreement pursuant
to
OAC rule 5101:3-26-10(G).
General
Provisions:
All
notifications of the imposition of a fine or freeze will be made via certified
or overnight mail to the identified MCP Medicaid Coordinator.
Pursuant
to procedures specified by ODJFS, refundable and nonrefundable monetary
sanctions/assurances must be remitted to ODJFS within thirty days of receipt
of
the invoice by the MCP. In addition, per Ohio Revised Code Section 131.02,
payments not received within forty-five 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 tine would be returned to the MCP
(minus any applicable collection fees owed to the Attorney General's Office
if
the MCP has been delinquent in submitting payment) after they have demonstrated
full compliance with the particular program requirement.
Appendix
M
Page
8
If
an MCP
does not comply within two years of the date of notification of noncompliance,
then the monies will not be refunded.
ODJFS
may
impose a combined remedy which will address all areas of noncompliance
ifODJFS
determines
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.
Again,
ODJFS can at any time move to terminate, amend or deny renewal of a provider
agreement pursuant to the provisions ofOAC rule 5101:3-26-10.
Upon
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.
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.
RECONSIDERATIONS
Requests
for reconsiderations of remedial action taken under the CAS may be submitted
as
follows:
•
MCPs
notified of ODJFS' imposition of remedial action taken under the CAS (i.e.,
occurrences, points, tines, assignment reductions and selection freezes), will
have five 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 must be submitted with the reconsideration request,
unless ODJFS extends the time frame in writing.
•
All
requests for reconsideration must be submitted by either facsimile transmission,
or overnight mail to the Chief. Bureau of Managed Health Care. and received
by
the fifth working day after receipt of notification of the imposition of the
remedial action by ODJFS.
Appendix
N
Page
9
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 w. ill 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 working days of receipt of the request for reconsideration.
If
additional information is requested by ODJFS, a final reconsideration decision
will be made within three working 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. The MCP may still be required to submit a CAP if the Bureau Chief
believes that a CAP is still warranted.
Appendix
N
Page
10
POINT
COMPLIANCE SYSTEM - POINT VALUES
OCCURRENCES:
Failures
to meet program requirements, including but not limited to, noncompliance with
administrative requirements. Examples are:
•
Unapproved use of marketing/member materials.
•
Failure
to attend ODJFS-required meetings or training sessions. Failure to maintain
ODJFS-required documentation.
•
Use
ofunapprovcd 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 OD.IFS.
•
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 the 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
physican 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. Examples
are:
•
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 an 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 SACMS file (as specified in Appendix L) 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) 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. Examples are:
•
Failure
to meet any of the provider panel requirements as specified in Appendix
H.
•
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 w ithin 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) 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.
PROPOSED
CHANGES FOR 2007
The
Compliance Assessment System (CAS) w as designed to monitor and to improve
the
quality of each MCP's performance in limited counties utilizing the
zero-tolerance approach to program requirements with progressive remedies in
the
form of occurences/points and fines based on the severity of the violation
or
repeated patterns. Due to the expansion of Ohio's Medicaid Managed Care Program
to all eighty-eight counties, the Ohio Department of Job and Family Services
(ODJFS) will be reassessing the current CAS based upon MCP compliance data
collected during state fiscal year 2007. ODJFS anticipates that the CAS will
be
redesigned and driven by a comprehensive approach to enhancing the quality
of
each MCP's performance by rewarding the MCPs that have continuously demonstrated
excellent compliance and performance and focusing attention on improving the
performance of MCPs for which deficiencies have been identified.
APPENDIX
0
PERFORMANCE
INCENTIVES
This
Appendix establishes incentives for managed care plans (MCPs) to improve
performance in specific areas important to the Medicaid MCP members. Incentives
include the at-risk amount included with the monthly premium payments (see
Appendix F, Rate
Chart),
and
possible additional monetary rewards up to $250.000.
To
qualify for consideration of any incentives, MCPs must meet minimum performance
standards established in Appendix M, Performance
Evaluation
on
selected measures, and achieve incentive standards established for the Emergency
Department Diversion and selected Clinical Performance Measures. For qualifying
MCPs, higher performance standards for three measures must be reached to be
awarded a portion of the at-risk amount and any additional incentives (see
Sections 1 and 2). An excellent and superior standard is set in this Appendix
for each of the three measures. Qualifying MCPs will be awarded a portion of
the
at-risk amount for each excellent standard met. If an MCP meets all three
excellent and superior standards, they may be awarded additional incentives
(see
Section 3).
Prior
to
the transition to a regional-based performance incentive system (SFY 2006
through SFY 2009). the county-based performance incentive system (sections
1 and
2 of this Appendix) will apply to MCPs with membership as of January 1. 2006.
Only counties with membership as of January 1, 2006 will be used to calculate
performance levels for the county-based performance incentives
system.
1.
SFY 2006 Incentives l.a. Qualifying Performance Levels
To
qualify for consideration of the SFY 2006 incentives, 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 incentive standards established for the Emergency Department Diversion
and
Clinical Performance Measures below.
A
detailed description of the methodologies for each measure can be found on
the
BMHC page of the ODJFSwebsite.
Measures
for which the minimum performance standard for SFY 2006 established in Appendix
M, Performance
Evaluation,
must be
met to qualify for consideration of incentives are as follows:
1.
Independent External Quality Review (Appendix M, Section l.a.i. - Minimum
Performance Standard 2)
Appendix
0
Page
2
Report
Period:
The most
recent Independent External Quality Review completed prior to the end of the
SFY
2006 contract period.
2.
PCP
Turnover (Appendix M, Section 2.a.)
Report
Period:
CY
2005
3.
Children's Access to Primary Care (Appendix M, Section 2.b.) Report
Period:
CY
2005
4.
Adults' Access to Preventive/Ambulatory Health Services (Appendix M, Section
2.c.) Report
Period:
CY
2005
5.
Overall Satisfaction with MCP (Appendix M. Section 3.)
Report
Period:
The most
recent consumer satisfaction survey completed prior to the end of the SFY 2006
contract period.
For
the
EDD performance measure, the MCP must meet the incentive standard for the report
period of July - December. 2005 to be considered for SFY 2006 incentives. The
MCP meets the incentive standard if one of two criteria are met. The incentive
standard is a performance level of either:
1)
The
minimum performance standard established in Appendix M, Section 4.b.;
or
2)
The
Medicaid benchmark of a performance level at or below 1.1%.
For
each
clinical performance measure listed below, the MCP must meet the incentive
standard to be considered for SFY 2006 incentives. The MCP meets the incentive
standard if one of two criteria are met. The incentive standard is a performance
level of either:
1)
The
minimum performance standard established in Appendix M, Performance
Evaluation,
for
seven of the nine clinical performance measures listed below; or
2)
The
Medicaid benchmarks for seven of the nine clinical performance measures listed
below.
|
Clinical
Performance Measure
|
Medicaid
Benchmark
|
|
1.
Perinatal Care- Frequency of Ongoing Prenatal Care
|
42%
|
|
2.
Perinatal Care- Initiation of Prenatal Care
|
71%
|
|
3.
Perinatal Care- Postpartum Care
|
48%
|
|
4.
Well-Child Visits- Children who turn 15 months old
|
34%
|
|
5.
Well-Child Visits- 3, 4, 5, or 6, years old
|
50%
|
|
6.
Well-Child Visits - 12 through 21 years old
|
30%
|
|
7.
Use of Appropriate Medications for People with Asthma
|
59%
|
|
8.
Annual Dental Visits
|
40%
|
|
9.
Blood Lead - 1 year olds
|
45%
|
Appendix
0
Page
3
l.b.
Excellent and Superior Performance Levels
For
qualifying MCPs as determined by Section 2.a.. performance will be evaluated
on
the measures below to determine the status of the at-risk amount or any
additional incentives that may be awarded. Excellent and Superior standards
are
set for the three measures described below.
A
brief
description of these measures is provided in Appendix M. Performance
Evaluation.
A
detailed description of the methodologies for each measure can be found on
the
BMHC page of the ODJFS website.
1.
Case
Management of Children (Appendix M, Section l.b.i.)
Report
Period:
July -
December 2005
Excellent
Standard:
2.5%
Superior
Standard:
3.8%
2.
Use of
Appropriate Medications for People with Asthma (Appendix M, Section 1 .▇.▇▇.)
Report
Period:
CY 2005
Excellent
Standard:
59%
Superior
Standard:
68%
3.
Adults' Access to Preventive/Ambulatory Health Services (Appendix M, Section
2.c.)
Report
Period:
CY
2005
Excellent
Standard:
76%
Superior
Standard:
83%
1.c.
Determining SFY 2006
Incentives
MCP's
reaching the minimum performance standards described in Section 2.a. will be
considered for incentives including retention of the at-risk amount and any
additional incentives. For each Excellent standard established in Section 2.b.
that an MCP meets, one-third of the at-risk amount may be retained. For MCPs
meeting all of the Excellent and Superior standards established in Section
2.b.,
additional incentives may be awarded. For MCPs receiving
Appendix
0
Page
4
additional
incentives, the amount in the incentive fund (see section 3.) will be divided
equally, up to the maximum amount, among all MCPs receiving additional
incentives. The maximum amount to be awarded to a single plan in incentives
additional to the at-risk amount is $250,000 per contract year.
2.
SFY 2007 Incentives
2.a.
Qualifying Performance Levels
To
qualify for consideration of the SFY 2007 incentives, 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 incentive standards established for the Emergency Department
Diversion
and
Clinical Performance Measures below.
A
detailed description of the methodologies for each measure can be found on
the
BMHC page of the ODJFS website.
Measures
for which the minimum performance standard for SFY 2007 established in Appendix
M. Performance
Evaluation,
must be
met to qualify for consideration of incentives are as follows:
1.
PCP
Turnover (Appendix M. Section 2.a.)
Report
Period:
CY
2006
2.
Children's Access to Primary Care (Appendix M. Section 2.b.)
Report
Period:
CY
2006
3.
Adults' Access to Preventive/Ambulatory Health Services (Appendix M, Section
2.c.)
Report
Period:
CY
2006
4.
Overall Satisfaction with MCP (Appendix M. Section 3.)
Report
Period:
The most
recent consumer satisfaction survey completed prior to the end of the SFY 2007
contract period.
For
the
EDD performance measure, the MCP must meet the incentive standard for the report
period of July - December, 2006 to be considered for SFY 2007 incentives. The
MCP meets the incentive standard if one of two criteria are met. The incentive
standard is a performance level of either:
1)
The
minimum performance standard established in Appendix M, Section 4.b.;
or
Appendix
0
Page
5
2)
The
Medicaid benchmark of a performance level at or below 1.1%.
For
each
clinical performance measure listed below, the MCP must meet the incentive
standard to be considered for SFY 2007 incentives. The MCP meets the incentive
standard if one of two criteria are met. The incentive standard is a performance
level of either:
1)
The
minimum performance standard established in Appendix M, Performance
Evaluation,
for
seven of the nine clinical performance measures listed below; or
2)
The
Medicaid benchmarks for seven of the nine clinical performance measures listed
below. The Medicaid benchmarks are subject to change based on the revision
or
update of applicable national standards, methods or benchmarks.
|
Clinical
Performance Measure
|
Medicaid
Benchmark
|
|
1.
Perinatal Care - Frequency of Ongoing Prenatal Care
|
42%
|
|
2.
Perinatal Care - Initiation of Prenatal Care
|
71%
|
|
3.
Perinatal Care - Postpartum Care
|
48%
|
|
4.
Well-Child Visits - Children who turn 15 months old
|
34%
|
|
5.
Well-Child Visits - 3. 4, 5. or 6. years old
|
50%
|
|
6.
Well-Child Visits •- 12 through 21 years old
|
30%
|
|
7.
Use of Appropriate Medications for People with Asthma
|
83%
|
|
8.
Annual Dental Visits
|
40%
|
|
9.
Blood Lead - 1 year olds
|
45%
|
2.b.
Excellent and Superior Performance Levels
For
qualifying MCPs as determined by Section 2.a.. performance will be evaluated
on
the measures below to determine the status of the at-risk amount or any
additional incentives that may be awarded. Excellent and Superior standards
are
set for the three measures described below. The standards are subject to change
based on the revision or update of applicable national standards, methods or
benchmarks.
A
brief
description of these measures is provided in Appendix M, Performance
Evaluation.
A
detailed description of the methodologies for each measure can be found on
the
BMHC page of the ODJFS website.
1.
Case
Management of Children (Appendix M, Section ▇.▇.▇▇.) Report
Period:
April -
June 2007
Excellent
Standard:
5.5%
Superior
Standard:
6.5%
2.
Use of
Appropriate Medications for People with Asthma (Appendix M, Section 1
.▇.▇▇.)
Appendix
0
Page
6
Report
Period:
CY 2006
Excellent
Standard:
86%
Superior
Standard:
88%
3.
Adults' Access to Preventive/Ambulatory Health Services (Appendix M, Section
2.c.) Report
Period:
CY 2006
Excellent
Standard:
76%
Superior
Standard:
83%
2.c.
Determining SFY 2007 Incentives
MCP's
reaching the minimum performance standards described in Section 2.a. will be
considered for incentives including retention of the at-risk amount and any
additional incentives. For each Excellent standard established in Section 2.b.
that an MCP meets, one-third of the at-risk amount may be retained. For MCPs
meeting all of the Excellent and Superior standards established in Section
2.b..
additional incentives may be awarded. For MCPs receiving additional incentives,
the amount in the incentive fund (see section 3.) will be divided equally,
up to
the maximum amount, among all MCPs receiving additional incentives. The maximum
amount to be awarded to a single plan in incentives additional to the at-risk
amount is $250,000 per contract year.
3.
NOTES
3.a.
Initiation of the Performance Incentive System
For
MCPs
in their first twenty-four months of Ohio Medicaid Managed Care Program
participation, the status of the at-risk amount will not be determined because
compliance with many of the standards cannot be determined in an MCP's first
two
contract years (see Appendix F., Rate
Chart).
In
addition. MCPs in their first two contract years are not eligible for the
additional incentive amount awarded for superior performance.
Starting
with the twenty-fifth month of participation in the program, a new MCP's at-risk
amount will be included in the incentive system. The determination of the status
of this at-risk amount will be after at least three full calendar years of
membership as many of the performance standards require three full calendar
years to determine an MCP's performance level. Because of this requirement,
more
than 12 months of at-risk dollars may be included in an MCP's first at-risk
status determination depending on when an MCP starts with the program relative
to the calendar year.
Appendix
0
Page
7
3-b.
Determination ofat-risk amounts and additional incentive
payments
For
MCPs
that have participated in the Ohio Medicaid Managed Care Program long enough
to
calculate performance levels for all of the performance measures included in
the
incentive system, determination of the status of an MCP's at-risk amount will
occur within six months of the end of the contract period. Determination of
additional incentive payments will be made at the same time the status of an
MCP's at-risk amount is determined.
3.c.
Transition from a county-based to a regional-based performance incentive
system.
The
current county-based performance incentive system will transition to a
regional-based system as managed care expands statewide. The regional-approach
will be fully phased in no later than SFY 2010. The regional-based performance
incentive system w'ill be modeled after the county-based system with adjustments
to performance standards where appropriate to account for regional
differences.
3.c.i.
County-based performance incentive system
During
the transition to a regional-based system (SFY 2006 through SFY 2009), MCPs
with
membership as of January 1. 2006 will continue in the county-based incentive
system until the transition is complete. These MCPs will be put at-risk for
a
portion of the premiums received for members in counties they are serving as
of
January 1, 2006.
3.c.ii.
Regional-based performance incentive system
All
MCPs
will be included in the regional-based performance incentive system. The at-risk
amount will be determined separately for each region an MCP serves.
The
status of the at-risk amount for counties not included in the county-based
performance incentive system will not be determined for the first twenty-four
months of regional membership. Starting with the twenty-fifth month of regional
membership, the MCP's at-risk amount will be included in the incentive system.
The determination of the status of this at-risk amount will be after at least
three full calendar years of regional membership as many of the performance
standards require three full calendar years to determine an MCP's performance
level. Because of this requirement, more than 12 months ofat-risk dollars may
be
included in an MCP's first regional at-risk status determination depending
on
when regional membership starts relative to the calendar year.
3.d.
Contract Termination, Nonrenewals, or Denials
Upon
termination, nonrenewal or denial of an MCP contract, the at-risk amount paid
to
the MCP under the current provider agreement will be returned to OD.IFS in
accordance with Appendix P., Termmations/Nonrenewals/AmendmenIs,
of the
provider agreement.
Appendix
0
Page
8
Additiontally,
in accordance with Article XI of the provider agreement, the return of the
at-risk amount paid to the MCP under the current provider agreement will be
a
condition necessary for ODJFS' approval of a provider agreement
assignment.
3.e.
Report Periods
The
report period used in determining the MCP's performance levels varies for each
measure depending on the frequency of the report and the data source. Unless
otherwise noted, the most recent report or study finalized prior to the end
of
the contract period will be used in determining the MCP's overall performa.nce
level for that contract period.
APPENDIX
P
MCPTERMINATIONS/NONRENEWAES/AMENDMENTS
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-FN1T1ATEDTERMINATIONS/NONRENEWAES
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 betw een the month the
termination/nonrenewal is issued and the end date of the provider agreement
will
be estimated as the MCP membership for the month the termination/nonrenewal
is
issued. Any over payment will be determined by comparing actual to estimated
MCP
membership and will be returned to the MCP following the end date of the
provider agreement.
The
MCP
must remit the monetary assurance and the at-risk amount in the specified
amounts via separate electronic fund transfers (EFT) payable to Treasurer
of State. Stale 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 5 PM on the third working day follov^ing receipt of the ODJFS notification.
(For example, if ODJFS notification is received on August 6 the MCP's request
for reconsideration must be delivered to the Deputy Director by no later than
5
PM on August 9.) The address and fax number to be used in making these requests
will be specified in the ODJFS notification 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.
Appendix
▇
▇▇▇▇
3
•
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.