PROVIDER AGREEMENT
Exhibit
10.2
BETWEEN
STATE
OF
OHIO
DEPARTMENT
OF JOB AND FAMILY SERVICES
AND
WELLCARE
OF OHIO, INC.
Amendment
No.
1
Pursuant
to Article IX.A. the Provider Agreement between the State of Ohio, Department
of
Job and Family Services, (hereinafter referred to as “ODJFS”) and WELLCARE OF
OHIO, INC. (hereinafter
referred to as “MCP”) for the Aged, Blind or Disabled (hereinafter referred to
as “ABD”) population dated July 1, 2007, is hereby amended as
follows:
1.
Appendices C, D, E, F, G, H, J, K, L, M, N and O are modified as
attached.
2.
All other terms of the provider agreement are hereby
affirmed.
The
amendment contained herein shall be effective January 1,
2008.
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WELLCARE
OF OHIO, INC.
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BY: /s/ ▇▇▇▇
▇. ▇▇▇▇▇
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DATE: 12/19/07 |
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▇▇▇▇
▇. ▇▇▇▇▇, PRESIDENT AND CEO
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OHIO
DEPARTMENT OF JOB AND FAMILY SERVICES:
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BY:
/s/ ▇▇▇▇▇ ▇.
▇▇▇▇▇-▇▇▇▇▇▇
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DATE:
12/26/07
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▇▇▇▇▇
▇. ▇▇▇▇▇-▇▇▇▇▇▇, DIRECTOR
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APPENDIX
C
MCP
RESPONSIBILITIES
ABD
ELIGIBLE
POPULATION
The
MCP must meet on an ongoing basis, all program requirements specified in Chapter
5101:3-26 of the Ohio Administrative Code (OAC) and the Ohio Department of
Job
and Family Services (ODJFS) - MCP Provider Agreement. The following are MCP
responsibilities that are not otherwise specifically stated in OAC rule
provisions or elsewhere in the MCP provider agreement, but
are
required by ODJFS.
General
Provisions
1. The
MCP
agrees to implement program modifications as soon as reasonably possible or
no
later than the required effective date, in response to changes in applicable
state and federal laws and regulations.
2. The
MCP must submit a current copy of their Certificate of Authority (COA) to ODJFS
within 30 days of
issuance by
the Ohio Department of Insurance.
3. The
MCP must
designate the following:
a.
A
primary
contact person (the Medicaid Coordinator) who will dedicate a majority of their
time to the Medicaid product line and coordinate overall communication between
ODJFS and the MCP. ODJFS may also require the MCP to designate
contact staff for specific program areas. The Medicaid Coordinator
will be responsible for ensuring the timeliness, accuracy, completeness and
responsiveness of all MCP submissions to ODJFS.
b. A
provider
relations representative for each service area included in their ODJFS provider
agreement. This provider relations representative can serve in this capacity
for
only one service area (as specified in Appendix H).
If
an MCP
serves both the CFC and ABD populations, they are not required to designate
a
separate provider relations representative or Medicaid Coordinator for each
population group.
4. All
MCP employees are to direct all day-to-day submissions and communications to
their ODJFS-designated Contract Administrator unless otherwise notified by
ODJFS.
5. The
MCP must be represented at all meetings and events designated by ODJFS as
requiring mandatory attendance.
6. The
MCP must have an administrative office located in Ohio.
7. Upon
request by ODJFS, the MCP must submit information on the current status of
their
company’s operations not specifically covered under this Agreement
(for example, other product lines, Medicaid contracts in other states, NCQA
accreditation, etc.) unless otherwise excluded by
law.
8. The
MCP must
have all new employees trained on applicable program requirements, and
represent, warrant and certify to ODJFS that such training occurs, or has
occurred.
9. If
an MCP determines that it does not wish to provide, reimburse, or cover a
counseling service or referral service due to an objection to the service on
moral or religious grounds, it must immediately notify ODJFS to coordinate
the
implementation of this change. MCPs will be required to notify their
members of this change at least
thirty
(30) days prior to the effective date. The MCP’s member handbook and
provider directory, as well as all marketing materials, will need to include
information specifying any such services that the MCP will not
provide.
10. For
any data and/or documentation that MCPs are required to maintain, ODJFS may
request that
MCPs
provide analysis of this data and/or documentation to ODJFS in an aggregate
format, such format to be solely determined by ODJFS.
11. The
MCP is responsible for determining medical necessity for services and supplies
requested for their members as specified in OAC rule
5101:3-26-03. Notwithstanding such responsibility, ODJFS retains the
right to make the final determination on medical necessity in specific member
situations.
12. In
addition to the timely submission of medical records at no cost for the annual
external quality review as specified in OAC rule 5101:3-26-07, the MCP may
be
required for other purposes to submit medical records at no cost to
ODJFS and/or designee upon request.
13. The
MCP must
notify the
BMHC of
the
termination of an MCP
panel
provider
that
is designated
as
the primary care provider for 100
or
more
of the MCP's
ABD
members. The
MCP must
provide notification within one working day of
the
MCP becoming
aware
of the termination.
14. Upon
request by
ODJFS, MCPs may be required to provide written notice to members of any
significant change(s) affecting contractual requirements, member services or
access to providers.
15. MCPs
may elect
to provide services that are in addition to those covered under the Ohio
Medicaid fee-for-service program. Before MCPs notify potential or
current members of the availability of these services, they must first notify
ODJFS and advise ODJFS of such planned
services availability. If an MCP elects to provide additional
services, the MCP must ensure
to the
satisfaction of ODJFS that the services are readily available and
accessible to members who are eligible to receive them.
a. MCPs
are required
to make transportation available to any member requesting
transportation
when they must travel
thirty
(30) miles or more from their home
to
receive a
medically-necessary Medicaid-covered
service. If the MCP offers transportation to their members as
an additional benefit and this transportation benefit only covers a
limited number of trips, the required transportation listed above
may not be counted toward this trip limit.
b. Additional
benefits may not vary by county within a region except out of necessity
for transportation arrangements (e.g., bus versus cab). MCPs approved
to serve consumers in more than one region may vary additional benefits
between regions.
c. MCPs
must give
ODJFS
and members
ninety (90) days prior notice when decreasing
or
ceasing any additional benefit(s). When it is beyond the control of
the
MCP, as
demonstrated to ODJFS’ satisfaction, ODJFS must be notified within one
(1) working
day.
16. MCPs
must
comply with any applicable Federal and State laws that pertain to member rights
and ensure that its staff adheres to such laws when furnishing services to
its
members. MCPs shall include a requirement in its contracts with
affiliated providers that such providers also adhere to applicable Federal
and
State laws when providing services to members.
17. MCPs
must
comply with any other applicable Federal and State laws (such as Title VI of
the
Civil rights Act of 1964, etc.) and other laws regarding privacy and
confidentiality.,
as such may
be applicable to this Agreement.
18. Upon
request,
the MCP will provide members and potential members with
a copy of
their practice guidelines.
19. The
MCP is
responsible for promoting the delivery of services in a culturally competent
manner, as solely determined by ODJFS, to all members, including those with
limited English proficiency (LEP) and diverse cultural and ethnic
backgrounds.
All
MCPs must comply with the requirements specified in OAC rules 5101:3-26-03.1,
5101:3-26-05(D),
5101:3-26-05.1(A), 5101:3-26-08 and 5101:3-26-08.2 for providing assistance
to
LEP members and eligible individuals. In addition, MCPs must provide
written translations of certain MCP materials in
the
prevalent non-English languages ofmembers
and
eligible individuals in
accordance
with the following:
a. When
10% or
more of
the ABD
eligible
individuals in
the
MCP’s
service
areahave
a common
primary language other than English, the MCP must translate
all ODJFS-approved
marketing materials into the primary language of that group. The
MCP must
monitor changes in the eligible population on an ongoing basis and
conduct an
assessment no less often than annually to determine which, if any, primary
language groups meet the 10% threshold for the eligible individuals
in each
service
area. When the 10% threshold is met, the MCP must report
this information
to
ODJFS, in a format as requested by ODJFS, translate their marketing
materials, and make these marketing materials available to
eligible individuals.
MCPs
must
submit to ODJFS, upon request,their
prevalent
nonEnglish
language analysis of eligible individuals and the results of this
analysis.
b. When
10% or
more
of an
MCP's ABD members
in
the
MCP’s service
area
have acommon
primary
language other than English, the MCP must translate all ODJFS-approved
member materials into the primary language of that group. The MCP
must
monitor their membership and conduct a quarterly assessment to determine
which, if any,
primary
language groups meet the 10% threshold. When the
10%
threshold is met, the MCP must report this information to ODJFS, in
a format
as
requested by ODJFS, translate their member materials, and make these materials
available to their members. MCPs must submit to ODJFS,
upon request,
their
prevalent non-English language member analysis and the results of this
analysis.
20. The
MCP must utilize a centralized database which records the special
communication needs
of all
MCP members (i.e., those with limited English proficiency, limited
reading proficiency,
visual impairment, and hearing impairment) and the provision of
related services
(i.e.,
MCP materials in alternate format, oral interpretation, oral
translation services,
written translations of MCP materials, and sign language
services). This database
must
include all MCP member primary language information (PLI) as well as
all other
special
communication needs information for MCP members, as indicated above, when
identified
by any source including but not limited to ODJFS, ODJFS selection services
entity, MCP staff, providers, and members. This centralized database
must be readily
available to MCP staff and beused
in
coordinating communication and services to members,
including the selection
of a
PCP who speaks the primary language of
an LEP
member,
when
such a provider is available. MCPs must share member specific communication
needs information with their providers [e.g., PCPs, Pharmacy
Benefit Managers
(PBMs), and Third Party Administrators (TPAs)], as applicable. MCPs must
submit
to
ODJFS, upon request, detailed information regarding the MCP’s members with
special
communication needs, which could include individual member names,
their specific
communication need, and any provision
of
special services
to
members (i.e.,
those
special services arranged by the MCP as well as those services
reported
to
the MCP
which were
arranged by the provider).
Additional
requirements
specific to providing assistance to hearing-impaired, vision- impaired,
limited
reading
proficient (LRP),
and LEP
members
and
eligible
individuals
are found
in OAC
rules 5101:3-26-03.1, 5101:3-26-05(D),
5101:3-26-05.1(A), 5101:3-26-08, and
5101-3-26-08.2.
21. The
MCP is
responsible for ensuring that all member materials use easily understood
language and format. The determination of what materials comply with
this requirement is in the sole discretion of ODJFS.
22. Pursuant
to OAC
rules 5101:3-26-08 and 5101:3-26-08.2, the MCP is responsible
for ensuring
that
all MCP marketing and member materials are prior approved by ODJFS before being
used or shared with members. Marketing and member materials are
defined as follows:
a. Marketing
materials are those items produced in any medium, by or on behalf of an MCP,
including gifts of nominal value (i.e., items worth no more than $15.00), which
can reasonably be interpreted as intended to market to eligible
individuals.
b. Member
materials are those items developed, by or on behalf of an MCP, to fulfill
MCP
program requirements or to communicate to all members or a group of
members. Member health education materials that are produced by a
source other than the MCP and which do not include any reference to the MCP
are
not considered to be member materials.
c. All
MCP marketing and member materials must represent the MCP in an honest and
forthright manner and must not make statements which are inaccurate, misleading,
confusing, or otherwise misrepresentative, or which defraud eligible individuals
or ODJFS.
d. All
MCP
marketing cannot contain any assertion or statement (whether written
or oral)
that the
MCP is endorsed by CMS, the Federal or State government or similar
entity.
e. MCPs
must
establish positive working relationships with the CDJFS offices
and must
not
aggressively solicit from local Directors, MCP County Coordinators,
or other
staff. Furthermore, MCPs are prohibitedfrom
offering
gifts of nominal value
(i.e.
clipboards, pens, coffee mugs, etc.) to CDJFS offices or managed
care
enrollment center (MCEC) staff,
as these
may influence an individual’s
decision to select a particular MCP.
23. Advance
Directives–
All
MCPs must
comply with the requirements specified in 42
CFR
422.128. At a minimum, the MCP must:
a. Maintain
written policies and procedures that meet the requirements for advance
directives, as set forth in 42 CFR Subpart I of part 489.
b. Maintain
written policies and procedures concerning advance directives with respect
to
all adult individuals receiving medical care by or through the MCP to ensure
that the MCP:
i. Provides
written information to all adult members concerning:
a. the
member’s rights under state law to make decisions concerning their medical care,
including the right to accept or refuse medical or surgical treatment and the
right to formulate advance
directives. (In meeting this requirement, MCPs must utilize form JFS
08095 entitled You
Have the
Right, or
include the
text from JFS 08095 in their ODJFS-approved member
handbook).
b. the
MCP’s policies concerning the implementation of those rights including a clear
and precise statement of any limitation regarding the implementation of advance
directives as a matter of conscience;
c. any
changes in state law
regarding
advance directives as soon as possible but no later than ninety (90) days
after the proposed effective date of the change; and
d. the
right to file complaints concerning noncompliance with the advance directive
requirements with the Ohio Department of Health.
ii. Provides
for education of staff concerning the MCP’s policies and procedures on advance
directives;
iii. Provides
for community education regarding advance directives directly or in concert
with
other providers or entities;
iv. Requires
that the member’s medical record document whether or not the member has executed
an advance directive; and
v. Does
not condition the provision of care, or otherwise discriminate against a member,
based on whether the member has executed an advance
directive.
24. NewMember
Materials
Pursuant
to OAC rule 5101:3-26-08.2 (B)(3), MCPs must provide to each member or
assistance group, as applicable, an MCP identification (ID) card, a new
member letter, a member handbook, a provider directory, and information on
advance directives.
a.
MCPs must use the model language specified by ODJFS for the new member
letter.
b.
The ID card and new member letter must be mailed together to the member via
a
method that will ensure their receipt prior to the member’s effective date
of coverage.
c.
The member
handbook, provider directory and advance directives information may be
mailed
to the
member separately from the ID card and new member letter. MCPs will
meet
the timely
receipt requirement for these materials if they are mailed to the member
within
(twenty-four) 24 hours of the MCP receiving the ODJFS produced monthly
membership roster (MMR). This is provided the materials are mailed via a
method
with an
expected delivery date of no more than five (5) days. If the member handbook,
provider directory and advance directives information are mailed separately
from
the ID
card and new member letter and the MCP is unable to mail the materials
within
twenty-four
(24) hours, themember
handbook, provider directory and advance directives
information must be mailed via a method that will ensure receipt by no
later
than
the
effective date of coverage. If the MCP mails the ID card and new member
letter
with
the other
materials (e.g., member handbook, provider directory, and advance directives),
the MCP must ensure that all
materials
are
mailed via a method that will ensure
their
receipt prior
to
the member’s effective date of coverage.
d.
MCPs must designate two (2) MCP staff members to receive a copy of the new
member materials on a monthly basis in order to monitor the timely receipt
of these materials. At least one of the staff members must receive the
materials at their home address.
25. Call CenterStandards
The
MCP must
provide assistance to members through a member services toll-free call-in system
pursuant to OAC rule 5101:3-26-08.2(A)(1). MCP member services staff
must be available nationwide to provide assistance to members through the
toll-free call-in system every Monday through Friday, at all times during the
hours of 7:00 am to 7:00 pm
Eastern
Time,
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
thirty (30) days in advance of the closure.
The
MCP must
also provide access to medical advice and direction through a centralized
twenty-four-hour, seven day, toll-free call-in system, available nationwide,
pursuant to OAC rule 5101:3-26-03.1(A)(6). The twenty-four (24)/7 hour call-in
system must be staffed by appropriately trained medical personnel. For the
purposes of meeting this requirement, trained medical professionals are defined
as physicians, physician assistants, licensed practical nurses, and registered
nurses.
MCPs
must meet the current American Accreditation HealthCare Commission/URAC-designed
Health Call Center Standards (HCC) for call center abandonment rate, blockage
rate and average speed of answer. By the 10th
of each month, MCPs must self-report their prior month
performance in these three areas for their member services and twenty-four
(24)
hour toll-free call-in systems to ODJFS. ODJFS will inform the MCPs of any
changes/updates to these URAC call center standards.
MCPs
are not
permitted to delegate grievance/appeal functions [Ohio Administrative
Code
(OAC) rule
5101:3-26-08.4(A)(9)]. Therefore, the member services call center
requirement
may
not be met through theexecution
of a
Medicaid Delegation Subcontract Addendum
or
Medicaid Combined Services Subcontract Addendum.
26. Notification
of Optional MCP Membership
In
order to
comply with the terms of the ODJFS State Plan Amendment for the managed care
program (i.e., 42 CFR 438.50), MCPs in mandatory membership service
areas must inform new members, as applicable, that MCP membership is
optional for certain populations. Specifically, MCPs must inform any
applicable pending member or member that the following ABD population is not
required to select an MCP in order to receive their Medicaid healthcare benefit
and what steps they need to take if they do not wish to be a member of an
MCP:
- Indians
who are
members of federally-recognized tribes, except as permitted under 42 C.F.R
438.50(d)(21).
27. HIPAA
Privacy Compliance Requirements
The
Health Insurance Portability and Accountability Act (HIPAA) Privacy Regulations
at 45 CFR. § 164.502(e) and § 164.504(e) require ODJFS to have agreements with
MCPs as a means of obtaining satisfactory assurance that the MCPs will
appropriately safeguard all personal identified health
information. Protected Health Information (PHI) is information
received from or on behalf of ODJFS that meets the definition of PHI as defined
by HIPAA and the regulations promulgated by the United States Department of
Health and Human Services, specifically 45 CFR 164.501, and any amendments
thereto. MCPs must agree to the following:
a. MCPs
shall not
use or disclose PHI other than is permitted by this Agreement or required by
law.
b. MCPs
shall use
appropriate safeguards to prevent unauthorized use or disclosure of
PHI.
c. MCPs
shall
report to ODJFS any unauthorized use or disclosure of PHI of which it becomes
aware. Any breach by the MCP or its representatives of protected
health information (PHI) standards shall be immediately reported to the State
HIPAA Compliance Officer through the Bureau of Managed Health
Care. MCPs must provide documentation of the breach and complete all
actions ordered by the HIPAA Compliance Officer.
d. MCPs
shall ensure that all its agents and subcontractors agree to these same PHI
conditions and restrictions.
e. MCPs
shall make PHI available for access as required by law.
f. MCP
shall make PHI available for amendment, and incorporate amendments as
appropriate as required by law.
g. MCPs
shall make PHI disclosure information available for accounting as required
by
law.
h. MCPs
shall make its internal PHI practices, books and records available to the
Secretary of Health and Human Services (HHS) to determine
compliance.
i. Upon
termination of their agreement with ODJFS, the MCPs, at ODJFS’ option, shall
return to ODJFS, or destroy, all PHI in its possession, and keep no copies
of
the information, except as requested by ODJFS or required by
law.
j. ODJFS
will propose termination of the MCP’s provider agreement if ODJFS determines
that the MCP has violated a material breach under this section of the agreement,
unless inconsistent with statutory obligations of ODJFS or the MCP.
28. Electronic
Communications –
MCPs
are
required to purchase/utilize Transport Layer Security (TLS) for all e-mail
communication between ODJFS and the MCP. The MCP’s e-mail gateway
must be able to support the sending and receiving of e-mail using Transport
Layer Security (TLS) and the MCP’s gateway must be able to enforce the sending
and receiving of email via TLS.
29. MCP
Membership acceptance, documentation and
reconciliation
a. Selection
Services Contractor: The
MCP shall provide to the MCEC
ODJFS
prior-approved MCP materials and directories for distribution to eligible
individuals who request additional information about the
MCP.
b. Monthly
Reconciliation of Membership and Premiums: The MCP shall reconcile member
data as reported on the MCEC
produced consumer contact record (CCR) with the ODJFS-produced monthly member
roster (MMR) and report to the ODJFS any difficulties in interpreting or
reconciling information received. Membership reconciliation questions
must be identified and reported to the ODJFS prior to the first of the month
to
assure that no member is left without coverage. The MCP shall reconcile
membership with premium payments reported on the monthly remittance advice
(RA).
The
MCP shall work directly with the ODJFS, or other ODJFS-identified entity, to
resolve any difficulties in interpreting or reconciling premium
information. Premium reconciliation questions must be identified
within thirty
(30) days of receipt of the RA.
c. Monthly
Premiums: The MCP must be able to receive monthly premiums in a method
specified by ODJFS. (ODJFS monthly prospective premium issue dates
are provided in advance to the MCPs.) Various retroactive premium payments
and recovery
of premiums paid (e.g., retroactive terminations of membership, deferments,
etc.,) may occur via any ODJFS weekly remittance.
d.
Hospital/Inpatient Facility Deferment: When an MCP learns of a currently
hospitalized member’s intent to disenroll through the CCR or the 834, the
disenrolling MCP must notify the hospital/inpatient facility and treating
providers as well as the enrolling MCP of the change in enrollment within five
(5) business days of receipt of the CCR or 834. The disenrolling MCP must notify
the inpatient facility that it will remain responsible for the inpatient
facility charges through the date of discharge; and must notify the treating
providers that it will remain responsible for provider charges through the
date
of disenrollment.
When
the enrolling MCP learns through the disenrolling MCP, through ODJFS
or other means, that a new member who was previously enrolled with another
MCP was admitted prior to the effective date of enrollment and remains an
inpatient on the effective date of enrollment, the enrolling MCP shall
contact the hospital/inpatient facility within five (5) business days of
learning of the hospitalization. The enrolling MCP shall verify that
it is responsible for all medically necessary Medicaid covered services
from the effective date of MCP membership, including treating provider
services related to the inpatient stay; the enrolling MCP must
reiterate that the admitting/disenrolling MCP remains responsible for the
hospital/inpatient facility charges through the date
of discharge. The enrolling MCP shall work with the
hospital/inpatient facility to facilitate discharge planning and authorize
services as needed.
When
an MCP learns that a new member who was previously on Medicaid fee for
service was admitted prior to the effective date of enrollment and
remains an inpatient on the effective date of enrollment, the enrolling MCP
shall notify the hospital/ inpatient facility and treating providers
that the MCP may not be the payer. The MCP shall work with
hospital/inpatient facility, treating providers and the ODJFS to
assure that discharge planning assures continuity of care and accurate
payment. Notwithstanding the MCP’s right to request a hospital deferment up to
six (6) months following the member’s effective date, when the enrolling MCP
learns of a deferment-eligible hospitalization, the MCP shall notify the
ODJFS
and request the deferment within five (5) business days
of learning of the potential deferment.
e. Just
Cause Requests:The
MCP shall
follow procedures as specified by ODJFS in assisting the ODJFS in resolving
member requests for member-initiated requests affecting
membership.
f. Eligible
Individuals: If
an eligible individual contacts the MCP, the MCP must provide
any
MCP-specific managed care program information requested. The
MCP
must not
attempt to assess the eligible individual’s health care
needs. However,
if the
eligible individual inquires about continuing/transitioning health care
services,
MCPs shall provide an assurance that all MCPs must cover all medically
necessary Medicaid-covered health care services and assist members with
transitioning their health care services.
g. Pending
Member: If
a
pending member (i.e., an
eligible
individual subsequent to plan selection or
assignment, but
prior to
their membership effective date) contacts
the selected
MCP, the MCP
must
provide any membership information requested,
including but
not limited
to, assistance in determining
whether the
current
medications
require prior
authorization. The
MCP must
also ensure
that any
care coordination (e.g., PCPselection, prescheduled
services and transition
of services)
information provided by the
pending
member
is
logged
in
the MCP’s
system
and forwarded
to
the appropriate MCP staff for
processing as
required. MCPs may confirm
any information provided on
the CCR
at this
time. Such communication
does not constitute confirmation
of membership. MCPs
are prohibited from initiating
contact with
a
pending member. Upon
receipt of
the 834, the MCP
may contact
a pending member to confirm information provided on the
CCR or the
834, assist with care coordination and transition of care, and
inquire if
the pending member has any membership questions.
h. Transition
of Fee-For-Service Members:
Providing
care
coordination, access to preventive and specialized care, case management,
member services, and education with minimal disruption to members’ established
relationships with providers and existing care treatment plans is critical
for
members transitioning from Medicaid fee-for-service to managed
care. MCPs must develop
and
implement a transition plan that outlines how the MCP will effectively address
the unique care coordination issues of members in their first three months
of
MCP membership and how the various MCP departments will coordinate and share
information regarding these new members. The transition plan must include at
a
minimum:
i. An
effective outreach process to identify each new
member’s
existing and/or potential health care needs that results in a new
member profile that includes, but is not limited to identification
of:
a. Health
care needs, including those services received through state sub-recipient
agencies [e.g., the Ohio Department of Mental Health (ODMH), the Ohio
Department of Mental Retardation and Developmental Disabilities ODMR/DD),
the Ohio Department of Alcohol and Drug Addiction Services
(ODADAS) and the Ohio Department
of
Aging (ODA)];
b. Existing
sources of care (i.e., primary physicians, specialists, case manager(s),
ancillary and other care givers); and
c. Current
care therapies for all aspects of health care services, including scheduled
health care appointments, planned and/or approved surgeries
(inpatient or outpatient), ancillary or medical therapies, prescribed drugs,
home health care services, private duty nursing (PDN), scheduled lab/radiology
tests, necessary durable medical equipment, supplies and needed/approved
transportation arrangements.
ii. Strategies
for how each new member will obtain care therapies from appropriate
sources of care as an MCP member. The MCP’s strategies must
include at
a minimum:
a. Allowing
their
new members that are transitioning from Medicaid fee-for-service
to receive services from out-of-panel providers if the
member or
provider contacts the MCP to discuss the scheduled health services in advance
of
the service date and one of the following applies:
i. The
member has
appointments within the initial three months of the MCP membership with a
primary care provider or
specialty
physician that was scheduled
prior
to the effective date of the MCP membership;
ii. The
member is in
her third trimester of pregnancy and has an
established
relationship with an obstetrician and/or delivery
hospital;
iii. The
member has
been scheduled for an inpatient oroutpatient
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);
iv.
The
member is
receiving ongoing chemotherapy or radiation
treatment; or
v. The
member has
been released from the hospital within thirty (30) days prior
to MCP
enrollment and is following
a
treatment plan.
If
contacted by
the member, the MCP must contact the provider’s office as expeditiously as the
situation warrants to confirm that the service(s) meets the above
criteria.
b.
Allowing
their
new members that are transitioning from Medicaid fee-for-service
to continue receiving home care services (i.e., nursing, aide, and skilled
therapy services) and private duty nursing (PDN) services if the member or
provider contacts the MCP
to discuss
the health services in advance of the service date. These services
must be covered from the date of the member or provider contact at the current
service level, and with the current provider, whether a panel or out-of-panel
provider, until the MCP conducts
a
medical necessity review and renders an authorization decision pursuant to
OAC
rule 5101:3-26-03.1. As soon as the MCP becomes aware of the member’s
current home care services, the MCP must initiate contact with the current
provider and member as applicable to ensure continuity of care and coordinate
a
transfer of services to a panel provider, if
appropriate.
c. Honoring
any
current fee-for-service prior authorization to allow their
new
members that are transitioning from Medicaid fee-for-service to receive services
from the authorized provider, whether a panel
or
out-of-panel provider, for the following approved
services:
i. an
organ, bone
marrow, or hematapoietic stem cell transplant
pursuant to OAC rule 5101:3-2-07.1;
ii. dental
services
that have not yet been received;
iii. vision
services
that have not yet been received;
iv. durable
medical
equipment (DME) that has not yet been received. Ongoing
DME services and supplies are to be covered by the MCP as previously-authorized
until the MCP conducts a medical necessity review and renders an authorization
decision pursuant to OAC rule 5101:3-26-03.1.
v. private
duty
nursing (PDN) services. PDN services must be
covered at
the previously-authorized service level until the MCP conducts a medical
necessity review and renders an authorization decision pursuant to OAC rule
5101:3-26-03.1.
As
soon as the
MCP becomes aware of the member’s current fee-for-service authorization
approval, the MCP must initiate contact with the authorized provider and member
as applicable to ensure continuity of care. The MCP must implement a
plan to meet the member’s immediate and ongoing medical needs and, with the
exception of organ, bone marrow, or hematapoietic stem cell transplants,
coordinate the transfer of services to a panel provider, if
appropriate.
When
an MCP
medical necessity review results in a decision to reduce, suspend, or terminate
services previously authorized by fee-for-service Medicaid, the MCP must notify
the member of their state hearing rights no less than 15 calendar days prior
to
the effective date of the MCP’s proposed action, per rule 5101:3-26-08.4 of the
Administrative Code.
d. Reimbursing
out-of-panel providers that agree to provide the transition
services at 100% of the current Medicaid fee-for-service provider
rate
for the service(s) identified in Section 29.h.ii.(a., b., and
c.) of this
appendix.
e. Documenting
the
provision of transition services identified in Section
29.h.ii.(a., b., and c.) of this appendix as follows:
i. For
non-panel
providers, notification to the provider confirming
the
provider’s agreement/disagreement to provide
the
service and accept 100% of the current Medicaid
fee-for-service rate as payment. If the provider agrees,
the
distribution of the MCP’s materials
as
outlined in
Appendix
G.4.e.
ii. Notification
to
the member of the non-panel provider’s agreement
/disagreement to provide the service. If the provider
disagrees, notification to the member of the MCP’s
availability to assist with locating a provider as expeditiously
as the member’s health condition warrants.
iii. For
panel
providers, notification to the provider and member
confirming the MCP’s responsibility to cover the service.
MCPs
must use
the ODJFS-specified model language for the provider and member
notices and maintain documentation of all member and/or provider contacts
relating to such services.
f. Implementing
a drug transition of care process that prevents drug access problems for new
members that are transitioning from Medicaid fee-for-service
(FFS). Such a process would involve the MCP covering at least one
prescription fill or refill without prior authorization (PA) of any covered
prescription drug not requiring PA by FFS. For new members that are
transitioning from FFS who utilize ongoing medications for chronic conditions
the MCP must educate the member about how to continue to access drugs for their
chronic condition before the MCP may implement PA requirements for that member’s
specific ongoing medication. The MCP’s process for covering the
prescription fill or refill without PA must be based on one of the following
approaches:
i.
the MCP covers without PA all prescriptions written within the two months prior
to the effective date of MCP enrollment that do not require PA by Medicaid
fee-for-service; or
ii.
the MCP covers without PA for at least the initial 30 days of the member’s MCP
membership all prescriptions that do not require PA by Medicaid
fee-for-service.
For
any new member transitioning from FFS who utilizes ongoing medications for
chronic conditions the MCP may require subsequent PA for those drugs once the
MCP has educated the member about the importance of working with their physician
to discuss initiating a PA request to continue the current medication and the
option of using alternative medications that may be available without
PA. Written member notices must use ODJFS-specified model language
and be ODJFS-approved. Verbal member education may be done in place
of written education but must contain the same information as a written notice
and must follow a call script that contains ODJFS-specified model language
and
be ODJFS-approved.
For
those new members who are not utilizing ongoing medications for chronic
conditions, no additional drug PA education is required beyond the MCP’s general
new member education that includes what drugs require MCP
PA.
MCPs
must receive ODJFS approval prior to implementing their transition of care
drug
PA process. An MCP’s proposal must document how the MCP
will:
i. implement
one of the above options to ensure that members transitioning from FFS receive
at least one prescription fill or refill without PA of any covered prescription
drug not requiring PA by FFS; and
ii.
identify new members that are transitioning from FFS who utilize ongoing
medications for chronic conditions and provide timely education to the member
about how to continue to access drugs for their chronic condition before the
MCP
will implement PA requirements for that member’s specific ongoing
medication.
MCPs
who have not received ODJFS approval for their transition of care drug PA
process must not require PA of any prescription drug that does not require
PA by
Medicaid fee-for-service for the initial three months of a member’s MCP
membership.
g. Covering
antipsychotic medications for new members as well as current members as
stipulated in Appendix G(3)(a)(i).
30. Health
Information System Requirements
The
ability to
develop and maintain information management systems capacity is crucial
to
successful
plan performance. ODJFS therefore requires MCPs to demonstrate their
ongoing capacity in this area by meeting several related
specifications.
a. Health
Information System
i. As
required by
42 CFR 438.242(a), each MCP must maintain a health information system that
collects, analyzes, integrates, and reports data. The system must
provide information on areas including, but not limited to, utilization,
grievances and appeals, and MCP membership terminations for other than loss
of
Medicaid eligibility.
ii. As
required by
42 CFR 438.242(b)(1), each MCP must collect data on member and provider
characteristics and on services furnished to its
members.
iii. As
required by
42 CFR 438.242(b)(2), each MCP must ensure that data received from providers
is
accurate and complete by verifying the accuracy and timeliness of reported
data;
screening the data for completeness, logic, and consistency; and collecting
service information in standardized formats to the extent feasible and
appropriate.
iv. As
required by 42 CFR 438.242(b)(3), each MCP must make all collected data
available upon request by ODJFS or the Center for Medicare and Medicaid Services
(CMS).
v.
Acceptance
testing of any data that is electronically submitted to ODJFS is
required:
a. Before
an MCP
may submit production files ODJFS-specified formats;
and/or
b. Whenever
an MCP
changes the method or preparer of the electronic media;
and/or
c. When
the ODJFS
determines an MCP’s data submissions havean
unacceptably
high error rate.
MCPs
that
change or modify information systems that are involved in producing any type
of
electronically submitted files, either internally or by changing vendors, are
required to submit to ODJFS for review and approval a transition plan including
the submission of test files in the ODJFS-specified
formats. Once an acceptable test file is submitted to ODJFS, as
determined solely by ODJFS, the MCP can return to submitting production
files. ODJFS will inform MCPs in writing when a test file is
acceptable. Once an MCP’s new or modified information
system is
operational,
that MCP will have up to ninety (90)
days to
submitan
acceptable
test file and an acceptable production file.
Submission
of
test files can start before the new or modified information system is
in production. ODJFS reserves
the right to verify any MCP’s capability
to
report elements in the minimum data set prior to executing the provider
agreement for the next contract period. Penalties for noncompliance with this
requirement are specified in Appendix N, Compliance Assessment
System of the Provider Agreement.
b. Electronic
Data Interchange and Claims Adjudication Requirements
Claims
Adjudication
The
MCP must have the capacity to electronically accept and adjudicate all claims
to final status (payment or denial). Information on claims
submission procedures must be provided to non-contracting providers within
thirty
(30) days of a request. MCPs must inform providers of
its ability to electronically process and adjudicate claims and the
process for submission. Such
information must be initiated by the MCP
and not
only in response to provider requests.
The
MCP must
notify providers who have submitted claims of claims status [paid, denied,
pended (suspended)]
within one month of receipt. Such notification may be in the
form of a claim payment/remittance advice produced on a routine monthly,
or more frequent, basis.
Electronic
Data Interchange
The
MCP shall comply with all applicable provisions of HIPAA including
electronic data interchange (EDI) standards for code sets and the
following electronic transactions:
Health
care claims;
Health
care claim status request and response;
Health
care
payment and remittance status;
Standard
code
sets; and
National
Provider Identifier (NPI).
Each
EDI transaction processed by the MCP shall be implemented in conformance
with the
appropriate version of the transaction implementation guide,
as
specified by applicable federal rule or regulation.
The
MCP must have the capacity to accept the following transactions from the
Ohio Department of Job and Family services consistent with EDI processing
specifications in the transaction implementation guides and in conformance
with the 820 and 834 Transaction Companion Guides issued by
ODJFS:
ASC
X12 820 - Payroll Deducted and Other Group Premium Payment for Insurance
Products; and
ASC
X12 834 - Benefit Enrollment and Maintenance.
The
MCP shall comply with the HIPAA mandated EDI transaction standards and
code sets no later than the required compliance dates as set forth in the
federal regulations.
Documentation
of Compliance with Mandated EDI Standards
The
capacity of the MCP and/or applicable trading partners and business
associates to electronically conduct claims processing and related
transactions in compliance
with
standards and effective dates mandated by HIPAA must be demonstrated,
to the satisfaction of ODJFS, as outlined below.
Verification
of Compliance with HIPAA (Health Insurance Portability and Accountability
Act of 1995)
MCPs
shall
comply with the transaction standards and code sets for sending and receiving
applicable transactions as specified
in 45
CFR Part 162 – Health Insurance
Reform: Standards for Electronic
Transactions (HIPAA regulations)
In
addition
the MCP must enterinto
the
appropriate trading partner
agreement and implemented
standard
code
sets. If the MCP has obtained
third-party certification of
HIPAA
compliance for any of the items listed
below,
that
certification may be
submitted
in lieu of
the MCP’s written verification
for the applicable item(s).
i. Trading
Partner
Agreements
ii. Code
Sets
iii. Transactions
a. Health
Care Claims or Equivalent Encounter Information (ASC
X12N 837 & NCPDP 5.1)
b. Eligibility
for a Health Plan (ASC X12N 270/271)
c. Referral
Certification and Authorization (ASC X12N 278)
d. Health
Care Claim Status (ASC X12N 276/277)
e. Enrollment
and Disenrollment in a Health Plan (ASC X12N 834)
f. Health
Care Payment and Remittance Advice (ASC X12N 835)
g. Health
Plan Premium Payments (ASC X12N 820)
h. Coordination
of Benefits
Trading
Partner Agreement with ODJFS
MCPs
must complete and submit an EDI trading partner agreement in a format
specified by the ODJFS. Submission of the copy of the trading
partner agreement prior to entering into
this
Agreement may be waived at the discretion of ODJFS; if submission
prior to entering into the
Agreement is waived, the trading partner agreement must be
submitted at a subsequent date determined by ODJFS.
Noncompliance
with the EDI and claims adjudication requirements will result in the
imposition of penalties, as outlined in Appendix N, Compliance Assessment
System, of the Provider Agreement.
c. Encounter
Data Submission Requirements
General
Requirements
Each
MCP must collect data on services furnished to members through an encounter
data
system and must report encounter data to the ODJFS. MCPs are required to submit
this data electronically to ODJFS on a monthly basis in the following
standard formats:
· Institutional
Claims - UB92 flat file
· Noninstitutional
Claims - National standard format
· Prescription
Drug Claims - NCPDP
ODJFS
relies heavily on encounter data for monitoring MCP performance. The ODJFS
uses
encounter data to measure clinical performance, conduct access and utilization
reviews, reimburse MCPs for newborn deliveries and
aid in
setting
MCP
capitation rates. For these reasons, it is important that encounter
data is timely, accurate, and complete. Data quality,
performance
measures and standards are described in the
Agreement.
An
encounter represents all of the services, including medical supplies and
medications, provided to a member of the MCP by a particular provider,
regardless of the payment arrangement between the MCP and
the
provider. (For example, if a member had an emergency department visit and was
examined by a physician,
this
would constitute two encounters, one related to the hospital provider and one
related to the physician provider. However, for the purposes of calculating
a
utilization measure, this would be counted as a single emergency department
visit. If a member visits their PCP and the PCP examines the member
and
has
laboratory procedures done within the office, then this is one encounter between
the member and their PCP.)
If
the PCP sends the member to a lab to have procedures performed, then this is
two
encounters; one with the PCP and another with the lab. For pharmacy
encounters, each prescription filled is a separate
encounter.
Encounters
include services paid for retrospectively,
through fee-for-service payment arrangements, and prospectively,
through capitated arrangements. Only encounters with services (line items)
that
are paid by the MCP, fully or in part, and for which no further payment is
anticipated, are acceptable encounter data submissions.
All
other services that are unpaid or paid in part and for which the MCP anticipates
further payment (e.g., unpaid services rendered during a delivery of a newborn)
may not be submitted to ODJFS until they are paid. Penalties for noncompliance
with this requirement are specified in Appendix N, Compliance
Assessment System of the Agreement.
Acceptance
Testing
The
MCP must have the capability to report all elements in the Minimum Data Set
as
set forth in the ODJFS Encounter Data Specifications and must submit a test
file
in the ODJFS-specified medium in the required formats prior to contracting
or
prior to an information systems replacement or update.
Acceptance
testing of encounter data is required as specified in Section 29(a)(v) of this
Appendix.
Encounter
Data File Submission Procedures
A
certification letter must accompany the submission of an encounter data file
in
the
ODJFS-specified medium. The certification letter must be signed by the MCP’s
Chief Executive Officer (CEO), Chief Financial Officer (CFO), or an individual
who has delegated authority to sign for, and who reports directly to, the MCP’s
CEO or CFO.
Timing
of Encounter Data Submissions
ODJFS
recommends that MCPs submit encounters no more
than
thirty-five (35) days after the end of the month in which they were paid. (For
example, claims paid in January are due March 5.) ODJFS recommends
that MCPs submit files inthe
ODJFS-specified medium by the 5th of each month. This will help to ensure that
the encounters are included in the ODJFS master file in the same month in which
they were submitted.
d. Information
Systems Review
ODJFS
or its designee may review the information system capabilities of each MCP
before ODJFS enters into a provider agreement with a new MCP, when a
participating MCP undergoes a major information system upgrade or
change, when there is identification of significant information
system problems, or at ODJFS’ discretion. Each MCP must participate in the
review. The review will assess the extent to which MCPs are capable of
maintaining a health information system including producing valid encounter
data, performance measures, and other data necessary to support quality
assessment and improvement, as well as managing the care delivered to its
members.
The
following activities,
at
a minimum, will be carried out during the review. ODJFS or its
designee will:
i. Review
the
Information Systems Capabilities Assessment (ISCA) forms, as developed by CMS;
which the MCP will be required to complete.
ii. Review
the
completed ISCA and accompanying documents;
iii. Conduct
interviews with MCP staff responsible for completing the ISCA, as well as staff
responsible for aspects of the MCP’s information systems
function;
iv. Analyze
the
information obtained through the ISCA, conduct follow-up interviews with MCP
staff, and write a statement of findings about the MCP’s information
system.
v. Assess
the
ability of the MCP to link data from multiple
sources;
vi.
Examine MCP
processes for data transfers;
vii. If
an MCP has a
data warehouse, evaluate its structure and reporting
capabilities;
viii. Review
MCP
processes, documentation, and data files to ensure that they comply with state
specifications for encounter data submissions; and
ix. Assess
the
claims adjudication process and capabilities of the
MCP.
31. If
the MCP will
be using the Internet functions that will allow approved users to access member
information (e.g., eligibility verification), the MCP must receive prior written
approval from ODJFS that verifies that the proper safeguards, firewalls, etc.,
are in place to protect member data.
32. MCPs
must
receive prior written approval from ODJFS before adding any information to
their
website that would require ODJFS prior approval in hard copy form (e.g.,
provider listings, member handbook information).
33. Pursuant
to 42
CFR 438.106(b), the MCP acknowledges that it is prohibited from holding a member
liable for services provided to the member in the event that the ODJFS fails
to
make payment to the MCP.
34. In
the event of
an insolvency of an MCP, the MCP, as directed by ODJFS, must cover the continued
provision of services to members until the end of the month in which insolvency
has occurred, as well as the continued provision of inpatient services until
the
date of discharge for a member who is institutionalized when insolvency
occurs.
35. Franchise
Fee
Assessment Requirements
a. Each
MCP is required to pay a franchise permit fee to ODJFS for each calendar
quarter
as
required by ORC Section 5111.176. The current fee
to be paid
is an amount
equal to
4½ percent of the managed care premiums, minus Medicare premiums
that
the MCP received from any payer in the quarter to which the fee applies. Any
premiums the MCP returned or refunded to members or premium payers
during
that quarter are excluded from the fee.
b. The
franchise
fee is due to ODJFS in the ODJFS-specified format on or before the 30th
day
following the end of the calendar quarter to which the fee
applies.
c. At
the time the fee is submitted, the MCP must also submit to ODJFS a completed
form and any supporting documentation pursuant to ODJFS
specifications.
d. Penalties
for noncompliance with this requirement are specified in Appendix N, Compliance
Assessment System of the Provider Agreement and in ORC Section
5111.176.
36. Information
Required for MCP Websites
a.
On-line
Provider Directory–
MCPs
must
have an internet-based provider directory
available in the same format as their ODJFS-approved provider directory,
that
allows members
to
electronically search for the MCP panel providers
based
on name, provider type, geographic proximity, and population
(as
specified in Appendix H). MCP provider directories must
include all
MCP-contracted providers [except as specified by ODJFS] as well as
certain ODJFS
non-contracted providers.
b. On-line
Member Website–
MCPs
must have a secure internet-based website which is regularly updated to
include the most current ODJFS approved materials. The website at a
minimum must include: (1) a list of the counties that are covered in their
service area; (2) the ODJFS-approved MCP member handbook, recent
newsletters/announcements, MCP contact information including member
services hours and closures; (3) the MCP provider directory as referenced
in section 36(a) of this appendix; (4) the MCP’s current preferred drug
list (PDL), including an explanation of the list, which drugs require
prior authorization (PA), and the PA process; (5) the MCP’s current list
of drugs covered only with PA, the PA process, and the MCP’s
policy for covering generic for brand-name drugs; and (6) the ability
for members to submit questions/comments/grievances/appeals/etc. and
receive a response (members must be given the option of a return e-mail or
phone call). Responses regarding questions or comments are
expected within one working day of receipt, whereas responses
regarding grievances and appeals must be within the timeframes specified in
OAC rule 5101:3-26-08.4. MCPs must ensure that all
member materials designated specifically for CFC and/or ABD consumers
(i.e. the MCP member handbook) are clearly labeled as such. The
MCP’s member website cannot be used as the only means to notify members of
new and/or revised MCP information (e.g., change in holiday closures,
change in additional benefits, revisions to approved member materials
etc.). ODJFS may require MCPs to include additional information
on the member website, as needed.
c. On-line
Provider Website –
MCPs
must have a secure internet-based website for contracting providers where
they will be able to confirm a consumer’s MCP enrollment and through this
website (or through e-mail process) allow providers to
electronically submit and receive responses to prior authorization
requests. This website must also include: (1) a list of the
counties that are covered in their service area; (2) the MCP’s provider
manual; (3) MCP contact information; (4) a link to the MCP’s on-line
provider directory as referenced in section 37(a) of this appendix; (5) the
MCP’s current PDL list, including an explanation of the list, which
drugs require PA, and the PA process; (6) the MCP’s current list
of drugs covered only with PA, the PA process, and the MCP’s policy
for covering generic for brand-name drugs. MCPs
must ensure that all provider materials designated specifically for CFC
and/or ABD consumers (i.e. the MCP’s provider manual) are clearly
labeled as such; and (7) information regarding the availability of
expedited prior authorization requests, as well as the information that
is required from that provider in order to substantiate an expedited prior
authorization request.
ODJFS
may require MCPs to include additional information on the provider website,
as needed.
38. MCPs
must
provide members with a printed version of their PDL and PA lists, upon
request.
39. MCPs
must not
use, or propose to use , any offshore programming or call center services
in
fulfilling the program requirements.
40. PCP
Feedback–
The
MCP must
have the administrative capacity to offer feedback to individual
providers on their: 1) adherence to evidence-based practice guidelines;
and 2)
positive and
negative care variances from standard clinical pathways that may impact
outcomes
or
costs. In addition, the feedback information may be used by the MCP
for activities
such as provider performance
improvement
projects that include incentive
programs
or the
development of quality improvement programs.
41. Coordination
of Benefits
When
a claim is denied due to third party liability, the managed care plan must
timely share appropriate and available information regarding the third
party to the provider for the purposes of coordination of benefits,
including, but not limited to third party liability information
received from the Ohio Department of Job and Family
Services.
APPENDIX
D
ODJFS
RESPONSIBILITIES
ABD
ELIGIBLE
POPULATION
The
following are ODJFS responsibilities or clarifications that are not otherwise
specifically stated in OAC Chapter 5101: 3-26 or elsewhere in the ODJFS-MCP
provider agreement.
General
Provisions
1. ODJFS
will provide MCPs with an opportunity to review and comment on the
rate-setting time line and proposed rates, and proposed changes to the OAC
program rules or the provider agreement.
2. ODJFS
will notify MCPs of managed
care program policy and procedural changes and, whenever possible, offer
sufficient time for comment and implementation.
3. ODJFS
will provide regular opportunities for MCPs to receive program updates and
discuss program
issues with ODJFS staff.
4. ODJFS
will provide technical assistance sessions where MCP attendance and
participation is required. ODJFS will also provide optional technical assistance
sessions to MCPs, individually or as a group.
5. ODJFS
will provide MCPs with an annual MCP Calendar of Submissions outlining major
submissions and due dates.
6. ODJFS
will identify contact staff, including the Contract Administrator, selected
for
each MCP.
7. ODJFS
will recalculate the minimum
provider panel specifications if ODJFS determines that significant
changes have occurred in the availability of specific provider types and the
number and composition of the eligible population.
8. ODJFS
will recalculate the
geographic accessibility standards, using the geographic information systems
(GIS) software, if ODJFS determines that significant changes have occurred
in
the availability of specific provider types and the number and composition
of
the eligible population and/or the ODJFS provider panel
specifications.
9. On
a monthly basis, ODJFS will
provide MCPs with an electronic file containing their MCP’s provider panel as
reflected in the ODJFS Provider Verification System (PVS) database, or
other designated system.
10. On
a monthly basis, ODJFS will
provide MCPs with an electronic Master Provider File containing all the Ohio
Medicaid fee-for-service providers, which includes their Medicaid Provider Number,
as well as all
providers who have been assigned a provider reporting number for current encounter
data
purposes.
11. It
is the intent of ODJFS to
utilize electronic commerce for many processes and procedures
that are now limited by
HIPAA privacy concerns to FAX, telephone, or hard copy. The use of
TLS will mean that private health information (PHI) and the identification
of
consumers as Medicaid recipients can be shared between ODJFS and the contracting
MCPs via e-mail such as reports, copies of letters, forms, hospital claims,
discharge records, general discussions of member-specific information, etc.
ODJFS may revise data/information exchange policies and procedures for many
functions that are now restricted to FAX, telephone, and hard copy, including,
but not limited to, monthly membership and premium payment reconciliation
requests, newborn reporting, Just Cause disenrollment requests, information
requests etc. (as specified in Appendix C).
12. ODJFS
will immediately report to
Center for Medicare and Medicaid Services (CMS) any breach
in privacy or security that
compromises protected health information (PHI), when reported
by the MCP or ODJFS
staff.
13. Service
Area Designation
Membership
in a service area is
mandatory unless
ODJFS approves membership in
the service area for
consumer initiated selections only. It is ODJFS’ current
intention
to implement a mandatory
managed
care program in
service areas wherever choice
and capacity allow and the criteria in 42 CFR 438.50(a) are
met.
14. Consumer
information
a. ODJFS,
or
its delegated entity, will
provide membership notices,
informational materials, and instructional materials relating to members and
eligible individuals in a manner and format that may be easily understood.
At
least annually, ODJFS or designee
will provide
MCP eligible individuals, including current MCP members, with a Consumer Guide. The Consumer Guide
will describe the managed care program and include information on the
MCP options in the service area and
other information regarding the managed care program as
specified in 42 CFR 438.10.
b. ODJFS
will notify members or ask MCPs to notify members about significant changes
affecting contractual requirements, member services or access to
providers.
c. If
an MCP elects not to provide, reimburse, or cover a counseling service or
referral service due to an objection to the service on moral or religious
grounds, ODJFS will provide coverage and reimbursement for these services for
the MCP’s members.
ODJFS
will provide information on what services the MCP will not cover and how and
where the MCP’s members may obtain these services in the applicable Consumer
Guides.
15. Membership
Selection and Premium Payment
a. The
managed care enrollment center
(MCEC): The
ODJFS-contracted MCEC
will
provide unbiased
education, selection services, and community outreach for the Medicaid
managed care
program. The
MCEC shall
operate a statewide toll-free
telephone center to assist eligible individuals in selecting an MCP or choosing
a health care delivery option.
The
MCEC shall
distribute the most current
Consumer Guide that includes the managed care program
information as specified in 42 CFR 438.10, as well as ODJFS prior-approved
MCP
materials, such as solicitation brochures and provider directories, to consumers
who request additional materials.
b. Auto-Assignment
Limitations – In order
to promote market and program stability, ODJFS may limit an MCP’s
auto-assignments if they meet any of the following enrollment
thresholds:
· 40%
of statewideAged,
Blind, or Disabled (ABD)
managed care eligibles; and/or
· 60%
of the ABD managed care
eligibles in any
region with two MCPs;
and/or
· 40%
of the ABD managed care
eligibles in any
region with three MCPs.
Once
an MCP meets one of these
enrollment thresholds, the MCP will only be permitted to receive the additional
new membership (in the region or statewide, as applicable) through: (1)
consumer-initiated enrollment; and (2) auto-assignments which are based on
previous enrollment in that MCP or an historical provider relationship with
a
provider who is not on the panel of any other MCP in that region. In the event
that an MCP in a
region meets one or more of these enrollment thresholds, ODJFS, may not impose
the auto-assignment limitation and auto-assign members to the MCPs in that
region as ODJFS deems appropriate.
c. Consumer
Contact
Record (CCR): ODJFS or their
designated entity shall forward CCRs to MCPs on no less than a weekly
basis. The
CCRs are a record of each consumer-initiated MCP enrollment, change, or
termination, and each
MCEC initiated MCP
assignment processed through the MCEC. The
CCR contains
information that is not included on the monthly member
roster.
d. Monthly
member roster (MR):
ODJFS verifies managed care plan enrollment on a monthly
basis via the monthly
membership roster. ODJFS or its designated entity provides
a full member roster (F)
and a change roster (C) via HIPAA 834 compliant transactions.
e. Monthly
Premiums: ODJFS will remit
payment to the MCPs via an electronic funds transfer (EFT), or at the discretion
of ODJFS, by paper warrant.
f. Remittance
Advice: ODJFS will confirm
all
premium payments paid
to
the MCP during the
month via a monthly remittance advice (RA), which is sent to the MCP the week
following state cut-off. ODJFS or its designated
entity provides a record of each payment via HIPAA 820 compliant
transactions.
g. MCP
Reconciliation Assistance: ODJFS will work
with an
MCP-designated contact(s) to resolve the MCP’s memberand
newborn eligibility
inquiries, and premium
inquiries/discrepancies
and to review/approve
hospital
deferment
requests.
16. ODJFS
will make available a website
which includes current program information.
17. ODJFS
will regularly provide
information to MCPs regarding different aspects of MCP performance
including, but not
limited to, information on MCP-specific and statewide external
quality review
organization surveys, focused clinical quality of care studies, consumersatisfaction
surveys and provider
profiles.
18. ODJFS
will
periodically review a random
sample of online and printed directories to assess whether MCP
information is both accessible
and updated.
19. Communications
a. ODJFS/BMHC:
The Bureau of Managed Health Care
(BMHC) is responsible
for the oversight of
the MCPs’ provider agreements with ODJFS.
Within the BMHC,
a specific Contract
Administrator (CA)
has
been assigned to each
MCP. Unless expressly directed otherwise,
MCPs shall first contact
their designated CA for questions/assistance
related to
Medicaid and/or the MCP’s program
requirements
/responsibilities. If their CA is not available and
the MCP needs immediate
assistance, MCP staff should request
to speak to a supervisor
within the Contract Administration Section. MCPs
should
take all necessary and appropriate steps to ensure all MCP staff are aware
of,
and follow, this communication process.
b. ODJFS
contracting entities: ODJFS-contracting
entities should never be contacted by the MCPs unless the MCPs have been
specifically instructed
by ODJFS to
contact the ODJFS contracting
entity directly.
c. MCP
delegated entities: In
that MCPs are ultimately responsible for meeting program
requirements, the BMHC will
not discuss MCP issues with
the MCPs’ delegated entities
unless the applicable MCP is also
participating in the
discussion. MCP delegated entities, with the applicable MCP
participating, should only
communicate with the specific CA assigned to that
MCP.
APPENDIX
E
RATE
METHODOLOGY ABD ELIGIBLE POPULATION
Chase
Center/Circle
▇▇▇
▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇
▇▇▇▇▇
▇▇▇
▇▇▇▇▇▇▇▇▇▇▇▇,
▇▇
▇▇▇▇▇-▇▇▇▇
▇▇▇
Tel
▇▇▇▇▇ ▇▇▇ ▇▇▇▇
Fax
▇▇▇▇▇ ▇▇▇ ▇▇▇▇
▇▇▇▇▇▇▇▇▇.▇▇▇
FINAL
and CONFIDENTIAL
December
12, 2007
▇▇.
▇▇▇ ▇▇▇▇▇▇, Ph.D., Bureau Chief
Bureau
of Managed Health Care
Ohio
Department of Job and Family Services
Lazarus
Building
▇▇
▇▇▇▇ ▇▇▇▇ ▇▇., ▇▇▇▇▇ ▇▇▇
▇▇▇▇▇▇▇▇,
▇▇ ▇▇▇▇▇
RE: CY
2008 CAPITATION RATE DEVELOPMENT - AGED. BLIND, OR
DISABLED
Dear
▇▇▇:
▇▇▇▇▇▇▇▇,
Inc. (Milliman) was retained by the State of Ohio, Department of Job and
Family
Services (ODJFS) to develop the calendar year 2008 actuarially sound capitation
rates for the Aged, Blind, or Disabled (ABD) Risk Based Managed Care (RBMC)
program. This letter provides the documentation for the actuarially sound
capitation rates.
LIMITATIONS
The
information contained in this letter, including the enclosures, has been
prepared for the State of Ohio, Department of Job and Family Services and
their
consultants and advisors. It is our understanding that the information contained
in this letter may be utilized in a public document. To the extent that the
information contained in this letter is provided to third parties, the letter
should be distributed in its entirety. Any user of the data must possess
a
certain level of expertise in actuarial science and healthcare modeling so
as
not to misinterpret the data presented.
Milliman
makes no representations or warranties regarding the contents of this letter
to
third parties. Likewise, third parties are instructed that they are to place
no
reliance upon this letter prepared for ODJFS by Milliman that would result
in
the creation of any duty or liability under any theory of law by Milliman
or its
employees to third parties. Other parties receiving this letter must rely
upon
their own experts in drawing conclusions about the capitation rates,
assumptions, and trends.
▇▇▇
▇▇▇▇▇▇, Ph.D.
December
12, 2007
Page
2
FINAL
and CONFIDENTIAL
The
information contained in this letter was prepared as documentation of the
actuarially sound capitation rates for Medicaid managed care organization
health
plans in the State of Ohio. The information may not be appropriate for any
other
purpose.
SUMMARY
OF METHODOLOGY
ODJFS
contracted with Milliman to develop the CY 2008 ABD actuarially sound capitation
rates. The actuarially sound capitation rates were developed from historical
claims and enrollment data for the fee for service (FFS) population. The
FFS
population is considered a comparable population to the population to be
enrolled with the health plans. The historical experience was converted to
a per
member per month (PMPM) basis and stratified by region and category of service.
The historical experience was trended forward using projected trend rates
to a
center point of July 1, 2008 for the 2008 calendar year contract period.
The
historical experience was adjusted to reflect adjustments to the utilization
and
average cost per service that would be expected in a managed care
environment.
Appendix
1 contains a chart outlining the methodology that was used to develop the
CY
2008 capitation rates for the ABD populations.
Appendix
2 contains the actuarial certification regarding the actuarial soundness
of the
capitation rates.
Appendix
3 contains the CY 2008 capitation rates by region, including the segmentation
of
the administrative cost allowance between guaranteed and at-risk
components.
DETAILS
OF METHODOLOGY
I.
COVERED POPULATION
The
CY 2008 ABD capitation rates have been developed using historical experience
from the FFS population. The historical experience was developed for the
population eligible for managed care enrollment based on age and program
assignment. The program assignments shown in Table 1 were included in the
development of the capitation rates.
▇▇.
▇▇▇ ▇▇▇▇▇▇, Ph.D.
December
12, 2007
Page
3
FINAL
and CONFIDENTIAL
Table
I
STATE
OF OHIO
DEPARTMENT
OF JOB AND FAMILY SERVICES
Summary
of Managed Care Eligible Population
|
Program
Assignment
|
Description
|
|
AGED
|
Aged
|
|
RAGED
|
Aged
as defined on RMF
|
|
BLIND
|
Blind
|
|
RBLIND
|
Blind
as defined on RMF
|
|
DISABLED
|
Disabled
|
|
RDISABLED
|
Disabled
as defined on RMF
|
|
RESMED
|
Residential
State Supplement &
Medicaid
|
Milliman
extracted the eligible population information from historical data. The eligible
population includes the adult ABD population excluding: retro-active periods,
back-dated periods, institutionalized, waiver, spend-down, Medicare
dual-eligibles, and long-term nursing facility recipients. Adults are defined
based on age greater than or equal to 21 during the base experience period.
Long-term nursing facility was defined as stays lasting past the last day
of the
month following the admission to the nursing
facility.
If
a member was ineligible during a month, all claims and eligibility for the
month
were excluded from the actuarial models.
II.CATEGORY
OF SERVICE DEFINITIONS
The
categories of service listed in Table 2 describe the actuarial model service
groupings. The units associated with the categories have been indicated.
Further, the primary method of classifying the claims has been
provided.
▇▇.
▇▇▇ ▇▇▇▇▇▇, Ph.D.
December
12, 2007
Page
4
FINAL
and CONFIDENTIAL
Table
2
STATE
OF OHIO
DEPARTMENT
OF JOB AND FAMILY SERVICES
Categories
of Service
|
Type
of Service
|
Service
Category
|
Utilization
Units
|
Classification
Basis
|
|
Inpatient
Hospital
|
Medical/Surgical
|
Admits/Days
|
COS,
DRG
|
|
MH/SA
|
Admits/Days
|
||
|
Maternity
Delivery
|
Admits/Days
|
||
|
Well
Newborn
|
Admits/Days
|
||
|
Maternity
Non-Deliveries
|
Admits/Days
|
||
|
Nursing
Facility
|
Admits/Days
|
||
|
Other
Inpatient
|
Admits/Days
|
||
|
Outpatient
Hospital
|
Emergency
Room
|
Claims
|
COS,
Revenue Code
|
|
Surgery/ASC
|
Services
|
||
|
Cardiovascular
|
Services
|
||
|
PT/ST/OT
|
Services
|
||
|
Clinic
|
Services
|
||
|
Other
|
Services
|
||
|
Professional
|
Inpatient/Outpatient
Surgery
|
Services
|
COS,
Provider Type, Procedure, Modifier
|
|
Anesthesia
|
Line
Items
|
||
|
Obstetrics
|
Services
|
||
|
Office
Visits/Consults
|
Services
|
||
|
Hospital
Inpatient Visits
|
Services
|
||
|
Emergency
Room Visits
|
Services
|
||
|
Immunizations
& Injections
|
Services
|
||
|
Physical
Medicine
|
Services
|
||
|
Miscellaneous
Services
|
Line
Items, Services
|
||
|
Rad/Path/Lab
|
Radiology
|
Services
|
COS,
Revenue Code, Provider Type, Procedure
|
|
Pathology/Laboratory
|
Services
|
||
|
Ancillaries
|
MH/SA
|
Services
|
COS,
Provider Type, Procedure
|
|
FQHC/RHF/OP
Health Facility
|
Services
|
COS
|
|
|
Pharmacy
|
Line
Items
|
COS
|
|
|
Dental
|
Services
|
COS
|
|
|
Vision
|
Services
|
COS,
Provider Type, Procedure
|
|
|
Home
Health
|
Line
Items
|
COS
|
|
|
Non-Emergent
Transportation
|
Line
Items
|
COS
|
|
|
Ambulance
|
Line
items
|
COS,
Procedure Code
|
|
|
Supplies
and DME
|
Line
Items
|
COS,
Provider Type, Procedure
|
|
|
Miscellaneous
Services
|
Line
Items
|
COS
|
▇▇.
▇▇▇ ▇▇▇▇▇▇, Ph.D.
December
12, 2007
Page
5
FINAL
and CONFIDENTIAL
III. RATE
GROUPS
The
CY 2008 ABD capitation rates will be risk adjusted using the Chronic Illness
and
Disability Payment System (CDPS). As such, the ABD capitation rates are provided
in one single rate group. Further information regarding the CDPS risk adjustment
is contained in a later section as well as documented in detail in other
correspondence provided by Milliman,
IV. DEVELOPMENT
OF CY 2006 ADJUSTED FFS DATA
As
discussed in other sections of this document, several adjustments were applied
to the base FFS data to develop the CY 2008 capitation rates. The following
outlines each of the adjustments applied to the base FFS
data.
a.
Historical Data Summaries
The
CY 2008 ABD capitation rates were developed using FFS claims for two state
fiscal year (SFY) periods:
|
§
|
SFY
2005 (Incurred during the 12 months ending June 30, 2005 paid through
May
31, 2007).
|
|
§
|
SFY
2006 (Incurred during the 12 months ending June 30, 2006 paid through
May
31, 2007).
|
The
claims data was provided by ODJFS from the data warehouse. The experience
was
stratified into geographic region based on the member's county of
residence.
The
reimbursement amounts captured on the FFS actuarial models reflect the amount
paid by ODJFS, net of third party liability recoveries and member co-payment
amounts. The reimbursement amounts have not been adjusted for payments made
outside the claims processing system. These amounts are discussed later in
the
documentation.
The
FFS historical experience was adjusted to include only those services that
are
included in the capitation payment. Services that are not covered under the
capitation payment have been excluded from the experience. The excluded services
were identified by the state-assigned Category of Service field, as shown
in
Table 3.
▇▇.
▇▇▇ ▇▇▇▇▇▇, Ph.D.
December
12, 2007
Page
6
FINAL
and CONFIDENTIAL
Table
3
STATE
OF OHIO
DEPARTMENT
OF JOB AND FAMILY SERVICES
FFS
Claim Exclusions
|
COS
Field Value
|
Description
|
|
08
|
PACE
|
|
13
|
ICF/MR
Public
|
|
18
|
ICF/MR
Private
|
|
35
|
Core
Services
|
|
36
|
Home
Care Facilitator Services
|
|
41
|
Mental
Health Services
|
|
42
|
Mental
Retardation
|
|
46
|
Model
50 Waiver Services
|
|
58
|
HMO
Services
|
|
59
|
Mental
Health Support Services
|
|
60
|
Mental
Retardation Support Services
|
|
63
|
PPO
Services
|
|
64
|
Passport
|
|
66
|
Passport
Waiver III
|
|
67
|
OBRA
MR/DD Waiver
|
|
80
|
Alcohol
and Drug Abuse
|
|
82
|
Department
of Education
|
|
84
|
ODADAS
|
b.
Completion Factors
Milliman
utilized 24 months of claims experience for the FFS population that was incurred
through June 2006 and paid through May 2007 (eleven months of run-out). Milliman
applied claim completion factors to the twelve months of fiscal year 2005
and
twelve months of fiscal year 2006 claims experience. The claim completion
factors were developed by service category based on claims experience for
the
FFS population incurred and paid through May
2007.
c.
Historical Program Adjustments
The
base experience data represents a historical time period from which projections
were developed. Certain program changes have occurred during and subsequent
to
the base data time period. The program adjustments were estimated and applied
to
the portion of the base experience data prior to the program change effective
date. For example, a program change implemented on January 1. 2006 will only
be
reflected in the second half of SFY 2006. As such, an adjustment was applied
to
all of SFY 2005 and half of SFY 2006 to include the program change in all
periods of the base experience data.
▇▇.
▇▇▇ ▇▇▇▇▇▇, Ph.D.
December
12, 2007
Page
7
FINAL
and CONFIDENTIAL
ODJFS
has provided a listing of all program changes impacting the base experience
data. Table 4 summarizes the historical program changes that were reflected
in
the development of the CY 2008 capitation
rates.
Table
4
STATE
OF OHIO
DEPARTMENT
OF JOB AND FAMILY SERVICES
Historical
Program Adjustments - FFS
|
Program
Adjustment
|
Effective
Date
|
Service
Category(s)
|
|
Inpatient
Market Basket Increase
|
1/1/2005
|
Inpatient
Hospital
|
|
Dental
Fee Schedule Reduction
|
1/1/2006
|
Dental
|
|
Inpatient
Recalibration and Outlier Policy
|
1/1/2006
|
Inpatient
|
|
Pharmacy
Co-pay ($2 Per Brand Prescription)
|
1/1/2006
|
Pharmacy
|
|
Dental
Co-pay ($3 Per Date of Service)
|
1/1/2006
|
Dental
|
|
Vision
Exam Co-Pay ($2 Per Exam)
|
1/1/2006
|
Vision
/ Optometric
|
|
Vision
Hardware Co-Pay ($ 1 Per Item)
|
1/1/2006
|
Vision
/ Optometric
|
|
ER
Co-Pay ($3 Per Non-Emergency Visit)
|
1/1/2006
|
Emergency
Room
|
|
Dental
Benefit Reduction
|
1/1/2006
|
Dental
|
d.
Third-Party Liability
The
FFS experience was calculated using the net paid claim data from the FFS
data
provided by ODJFS. The paid amounts reflect a reduction for the amounts paid
by
third party carriers. Additionally, Milliman reduced the FFS experience to
reflect third party liability recoveries following payment of claims. The
reduction represents the average third party liability recovery rate received
by
the state under the "pay-and-chase" recovery program for each base year.
It is
expected that the health plans will collect the third party liability recoveries
for managed care enrolled individuals.
e.
Fraud and Abuse
The
FFS experience was calculated using the net paid claim data from the FFS
data
provided by ODJFS. Milliman reduced the FFS experience to reflect fraud and
abuse recoveries following payment of claims. The reduction represents the
average fraud and abuse recovery rate received by the state for each, base
year.
It is expected that the health plans will pursue fraud and abuse detection
activities for managed care enrolled
individuals.
▇▇.
▇▇▇ ▇▇▇▇▇▇,
Ph.D.
December 12,
2007
Page
8
FINAL
and CONFIDENTIAL
▇.
▇▇▇▇▇ Adjustments
The
FFS experience was calculated using the net paid claim data from the FFS
data
provided by ODJFS. Milliman adjusted the FFS experience to reflect
payments/refunds occurring outside of normal claim adjudication. Milliman
received a "gross adjustments" tile from ODJFS containing the additional
adjustments.
g.
Non-State Flan Services
CMS
requires removal of non-state plan services from rate-setting. The FFS data
does
not contain any such services. As such, no adjustment was applied to the
base
FFS data for non-state plan services.
h.
Trends/Inflation to CY 2006
Milliman
developed trend rates to progress the historical experience from state fiscal
years 2005 and 2006 forward to a common center point (CY 2006). Milliman
reviewed historical experience and performed linear regression on the experience
data to develop trend rates by category of service for both utilization and
unit
cost. Additionally, Milliman reviewed the resulting trends with internal
data
sources to develop the trends used to develop the CY 2008 ABD capitation
rates.
The
base experience data was normalized for artificial program adjustments prior
to
the trend rate development. Milliman did not consider items such as fee schedule
changes or benefit modifications as standard components of trend. Removing
the
impact of historical changes allows for transparent inclusion of prospective
program changes for future periods.
i.
Blend Base Experience Years
Each
of the base experience years was trended to CY 2006. At this point, each
base
year was on a comparable basis and could be aggregated. The weighting was
developed with the intention of placing more credibility on the most recent
experience and is consistent with the CY 2007 methodology. Specifically,
SFY
2005 received a weight of 30% and SFY 2006 received a weight of
70%.
j.
Managed Care Adjustments
Utilization
and cost per service adjustments were developed for each service category
and
region.
Utilization
Milliman
adjusted the FFS utilization and cost per service to reflect the managed
care
environment. After reviewing utilization benchmarks in the Milliman Medicaid
Guidelines (Guidelines)
as well as other sources, Milliman calculated percentage adjustments
to
reflect the utilization differential between an economic and efficiently
managed
plan and the FFS base experience.
▇▇.
▇▇▇ ▇▇▇▇▇▇, Ph.D.
December
12, 2007
Page
9
FINAL
and CONFIDENTIAL
Cost
Per Service
Milliman
adjusted the average reimbursement rates to reflect changes in the mix /
intensity of services due to the management of health care. The reimbursement
rate changes were also developed following a review of benchmarks in the
Guidelines
as well as other sources.
In
addition to the intensity adjustments applied to the cost per service amounts,
Milliman also included adjustments to reflect the health plan contracted
rates
with providers in the managed care adjustments.
V.
CY 2006 ADJUSTED BASE DATA TO CY 2008 CAPITATION
RATES
The
adjusted CY 2006 utilization and cost per service rates are trended forward
to
CY 2008 and adjusted for prospective program changes that will be effective
for
the CY 2008 contract period. The resulting PMPM, after trend and prospective
program changes establishes the regional adjusted claim cost for the health
plans in CY 2008. The administrative cost allowance and franchise fee components
are applied to the adjusted claim cost to develop the CY 2008 capitation
rate.
a.
Trend to CY 2008
The
trend rates that were used to progress the CY 2006 experience forward to
the CY
2008 rating period were developed from the historical experience, the experience
from other Medicaid managed care programs, and our actuarial judgment. The
trend
rates include a component for utilization and unit cost by major category
of
service.
b.
Prospective Program Adjustments
The
SFY 2008/2009 Budget contains several program changes that impacted the
development of the capitation rates. The program changes include items such
as
provider fee changes, benefit changes, and administrative changes. Adjustments
to the CY 2006 experience were developed for each item based on its expected
impact to the prospective claims cost. Table 5 lists the program changes
that
were included in the CY 2008 capitation rate
development.
▇▇.
▇▇▇ ▇▇▇▇▇▇, Ph.D.
December
12, 2007
Page
10
FINAL
and CONFIDENTIAL
Table
5
STATE
OF OHIO
DEPARTMENT
OF JOB AND FAMILY SERVICES
Prospective
Program Adjustments
|
Program
Adjustment
|
Effective
Date
|
Service
Category(s)
|
|
Nursing
Facility Fee Increase
|
7/1/2007
|
Nursing
Facility
|
|
7/1/2008
|
||
|
Chiropractor
Benefit Restoration
|
1/1/2008
|
Miscellaneous
Services
|
|
Independent
Psychologists Benefit Restoration
|
1/1/2008
|
Mental
Health / Substance Abuse
|
|
Occupational
Therapy-Independent Provider Status
|
1/1/2008
|
Miscellaneous
Services
|
|
Improved
TPL Management
|
1/1/2008
|
All
Service Categories
|
|
Prior
Authorization Policy Change
|
1/1/2008
|
Pharmacy
|
|
Prior
Authorization of Atypical Anti-Psychotic Medication
|
1/1/2008
|
Pharmacy
|
c.
Prospective Selection Adjustment
Milliman
adjusted the CY 2006 experience to reflect the expected penetration of managed
care in CY 2008. Table 6 provides the target managed care penetration used
in
the development of the CY 2008 capitation
rates.
Table
6
STATE
OF OHIO
DEPARTMENT
OF JOB AND FAMILY SERVICES
Prospective
Selection Adjustments
|
Region
|
June
▇▇▇▇ ▇▇ ▇▇▇▇▇▇▇▇▇▇▇
|
Target
MC Penetration
|
|
Central
|
89.5%
|
93%
|
|
East
Central
|
88.8%
|
93%
|
|
Northeast
|
89.7%
|
93%
|
|
Northeast
Central
|
0.0%
|
93%
|
|
Northwest
|
87.6%
|
93%
|
|
Southeast
|
92.3%
|
93%
|
|
Southwest
|
86.0%
|
93%
|
|
West
Central
|
87.7%
|
93%
|
▇▇.
▇▇▇ ▇▇▇▇▇▇. Ph.D.
December
12, 2007
Page
11
FINAL
and CONFIDENTIAL
d.
Administrative Allowance
Milliman
included an administrative cost allowance in the development of the actuarially
sound capitation rates for CY 2008. The administrative cost allowance contains
provision for administrative expenses, profit/contingency, and surplus
contribution and was calculated as a percentage of the capitation rate prior
to
the franchise fee. As such, the pre-franchise fee capitation rate will be
determined by dividing the projected managed care claim cost by one minus
the
administrative cost allowance. By determining the pre-franchise fee capitation
rate in this manner, the administrative allowance may be expressed as a
percentage of the pre-franchise fee capitation rate. Milliman developed the
administrative cost allowance following a review of cost information from
other
representative Medicaid managed care
organizations.
For
health plans in plan year 3 or later, 1% of the administrative component
will be
at-risk and contingent upon performance requirements defined in the ODJFS
provider agreements. Table 7 provides the administrative cost allowance for
each
plan year.
Table
7
STATE
OF OHIO
DEPARTMENT
OF JOB AND FAMILY SERVICES
Administrative
Cost Allowance
|
Plan
Year
|
Guaranteed
%
|
At-Risk
%
|
Total %
|
|
Plan
Year 1 (1-12 Months)
|
11.5%
|
0.0%
|
11.5%
|
|
Plan
Year 2 (13-24 Months)
|
10.5%
|
0.0%
|
10.5%
|
|
Plan
Year 3 (25 + Months)
|
9.5%
|
1.0%
|
10.5%
|
The
administrative cost allowance percentages contained in Table 7 reflect a
change
from the 2007 methodology.
e.
Franchise Fee
Milliman
included a franchise fee component in the development of the actuarially
sound
capitation rates for CY 2008. The franchise fee was calculated as a percentage
of the capitation rates. Therefore, the capitation rate will be determined
by
dividing the pre-franchise fee capitation rate by one minus the franchise
fee
component. By determining the pre-franchise fee capitation rate in this manner,
the franchise fee may be expressed as a percentage of the capitation rate.
The
franchise fee component is 4.5% of the capitation
rate.
▇▇.
▇▇▇ ▇▇▇▇▇▇, Ph.D.
December
12, 2007
Page
12
FINAL
and CONFIDENTIAL
VI.
CDPS
RISK ADJUSTMENT
The
methodology described in this correspondence was used to develop the base
capitation rates for CY 2008 for each region. Milliman will then apply the
Chronic Illness and Disability Payment System (CDPS) to adjust the actuarially
sound base capitation rates for the ABD population on a regional basis for
each
health plan. The CDPS risk adjustment will be updated each six month period
for
existing regions and plans. For the initial period of managed care within
a
region and plan, a monthly risk score will be developed for the first three
months.
The
next anticipated risk score update will be January 1, 2008. The CDPS risk
scores
will be developed for ABD recipients enrolled in managed care during December
2007 using diagnosis information from claims incurred in calendar year 2006
with
paid dates between January 1, 2006 and June 30, 2007. Health plan and region
specific prevalence reports will be provided with the updated risk
scores.
DATA
RELIANCE
In
developing the CY 2008 ABD capitation rates, we have relied upon certain
data
and information from ODJFS. While limited review was performed for
reasonableness, the data and information was accepted without audit. To the
extent that the data and information was not accurate or complete, the values
shown in this letter will need to be revised.
♦♦♦♦
If
you have any questions regarding the enclosed information, please do not
hesitate to contact me at
(▇▇▇) ▇▇▇-▇▇▇▇.
Sincerely,
/s/
▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇
▇▇▇▇▇▇
▇. ▇▇▇▇▇▇, FSA, MAAA
Principal
and Consulting Actuary
RMD/mle
|
cc:
|
▇▇▇
▇▇▇▇▇ (ODJFS)
▇▇▇▇▇▇
▇▇▇▇▇▇ (ODJFS)
▇▇▇▇▇▇
▇▇▇▇▇ (ODJFS)
|
FINAL
and CONFIDENTIAL
APPENDIX
1
FINAL
and CONFIDENTIAL
Illustration
of Rate Development Methodology
[Graph]
FINAL and CONFIDENTIAL
APPENDIX
2
FINAL
and CONFIDENTIAL
STATE
OF OHIO
DEPARTMENT
OF JOB AND FAMILY SERVICES
Aged,
Blind, or Disabled - CY 2008 Capitation Rates
Actuarial
Certification
I,
▇▇▇▇▇▇ ▇. ▇▇▇▇▇▇, am a Principal and Consulting Actuary with the firm of
▇▇▇▇▇▇▇▇, Inc. I am a Fellow of the Society of Actuaries and a Member of
the
American Academy of Actuaries. I was retained by the State of Ohio, Department
of Job and Family Services to perform an actuarial review and certification
regarding the development of the capitation rates to be effective for calendar
year 2008. The capitation rates were developed for the Aged, Blind, or Disabled
managed care eligible populations. I have experience in the examination of
financial calculations for Medicaid programs and meet the qualification
standards for rendering this opinion.
I
reviewed the historical claims experience for reasonableness and consistency.
I
have developed certain actuarial assumptions and actuarial methodologies
regarding the projection of healthcare expenditures into future periods.
I have
complied with the elements of the rate setting checklist CMS developed for
its
Regional Offices regarding 42 CFR 438.6(c) for capitated Medicaid managed
care
plans.
The
capitation rates provided with this certification are effective for a one-year
rating period beginning January 1, 2008 through December 31, 2008. At the
end of
the one-year period, the capitation rates will be updated for calendar year
2009. The update may be based on fee-for-service experience, managed care
utilization and trend experience, policy and procedure changes, and other
changes in the health care market. A separate certification will be provided
with the updated rates.
The
capitation rates provided with this certification are considered actuarially
sound, defined as:
|
•
|
the capitation
rates have been
developed in accordance with generally accepted actuarial
principles and practices;
|
|
•
|
the
capitation rates are appropriate for the populations to be covered,
and
the services to be furnished under the contract; and,
|
| • | the capitation rates meet the requirements of 42 CFR 438.6(c). |
This
actuarial certification has been based on the actuarial methods, considerations,
and analyses promulgated
from time to time through the Actuarial Standards of Practice by the Actuarial
Standards
Board.
/s/
▇▇▇▇▇▇ ▇. Dalmer_
▇▇▇▇▇▇
▇. ▇▇▇▇▇▇, FSA
Member,
American Academy of Actuaries
December
4, 2007
Date
FINAL
and CONFIDENTIAL
APPENDIX
3
FINAL
AND CONFIDENTIAL
State
of Ohio
Department
of Job and Family Services
CY2008
ABD Capitation Rate Development
|
Projected
CY
|
CY
2008
|
|||||||||||||||
|
2008
Member
|
Guaranteed
|
CY
2008 At
|
||||||||||||||
|
Region
|
Months
|
Rate
|
Risk
Rate
|
CY
2008 Rate
|
||||||||||||
|
Central
|
284,169
|
$1,101.26 | $10.62 | $1,111.88 | ||||||||||||
|
East
Central
|
149,045 | 1,091.21 | 10.52 | 1,101.73 | ||||||||||||
|
Northeast
|
287,103 | 1,099.46 | 10.60 | 1,110.06 | ||||||||||||
|
Northeast
Central
|
85,309 | 1,098.34 | 10.59 | 1,108.93 | ||||||||||||
|
Northwest
|
137,407 | 1,107.94 | 10.68 | 1,118.62 | ||||||||||||
|
Southeast
|
152,735 | 981.68 | 9.47 | 991.15 | ||||||||||||
|
Southwest
|
174,390 | 1,120.61 | 10.80 | 1,131.41 | ||||||||||||
|
West
Central
|
123,260 | 1,133.13 | 10.93 | 1,144.06 | ||||||||||||
|
Statewide
|
1,393,418 | $1,092.43 | $10.53 | $1,102.96 | ||||||||||||
Appendix
F
|
|
PREMIUM
RATES WITHOUT THE AT-RISK PAYMENT AMOUNTS FOR 01/01/08 THROUGH
06/30/08
MCP's
premiums will be at-risk starting the 25th month of the ABD Medicaid
Managed Care Program participation.
|
MCP: WellCare
of Ohio, Inc.
|
Service
Enrollment
Area
|
Risk Adjusted Rate |
At-Risk
Amounts
|
|
Northeast
Region
|
$1,125.45
|
$0.00
|
| List of Eligible Assistance Groups (AGs) | |
| Aged, Blind or Disabled: | MA-A Aged |
| MA-B Blind | |
| MA-D Disabled |
APPENDIX
G
COVERAGE
AND SERVICES
ABD
ELIGIBLE
POPULATION
1.
Basic
Benefit
Package
Pursuant
to OAC rule 5101:3-26-03(A), with limited exclusions (see section G.2 of this
appendix), MCPs must ensure that members have access to medically-necessary
services covered by the Ohio Medicaid fee-for-service (FFS)
program. For information on Medicaid-covered services, MCPs must
refer to the
ODJFS website. The following is a general list of the benefits pertinent to
the
ABD population covered by the MCPs:
·
Inpatient hospital services
·
Outpatient hospital services
·
Rural health clinics (RHCs)
and
Federally qualified health centers (FQHCs)
·
Physician services whether furnished in the physician’s office, the covered
person’s home, a hospital, or elsewhere
·
Laboratory and x-ray services
·
Family planning services and supplies
·
Home health and private duty
nursing services
·
Podiatry
·
Physical therapy, occupational therapy, and speech therapy
·
Nurse-midwife, certified family nurse practitioner, and certified pediatric
nurse practitioner services
·
Prescription drugs
·
Ambulance and ambulette services
·
Dental services
·
Durable medical equipment and medical supplies
·
Vision care services, including
eyeglasses
·
Nursing facility stays as
specified in OAC rule 5101:3-26-03
·
Hospice care
·
Behavioral health services (see section G.2.b.iii of this appendix)
·
Chiropractic services
2. Exclusions,
Limitations and
Clarifications
a. Exclusions
MCPs
are
not required to pay for Ohio Medicaid FFS program (Medicaid) non-covered
services. For information regarding Medicaid noncovered services, MCPs must
refer to the ODJFS website. The following is a general list of the services
not
covered by the Ohio Medicaid fee-for-service program:
·
Services or supplies that are not medically necessary
·
Experimental services and procedures, including drugs and equipment, not covered
by Medicaid
·
Organ transplants that are not covered by Medicaid
·
Abortions, except in the case of a reported rape, incest, or when medically
necessary to save the life of the mother
·
Infertility services for males or females
·
Voluntary sterilization if under 21 years of age or legally incapable of
consenting to the procedure
·
Reversal of voluntary sterilization procedures
·
Plastic or cosmetic surgery
that is not
medically necessary*
·
Immunizations for travel outside of the United States
·
Services for the treatment of obesity unless medically necessary*
·
Custodial or supportive care not
covered by Medicaid
·
Sex change surgery and related services
·
Sexual or marriage counseling
·
Acupuncture and biofeedback services
·
Services to find cause of death (autopsy)
·
Comfort items in the hospital (e.g., TV or phone)
·
Paternity testing
MCPs
are
also not required to pay for non-emergency services or supplies received without
members following the directions in their MCP member handbook, unless otherwise
directed by ODJFS.
*These
services
could be deemed medically necessary if medical complications/conditions in
addition to the obesity or physical imperfection are present.
b. Limitations
&
Clarifications
i. Member
Cost-Sharing
As
specified in OAC rules 5101:3-26-05(D) and 5101:3-26-12, MCPs
are permitted to impose the applicable member co-payment amount(s) for dental
services, vision services, non-emergency emergency department services, or
prescription drugs, other than generic drugs. MCPs must notify ODJFS if they
intend to impose a co-payment. ODJFS must approve the notice to be
sent to the MCP’s members and the timing of when the co-payments will begin to
be imposed. If ODJFS determines that an MCP’s decision to impose a
particular co-payment on their members would constitute a significant change
for
those members, ODJFS may require the effective date of the co-payment to
coincide with the “Open
Enrollment” month.
Notwithstanding
the preceding paragraph, MCPs must provide an ODJFS-approved notice to all
their
members 90 days in advance of the date that the MCP will impose the co-payment.
With the exception of member co-payments the MCP has elected to implement in
accordance with OAC rules 5101:3-26-05(D) and 5101:3-26-12, the MCP’s payment
constitutes payment in full for any covered services and their subcontractors
must not charge members or ODJFS any additional co-payment, cost sharing,
down-payment, or similar charge, refundable or otherwise.
ii. Abortion
and
Sterilization
The
use
of federal funds to pay for abortion and sterilization services is prohibited
unless the specific criteria found in 42 CFR 441 and OAC rules 5101:3-17-01
and
5101:3-21-01 are met. MCPs must verify that all of the information on
the required forms (JFS 03197, 03198, and 03199) is provided and that the
service meets the required criteria before any such claim is paid.
Additionally,
payment must not be made for associated services such as anesthesia, laboratory
tests, or hospital services if the abortion or sterilization itself does not
qualify for payment. MCPs are responsible for educating their
providers on the requirements; implementing internal procedures including
systems edits to ensure that claims are only paid once the MCP has determined
if
the applicable forms are completed and the required criteria are met, as
confirmed by the appropriate certification/consent forms; and for maintaining
documentation to justify any such claim payments.
iii. Behavioral
Health
Services
Coordination
of Services: MCPs must have a process
to
coordinate benefits of and referrals to the publicly funded community behavioral
health system. MCPs must ensure
that
members have access to all medically-necessary behavioral health services
covered by the Ohio Medicaid FFS program and are responsible for coordinating
those services with other medical and support services. MCPs must
notify members via the member handbook and provider directory of where and
how
to access behavioral health services, including the ability to self-refer to
mental health services offered through ODMH community mental health
centers (CMHCs) as well as substance abuse services offered through Ohio
Department of Alcohol and Drug Addiction Services (ODADAS)-certified Medicaid
providers. Pursuant to ORC Section 5111.16, alcohol, drug addiction and mental
health services covered by Medicaid are not to be paid by the managed care
program when the nonfederal share of the cost of those services is provided
by a
board of alcohol, drug addiction, and mental health services or a
state agency
other than ODJFS. MCPs are also not responsible for providing mental
health services to persons between 22 and 64 years of age while residing
in an institution for mental disease (IMD) as defined in Section 1905(i) of
the
Social Security Act.
MCPs
must provide
Medicaid-covered behavioral health
services
for members who are unable to timely access services or unwilling to access
services through community providers.
Mental
Health
Services: There are a number of Medicaid-covered mental health (MH) services available
through
ODMH CMHCs.
Where
an
MCP is responsible for providing MH services for their members, the MCP is
responsible for ensuring access to counseling and psychotherapy,
physician/psychiatrist services, outpatient clinic services, general hospital
outpatient psychiatric services, pre-hospitalization screening, diagnostic
assessment (clinical evaluation), crisis intervention, psychiatric
hospitalization in general hospitals (for all ages), and Medicaid-covered
prescription drugs and laboratory services. MCPs are not required to
cover partial hospitalization, or inpatient psychiatric care in a private or public
free-standing psychiatric
hospital. However, MCPs are required to cover the payment of
physician services in a private or public free-standing psychiatric hospital
when such services are billed independent of the hospital.
Substance
Abuse
Services: There are a number of Medicaid-covered substance
abuse services available through ODADAS-certified Medicaid
providers.
Where
an
MCP is responsible for providing substance abuse services for their members,
the
MCP is responsible for ensuring access to alcohol and other drug (AOD)
urinalysis screening, assessment, counseling, physician/psychiatrist AOD
treatment services, outpatient clinic AOD treatment services, general hospital
outpatient AOD treatment services, crisis intervention, inpatient detoxification
services in a general hospital, and Medicaid-covered prescription drugs and
laboratory services. MCPs are not required to cover outpatient detoxification
and methadone maintenance.
Financial
Responsibility
for Behavioral Health Services: MCPs are responsible
for the
following:
· payment
of Medicaid-covered prescription
drugs prescribed by an ODMH CMHC or ODADAS-certified provider when obtained
through an MCP’s panel pharmacy;
· payment
of Medicaid-covered services
provided by an MCP’s panel laboratory when referred by an ODMH CMHC or
ODADAS-certified provider;
· payment
of all other Medicaid-covered
behavioral health services obtained through providers other than those who
are
ODMH CMHCs or ODADAS-certified providers when arranged/authorized by the
MCP.
Limitations:
· Pursuant
to ORC Section 5111.16,
alcohol, drug addiction and mental health services covered by Medicaid are
not
to be paid by the managed care program when the nonfederal share of the cost
of
those services is provided by a board of alcohol, drug addiction, and mental
health services or a state agency other than ODJFS. As part of this
limitation:
· MCPs
are not responsible for paying for
behavioral health services provided through ODMH CMHCs and ODADAS-certified
Medicaid providers;
· MCPs
are not responsible for payment of
partial hospitalization (mental health), inpatient psychiatric care in a private
or public free-standing inpatient psychiatric hospital, outpatient
detoxification, intensive outpatient programs (IOP) (substance abuse) or
methadone maintenance.
· However,
MCPs are required to cover the
payment of physician services in a private or public free-standing psychiatric
hospital when such services are billed independent of the
hospital.
iv. Pharmacy
Benefit: In providing the Medicaid pharmacy benefit to their
members, MCPs must cover the same
drugs covered by the Ohio Medicaid
fee-for-service program.
MCPs
may
establish a preferred drug list for members and providers which includes a
listing of the drugs that they prefer to have prescribed. Preferred drugs
requiring prior authorization approval must be clearly indicated as
such. Pursuant to ORC §5111.172, ODJFS may approve MCP-specific
pharmacy program utilization management strategies (see appendix
G.3.a).
v. Organ
Transplants: MCPs
must ensure coverage for organ
transplants
and related services in
accordance with OAC 5101-3-2- 07.1
(B)(4)&(5). Coverage
for all organ transplant services, except kidney
transplants, is contingent upon
review and recommendation by
the “Ohio Solid Organ Transplant
Consortium” based on criteria
established by Ohio organ
transplant surgeons and
authorization
from the ODJFS prior
authorization unit. Reimbursement
for bone marrow transplant
and hematapoietic stem
cell transplant services, as
defined in OAC 3701:84-01, is contingent
upon review and
recommendation by the “Ohio Hematapoietic
Stem Cell Transplant
Consortium” again based on criteria established
by Ohio experts
in the field of bone marrow
transplant. While
MCPs may
require prior authorization for these transplant services,
the
approval criteria would be limited to confirming the consumer is being
considered and/or has been recommended for a transplant by either
consortium and authorized by ODJFS. Additionally, in accordance
with OAC 5101:3-2-03 (A)(4) all services related to organ donations are
covered for the donor recipient when the consumer is Medicaid
eligible.
3. Care
Coordination
a. Utilization
Management Programs
General
Provisions -
Pursuant to OAC rule 5101:3-26-03.1(A)(7), MCPs must implement a utilization
management (UM) program to maximize the effectiveness of the care provided
to
members and may develop other UM programs, subject to prior approval by
ODJFS. For the purposes of this requirement, the specific UM programs which
require ODJFS prior-approval are an MCP’s general pharmacy program, a controlled
substances and member management program, and any other program designed by
the
MCP with the purpose of redirecting or restricting access to a particular
service or service location.
i. Pharmacy
Programs -
Pursuant to ORC Sec. 5111.172 and OAC rule 5101:3-26-03(A) and (B), MCPs
may, subject to ODJFS prior- approval, implement strategies for the
management of pharmacy utilization. Pharmacy utilization
management strategies may include developing preferred drug lists,
requiring prior authorization for certain drugs, placing limitations on
the type of provider and locations where certain medications may be
administered, and developing and implementing a specialized pharmacy
program to address the utilization of controlled substances, as defined in
section 3719.01 of the Ohio Revised
Code.
Drug
Prior
Authorizations: MCPs must receive prior approval from ODJFS for the
medications that they wish to cover through prior
authorization. MCPs must establish their prior authorization
system so that it does not unnecessarily impede member access to
medically-necessary Medicaid-covered services. As outlined in
paragraph 29(i)(ii)(f) of Appendix C, MCPs must adhere to specific
prior-authorization limitations to assist with the transition of new ABD
members from FFS Medicaid. MCPs must make their approved list of drugs
covered only with prior authorization available to members and providers,
as outlined in paragraphs 36(b) and (c) of Appendix C.
Beginning
January 1, 2008, MCPs may require prior authorization for the coverage of
antipsychotic drugs with ODJFS approval. MCPs must,
however, allow any member to continue receiving a specific antipsychotic
drug if the member is stabilized on that particular
medication. The MCP must continue to cover that specific drug
for the stabilized member for as long as that medication continues to be
effective for the member. MCPs may also implement a drug
utilization review program designed to promote the appropriate clinical
prescribing of antipsychotic drugs. This can be accomplished
through the MCP’s retrospective analysis of drug claims to identify
potential inappropriate use and provide education to those providers who
are outliers to acceptable standards for prescribing/dispensing
antipsychotic drugs.
MCPs
must comply with the provisions of
1927(d)(5) of the Social Security Act, 42 USC 1396r-8(k)(3), and
OAC rule 5101:3-26- 03.1
regarding the timeframes for prior authorization of covered outpatient
drugs.
Controlled
Substances and
Member Management Programs: MCPs may also, with ODJFS prior
approval, develop and implement Controlled Substances and Member
Management (CSMM) programs designed to address use of controlled
substances. Utilization management strategies may include prior
authorization as a condition of obtaining a controlled substance, as
defined in section 3719.01 of the Ohio Revised Code. CSMM
strategies may also include processes for requiring MCP members at high
risk for fraud or abuse involving controlled substances to have their
narcotic medications prescribed by a designated provider/providers
and filled by a pharmacy, medical provider, or health care facility
designated by the program.
ii. Emergency
Department
Diversion (EDD) – MCPs must
provide
access to services in a way that assures access to
primary, specialist and urgent care in the most appropriate settings
and that minimizes frequent, preventable utilization of
emergency department (ED) services. OAC rule 5101:3-26-03.1(A)(7)(d) requires MCPs to
implement the ODJFS-required emergency department diversion (EDD) program for
frequent utilizers.
Each
MCP must establish an ED diversion (EDD) program with the goal of
minimizing frequent ED utilization. The MCP’s EDD program must include the
monitoring of ED utilization, identification of frequent ED utilizers, and
targeted approaches designed to reduce avoidable ED utilization. MCP EDD
programs must, at a minimum, address those ED visits which could have been
prevented through improved education, access, quality or care management
approaches.
Although
there is often an assumption that frequent ED visits are solely the result
of a
preference on the part of the member and education is therefore the standard
remedy, it is also
important to ensure that a member’s frequent ED utilization is not due to
problems such as their PCP’s lack of accessibility or failure to make
appropriate specialist referrals. The MCP’s EDD program must
therefore also include the identification of providers who serve as PCPs for
a
substantial number of frequent ED utilizers and the implementation of corrective
action with these providers as so indicated.
This
requirement does not replace the MCP’s responsibility to inform and educate all
members regarding the appropriate use of the ED.
MCPs
must
also implement the ODJFS-required emergency department diversion (EDD) program
for frequent users. In that ODJFS has developed the parameters for an
MCP’s EDD program, it therefore does not require ODJFS prior approval
(Moved).
b. Integration
of Member Care
The
MCP must ensure that a discharge
plan is in place to meet a member’s health
care needs following discharge
from a nursing facility, and integrated into the member’s continuum
of care. The discharge plan must address the services
to be provided for
the member and must be developed prior to the date of
discharge from the
nursing facility. The MCP must ensure follow-up contact
occurs with the
member, or authorized representative, within
thirty (30) days
of the member’s discharge from the nursing facility
to ensure that
the member’s health care needs are being met.
c. Care
Coordination with
ODJFS-Designated Providers
Per
OAC
rule 5101:3-26-03.1(A)(4), MCPs are required to share specific information
with
certain ODJFS-designated non-contracting providers in order to ensure that
these
providers have been supplied with specific information needed to coordinate
care
for the MCP’s members. 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 Mental Health
Centers, ODADAS-certified Medicaid providers, FQHCs/RHCs, QFPPs, CNMs, CNPs
[if
applicable], and hospitals) a quick reference information packet which
includes the following:
i. A
brief cover letter explaining the
purpose of the mailing; and
ii. A
brief summary document that includes the following
information:
· Claims
submission information including the MCP’s Medicaid provider number for each
region;
· The
MCP’s prior authorization and referral procedures or the MCP’s
website;
· A
picture of the MCP’s member identification card (front and back);
· Contact
numbers and/or website location for obtaining information for eligibility
verification, claims processing, referrals/prior authorization, and information
regarding the MCP’s behavioral health administrator;
· A
listing of the MCP’s major pharmacy chains and the contact number for the MCP’s
pharmacy benefit administrator (PBM);
· A
listing of the MCP’s laboratories and radiology providers; and
· A
listing of the MCP’s contracting behavioral health providers and how to access
services through them (this information is only to be provided to
non-contracting community mental health and substance abuse
providers).
d. Care
coordination with Non-Contracting Providers
Per
OAC
rule 5101:3-26-05(A)(9), MCPs authorizing the delivery of services
from a provider who does not have an executed subcontract must ensure that they have a mutually
agreed
upon compensation amount for the authorized service and notify the provider
of
the applicable provisions of paragraph D of OAC rule
5101:3-26-05. This notice is provided when an MCP authorizes a
non-contracting provider to furnish services on a one-time or infrequent
basis to an MCP member and must include required ODJFS-model language and
information. This notice must also be included with the transition of services
form sent to providers as outlined in paragraph 29.h. of Appendix
C.
4. Case
Management
In
accordance with 5101:3-26-03.1(A)(8),
MCPs must offer and provide comprehensive case
management services which
coordinate and monitor the care of members with specific diagnoses, or who
require high-cost and/or extensive services.
a. Each
MCP must inform all members and contracting providers of the MCP’s case
management services.
b. The
MCP must assure and coordinate the placement of the member into
case management - including identification of the member's need for case
management services, completion of the comprehensive health needs assessment,
and timely development of a care treatment plan. This process must
occur within the following timeframes for:
i.
newly
enrolled members – 90 days from the effective date of enrollment;
and
ii.
existing members – 90 days from identifying their need for case
management.
c. The
MCP’s comprehensive case management program must include, at a minimum, the
following components:
i. Identification
–
The
MCP
must have mechanisms in place to identify members potentially eligible for
case
management services. These mechanisms must include an administrative
data review (e.g. diagnosis, cost threshold, and/or service utilization) and
may
also include telephone interviews; provider/self-referrals; information as
reported by the Managed Care Enrollment Center (MCEC) during membership
selection; or
home visits.
ii. Assessment
-
The
MCP must arrange for or conduct a
comprehensive assessment of the member’s physical and/or behavioral health
condition(s) to confirm the results of a positive identification, and to
determine the need for case management services. The
goals of the assessment are to identify the member’s existing and/or potential
health care needs and assess the member’s need for case management
services.
The
assessment must be completed by a
physician, physician assistant, RN, LPN, licensed social worker, or a graduate
of a two or four year allied health program. If the assessment is
completed by another medical professional, there should be oversight and
monitoring by either a registered nurse or a physician.
The
MCP must have a process to inform
members and their PCPs that
they have been identified as meeting the criteria for case management, including
their enrollment into case management services.
The
MCP must develop a strategy to
assign members to risk stratification levels, based on the member’s
comprehensive needs assessment.
iii. Care
Treatment Plan –
The
care treatment plan is defined by
ODJFS as the one developed by the MCP for the member.
The
development of the care treatment
plan must be based on the comprehensive health assessment and reflect the
member’s primary medical diagnosis and health conditions, any comorbidities, and
the member’s psychological, behavioral health and community support
needs. The care treatment plan must also include specific provisions
for periodic reviews (i.e.,
no less than semi-annually) of the member’s condition and
appropriate updates to the plan. The member and the member’s PCP must
be actively involved in the development of and revisions to the care treatment
plan. The designated PCP is the provider, or specialist, who will
manage and
coordinate the overall care for the member. Ongoing communication
regarding the status of the care treatment plan may be accomplished between
the
MCP and the PCP’s designee (i.e., qualified health
professional). Revisions to the clinical portion of the care
treatment plan should be completed in consultation with the
PCP.
The
elements of a comprehensive care treatment plan include:
Goals
and
actions that address medical, social, behavioral and psychological
needs;
Member
level interventions, (i.e., referrals and making appointments) that assist
members in obtaining services, providers and programs;
Continuous
review, revision and contact follow-up, as needed, to ensure the
care treatment plan is adequately monitored including the
following:
· Documentation
that services are provided in accordance with the care treatment
plan;
· Re-evaluation
to determine if the care treatment plan is adequate to meet the member's current
needs;
· Identification
of gaps between recommended care and actual care provided;
· A
change
in needs or status from the re-evaluation that requires revisions to the care
treatment plan;
· Active
participation by the member or representative in the care treatment plan
development;
· Monitoring
of specific service delivery including service utilization; and
· Re-evaluation
of a member's risk stratification level with adjustment to the level of case
management services provided.
iv. Coordination
of Care and Communication
There
should be an accountable point of contact at the MCP for each member in case
management who can help obtain medically necessary care, assist with
health-related services and coordinate care needs, including behavioral
health. The MCP must
arrange or provide for professional case management services that are performed
collaboratively by a team ofprofessionals
appropriate for the
member’s condition and health care needs. At a minimum, the MCP’s
case manager must attempt to coordinate with the member’s case manager from
other health systems, including behavioral health. The MCP must have
a process to facilitate, maintain, and coordinate both care and communication
with the member, PCP, and other service providers and case
managers. The MCP must also have a process to coordinate care for a
member that is receiving services from state sub-recipient agencies as
appropriate [e.g., the Ohio Department of Mental Health (ODMH); the Ohio
Department of Mental Retardation and Developmental Disabilities (ODMR/DD);
and
the Ohio Department of Alcohol and Drug Addiction Services
(ODADAS)].
The
MCP must have a provision to
disseminate information to the member/caregiver concerning the health condition,
types of services that may be available, and how to access
services.
The
MCP
must implement mechanisms to notify all Members with Special Health Care Needs
of their right to directly access a specialist. Such access may be
assured through, for example, a standing referral or an approved number of
visits, and documented in the care treatment plan.
v. ODJFS
Targeted Case Management
Conditions:
The
MCP must,
at a minimum, case manage members with
the following physical and behavioral health conditions:
· Congestive
Heart
Failure
· Coronary
Artery
Disease
· Non-Mild
Hypertension
· Diabetes
· Chronic
Obstructive Pulmonary
Disease
· Asthma
· Severe
mental
illness
· High
risk or high cost substance abuse
disorders
· Severe
cognitive and/or developmental
limitation
The
MCP
must also case manage any member enrolled in an MCP’s CSMM as specified in
section G(3)(a)(i).
The
MCP should also focus on all members
whose health conditions warrant case management services and should not limit
these services only to members with these conditions (e.g., cystic fibrosis,
cerebral palsy and sickle cell anemia).
Refer
to Appendix
M
for the performance
measures and standards related to case management.
vi. Case
Management Program
Staffing
The
MCP must identify the staff that
will be involved in the operations of the case management program, including
but
not limited to: case manager supervisors, case managers, and
administrative support staff. The MCP must identify the role and
functions of each case management staff member as well as the educational
requirements, clinical licensure standards, certification and relevant
experience with case management standards and/or activities. The MCP
must provide case manager staff/member ratios based on the member risk
stratification and different levels of care being provided to
members.
vii. Case
Management
Strategies
The
MCP must follow best-practice and/or
evidence based clinical guidelines when devising a member’s care treatment plan
and coordinating the case management needs. If an MCP uses a disease
management methodology to identify and/or stratify members in need of case
management services, the methods must be validated by scientific research and/or
nationally accepted in the health care industry.
The
MCP must develop and implement
mechanisms to educate and equip providers and case managers with evidence-based
clinical
guidelines or best practice approaches to assist in providing a high level
of
quality of care to members.
viii.
Information Technology System
for
Case Management
The
MCP’s information technology system
for its case management program must maximize the opportunity for communication
between the plan, PCP, the member, and other service providers and case
managers. The MCP must have an integrated database that allows MCP
staff that may be contacted by a member in case management to have immediate
access to, and review of, the most recent information with the MCP’s information
systems relevant to the case. The integrated database may include the
following: administrative data, call center communications, service
authorizations, care treatment plans, patient assessments, case management
notes, and PCP notes. The information technology system must also
have the capability to share relevant information with the member, the PCP,
and
other service providers and case managers.
ix.
Data Submission
The
MCP must submit a monthly electronic
report to the Case
Management System (CAMS) for all members that are case managed. In
order for a member to be submitted as case managed in CAMS, the MCP
must: (1) complete the identification process, a
comprehensive health needs assessment and development of a care treatment plan
for the member; and (2) document the member's written or verbal confirmation
of
his/her case management status in the case management record. ODJFS,
or its designated entity, the external quality review vendor, will validate
on
an annual basis the accuracy of the information contained in CAMS with the
member's case management record. The
CAMS files are due the
10thbusiness
day of each
month.
d. Annual
Case Management Program Submission
The
MCP
must have an ODJFS-approved case
management programwhich
includes the items in Section
4. 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
program description
must be submitted to
ODJFS in writing for review and approval prior to
implementation.
APPENDIX
H
PROVIDER
PANEL SPECIFICATIONS
ABD
ELIGIBLE
POPULATION
|
1.
|
GENERAL
PROVISIONS
|
MCPs
must
provide or arrange for the
delivery of all medically necessary, Medicaid-covered health services, as well
as assure that they meet all applicable provider panel requirements for their
entire designated
service area. The
ODJFS provider panel requirements are specified in the charts included with
this
appendix and must be met prior to the MCP receiving a provider agreement with
ODJFS. The MCP must remain in compliance with these requirements for
the duration of the provider agreement.
If
an MCP is unable to provide the
medically necessary, Medicaid-covered services through their contracted provider
panel, the MCP must ensure access to these services on an as needed
basis. For
example, if an MCP meets
the gastroenterologist
requirement but a member is unable to obtain a timely appointment from a
gastroenterologist on the MCP’s provider panel, the MCP will be required to
secure an appointment from a panel gastroenterologist or arrange for an
out-of-panel referral to a gastroenterologist.
MCPs
are
required to make
transportation available to any member requesting transportation when
they
must travel 30
miles or more from their home to
receive a medically-necessary Medicaid-covered service. If the MCP
offers transportation to their members as an additional benefit and this
transportation benefit only covers a limited number of trips, the required
transportation listed above may not
be counted toward this trip limit (as
specified in Appendix C).
In
developing the provider panel requirements, ODJFS considered, on a
county-by-county basis, the population size and utilization patterns of the
Aged, Blind or Disabled (ABD)
consumers, as well as the potential availability of the designated provider
types. ODJFS has integrated existing utilization patterns into the
provider network requirements to avoid disruption of care. Most
provider panel requirements are county-specific but in certain circumstances,
ODJFS requires providers to be located anywhere in the region.
Although all provider types
listed in this appendix are required provider types, only those listed on the
attached charts must be submitted for ODJFS prior approval.
2.
PROVIDER SUBCONTRACTING
Unless
otherwise specified in this appendix or OAC rule 5101:3-26-05, all MCPs are required to enter
into
fully-executed subcontracts with their providers. These subcontracts
must include
a baseline contractual
agreement, as well as the appropriate ODJFS-approved Model Medicaid Addendum.
The Model Medicaid Addendum incorporates all applicable Ohio
Administrative Code rule requirements specific to provider subcontracting and
therefore cannot be modified except to add personalizing information such as
the
MCP’s name.
ODJFS
must prior approve all MCP providers in the ODJFS- required provider type
categories before they can begin to provide services to that MCP’s
members. MCPs may not employ or contract with providers excluded from
participation in Federal health care programs under either section 1128 or
section 1128A of the Social Security Act. As part of the prior
approval process, MCPs
must submit documentation verifying that all necessary contract
documents have been appropriately completed. ODJFS will verify the
approvability of the submission and process this information using the ODJFS
Provider Verification System (PVS), or other designated process. The PVS is a centralized
database system that maintains information on the status of all MCP-submitted
providers.
Only
those providers who meet the
applicable criteria specified in this document, and as determined by ODJFS,
will
be approved by ODJFS. MCPs must credential/recredential
providers in accordance with the standards specified by the National Committee
for Quality Assurance (or receive approval from ODJFS to use an alternate
industry standard) and must have completed the credentialing review before
submitting any provider to ODJFS for approval. Regardless of whether
ODJFS has approved a provider, the MCP must ensure that the provider has met
all
applicable credentialing criteria before the provider can render services to
the
MCP’s members.
MCPs
must
notify ODJFS of the addition and deletion of their contracting providers as
specified in OAC rule 5101:3-26-05, and must notify ODJFS within one working
day
in instances where the MCP has identified that they are not in compliance with
the provider panel requirements specified in this appendix.
3.
PROVIDER
PANEL REQUIREMENTS
The
provider network criteria that must be met by each MCP are as
follows:
a.
Primary Care
Providers (PCPs)
Primary
Care Provider (PCP) means an individual physician (M.D. or D.O.), certain
physician group practice/clinic (Primary Care Clinics [PCCs]), or an advanced
practice nurse (APN) as defined in ORC 4723.43 or advanced practice nurse group
practice within an acceptable specialty, contracting with an MCP to provide
services as specified in paragraph (B) of OAC rule 5101:
3-26-03.1. Acceptable specialty types for PCPs include family/general
practice, internal medicine, pediatrics, and obstetrics/gynecology
(OB/GYN). Acceptable
PCCs include FQHCs, RHCs
and the acceptable group practices/clinics specified by ODJFS. As part
of their subcontract with an MCP, PCPs
must stipulate the total Medicaid member capacity that they can ensure for
that
individual MCP. Each PCP must have the capacity and agree to serve at
least 50 Medicaid members at each practice site in order to be approved by
ODJFS
as a PCP. The capacity-by-site
requirement must be met
for all ODJFS-approved PCPs.
ODJFS
reviews the capacity totals for
each PCP to determine if they appear excessive. DJFS
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 allow
up to an additional 750 member
capacity for each nurse practitioner
or physician’s assistant
that is used to provide clinical support for a PCP.
For
PCPs
contracting with more than one MCP, the MCP must ensure that the capacity figure
stated by the PCP in their subcontract reflects only the capacity the PCP
intends to provide for that one MCP. ODJFS utilizes each approved PCP’s capacity
figure to determine if an MCP meets the provider panel requirements and this
stated capacity figure does not prohibit a PCP from actually having a caseload
that exceeds the capacity figure indicated in their subcontract.
ODJFS
expects that
MCPs will need to
utilize specialty physicians to serve as PCPs for some special needs
members. In these
situations it will not be necessary for the MCP to submit these
specialists to the PVS database, or other system, as PCPs, however,
they
must be submitted to PVS, or other system, as the appropriate required provider
type. Also, in some situations (e.g., continuity of care) a PCP may
only want to serve a very small number of members for an MCP. In
these situations it will not be necessary for the MCP to submit these PCPs
to
ODJFS for prior approval. These PCPs will not be included in the
ODJFS PVS database, or other system and therefore may not appear as PCPs in
the
MCP’s provider directory. These PCPs will, however, need to execute a
subcontract with the MCP which includes the appropriate Model Medicaid
Addendum.
The
PCP requirement is based on an MCP
having sufficient PCP capacity to serve 40% of
the eligibles in the
region if
three MCPs are serving the region and
55% of the eligibles in the region if two MCPs are serving the
region. Each
MCP must meet the PCP minimum FTE
requirement for that region. MCPs must also satisfy a PCP geographic
accessibility standard. ODJFS will match the PCP practice sites and the stated
PCP capacity with the geographic location of the eligible population in that
region (on a county-specific basis) and perform analysis using Geographic
Information Systems (GIS) software. The analysis will be used to determine
if at
least 40% of the eligible population is located within 10 miles of a PCP with
available capacity in urban
counties and 40% of the eligible population within 30 miles of a PCP with
available capacity in rural counties. [Rural areas are defined pursuant to
42
CFR 412.62(f)(1)(iii).]
Until
July 1, 2008, MCPs may only use PCPs who are individual physicians (M.D. or
D.O.), physician group practices, or PCCs to meet capacity and FTE
requirements.
b.
Non-PCP Provider
Network
In
addition to the PCP capacity requirements, each MCP is also required to maintain
adequate capacity in the remainder of its provider network within the following
categories: hospitals, cardiovascular, dentists,
gastroenterology, nephrology, neurology, oncology, physical medicine, podiatry,
psychiatry, urology, vision care providers, obstetricians/gynecologists
(OB/GYNs), allergists, general surgeons, otolaryngologists, orthopedists,
federally qualified health centers (FQHCs)/rural health centers (RHCs) and
qualified family planning providers (QFPPs). CNMs,
CNPs, FQHCs/RHCs and QFPPs are
federally-required provider types.
All
Medicaid-contracting MCPs must provide all medically-necessary Medicaid-covered
services to their members and therefore their complete provider network will
include many other additional specialists and provider types. MCPs
must ensure that all non-PCP network providers follow community standards in
the
scheduling of routine appointments (i.e., the amount of time members must wait
from the time of their request to the first available time when the visit can
occur).
Although
there are currently no capacity requirements for the non-PCP required provider
types, MCPs are required to ensure that adequate access is available to members
for all required provider types. Additionally, for certain non-PCP
required provider types, MCPs must ensure that these providers maintain a
full-time practice at a site(s) located in the
specified county/region
(i.e., the ODJFS-specified
county within the region or anywhere within the region if no particular county
is specified). A full-time practice is defined as one where the
provider is available to patients at their practice site(s) in the specified
county/region for at least 25 hours a week. ODJFS will monitor access to
services through a variety of data sources, including: consumer
satisfaction surveys; member appeals/grievances/complaints and state hearing
notifications/requests; clinical quality studies; encounter data volume;
provider complaints, and clinical performance measures.
Hospitals
-
MCPs must contract with
the
number and type of hospitals specified by ODJFS for each county/region. In
developing these hospital
requirements, ODJFS considered, on a county-by-county basis, the population
size
and utilization patterns of the Aged, Blind or Disabled (ABD) consumers and integrated
the existing
utilization patterns into the hospital network requirements to avoid disruption
of care. For this reason, ODJFS may require that MCPs contract with
out-of-state hospitals (i.e. Kentucky,
West
Virginia, etc.).
For
each Ohio hospital,
ODJFS utilizes the hospital’s
most current Annual Hospital Registration and Planning Report, as filed with
the
Ohio Department of Health, in verifying types of services that hospital
provides. Although ODJFS has the authority, under certain situations,
to obligate a non-contracting hospital to provide non-emergency hospital
services to an MCP’s members, MCPs must still contract with the specified number
and type of hospitals unless ODJFS approves a provider panel exception (see
Section 4 of this appendix – Provider Panel Exceptions).
If
an
MCP-contracted hospital elects not to provide specific Medicaid-covered hospital
services because of an objection on moral or religious grounds, the MCP must
ensure that these hospital services are available to its members through another
MCP-contracted hospital in the specified
county/region.
OB/GYNs-
MCPs must contract with the
specified number of OB/GYNs for each county/region, all of whom must
maintain a full-time obstetrical practice at a site(s) located in the
specified
county/region. Only MCP-contracting OB/GYNs with current
hospital delivery privileges at a hospital under contract with the MCP in the
region can be submitted to the PVS, or other system, count towards MCP minimum
panel requirements, and be listed in the MCPs’ provider directory.
Certified
Nurse Midwives (CNMs)
and
Certified Nurse Practitioners (CNPs) - MCPs must ensure access to CNM
and CNP services in
the region if such provider types are present within the
region. The
MCP may contract directly with the CNM
or CNP providers, or with a physician or other provider entity who is able
to
obligate the participation of a CNM or CNP. If an MCP does not
contract for CNM or CNP services and such providers are present within the
region, the MCP will be required to allow members to receive CNM or CNP services
outside of the MCP’s provider network.
Only
CNMs
with hospital delivery privileges at a hospital under contract to the MCP in
the
region can be submitted to the PVS, or other system, count towards MCP minimum
panel requirements, and be listed in the MCPs’ provider directory. The MCP must ensure a member’s access to CNM
and CNP services if such providers are practicing within the
region.
Vision
Care Providers - MCPs
must contract with the specified number of ophthalmologists/optometrists
for each
specified
county/region, all
of whom must maintain a full-time
practice at a site(s) located in the specified county/region. All ODJFS-approved
vision providers must regularly perform routine eye exams. (MCPs
will be expected to contract with
an adequate number of ophthalmologists as part of their overall provider panel,
but only ophthalmologists who regularly perform routine eye exams can be used
to
meet the vision care provider panel requirement.) If optical dispensing
is not
sufficiently available in a region through the MCP’s contracting
ophthalmologists/optometrists, the MCP must
separately
contract with an adequate
number of optical dispensers located in the region.
Dental
Care
Providers - MCPs must
contract with the specified number of dentists.
Federally
Qualified Health
Centers/Rural Health Clinics(FQHCs/RHCs) - MCPs are
required to ensure member access
to any federally qualified health center or rural health clinic
(FQHCs/RHCs), regardless of contracting status. Contracting FQHC/RHC
providers must be submitted for ODJFS approval via the PVS process, or
other designated process. Even if
no FQHC/RHC is available within the region, MCPs must have mechanisms in place
to ensure coverage for FQHC/RHC services in the event that a member accesses
these services outside of the region.
In
order
to ensure that any FQHC/RHC has the ability
to
submit a claim to ODJFS for the state’s supplemental payment, MCPs must offer
FQHCs/RHCs reimbursement pursuant to the following:
|
|
•
|
MCPs
must provide expedited reimbursement on a service-specific basis
in an
amount no less than the payment made to other providers for the same
or
similar service.
|
|
|
•
|
If
the MCP has no comparable service-specific rate structure, the MCP
must
use the regular Medicaid
fee-for-service payment schedule for non-FQHC/RHC providers.
|
|
|
•
|
MCPs
must make all efforts to pay FQHCs/RHCs as quickly as possible and
not
just attempt to pay these claims within the prompt pay time frames.
|
MCPs
are
required to educate their staff and providers on the need to assure member
access to FQHC/RHC services.
Qualified
Family Planning Providers
(QFPPs) - All MCP members must be permitted to self-refer to family
planning services provided by a QFPP. A QFPP is defined as
any public or not-for-profit health care provider that complies with Title
X
guidelines/standards, and receives either Title X funding or family planning
funding from the Ohio Department of Health. MCPs must reimburse all
medically-necessary Medicaid-covered family planning services
provided to eligible members by a QFPP provider (including on-site pharmacy
and
diagnostic services) on a patient self-referral
basis, regardless of the
provider’s status as a panel or non-panel provider. MCPs will be
required to work with QFPPs in the region to develop mutually-agreeable HIPAA
compliant policies and procedures to preserve patient/provider
confidentiality, and convey pertinent information to the member’s PCP and/or
MCP.
Behavioral
Health Providers –
MCPs must assure member access to all Medicaid-covered behavioral health
services for members as specified in Appendix G.b.ii. herein. Although
ODJFS is aware that certain outpatient substance abuse services may only be
available through Medicaid providers certified by the
Ohio Department of Drug and Alcohol Addiction
Services (ODADAS) in some areas, MCPs must maintain an
adequate number of contracted mental health providers in the region to assure
access for members who are
unable to timely access services or
unwilling to access services through community mental health
centers. MCPs are advised not to contract with community mental
health centers as all services they provide to MCP members are to be billed
to
ODJFS.
Other
Specialty
Types(general
surgeons,
otolaryngologists, orthopedists, cardiologists, gastroenterologists,
nephrologists, neurologists, oncologists, podiatrists, physiatrists,
psychiatrists, and urologists ) - MCPs must contract
with the specified
number of all other ODJFS designated specialty provider types. In order to
be
counted toward meeting the provider panel requirements, these specialty
providers must maintain a full-time practice at a site(s) located within the
specified county/region. Only contracting general surgeons, orthopedists,
otolaryngologists, cardiologists, gastroenterologists,
nephrologists, neurologists, oncologists, podiatrists, physiatrists,
psychiatrists, and urologists with admitting privileges at a hospital
under
contract with the MCP in the region can be submitted to the PVS, or other
system, count towards MCP minimum panel requirements, and be listed in the
MCPs’
provider directory.
4.
PROVIDER PANEL
EXCEPTIONS
ODJFS
may specify provider panel
criteria for a service area that deviates from that specified in this appendix
if:
|
|
-
|
the
MCP presents sufficient
documentation to ODJFS to verify that they have been unable to meet
or
maintain certain provider panel requirements in a particular service
area
despite all reasonable efforts on their part to secure such a contract(s),
and
|
|
|
-
|
if
notified by ODJFS, the
provider(s) in
question fails to provide a reasonable argument why they would not
contract with the MCP, and
|
|
|
-
|
the
MCP presents sufficient
assurances to ODJFS that their members will have adequate access
to the
services in question.
|
If
an MCP is unable to contract with or
maintain a sufficient number of providers to meet the ODJFS-specified provider
panel criteria, the MCP may request an exception to these criteria by submitting
a provider panel exception request as specified by ODJFS. ODJFS will
review the exception request and determine whether the MCP has sufficiently
demonstrated that all reasonable efforts were made to obtain contracts with
providers of the type in question and that they will be able to provide access
to the services in question.
ODJFS
will aggressively monitor access
to all services related
to
the approval of
a provider
panel exception request through
a variety of data sources, including: consumer satisfaction
surveys; member
appeals/grievances/complaints and state hearing notifications/requests;
member
just-cause for termination requests; clinical quality studies; encounter
data volume; provider
complaints, and clinical performance measures. ODJFS approval of a
provider panel exception request does not exempt the MCP from assuring access
to
the services in question. If ODJFS determines that an MCP has not
provided sufficient access to these services, the MCP may be subject to
sanctions.
|
5.
|
PROVIDER
DIRECTORIES
|
MCP
provider directories must include
all MCP-contracted providers [except as specified by ODJFS] as well as certain
non-contracted providers. At the time of ODJFS’ review, the
information listed in the MCP’s provider directory for all ODJFS-required
provider types specified on the attached charts must exactly match the data
currently on file in the ODJFS PVS, or other designated
process.
MCP
provider directories must utilize a
format specified by ODJFS. Directories may be region-specific or include
multiple regions, however, the providers within the directory must be divided
by
region, county, and provider type, in that order.
The
directory must also specify:
|
|
•
|
provider
address(es) and phone
number(s);
|
|
|
•
|
an
explanation of how to access
providers (e.g. referral required vs.
self-referral);
|
|
|
•
|
an
indication of which providers
are available to members on a self-referral basis;
|
|
|
•
|
foreign-language
speaking PCPs and
specialists and the specific foreign language(s) spoken;
|
|
|
•
|
how
members may obtain directory information in alternate formats that
takes
into consideration the special needs of eligible individuals including
but
not limited to, visually-limited, LEP, and LRP eligible individuals;
and
|
|
|
•
|
any
PCP or specialist practice limitations.
|
Printed
Provider Directory
Prior
to receiving a provider agreement,
all MCPs must develop a printed provider directory that shall be prior-approved
by ODJFS for each population. For example, an MCP who serves CFC and
ABD in the Central Region would have two provider directories, one for CFC
and
one for ABD. Once approved, this directory may be regularly updated
with provider
additions or deletions by the MCP without ODJFS prior-approval, however, copies
of the revised directory (or inserts) must be submitted to ODJFS prior to
distribution to members.
On
a quarterly basis, MCPs must
create
an insert to each printed directory
that lists those providers
deleted
from the MCP’s provider
panel during the previous three months. Although this insert does not
need to be prior approved by ODJFS, copies of the insert must be submitted
to
ODJFS two weeks prior to distribution to members.
Internet
Provider Directory
MCPs
are required to have an
internet-based provider directory available in the same format as their
ODJFS-approved printed directory. This internet directory must allow
members to electronically
search for MCP panel providers based on name, provider type, and geographic
proximity, and population (e.g. CFC and/or ABD). If an MCP has one
internet-based directory for multiple populations, each provider must include
a
description of which population they serve.
The
internet directory may be updated at
any time to include providers who are not
one
of the ODJFS-required provider types
listed on the charts included with this appendix. ODJFS-required
providers must
be
added to the internet directory
within one week of the MCP’s notification of ODJFS-approval of the provider via
the Provider Verification process. Providers being deleted from the
MCP’s panel must be deleted
from the internet directory
within one week of notification from the provider to the MCP. These
deleted providers must be included
in the inserts to the MCP’s provider directory referenced
above.
|
6
.
|
FEDERAL
ACCESS
STANDARDS
|
MCPs
must
demonstrate that they are in compliance with the following federally
defined provider panel access standards as required by 42 CFR
438.206:
In
establishing and maintaining their provider panel, MCPs must consider the
following:
|
•
|
The
anticipated Medicaid membership.
|
|
•
|
The
expected utilization of services, taking into consideration the
characteristics and health care needs of specific Medicaid populations
represented in the MCP.
|
|
•
|
The
number and types (in terms of training, experience, and specialization)
of
panel providers required to deliver the contracted
Medicaid services.
|
|
•
|
The
geographic location of panel providers and Medicaid members, considering
distance, travel time, the means of transportation ordinarily used
by
Medicaid members, and whether the location provides physical access
for
Medicaid members with disabilities.
|
|
•
|
MCPs
must adequately and timely cover services to an out-of-network provider
if
the MCP’s contracted provider panel is unable to provide the services
covered under the MCP’s provider agreement. The MCP must cover
the out-of-network services for as long as the MCP network is unable
to
provide the services. MCPs must coordinate
with the out-of-network provider with respect to payment and ensure
that
the provider agrees with the applicable requirements.
|
Contracting
providers must offer hours of operation that are no less than the hours of
operation offered to commercial members or comparable to Medicaid
fee-for-service, if the provider serves only Medicaid members. MCPs
must ensure that services are available 24 hours a day, 7 days a week, when
medically necessary. MCPs must establish mechanisms to ensure that
panel providers comply with timely access
requirements, and
must take corrective action
if there is failure to comply.
In
order
to demonstrate adequate provider panel capacity and services, 42 CFR 438.206
and
438.207 stipulates that the MCP must submit documentation to ODJFS, in a format
specified by ODJFS, that demonstrates it offers an appropriate range of
preventive, primary care and specialty services adequate for the anticipated
number of members in the service
area, while maintaining a provider panel that is sufficient in number,
mix, and geographic distribution to meet the needs of the number of members
in
the service
area.
This
documentation of assurance of adequate capacity and services must be submitted
to ODJFS no less frequently than at the time the MCP enters into a contract
with
ODJFS; at any time there is a significant change (as defined by
ODJFS) in the MCP’s operations that would affect adequate capacity
and services (including changes in services, benefits, geographic service or
payments); and at any time there is enrollment of a new population in the
MCP.
APPENDIX
K
QUALITY
ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM
AND
EXTERNAL
QUALITY
REVIEW
ABD
ELIGIBLE
POPULATION
1. As
required by federal regulation, 42 CFR 438.240, each managed care plan (MCP)
must have an ongoing Quality Assessment and Performance Improvement Program
(QAPI) that is annually prior-approved by the Ohio Department of Job and Family
Services (ODJFS). The program must include the following
elements:
a. PERFORMANCE
IMPROVEMENT
PROJECTS
Each
MCP
must conduct performance improvement projects (PIPs), including those specified
by ODJFS. PIPs must achieve, through periodic measurements and
intervention, significant and sustained improvement in clinical and non-clinical
areas which are expected to have a favorable effect on health outcomes and
satisfaction. MCPs must adhere to ODJFS PIP content and format
specifications.
All
ODJFS-specified PIPs must be prior-approved by ODJFS. As part of the
external quality review organization (EQRO) process, the EQRO will assist MCPs
with conducting PIPs by providing technical assistance and will annually
validate the PIPs. In addition, the MCP must annually submit to ODJFS
the status and results of each PIP.
ODJFS
will identify the clinical and/or
non-clinical study topics for the SFY 2009 Provider
Agreement. Initiation of the PIPs will begin in the second year of
participation in the ABD Medicaid managed care program.
b. UNDER-
AND
OVER-UTILIZATION
Each
MCP
must have mechanisms in place to detect under- and over-utilization of health
care services. The MCP must specify the mechanisms used to monitor
utilization in its annual submission of the QAPI program to ODJFS.
It
should
also be noted that pursuant to the program integrity provisions outlined in
Appendix I, MCPs must monitor for the potential under-utilization of services
by
their members in order to assure that all Medicaid-covered services are being
provided, as required. If any under-utilized services are identified,
the MCP must immediately investigate and correct the problem(s) which resulted
in such under-utilization of services.
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. SPECIALHEALTH
CARE
NEEDS
Each
MCP
must have mechanisms in place to assess the quality and appropriateness of
care furnished to members with
special
health care needs. The MCP must specify the mechanisms used in its
annual submission of the QAPI program to ODJFS.
d. SUBMISSION OF
PERFORMANCE MEASUREMENT DATA
Each
MCP
must submit clinical performance measurement data as required by ODJFS that
enables ODJFS to calculate standard measures. Refer to Appendix M
“Performance Evaluation” for a more comprehensive description of the clinical
performance measures.
Each
MCP
must also submit clinical performance measurement data as required by ODJFS
that
uses standard measures as specified by ODJFS. MCPs will be required
to submit Health Employer Data Information Set (HEDIS) audited data for measures
that will be identified by ODJFS for the SFY 2009 Provider
Agreement.
The
measures must have received a “report” designation from the HEDIS certified
auditor and must be specific to the Medicaid population. Data must be
submitted annually and in an electronic format. Data will be used for
MCP clinical performance monitoring and will be incorporated into comparative
reports developed by the EQRO.
Initiation
of submission of performance
data will begin in the second year of participation in the Medicaid managed
care
program.
e. QAPI
PROGRAM
SUBMISSION
Each
MCP
must implement an evaluation process to review, revise, and/or update the
QAPI
program. The MCP must annually submit its QAPI program for review and
approval by ODJFS.
2. EXTERNAL
QUALITY
REVIEW
In
addition to the following
requirements, MCPs must participate in external quality review activities as
outlined in OAC 5101:3-26-07.
a.
EQRO
ADMINISTRATIVE REVIEWS
The
EQRO
will conduct annual
focused administrative
compliance assessments
for each MCP which will
include, but not be limited to, the
following domains as specified by ODJFS: member rights and services,
QAPI program, case
management, provider
networks, grievance
system, coordination and continuity of care, and
utilization management. In addition, the EQRO will complete a
comprehensive administrative compliance assessment every three (3) years as
required by 42 CFR 438.358 and specified by ODJFS.
In
accordance with 42 CFR 438.360 and
438.362, MCPs with
accreditation from a national accrediting organization approved by the Centers
for Medicare and Medicaid Services (CMS) may request a non-duplication exemption
from certain specified components of the administrative
review. Non-duplication exemptions may not be requested for SFY 2008.
b. EXTERNAL
QUALITY
REVIEW PERFORMANCE
In
accordance with OAC rule
5101:3-26-07, each MCP must participate in an annual
external quality review
survey. If the EQRO cites a deficiency in performance, the MCP will
be required to complete a Corrective Action Plan (e.g., ODJFS technical
assistance session) or Quality
Improvement Directives depending
on the severity of the deficiency. (An example of a deficiency is if
an MCP fails to meet certain clinical or administrative standards as supported
by national evidence-based guidelines or best
practices.) Serious deficiencies may result in immediate
termination or non-renewal of the provider agreement. These quality
improvement measures recognize the importance of ongoing MCP performance
improvement related to clinical care and service delivery.
APPENDIX
L
DATA
QUALITY
ABD
ELIGIBLE
POPULATION
A
high level of performance on the data
quality measures established in this appendix is crucial in order for the Ohio
Department of Job and Family Services (ODJFS) to determine the value of the
Aged, Blind or Disabled
(ABD) Medicaid Managed
Health Care programand
to evaluate Medicaid consumers’
access to and quality of services. Data collected from MCPs are used in key
performance assessments such as the external quality review, clinical
performance measures, utilization review, care coordination and case management,
and in determining incentives. The data will also be used in
conjunction with the cost reports in setting the premium payment
rates. The
following measures, as specified in this appendix, will be calculated per MCP
and include all Ohio Medicaid members receiving services from the MCP (i.e.,
Covered Families and Children (CFC) and ABD membership, if
applicable): Incomplete Outpatient Hospital
Data,
Rejected
Encounters, Acceptance
Rate, Encounter Data
Accuracy, and Generic Provider Number Usage.
Data
sets
collected from MCPs with data quality standards include: encounter data; case
management data; data used in the external quality review; members’ PCP data;
and appeal and grievance data.
1.
ENCOUNTER DATA
For
detailed descriptions of the
encounter data quality measures below, see ODJFS
Methods for
the
ABD
and CFC Medicaid Managed Care Programs DataQuality
Measures.
1.a. Encounter
Data Completeness
Each
MCP’s encounter data submissions will be assessed for
completeness. The MCP is responsible for collecting information from
providers and reporting the data to ODJFS in accordance with program
requirements established in Appendix C, MCP
Responsibilities. Failure to do so jeopardizes the MCP’s
ability to demonstrate compliance with other performance standards.
1.a.i.
Encounter Data Volume
Measure: The
volume measure for each
service category, as listed in Table 2 below, is the rate of utilization (e.g.,
discharges, visits) per 1,000 member months (MM) for the ABD
program. The measure will be
calculated per
MCP.
Report
Period: The
report periods for the SFY
2008 and
SFY 2009 contract periods are listed
in Table
1. below.
Table
1. Report Periods for the
SFY 2008 and
2009 Contract Periods
|
Report
Period
|
Data
Source:
Estimated
Encounter Data File Update
|
Quarterly
Report
Estimated
Issue
Date
|
Contract
Period
|
|
Qtr
1 2007
|
July
2007
|
August
2007
|
SFY 2008
|
|
Qtr
1, Qtr 2
2007
|
October
2007
|
November2007
|
|
|
Qtr
1 thru Qtr 3
2007
|
January
2008
|
February
2008
|
|
|
Qtr
1 thru Qtr 4
2007
|
April
2008
|
May 2008
|
|
|
Qtr
1 thru Qtr 4 2007, Qtr 1
2008
|
July
2008
|
August
2008
|
SFY
2009
|
|
Qtr
1 thru Qtr 4
2007,
Qtr
1, Qtr 2
2008
|
October
2008
|
November
2008
|
|
|
Qtr
1 thru Qtr 4
2007,
Qtr
1 thru Qtr 3
2008
|
January
2009
|
February
2009
|
|
|
Qtr
1 thru Qtr 4
2007,
Qtr
1 thru Qtr 4
2008
|
April
2009
|
May
2009
|
|
| Qtr1 = January to March Qtr2 = April to June Qtr3 = July to September Qtr 4 = October to December | |||
Data
Quality
Standard: The
utilization rate for all service categories listed in Table 2 must be equal
to
or greater than the interim
standards
established in Table 2. below (Interim
Standards - Encounter Data
Volume).
Statewide
Approach: Prior
to establishment of
statewide
minimum
performance standards,
ODJFS
will evaluate MCP
performance using the interim standards for Encounter data volume. ODJFS will use the first
four quarters
of data (i.e., full calendar year quarters) from all MCPs serving ABD program membership
to determine statewide
minimum encounter volume data quality standards.
Table
2. Interim
Standards–
Encounter
Data Volume
|
Category
|
Measure
per 1,000/MM
|
Standard
for Dates of
Service
on
or after 1/1/2007
|
Description
|
|
Inpatient
Hospital
|
Discharges
|
2.7
|
General/acute
care, excluding newborns and mental health and chemical dependency
services
|
|
Emergency
Department
|
Visits
|
25.3
|
Includes
physician and hospital emergency department encounters
|
|
Dental
|
25.5
|
Non-institutional
and hospital dental visits
|
|
|
Vision
|
5.3
|
Non-institutional
and hospital outpatient optometry and ophthalmology
visits
|
|
|
Primary
and Specialist Care
|
116.6
|
Physician/practitioner
and hospital outpatient visits
|
|
|
Ancillary
Services
|
66.8
|
Ancillary
visits
|
|
|
Behavioral
Health
|
Service
|
5.2
|
Inpatient
and outpatient behavioral encounters
|
|
Pharmacy
|
Prescriptions
|
246.1
|
Prescribed
drugs
|
Determination
of
Compliance: Performance is
monitored once every quarter for the entire report period. If the
standard is not met for every service category in all quarters of the report
period, then the MCP will be determined to be noncompliant for the report
period.
Penalty
for
noncompliance: The first time an MCP is noncompliant with a
standard for this measure, ODJFS will issue a Sanction Advisory informing the
MCP that any future noncompliance instances with the standard for this measure
will result in ODJFS imposing a monetary sanction. Upon all subsequent
measurements of performance, if an MCP is again determined to be noncompliant
with the standard, ODJFS will impose a monetary sanction (see Section 6.) of
two
percent of the current month’s premium payment. Monetary
sanctions will
not be levied for
consecutive quarters
that an MCP is determined to be
noncompliant. If an MCP is noncompliant for three consecutive quarters, membership
will
be frozen. Once
the MCP is determined to be
compliant with the standard and the violations/deficiencies are resolved to
the
satisfaction of ODJFS, the penalties will be lifted, if applicable, and monetary
sanctions will be returned.
1.a.ii.Incomplete
Outpatient Hospital Data
ODJFS
will be monitoring, on a quarterly basis, the percentage of hospital encounters
which contain a revenue code and CPT/HCPCS code. A CPT/HCPCS code
must accompany certain revenue center codes. These codes are listed in Appendix
B of Ohio Administrative Code rule 5101:3-2-21 (fee-for-service outpatient
hospital policies) and in the methods for calculating the completeness
measures.
Measure:
The percentage of outpatient hospital
line
items with certain revenue center codes, as explained above, which had an
accompanying valid procedure (CPT/HCPCS) code. The measure will be
calculated per MCP.
Report
Period: The report periods for
the SFY 2008 and SFY 2009 contract periods are listed
in Table 3. below.
Table
3. Report Periods
for the SFY 2008 and 2009 Contract Periods
|
Quarterly
Report
Periods
|
Data
Source:
Estimated
Encounter Data File Update
|
Quarterly
Report
Estimated
Issue
Date
|
Contract
Period
|
|
Qtr 3
& Qtr 4 2004, 2005,
2006
Qtr
1 2007
|
July
2007
|
August
2007
|
SFY
2008
|
|
Qtr
3 & Qtr 4 2004, 2005,
2006
Qtr
1, Qtr 2
2007
|
October
2007
|
November
2007
|
|
|
Qtr
4 2004, 2005,
2006
Qtr
1 thru Qtr 3
2007
|
January
2008
|
February
2008
|
|
|
Qtr
1 thru Qtr 4: 2005, 2006,
2007
|
April
2008
|
May
2008
|
|
|
Qtr
2 thru Qtr 4
2005,
Qtr
1 thru Qtr 4: 2006,
2007
Qtr
1 2008
|
July
2008
|
August
2008
|
SFY
2009
|
|
Qtr
3, Qtr 4:
2005,
Qtr
1 thru Qtr 4: 2006,
2007
Qtr
1, Qtr 2
2008
|
October
2008
|
November
2008
|
|
|
Qtr
4: 2005,
Qtr
1 thru Qtr 4: 2006,
2007
Qtr
1 thru Qtr 3:
2008
|
January
2009
|
February
2009
|
|
|
Qtr
1 thru Qtr 4: 2006, 2007,
2008
|
April
2009
|
May
2009
|
Qtr1
= January to March Qtr2
= April to June Qtr3
= July to September Qtr4
= October to
December
Data
Quality Standard: The
data quality standard is a minimum rate of 95%.
Determination
of
Compliance: Performance is
monitored once every quarterfor all report
periods.
For
quarterly reports that are issued on
or after July 1, 2007, an MCP will be determined to be noncompliant for the
quarter if the standard is not met in any report period and the initial instance
of noncompliance in a report period is determined on or after July 1,
2007. An initial instance of noncompliance means that the result for
the applicable report period was in compliance as determined in the prior
quarterly report, or the instance of noncompliance is the first determination
for an MCP’s first quarter of measurement.
Penalty
for
noncompliance: The first time an MCP is noncompliant with a
standard for this measure, ODJFS will issue a Sanction Advisory informing the
MCP that any future noncompliance instances with the standard for this measure
will result in ODJFS imposing a monetary sanction.
Upon
all
subsequent quarterly measurements of performance, if an MCP is again determined
to be noncompliant with the standard, ODJFS will impose a monetary sanction
(see
Section 6) of one percent
of the current month’s premium payment. Once the MCP is performing at
standard levels and violations/deficiencies are resolved to the satisfaction
of
ODJFS, the money will be refunded.
1.a.iii. Rejected
Encounters
Encounters submitted
to ODJFS that are incomplete or inaccurate are rejected and reported
back to the MCPs on the Exception Report. If an MCP does not resubmit
rejected encounters, ODJFS’ encounter data set will be incomplete.
Measure
1 only applies to
MCPs that have had Medicaid
membership for more
than one year.
Measure
1: The
percentage of encounters submitted to ODJFS that are rejected. The
measure will be calculated per MCP.
Report
Period: For the
SFY 2008 contract period, performance will be evaluated using the following report
periods July
- September 2007; October -
December 2007; January - March 2008; April – June 2008. For
the SFY 2009 contract period,
performance will be evaluated using the following report periods July -
September 2008; October - December 2008; January - March 2009; April
– June 2009.
Data
Quality
Standard for
measure 1: Data Quality
Standard 1 is a maximum encounter data rejection rate of 10% for each
file in the ODJFS-specified medium per
format. The
measure will be calculated per
MCP.
Files
in the ODJFS-specified medium per
format that are totally rejected will not be considered in the
determination of noncompliance.
Determination
of
Compliance: Performance is monitored once every quarter.
Compliance determination with the standard applies only to the quarter under
consideration and does not include performance in previous
quarters.
Penalty
for noncompliance
with
the
Data
Quality Standardfor
measure
1: The
first time
an MCP is noncompliant with a standard for this measure, ODJFS will issue a
Sanction Advisory informing the MCP that any future noncompliance instances
with
the standard for this measure will result in ODJFS imposing a monetary sanction.
Upon all subsequent measurements of performance, if an MCP is again determined
to be noncompliant with the standard, ODJFS will impose a monetary sanction
(see
Section 6.) of one percent of the current month’s premium
payment. The monetary sanction will be applied for each file type
in the ODJFS-specified medium per
format that is determined to be out of compliance.
Once
the
MCP is performing at standard levels and violations/deficiencies are resolved
to
the satisfaction of ODJFS, the money will be refunded.
Measure
2 only applies to
MCPs that have had Medicaid membership for one year or less.
Measure
2: The
percentage of encounters submitted to ODJFS that are rejected. The measure will be calculated
per
MCP.
Report
Period: The report period
for Measure 2 is monthly. Results are calculated and performance is
monitored monthly. The first reporting month begins with the third month of
enrollment.
Data
Quality Standard for
measure
2: The data
quality standard is a maximum encounter data rejection rate for each file in the ODJFS-specified
medium per
format as follows:
Third
through sixth month with
membership:
50%
Seventh
through twelfth month with
membership: 25%
Files
in the ODJFS-specified medium per
format that are totally rejected will not be considered in the
determination of noncompliance.
Determination
of
Compliance: Performance is monitored once every
month. Compliance determination with the standard applies only to the
month under consideration and does not include performance in previous
quarters.
Penalty
for Noncompliance
with the
Data
Quality
Standardfor
measure
2: If
the MCP is determined to be noncompliant for either standard, ODJFS will impose
a monetary sanction of one percent
of the MCP’s current month’s
premium payment. The monetary sanction
will
be applied for each file type in the ODJFS-specified medium per
format that is determined to be out of compliance. The monetary sanction
will be applied
only once per file type
per
compliance
determination period and will not exceed a total of two percent of the MCP’s
current month’s premium payment. Once the MCP
is performing at standard levels and violations/deficiencies are resolved to
the
satisfaction of ODJFS, the money will be refunded. Special
consideration will be made for MCPs with less than 1,000 members.
1.a.iv. Acceptance
Rate
This
measure only applies to
MCPs that have had Medicaid membership for one year or less.
Measure: The
rate
of encounters that
are submitted to ODJFS
and accepted (i.e. accepted encounters
per 1,000 member months). The
measure will be calculated per
MCP.
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
|
|
|
20
encounters per 1,000 MM for
UB-92
|
|
Seventh
through twelfth month
of membership:
|
|
|
250
encounters per 1,000 MM for
NCPDP
|
|
|
350
encounters per 1,000 MM for
NSF
|
|
|
100
encounters per 1,000 MM for
UB-92
|
Determination
of
Compliance: Performance is monitored
once every month. Compliance determination with the standard applies only to
the
month under consideration and does not include performance in previous
months.
Penalty
for
Noncompliance: If the MCP is determined to be noncompliant
with the standard, ODJFS will impose a monetary sanction of one percent of
the
MCP’s current month’s premium payment. The monetary sanction will be
applied
for each file type in the ODJFS-specified medium per format that is
determined to be out of compliance. The monetary sanction
will be applied
only once per file
type per
compliance determination period and
will not exceed a total of two percent ofthe
MCP’s current month’s premium
payment. Once the MCP is performing at standard levels and
violations/deficiencies are resolved to the satisfaction of ODJFS, the money
will be refunded. Special consideration will be
made for
MCPs with less than 1,000 members.
1.a.v.
Informational Encounter Data
Completeness Measure
The
‘Incomplete
Data for Last Menstrual
Period’ measure is informational only for the ABD
population. Although there is no minimum performance standard for
this measure, results will be reported and used as one component in monitoring
the quality of data submitted to ODJFS by the MCPs.
1.b. Encounter
Data
Accuracy
As
with data completeness, MCPs are
responsible for assuring the collection and submission of accurate data to
ODJFS. Failure to do so jeopardizes MCPs’ performance, credibility
and, if not corrected, will be assumed to indicate a failure in actual
performance.
1.b.i. Encounter
Data
Accuracy Study
Measure: This
accuracy study will
compare the accuracy and completeness of payment data stored
in MCPs’ claims systems during the study period to payment data
submitted to and accepted by ODJFS. The measure will be calculated per
MCP.
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: TBD for SFY 2008 and
SFY 2009.
Penalty
for
Noncompliance: The
first time an MCP is noncompliant
with a standard for this measure, ODJFS will issue a Sanction Advisory informing
the MCP that any future noncompliance instances with the standard for this
measure will result in ODJFS imposing a monetary sanction.
Upon
all subsequent measurements of
performance, if an MCP is again determined to be noncompliant with the standard,
ODJFS will impose a monetary sanction (see Section 6.)
of one percent
of the current month’s premium
payment. Once the MCP is performing at standard levels and
violations/deficiencies are resolved to the satisfaction of ODJFS, the money
will be refunded.
1.b.ii. Generic
Provider Number Usage
Measure:
This measure is the
percentage of non-pharmacy encounters with the generic provider
number. Providers submitting claims which do not have an MMIS
provider number must be submitted to ODJFS with the generic provider number
9111115. The measure will be calculated per MCP.
All
other
encounters are required to have the MMIS provider number of the servicing
provider. The report period for this measure
is quarterly.
Report
Period: For
the SFY 2008 and SFY 2009 contract
period, performance will be evaluated using the report periods listed in
1.a.iii., Table 3.
Data
Quality Standard: A
maximum generic provider
number
usage
rate of 10%.
Determination
of
Compliance: Performance is
monitored
once every
quarter for all report periods. For
quarterly reports that are issued on
or after July 1, 2007, an MCP will be determined to be noncompliant for the
quarter if the standard is not met in any report period and the initial instance
of noncompliance in a report period is determined on or after July 1,
2007. An initial instance of noncompliance means that the result for
the applicable report period was in compliance as determined in the prior
quarterly report, or the instance of noncompliance is the first determination
for an MCP’s first quarter of measurement.
Penalty
for
noncompliance: The first time an MCP is noncompliant
with a standard for this measure, ODJFS will issue a Sanction Advisory informing
the MCP that any future noncompliance instances with the standard for this
measure will result in ODJFS imposing a monetary sanction. Upon all subsequent
measurements of performance, if an MCP is again determined to be noncompliant
with the standard, ODJFS will impose a monetary sanction (see Section 6.) of
three percent of the current month’s premium payment. Once the MCP is
performing at standard levels and violations/deficiencies are resolved to the
satisfaction of ODJFS, the money will be refunded.
1.c.
Timely Submission of Encounter Data
1.c.i. Timeliness
ODJFS
recommends submitting encounters no later than thirty-five days after the end
of
the month in which they were paid. ODJFS does not monitor standards
specifically for timeliness, but the minimum claims volume (Section 1.a.i.)
and
the rejected encounter (Section 1.a.iv.) standards are based
on
encounters being submitted within this time frame.
1.c.ii. Submission
of Encounter Data Files
in the ODJFS-specified medium per
format
Information
concerning the proper submission of encounter data may be obtained from the
ODJFS Encounter Data File
Submission Specifications document. The MCP must submit a
letter of certification, using the form required by ODJFS, with each
encounter data file in the
ODJFS-specified medium per format.
The
letter of certification must be signed by the MCP’s Chief Executive Officer
(CEO), Chief Financial Officer (CFO), or an individual who has delegated
authority to sign for, and who reports directly to, the MCP’s CEO or
CFO.
2.
CASE MANAGEMENT DATA
ODJFS
designed a case management system
(CAMS) in order to monitor MCP compliance with program requirements
specified in Appendix G, Coverage and
Services. Each MCP’s case management data submissions will be
assessed for completeness and accuracy. The MCP is responsible
for submitting a case
management file every
month. Failure to do so jeopardizes the MCP’s
ability to demonstrate compliance
with case management
requirements. For
detailed descriptions of the case management measures below, see ODJFS
Methods for
the ABD and CFC Medicaid Managed Care Programs Data Quality
Measures.
2.a. Case
Management System Data Accuracy
2.a.i.
Open Case Management Spans for
Disenrolled Members (this measure will
be discontinued
as of January 2008)
Measure: The
percentage of the MCP’s case management records in
CAMS for the ABD
program that have open case
management date spans for members who have disenrolled from the
MCP.
Report
Period: For
the third and fourth
quarters of SFY 2007, January
–
March
2007, and April – June
2007 report periods. For
the SFY
2008 contract period, July – September
2007, and October
–
December
2007 report
periods.
Data
Quality
Standard: A rate of open case management spans for disenrolled
members of no more than 1.0%.
Statewide Approach: MCPs
will be evaluated using
a statewide resultspecific
for the ABD program,
including all regions in which an MCP has ABD membership. An
MCP will not
be evaluated until the MCP has at least 3,000 ABD members
statewide. As
the ABD Medicaid managed care program
expands statewide and regions become active in different months, statewide
results will include
every region in which an MCP has
membership [Example: MCP AAA has: 6,000 members in the South West
region beginning in January 2007; 7,000 members in the West Central
regionbeginning
in February 2007; and 8,000
members in the South East region beginning in March 2007. MCP AAA’s statewide
results for the April-June 2007 report period will include data for the ▇▇▇▇▇
▇▇▇▇, ▇▇▇▇ ▇▇▇▇▇▇▇, ▇▇▇ ▇▇▇▇▇ ▇▇▇▇ regions.]
Penalty
for
noncompliance: If an MCP is noncompliant with the
standard, then the ODJFS will issue a Sanction Advisory informing the MCP that
a
monetary sanction will be imposed if the MCP is noncompliant for any future
report periods. Upon all subsequent semi-annual measurements of
performance, if an MCP is again determined to be noncompliant with the standard,
ODJFS will impose a monetary sanction of one-half of one percent of the current
month’s premium payment. Once the MCP is performing at standard levels and
violations/deficiencies are resolved to the satisfaction of ODJFS, the money
will be refunded.
2.b. Timely
Submission of Case Management Files
Data
Quality Submission
Requirement: The MCP must submit Case Management files on a monthly basis
according to the specifications established in ODJFS’ Case Management File and
Submission Specifications.
Penalty
for noncompliance:
See Appendix N, Compliance
Assessment System, for the
penalty for noncompliance with this requirement.
3.
EXTERNAL QUALITY REVIEW DATA
In
accordance with federal law and regulations, ODJFS is required to
conduct an independent quality review of contracting managed care
plans. The OAC rule 5101:3-26-07(C) requires MCPs to
submit data and information as requested by ODJFS or its designee for the annual
external quality review.
Two
information sources are integral to these studies: encounter data and medical
records. Because encounter data is used to draw samples for these studies,
quality must be sufficient to ensure valid sampling.
An
adequate number of medical records must then be retrieved from
providers and submitted to ODJFS or its designee in order to generalize results
to all applicable members. To aid MCPs in achieving the required
medical record submittal rate, ODJFS will give at least an eight week period
to
retrieve and submit medical records.
3.a.
Independent External Quality Review
Measure: The
percentage of requested records for
a study conducted by the External Quality Review Organization (EQRO) that are
submitted by the managed care plan.
Report
Period: The
report period is one year. Results are calculated and performance is monitored
annually. Performance is measured with each review.
Data
Quality Standard: A
minimum record submittal rate of 85% for each clinical measure.
Penalty
for noncompliance for Data
Quality Standard: For each study that is completed during this
contract period, if an MCP is noncompliant with the standard, ODJFS will impose
a non-refundable $10,000 monetary sanction.
4. MEMBERS’
PCP DATA
The
designated PCP is the
provider who will manage
and coordinate the overall care for ABD members including those who have case
management needs. The MCP must submit a Members’
Designated PCP file every month. Specialists may and should be
identified as the PCP as appropriate for the member’s
condition per the specialty
types specified for the ABD population in ODJFS Member’s
PCP Data
File and Submission Specifications; however, no ABD member
may have more
than one PCP identified for
a given month.
4.a. Timely
submission of Member’s PCP Data
Data
Quality Submission
Requirement: The MCP must submit a Members’ Designated PCP
Data files on a monthly basis according to the specifications established in
ODJFS Member’s
PCP Data File and
Submission Specifications.
Penalty
for
noncompliance: See Appendix N, Compliance
Assessment
System, for the penalty for noncompliance with this
requirement.
4.b. Designated
PCP for newly enrolled members (applicable
for report periods prior
to January 2008)
Measure: The
percentage of MCP’s newly enrolled
members who were designated a PCP by their effective date of
enrollment.
Report
Periods: For
the third and fourth
quarters
of SFY 2007 contract period, performance will be evaluated quarterly using
the
January – March 2007 and April – June 2007 report periods. For the SFY 2008
contract period, performance will be evaluated quarterly using the
July-September 2007, and October–
December 2007 report
periods.
Data
Quality
Standard: A
minimum rate of 65% of new members with PCP designation by their
effective date of enrollment for quarter 3 and quarter 4 of SFY
2007. A
minimum rate of 75% of new members
with PCP designation by their effective date of enrollment for quarter 1 and
quarter 2 of SFY 2008.
Statewide
Approach: MCPs
will be evaluated using a statewide result, including all regions in which
an
MCP has ABD membership. An MCP will not be evaluated until the
MCP has at least 3,000 ABD members statewide.
Penalty
for
noncompliance: If an MCP is 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. As stipulated in OAC
rule
5101:3-26-08.2, each new member must have a designated primary care
provider (PCP) prior to their
effective date of coverage. Therefore, MCPs are subject to additional
corrective action measures
under Appendix N, Compliance Assessment System, for failure to meet this
requirement.
4.b.i. Designated
PCP for
newly enrolled members (applicable for report
periods after
December 2007)
Measure: The
percentage of MCP’s newly enrolled members who were designated a PCP by their
effective date of enrollment.
Report
Periods: For the SFY 2009 contract period, performance will be
evaluated annually using CY 2008.
Data
Quality Standards: For SFY 2009, a minimum rate of 85% of new members
with PCP designation by their effective date of enrollment.
Statewide
Approach: MCPs will be evaluated using a statewide result,
including all regions in which an MCP has ABD membership. An MCP will
not be evaluated until the MCP has at least 3,000 ABD members
statewide.
Penalty
for
noncompliance: If an MCP is 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. As stipulated in OAC rule 5101:3-26-08.2,
each new member must have a designated primary care provider (PCP) prior to
their effective date ofcoverage. Therefore,
MCPs are subject to additional corrective action measures under Appendix N,
Compliance Assessment System, for failure to meet this requirement.
5.
APPEALS AND GRIEVANCES DATA
Pursuant
to OAC rule 5101:3-26-08.4, MCPs are required to submit information at least
monthly to ODJFS regarding appeal and grievance activity. ODJFS
requires these submissions to be in an electronic data file format pursuant
to
the Appeal File and Submission
Specifications and Grievance File and
Submission
Specifications.
The
appeal data file and the grievance data file must include all appeal and
grievance activity, respectively, for the previous month, and must be submitted
by the ODJFS-specified due date. These data files must be submitted
in the ODJFS-specified format and with the ODJFS-specified filename in order
to
be successfully processed.
Penalty
for
noncompliance: MCPs who fail to submit their monthly
electronic data files to the ODJFS by the specified due date or who fail to
resubmit, by no later than the end of that month, a file which meets the data
quality requirements will be subject to penalty as stipulated under the Compliance Assessment System
(Appendix
N).
6. NOTES
6.a.
Penalties,
Including Monetary
Sanctions, for Noncompliance
Penalties
for noncompliance with standards outlined in this appendix, including monetary
sanctions, will be imposed as the results are finalized. With the
exception of Sections
1.a.i., 1.a.iii.,
1.a.iv., 1.a.v.,
and 1.b.ii 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.
Refundable
monetary sanctions will be based on
the
premium payment in the month of the cited deficiency and due within
30 days of notification by ODJFS to the MCP of the amount.
Any
monies collected through the imposition of such a sanction will be returned
to
the MCP (minus any applicable collection fees owed to the Attorney General’s
Office, if the MCP has been delinquent in submitting payment) after the MCP
has
demonstrated full compliance with the particular program requirement and the
violations/deficiencies are resolved to the satisfaction of ODJFS. If
an MCP does not comply within two years of the date of notification of
noncompliance, then the monies will not be refunded.
6.b.
Combined Remedies
If
ODJFS
determines that one systemic problem is responsible for multiple deficiencies,
ODJFS may impose a combined remedy which will address all areas of deficient
performance. The total fines assessed
in any one month will not exceed
15% of the MCP’s monthly premium payment for the Ohio Medicaid
program.
6.c. Membership
Freezes
MCPs
found to have a pattern of repeated or ongoing noncompliance may be subject
to a
membership freeze.
6.d. Reconsideration
Requests
for reconsideration of monetary
sanctions and enrollment freezes may be submitted as provided in Appendix N,
Compliance
Assessment System.
6.e. Contract
Termination, Nonrenewals, or Denials
Upon
termination either by the MCP or ODJFS, nonrenewal, or denial of an MCP provider
agreement, all previously collected refundable monetary sanctions will be
retained by ODJFS.
APPENDIX
M
PERFORMANCE
EVALUATION
ABD
ELIGIBLE
POPULATION
This
appendix establishes minimum performance standards for
managed care
plans (MCPs) in key program areas, under the Agreement. Standards
are subject to
change based on the revision or update of applicable national standards,
methods, benchmarks,
or other factors as deemed
relevant. Performance will be
evaluated in the categories of Quality of Care, Access, Consumer Satisfaction,
and Administrative Capacity. Each performance measure has an
accompanying minimum performance standard. MCPs with performance levels below
the minimum performance standards will be required to take corrective
action. All
performance measures, as specified
in this appendix, will be calculated per MCP and include only members in
the ABD
Medicaid managed
care
program.
Selected
measures in this appendix will be used to determine incentives as specified
in
Appendix O, Pay
for Performance
(P4P).
1. QUALITY
OF CARE
1.a.
Independent External Quality
Review
In
accordance with federal law and
regulations, state Medicaid agencies must annually provide for an external
quality review of the quality outcomes and timeliness of, and access to,
services provided by Medicaid-contracting MCPs [(42 CFR
438.204(d)]. The external review assists the state in assuring MCP
compliance with program requirements and facilitates the collection of accurate
and reliable information concerning MCP performance.
Measure: The
independent
external quality reviewcovers a review of
clinical and
non-clinical performance as outlined in Appendix K.
Report
Period: Performance
will be evaluated using the reviews conducted during SFY 2008.
Action
Required for
Deficiencies: For all reviews conducted during the contract period,
if the EQRO cites a deficiency in performance the MCP will be required to
complete a Corrective Action Plan or Quality Improvement Directive, depending
on
the severity of the deficiency. Serious deficiencies may result in immediate
termination or non-renewal of the Agreement.
1.b. Members
with Special Health Care Needs (MSHCN)
Given
the substantial proportion of
members with chronic conditions and co-morbidities in the ABD population,
one of
the quality of care initiatives of the ABD Medicaid managed
care
program focuses on case
management. In order to ensure state compliance with the
provisions of 42 CFR 438.208, the
Bureau of Managed Health Care
established Members with Special Health Care Needs (MSHCN) basic program
requirements as set
forth in Appendix G,
Coverage
and
Services of the
Agreement, and
corresponding minimum
performance standards as described below. The purpose of these measures is
to
provide appropriate and targeted case management services to MSHCN who have
specific diagnoses and/or who require high-cost or extensive
services. Given
the expedited schedule for implementing the ABD Medicaid managed care program,
coupled with the challenges facing a new Medicaid program in the State of
Ohio,
the minimum performance standards for
the case management requirements for MSHCN are phased in throughout SFY 2007
and
SFY 2008. The minimum standards for these performance measures will
be fully phased in by no later than SFY 2009. For detailed
methodologies of each measure, see ODJFS
Methods for
the ABD Medicaid Managed Care Program’s Case Management Performance
Measures.
1.b.i
Case
Management
of
Members
Measure:
The average monthly
case
management rate for
members
who have at least three months of consecutive enrollment in one MCP.
Report
Period: For
the SFY 2007 contract period, April
– June 2007 report period. For
the SFY 2008 contract
period, July – September 2007, October
– December 2007,
January – March 2008, and April – June 2008 report periods. For the SFY 2009 contract
period, July – September 2008, October – December 2008, January –
March 2009, and April – June 2009 report periods.
Statewide
Approach: MCPs
will be evaluated using a statewide result, including all regions in which
an
MCP has membership. An MCP will not be evaluated until the MCP has at
least 3,000 members statewide who have had at least three months of continuous
enrollment during each month of the entire report period. As the ABD
Medicaid managed care program expands statewide and regions become active
in
different months, statewide results will include every region in which an
MCP
has membership [Example: MCP AAA has: 6,000 members in the South West
region beginning in January 2007; 7,000 members in the West Central region
beginning in February 2007; and 8,000 members in the South East region beginning
in March 2007. MCP AAA’s statewide results for the April-June 2007
report period will include case management rates for all members who meet
minimum continuous enrollment criteria for this measure in: the South West
region for April 2007’s monthly rate calculation; the South West
and West Central regions for May 2007’s monthly rate calculation; and
the ▇▇▇▇▇ ▇▇▇▇, ▇▇▇▇ ▇▇▇▇▇▇▇, ▇▇▇ ▇▇▇▇▇ ▇▇▇▇ regions for June 2007’s monthly
rate calculation.]
Statewide
Target: For the first and second quarters of SFY 2008, a case
management rate of 30%. For the third and fourth quarters of SFY
2008, a case management rate of 35%. For the first and second
quarters of SFY 2009, a case management rate of 40%. For the third
and fourth quarters of SFY 2009, a case management rate of 45%.
Statewide
Minimum Performance
Standard: The level of improvement must result in at least a
20% decrease in the difference between the target and the previous report
period’s results.
Penalty
for
Noncompliance: The
first time an MCP is noncompliant
with a standard for this measure, ODJFS will issue a Sanction Advisory informing
the MCP that any future noncompliance instances with the standard for this
measure will result in ODJFS imposing a monetary sanction. Upon all
subsequent measurements of performance, if an MCP is again determined to
be
noncompliant with the standard, ODJFS will impose a monetary sanction (see
Section 5) of two percent of the current month’s premium payment. Monetary
sanctions will not be levied for consecutive quarters that an MCP is determined
to be noncompliant. If an MCP is noncompliant for a subsequent
quarter, new member selection freezes or a reduction of assignments will
occur
as outlined in Appendix N of the Provider Agreement. Once
the MCP is performing at standard
levels and the violations/deficiencies are resolved to the satisfaction of
ODJFS, the penalties
will be lifted, if applicable,
and monetary sanctions will be returned.
1.b.ii.
Case Management of Members with
an ODJFS-Mandated Condition
Measure
1: The percent
of members with a positive identification through an ODJFS administrative
review
of data for the ODJFS-mandated case management condition
of asthma who
have had at least three consecutive
months of enrollment in one MCP that are case
managed.
Measure
2: The percent
of members with a positive identification through an ODJFS administrative
review
of data for the ODJFS-mandated case management condition
of chronic
obstructive pulmonary disease who
have had at least three consecutive
months of enrollment in one MCP that are case
managed.
Measure
3: The percent
of members with a positive identification through an ODJFS administrative
review
of data for the ODJFS-mandated case management condition
of congestive
heart failure who
have had at least three
consecutive months of enrollment in one MCP that are case
managed.
Measure
4: The
percent of members with a positive identification through an ODJFS
administrative review of data for the ODJFS mandated case management condition
of behavioral health who have had at least three consecutive months of
enrollment in one MCP that are case managed.
Measure
5: The
percent of members with a positive identification through an ODJFS
administrative review of data for the ODJFS-mandated case management condition
of diabetes who have had at least three consecutive months of
enrollment in one MCP that are case managed.
Measure
6: The
percent of members with a positive identification through an ODJFS
administrative review of data for the ODJFS-mandated case management condition
of non-mild hypertension who have had at least three consecutive
months of enrollment in one MCP that are case managed.
Measure
7: The
percent of members with a positive identification through an ODJFS
administrative review of data for the ODJFS-mandated case management condition
of coronary arterial disease who have had at least three consecutive
months of enrollment in one MCP that are case managed.
Report
Periods for Measures 1-
7: For the SFY 2007 contract period April – June 2007
report periods. For the SFY 2008 contract period, July – September
2007, October – December 2007, January – March 2008, and April – June 2008
report periods. For the SFY 2009 contract
period, July – September 2008, October – December 2008, January –
March 2009, and April – June 2009 report periods.
Statewide
Approach: MCPs
will be evaluated using
a statewide result, including all regions in which an MCP has
membership. An MCP will not be evaluated until the MCP has at least
3,000 members statewide who have had at least three months of continuous
enrollment during each month of the entire report period. As the ABD
Medicaid managed care programs expands statewide and regions become active
in
different months, statewide results will include every region in which an
MCP
has membership [Example: MCP AAA has: 6,000 members in the South West
region beginning in January 2007; 7,000 members in the West Central region
beginning in February 2007; and 8,000 members in the South East region beginning
in March 2007. MCP AAA’s statewide results
for the
April-June 2007 report period will include case management rates for all
members
in the ▇▇▇▇▇ ▇▇▇▇, ▇▇▇▇ ▇▇▇▇▇▇▇, ▇▇▇ ▇▇▇▇▇ ▇▇▇▇ regions who are identified
through the administrative data review as having a mandated condition and
are
continuously enrolled for at least three consecutive months in one
MCP.]
Statewide
Target for Measures 1, 2,
3, 5, 6, and 7: For the first and second quarters of SFY 2008,
a case management rate of 60%. For the third and fourth quarters of
SFY 2008, a case management rate of 65%. For SFY 2009, a case
management rate of 75%.
Statewide
Minimum Performance
Standard: The level of improvement must result in at least a
20% decrease in the difference between the target and the previous report
period’s results.
Statewide
Target for Measure
4: For the first and second quarters of SFY 2008, a case
management rate of 30%. For the third and fourth quarters of SFY
2008, a case management rate of 35%. For SFY 2009, the case
management rate is TBD.
Statewide
Minimum Performance
Standard: The level of improvement must result in at least a
20% decrease in the difference between the target and the previous report
period’s results.
Penalty
for
Noncompliance for
Measures
1-7: The first
time an MCP is noncompliant with a standard for this measure, ODJFS will
issue a
Sanction Advisory informing the MCP that any future noncompliance instances
with
the standard for this measure will result in ODJFS imposing a monetary
sanction. Upon all subsequent measurements of performance, if an MCP
is again determined to be noncompliant with the standard, ODJFS will impose
a
monetary sanction (see Section 5) of two percent of the current month’s premium
payment. Monetary sanctions will not be levied for consecutive quarters that
an
MCP is determined to be noncompliant. If an MCP is noncompliant for a
subsequent quarter, new member selection freezes or a reduction of assignments
will occur as outlined in Appendix N of the Provider Agreement. Once
the MCP is performing at
standard levels and
the
violations/deficiencies are resolved to the satisfaction of ODJFS, the
penalties will be lifted, if
applicable, and monetary sanctions will be returned.
1.c.
Clinical Performance
Measures
MCP
performance will be assessed based on the analysis of submitted encounter
data
for each year. For certain measures, standards are established; the
identification of these standards is not intended to limit the assessment
of
other indicators for performance improvement activities. Performance
on multiple measures will be assessed and reported to the MCPs and others,
including Medicaid consumers.
The
clinical performance measures described below closely follow the National
Committee for Quality Assurance’s
(NCQA)
Health Plan
Employer Data and Information Set (HEDIS). NCQA may annually change
its method for calculating a measure. These changes can make it
difficult to evaluate whether improvement occurred from a prior
year. For this reason, ODJFS will use the same
methods to calculate the baseline results and the results for the period
in
which the MCP is being held
accountable. For example, the same methods are used
to calculate calendar year 2008 results
(the baseline period) and
calendar year 2009 results. The methods will be updated
and a new baseline will be created during 2009 for
calendar year 2010 results. These results will
then serve as the baseline to evaluate whether improvement occurred from
calendar year 2009 to calendar year 2010.
Clinical performance measure results
will be calculated after a sufficient amount of time has passed after the
end of
the report period in order to allow for claims runout. For a
comprehensive description of the clinical performance measures below, see
ODJFS
Methods for Clinical Performance Measures, ABD
Medicaid
Managed
Care Program. Performance standards
are subject to
change, based
on the revision or update of NCQA
methods or other national
standards, methods or benchmarks.
MCPs
will be evaluated using a statewide
result, including all regions in which an MCP has
membership. ODJFS will use the
first calendar year
of an MCP’s ABD managed care program membership as
the baseline year (i.e.,
CY2007). The
baseline year will be
used to determine performance standards and targets; baseline data will
come
from a combination of
FFS claims data and MCP encounter
data. For those
performance measures that require two calendar years of baseline data, the
additional calendar year (i.e., the calendar year prior to the first calendar
year of ABD managed care program
membership, i.e.,
CY2006)
data will come
from FFS claims data.
An
MCP’s second calendar
year of
ABD managed care program membership
(i.e., CY2008)
will
be the initial report period of
evaluation for performance measures that require one calendar year of
baseline
data(i.e., CY2007),
and for performance measures that
require two calendar years
of
baseline data (i.e.,
CY2006and
CY2007).
Report
Period: For the
SFY 2008 contract
period, performance will be
evaluated using the January - December 2007 report
period and may be adjusted
based on the number
of months of ABD managed care membership. For the SFY 2009
contract
period, performance will be
evaluated using the January - December 2008 report
period.
1.c.i. Congestive
Heart
Failure (CHF) – Inpatient Hospital
Discharge
Rate
Measure: The
number
of acute inpatient hospital discharges in the reporting year
where the
principal diagnosis was CHF, per thousand member
months, for members
who had a
diagnosisof CHF in the year
prior to the reporting year.
Target: TBD
Minimum
Performance
Standard: The
level of improvement must result in at least a TBD% decrease
in the difference between the
target and the previous report period’s results. (For example, if last year’s
results were TBD%,
then
the difference between
the target and last year’s results is TBD%. In
this example, the
standard is an improvement in performance of TBD%
of this difference or TBD%.
In this example, results of
TBD%
or better would be compliant with the
standard.)
Action
Required for
Noncompliance: If the standard is
not met and the
results are below TBD%,
the MCP is required to complete a
Corrective Action Plan to address the area of
noncompliance. If the standard is not met and the results are at or
above TBD%, 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.
1.c.ii. Congestive
Heart
Failure (CHF) – Emergency Department (ED) Utilization Rate
Measure: The
number of emergency department
visits
inthe reporting year
where the primary
diagnosis was CHF, per
thousand member months,
for
members who had
a diagnosis of
CHF
in the year prior to the
reporting year.
Target: TBD
Minimum
Performance
Standard: The
level of improvement must result in at least a TBD%
decrease in the difference between the
target and the previous report period’s results.
Action
Required for
Noncompliance: If
the standard is not met and the results are below TBD%, the MCP is
required to complete a Corrective Action Plan to address the area of
noncompliance. If the standard is not met and the results are at or
above TBD%, 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.
1.c.iii.
Congestive
Heart Failure (CHF) –
Cardiac Related Hospital
Readmission
Measure: The
rateof
cardiac related readmissions
during the reporting
period
for members who had
a diagnosis of CHF
in the year prior to the
reporting period. A readmission is defined as a cardiac related
admission that occurs within 30 days of a prior cardiac related
admission.
Target: TBD.
Minimum
Performance
Standard: The
level of improvement must result in
at least a TBD% decrease
in the difference
between the target and the previous year’s results.
Action
Required for
Noncompliance: If
the standard is not met and the
results are below TBD%, the
MCP is required to
complete a Corrective Action Plan
to address the area of noncompliance.
If the standard is not met and the results are at or above TBD%, 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.
1.c.iv. Coronary
Artery Disease
(CAD) – Inpatient HospitalDischarge
Rate
Measure: The
number
of acute inpatient hospital discharges in the reporting year
where the primary
diagnosis was CAD, per thousand member
months,
for members who had
a
diagnosis of CAD in the year prior
to
the reporting year.
Target: TBD
Minimum
Performance
Standard: The
level of improvement must result in at least a TBD%
decrease in the difference between the
target and the previous report period’s results.
Action
Required for
Noncompliance: If the standard is
not met and the
results are below TBD%, the
MCP is required to
complete a Corrective Action Plan
to address the area of
noncompliance. If
the standard is not met and the
results are at or above TBD%,
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.
1.c.v. Coronary
Artery Disease
(CAD) – Emergency Department (ED) Utilization Rate
Measure: The
number
of emergency department visitsin the reporting year
where the
principal diagnosis was CAD, per thousand member
months,
for members who had a
diagnosisof CAD in the year
prior to the reporting year.
Target: TBD
Minimum
Performance
Standard: The
level of improvement must result in at least a TBD%
decrease in the difference between the
target and the previous report period’s results.
Action
Required for
Noncompliance: If the standard is
not met and the
results are below TBD%, the
MCP is required to
complete a Corrective Action Plan to
address the area of
noncompliance. If
the standard is not met and the
results are at or above TBD%, ODJFS
will issue a Quality
Improvement Directive which will notify the MCP of noncompliance and may
outline
the steps that the MCP must take to improve the results.
▇.▇.▇▇.
Coronary
Artery Disease (CAD) –
Cardiac Related Hospital
Readmission
Measure: The
rate
of
cardiac related readmissions
in the reporting year
for members who had
a diagnosis of
CAD in the year prior to the
reporting year. A
readmission is defined as
a cardiac related admission that occurs within 30 days of a prior
cardiac related admission.
Target: TBD.
Minimum
Performance
Standard: The
level of improvement must result in
at least a TBD%
decrease in the difference between the
target and the previous year’s results.
Action
Required for
Noncompliance: If
the standard is not met and the
results are below TBD%, the
MCP is required to
complete a Corrective Action
Plan to
address the area of noncompliance. If
the standard is not met and the results are at or above TBD%, 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.
1.c.vii.
Coronary Artery Disease (CAD) –
Beta Blocker Treatment
after Heart Attack
The
evaluation report period for this
measure is CY 2008 only.
Measure: The
percentage of members 35
years of
age and older as of December
31st
of the
reporting year who were hospitalized
from January 1 – December 24th
of the reporting year
with
a diagnosis of acute myocardial infarction (AMI) and who received an ambulatory
prescription for beta blockers within seven days of
discharge.
Target: TBD.
Minimum
Performance
Standard: The
level of improvement must result in
at least a TBD%
decrease in the difference between the
target and the previous year’s results.
Action
Required for
Noncompliance: If
the standard is not met and the
results are below TBD%, the
MCP is required to
complete a Corrective Action Plan
to address the area of noncompliance.
If the standard is not met and the results are at or above TBD%, 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.
1.c.viii. Persistence
of Beta
Blocker Treatment after Heart Attack
The
initial report period of evaluation
for this measure is CY 2009. This measure will replace the
Coronary Artery Disease
(CAD) – Beta Blocker Treatment after Heart Attack measure (1.c.vii.) in the P4P
for SFY 2010.
Measure: The
percentage of members 35
years of age and older as of December 31stof
the reporting year who were
hospitalized and discharged alive from July 1 of the year prior to the reporting
year to June 30 of the measurement year with a diagnosis of acute myocardial
information (AMI) and who received persistent beta-blocker treatment
for six months after discharge.
Target: TBD.
Minimum
Performance
Standard: The
level of improvement must result in
at least a TBD% decrease in the difference between the target and the previous
year’s results.
Action
Required for
Noncompliance: If the standard is
not met and the
results are below TBD%, the MCP is required to complete a Corrective Action
Plan to
address the area of noncompliance. If
the standard is not met and the results are at or above TBD%, 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.
1.c.ix.
Coronary Artery Disease (CAD) –
Cholesterol Management for Patients with Cardiovascular Conditions/LDL-C
Screening Performed
Measure: The
percentage of members
who had a diagnosis
of
CAD
in the year
prior to the reporting year, who were enrolled for at least 11 months in
the
reporting year, and
who
received a lipid
profile during the reporting year.
Target: TBD.
Minimum
Performance
Standard: The
level of improvement must result in
at least a TBD% decrease
in the difference
between the target and the previous year’s results.
Action
Required for
Noncompliance: If
the standard is not met and the
results are below TBD%, the
MCP is required to
complete a Corrective Action Plan to address the area
of noncompliance. If
the standard is not met and the results are at or above TBD%, 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.
1.c.x. Hypertension –
Inpatient Hospital
Discharge Rate
Measure: The
number
of acute inpatient hospital dischargesin the reporting year
where the primary
diagnosis was non-mild hypertension, per thousand member
months,
for members who had a
diagnosis of non-mild
hypertension in the year prior to the reporting year.
Target: TBD
Minimum
Performance
Standard: The
level of improvement must result in at least a TBD%
decrease in the difference between the
target and the previous report period’s results.
Action
Required for
Noncompliance: If the standard is
not met and the
results are below TBD%, the
MCP is required to
complete a Corrective Action Plan to address the area of
noncompliance. If
the standard is not met and the results are at or above TBD%,
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.
1.c.xi. Hypertension
–
Emergency
Department (ED) Utilization Rate
Measure: The
number
of emergency department visitsin the reporting year
where the
principal diagnosis was non-mild hypertension, per
thousand member months, for members
who had a diagnosis
of
non-mild
hypertension in the year prior to the reporting
year.
Target: TBD
Minimum
Performance
Standard: The
level of improvement must result in at least a TBD%
decrease in the difference between the
target and the previous report period’s results.
Action
Required for
Noncompliance: If the standard is
not met and the
results are below TBD%,
the MCP is required to complete a
Corrective Action Plan to
address the area of noncompliance.
If
the standard is not met and the
results are at or above TBD%, 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.
1.c.xii. Diabetes –
Inpatient Hospital
Discharge Rate
Measure: The
number of acute inpatient
hospital discharges
in the reporting year
where
the principal diagnosis was diabetes, per thousand
member months, for members
identified as diabetic
in
the year prior
to the reporting
year.
Target: TBD
Minimum
Performance
Standard: The
level of improvement must result in at least a TBD%
decrease in the difference between the
target and the previous report period’s results.
Action
Required for
Noncompliance: If the standard is
not met and the
results are below TBD%, the
MCP is required to
complete a Corrective Action Plan to address the area of
noncompliance. If the standard is not met and the results are at or
above TBD%, 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.
1.c.xiii. Diabetes
–
Emergency
Department (ED) Utilization Rate
Measure: The
number of
emergency department visits
in the reporting year
where
the primary diagnosis was diabetes, per
thousand member months, for members
identified as
diabetic in the
year prior to the reporting year.
Target: TBD
Minimum
Performance
Standard: The
level of improvement must result in at least a TBD%
decrease in the difference between the
target and the previous report period’s results.
Action
Required for
Noncompliance: If the standard is
not met and the
results are below TBD%,
the MCP is required to complete a
Corrective Action Plan to
address the area of
noncompliance. If
the standard is not met and the
results are at or above TBD%, 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.
1.c.xiv. Diabetes
–
Eye
Exam
Measure: The
percentage of
diabetic members who
were enrolled for at least 11 months
during the reporting year, who received one or more retinal or dilated eye
exams
from an ophthalmologist or optometrist during the reporting
year.
Target:TBD.
Minimum
Performance
Standard: The
level of improvement must result in
at least a TBD% increase in
the
difference between the target and the previous year’s
results.
Action
Required for
Noncompliance: If the standard is
not met and the
results are below TBD%, the
MCP is required to
complete a Corrective Action Plan to
address the area of noncompliance. If
the standard is not met and the results are at or above TBD%, 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.
1.c.xv. Chronic
Obstructive
Pulmonary Disease (COPD) – Inpatient Hospital
Discharge Rate
Measure: The
number
of acute inpatient hospital discharges in the reporting year
where the primary
diagnosis was COPD, per thousand member
months,
for
members who had a diagnosis of
COPD
in the year prior to the
reporting year.
Target: TBD
Minimum
Performance
Standard: The
level of improvement must result in at least a TBD%
decrease in the difference between the
target and the previous report period’s results.
Action
Required for
Noncompliance: If the standard is
not met and the
results are below TBD%, the
MCP is required to
complete a Corrective Action Plan to
address the area of
noncompliance. If
the standard is not met and the
results are at or above TBD%, 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.
1.▇.▇▇▇. Chronic
Obstructive
Pulmonary Disease (COPD) – Emergency Department (ED) Utilization
Rate
Measure: The
number
of emergency department visits in the reporting year
where the
principal diagnosis was COPD, per thousand member
months,
for members who had a
diagnosis of
COPD in the year prior to
the reporting
year.
Target: TBD
Minimum
Performance
Standard: The
level of improvement must result in at least a TBD%
decrease in the difference between the
target and the previous report period’s results.
Action
Required for
Noncompliance: If the standard is
not met and the
results are below TBD%, the
MCP is required to
complete a Corrective Action Plan to
address the area of noncompliance.
If
the standard is not met and the
results are at or above TBD%, 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.
1.c.xvii. Asthma
–
Inpatient Hospital
Discharge Rate
Measure: The
number of acute
inpatient hospital discharges in the reporting year
where the primary
diagnosis was asthma, per
thousand member months, for
members with persistent asthma.
Target: TBD
Minimum
Performance
Standard: The
level of improvement must result in at least a TBD%
decrease in the difference between the
target and the previous report period’s results.
Action
Required for
Noncompliance: If the standard is
not met and the
results are below TBD%, the
MCP is required to
complete a Corrective Action Plan to
address the area of noncompliance.
If
the standard is not met and the
results are at or above TBD%, 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.
1.c.xviii. Asthma
–
Emergency
Department (ED) Utilization Rate
Measure: The
number
of emergency department visits in the reporting year
where the
principal diagnosis was asthma, per thousand member
months,
for members with persistent
asthma.
Target: TBD
Minimum
Performance
Standard: The
level of improvement must result in at least a TBD%
decrease in the difference between the
target and the previous report period’s results.
Action
Required for
Noncompliance: If the standard is
not met and the
results are below TBD%, the
MCP is required to
complete a Corrective Action Plan to
address the area of
noncompliance. If
the standard is not met and the
results are at or above TBD%, 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.
1.c.xix. Asthma
–
Use
of Appropriate
Medications for People with Asthma
Measure: The
percentage of members
with persistent asthma who received prescribed medications acceptable as
primary
therapy for long-term control of asthma.
Target: TBD
Minimum
Performance
Standard: The
level of improvement must result in at least a TBD%
decrease in the difference between the
target and the previous report period’s results.
Action
Required for
Noncompliance: If the standard is
not met and the
results are below TBD%,
the MCP is required to
complete a Corrective Action Plan to address the area of
noncompliance. If the standard is not met and the results are
at or above TBD%, 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.
1.c.xx.
Mental Health, Severely
Mentally Disabled (SMD) – Inpatient Hospital
Discharge Rate
Measure: The
number
of acute inpatient hospital discharges in the reporting year
where
the primary diagnosis
was SMD, per thousand member
months, for members who
had a primary diagnosis
of SMD in the year prior
to the reporting
year.
Target: TBD
Minimum
Performance
Standard: The
level of improvement must result in at least a TBD%
decrease in the difference between the
target and the previous report period’s results.
Action
Required for
Noncompliance: If the standard is
not met and the
results are below TBD%,
the MCP is required to complete a
Corrective Action Plan to
address the area of noncompliance.
If
the standard is not met and the
results are at or above TBD%,
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.
1.c.xxi. Mental
Health, Severely
Mentally Disabled (SMD) – Emergency
Department Utilization Rate
Measure: The
number
of emergency department visits in the reporting year
where
the primary diagnosis
was SMD, per thousand member
months, for members who had
a primary diagnosis of SMD in the year prior to the reporting
year.
Target: TBD
Minimum
Performance
Standard: The
level of improvement must result in at least a TBD%
decrease in the difference between the
target and the previous report period’s results.
Action
Required for
Noncompliance: If the standard is
not met and the
results are below TBD%, the
MCP is required to
complete a Corrective Action Plan to
address the area of
noncompliance. If
the standard is not met and the
results are at or above TBD%,
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.
1.c.xxii. Follow-up
After Hospitalization for
Mental Illness
Measure: The
percentage of discharges
for members enrolled from the date of discharge through 30 days after discharge,
who were hospitalized for treatment of selected mental health
disorders and
who
had
a follow-up visit (i.e.,
were seen on an outpatient
basis or were in intermediate treatment with a mental health
provider) within:
1)
30 Days of discharge,
and
2)
7 Days of
discharge.
Target: TBD.
Minimum
Performance
Standard For
Each
Measure: The
level of improvement must result in
at least a TBD% decrease
in the difference
between the target and the previous year’s results.
Action
Required for
Noncompliance
(Follow-up visits
within 30 days of discharge): If
the standard is not met and the
results are below TBD%, the
MCP is required to
complete a Corrective Action Plan to
address the area of noncompliance. If
the standard is not met and the results are at or above TBD%, ODJFS
will issue a Quality Improvement
Directive which will notify the MCP of noncompliance and may outline the
steps
that the MCP must take to improve the results.
Action
Required for
Noncompliance (Follow-up visits within 7 days of
discharge): If
the standard is not met and the results are below TBD%, the MCP is required
to
complete a Corrective Action Plan to
address the area of noncompliance. If
the standard is not met and the results are at or above TBD%, 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.
1.c.xxiii.
Mental Health, Severely
Mentally Disabled (SMD) – SMD Related Hospital
Readmission
Measure: The
number of SMD related
readmissions for members who
had a diagnosis
of SMD in the year prior to
the reporting year. A
readmission is defined as a SMD
related admission that occurs within 30 days of a prior SMD related
admission.
Target: TBD.
Minimum
Performance
Standard: The
level of improvement must result in
at least a TBD% decrease
in the difference
between the target and the previous year’s results.
Action
Required for
Noncompliance: If
the standard is not met and the
results are below TBD%, the
MCP is required to
complete a Corrective Action Plan to address the area
of noncompliance. If
the standard is not met and the results are at or above TBD%, 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.
1.c.xxiv. Substance
Abuse –
Inpatient Hospital
Discharge Rate
Measure: The
number of acute
inpatient hospital discharges in the reporting year
where
the primary diagnosis
was alcohol and other drug
abuse or dependence (AOD), per thousand member months, for members who
had, in
the year prior to the reporting year,
a diagnosis of AOD and
one of the following:
AOD-related acute inpatient admission or two AOD related Emergency Department
visits.
Target: TBD
Minimum
Performance
Standard: The
level of improvement must result in at least a TBD%
decrease in the difference between the
target and the previous report period’s results.
Action
Required for
Noncompliance: If the standard is
not met and the
results are below TBD%, the
MCP is required to
complete a Corrective Action Plan to address the area of
noncompliance. If
the standard is not met and the
results are at or above TBD%,
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.
1.c.xxv. Substance
Abuse – Emergency Department
Utilization
Rate
Measure: The number of emergency department visits in the reporting year where the principal diagnosis was AOD, per thousand member months, for members who had, in the year prior to the reporting year, a diagnosis of AOD and one of the following: AOD-related acute inpatient admission or two AOD related Emergency Department visits .
Target: TBD
Minimum
Performance
Standard: The
level of improvement must result in at least a TBD%
decrease in the difference between the
target and the previous report period’s results.
Action
Required for
Noncompliance: If the standard is
not met and the
results are below TBD%,
the MCP is required to complete a
Corrective Action Plan to
address the area of
noncompliance. If
the standard is not met and the
results are at or above TBD%,
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.
1.c.xxvi.
Substance Abuse – Inpatient Hospital
Readmission Rate
Measure: The
number of AOD related
readmissions in
the reporting year for members who
had, in the year prior to the
reporting year, a diagnosis of AOD and
one of the following:
AOD-related acute inpatient admission or two AOD related Emergency Department
visits. A readmission is
defined as an
AOD-related admission that
occurs within 30 days of a prior AOD-related admission.
Target: TBD.
Minimum
Performance
Standard: The
level of improvement must result in
at least a TBD% decrease
in the difference
between the target and the previous year’s results.
Action
Required for
Noncompliance: If
the standard is not met and the
results are below TBD%, the
MCP is required to
complete a Corrective Action
Plan to
address the area of noncompliance. If
the standard is not met and the results are at or above TBD%, 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.
1.c.xxvii.
Informational Clinical Performance
Measures
The
clinical performance measures listed
in Table 1 are informational only. Although there are no performance
targets or minimum performance standards for these measures, results will
be
reported and used as one component in assessing the quality of care
provided by MCPs to the ABD managed care population.
Table
1. Informational Clinical
Performance Measures
|
Condition
|
Informational
Performance Measure
|
|
CHF
|
Discharge
rate with age group
breakouts
|
|
CAD
|
Discharge
rate with age group
breakouts
|
|
Hypertension
|
Discharge
rate with age group
breakouts
|
|
Diabetes
|
Discharge
rate with age group
breakouts
|
|
Comprehensive
Diabetes Care
(CDC)/HbA1c testing
|
|
|
CDC/kidney
disease
monitored
|
|
|
CDC/LDL-C
screening
performed
|
|
|
COPD
|
Discharge
rate with age group
breakouts
|
|
Use
of Spirometry Testing in the
Assessment and Diagnosis of COPD
|
|
|
Asthma
|
Discharge
rate with age group
breakouts
|
|
Mental
Health
(SMD)
|
Discharge
rate with age group
breakouts
|
|
Antidepressant
Medication
Management
|
|
|
Substance
Abuse
|
Discharge
rate with age group
breakouts
|
|
Initiation
and Engagement of
Alcohol and Other Drug Dependence
Treatment
|
2. ACCESS
Performance
in the Access category will
be determined by the following measures: Primary Care Provider (PCP) Turnover, Adults’ Access to
Preventive/Ambulatory Health Services, and Adults’ Access to Designated
PCP. For a comprehensive description of the access performance
measures below, see ODJFS
Methods
for
the
ABD Medicaid Managed Care Program Access
Performance
Measures.
2.a.
PCP Turnover
A
high
PCP turnover rate may affect continuity of care and may signal poor management
of providers. However, some turnover may be expected when MCPs end
contracts with providers who are not adhering to the MCP’s standard of
care. Therefore, this measure is used in conjunction with the adult
access and designated PCP measures to assess performance in the access
category.
Measure:
The percentage of
primary care providers affiliated with the MCP as of the beginning of the
measurement year who were not affiliated with the MCP as of the end of the
year.
Statewide
Approach:
MCPs will be evaluated
using a statewide result, including all regions in which an MCP has
membership. ODJFS will use the
first calendar year
of ABD managed care program membership as the baseline year (i.e., CY2007).
The
baseline year will be used to determine a minimum statewide performance
standard. An MCP’s second calendar year of ABD managed care program
membership (i.e., CY2008) will be the initial report period of evaluation,
and
penalties will be applied for noncompliance.
Report
Period: For the SFY 2008 contract
period, a
baseline level of performance will be established using the CY 2007
report period (and may be adjusted
based on the number of months of ABD managed care
membership). For
the SFY 2009 contract period, performance will be evaluated using the CY
2008
report period. The first
reporting period in which MCPs will be held accountable to the performance
standards will be the SFY
2009 contract
period.
Minimum
Performance
Standard: A maximum PCP Turnover rate of TBD.
Action
Required for
Noncompliance: MCPs are required to perform a causal analysis
of the high PCP turnover rate and assess the impact on timely access to health
services, including continuity of care. If access has been reduced or
coordination of care affected, then the MCP must develop and implement a
corrective action plan to address
the
findings.
2.b. Adults’
Access
to
Designated PCP
The
MCP must encourage and assist ABD
members without a designated primary care provider (PCP)
to establish such a relationship,
so that a designated PCP can coordinate and manage
member’s health care
needs. This measure is used to assess MCPs’ performance in the access
category.
Measure: The
percentage of members who had a
visit through the
members’ designated
PCPs.
Statewide
Approach: MCPs will be
evaluated using a statewide result, including all regions in which an MCP
has
membership. ODJFS will use the
first calendar year of ABD managed care program
membership as
the baseline year (i.e.,
CY2007). The
baseline year will be used
to determine a minimum
statewide performance standard. An MCP’s second calendar year of ABD
managed care program membership (i.e.,
CY2008)
will be the initial report period of
evaluation, and penalties will be applied for noncompliance.
Report
Period: For the
SFY 2008 contract period, performance will be evaluated using the January
-
December 2007 report period (and may be adjusted
based on the number
of months of ABD managed care membership). For the SFY 2009 contract
period, performance will be evaluated using the January - December 2008 report
period. The first reporting period in which MCPs will be held
accountable to the performance standards will be the SFY 2009 contract period.
Minimum
Performance Standards:
TBD
Penalty
for
Noncompliance: If an MCP is noncompliant
with the
Minimum Performance Standard, then the MCP must develop and implement a
corrective action plan.
2.c.
Adults’ Access to Preventive/Ambulatory Health Services
This
measure indicates whether adult members are accessing health
services.
Measure:
The percentage of
members who had an ambulatory
or
preventive-care visit.
Statewide
Approach: MCPs will be
evaluated using a statewide result, including all regions in which an MCP
has
membership. ODJFS will use the
first calendar year
of ABD managed care program membership as the baseline year (i.e., CY2007).
The
baseline year will be used to determine
a minimum statewide
performance standard. An MCP’s second calendar year of ABD managed
care program membership (i.e., CY2008) will be the initial report period
of
evaluation, and penalties will be applied for noncompliance.
Report
Period: For the
SFY 2008 contract period, performance will be evaluated using the January
-
December 2007 report period(and may be adjusted
based on the number
of months of ABD managed care membership). For the SFY 2009 contract
period,
performance will be
evaluated using the January - December 2008 report period. The first
reporting period in which MCPs will be held accountable to the performance
standards will be the SFY
2009 contract
period.
Minimum
Performance Standards:
TBD
Penalty
for
Noncompliance: If an MCP is noncompliant with the Minimum
Performance Standard,
then the MCP must develop and implement a corrective action plan.
3.
CONSUMER SATISFACTION
MCPs
will be evaluated using a statewide
result, including all regions in which an MCP has
membership.
In
accordance with federal requirements and in the interest of assessing enrollee
satisfaction with MCP performance, ODJFS annually conducts independent
consumer satisfaction surveys. Results are used to assist in identifying
and
correcting MCP performance overall and in the areas of access, quality of
care,
and member services. Results from the SFY 2009
evaluation
will be used to set a
standard. For the SFY 2009
contract period, this measure is
a reporting only measure. SFY 2010 will be the first contract period
in which MCPs will be held accountable to the performance standards for this
measure.
Measure: TBD.
The results of this measure are
reported annually.
Report
Period: For
the SFY 2009 contract period, the measure
is under review and
the report period has not been determined.
Minimum
Performance Standard: TBD.
Penalty
for
noncompliance: If an MCP is determined noncompliant with the
Minimum Performance Standard, then the MCP must develop a corrective action
plan
and provider agreement renewals
may be affected.
4.
ADMINISTRATIVE CAPACITY
The
ability of an MCP to meet
administrative requirements has been found to be both an indicator of current
plan performance and a predictor of future performance. Deficiencies
in administrative capacity make the accurate assessment of performance in
other
categories difficult, with findings uncertain. Performance in this
category will be determined by the Compliance
Assessment
System, and
the emergency department diversion
program. For a comprehensive description of the Administrative Capacity
performance
measures below, see ODJFS
Methods
for the ABD
Medicaid Managed
Care Program Administrative Capacity Performance Measure,
which are incorporated in this
Appendix.
4.a.
Compliance Assessment
System
Measure: The
number of points accumulated during
a rolling 12-month period through the Compliance
Assessment System.
Report
Period: For
the SFY 2008 and SFY 2009 contract
periods, performance will be evaluated using a rolling 12-month report
period.
Performance
Standard: A
maximum of 15 points
Penalty
for
Noncompliance: Penalties
for points are established in Appendix N, Compliance
Assessment System.
4.b.
Emergency Department
Diversion
Managed
care plans must provide access
to services in a way that assures access to primary and urgent care in the
most
effective settings and minimizes inappropriate utilization of emergency
department
(ED) services. MCPs are required to identify high utilizers of
targeted ED services and implement action plans designed to minimize
inappropriate, preventable and/or primary care sensitive ED
utilization.
Measure:
The percentage of
members who had TBD
targeted ED visits during the twelve month reporting period.
Statewide
Approach: MCPs will be
evaluated using a statewide result, including all regions in which an MCP
has
membership. ODJFS will use the first calendar year of ABD managed care membership
as the
baseline year (i.e.,
CY2007). The
baseline year will be used
to determine a minimum
statewide performance standard and a target. The number of members
with an ED visit
used to calculate the measure for the baseline year will be adjusted based
on
the number of months of ABD managed care membership in the baseline
year. An
MCP’s second calendar year of ABD managed care program membership (i.e.,
CY2008)
will be the initial report period
of
evaluation, and penalties will be
applied for noncompliance.
Report
Period: For
the SFY 2008 contract
period, a baseline level of
performance will be established using the CY 2007 report
period (and may be adjusted
based on the number
of months of ABD managed care membership). For the SFY 2009
contract
period, results will be
calculated for the reporting period of CY2008 and
compared to the CY2007 baseline
results to determine if the
minimum performance standard is met.
Target: TBD
Minimum
Performance Standard: TBD
Penalty
for
Noncompliance: If the standard
is not met
and the results are above
TBD%, then the MCP
must develop a
corrective action plan, for which ODJFS may direct the MCP to develop the
components of their targeted EDD program as specified by ODJFS. If
the standard is not met and the results are at or below TBD%,
then the MCP must develop a
Quality Improvement Directive.
5.
Notes
Given
that unforeseen circumstances
(e.g., revision or update
of applicable national standards, methods or benchmarks, or issues related
to program
implementation) may impact
performance assessment
as specified in Sections 1
through 4, ODJFS
reserves the right to apply the
most appropriate penalty to the area of deficiency identified with any
individual measure, notwithstanding the penalties specified in this
Appendix.
5.a.
Monetary
Sanctions
Penalties
for noncompliance with
individual standards in this appendix will be imposed as the results are
finalized. Penalties for noncompliance with individual standards for each
period
of compliance is determined in this appendix and will not exceed
$250,000.
Refundable
monetary sanctions will be
based on the capitation payment for the month of the cited deficiency
and will be due within 30 days of notification by ODJFS to the MCP of the
amount. Any monies collected through the imposition of such a
sanction would be returned to the MCP (minus any applicable collection fees
owed
to the Attorney General’s Office, if the MCP has been delinquent in submitting
payment) after they have demonstrated improved performance in accordance
with
this appendix. If
an MCP does not
comply within two years of the date of notification of noncompliance, then
the
monies will not be refunded.
5.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
capitation payment.
5.c.
Enrollment
Freezes
MCPs
found to have a pattern of repeated
or ongoing noncompliance may be subject to an enrollment
freeze.
5.d.
Reconsideration
Requests
for reconsideration of monetary
sanctions and enrollment freezes may be submitted as provided in Appendix
N,
Compliance
Assessment System.
5.e.
Contract Termination, Nonrenewals
or Denials
Upon
termination, nonrenewal or denial
of an MCP contract, all
monetary sanctions collected under this appendix will be retained by ODJFS.
The
at-risk amount paid to the MCP under the current provider agreement will
be
returned to ODJFS in accordance with Appendix P, Terminations,
of the provider
agreement.
APPENDIX
N
COMPLIANCE
ASSESSMENT SYSTEM
ABD
ELIGIBLE POPULATION
I.
General Provisions of the Compliance Assessment System
A.
The
Compliance Assessment System
(CAS) is designed
to improve the
quality of each managed care plan’s (MCP’s) performance through actions taken by
the Ohio Department of Job and Family Services (ODJFS) to address identified
failures to meet program requirements. This appendix applies to the
MCP specified in the baseline of this MCP Provider Agreement (hereinafter referred to as
the
Agreement).
B.
The
CAS assesses
progressive remedies with
specified values (e.g., points, fines, etc.) assigned for certain documented
failures to satisfy the deliverables required by Ohio Administrative
Code (OAC) rule or
the Agreement. Remedies
are progressive based upon the
severity of the violation, or a repeated pattern of violations. The CAS
allows the accumulated point total to
reflect patterns of less serious violations as well as less frequent, more
serious violations.
C.
The
CAS focuses on clearly
identifiable deliverables and sanctions/remedial actions are only assessed
in
documented and verified instances of noncompliance. The CAS
does not include categories which
require subjective assessments or which are not within the MCPs
control.
D.
The
CAS does not replace ODJFS’ ability to require corrective action plans (CAPs)
and program improvements, or to impose any of the sanctions specified
in OAC rule 5101:3-26-10, including the proposed termination, amendment,
or
nonrenewal of the MCP’s Provider Agreement.
E.
As
stipulated in OAC rule 5101:3-26-10(F), regardless of whether ODJFS imposes
a
sanction, MCPs are required to initiate corrective action for any MCP program
violations or deficiencies as soon as they are identified by the MCP or
ODJFS.
F.
In addition to the remedies imposed
in Appendix N, remedies related to areas of financial performance,
data
quality,and
performance
management may also be imposed
pursuant to
Appendices J, L, and M respectively, of the Agreement.
G.
If
ODJFS determines that an MCP has violated any of the requirements of sections
1903(m) or 1932 of the Social Security Act which are not specifically identified
within the CAS, ODJFS may, pursuant to the provisions of OAC rule
5101:3-26-10(A), notify the MCP’s members that they may terminate from the MCP
without cause and/or suspend any further new member selections.
H.
For
purposes of the CAS, the date that ODJFS first becomes aware of an MCP’s program
violation is considered the date on which the violation
occurred. Therefore, program violations that technically reflect
noncompliance from the previous compliance term will be subject to remedial
action under CAS at the time that ODJFS first becomes aware of this
noncompliance.
I.
In
cases where an MCP contracted healthcare provider is found to have violated
a
program requirement (e.g., failing to provide adequate contract termination
notice, marketing to potential members, inappropriate member billing, etc.),
ODJFS will not assess points if: (1) the MCP can document that they provided
sufficient notification/education to providers of applicable program
requirements and prohibited activities; and (2) the MCP takes immediate and
appropriate action to correct
the
problem and to ensure that it does not happen again to the satisfaction of
ODJFS. Repeated incidents will be reviewed to determine if the MCP
has a systemic problem in this area, and if so, sanctions/remedial actions
may
be assessed, as determined by ODJFS.
J.
All
notices of noncompliance will be issued in writing via email and facsimile
to
the identified MCP contact.
II.
Types of Sanctions/Remedial Actions
ODJFS
may
impose the following types of sanctions/remedial actions, including, but
not
limited to, the items listed below. The following are examples of
program violations and their related penalties. This list is not all
inclusive. As with any instance of noncompliance, ODJFS retains the
right to use their sole discretion to determine the most appropriate penalty
based on the severity of the offense, pattern of repeated noncompliance,
and
number of consumers affected. Additionally, if an MCP has received
any previous written correspondence regarding their duties and obligations
under
OAC rule or the Agreement, such notice may be taken into consideration when
determining penalties and/or remedial actions.
A.
Corrective Action Plans
(CAPs)– A CAP is a structured activity/process implemented by the MCP to
improve identified operational deficiencies.
MCPs
may
be required to develop CAPs for any instance of noncompliance, and CAPs are
not
limited to actions taken in this Appendix. All CAPs requiring ongoing
activity on the part of an MCP to ensure their compliance with a program
requirement remain in effect for twenty-four months.
In
situations where ODJFS has already determined the specific action which must
be
implemented by the MCP or if the MCP has failed to submit a CAP, ODJFS may
require the MCP to comply with an ODJFS-developed or “directed”
CAP.
In
situations where a penalty is assessed for a violation an MCP has previously
been assessed a CAP (or any penalty or any other related written
correspondence), the MCP may be assessed escalating penalties.
B.
Quality Improvement Directives (QIDs) – A QID is a general
instruction that directs the MCP to implement a quality improvement
initiative to improve identified administrative or clinical
deficiencies. All QIDs remain in effect for twelve months from
the date of implementation.
MCPs
may
be required to develop QIDs for any instance of noncompliance.
In
situations where ODJFS has already determined the specific action which must
be
implemented by the MCP or if the MCP has failed to submit a QID, ODJFS may
require the MCP to comply with an ODJFS-developed or “directed”
QID.
In
situations where a penalty is assessed for a violation an MCP has previously
been assessed a QID (or any penalty or any other related written
correspondence), the MCP may be assessed escalating
penalties.
C.
Points - Points
will accumulate over a rolling 12-month schedule. Each month, points
that are more than 12-months old will expire. Points will be tracked
and monitored separately for each Agreement the MCP concomitantly holds with
the
BMHC, beginning with the commencement of this Agreement (i.e., the MCP will
have
zero points at the onset of this Agreement).
No
points
will be assigned for any violation where an MCP is able to document that
the
precipitating circumstances were completely beyond their control and could
not
have been foreseen (e.g., a construction crew ▇▇▇▇▇▇ a phone line, a lightning
strike blows a computer system, etc.).
C.1.
5
Points -- Failures to meet
program requirements, including but not limited to, actions
which could impair the member’s ability to obtain correct
information
regarding services or which could
impair a consumer’s or member’s rights, as determined by ODJFS, will result in
the assessment of 5 points. Examples include, but are not limited to,
the following:
•Violations
which result in a member’s MCP selection or termination based on inaccurate
provider panel information from the MCP.
•Failure
to provide member materials to new members in a timely manner.
•Failure
to comply with appeal, grievance, or state hearing
requirements, including the failure to notify a member of their right to
a state
hearing when the MCP proposes to deny, reduce, suspend or terminate a
Medicaid-covered service.
•Failure
to staff 24-hour call-in system with appropriate trained medical personnel.
•Failure
to meet the monthly call-center requirements for either the member services
or
the 24-hour call-in system lines.
•Provision
of false, inaccurate or materially misleading information to health care
providers, the MCP’s members, or any
eligible individuals.
•Use
of unapproved marketing or member
materials.
•Failure
to appropriately notify ODJFS or members of provider panel terminations.
•Failure
to update website provider directories as required.
C.2.
10 Points --
Failures to meet program requirements, including but not limited to, actions
which could affect the ability of the MCP to deliver or the consumer to access covered
services, as determined by ODJFS. Examples include, but are not
limited to, the following:
•Discrimination
among members on the basis of their health status or need for health care
services (this includes any practice that would reasonably be expected
to
encourage termination or discourage selection by individuals whose medical
condition indicates probable need for substantial future medical services).
•Failure
to assist a member in accessing needed services in a timely manner after
request
from the member.
•Failure
to provide medically-necessary Medicaid covered services to members.
•Failure
to process prior authorization requests within the prescribed time frames.
D.
Fines– Refundable
or nonrefundable fines may be assessed as a penalty separate to or in
combination with other sanctions/remedial actions.
D.1.
Unless otherwise
stated, all fines are nonrefundable.
D.2.
Pursuant to procedures as established
by ODJFS,
refundable and nonrefundable monetary sanctions/assurances must be remitted
to
ODJFS within thirty (30) days of receipt of the invoice by the
MCP. In addition, per Ohio Revised Code Section 131.02, payments not
received within forty-five (45) days will be certified to the Attorney General’s
(AG’s) office. MCP payments certified to the AG’s office will be assessed the
appropriate collection fee by the AG’s office.
D.3.
Monetary
sanctions/assurances imposed by ODJFS will be based on the most recent premium
payments.
D.4.
Any monies
collected through the imposition of a refundable fine will be returned to
the
MCP (minus any applicable collection fees owed to the Attorney General’s Office
if the MCP has been delinquent in submitting payment) after they have
demonstrated full compliance, as determined by ODJFS, with the particular
program requirement. If an MCP does not comply within one (1) year of
the date of notification of noncompliance involving issues of case management
and two (2) years of the date of notification of noncompliance in issues
involving encounter data, then the monies will not be refunded.
D.5.
MCPs are
required to submit a written request for refund to ODJFS at the time they believe is appropriate before
a refund
of monies will be considered.
E.
Combined Remedies
- Notwithstanding any other action ODJFS may take under this Appendix, ODJFS
may
impose a combined remedy which will address all areas of noncompliance if
ODJFS
determines, in its sole discretion, that (1) one systemic problem is responsible
for multiple areas of noncompliance and/or (2) that there are a number of
repeated instances of noncompliance with the same program
requirement.
F.
Progressive
Remedies - Progressive remedies will be based on the number of points
accumulated at the time of the
most recent incident. Unless specifically otherwise indicated
in this appendix, all fines are nonrefundable. The designated fine
amount will be assessed when the number of accumulated points falls within
the
ranges specified below:
0
-15
Points Corrective
Action Plan (CAP)
16-25Points CAP
+ $5,000
fine
26-50Points CAP
+ $10,000
fine
51-70
Points CAP
+ $20,000
fine
71-100
Points CAP
+ $30,000
fine
100+
Points Proposed Contract Termination
G.
New Member Selection
Freezes - Notwithstanding any other penalty or point assessment that
ODJFS may impose on the MCP under this Appendix, ODJFS may prohibit an MCP
from
receiving new membership through consumer initiated selection or the assignment
process if: (1) the MCP has accumulated a total of 51 or more points during
a
rolling 12-month period; (2) or
the MCP fails to fully implement a CAP within the designated time frame;
or (3) circumstances exist which potentially jeopardize the MCP’s
members’ access to care. [Examples of circumstances that ODJFS may
consider as jeopardizing member access to care include:
- the
MCP has been found by ODJFS to be
noncompliant with the prompt payment or the non-contracting provider payment
requirements;
- the
MCP has been found by ODJFS to be
noncompliant with the provider panel requirements specified in Appendix H
of the
Agreement;
- the
MCP’s refusal to comply with a
program requirement after ODJFS has directed the MCP to comply with the specific
program requirement; or
- the
MCP has received notice of proposed
or implemented adverse action by the Ohio Department of
Insurance.]
Payments
provided for under the
Agreement will be denied for new enrollees, when and for so long as, payments
for those enrollees are denied by CMS in accordance with the requirements
in 42
CFR 438.730.
H.
Reduction of Assignments
– ODJFS has sole discretion over how member auto-assignments are
made. ODJFS may reduce the number of assignments an MCP receives to
assure program stability within a region or if ODJFS determines that the
MCP
lacks sufficient capacity to meet the needs of the increased volume in
membership. Examples of circumstances which ODJFS may determine
demonstrate a lack of sufficient capacity include, but are not limited to
an
MCP’s failure to: maintain an adequate provider network; repeatedly provide new
member materials by the member’s effective date; meet the minimum call center
requirements; meet the minimum performance standards for identifying and
assessing children with special health care needs and members needing case
management services; and/or provide complete and accurate appeal/grievance,
member’s PCP and CAMS data files.
I.
Termination, Amendment,
or Nonrenewal of MCP Provider Agreement - ODJFS can at any time move to
terminate, amend or deny renewal of a provider agreement. Upon such
termination, nonrenewal, or denial of an MCP provider agreement, all previously
collected monetary sanctions will be retained by ODJFS.
J.
Specific Pre-Determined
Penalties
I.1.
Adequate network-minimum provider panel requirements- Compliance with provider
panel
requirements will be assessed quarterly. Any deficiencies in
the MCP’s provider network as specified in Appendix H of the Agreement or by
ODJFS, will result in the assessment of a $1,000 nonrefundable fine for each
category (practitioners, PCP capacity, hospitals), for each county, and for
each
population (e.g., ABD, CFC). For example if the MCP did not meet the
following minimum panel requirements, the MCP would be assessed (1) a $3,000
nonrefundable fine for the failure to meet CFC panel requirements; and, (2)
a
$1,000 nonrefundable fine for the failure to meet ABD panel
requirements).
·
practitioner
requirements in Franklin county for the CFC population
·
practitioner
requirements in Franklin county for the ABD population
·
hospital
requirements in Franklin county for the CFC population
·
PCP
capacity requirements in Fairfield county for the CFC population
In
addition to the pre-determined penalties, ODJFS may assess additional penalties
pursuant to this Appendix (e.g. CAPs, points, fines) if member specific access
issues are identified resulting from provider panel noncompliance.
J.2.
Geographic Information
System - Compliance with the Geographic Information System (GIS)
requirements will be assessed semi-annually. Any failure to meet GIS
requirements as specified in Appendix H of the Agreement will result a $1,000
nonrefundable fine for each county and for each population (e.g., ABD, CFC,
etc.). For example if the MCP did not meet GIS requirements in the
following counties, the MCP would be assessed (1) a nonrefundable $2,000
fine
for the failure to meet GIS requirements for the CFC population and (2) a
$1,000
nonrefundable fine for the failure to meet GIS requirements for the ABD
population.
·
GIS
requirements in Franklin county for the CFC population
·
GIS
requirements in Fairfield county for the CFC population
·
GIS
requirements in Franklin county for the ABD population
J.3.
Late Submissions
- All required submissions/data and documentation requests must be received
by
their specified deadline and must represent the MCP in an honest and forthright
manner. Failure to provide ODJFS with a required submission or any
data/documentation requested by ODJFS will result in the assessment of a nonrefundable fine of $100
per day,
unless the MCP requests and is granted an extension by
ODJFS. Assessments for late submissions will be done
monthly. Examples of such program violations include, but are not
limited to:
·
Late
required
submissions
o
Annual
delegation
assessments
o
Call
center
report
o
Franchise
fee
documentation
o
Reinsurance
information (e.g., prior approval of
changes)
o
State
hearing
notifications
·Late
required data
submissions
o
Appeals
and grievances, case management,
or PCP
data
·Late
required information
requests
o
Automatic
call distribution
reports
o
Information/resolution
regarding
consumer or provider complaint
o
Just
cause or other coordination care
request from ODJFS
o
Provider
panel documentation
o
Failure
to provide ODJFS with a required submission after ODJFS has notified the
MCP
that the prescribed deadline for that submission has passed
If
an MCP
determines that they will
be
unable to meet a program deadline or data/documentation submission deadline,
the
MCP must submit a written request to its Contract Administrator
for an extension of
the
deadline, as soon as possible, but no later than 3 PM EST on the date of
the
deadline in question. Extension requests should only be submitted in situations
where unforeseeable circumstances have
occurred which make it impossible
for the MCP to
meet an ODJFS-stipulated deadline and all such requests will be evaluated
upon
this standard. Only
written approval as may
be granted by ODJFS of a deadline extension will preclude the assessment
of
compliance action for untimely submissions.
J.4.
Noncompliance with
Claims Adjudication Requirements - If ODJFS finds that an MCP is unable
to (1) electronically accept and adjudicate claims to final status and/or
(2)
notify providers of the status of their submitted claims, as stipulated in
Appendix C of the Agreement, ODJFS will assess the MCP with a monetary sanction
of $20,000 per day for the period of noncompliance.
If
ODJFS
has identified specific instances where an MCP has failed to take the necessary
steps to comply with the requirements specified in Appendix C of the Agreement
for (1) failing to notify non-contracting providers of procedures for claims
submissions when requested and/or (2) failing to notify contracting and
non-contracting providers of the status of their submitted claims, the MCP
will
be assessed 5 points per incident of noncompliance.
J.5.
Noncompliancewith
Prompt
Payment:- Noncompliance
with the prompt pay requirements as specified in Appendix J of the Agreement
will result in progressive penalties. The first violation during
a rolling 12-month
period
will result in the
submission of quarterly
prompt pay and monthly
status reports to ODJFS until the next quarterly report is due. The
second violation during
a
rolling 12-month period will result in the
submission of
monthly status reports and a refundable fine equal to 5% of the MCP’s
monthly premium payment or $300,000, whichever is less. The
refundable fine will be applied in lieu of a nonrefundable fine and the money
will be refunded by ODJFS
only
after the MCP complies with the required standards for two (2) consecutive
quarters. Subsequent violations
will
result in an enrollment freeze.
If
an MCP is found to have not been in
compliance with the prompt pay requirements for any time period for which
a
report and signed attestation have been submitted representing the MCP as
being
in compliance, the MCP will
be subject to an enrollment freeze of not less
than three (3) months
duration.
J.6.
Noncompliance with
Franchise Fee Assessment Requirements - In accordance with ORC Section
5111.176, and in addition to the imposition of any other penalty, occurrence
or
points under this Appendix, an MCP that does not pay the franchise permit
fee in
full by the due date is subject to any or all of the following:
·
A
monetary penalty in the amount of $500 for each day any part of the fee
remains
unpaid, except the penalty will
not exceed an amount equal to 5 % of the total fee that was due for the
calendar
quarter for which the penalty was imposed;
·
Withholdings
from future ODJFS
capitation payments. If an MCP fails to pay the full amount of its
franchise fee when due, or the full amount of the imposed penalty, ODJFS
may
withhold an amount equal to the remaining amount due from any future ODJFS
capitation payments. ODJFS will return all withheld capitation payments
when the
franchise fee amount has been paid in full;
·
Proposed
termination or non-renewal of
the MCP’s Medicaid provider agreement may occur if the
MCP:
a.Fails
to pay its franchise permit fee or
fails to pay the fee promptly;
b.Fails
to pay a penalty imposed under
this Appendix or fails to pay the penalty promptly;
c.Fails
to cooperate with an audit
conducted in accordance with ORC Section 5111.176.
J.7.
Noncompliance with
Clinical Laboratory Improvement Amendments - Noncompliance with CLIA
requirements as specified by ODJFS will result in the assessment of a
nonrefundable $1,000 fine for each violation.
J.8.
Noncompliance with
Abortion and Sterilization Payment - Noncompliance with abortion and
sterilization requirements as specified by ODJFS will result in the assessment
of a nonrefundable $2,000 fine for each documented
violation. Additionally, MCPs must take all appropriate action to
correct each ODJFS-documented violation.
J.9.
Refusal to
Comply
with Program Requirements - If ODJFS has instructed
an MCP that they
must comply with a specific program requirement and the MCP refuses, such
refusal constitutes documentation that the MCP is no longer operating in
the
best interests of the MCP’s members or the state of Ohio and ODJFS will move to
terminate or nonrenew the MCP’s provider agreement.
III.
Request
for Reconsiderations
MCPs
may request a reconsideration of
remedial action taken under the CAS for
penalties that include points,
fines, reductions in assignments and/or selection freezes. Requests
for reconsideration must be submitted on the ODJFS required form as
follows:
A.
MCPs notified of ODJFS’ imposition of
remedial action taken under the CAS will have ten
(10) working days from
the date of receipt
of the facsimile to request
reconsideration, although ODJFS will impose enrollment
freezes based on an access to care
concern concurrent with initiating notification to the
MCP. Any information
that the MCP would like reviewed as part of the reconsideration request must
be
submitted at the time of submission of the reconsideration request, unless
ODJFS
extends the time frame in writing.
B.
All requests for reconsideration must
be submitted by either facsimile transmission or overnight mail to the Chief,
Bureau of Managed Health Care, and received by ODJFS by the tenth business
day after receipt of the
faxed notification of the imposition of the remedial action by
ODJFS.
C.
The
MCP will be responsible for verifying timely receipt of all reconsideration
requests. All requests for reconsideration must explain in detail why
the specified remedial action
should not be imposed. The MCP’s justification for reconsideration
will be limited to a review of the written material submitted by the
MCP. The Bureau Chief will review all correspondence and materials
related to the violation in question in making the final reconsideration
decision.
D.
Final decisions or requests for
additional information will be made by ODJFS within ten (10) business days
of
receipt of the request for reconsideration.
E.
If additional information is
requested by ODJFS, a final reconsideration decision will be made within
three
(3) business days of the due date for the submission. Should ODJFS
require additional time in rendering the final reconsideration decision,
the MCP
will be notified of such in writing.
F.
If a reconsideration request is
decided, in whole or in part, in favor of the MCP, both the penalty and the
points associated
with the incident, will be
rescinded or reduced, in the sole discretion of ODJFS. The MCP may
still be required to submit a CAP if ODJFS, in its sole discretion, believes
that a CAP is still warranted under the circumstances.
APPENDIX
O
PAY-FOR-PERFORMANCE
(P4P)
ABD
ELIGIBLE
POPULATION
This
Appendix establishes a
Pay-for-performance (P4P)
incentive
system for
managed care plans (MCPs) to improve performance in specific areas important
to
the Medicaid MCP members. P4P
includes the at-risk amount included
with the monthly premium payments (see Appendix F, Rate
Chart), and possible
additional monetary rewards up to $250,000.
To
qualify for consideration of any
P4P,
MCPs must meet minimum performance
standards established in Appendix M, Performance
Evaluation on selected
measures, and achieve P4P
standards
established for
selected Clinical Performance Measures, as set forth herein
below. For qualifying MCPs, higher performance standards for three
measures must be reached to be awarded a portion of the at-risk amount and
any
additional P4P (see
Sections 1). An
excellent and superior standard is set in this Appendix for each of the three
measures. Qualifying MCPs will be awarded a portion of the at-risk
amount for each excellent standard met. If an MCP meets all three
excellent and superior standards, they may be awarded additional P4P (see
Section 2).
ODJFS
will use the first calendar year
of an MCP’s ABD managed care program membership as the baseline year (i.e.,
CY2007). The baseline year will be used to determine performance
standards and targets; baseline data may come from a combination of FFS claims
data and MCP encounter data. As many of the performance measures used
in the determination of P4P
require
two calendar years
of baseline data, the additional calendar year (i.e., the calendar year prior
to
the first calendar year of ABD managed care program membership, [i.e., CY2006])
data will come from FFS
claims.
An
MCP’s second calendar year of ABD
managed care program membership (i.e., CY2008) will be the initial report
period
of evaluation for performance measures that require one calendar year of
baseline data (i.e., CY2007), and for performance measures that require two
calendar years of baseline data (i.e., CY2006 and CY2007). CY2008
will be the initial report period upon which compliance with the performance
standards will be determined. SFY 2009
will become the first year an MCP’s
performance level for P4Pcan
be determined.
1.
SFY 2009 P4P
1.a.
Qualifying Performance
Levels
To
qualify for consideration of the SFY
2009 P4P, an MCP’s performance level must:
1)
Meet the minimum performance
standards set in Appendix M, Performance
Evaluation, for the
measures listed below; and
2) Meet
the P4P
standards established for the
Clinical Performance Measures below.
·
A
detailed description of the
methodologies for each measure can be found on the BMHC page of the ODJFS
website.
Measures
for which the minimum
performance standard for SFY 2009 established in Appendix M, Performance
Evaluation, must be met to
qualify for consideration of incentives are as follows:
1. PCP
Turnover (Appendix M,
Section 2.a.)
Report
Period: CY
2008
2. Adults’
Access
to
Preventive/Ambulatory Health Services (Appendix M, Section
2.c.)
Report
Period: CY
2008
For
each clinical performance measure
listed below, the MCP must meet the P4P standard
to be considered for SFY 2009
P4P. The
MCP meets the P4P
standard if one of two criteria is met. The P4P standard is a
performance level of either:
1)
The minimum performance standard
established in Appendix M, Performance
Evaluation, for five of
eight clinical performance measures listed below; or
2)
The Medicaid benchmarks for five of
eight clinical performance measures listed below. The Medicaid
benchmarks are subject to change based on the revision or update of applicable
national standards, methods or benchmarks.
|
Clinical
Performance Measure
|
Medicaid
Benchmark
|
|
|
CHF:
Inpatient HospitalDischarge
Rate
|
TBD
|
|
|
1.
CAD:
Beta-Blocker Treatment after
Heart Attack (AMI -related admission)
|
TBD
|
|
|
2.
CAD:
Cholesterol Management for
Patients with Cardiovascular Conditions/LDL-C screening
performed
|
TBD
|
|
|
3.
Hypertension:
Inpatient HospitalDischarge
Rate
|
TBD
|
|
|
4.
Diabetes:
Comprehensive Diabetes
Care (CDC)/Eye exam
|
TBD
|
|
|
5.
COPD:
Inpatient HospitalDischarge
Rate
|
TBD
|
|
|
6.
Asthma:
Use of Appropriate
Medications for People with Asthma
|
TBD
|
|
|
7.
Mental
Health: Follow-up After
Hospitalization for Mental Illness
|
TBD
|
|
1.b.
Excellent and Superior Performance
Levels
For
qualifying MCPs as determined by
Section 1.a.. herein, performance will be evaluated on the measures below
to
determine the status of the at-risk amount or any additional P4P
that may be awarded. Excellent and
Superior
standards
are set for the three measures
described below. The standards are subject to change based on the
revision or update of applicable national standards, methods or
benchmarks.
A
brief description of these measures is
provided in Appendix M, Performance
Evaluation. A
detailed description of the methodologies for each measure can be found on
the
BMHC page of the ODJFS website.
1.
Case Management of Members (Appendix
M, Section
1.b.i)
Report
Period: April – June
2009
Excellent
Standard: TBD
Superior
Standard: TBD
2.
Comprehensive
Diabetes Care (CDC)/Eye
exam (Appendix M, Section
1.c.xiv.)
Report
Period: CY
2008
Excellent
Standard:
TBD
Superior
Standard:
TBD
3.
Adults’ Access to
Preventive/Ambulatory Health Services (Appendix M, Section
2.c.)
Report
Period: CY
2008
Excellent
Standard:
TBD
Superior
Standard:
TBD
1.c.
Determining SFY 2009
P4P
MCPs
reaching
the minimum performance
standards described in Section 1.a. herein, will be considered for P4P including
retention of the at-risk amount and any additional P4P. For each
Excellent standard established in Section 1.b. herein, that an MCP
meets, one-third of the at-risk amount may be retained. For MCPs
meeting all of the Excellent and Superiorstandards
established in Section 1.b.
herein, additional P4P may be awarded. For MCPs receiving additional
P4P, the amount in the P4P fund
(see section 2.) will be divided
equally, up to the maximum
additional amount,
among all MCPs’ABD and/or CFC
programs receiving
additional P4P. The maximum additional amount to be awarded per plan,
per program, per contract year is $250,000. An MCP may receive up to
$500,000 should both of the MCP’s ABD and CFC programs achieve the Superior
Performance Levels.
2.
NOTES
2.a. Initiation
of the P4P
System
For
MCPs in their first twenty-four (24)
months of Ohio Medicaid ABD Managed Care Program participation, the status
of
the at-risk amount will not be determined because compliance with many of
the
standards in the ABD program cannot be determined in an MCP’s first two contract
years
(see Appendix F., Rate
Chart). In addition, MCPs
in their first two (2) contract years in the ABD program are not eligible
for
the additional P4P
amount
awarded for
superior
performance.
Starting
with the twenty-fifth
(25th)
month of participation in the ABD
program, the MCP’s at-risk amount will be included in
the P4P
system. The
determination of the status of this at-risk amount will occur after two (2)
calendar years of ABD membership. Because
of this requirement, the number
of months of at-risk dollars to be included in an MCP’s first at-risk status
determination may vary depending on when an MCP starts with the ABD program
relative to the calendar year.
2.b.
Determination of at-risk amounts
and additional P4P payments
For
MCPs that have participated in the
Ohio Medicaid ABD Managed Care Program long enough to calculate performance
levels for all of the performance measures included in the P4P system,
determination of the status of
an MCP’s at-risk amount will occur within six (6) months of the end of the
contract period. Determination of additional P4P payments
will be made at the same time
the status of an MCP’s at-risk amount is determined.
2.c.
Statewide P4P
system
All
MCPs will be included in a statewide
P4P system for the ABD program. The at-risk amount will be determined
using a statewide result for all regions in which an MCP serves ABD
membership.
2.d.
Contract Termination, Nonrenewals,
or Denials
Upon
termination, nonrenewal or denial of an MCP contract, the at-risk amount
paid to
the MCP under the current provider agreement will be returned to
ODJFS in accordance with Appendix P., Terminations/Nonrenewals/Amendments,
of the provider agreement.
Additionally,
in accordance with Article
XI of the provider agreement, the return of the at-risk amount paid to the
MCP
under the current provider agreement will be a condition necessary for ODJFS’
approval of a provider agreement assignment.
2.e.
Report Periods
The
report period used in determining
the MCP’s performance levels varies for each measure depending on the
frequency of the report and the data source. Unless otherwise noted,
the most recent report or study finalized prior to the end of the contract
period will be used in determining the MCP’s overall performance level for that
contract period.