Back to Form 8-K [form8k.htm]
Exhibit 10.1
Baseline
Covered Families and Children (CFC) Population

 
OHIO DEPARTMENT OF JOB AND FAMILY SERVICES

OHIO MEDICAL ASSISTANCE PROVIDER AGREEMENT
FOR MANAGED CARE PLAN
CFC ELIGIBLE POPULATION

This provider agreement is entered into this first day of July, 2008, at
Columbus, Franklin County, Ohio, between the State of Ohio, Department of Job
and Family Services, (hereinafter referred to as ODJFS) whose principal offices
are located in the City of Columbus, County of Franklin, State of Ohio, and
WellCare of Ohio, Inc, Managed Care Plan (hereinafter referred to as MCP), an
Ohio for-profit corporation, whose principal office is located in the city of
Independence, County of Cuyahoga, State of Ohio.

MCP is licensed as a Health Insuring Corporation by the State of Ohio,
Department of Insurance (hereinafter referred to as ODI), pursuant to Chapter
1751. of the Ohio Revised Code and is organized and agrees to operate as
prescribed by Chapter 5101:3-26 of the Ohio Administrative Code (hereinafter
referred to as OAC), and other applicable portions of the OAC as amended from
time to time.

MCP is an entity eligible to enter into a provider agreement in accordance with
42 CFR 438.6 and is engaged in the business of providing prepaid comprehensive
health care services as defined in 42 CFR 438.2 through the managed care program
for the Covered Families and Children (CFC) eligible population described in OAC
rule 5101:3-26-02 (B).

ODJFS, as the single state agency designated to administer the Medicaid program
under Section 5111.02 of the Ohio Revised Code and Title XIX of the Social
Security Act, desires to obtain MCP services for the benefit of certain Medicaid
recipients.  In so doing, MCP has provided and will continue to provide proof of
MCP's capability to provide quality services, efficiently, effectively and
economically during the term of this agreement.
 
1

--------------------------------------------------------------------------------

Baseline
Covered Families and Children (CFC) Population
    
                This provider agreement is a contract between ODJFS and the
undersigned Managed Care Plan (MCP), provider of medical assistance, pursuant to
the federal contracting provisions of 42 CFR 434.6 and 438.6 in which the MCP
agrees to provide comprehensive medical services through the managed care
program as provided in Chapter 5101:3-26 of the Ohio Administrative Code,
assuming the risk of loss, and complying with applicable state statutes, Ohio
Administrative Code, and Federal statutes,  rules, regulations and other
requirements, including but not limited to title VI of the Civil Rights Act of
1964; title IX of the Education Amendments of 1972 (regarding education programs
and activities); the Age Discrimination Act of 1975; the Rehabilitation Act of
1973; and the Americans with Disabilities Act.
 
ARTICLE I  -  GENERAL

A.
ODJFS enters into this Agreement in reliance upon MCP’s representations that it
has the necessary expertise and experience to perform its obligations hereunder,
and MCP warrants that it does possess the necessary expertise and experience.

B.
MCP agrees to report to the Chief of Bureau of Managed Health Care (hereinafter
referred to as BMHC) or his or her designee as necessary to assure understanding
of the responsibilities and satisfactory compliance with this provider
agreement.

C.
MCP agrees to furnish its support staff and services as necessary for the
satisfactory performance of the services as enumerated in this provider
agreement.

D.
ODJFS may, from time to time as it deems appropriate, communicate specific
instructions and requests to MCP concerning the performance of the services
described in this provider agreement.  Upon such notice and within the
designated time frame after receipt of instructions, MCP shall comply with such
instructions and fulfill such requests to the satisfaction of the
department.  It is expressly understood by the parties that these instructions
and requests are for the sole purpose of performing the specific tasks requested
to ensure satisfactory completion of the services described in this provider
agreement, and are not intended to amend or alter this provider agreement or any
part thereof.

 
E.
If the MCP previously had a provider agreement with the ODJFS and the provider
agreement terminated more than two years prior to the effective date of any new
provider agreement, such MCP will be considered a new plan in its first year of
operation with the Ohio Medicaid managed care program.

 
ARTICLE II  -  TIME OF PERFORMANCE

A.
Upon approval by the Director of ODJFS this provider agreement shall be in
effect from the date entered through June 30, 2009, unless this provider
agreement is suspended or terminated pursuant to Article VIII prior to the
termination date, or otherwise amended pursuant to Article IX.

B.
It is expressly agreed by the parties that none of the rights, duties and
obligations herein shall be binding on either party if award of this Agreement
would be contrary to the terms of Ohio Revised Code (“O.R.C.”) Section 3517.13,
O.R.C. Section 127.16, or O.R.C. Chapter 102.

 
2

--------------------------------------------------------------------------------

Baseline
Covered Families and Children (CFC) Population
 
ARTICLE III  -  REIMBURSEMENT

A.
ODJFS will reimburse MCP in accordance with rule 5101:3-26-09 of the Ohio
Administrative Code and the appropriate appendices of this provider agreement.

ARTICLE IV  -  RELATIONSHIP OF PARTIES

A.
ODJFS and MCP agree that, during the term of this Agreement, MCP shall be
engaged by ODJFS solely on an independent contractor basis, and neither MCP nor
its personnel shall, at any time or for any purpose, be considered as agents,
servants or employees of ODJFS or the State of Ohio. MCP shall therefore be
responsible for all MCP’s business expenses, including, but not limited to,
employee’s wages and salaries, insurance of every type and description, and all
business and personal taxes, including income and Social Security taxes and
contributions for Workers’ Compensation and Unemployment Compensation coverage,
if any.

B.
MCP agrees to comply with all applicable federal, state and local laws in the
conduct of the work hereunder.

C.
While MCP shall be required to render services described hereunder for ODJFS
during the term of this Agreement, nothing herein shall be construed to imply,
by reason of MCP’s engagement hereunder on an independent contractor basis, that
ODJFS shall have or may exercise any right of control over MCP with regard to
the manner or method of MCP’s performance of services hereunder. The management
of the work, including the exclusive right to control or direct the manner or
means by which the work is performed, remains with MCP.  ODJFS retains the right
to ensure that MCP's work is in conformity with the terms and conditions of this
Agreement.

 
D.
Except as expressly provided herein, neither party shall have the right to bind
or obligate the other party in any manner without the  other party’s prior
written consent.

 
ARTICLE V  -  CONFLICT OF INTEREST; ETHICS LAWS

A.
In accordance with the safeguards specified in section 27 of the Office of
Federal Procurement Policy Act (41 U.S.C. 423) and other applicable federal
requirements, no officer, member or employee of MCP, the Chief of BMHC, or other
ODJFS employee who exercises any functions or responsibilities in connection
with the review or approval of this provider agreement or provision of services
under this provider agreement shall, prior to the completion of such services or
reimbursement, acquire any interest, personal or otherwise, direct or indirect,
which is incompatible or in conflict with, or would compromise in any manner or
degree the discharge and fulfillment of his or her functions and
responsibilities with respect to the carrying out of such services.  For
purposes of this article, "members" does not include individuals whose sole
connection with MCP is the receipt of services through a health care program
offered by MCP.

 
3

--------------------------------------------------------------------------------

Baseline
Covered Families and Children (CFC) Population
 
B.
MCP represents, warrants, and certifies that it and its employees engaged in the
administration or performance of this Agreement are knowledgeable of and
understand the Ohio Ethics and Conflicts of Interest laws and Executive Order
2007-01S.  MCP further represents, warrants, and certifies that neither MCP nor
any of its employees will do any act that is inconsistent with such laws and
Executive Order.  The Governor’s Executive Orders may be found by accessing the
following
website:  http://governor.ohio.gov/GovernorsOffice/ExecutiveOrdersDirectives/tabid/105/Default.aspx.

 
C.
MCP hereby covenants that MCP, its officers, members and employees of the MCP,
shall not, prior to the completion of the work under this Agreement, voluntarily
acquire any interest, personal or otherwise, direct or indirect, which is
incompatible or in conflict with or would compromise in any manner of
degree  the discharge and fulfillment of his or her functions and
responsibilities under this provider agreement.  MCP shall periodically inquire
of its officers, members and employees concerning such interests.

D.
Any such person who acquires an incompatible, compromising or conflicting
personal or business interest, on or after the effective date of this Agreement,
or who involuntarily acquires any such incompatible or conflicting personal
interest, shall immediately disclose his or her interest to ODJFS in
writing.  Thereafter, he or she shall not participate in any action affecting
the services under this provider agreement, unless ODJFS shall determine in its
sole discretion that, in the light of the personal interest disclosed, his or
her participation in any such action would not be contrary to the public
interest.  The written disclosure of such interest shall be made to:  Chief,
Bureau of Managed Health Care, ODJFS.

 
E.
No officer, member or employee of MCP shall promise or give to any ODJFS
employee anything of value that is of such a character as to manifest a
substantial and improper influence upon the employee with respect to his or her
duties.  No officer, member or employee of MCP shall solicit an ODJFS employee
to violate any ODJFS rule or policy relating to the conduct of the parties to
this agreement or to violate sections 102.03, 102.04, 2921.42 or 2921.43 of the
Ohio Revised Code.

F.
MCP hereby covenants that MCP, its officers, members and employees are in
compliance with section 102.04 of the Revised Code and that if MCP is required
to file a statement pursuant to 102.04(D)(2) of the Revised Code, such statement
has been filed with the ODJFS in addition to any other required filings.

 
ARTICLE VI  -  NONDISCRIMINATION OF EMPLOYMENT

A.
MCP agrees that in the performance of this provider agreement or in the hiring
of any employees for the performance of services under this provider agreement,
MCP shall not by reason of race, color, religion, gender, sexual orientation,
age, disability, national origin, veteran's status, health status, or ancestry,
discriminate against any citizen of this state in the employment of a person
qualified and available to perform the services to which the provider agreement
relates.

 
4

--------------------------------------------------------------------------------

Baseline
Covered Families and Children (CFC) Population
 
B.
MCP agrees that it shall not, in any manner, discriminate against, intimidate,
or retaliate against any employee hired for the performance or services under
the provider agreement on account of race, color, religion, gender, sexual
orientation, age, disability, national origin, veteran's status, health status,
or ancestry.

C.
In addition to requirements imposed upon subcontractors in accordance with OAC
Chapter 5101:3-26, MCP agrees to hold all subcontractors and persons acting on
behalf of MCP in the performance of services under this provider agreement
responsible for adhering to the requirements of paragraphs (A) and (B) above and
shall include the requirements of paragraphs (A) and (B) above in all
subcontracts for services performed under this provider agreement, in accordance
with rule 5101:3-26-05 of the Ohio Administrative Code.

 
ARTICLE VII  -  RECORDS, DOCUMENTS AND INFORMATION

A.
MCP agrees that all records, documents, writings or other information produced
by MCP under this provider agreement and all records, documents, writings or
other information used by MCP in the performance of this provider agreement
shall be treated in accordance with rule 5101:3-26-06 of the Ohio Administrative
Code.  MCP must maintain an appropriate record system for services provided to
members. MCP must retain all records in accordance with 45 CFR Part 74.

B.
All information provided by MCP to ODJFS that is proprietary shall be held to be
strictly confidential by ODJFS.  Proprietary information is information which,
if made public, would put MCP at a disadvantage in the market place and trade of
which MCP is a part [see Ohio Revised Code Section 1333.61(D)].  MCP is
responsible for notifying ODJFS of the nature of the information prior to its
release to ODJFS.  Failure to provide such prior notification is deemed to be a
waiver of the proprietary nature of the information, and a waiver of any right
of MCP to proceed against ODJFS for violation of this agreement or of any
proprietary or trade secret laws.  Such failure shall also be deemed a waiver of
trade secret protection in that the MCP will have failed to make efforts that
are reasonable under the circumstances to maintain the information’s secrecy.
ODJFS reserves the right to require reasonable evidence of MCP's assertion of
the proprietary nature of any information to be provided and ODJFS will make the
final determination of whether any or all of the information identified by the
MCP is proprietary or a trade secret.  The provisions of this Article are not
self-executing.

C.
MCP shall not use any information, systems, or records made available to it for
any purpose other than to fulfill the duties specified in this provider
agreement.  MCP agrees to be bound by the same standards of confidentiality that
apply to the employees of the ODJFS and the State of Ohio.  The terms of this
section shall be included in any subcontracts executed by MCP for services under
this provider agreement.  MCP must implement procedures to ensure that in the
process of coordinating care, each enrollee's privacy is protected consistent
with the confidentiality requirements in 45 CFR parts 160 and 164.

 
5

--------------------------------------------------------------------------------

Baseline
Covered Families and Children (CFC) Population
 
ARTICLE VIII  -  SUSPENSION AND TERMINATION

A.
This provider agreement may be suspended or terminated by the department or MCP
upon written notice in accordance with the applicable rule(s) of the Ohio
Administrative Code, with termination to occur at the end of the last day of a
month.

B.
MCP, upon receipt of notice of suspension or termination, shall cease provision
of services on the suspended or terminated activities under this provider
agreement; suspend, or terminate all subcontracts relating to such suspended or
terminated activities, take all necessary or appropriate steps to limit
disbursements and minimize costs, and furnish a report, as of the date of
receipt of notice of suspension or termination describing the status of all
services under this provider agreement.

C.
In the event of suspension or termination under this Article, MCP shall be
entitled to reconciliation of reimbursements through the end of the month for
which services were provided under this provider agreement, in accordance with
the reimbursement provisions of this provider agreement.  MCP agrees to waive
any right to, and shall make no claim for, additional compensation against ODJFS
by reason of such suspension or termination.

D.
ODJFS may, in its judgment, suspend, terminate or fail to renew this provider
agreement if the MCP or MCP's subcontractors violate or fail to comply with the
provisions of this agreement or other provisions of law or regulation governing
the Medicaid program.  Where ODJFS proposes to suspend, terminate or refuse to
enter into a provider agreement, the provisions of applicable sections of the
Ohio Administrative Code with respect to ODJFS' suspension, termination or
refusal to enter into a provider agreement shall apply, including the MCP's
right to request an adjudication hearing under Chapter 119. of the Revised Code.

E.
When initiated by MCP, termination of or failure to renew the provider agreement
requires written notice to be received by ODJFS at least 120 days in advance of
the termination or renewal date, provided, however, that termination or
non-renewal must be effective at the end of the last day of a calendar
month.  In the event of non-renewal of the provider agreement with ODJFS, if MCP
is unable to provide notice to ODJFS 120 days prior to the date when the
provider agreement expires, and if, as a result of said lack of notice, ODJFS is
unable to disenroll Medicaid enrollees prior to the expiration date, then the
provider agreement shall be deemed extended for up to four calendar months
beyond the expiration date and both parties shall, for that time, continue to
fulfill their duties and obligations as set forth herein. If an MCP wishes to
terminate or not renew their provider agreement for a specific region(s), ODJFS
reserves the right to initiate a procurement process to select additional MCPs
to serve Medicaid consumers in that region(s). ODJFS, at its discretion, may use
an MCP’s termination or non-renewal of this provider agreement as a factor in
any future procurement process.

 
6

--------------------------------------------------------------------------------

Baseline
Covered Families and Children (CFC) Population
 
ARTICLE IX  -  AMENDMENT AND RENEWAL

A.
This writing constitutes the entire agreement between the parties with respect
to all matters herein.  This provider agreement may be amended only by a writing
signed by both parties.  Any written amendments to this provider agreement shall
be prospective in nature.

B.
This provider agreement may be renewed one or more times by a writing signed by
both parties for a period of not more than twelve months for each renewal.

C.
In the event that changes in State or Federal law, regulations, an applicable
waiver or state plan amendment, or the terms and conditions of any applicable
federal waiver or state plan amendment, require ODJFS to modify this agreement,
ODJFS shall notify MCP regarding such changes and this agreement shall be
automatically amended to conform to such changes without the necessity for
executing written amendments pursuant to this Article of this provider
agreement.

D.
This Agreement supersedes any and all previous agreements, whether written or
oral, between the parties.

E.
A waiver by any party of any breach or default by the other party under this
Agreement shall not constitute a continuing waiver by such party of any
subsequent act in breach of or in default hereunder.

 
ARTICLE X  -  LIMITATION OF LIABILITY

A.
MCP agrees to indemnify and to hold ODJFS and the State of Ohio harmless and
immune from any and all claims for injury or damages resulting from the actions
or omissions of MCP or its subcontractors in the fulfillment of this provider
agreement or arising from this Agreement which are attributable to the MCP’s own
actions or omissions of those of its trustees, officers, employees,
subcontractors, suppliers, third parties utilized by MCP, or joint venturers
while acting under this Agreement.  Such claims shall include any claims made
under the Fair Labor Standards Act or under any other federal or state law
involving wages, overtime, or employment matters and any claims involving
patents, copyrights, and trademarks.  MCP shall bear all costs associated with
defending ODJFS and the State of Ohio against these claims.

B.
MCP hereby agrees to be liable for any loss of federal funds suffered by ODJFS
for enrollees resulting from specific, negligent acts or omissions of the MCP or
its subcontractors during the term of this agreement, including but not limited
to the nonperformance of the duties and obligations to which MCP has agreed
under this agreement.

 
7

--------------------------------------------------------------------------------

Baseline
Covered Families and Children (CFC) Population
 
C.
In the event that, due to circumstances not reasonably within the control of MCP
or ODJFS, a major disaster, epidemic, complete or substantial destruction of
facilities, war, riot or civil insurrection occurs, neither ODJFS nor MCP will
have any liability or obligation on account of reasonable delay in the provision
or the arrangement of covered services; provided that so long as MCP's
certificate of authority remains in full force and effect, MCP shall be liable
for the covered services required to be provided or arranged for in accordance
with this agreement.

 
D.
In no event shall either party be liable to the other party for indirect,
consequential, incidental, special or punitive damages, or lost profits.

 
ARTICLE XI - ASSIGNMENT

A.
ODJFS will not allow the transfer of Medicaid members by one MCP to another MCP
unless this membership has been obtained as a result of an MCP selling their
entire Ohio corporation to another health plan. MCP shall not assign any
interest in this provider agreement and shall not transfer any interest in the
same (whether by assignment or novation) without the prior written approval of
ODJFS and subject to such conditions and provisions as ODJFS may deem
necessary.  Any such assignments shall be submitted for ODJFS’ review 120 days
prior to the desired effective date.  No such approval by ODJFS of any
assignment shall be deemed in any event or in any manner to provide for the
incurrence of any obligation by ODJFS in addition to the total agreed-upon
reimbursement in accordance with this agreement.

B.
MCP shall not assign any interest in subcontracts of this provider agreement and
shall not transfer any interest in the same (whether by assignment or novation)
without the prior written approval of ODJFS and subject to such conditions and
provisions as ODJFS may deem necessary.  Any such assignments of subcontracts
shall be submitted for ODJFS’ review 30 days prior to the desired effective
date.  No such approval by ODJFS of any assignment shall be deemed in any event
or in any manner to provide for the incurrence of any obligation by ODJFS in
addition to the total agreed-upon reimbursement in accordance with this
agreement.

 
ARTICLE XII  -  CERTIFICATION MADE BY MCP

A.
This agreement is conditioned upon the full disclosure by MCP to ODJFS of all
information required for compliance with federal regulations as requested by
ODJFS.

B.
By executing this agreement, MCP certifies that no federal funds paid to MCP
through this or any other agreement with ODJFS shall be or have been used to
lobby Congress or any federal agency in connection with a particular contract,
grant, cooperative agreement or loan.  MCP further certifies compliance with the
lobbying restrictions contained in Section 1352, Title 31 of the U.S. Code,
Section 319 of Public Law 101-121 and federal regulations issued pursuant
thereto and contained in 45 CFR Part 93, Federal Register, Vol. 55, No. 38,
February 26, 1990, pages 6735-6756.  If this provider agreement exceeds
$100,000, MCP has executed the Disclosure of Lobbying Activities, Standard Form
LLL, if required by federal regulations.  This certification is material
representation of fact upon which reliance was placed when this provider
agreement was entered into.

 
8

--------------------------------------------------------------------------------

Baseline
Covered Families and Children (CFC) Population
 
C.
By executing this agreement, MCP certifies that neither MCP nor any principals
of MCP (i.e., a director, officer, partner, or person with beneficial ownership
of more than 5% of the MCP’s equity) is presently debarred, suspended, proposed
for debarment, declared ineligible, or otherwise  excluded from participation in
transactions by any Federal  agency.  The MCP also certifies that it is not
debarred from consideration for contract awards by the Director of the
Department of Administrative Services, pursuant to either O.R.C. Section 153.02
or O.R.C. Section 125.25.  The MCP also certifies that the MCP has no
employment, consulting or any other arrangement with any such debarred or
suspended person for the provision of items or services or services that are
significant and material to the MCP’s contractual obligation with ODJFS.  This
certification is a material representation of fact upon which reliance was
placed when this provider agreement was entered into. If it is ever determined
that MCP knowingly executed this certification erroneously, then in addition to
any other remedies, this provider agreement shall be terminated pursuant to
Article VII, and ODJFS must advise the Secretary of the appropriate Federal
agency of the knowingly erroneous certification.

 
D.
By executing this agreement, MCP certifies compliance with Article V as well as
agreeing to future compliance with Article V.  This certification is a material
representation of fact upon which reliance was placed when this contract was
entered into.

 
E.
By executing this agreement, MCP certifies compliance with the executive agency
lobbying requirements of sections 121.60 to 121.69 of the Ohio Revised Code.
This certification is a material representation of fact upon which reliance was
placed when this provider agreement was entered into.

F.
By executing this agreement, MCP certifies that MCP is not on the most recent
list established by the Secretary of State, pursuant to section 121.23 of the
Ohio Revised Code, which identifies MCP as having more than one unfair labor
practice contempt of court finding.  This certification is a material
representation of fact upon which reliance was placed when this provider
agreement was entered into.

 
G.
By executing this agreement MCP agrees not to discriminate against individuals
who have or are participating in any work program administered by a county
Department of Job and Family Services under Chapters 5101 or 5107 of the Revised
Code.

H.
By executing this agreement, MCP certifies and affirms that, as applicable to
MCP, that no party listed or described in Division (I) or (J) of Section 3517.13
of the Ohio Revised Code who was actually in a listed position at the time of
the contribution, has made as an individual, within the two previous calendar
years, one or more contributions in excess of One Thousand and 00/100
($1,000.00) to the present Governor or to the governor’s campaign committees
during any time he/she was a candidate for office.  This certification is a
material representation of fact upon which reliance was placed when this
provider agreement was entered into.  If it is ever determined that MCP's
certification of this requirement is false or misleading, and not withstanding
any criminal or civil liabilities imposed by law, MCP shall return to ODJFS all
monies paid to MCP under this provider agreement.  The provisions of this
section shall survive the expiration or termination of this provider agreement.

 
9

--------------------------------------------------------------------------------

Baseline
Covered Families and Children (CFC) Population
 
I.
MCP agrees to refrain from promising or giving to any ODJFS employee anything of
value that is of such a character as to manifest a substantial and improper
influence upon the employee with respect to his or her duties.  MCP also agrees
that it will not solicit an ODJFS employee to violate any ODJFS rule or policy
relating to the conduct of contracting parties or to violate sections 102.03,
102.04, 2921.42 or 2921.43 of the Ohio Revised Code.

J.
By executing this agreement, MCP certifies and affirms that HHS, US Comptroller
General or representatives will have access to books, documents, etc. of MCP.

K.
By executing this agreement, MCP agrees to comply with the false claims recovery
requirements of Section 6032 of The Deficit Reduction Act of 2005 (also see
Section 5111.101 of the Revised Code).

 
L.
MCP, its officers, employees, members, any subcontractors, and/or any
independent contractors (including all field staff) associated with this
agreement agree to comply with all applicable state and federal laws regarding a
smoke-free and drug-free workplace.  The MCP will make a good faith effort to
ensure that all MCP officers, employees, members, and subcontractors will not
purchase, transfer, use or possess illegal drugs or alcohol, or abuse
prescription drugs in any way while performing their duties under this
Agreement.

M.
MCP hereby represents and warrants to ODJFS that it has not provided any
material assistance, as that term is defined in O.R.C. Section 2909.33(C), to
any organization identified by and included on the United States Department of
State Terrorist Exclusion List and that it has truthfully answered “no” to every
question on the “Declaration Regarding Material Assistance/Non-assistance to a
Terrorist Organization.”  MCP further represents and warrants that it has
provided or will provide such to ODJFS prior to execution of this Agreement.  If
these representations and warranties are found to be false, this Agreement is
void ab initio and MCP shall immediately repay to ODJFS any funds paid under
this Agreement.

 
ARTICLE XIII - CONSTRUCTION

A.
This provider agreement shall be governed, construed and enforced in accordance
with the laws and regulations of the State of Ohio and appropriate federal
statutes and regulations.  The provisions of this Agreement are severable and
independent, and if any such provision shall be determined to be unenforceable,
in whole or in part, the remaining provisions and any partially enforceable
provision shall, to the extent enforceable in any jurisdiction, nevertheless be
binding and enforceable.

 
10

--------------------------------------------------------------------------------

Baseline
Covered Families and Children (CFC) Population
 
ARTICLE XIV - INCORPORATION BY REFERENCE

A.
Ohio Administrative Code Chapter 5101:3-26 (Appendix A) is hereby incorporated
by reference as part of this provider agreement having the full force and effect
as if specifically restated herein.

 
B.
Appendices B through P and any additional appendices are hereby incorporated by
reference as part of this provider agreement having the full force and effect as
if specifically restated herein.

C.
In the event of inconsistence or ambiguity between the provisions of OAC Chapter
5101:3-26 and this provider agreement, the provisions of OAC Chapter 5101:3-26
shall be determinative of the obligations of the parties unless such
inconsistency or ambiguity is the result of changes in federal or state law, as
provided in Article IX of this provider agreement, in which case such federal or
state law shall be determinative of the obligations of the parties.  In the
event OAC 5101:3-26 is silent with respect to any ambiguity or inconsistency,
the provider agreement (including Appendices B through P and any additional
appendices), shall be determinative of the obligations of the parties.  In the
event that a dispute arises which is not addressed in any of the aforementioned
documents, the parties agree to make every reasonable effort to resolve the
dispute, in keeping with the objectives of the provider agreement and the
budgetary and statutory constraints of ODJFS.

ARTICLE XV – NOTICES

All notices, consents, and communications hereunder shall be given in writing,
shall be deemed to be given upon receipt thereof, and shall be sent to the
addresses first set forth above.

ARTICLE XVI – HEADINGS

The headings in this Agreement have been inserted for convenient reference only
and shall not be considered in any questions of interpretation or construction
of this Agreement.
 
 
11

--------------------------------------------------------------------------------

Baseline
Covered Families and Children (CFC) Population

The parties have executed this agreement the date first written above.  The
agreement is hereby accepted and considered binding in accordance with the terms
and conditions set forth in the preceding statements.

WELLCARE OF OHIO, INC.:

BY:  /s/ Heath
Schiesser                                                                  
DATE: 6/23/08
        HEATH SCHIESSER, CHIEF EXECUTIVE OFFICER AND PRESIDENT
        
 

OHIO DEPARTMENT OF JOB AND FAMILY SERVICES:

BY:  /s/ Helen Jones-Kelly
DATE: 6/30/08
        HELEN E. JONES-KELLY, DIRECTOR
 

 
12

--------------------------------------------------------------------------------

 

CFC PROVIDER AGREEMENT INDEX
 July 1, 2008

    APPENDIX                                                        TITLE

    APPENDIX A                                                    OAC RULES
5101:3-26

    APPENDIX B
SERVICE AREA SPECIFICATIONS – CFC ELIGIBLE POPULATION

    APPENDIX C                                                     MCP
RESPONSIBILITIES – CFC ELIGIBLE POPULATION
 
    APPENDIX D
ODJFS RESPONSIBILITIES – CFC ELIGIBLE  POPULATION

    APPENDIX E                                                     RATE
METHODOLOGY – CFC ELIGIBLE POPULATION

    APPENDIX F                                                     REGIONAL
RATES – CFC ELIGIBLE  POPULATION

    APPENDIX G
COVERAGE AND SERVICES – CFC ELIGIBLE POPULATION

    APPENDIX H
PROVIDER PANEL SPECIFICATIONS – CFC ELIGIBLE POPULATION

    APPENDIX I                                                      PROGRAM
INTEGRITY– CFC ELIGIBLE POPULATION

    APPENDIX J
FINANCIAL PERFORMANCE – CFC ELIGIBLE POPULATION

    APPENDIX K
QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM – CFC ELIGIBLE POPULATION

    APPENDIX L                                                     DATA QUALITY
– CFC ELIGIBLE POPULATION

    APPENDIX M
PERFORMANCE EVALUATION – CFC ELIGIBLE POPULATION

    APPENDIX N
COMPLIANCE ASSESSMENT SYSTEM – CFC ELIGIBLE POPULATION

    APPENDIX O
PAY-FOR-PERFORMANCE (P4P) – CFC ELIGIBLE POPULATION

 
    APPENDIX P
MCP TERMINATIONS/NONRENEWALS/AMENDMENTS – CFC ELIGIBLE POPULATION

 
 

--------------------------------------------------------------------------------

Appendix A
Covered Families and Children (CFC) Population 

APPENDIX A

OAC RULES 5101:3-26

The managed care program rules can be accessed electronically through the BMHC
page of the ODJFS website.
 
 
1

--------------------------------------------------------------------------------

Appendix B
Covered Families and Children (CFC) Population 

APPENDIX B

SERVICE AREA SPECIFICATIONS
CFC ELIGIBLE POPULATION

MCP : WELLCARE OF OHIO, INC.

The MCP agrees to provide services to Covered Families and Children (CFC)
members  residing in the following service area(s):

Service Area: Northeast Region – Ashtabula, Cuyahoga, Erie, Geauga, Huron, Lake,
Lorain, and Medina counties.
 
 
1

--------------------------------------------------------------------------------

Appendix C
Covered Families and Children (CFC) population
 
APPENDIX C

MCP RESPONSIBILITIES
CFC 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).

As long as the MCP serves both the CFC and ABD populations, they are not
required to have separate provider relations representatives or Medicaid
coordinators.

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.
 
1

--------------------------------------------------------------------------------

Appendix C
Covered Families and Children (CFC) population
 
7.
Upon request by ODJFS, the MCP must submit information on the current status of
their company’s operations not specifically covered under this provider
agreement (for example, other product lines, Medicaid contracts in other states,
NCQA accreditation, etc.) 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 500 or more of the MCP’s CFC
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.

 
2

--------------------------------------------------------------------------------

Appendix C
Covered Families and Children (CFC) population
 
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.  Additional benefits must be made available to members
for at least six (6) calendar months from date approved by ODJFS.

 
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.

 
3

--------------------------------------------------------------------------------

Appendix C
Covered Families and Children (CFC) population
 
All MCPs must comply with the requirements specified in OAC rules
5101:3-26-03.1, 5101:3-26-05(D), 5101:3-26-05.1(A), 5101:3-26-08 and
5101:3-26-08.2 for providing assistance to LEP members and eligible
individuals.  In addition, MCPs must provide written translations of certain MCP
materials in the prevalent non-English languages of members and eligible
individuals in accordance with the following:

 
a.
When 10% or more of the CFC eligible individuals in the MCP’s service area have
a common primary language other than English, the MCP must translate all
ODJFS-approved marketing materials into the primary language of that group.  The
MCP must monitor changes in the eligible population on an ongoing basis and
conduct an assessment no less often than annually to determine which, if any,
primary language groups meet the 10% threshold for the eligible individuals in
each service area.  When the 10% threshold is met, the MCP must report this
information to ODJFS, in a format as requested by ODJFS, translate their
marketing materials, and make these marketing materials available to eligible
individuals.  MCPs must submit to ODJFS, upon request, their prevalent
non-English language analysis of eligible individuals and the results of this
analysis.

 
b.
When 10% or more of an MCP's CFC members in the MCP’s service area have a common
primary language other than English, the MCP must translate all ODJFS-approved
member materials into the primary language of that group. The MCP must monitor
their membership and conduct a quarterly assessment to determine which, if any,
primary language groups meet the 10% threshold.  When the 10% threshold is met,
the MCP must report this information to ODJFS, in a format as requested by
ODJFS, translate their member materials, and make these materials available to
their members.  MCPs must submit to ODJFS, upon request, their prevalent
non-English language member analysis and the results of this analysis.

 
20.
The MCP must utilize a centralized database which records the special
communication needs of all MCP members (i.e., those with limited English
proficiency, limited reading proficiency, visual impairment, and hearing
impairment) and the provision of related services (i.e., MCP materials in
alternate format, oral interpretation, oral translation services, written
translations of MCP materials, and sign language services).  This database must
include all MCP member primary language information (PLI) as well as all other
special communication needs information for MCP members, as indicated
above, when identified by any source including but not limited to ODJFS, ODJFS
selection services entity, MCP staff, providers, and members.  This centralized
database must be readily available to MCP staff and be used in coordinating
communication and services to members, including the selection of a PCP who
speaks the primary language of an LEP member, when such  a provider is
available.  MCPs must share specific communication needs information with their
provider [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 member 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). 

 
4

--------------------------------------------------------------------------------

Appendix C
Covered Families and Children (CFC) population
 
 
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 prohibited from 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.

 
5

--------------------------------------------------------------------------------

Appendix C
Covered Families and Children (CFC) population
 
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.

 
6

--------------------------------------------------------------------------------

Appendix C
Covered Families and Children (CFC) population
 
24.           New Member Materials
 
Pursuant to OAC rule 5101:3-26-08.2 (B)(3), MCPs must provide to each member or
assistance group, as applicable, an MCP identification (ID) card, a new member
letter, a member handbook, a provider directory, and information on advance
directives.

 
a.
MCPs must use the model language specified by 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, the member
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 Center Standards
 
The MCP must provide assistance to members through a member services toll-free
call-in system pursuant to OAC rule 5101:3-26-08.2(A)(1).  MCP member services
staff must be available nationwide to provide assistance to members through the
toll-free call-in system every Monday through Friday, at all times during the
hours of 7:00 am to 7:00 pm Eastern Time, except for the following major
holidays:
·  
New Year’s Day

·  
Martin Luther King’s 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.

   
7

--------------------------------------------------------------------------------

Appendix C
Covered Families and Children (CFC) population
 
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 (24/7) toll-free call-in system,
available nationwide, pursuant to OAC rule 5101:3-26-03.1(A)(6). The 24/7
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 24/7 toll-free call-in systems to ODJFS.  ODJFS
will inform the MCPs of any changes/updates to these URAC call center standards.
 
MCPs are not permitted to delegate grievance/appeal functions [Ohio
Administrative Code (OAC) rule 5101:3-26-08.4(A)(9)].  Therefore, the member
services call center requirement may not be met through the execution of a
Medicaid Delegation Subcontract Addendum or Medicaid Combined Services
Subcontract Addendum.
 
26.           Notification of Optional MCP Membership

In order to comply with the terms of the ODJFS State Plan Amendment for the
managed care program (i.e.,  42 CFR 438.50), MCPs in mandatory
membership  service areas must inform new members that MCP membership is
optional for certain populations.  Specifically, MCPs must inform any applicable
pending member or member that the following CFC populations are not required to
select an MCP in order to receive their Medicaid healthcare benefit and what
steps they need to take if they do not wish to be a member of an MCP:
-  
Indians who are members of federally-recognized tribes.

-  
Children under 19 years of age who are:

o  
Eligible for Supplemental Security Income under title XVI;

o  
In foster care or other out-of-home placement;

o  
Receiving foster care of adoption assistance;

o  
Receiving services through the Ohio Department of Health’s Bureau for Children
with Medical Handicaps (BCMH) or any other family-centered, community-based,
coordinated care system that receives grant funds under section 501(a)(1)(D) of
title V, and is defined by the State in terms of either program participation or
special health care needs.

 
8

--------------------------------------------------------------------------------

Appendix C
Covered Families and Children (CFC) population
 
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.

 
9

--------------------------------------------------------------------------------

Appendix C
Covered Families and Children (CFC) population
 
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 and delivery payments as
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.  Monthly reconciliation data must be submitted
in the format specified by ODJFS.

 
c.
Monthly Premiums and Delivery Payments: The MCP must be able to receive monthly
premiums and delivery payments in a method specified by ODJFS.  (ODJFS monthly
prospective premium and delivery payment issue dates are provided in advance to
the MCPs.) Various retroactive premium payments (e.g., newborns), and recovery
of premiums paid (e.g., retroactive terminations of membership for children in
custody, deferments, etc.,) may occur via any ODJFS weekly remittance.

 
d.
Hospital/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.

 
10

--------------------------------------------------------------------------------

Appendix C
Covered Families and Children (CFC) population
 
 
e.
Just Cause Requests: The MCP shall follow procedures as specified by ODJFS in
assisting the ODJFS in resolving member requests for member-initiated requests
affecting membership.

 
f.
Newborn Notifications:  The MCP is required to submit newborn notifications to
ODJFS in accordance with the ODJFS Newborn Notification File and Submissions
Specifications.

 
g.
Eligible Individuals:  If an eligible individual contacts the MCP, the MCP must
provide any MCP-specific managed care program information requested.  The MCP
must not attempt to assess the eligible individual’s health care needs. However,
if the eligible individual inquires about continuing/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.

 
h.
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., PCP selection, 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.   

 
i.              Transition of Fee-For-Service Members

Providing care coordination for prescheduled health services and existing care
treatment plans, is critical for members transitioning from Medicaid fee-for
service (FFS) to managed care.  Therefore, MCPs must:
 
 
i.
Allow 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:

 
11

--------------------------------------------------------------------------------

Appendix C
Covered Families and Children (CFC) population
 
 
a.
The member is in her third trimester of pregnancy and has an established
relationship with an obstetrician and/or delivery hospital;

 
b.
The member has been scheduled for an inpatient/outpatient surgery and has been
prior-approved and/or precertified pursuant to OAC rule 5101:3-2-40 (surgical
procedures would also include follow-up care as appropriate);

 
c.
The member has appointments within the initial month of MCP membership with
specialty physicians that were scheduled prior to the effective date of
membership; or

 
d.
The member is receiving ongoing chemotherapy or radiation treatment.

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.
 

 
ii.  
Allow 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.

 
iii.
Honor 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:

 
12

--------------------------------------------------------------------------------

Appendix C
Covered Families and Children (CFC) population
 
 
a.
an organ, bone marrow, or hematapoietic stem cell transplant pursuant to OAC
rule 5101:3-2-07.1 and 2.b.v of Appendix G;

 
b.
dental services that have not yet been received;

 
c.  
vision services that have not yet been received;

 
d.  
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.

 

 
e.  
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,
coordinate the transfer of services to a panel provider, if appropriate. For
organ, bone marrow or hematapoietic stem cell transplants, MCPs must receive
prior approval from ODJFS to transfer services to a panel provider.
 
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.
 
 
iv.
Reimburse 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.i. (i., ii., and iii.) of this appendix.

 
13

--------------------------------------------------------------------------------

Appendix C
Covered Families and Children (CFC) population
 
 
v.
Document the provision of transition of services identified in Section 29.i.
(i., ii., and iii.) of this appendix as follows:

 
a.
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.3.e.

 
b.
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.

 
c.
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.

 
 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:

 
14

--------------------------------------------------------------------------------

Appendix C
Covered Families and Children (CFC) population
 
 
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 have an unacceptably high
error rate.

MCPs that change or modify information systems that are involved in producing
any type of electronically submitted files, either internally or by changing
vendors, are required to submit to ODJFS for review and approval a transition
plan including the submission of test files in the ODJFS-specified
formats.  Once an acceptable test file is submitted to ODJFS, as determined
solely by ODJFS, the MCP can return to submitting production files.  ODJFS will
inform MCPs in writing when a test file is acceptable.  Once an MCP’s new or
modified information system is operational, that MCP will have up to ninety (90)
days to submit an acceptable test file and an acceptable production file.
 
Submission of test files can start before the new or modified information system
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).
 
15

--------------------------------------------------------------------------------

Appendix C
Covered Families and Children (CFC) population
 
Each EDI transaction processed by the MCP shall be implemented inconformance
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 enter into 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

 
16

--------------------------------------------------------------------------------

Appendix C
Covered Families and Children (CFC) population 
 
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 this 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.
 
17

--------------------------------------------------------------------------------

Appendix C
Covered Families and Children (CFC) population
 
Encounters include services paid for retrospectively through fee-for-service
payment arrangements, and prospectively through capitated arrangements. Only
encounters with services (line items) that are paid by the MCP, fully or in
part, and for which no further payment is anticipated, are acceptable encounter
data submissions, except for immunization services. Immunization services
submitted to the MCP must be submitted to ODJFS if these services were paid for
by another entity (e.g., free vaccine program).

All other services that are unpaid or paid in part and for which the MCP
anticipates further payment (e.g., unpaid services rendered during a delivery of
a newborn) may not be submitted to ODJFS until they are paid. Penalties for
noncompliance with this requirement are specified in Appendix N, Compliance
Assessment 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 in the
ODJFS-specified medium by the 5th of each month. This will help to ensure that
the encounters are included in the ODJFS master file in the same month in which
they were submitted.

 
18

--------------------------------------------------------------------------------

Appendix C
Covered Families and Children (CFC) population 
 
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.

 
19

--------------------------------------------------------------------------------

Appendix C
Covered Families and Children (CFC) population
 
31.           Delivery Payments

MCPs will be reimbursed for paid deliveries that are identified in the submitted
encounters using the methodology outlined in the ODJFS Methods for Reimbursing
for Deliveries (as specified in Appendix L). The delivery payment represents the
facility and professional service costs associated with the delivery event and
postpartum care that is rendered in the hospital immediately following the
delivery event; no prenatal or neonatal experience is included in the delivery
payment.

If a delivery occurred, but the MCP did not reimburse providers for any costs
associated with the delivery, then the MCP shall not submit the delivery
encounter to ODJFS and is not entitled to receive payment for the delivery. MCPs
are required to submit all delivery encounters to ODJFS no later than one year
after the date of the delivery. Delivery encounters which are submitted after
this time will be denied payment.  MCPs will receive notice of the payment
denial on the remittance advice.

If an MCP is denied payment through ODJFS’ automated payment system because the
delivery encounter was not submitted within a year of the delivery date, then it
will be necessary for the MCP to contact BMHC staff to receive payment.  Payment
will be made for the delivery, at the discretion of ODJFS if a payment had not
been made previously for the same delivery.

To capture deliveries outside of institutions (e.g., hospitals) and deliveries
in hospitals without an accompanying physician encounter, both the institutional
encounters (UB-92) and the noninstitutional encounters (NSF) are searched for
deliveries.

If a physician and a hospital encounter is found for the same delivery, only one
payment will be made. The same is true for multiple births; if multiple delivery
encounters are submitted, only one payment will be made. The method for
reimbursing for deliveries includes the delivery of stillborns where the MCP
incurred costs related to the delivery.

Rejections
If a delivery encounter is not submitted according to ODJFS specifications, it
will be rejected and MCPs will receive this information on the exception report
(or error report) that accompanies every file in the ODJFS-specified format.
Tracking, correcting and resubmitting all rejected encounters is the
responsibility of the MCP and is required by ODJFS.

 
20

--------------------------------------------------------------------------------

Appendix C
Covered Families and Children (CFC) population
 
Timing of Delivery Payments
MCPs will be paid monthly for deliveries.  For example, payment for a delivery
encounter submitted with the required encounter data submission in March, will
be reimbursed in March. The delivery payment will cover any encounters submitted
with the monthly encounter data submission regardless of the date of the
encounter, but will not cover encounters that occurred over one year ago.

This payment will be a part of the weekly update (adjustment payment) that is in
place currently.  The third weekly update of the month will include the delivery
payment.  The remittance advice is in the same format as the capitation
remittance advice.

Updating and Deleting Delivery Encounters
The process for updating and deleting delivery encounters is handled differently
from all other encounters. See the ODJFS Encounter Data Specifications for
detailed instructions on updating and deleting delivery encounters.

The process for deleting delivery encounters can be found on page 35 of the
UB-92 technical specifications (record/field 20-7) and page III-47 of the NSF
technical specifications (record/field CA0-31.0a).

Auditing of Delivery Payments
A delivery payment audit will be conducted periodically. If medical records do
not substantiate that a delivery occurred related to the payment that was made,
then ODJFS will recoup the delivery payment from the MCP. Also, if it is
determined that the encounter which triggered the delivery payment was not a
paid encounter, then ODJFS will recoup the delivery payment.

32.
If the MCP will be using the Internet functions that will allow approved users
to access member information (e.g., eligibility verification), the MCP must
receive prior approval from ODJFS that verifies that the proper safeguards,
firewalls, etc., are in place to protect member data.

33.
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).

34.
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.

 
35.
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.

 
21

--------------------------------------------------------------------------------

Appendix C
Covered Families and Children (CFC) population
 
36.
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 5.5 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.

 
37.           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
provides members the ability to submit questions, comments, grievances, and
appeals,  and receive a response (members must be given the option of a return
e-mail or phone call).  MCP responses to questions or comments must be made
within one working day of receipt.  MCP responses to grievances and appeals must
adhere to the timeframes specified in OAC rule 5101:3-26-08.4.  The member
website must be regularly updated to include the most current ODJFS-approved
materials, although this website must not be the only means for notifying
members of new and/or revised MCP information (e.g., change in holiday closures,
changes in additional benefits, revisions to approved member materials.)

The MCP member website must also include, at a minimum, the following
information which must be accessible to members and the general public without
any log-in restrictions by October 1, 2008: (1) MCP contact information,
including the MCP’s toll-free member services phone number, service hours, and
closure dates; (2) a list of counties covered in the MCP’s service area; (3) the
ODJFS-approved MCP member handbook, recent newsletters and announcements; (4)
the MCP’s on-line provider directory as referenced in section 36(a) of this
appendix; (5) the MCP’s current preferred drug list (PDL), including an
explanation of the list, which drugs require prior authorization (PA), and how
to initiate a PA; and (6) the MCP’s current list of drugs covered only with PA,
how to initiate a PA, and the MCP’s policy for covering name brand drugs. MCPs
must ensure that all website member information and materials are clearly
labeled for CFC members and/or ABD members, as applicable.  ODJFS may require
MCPs to include additional information on the member website as needed.
 
22

--------------------------------------------------------------------------------

Appendix C
Covered Families and Children (CFC) population
 
 
c.
On-line Provider Website – MCPs must have a secure internet-based website for
contracting providers through which providers can confirm a consumer’s
enrollment and through which providers can submit and receive responses to prior
authorization requests (an e-mail process is an acceptable substitute if the
website includes the MCP’s e-mail address for such submissions).

The MCP provider website must also include, at a minimum, the
following information which must be accessible to providers and the general
public without any log-in restrictions by October 1, 2008: (1) MCP contact
information, including the MCP’s designated contact for provider issues; (2) a
list of counties covered in the MCP’s service area; (3) the MCP’s provider
manual, recent newsletters and announcements; (4) the MCP’s on-line  provider
directory as referenced in section 36(a) of this appendix; (5) the MCP’s current
PDL, including an explanation of the list, which drugs require PA, and how to
initiate a PA; and (6) the MCP’s current list of drugs covered only with PA, how
to initiate a PA, and the MCP’s policy for covering name brand drugs.  MCPs must
ensure that all website information and materials are clearly labeled for CFC
members and/or ABD members, as applicable.   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.           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.

41.
MCP submissions with due dates that fall on a weekend or holiday are due the
next business day.

 
 
23

--------------------------------------------------------------------------------

Appendix D
Covered Families and Children (CFC) population  
 
APPENDIX D

ODJFS RESPONSIBILITIES
CFC 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.

 
1

--------------------------------------------------------------------------------

Appendix D
Covered Families and Children (CFC) population  
 
10.
On a monthly basis, ODJFS will provide MCPs with an electronic Provider Master
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.  This file also
includes National Provider Identifier (NPI) information where applicable.

 
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.

 
2

--------------------------------------------------------------------------------

Appendix D
Covered Families and Children (CFC) population  
 
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 ensure market and program stability,
ODJFS may limit an MCP’s auto-assignments if they meet any of the following
enrollment thresholds:

 
·
55% of the statewide Covered Families and Children (CFC) eligible population;
and/or

 
·
70% of the CFC eligibles in any region with two MCPs; and/or

 
·
55% of the CFC eligibles in any region with three MCPs

Once an MCP meets one of these enrollment thresholds, the MCP will only be
permitted to receive the additional new membership (in the region or statewide,
as applicable) through: (1) consumer-initiated enrollment; and (2)
auto-assignments which are based on previous enrollment in that MCP or an
historical provider relationship 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, in their sole discretion, may not impose
the auto-assignment limitation and auto-assign members to the MCPs in that
region as ODJFS deems appropriate.

 
c.
Performance Based Auto-Assignments – Consumers who do not voluntarily select an
MCP or are not auto-assigned to an MCP based on previous enrollment in that MC
or an historical provider relationship with a provider who is not on the panel
of another MCP in that region, will be auto-assigned based on the MCP
performance using the following performance rating system:

 
3

--------------------------------------------------------------------------------

Appendix D
Covered Families and Children (CFC) population  
 
MCPs will be scored based on the following ten measures:

 
i.
MCP Consumer Call Center  (see Appendix C)

 
–
Average Speed of Answer

 
–
Abandonment Rate

 
–
Blockage rate

 
ii.
MCP Provider Call Center (measurement and standards will match those set for the
MCP Consumer Call Center outlined in Appendix C. For a detailed description of
the MCP Provider Call Center measure, see ODJFS Method for the MCP Provider Call
Center Measure.)

–
Average Speed of Answer

 
–
Abandonment Rate

 
–
Blockage rate

 

 
iii.
MCP Prior Authorization (see OAC 5101:3-26-03.1)

 
–
Average Time to Process Non-Pharmacy Requests

 
–
Average Time to Process Pharmacy Requests

 
iv.
Prompt Payment of Claims (see Appendix J)

 
–
Percentage of Claims Paid within 30 days

 
–
Percentage of Claims Paid within 90 days

 
Each MCP will receive a point for meeting the established standard.  If an MCP
meets the established standard for each measure, they will receive ten
points.  For each region, the MCP with the highest score will receive the
performance-based auto-assignments for the region.  If there is a tie for the
highest score, then each tying MCP will be considered equal in the
auto-assignment process.  Scoring will take place quarterly and applied to the
auto-assignment process once the results are finalized.

On a regional basis, MCPs that have auto-assignment limitations in accordance
with 15(b) do not qualify for performance-based auto-assignments unless (1)
there are two MCPs in the region, (2) the auto-assignment limited MCP received
10 points and (3) the other MCP in the regional failed to receive 10 points.  In
this case, the MCP with the auto-assignment limitation shall receive
auto-assignments in the amount of 10% of the performance based auto-assignments
for every point the other MCP is below 10 points (i.e. if the other MCP has 7
points then the MCP would receive 30% (3 points * 10%)).
 
 
d.
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.

 
4

--------------------------------------------------------------------------------

Appendix D
Covered Families and Children (CFC) population  
 
 
e.
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.

 
f.
Monthly Premiums and Delivery Payments:  ODJFS will remit payment to the MCPs
via an electronic funds transfer (EFT), or at the discretion of ODJFS, by paper
warrant.

 
g.
Remittance Advice:  ODJFS will confirm all premium payments and
delivery   payments paid to the MCP during the month via a monthly remittance
advice (RA), which is sent to the MCP the week following state cut-off.  ODJFS
or its designated entity provides a record of each payment via HIPAA 820
compliant transactions.

 
 
h.
MCP Reconciliation Assistance:  ODJFS will work with an MCP-designated
contact(s) to resolve the MCP’s member and newborn eligibility inquiries,
premium and delivery payment inquiries/discrepancies and to review/approve
hospital deferment requests.

 
16.           ODJFS will make available a website which includes current program
information.

17.
ODJFS will regularly provide information to MCPs regarding different aspects of
MCP performance including, but not limited to, information on MCP-specific and
statewide external quality review organization surveys, focused clinical quality
of care studies, consumer satisfaction surveys and provider profiles.

18.           ODJFS will periodically review a random sample of online and
printed directories to assess whether MCP information is both accessible and
updated.

19.           Communications
 
a.           ODJFS/BMHC: The Bureau of Managed Health Care (BMHC) is responsible
for the oversight of the MCPs’ provider agreements with ODJFS.Within the BMHC,
a specific Contract Administrator (CA) has been assigned to each MCP.  Unless
expressly directed otherwise, MCPs shall first contact their designated CA for
questions/assistance related to Medicaid and/or the MCP’s program requirements
/responsibilities. If their CA is not available and the MCP needs immediate
assistance, MCP staff should request to speak to a supervisor within the
Contract Administration Section.  MCPs should take all necessary and appropriate
steps to ensure all MCP staff are aware of, and follow, this communication
process.
 
b.           ODJFS contracting-entities:  ODJFS-contracting entities should
never be contacted by the MCPs unless the MCPs have been specifically instructed
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.
 
 

 
5 

--------------------------------------------------------------------------------

Appendix E
Covered Families and Children (CFC) population   

APPENDIX E
RATE METHODOLOGY
CFC ELIGIBLE POPULATION
 
FINAL and CONFIDENTIAL

 
Chase Center/Circle
111 Monument Circle
Suite 601 Indianapolis, IN 46204-5128
USA
Tel    +1 317 638 1000 Fax   +1317 639 1001
mllliman.com
June 5, 2008
 
 
 
Mr. Jon Barley, Ph.D., Bureau Chief
Bureau of Managed Health Care
Ohio Department of Job and Family Services
Lazarus Building
50 West Town St., Suite 400
Columbus, OH 43215
 
RE:
CAPITATION RATE CERTIFICATION - COVERED FAMILIES AND CHILDREN (CFC) July 1,
2008 TO DECEMBER 31, 2008

 
Dear Jon:
 
Milliman, Inc. (Milliman) was retained by the State of Ohio, Department of Job
and Family Services (ODJFS) to develop the calendar year (CV) 2008 actuarially
sound capitation rates for the Covered Families and Children (CFC) Risk Based
Managed Care (RBMC) program. This letter provides the revised capitation rates
to be effective from July 1, 2008 to December 31, 2008. The revisions are a
result of specific policy changes effective subsequent to the development of the
CY 2008 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.
 
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.

 
1

--------------------------------------------------------------------------------

Appendix E
Covered Families and Children (CFC) population   

EXECUTIVE SUMMARY
 
The calendar year (CY) 2008 capitation rates for the Covered Families and
Children (CFC) Risk Based Managed Care (R.BMC) program were revised for the
period of July 1, 2008 to December 31, 2008. The revisions are a result of
specific policy changes effective subsequent to the development of the CY 2008
capitation rates. The base data and actuarial assumptions underlying the CY 2008
capitation rates remain unchanged from the December 4, 2007 rate certification
and data book.
 
Table 1 summarizes the current (January to June 2008) and the revised (July to
December 2008) capitation rate expenditures as well as the percentage changes by
region on a composite all rate group basis.
Table 1
STATE OF OHIO
DEPARTMENT OF JOB AND FAMILY SERVICES
COVERED FAMILIES AND CHILDREN
Capitation Comparison - Aggregate Expenditures
($ millions)
 
Region
 
Jan – Jun
2008
   
Jul – Dec
2008
   
Expenditure
Change
   
Percentage Change
 
Central
  $ 300.7     $ 316.4     $ 15.8       5.2 %
East Central
  $ 163.3     $ 171.9     $ 8.6       5.3 %
Northeast
  $ 270.0     $ 283.8     $ 13.8       5.1 %
Northeast Central
  $ 76.8     $ 80.8     $ 4.0       5.2 %
Northwest
  $ 156.9     $ 165.4     $ 8.5       5.4 %
Southeast
  $ 104.8     $ 110.4     $ 5.6       5.3 %
Southwest
  $ 197.5     $ 207.0     $ 9.5       4.8 %
West Central
  $ 132.1     $ 139.2     $ 7.1       5.4 %    
Statewide Composite
  $ 1,402.1     $ 1,475.0     $ 72.9    
5.2% |
 

 
Note: Values have been rounded

 
2

--------------------------------------------------------------------------------

Appendix E
Covered Families and Children (CFC) population   
 
In aggregate, the July to December 2008 capitation rates will result in a 5.2%
increase relative to the current January to June 2008 capitation rates.  The
composite rate increase reflects assumed health plan enrollment consistent with
the previously projected CY 2008 estimates.   Additionally, the expenditure
estimates assume equal distribution of member months and deliveries throughout
CY 2008.
 
Enclosure 1 provides the current and proposed capitation rates and expenditures
for each rate group and geographic region as well as on a statewide composite
basis.
Enclosure 2 contains the actuarial certification regarding the actuarial
soundness of the capitation rates.
 
DETAILS OF PROGRAM CHANGES
 
The capitation rates for the CFC program were revised for the period of July 1,
2008 to December 31, 2008. The revisions are a result of specific program
changes effective subsequent to the development of the CY 2008 capitation rates.
Table 2 summarizes the changes that were reflected in the capitation rate change
to be effective July 1, 2008.

Table 2
STATE OF OHIO
DEPARTMENT OF JOB AND FAMILY SERVICES
COVERED FAMILIES AND CHILDREN
Prospective Program Adjustments
 
Program
Adjustment
Effective
Date
Service Category(s)
Rate
Groups
Adjustment Factor
Estimated Aggregate Impact
Inpatient Capital Component
1/1/2008
Inpatient (excl. Nursing Facility)
All Rate Groups (incl. Delivery)
2.50%
$11.5 M/ 0.8%
Community Providers Fee Schedule Increase
7/1/2008
Community Based Provider Categories
All Rate Groups (incl. Delivery)
4.13%
$25.7 M/ 1.8%
Dental Benefit Restoration
7/1/2008
Dental
HF M-19 to44
30.24%
$9.8 M/ 0.7%
     
HF F-19 to 44
34.16%
       
HF M/F - 45 to 64
30.18%
       
HST F- 19 to 64
49.48%
 
CHIP III Expansion Revision
1/1/2008
All Service Categories
HST M/F- 2 to 13
 
(0.34%)
($1.4) M/ (0.1%)
HST M - 14 to 18
     
HST F-14 to l8
   
Improved TPL Management Revision
1/1/2008
All Service Categories
All Rate Groups (incl. Delivery)
0.84%
$11.5 M/ .8%
Franchise Fee Increase
7/1/2008
All Service Categories
All Rate Groups (incl. Delivery)
1.06%
$15.4 M/ 1.1%
Franchise Fee - Timing Adjustment
7/1/2008
All Service Categories
Delivery
0.42%
$0.4 M/ <0.1%

Note: Estimated aggregate impact includes administrative cost and franchise fee
components (values have been rounded).

 
3

--------------------------------------------------------------------------------

Appendix E
Covered Families and Children (CFC) population   
 
Inpatient Capital Component
 
The capital component of the CY 2008 DRG hospital payment rates was increased on
January 1, 2008. The changes are being reflected in the managed care capitation
rates as it is recognized that the majority of contracts held by the health
plans reflect a percentage of the base FFS reimbursement prior to annual capital
settlements with providers. As such, Milliman reviewed the impact of the capital
changes using a distribution of admissions and paid claims by provider
appropriate for the CFC managed care enrolled population.
 
The increase was not included in the capitation rates effective January 1, 2008
due to the timing of this change. Milliman has included this adjustment into the
capitation rates to be effective from July 1, 2008 to December 31, 2008. The
adjustment reflects a retro-active payment for January to June 2008 as well as a
prospective adjustment for July to December 2008.
 
Milliman obtained the hospital capital rates for CY 2007 and CY 2008 by provider
as well as the distribution of paid claims and admissions by provider for SFY
2006. The adjustment factor was calculated using the following Methodology:
 
Adjustment Factor = [Admissions SFY2006  X (Capital CY2008 – Capital CY2007)]
/Total Paid
SFY2006
 
Community Provider Fee Schedule Update
 
The fee schedule used to reimburse FFS community providers was updated by ODJFS
effective July 1, 2008. The changes are being reflected in the managed care
capitation rates as it is recognized that the majority of contracts held by the
health plans reflect a percentage of the FFS reimbursement. As such, Milliman
reviewed the impact of the fee changes using a distribution of services and paid
claims appropriate for the CFC managed care enrolled population.
 
Milliman obtained the fee schedule by procedure code and modifier code for the
current fees (prior to July 1, 2008) and the revised fees (post July 1, 2008) as
well as the distribution of paid claims and utilization counts for SFY 2006. The
adjustment factor was calculated using the following Methodology:
 
Adjustment Factor = [Total Paid SFY2006 X (Fee Post 7 1 08 / Fee Prior to 7 1
08)] / Total Paid SFY2006 - 1
 
Table 3 summarizes the impact of the community provider fee schedule update by
category of service.
 
 
 
4

--------------------------------------------------------------------------------

Appendix E
Covered Families and Children (CFC) population   
 
Table 3
STATE OF OHIO
DEPARTMENT OF JOB AND FAMILY SERVICES
COVERED FAMILIES AND CHILDREN
Community Provider Fee Adjustments
 
Service Category
Impact of Fee
Changes
 
Outpatient
 
Surgery/ASC
0.3%
Professional
 
Surgery
(1.2%)
Anesthesia
0.0%
Obstetrics
6.5%
Office Visits/Consults
14.0%
inpatient Visits
9.2%
Periodic Exams
5.7%
Emergency Room
6.7%
Immunizations & Injection
15.0%
Physical Medicine
3.2%
Miscellaneous Services
5.7%
Rad/Path/Lab
 
Radiology
(0.6%)
Path/Lab
0.3%
Other Benefits
   Mental Health/Substance Abuse             7.1 %
Dental
2.3%
Vision - Optometric
6.1%
Home Health
3.0%  Non-Emergent Transportation 2.3 %
Ambulance
2.1%
Supplies & DME
0.0%
Miscellaneous Services
2.9%

Note: Values have been rounded.
 
 
5

--------------------------------------------------------------------------------

Appendix E
Covered Families and Children (CFC) population   
 
Dental Benefit Restoration
 
Dental benefits will be restored to the adult rate groups effective July 1,
2008. This impact was calculated and included in previous drafts of the CY 2008
capitation rates. However, the benefit restoration was delayed and, as such, was
not included in the final capitation rates effective January 1, 2008.
 
The adjustment factors summarized in Table 2 for the dental benefit restoration
are consistent with the previously provided amounts, with one exception. The
impact of pent-up demand previously included was increased from 2% to 4%. This
reflects that the total of the pent-up demand is still assumed to occur;
however, it will occur over only half of the calendar year.
 
CHIP III Expansion
 
The capitation rates effective January 1, 2008 included an increase due to the
expansion of coverage to the CHIP program from 200% to 300% FPL. This expansion
has not begun as of this time and remains uncertain for the remainder of the
calendar year. As such, Milliman has included an adjustment in the capitation
rates effective for July to December 2008. The adjustment reflects a
retro-active adjustment for January to June 2008 as well as a prospective
adjustment for July to December 2008 to remove the total impact of the CHIP III
expansion from the entire calendar year.
 
The adjustment factor was calculated by removing the increase from the current
rates
[1 / (1+0.17%)] and retro-actively removing the previously increased amount
[1-0.17%].
Milliman and ODJFS will monitor the progress of the CHIP III expansion and may
revise the rates prior to CY 2009 should a material change occur.
 
Improved TPL Management
 
The capitation rates effective January 1, 2008 included a reduction due to the
anticipated improvements in the TPL data and information that would allow for
increased TPL collections and cost avoidance by the health plans. The planned
improvements have been delayed until October 1, 2008. As such, Milliman has
included an adjustment in the capitation rates effective for July to December
2008. The adjustment reflects a retro-active payment for January to June 2008 as
well as a prospective adjustment for July to September 2008 to remove the value
of the TPL improvements from the first nine months of calendar year 2008. The
adjustment will be applied to the payments for July to December 2008.
 
The adjustment factor was calculated by modifying the reduction from the current
rates and retro-actively restoring the previously reduced amount [(l+.28%) / (1
-.55%)].
 
 
6

--------------------------------------------------------------------------------

Appendix E
Covered Families and Children (CFC) population   
 
Franchise Fee Increase
 
The franchise fee amount was increased from 4.5% to 5.5% of the capitation rate
effective July 1, 2008. This adjustment was applied by removing the current
franchise fee percent and applying the revised franchise fee percent for all
regions and rate groups.
 
Franchise Fee - Timing Adjustment
 
The revision of the franchise fee amount creates an exposure issue for the
health plans as the timing and methodology of the capitation payments differs
from the collection of the fees by the State. Franchise fee payments included in
the capitation rates are paid based on the incurred dates of service for the
Delivery and Non-Delivery rate groups. Collections of the franchise fee by the
State are based on the date of payment-of the capitation rate. As such, to the
extent there is a lag in payment of the capitation rate, there is an inherent
mis-alignment of payment and collection of the franchise fee. This issue only
arises when a change in the franchise fee percent occurs.
 
Milliman reviewed the lag time of capitation incurred periods to capitation
payment periods to estimate the impact of this change. For the Non-Delivery rate
groups, the capitation payments primarily occur on or 'before the service month
eliminating the impact of this change. For the Delivery rate group, the
capitation payments are paid with significant lag times, similar to the lag
found in FFS claims. As such, Milliman included an adjustment to the Deliver)'
payment for July to December 2008 to reflect this change.
 
Table 4 summarizes the percentage of deliver)' capitation payment amounts
between those paid prior to July 1, 2008 and those paid after July 1, 2008. The
percentages reflect an average historical amount using a 12 month completion
factor estimate, after removing the highest and lowest values.
 
 
7

--------------------------------------------------------------------------------

Appendix E
Covered Families and Children (CFC) population   
 
Table 4
STATE OF OHIO
DEPARTMENT OF JOB AND FAMILY SERVICES
COVERED FAMILIES AND CHILDREN
Delivery Rate Group - Lag Factors
 
Delivery Month
Percentage Paid Prior to July 1, 2008
Percentage Paid After July 1, 2008
July 2007
99.9%
0.1%
August 2007
99.7%
0.3%
September 2007
99.1%
0.9%
October 2007
98.7%
1.3%
November 2007
98.3%
1.7%
December 2007
97.5%
2.5%
January 2008
96.2%
3.8%
February 2008
93.9%
6.1%
March 2008
86.8%
13.2%
April 2008
59.0%
41.0%
May 2008
17.9%
82.1%
June 2008
0.0%
100.0%

Note: Values have been rounded.
 
If you have any questions regarding the enclosed information, please do not
hesitate to contact me at
(317) 524-3512.
Sincerely,
 
Robert M. Damler, FSA, MAAA
Principal and Consulting Actuary
 
 
RMD/1rb
Enclosures
 
 
8

--------------------------------------------------------------------------------

Appendix E
Covered Families and Children (CFC) population   
 
ENCLOSURE 1
 
State of Ohio
Department of Job and Family Services
Capitation Rate Comparison - CFC
 
Region
Rate Group
 
Projected
Jul - Dec 2008
MMs/Deliveries
   
Jan-Jun
2008
Cap Rate
   
Jan-Jun 2008
Expenditures
   
Jul-Dec 2008
Cap Rate
   
Jul-Dec 2008
Expenditures
   
% Change
   
$ Change
 
Central
HF/HST <1 M+F
    101,760     $ 568.17     $ 57,816,695     $ 596.95     $ 60,745,334      
5.1 %   $ 2,928,638  
Central
HF/HST 1 M+F
    79,228       146.51       11,607,694       154.00       12,201,112       5.1
%     593,418  
Central
HF/HST 2-13 M+F
    613,230       99.10       60,771,093       103.23       63,303,733       4.2
%     2,532,640  
Central   
HF/HST 14-18 F
    81,608       165.19       13,480,826       172.11       14,045,553       4.2
%     564,727  
Central
HF/HST 14-18 M
    73,398       118.54       8,700,599       122.99       9,027,220       3.8 %
    326,621  
Central
HF 19-44 F
    275,119       304.31       83,721,311       322.46       88,714,712      
6.0 %     4,993,401  
Central
HF 19-44 M
    84,102       198.75       16,715,273       211.71       17,805,234       6.5
%     1,089,962  
Central
HF45+M+F
    32,705       485.77       15,886,865       509.32       16,657,056       4.8
%     770,191  
Central
HST 19-64 F
    30,857       376.25       11,609,758       401.72       12,395,673       6.8
%     785,915  
Central
Composite Non-Delivery
    1,372,005       204.31       280,310,113       214.94       294,895,626    
  5.2 %     14,585,513  
Central
Delivery CFC
    5,427       3,754.26       20,374,369       3,969.58       21,542,911      
5.7 %     1,168,542  
Central
Composite with Delivery
    1,372,005     $ 219.16     $ 300,684,482     $ 230.64     $ 316,438,537    
  5.2 %   $ 15,754,055  
East Central
HF/HST <1 M+F
    50,472     $ 553.95     $ 27,958,687     $ 582.04     $ 29,376,432       5.1
%   $ 1,417,744  
East Central
HF/HST 1 M+F
    37,738       142.85       5,390,873       150.15       5,666,361       5.1 %
    275,487  
East Central
HF/HST 2-13 M+F
    334,892       96.62       32,357,265       100.66       33,710,229       4.2
%     1,352,964  
East Central
HF/HST 14-18 F
    48,233       161.06       7,768,326       167.81       8,093,896       4.2 %
    325,569  
East Central
HF/HST 14-18 M
    44,187       115.57       5,106,692       119.92       5,298,905       3.8 %
    192,213  
East Central
HF 19-44 F
    160,491       296.69       47,616,075       314.41       50,459,975      
6.0 %     2,843,901  
East Central
HF 19-44 M
    45,442       193.78       8,805,654       206.42       9,380,034       6.5 %
    574,381  
East Central
HF 45+M+F
    19,782       473.60       9,368,518       496.60       9,823,493       4.9 %
    454,974  
East Central
HST 19-64 F
    16,944       366.84       6,215,737       391.69       6,636,795       6.8 %
    421,058  
East Central
Composite Non-Delivery
    758,179       198.62       150,587.828       208.98       158,446,120      
5.2 %     7,858,292  
East Central
Delivery CFC
    3,193       3,990.44       12,741,475       4,217.02       13,464,945      
5.7 %     723,470  
East Central
Composite with Delivery
    758,179     $ 215.42     $ 163,329,303     $ 226.74     $ 171,911,065      
5.3 %   $ 8,581,762  
Northeast
HF/HST <l M+F
    81,194     $ 537.65     $ 43,653,685     $ 564.33     $ 45,819,928       5.0
%   $ 2,166,243  
Northeast
HF/HST 1 M+F
    65,469       138.65       9,077,208       145.58       9,530,904       5.0 %
    453,697  
Northeast
HF/HST 2-13 M+F
    580,015       93.78       54,393,760       97.58       56,597,815       4.1
%     2,204,055  
Northeast
HF/HST 14-18 F
    90,422       156.32       14,134,689       162.70    
14,711,578
      4.1 %     576,889  
Northeast
HF/HST 14-18 M
    82,194       112.18       9,220,523       116.25       9,555,053       3.6 %
    334,530  
Northeast
HF 19-44 F
    280,510       287.97       80,778,321       304.84       85,510,516      
5.9 %     4,732,195  
Northeast
HF 19-44 M
    59,915       188.08       11,268,813       200.14       11,991,388       6.4
%     722,575  
Northeast
HF 45+ M+F
    39,374       459.68       18,099,440       481.47       18,957,400       4.7
%     857,959  
Northeast
HST 19-64 F
    25,467       356.04       9,067,271       379.76       9,671,348       6.7
%.     604,077  
Northeast
Composite Non-Delivery
    1,304,558       191.40       249,693,709       201.10       262,345,929•    
  5.1 %     12,652,220  
Northeast
Delivery CFC
    4,936       4,105.75       20,263,929       4,343.69       21,438,282      
5.8 %.     1,174,353  
Northeast
Composite with Delivery
    1,304,558     $ 206.93     $ 269,957,638     $ 217.53     $ 283,784,211    
  5.1 %   $ 13,826,573  
Northeast Central
HF/HST <1 M+F
    21,399     $ 580.71     $ 12,426,613     $ 610.12     $ 13,055,958       5.1
%   $ 629,345  
Northeast Central
HF/HST 1 M+F
    16,275       149.76       2,437,344       157.39       2,561,522       5.1 %
    124,178  
Northeast Central
HF/HST 2-13 M+F
    153,239       101.29       15,521,528       105.49       16,165,129      
4.1 %     643,602  
Northeast Central
HF/HST 14-18 F
    23,927       168.84       4,039,750       175.90       4,208,671       4.2 %
    168,921  
Northeast Central
HF/HST 14-18 M
    22,188       121.16       2,688,298       125.70       2,789,032       3.7
%,     100,734  
Northeast Central
HF 19-44 F
    72,662       311.04       22,600,633       329.58       23,947,777       6.0
%     1,347,144  
Northeast Central
HF 19-44 M
    20,846       203.14       4,234,656       216.39       4,510,866       6.5 %
    276,210  
Northeast Central
HF 45+ M+F
    9,292       496.49       4,613,137       520.55       4,836,690       4.8 %
    223,553  
Northeast Central
HST 19-64 F
    7,043       384.55       2,708,193       410.58       2,891,510       6.8 %
    183,316  
Northeast Central
Composite Non-Delivery
    346,869       205.47       71,270,153       216.13       74,967,156      
5.2 %     3,697,003  
Northeast Central
Delivery CFC
    1,342       4,113.88       5,518,770       4,351.17       5,837,095      
5.8 %     318,325  
Northeast Central
Composite with Delivery
    346,869     $ 221.38    
$            76,788,923
    $ 232.95     $ 80,804,250       5.2 %   $ 4,015,327  
Northwest
HF/HST <1 M+F
    51,535     $ 565.81     $ 29,159,018     $ 595.46     $ 30,687,031       5.2
%   $ 1,528,013  
Northwest
HF/HST 1 M+F
    38,387       145.91       5,600,974       153.61       5,896,550       5.3 %
    295,576  
Northwest
HF/HST 2-13 M+F
    313,927       98.69       30,981,456       102.96       32,321,924       4.3
%     1,340,468  
Northwest
HF/HST 14-18 F
    45,514       164.51       7,487,508       171.68       7,813,844       4.4 %
    326,335  
Northwest
HF/HST 14-18 M
    41,124       118.04       4,854,218       122.68       5,045,031       3.9 %
    190,813  
Northwest
HF 19-44 F
    145,022       303.05       43,948,917       321.64       46,644,876      
6.1 %     2,695,959  
Northwest
HF 19-44 M
    44,005       197.94       8,710,350       211.19       9,293,416       6.7 %
    583,066  
Northwest
HF 45+ M+F
    16,482       483.76       7,973,090       508.04       8,373,261       5.0 %
    400,171  
Northwest
HST 19-64 F
    18,071       374.69       6,771,023       400.72       7,241,411       6.9 %
    470,388  
Northwest
Composite Non-Delivery
    714.066       203.74       145,486,555       214.71       153,317,344      
5.4 %     7,830,790  
Northwest
Delivery* CFC
    3,040       3,768.39               3,981.10       12,102,544       5.6 %    
646,638  
Northwest
Composite with Delivery
    714,066     $ 219.79     $ 156,942,460     $ 231.66     $ 165,419,888      
5.4 %   $ 8,477,428  

 
9

--------------------------------------------------------------------------------

Appendix E
Covered Families and Children (CFC) population   
 
State of Ohio
Department of Job and Family Services
Capitation Rate Comparison - CFC
 
Region
Rate Group
 
 
Projected
Jul-Dec 2008
MMs/Deliveries
   
Jan - Jun
2008
Cap Rate
   
Jan-Jun 2008
Expenditures
   
Jul – Dec 2008
Cap Rate

   
Jul - Dec 2008
Expenditures
   
% Change
   
$ Change
 
Southeast
HF/HST <l M+F
    27,057     $ 575.04     $ 15,558,570     $ 604.37     $ 16,352,137       5.1
%   $ 793,567  
Southeast
HF/HST 1 M+F
    22,178       148.29       3,288,701       155.90       3,457,472       5.1 %
    168,771  
Southeast
HF/HST 2-13 M+F
    202,856       100.30       20,346,407       104.51       21,200,428      
4.2 %     854,022  
Southeast
HF/HST 14-18 F
    30,272       167.19       5,061,176       174.25       5,274,896       4.2 %
    213,720  
Southeast
HF/HST 14-18 M
    28,111       119.98       3,372,698       124.52       3,500,319       3.8 %
    127.622  
Southeast
HF 19-44 F
    102,587       308.00       31,596,796       326.47       33,491,578      
6.0 %     1,894,782  
Southeast
HF 19-44 M
    45,156       201.16       9,083,581       214.34       9,678,737       6.6 %
    595,156  
Southeast
HF 45+ M+F
    13,518       491.63       6,645,854       515.65       6,970,557       4.9 %
    324.702  
Southeast
HST 19-64 F
    9,472       380.81       3,606,842       406.72       3,852,248       6.8 %
    245,407  
Southeast
Composite Non-Delivery
    481,205       204.82       98,560,625       215.66       103,778,373      
5.3 %     5,217,748  
Southeast
Delivery CFC
    1,764       3,557.15       6,274,813       3,765.08       6,641,601      
5.8 %     366,789  
Southeast
Composite with Delivery
    481,205     $ 217.86     $ 104,835,437     $ 229.47     $ 110,419,974      
5.3 %   $ 5,584,537  
Southwest
HF/HST <1 M+F
    68,146     $ 606.96     $ 41,361,896     $ 635.17     $ 43,284,295       4.6
%   $ 1,922,399  
Southwest
HF/HST 1 M+F
    49,201       156.52       7,700,862       163.85       8,061,502       4.7 %
    360,640  
Southwest
HF/HST 2-13 M+F
    380,559       105.87       40,289,781       109.84       41,800,601      
3.7 %     1,510,819  
Southwest
HF/HST 14-18 F
    51,497       176.47       9,087,676       183.12       9,430,131       3.8 %
    342.455  
Southwest
HF/HST 14-18 M
    44,200       126.64       5,597,488       130.86       5,784,012       3.3 %
    186,524  
Southwest
HF 19-44 F
    160,588       325.09       52,205,553       343.11       55,099,349      
5.5 %     2,893,796  
Southwest
HF 19-44 M
    42,270       212.34       8,975,612       225.27       9,522,163       6.1 %
    546,551  
Southwest
HF 45+ M+F
    17,095       518.94       8,871,020       541.93       9,264,022       4.4 %
    393,003  
Southwest
HST 19-64 F
    21,442       401.95       8,618,612       427.44       9,165,168       6.3 %
    546,557  
Southwest
Composite Non-Delivery
    834,997       218.81       182,708,500       229.24       191,411,242      
4.8 %     8,702,743  
Southwest
Delivery CFC
    3,675       4,011.88       14,743,659       4,242.15       15,589,901      
5.7 %     846,242  
Southwest
Composite with Delivery
    834,997     $ 236.47     $ 197,452,159     $ 247.91     $ 207,001,144      
4.8 %   $ 9,548,985  
West Central
HF/HST <1 M+F
    44,127     $ 572.54     $ 25,264,473     $ 602.37     $ 26,580,781       5.2
%   $ 1,316,308  
West Central
HF/HST 1 M+F
    32,928       147.65       4,861,819       155.40       5,117,011       5.2 %
    255,192  
West Central
   HF/HST 2-13 M+F
    264,267       99.86       26,389,703       104.16       27,526,051       4.3
%     1,136,348  
West. Central
HF/HST 14-18 F
    38,572       166.47       6,420,998       173.67       6,698,712       4.3 %
    277,715  
West Central
HF/HST 14-18 M
    33,698       119.46       4,025,503       124.11       4,182,197       3.9 %
    156,693  
West Central
HF 19-44 F
    117,439       306.66       36,013,844       325.39       38,213,476      
6.1 %     2,199,632  
West Central
HF 19-44 M
    33,241       200.29       6,657,840       213.64       7,101,607       6.7 %
    443,767  
West Central
HF 45+ M+F
    13,516       489.51       6,616,217       513.95       6,946,548       5.0 %
    330,331  
West Central
HST 19-64 F
    13,711       379.15       5,198,526       405.37       5,558,028       6.9 %
    359,502  
West Central
Composite Non-Delivery
    591,498       205.32       121,448,922       216.27       127,924,412      
5.3 %     6,475,490  
West Central
Delivery CFC
    2,458       4,342,68       10,674,307       4,589.24       11,280,352      
5.7 %     606,044  
West Central
Composite with Delivery
    591,498     $ 223.37     $ 132,123,229     $ 235.34     $ 139,204,764      
5.4 %   $ 7,081,534  
Statewide
HF/HST <l M+F
    445,688     $ 568.11     $ 253,199,638     $ 596.61     $ 265,901,895      
5.0 %   $ 12,702,257  
Statewide
HF/HST 1 M+F
    341,402       146.35       49,965,476       153.76       52,492,435      
5.1 %     2,526,959  
Statewide
HF/HST 2-13 M+F
    2,842,984       98.86       281,050,992       102.93       292,625,909      
4.1 %     11,574,918  
Statewide
HF/HST 14-18 F
    410,043       164.57       67,480,948       171.39       70,277,281      
4.1 %     2,796,333  
Statewide
HF/HST 14-18 M
    369,099       118.03       43,566,019       122.41       45,181,768      
3.7 %     1,615,750  
Statewide
HF 19-44 F
    1,314,417       303.16       398,481,449       321.12       422,082,259    
  5.9 %     23,600,810  
Statewide
HF 19-44 M
    374,977       198.55       74,451,778       211.44       79,283,446      
6.5 %     4,831,668  
Statewide
HF 45+ M+F
    161,762       482.65       78,074,142       505.86       81,829,027      
4.8 %     3,754,885  
Statewide
HST 19-64 F
    143,006       376.18       53,795,962       401.47       57,412,182      
6.7 %     3,616,221  
Statewide
Composite Non-
Delivery
    6,403,375       203.03       1,300,066,404       213.49       1,367.086,203
      5.2 %     67,019,799  
Statewide
Delivery CFC
    25,834       3,950.11       102,047,228       4,176.57       107,897,630    
  5.7 %     5,850,403  
Statewide
Composite with Delivery
    6,403,375     $ 218.96     $ 1,402,113,632     $ 230.34     $ 1,474,983,833
      5.2 %   $ 72,870,202  

 
10

--------------------------------------------------------------------------------

Appendix E
Covered Families and Children (CFC) population   
 
ENCLOSURE 2
 
STATE OF OHIO
DEPARTMENT OF JOB AND FAMILY SERVICES
Covered Families and Children
Capitation Rates July 1, 2008 to December 1, 2008
 
Actuarial Certification
 
I, Robert M. Damler, am a Principal and Consulting Actuary with the firm of
Milliman, Inc. I am a Fellow of the Society of Actuaries and a Member of the
American Academy of Actuaries. 1 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 from July 1,
2008 to December 31, 2008. The capitation rates were developed for the Covered
Families and Children 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 CM.S 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 six
month rating period beginning July 1, 2008 through December 31, 2008. The
capitation rates associated with this certification were previously certified by
Milliman and approved by CMS for the period of Jan 1, 2008 through Dec 31, 2008.
This certification reflects modifications to the rates for policy and program
changes. At the end of the six month 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).
 
 
11

--------------------------------------------------------------------------------

Appendix E
Covered Families and Children (CFC) population  
 
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/ Robert Damler
Robert M. Damler, FSA
Member, American Academy of Actuaries
 
June 5, 2008
Date
 
 
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.
 
12

--------------------------------------------------------------------------------

Appendix F
Covered Families and Children (CFC) population   
 
APPENDIX F
 
REGIONAL RATES
                                                                 
1. PREMIUM RATES WITHOUT THE AT-RISK PAYMENT AMOUNTS FOR 07/01/08 THROUGH
11/30/08 SHALL BE AS FOLLOWS:
 
An at-risk amount of 1% is applied to the MCP rates. The status of the at-risk
amount is determined in accordance with Appendix O, performance incentives.
 
MCP:  WellCare of Ohio, Inc.
                                                                               
                                           
SERVICE
REGIONAL
 
HF/HST
   
HF/HST
   
HF/HST
   
HF/HST
   
HF/HST
   
HF
   
HF
   
HF
   
HST
   
Delivery
 
ENROLLMENT
STATUS
 
Age < 1
   
Age 1
   
Age 2-13
   
Age 14-18
   
Age 14-18
   
Age 19-44
   
Age 19-44
   
Age 45
   
Age 19-64
   
Payment
 
AREA
                     
Male
   
Female
   
Male
   
Female
   
and over
   
Female
       
Northeast
Mandatory
  $ 564.33     $ 145.58     $ 97.58     $ 116.25     $ 162.70     $ 200.14     $
304.84     $ 481.47     $ 379.76     $ 4,343.69                                
                                                                               
                                                                               
                                                                               
                                                                               
                                                                     
List of Eligible Assistance Groups (AGs)
                                                                               
                                                                             
Healthy Families:  - MA-C Categorically eligible due to TANF cash
                 
                                - MA-T Children under 21
                                         
                                - MA-Y Transitional Medicaid
                                                                               
                                                                     
Healthy Start:        - MA-P Pregnant Women and Children
                                                                               
                                                                               
                                                                         
For the SFY 2009 contract period, MCPs will be put at-risk for a portion of the
premiums received for members in regions they served as of January 1, 2006,
provided the MCP has participated in the program for more than twenty-four
months. 
 
MCPs will be put at-risk for a portion of the premiums received for members in
regions they began serving after January 1, 2006, beginning with the MCP's
twenty-fifth month of membership in each region. The at-risk amount will be
determined separately for each region an MCP serves.
         

 
1

--------------------------------------------------------------------------------

Appendix F
Covered Families and Children (CFC) population   
 
APPENDIX F
 
REGIONAL RATES
                                                                 
2. AT-RISK AMOUNTS FOR 07/01/08 THROUGH 11/30/08 SHALL BE AS FOLLOWS:
 
An at-risk amount of 1% is applied to the MCP rates. The status of the at-risk
amount is determined in accordance with Appendix O, performance incentives.
 
MCP:  WellCare of Ohio, Inc.
                                                                               
                                           
SERVICE
REGIONAL
 
HF/HST
   
HF/HST
   
HF/HST
   
HF/HST
   
HF/HST
   
HF
   
HF
   
HF
   
HST
   
Delivery
 
ENROLLMENT
STATUS
 
Age < 1
   
Age 1
   
Age 2-13
   
Age 14-18
   
Age 14-18
   
Age 19-44
   
Age 19-44
   
Age 45
   
Age 19-64
   
Payment
 
AREA
                     
Male
   
Female
   
Male
   
Female
   
and over
   
Female
       
Northeast
Mandatory
  $ 0.00     $ 0.00     $ 0.00     $ 0.00     $ 0.00     $ 0.00     $ 0.00     $
0.00     $ 0.00     $ 0.00                                                      
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                   
List of Eligible Assistance Groups (AGs)
                                                                               
                                                                             
Healthy Families:  - MA-C Categorically eligible due to TANF cash
                         
                                - MA-T Children under 21
                                         
                                - MA-Y Transitional Medicaid
                                                                               
                                                                     
Healthy Start:        - MA-P Pregnant Women and Children
                                                                               
                                                                     

For the SFY 2009 contract period, MCPs will be put at-risk for a portion of the
premiums received for members in regions they served as of January 1, 2006,
provided the MCP has participated in the program for more than twenty-four
months. 
 
MCPs will be put at-risk for a portion of the premiums received for members in
regions they began serving after January 1, 2006, beginning with the MCP's
twenty-fifth month of membership in each region. The at-risk amount will be
determined separately for each region an MCP serves.
 
2

--------------------------------------------------------------------------------

Appendix F
Covered Families and Children (CFC) population   
 
APPENDIX F
 
REGIONAL RATES
                                                                 
3. PREMIUM RATES FOR 07/01/08 THROUGH 11/30/08 SHALL BE AS FOLLOWS:
 
An at-risk amount of 1% is applied to the MCP rates. The status of the at-risk
amount is determined in accordance with Appendix O, performance incentives.
 
MCP:  WellCare of Ohio, Inc.
                                                                               
                                           
SERVICE
REGIONAL
 
HF/HST
   
HF/HST
   
HF/HST
   
HF/HST
   
HF/HST
   
HF
   
HF
   
HF
   
HST
   
Delivery
 
ENROLLMENT
STATUS
 
Age < 1
   
Age 1
   
Age 2-13
   
Age 14-18
   
Age 14-18
   
Age 19-44
   
Age 19-44
   
Age 45
   
Age 19-64
   
Payment
 
AREA
                     
Male
   
Female
   
Male
   
Female
   
and over
   
Female
       
Northeast
Mandatory
  $ 564.33     $ 145.58     $ 97.58     $ 116.25     $ 162.70     $ 200.14     $
304.84     $ 481.47     $ 379.76     $ 4,343.69                                
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                         
List of Eligible Assistance Groups (AGs)
                                                                               
                                                                             
Healthy Families:  - MA-C Categorically eligible due to TANF cash
                 
                                - MA-T Children under 21
                                 
                                - MA-Y Transitional Medicaid
                                                                               
                                                                     
Healthy Start:  - MA-P Pregnant Women and Children
                                                                               
                                                                     
For the SFY 2009 contract period, MCPs will be put at-risk for a portion of the
premiums received for members in regions they served as of January 1, 2006,
provided the
         
MCP has participated in the program for more than twenty-four months. 
 
MCPs will be put at-risk for a portion of the premiums received for members in
regions they began serving after January 1, 2006, beginning with the MCP's
twenty-fifth month of membership in each region. The at-risk amount will be
determined separately for each region an MCP serves.
       

 
3

--------------------------------------------------------------------------------

Appendix F
Covered Families and Children (CFC) population 
 
APPENDIX F
 
REGIONAL RATES
                                                                 
1. PREMIUM RATES WITHOUT THE AT-RISK PAYMENT AMOUNTS FOR 12/01/08 THROUGH
12/31/08 SHALL BE AS FOLLOWS:
 
An at-risk amount of 1% is applied to the MCP rates. The status of the at-risk
amount is determined in accordance with Appendix O, performance incentives.
                                                                 
MCP:  WellCare of Ohio, Inc.
                                                                               
                                           
SERVICE
REGIONAL
 
HF/HST
   
HF/HST
   
HF/HST
   
HF/HST
   
HF/HST
   
HF
   
HF
   
HF
   
HST
   
Delivery
 
ENROLLMENT
STATUS
 
Age < 1
   
Age 1
   
Age 2-13
   
Age 14-18
   
Age 14-18
   
Age 19-44
   
Age 19-44
   
Age 45
   
Age 19-64
   
Payment
 
AREA
                     
Male
   
Female
   
Male
   
Female
   
and over
   
Female
       
Northeast
Mandatory
  $ 559.00     $ 144.20     $ 96.66     $ 115.15     $ 161.16     $ 198.25     $
301.96     $ 476.92     $ 376.17     $ 4,302.64                                
                                                                               
                                                                               
                                                                               
                                                                               
                                                                     
List of Eligible Assistance Groups (AGs)
                                                                               
                                                                             
Healthy Families:   - MA-C Categorically eligible due to TANF cash
         
                                 - MA-T Children under 21
                                 
                                 - MA-Y Transitional Medicaid
                                                                               
                                                                     
Healthy Start:         - MA-P Pregnant Women and Children
                                                                               
                                                             
For the SFY 2009 contract period, MCPs will be put at-risk for a portion of the
premiums received for members in regions they served as of January 1, 2006,
provided the MCP has participated in the program for more than twenty-four
months. 
 
MCPs will be put at-risk for a portion of the premiums received for members in
regions they began serving after January 1, 2006, beginning with the MCP's
twenty-fifth month of membership in each region. The at-risk amount will be
determined separately for each region an MCP serves. WellCare's regions at risk:
Northeast
                 

 
4

--------------------------------------------------------------------------------

Appendix F
Covered Families and Children (CFC) population 
 
APPENDIX F
 
REGIONAL RATES
                                                                 
2. AT-RISK AMOUNTS FOR 12/01/08 THROUGH 12/31/08 SHALL BE AS FOLLOWS:
 
An at-risk amount of 1% is applied to the MCP rates. The status of the at-risk
amount is determined in accordance with Appendix O, performance incentives.
                                                                 
MCP:  WellCare of Ohio, Inc.
                                                                               
                                           
SERVICE
REGIONAL
 
HF/HST
   
HF/HST
   
HF/HST
   
HF/HST
   
HF/HST
   
HF
   
HF
   
HF
   
HST
   
Delivery
 
ENROLLMENT
STATUS
 
Age < 1
   
Age 1
   
Age 2-13
   
Age 14-18
   
Age 14-18
   
Age 19-44
   
Age 19-44
   
Age 45
   
Age 19-64
   
Payment
 
AREA
                     
Male
   
Female
   
Male
   
Female
   
and over
   
Female
       
Northeast
Mandatory
  $ 5.33     $ 1.38     $ 0.92     $ 1.10     $ 1.54     $ 1.89     $ 2.88     $
4.55     $ 3.59     $ 41.05                                                    
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                     
List of Eligible Assistance Groups (AGs)
                                                                               
                                                                             
Healthy Families:   - MA-C Categorically eligible due to TANF cash
         
                                 - MA-T Children under 21
                                 
                                 - MA-Y Transitional Medicaid
                                                                               
                                                                     
Healthy Start:         - MA-P Pregnant Women and Children
                                                                               
                                                             
For the SFY 2009 contract period, MCPs will be put at-risk for a portion of the
premiums received for members in regions they served as of January 1, 2006,
provided the MCP has participated in the program for more than twenty-four
months.
         
 
                                 
MCPs will be put at-risk for a portion of the premiums received for members in
regions they began serving after January 1, 2006, beginning with the MCP's
twenty-fifth month of membership in each region. The at-risk amount will be
determined separately for each region an MCP serves. WellCare's regions at risk:
Northeast.
         

 
5

--------------------------------------------------------------------------------

Appendix F
Covered Families and Children (CFC) population

APPENDIX F
 
REGIONAL RATES
                                                                 
3. PREMIUM RATES FOR 12/01/08 THROUGH 12/31/08 SHALL BE AS FOLLOWS:
 
An at-risk amount of 1% is applied to the MCP rates. The status of the at-risk
amount is determined in accordance with Appendix O, performance incentives.
                                                                 
MCP:  WellCare of Ohio, Inc.
                                                                               
                                           
SERVICE
REGIONAL
 
HF/HST
   
HF/HST
   
HF/HST
   
HF/HST
   
HF/HST
   
HF
   
HF
   
HF
   
HST
   
Delivery
 
ENROLLMENT
STATUS
 
Age < 1
   
Age 1
   
Age 2-13
   
Age 14-18
   
Age 14-18
   
Age 19-44
   
Age 19-44
   
Age 45
   
Age 19-64
   
Payment
 
AREA
                     
Male
   
Female
   
Male
   
Female
   
and over
   
Female
       
Northeast
Mandatory
  $ 564.33     $ 145.58     $ 97.58     $ 116.25     $ 162.70     $ 200.14     $
304.84     $ 481.47     $ 379.76     $ 4,343.69                                
                                                                               
                                                                               
                                                                               
                                                                               
                                                                               
                                                                         
List of Eligible Assistance Groups (AGs)
                                                                               
                                                                             
Healthy Families:   - MA-C Categorically eligible due to TANF cash
         
                                 - MA-T Children under 21
                         
                                 - MA-Y Transitional Medicaid
                                                                               
                                                                     
Healthy Start:         - MA-P Pregnant Women and Children
                                                                               
                                                             
For the SFY 2009 contract period, MCPs will be put at-risk for a portion of the
premiums received for members in regions they served as of January 1, 2006,
provided the MCP has participated in the program for more than twenty-four
months.
                                                     
MCPs will be put at-risk for a portion of the premiums received for members in
regions they began serving after January 1, 2006, beginning with the MCP's
twenty-fifth month of membership in each region. The at-risk amount will be
determined separately for each region an MCP serves. WellCare's regions at risk:
Northeast.
                 

 
6

--------------------------------------------------------------------------------

Appendix G
Covered Families and Children (CFC) population 

APPENDIX G

COVERAGE AND SERVICES
CFC 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 covered by the
Ohio Medicaid fee-for-service program:

 
·
Inpatient hospital services

 
·
Outpatient hospital services

 
·
Rural health clinics (RHCs) and Federally qualified health centers (FQHCs)

 
·
Physician services whether furnished in the physician’s office, the covered
person’s home, a hospital, or elsewhere

 
·
Laboratory and x-ray services

 
·
Screening, diagnosis, and treatment services to children under the age of
twenty-one (21) under the HealthChek (EPSDT) program

 
·
Family planning services and supplies

 
·
Home health and private duty nursing services

 
·
Podiatry

 
·
Chiropractic services

 
·
Physical therapy, occupational therapy, developmental therapy and speech therapy

 
·
Nurse-midwife, certified family nurse practitioner, and certified pediatric
nurse practitioner services

 
·
Prescription drugs

 
·
Ambulance and ambulette services

 
 
·
Dental services

 
1

--------------------------------------------------------------------------------

Appendix G
Covered Families and Children (CFC) population 
 
 
·
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)

 
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

 
2

--------------------------------------------------------------------------------

Appendix G
Covered Families and Children (CFC) population 
 
 
·
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.
 
3

--------------------------------------------------------------------------------

Appendix G
Covered Families and Children (CFC) population 
 
  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 are unwilling to access services through
community providers.
 
4

--------------------------------------------------------------------------------

Appendix G
Covered Families and Children (CFC) population 
 
 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/psychologist/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.  The payment
of physician services in an IMD is also covered by the MCPs, as long as the
member is 21 years of age and under or 65 years of age and older.     
 
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/psychologist/psychiatrist AOD treatment services, outpatient clinic
AOD treatment services, general hospital outpatient AOD treatment services,
crisis intervention, inpatient detoxification services in a general hospital,
and Medicaid-covered prescription drugs and laboratory services. MCPs are not
required to cover outpatient detoxification, intensive outpatient programs
(IOP)(substance abuse) or 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.

 
5

--------------------------------------------------------------------------------

Appendix G
Covered Families and Children (CFC) population 
 
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, in accordance with OAC rule 5101:3-26-03(A) and (B).

 
Pursuant to ORC Section 5111.172, MCPs may, subject to ODJFS approval, implement
strategies for the management of drug utilization. (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.

        
6

--------------------------------------------------------------------------------

Appendix G
Covered Families and Children (CFC) population 
 
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, MCPs may, subject to ODJFS
prior-approval, implement strategies for the management of drug
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.  MCPs may also implement a retrospective
drug utilization review program designed to promote the appropriate clinical
prescribing of covered drugs.
 

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.  MCPs
must make their approved list of drugs covered only with prior authorization
available to members and providers, as outlined in paragraphs 37(b) and (c) of
Appendix C.

While MCPs may, with ODJFS approval,    require prior authorization for the
coverage of 2nd generation antipsychotic drugs, MCPs must allow any member to
continue receiving a specific 2nd generation antipsychotic drug if the member is
stabilized on that particular medication.  The MCP must continue to cover that
specific antipsychotic for the stabilized member for as long as that medication
continues to be effective for the member.  MCPs must also collaborate with ODJFS
in the retrospective review of 2nd generation antipsychotic utilization.
 
7

--------------------------------------------------------------------------------

Appendix G
Covered Families and Children (CFC) population 
 
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 controlled substances 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.

 
8

--------------------------------------------------------------------------------

Appendix G
Covered Families and Children (CFC) population 
 
                                 b.           Care Management Programs

In accordance with 5101:3-26-03.1(A)(8), MCPs must offer and provide care
management services which coordinate and monitor the care of members who require
high-cost and/or extensive services.  The MCP’s care management program must
also include a Children with Special Health Care Needs component as specified
below.

 
i.
Each MCP must inform all members and contracting providers of the MCP’s care
management services.

 
ii.
Children with Special Health Care Needs (CSHCN):

CSHCN are a particularly vulnerable population which often have chronic and
complex medical health care conditions.  In order to ensure compliance with the
provisions of 42 CFR 438.208, each MCP must establish a CSHCN component as part
of the MCP’s care management program.  The MCP must establish a process for the
timely identification, completion of a comprehensive health assessment, and
providing appropriate care management services for any CSHCN.

                                                       CSHCN are defined as
children age 17 and under who are pregnant, and members under 21 years of age
with one or more of the following:
-Asthma
-HIV/AIDS
-A chronic physical, emotional or mental condition for which they are receiving
treatment or counseling
-Supplemental security income (SSI) for a health-related condition
-A current letter of approval from the Bureau of Children with Medical Handicaps
(BCMH), Ohio Department of Health
 
9

--------------------------------------------------------------------------------

Appendix G
Covered Families and Children (CFC) population 
 
 
iii.
Care Management Program

 
1.
The MCP must have a process to inform members and their PCPs in writing that
they have been identified as meeting the criteria for care management, including
their enrollment into a  care  management program.

 
2.
The MCP must assure and coordinate the placement of the member into care
management – including identification of the member’s need for care management
services, completion of the comprehensive health assessment, and timely
development of a care treatment plan.  This process must occur within the
following timeframes for:

a) newly enrolled members, 90 days from the effective date    of enrollment; and

b) existing members, 90 days from identifying their need     for care
management.
 
 
3.
The MCP’s care management program must include, at a minimum, the following
components:

 
a.  
Identification

The MCP must have a variety of mechanisms in place to identify members
potentially eligible for care management.  These mechanisms must include an
administrative data review (e.g., diagnosis, cost threshold, and/or service
utilization) and may include provider/self referrals, telephone interviews,
information as reported by MCEC during membership selection, or home visits.

 
b.
Assessment

 
The MCP must arrange for or conduct an initial comprehensive health assessment
to confirm the results of a positive identification, and determine the need for
care management services.

The comprehensive health assessment must evaluate the member’s medical
condition(s), including physical, behavioral, social, and psychological
needs.    The comprehensive health assessment must also evaluate if the member
has co-morbidities, or multiple complex health care conditions.  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 care management services.
 
10

--------------------------------------------------------------------------------

Appendix G
Covered Families and Children (CFC) population 
 
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 a physician assistant, LPN, licensed
social worker, or a graduate of a two- or four-year allied health program, there
should be oversight and monitoring by either a registered nurse or physician.

The MCP must develop a strategy to assign members to risk stratification levels,
based on the member’s comprehensive health  assessment.
 
c.
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 medical condition(s),
including physical, behavioral, social, and psychological needs, as well as
co-morbidities. The care treatment plan must also include specific provisions
for periodic reviews of the member's health care needs. Periodic reviews may
include administrative data reviews or screening questions to alert
appropriately qualified MCP staff to update the comprehensive health assessment
and  the care treatment plan.  At a minimum, there must be verbal/written
contact with the member once every six (6) months.  The MCP must ensure there is
a provision for two-way communication or feedback with the MCP.

 
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 care treatment plan include:

Goals and actions that address health care conditions identified in the
comprehensive health assessment;
Member level interventions (i.e., referrals and making appointments) that assist
members in obtaining services, providers and programs related to the health care
conditions identified in the comprehensive health assessment;
 
11

--------------------------------------------------------------------------------

Appendix G
Covered Families and Children (CFC) population 
 
Continuous review, revision and contact follow-up, as needed,to insure 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 health care 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; and

 
·
Re-evaluation of a member's risk level with adjustment to the level of care
management services provided.

 
4.     Coordination of Care and Communication

The MCP must provide care management services for:

 
·
all CSHCN, including the ODJFS mandated conditions as specified in Appendix M,
Care Management Program Performance Measures;

 
·
all members enrolled in an MCP’s CSMM program as specified in Section
G(3)(a)(i); and

 
·      adults whose health conditions warrant care management services.

Care management services should not be limited only to members with the mandated
conditions.

There should be an accountable point of contact (i.e., case manager) who can
help obtain medically necessary care, assist with health-related services and
coordinate care needs. The MCP must arrange or provide for professional care
management services that are performed collaboratively by a team of
professionals appropriate for the member’s condition and health care needs.  At
a minimum, the MCP’s care manager must attempt to coordinate with the member’s
care manager from other health systems.  The MCP must have a process to
facilitate, maintain, and coordinate communication between service providers,
the member, and the member’s family.  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 the services.
 
12

--------------------------------------------------------------------------------

Appendix G
Covered Families and Children (CFC) population 
 
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.
 
                                    iv.           Care Management Strategies

The MCP must follow best-practice and/or evidence based clinical guidelines when
developing a member’s care treatment plan and coordinating the care management
needs. The MCP must develop and implement mechanisms to educate and equip
providers and care managers with evidence-based clinical guidelines or best
practice approaches to assist in providing a high level of quality of care to
members.
 
v.            Care Management Program Staffing

The MCP must identify the staff that will be involved in the operations of the
care management program, including but not limited to:  care manager
supervisors, care manager, and administrative support staff.  The MCP must
identify the role and functions of each care management staff member as well as
the educational requirements, clinical licensure standards, certification and
relevant experience with care management standards and/or activities.  The MCP
must provide care manager staff/member ratios based on the member risk
stratification and different levels of care being provided to members.

                                                vi.           Care Management
Data Submission
 
The MCP must submit a monthly electronic report to the Care Management System
(CAMS) for all members who are provided care management services by the MCP as
outlined in the ODJFS Case Management File and Submission Specifications.In
order for a member to be submitted as care managed in CAMS, the MCP must (1)
complete the identification process, a comprehensive  health assessment  and
development of a care treatment plan for the member; and (2) document the
member’s written or verbal confirmation of his/her care management status in the
care 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 care management record.
 
13

--------------------------------------------------------------------------------

Appendix G
Covered Families and Children (CFC) population 
 
The CAMS files are due the 15th calendar day of each month.

 
The MCP must also have an ODJFS-approved care management program which includes
the items in Section 3.b..  Each MCP should implement an evaluation process to
review, revise and/or update the care management program.  The MCP must annually
submit its care management program for review and approval by ODJFS. Any
subsequent changes to an approved care management program description must be
submitted to ODJFS in writing for review and approval prior to implementation.

 
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.  Once an MCP has obtained a provider
agreement, but within the first month of operation, 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 which
includes this information;

 
14

--------------------------------------------------------------------------------

Appendix G
Covered Families and Children (CFC) population 
 
 
·
A picture of the MCP’s member identification card (front and back);

 
 
·
Contact numbers and 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.

 
                                e.        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.

 
15

--------------------------------------------------------------------------------

Appendix H
Covered Families and Children (CFC) population  

APPENDIX H

PROVIDER PANEL SPECIFICATIONS
CFC 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
pediatrician requirement but a member is unable to obtain a timely appointment
from a pediatrician on the MCP’s provider panel, the MCP will be required to
secure an appointment from a panel pediatrician or arrange for an out-of-panel
referral to a pediatrician.

MCPs are required to make transportation available to any member 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
Covered Families and Children (CFC) 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.  
 
1

--------------------------------------------------------------------------------

Appendix H
Covered Families and Children (CFC) population 
 
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, 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.  The
APN capacity can count up to 10% of the total requirement for the
county.  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.
 
2

--------------------------------------------------------------------------------

Appendix H
Covered Families and Children (CFC) population 
 
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.
 
In determining whether an MCP has sufficient PCP capacity for a region, ODJFS
considers a provider who can serve as a PCP for 2000 Medicaid MCP members as one
full-time equivalent (FTE).

ODJFS reviews the capacity totals for each PCP to determine if they appear
excessive. ODJFS reserves the right to request clarification from an MCP for any
PCP whose total stated capacity for all MCP networks added together exceeds 2000
Medicaid members (i.e., 1 FTE) where indicated, ODJFS may set a cap on the
maximum amount of capacity that we will recognize for a specific PCP. ODJFS may
allow up to an additional 750 member capacity for each nurse practitioner or
physician’s assistant that is used to provide clinical support for a PCP.
 
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 recognizes that MCPs will need to utilize specialty providers to serve as
PCPs for some special needs members.  Also, in some situations (e.g., continuity
of care) a PCP may only want to serve a very small number of members for an
MCP.  In these situations it will not be necessary for the MCP to submit these
PCPs to ODJFS for prior approval.  These PCPs will not be included in the ODJFS
PVS database, or other designated process, 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.  At a
minimum, each MCP must meet both the PCP FTE requirement for that region, and a
ratio of one PCP FTE for each 2,000 of their Medicaid members in that
region.  MCPs must also satisfy a PCP geographic accessibility standard. ODJFS
will match the PCP practice sites and the stated PCP capacity with the
geographic location of the eligible population in that region (on a
county-specific basis) and perform analysis using Geographic Information Systems
(GIS) software. The analysis will be used to determine if at least 40% of the
eligible population is located within 10 miles of PCP with available capacity in
urban counties and 40% of the eligible population within 30 miles of a PCP with
available capacity in rural counties. [Rural areas are defined pursuant to 42
CFR 412.62(f)(1)(iii).]
 
3

--------------------------------------------------------------------------------

Appendix H
Covered Families and Children (CFC) population 
 
In addition to the PCP FTE capacity requirement, MCPs must also contract with
the specified number of pediatric PCPs for each region.  These pediatric PCPs
will have their stated capacity counted toward the PCP FTE requirement.
 
A pediatric PCP must maintain a general pediatric practice (e.g., a pediatric
neurologist would not meet this definition unless this physician also operated a
practice as a general pediatrician) at a site(s) located within the
county/region and be listed as a pediatrician with the Ohio State Medical
Board.  In addition, half of the required number of pediatric PCPs must also be
certified by the American Board of Pediatrics.  The provider panel requirements
for pediatricians are included in the practitioner charts in this appendix.

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, dentists, pharmacies, vision care providers,
obstetricians/gynecologists (OB/GYNs), allergists, general surgeons,
otolaryngologists, orthopedists, certified nurse midwives (CNMs), certified
nurse practitioners (CNPs), federally qualified health centers (FQHCs)/rural
health centers (RHCs) and qualified family planning providers (QFPPs). CNMs,
CNPs, FQHCs/RHCs and QFPPs are federally-required provider types.

All Medicaid-contracting MCPs must provide all medically-necessary
Medicaid-covered services to their members and therefore their complete provider
network will include many other additional specialists and provider types.  MCPs
must ensure that all non-PCP network providers follow community standards in the
scheduling of routine appointments (i.e., the amount of time members must wait
from the time of their request to the first available time when the visit can
occur).
 
Although there are currently no FTE capacity requirements of the non-PCP
required provider types, MCPs are required to ensure that adequate access is
available to members for all required provider types.  Additionally, for certain
non-PCP required provider types, MCPs must ensure that these providers maintain
a full-time practice at a site(s) located in the specified county/region (i.e.,
the ODJFS-specified county within the region or anywhere within the region if no
particular county is specified).  A full-time practice is defined as one where
the provider is available to patients at their practice site(s) in the specified
county/region for at least 25 hours a week. ODJFS will monitor access to
services through a variety of data sources, including:  consumer satisfaction
surveys; member appeals/grievances/complaints and state hearing
notifications/requests; clinical quality studies; encounter data volume;
provider complaints, and clinical performance measures.

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 Covered Families and Children (CFC) 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.).
 
4

--------------------------------------------------------------------------------

Appendix H
Covered Families and Children (CFC) population 
 
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 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 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.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.
 
5

--------------------------------------------------------------------------------

Appendix H
Covered Families and Children (CFC) population 
 
Dental Care Providers - MCPs must contract with the specified number of
dentists. In order to assure sufficient access to adult MCP members, no more
than two-thirds of the dentists used to meet the provider panel requirement may
be pediatric dentists.

Federally Qualified Health Centers/Rural Health Clinics (FQHCs/RHCs) - MCPs are
required to ensure member access to any  federally qualified health center or
rural health clinic (FQHCs/RHCs), regardless of contracting status.  Contracting
FQHC/RHC providers must be submitted for ODJFS approval via the PVS process, 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.
 
6

--------------------------------------------------------------------------------

Appendix H
Covered Families and Children (CFC) population 
 
Behavioral Health Providers – MCPs must assure member access to all
Medicaid-covered behavioral health services for members as specified in Appendix
G.b.ii.  Although ODJFS is aware that certain outpatient substance abuse
services may only be available through Medicaid providers certified by  the Ohio
Department of Drug and Alcohol Addiction Services  (ODADAS)  in some areas, MCPs
must maintain an adequate number of contracted mental health providers in the
region to assure access for members who are unable to timely access services or
unwilling to access services through community mental health centers.  MCPs are
advised not to contract with community mental health centers as all services
they provide to MCP members are to be billed to ODJFS.
 
Other Specialty Types (pediatricians, general surgeons, otolaryngologists,
allergists, andorthopedists) - 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, and
otolaryngologists 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.
 
7

--------------------------------------------------------------------------------

Appendix H
Covered Families and Children (CFC) population 
 
A provider panel exception request (PPE) may be approved for a period of not
more than one year.  Approvals shall have an effective date of the 1st day of
the month in which the PPE is approved by ODJFS.   ODJFS will not accept or
review a request to extend the effective date of a PPE that is submitted earlier
than 15 calendar days prior to the date of expiration. Once the MCP has resolved
the deficiency, the PPE is no longer valid.  If the MCP becomes deficient in the
same area a new PPE request will need to be submitted prior to the next
compliance review.

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.

 
8

--------------------------------------------------------------------------------

Appendix H
Covered Families and Children (CFC) population 
 
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 covered
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 deleted from the internet directory
within one week of notification from the provider to the MCP. Providers being
deleted from the MCP’s panel must be posted to the internet directory within one
week of notification from the provider to the MCP of the deletion.  These
deleted providers must be included in the inserts to the MCP’s provider
directory referenced above.
 
9

--------------------------------------------------------------------------------

Appendix H
Covered Families and Children (CFC) population 
 
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.

 
10

--------------------------------------------------------------------------------

 
 
North East Region - Hospitals

 
 
Minimum Provider Panel Requirements
 
Total Required Hospitals
Ashtabula
Cuyahoga
Erie
Geauga
Huron
Lake
Lorain
Medina
Additional Required Hospitals: Out-of-Region
General Hospital1
8 2
1
1 2
1
1
1
1
1
1
 
Hospital System
1
 
1
             

1  These hospitals must provide obstetrical services if such a hospital is
available in the county/region.
         
2 The Cuyahoga hospital requirement may be met by either contracting with (1) a
single hospital system that includes fifty (50) pediatric beds and five (5)
pediatric intensive care unit (PICU) beds OR (2) a single general hospital that
includes fifty (50) pediatric beds and five (5) pediatric intensive care unit
(PICU) beds and a hospital system.

 
 

--------------------------------------------------------------------------------

 

North East Central Region - Hospitals

Minimum Provider Panel Requirements
 
Total Required Hospitals
Columbiana
Mahoning
Trumbull
Additional Required Hospitals: Out-of-Region
General Hospital1
3
1
1 2
1
 
 Hospital System
         

 
1  These hospitals must provide obstetrical services if such a hospital is
available in the county/region, except where a hospital must meet the criteria
specified in footnote #4 below.
 
2   Must be a hospital that includes thirty (30) pediatric beds and  five (5)
pediatric intensive care unit (PICU) beds.
     

 
 

--------------------------------------------------------------------------------

 

East Central Region - Hospitals
 
 
Minimum Provider Panel Requirements
 
Total Required Hospitals
Ashland
Carroll
Holmes
Portage
Richland
Stark
Summit
Tuscarawas
Wayne
Additional Required Hospitals: Out-of-Region
General Hospital1
8
1
 
1
1
1
1
1 2
1
1
 
Hospital System
1
           
1
     

 
1  These hospitals must provide obstetrical services if such a hospital is
available in  the county/region, except where a hospital must meet the criteria
specified in footnote #4 below.
2   Must be a hospital that includes one hundred (100) pediatric beds and five
(5) pediatric intensive care unit (PICU) beds.
         

 
 
 

--------------------------------------------------------------------------------

 

South East Region - Hospitals
 
 
Minimum Provider Panel Requirements
 
Total Required Hospitals
Athens
Belmont
Coshocton
Gallia
Guernsey
Harrison
Jackson
Jefferson
Lawrence
Meigs
Monroe
Morgon
Muskingum
Noble
Vinton
Washington
Additional Required Hospitals: Out-of-Region
General Hospital1
11
1
1
1
1
1
   
1
       
1
   
1
Cabell AND King's Daughter AND Children's Hospital Columbus
Hospital System
                                 

 
1   These hospitals must provide obsetrical services if such a hospital is
available in the county/region.
 
 

--------------------------------------------------------------------------------

 
 
Central Region - Hospitals
 
 
Minimum Provider Panel Requirements
 
Total Required Hospitals
Crawford
Delaware
Fairfield
Fayette
Franklin
Hocking
Knox
Licking
Logan
Madison
Marion
Morrow
Perry
Pickaway
Pike
Ross
Scioto
Union
Additional Required Hospitals: Out-of-Region
General Hospital1
14
1
 
1
1
1 2
 
1
1
1
1
1
   
1
 
1
1
1
Genesis Health Care System, Inc.
Hospital System
2
       
2
                           

 
1  These hospitals must provide obstetrical services if such a hospital is
available in  the county/region, except where a hospital must meet the criteria
specified in footnote #4 below.
2   Must be a hospital that includes one hundred fifty (150) pediatric beds and
twenty-five (25) pediatric intensive care unit (PICU) beds.
                   

 
 

--------------------------------------------------------------------------------

 
 
South West Region - Hospitals
 
 
Minimum Provider Panel Requirements
 
Total Required Hospitals
Adams
Brown
Butler
Clermont
Clinton
Hamilton
Highland
Warren
Additional Required Hospitals: Out-of-Region
General Hospital1
6
 
1
1
 
1
1 2
1
 
Grandview or Miami Valley
Hospital System
2
         
2
     

 
1  These hospitals must provide obstetrical services if such a hospital is
available in the county/region, except where a hospital must meet the criteria
specified in footnote #4 below.
2   Must be a hospital that includes two-hundred  (200) pediatric beds and
thirty-five (35) pediatric intensive care unit (PICU) beds.
       

 
 

--------------------------------------------------------------------------------

 
 
West Central Region - Hospitals
 
 
Minimum Provider Panel Requirements
 
Total Required Hospitals
Champaign
Clark
Darke
Greene
Miami
Montgomery
Preble
Shelby
Additional Required Hospitals: Out-of-Region
General Hospital1
6
 
1
1
1
1
1 2
 
1
 
Hospital System
1
         
1
     

 
1  These hospitals must provide obsetrical services if such a hospital is
available in the county/region, except where a hospital must meet the criteria
specified in footnote #4 below.
2  Must be a hospital that includes seventy-five (75) pediatric beds and ten
(10) pediatric intensive care unit (PICU) beds.
       

 
 

--------------------------------------------------------------------------------

 
 
North West Region - Hospitals
 
 
Minimum Provider Panel Requirements
 
Total Required Hospitals
Allen
Auglaize
Defiance
Fulton
Hancock
Hardin
Henry
Lucas
Mercer
Ottawa
Paulding
Putnam
Sandusky
Seneca
Van Wert
Williams
Wood
Wyandot
Additional Required Hospitals: Out-of-Region
General Hospital1
10
1
 
1
1
1
     
1
     
1
 
1
1
 
1
Bellevue Hospital Association
Hospital System
1
             
1 2
                     

 
1  These hospitals must provide obsetrical services if such a hospital is
available in   the county/region.
   
2  Must be a hospital system that includes forty-five (45) pediatric beds and
ten (10) pediatric intensive care unit (PICU) beds.
             

 
 

--------------------------------------------------------------------------------

 
 
North East Region - PCP Capacity
 
 
Minimum PCP Capacity Requirements
PCPs
Total Required
Ashtabula
Cuyahoga
Erie
Geauga
Huron
Lake
Lorain
Medina
Additional Required: In-Region *
Capacity 1
98,212
5,256
66,564
2,873
1,111
2,612
5,210
11,431
3,155
 
FTEs
49.11
2.63
33.28
1.44
0.56
1.31
2.61
5.72
1.58
 

 
1  Based on an FTE of 2000 members
     
* Must be located within the region.
     

 
 

--------------------------------------------------------------------------------

 
 
 
North East Central Region - PCP Capacity
 
 
Minimum PCP Capacity Requirements
PCPs
Total Required
Columbiana
Mahoning
Trumbull
Additional Required: In-Region *
Capacity 1
31,367
5,281
12,039
9,047
5,000
FTEs
15.68
2.64
6.02
4.52
2.50

 
1  Based on an FTE of 2000 members
       
* Must be located within the region.
       

 
 

--------------------------------------------------------------------------------

 
 
East Central Region - PCP Capacity
 
 
Minimum PCP Capacity Requirements
PCPs
Total Required
Ashland
Carroll
Holmes
Portage
Richland
Stark
Summit
Tuscarawas
Wayne
Additional Required:     In-Region *
Capacity 1
55,006
1,732
1,226
794
4,329
5,363
14,376
20,279
3,616
3,291
 
FTEs
27.50
0.87
0.61
0.40
2.16
2.68
7.19
10.14
1.81
1.65
 

 
1  Based on an FTE of 2000 members
     
* Must be located within the region.
     

 
 

--------------------------------------------------------------------------------

 
 
Central Region - PCP Capacity
 
 
County
Capacity 1
FTEs
     
Total Required
100,253
50.13
Crawford
2,016
1.01
Delaware
2,307
1.15
Fairfield
4,698
2.35
Fayette
1,341
0.67
Franklin
55,101
27.55
Hocking
1,672
0.84
Knox
2,236
1.12
Licking
5,897
2.95
Logan
1,656
0.83
Madison
1,378
0.69
Marion
3,042
1.52
Morrow
1,492
0.75
Perry
2,263
1.13
Pickaway
2,123
1.06
Pike
2,116
1.06
Ross
4,442
2.22
Scioto
5,204
2.60
Union
1,269
0.63

 
1  Based on an FTE of 2000 members
       
* Must be located within the region.
       

 
 

--------------------------------------------------------------------------------

 
 
South East Region - PCP Capacity
 
 
County
Capacity 1
FTEs
     
Total Required
53,000
26.50
Athens
2,664
1.33
Belmont
3,178
1.59
Coshocton
1,840
0.92
Gallia
1,918
0.96
Guernsey
2,518
1.26
Harrison
810
0.41
Jackson
2,107
1.05
Jefferson
3,418
1.71
Lawrence
4,021
2.01
Meigs
1,557
0.78
Monroe
750
0.38
Morgon
930
0.47
Muskingum
5,304
2.65
Noble
581
0.29
Vinton
1,061
0.53
Washington
2,755
1.38
Additional Required: In-Region *
7,000
3.50

 
1  Based on an FTE of 2000 members
       
* Must be located within the region.
       

 
 

--------------------------------------------------------------------------------

 
 
South West Region - PCP Capacity
 
 
Minimum PCP Capacity Requirements
PCPs
Total Required
Adams
Brown
Butler
Clermont
Clinton
Hamilton
Highland
Warren
Additional Required: In-Region *
Capacity 1
58,754
2,063
2,122
12,296
5,787
1,705
29,787
2,240
2,754
 
FTEs
29.38
1.03
1.06
6.15
2.89
0.85
14.89
1.12
1.38
 

 
1  Based on an FTE of 2000 members
       
* Must be located within the region.
     

 
 

--------------------------------------------------------------------------------

 
 
West Central Region - PCP Capacity
 
 
Minimum PCP Capacity Requirements
PCPs
Total Required
Champaign
Clark
Darke
Greene
Miami
Montgomery
Preble
Shelby
Additional Required: In-Region *
Capacity 1
42,784
1,472
7,225
1,476
4,347
2,550
22,751
1,541
1,422
 
FTEs
21.39
0.74
3.61
0.74
2.17
1.28
11.38
0.77
0.71
 

 
1  Based on an FTE of 2000 members
       
* Must be located within the region.
       

 
 

--------------------------------------------------------------------------------

 
 
North West Region - PCP Capacity
 
 
County
Capacity 1
FTEs
     
Total Required
68,540
34.27
Allen
4,262
2.13
Auglaize
1,228
0.61
Defiance
1,555
0.78
Fulton
1,270
0.64
Hancock
2,038
1.02
Hardin
1,096
0.55
Henry
894
0.45
Lucas
24,752
12.38
Mercer
821
0.41
Ottawa
1,271
0.64
Paulding
710
0.36
Putnam
770
0.39
Sandusky
2,142
1.07
Seneca
2,128
1.06
Van Wert
847
0.42
Williams
1,478
0.74
Wood
2,444
1.22
Wyandot
634
0.32
Additional Required: In-Region *
18,200
9.10

 
1  Based on an FTE of 2000 members
* Must be located within the region.
 
 

--------------------------------------------------------------------------------

 
 
North East Region - Practitioners
 
 
Minimum Provider Panel Requirements
Provider Types
Total Required Providers1
Ashtabula
Cuyahoga
Erie
Geauga
Huron
Lake
Lorain
Medina
Additional Required Providers2
Pediatricians4
90
1
66
2
   
3
8
3
7
OB/GYNs
25
1
16
1
 
1
1
2
1
2
Vision
33
1
25
1
   
1
2
1
2
General Surgeons
20
 
12
1
 
1
1
2
1
2
Otolaryngologist
6
 
2
       
1
 
3
Allergists
5
 
2
       
1
 
2
Orthopedists
16
 
8
1
   
1
2
1
3
Dentists5
89
2
65
1
1
1
5
10
3
1

 
1 All required providers must be located within the region.
2 Additional required providers may be located anywhere within the region.
3 Preferred Providers are the additional provider contracts that must be secured
in order for the MCP to receive bonus points.
4 Half of this number must be certified by the American Board of Pediatrics.
5 No more than two-thirds of this number can be pediatric dentists.

 
 

--------------------------------------------------------------------------------

 
 
North East Central - Practitioners
 
 
Minimum Provider Panel Requirements
Provider Types
Total Required Providers1
Columbiana
Mahoning
Trumbull
Additional Required Providers2
Pediatricians4
23
2
10
6
5
OB/GYNs
7
1
3
2
1
Vision
7
 
3
2
2
General Surgeons
6
1
3
1
1
Otolaryngologist
2
 
1
 
1
Allergists
1
     
1
Orthopedists
4
 
2
1
1
Dentists5
23
2
11
8
2
           
1 All required providers must be located within the region.
       
2 Additional required providers may be located anywhere within the region.
 
3 Preferred Providers are the additional provider contracts that must be secured
in order for the MCP to receive bonus points.
 
4 Half of this number must be certified by the American Board of Pediatrics.
 
5 No more than two-thirds of this number can be pediatric dentists.
 

 
 

--------------------------------------------------------------------------------

 
 
East Central - Practitioners
 
 
Minimum Provider Panel Requirements
Provider Types
Total Required Providers1
Ashland
Carroll
Holmes
Portage
Richland
Stark
Summit
Tuscarawas
Wayne
Additional Required
Providers2
Pediatricians4
49
1
   
2
3
#
#
2
2
5
OB/GYNs
17
       
1
5
8
 
1
2
Vision
18
       
1
5
8
   
4
General Surgeons
13
     
1
2
3
4
1
1
1
Otolaryngologist
7
         
2
2
   
3
Allergists
3
         
1
1
   
1
Orthopedists
9
       
1
2
2
 
1
3
 Dentists5     
 48
2
   
3 
5 
13
 17
 3
3
2 
                         
1 All required providers must be located within the region.
                   
2 Additional required providers may be located anywhere within the region.
             
3 Preferred Providers are the additional provider contracts that must be secured
in order for the MCP to receive bonus points.
     
4 Half of this number must be certified by the American Board of Pediatrics.
           
5 No more than two-thirds of this number can be pediatric dentists.
               

 
 
 

--------------------------------------------------------------------------------

 
 
South East  - Practitioners
 
 
Minimum Provider Panel Requirements
Provider
Types
Total Required Providers1
Athens
Belmont
Coshocton
Gallia
Guernsey
Harrison
Jackson
Jefferson
Lawrence
Meigs
Monroe
Morgon
Muskingum
Noble
Vinton
Washington
Additional Required Providers2
Pediatricians4
31
1
1
 
2
1
   
1
       
2
   
1
22
OB/GYNs
9
1
     
1
   
1
       
1
   
1
4
Vision
13
1
1
 
1
1
 
1
1
1
     
2
   
1
3
General Surgeons
8
 
1
 
1
1
   
1
       
1
   
1
2
Otolaryngolo-gist
3
     
1
               
1
     
1
Allergists
1
                               
1
Orthopedists
5
     
1
                       
4
Dentists5
30
2
3
1
1
3
 
1
3
2
     
3
   
2
9
 
1 All required providers must be located within the region.
                         
2 Additional required providers may be located anywhere within the region.
                   
3 Preferred Providers are the additional provider contracts that must be secured
in order for the MCP to receive bonus points.
         
4 Half of this number must be certified by the American Board of Pediatrics.
               
5 No more than two-thirds of this number can be pediatric dentists.
                   

 
 

--------------------------------------------------------------------------------

 
 
Central - Practitioners
 
 
Minimum Provider Panel Requirements
Provider Types
Total Required Providers1
Crawford
Delaware
Fairfield
Fayette
Franklin
Hocking
Knox
Licking
Logan
Madison
Marion
Morrow
Perry
Pickaway
Pike
Ross
Scioto
Union
Additional Required Providers2
Pediatricians4
86
 
4
3
 
55
 
1
2
1
1
2
   
1
 
2
2
1
11
OB/GYNs
24
 
2
2
 
12
 
1
1
   
1
       
1
1
 
3
Vision
31
1
2
2
 
15
 
1
1
1
 
1
   
1
 
1
1
1
3
General Surgeons
22
1
1
1
 
10
 
1
1
1
 
1
       
1
1
1
2
Otolaryngologist
6
 
1
   
4
                         
1
Allergists
4
       
2
                         
2
Orthopedists
13
   
1
 
7
   
1
   
1
       
1
   
2
Dentists5
77
1
2
3
1
45
1
2
3
1
1
2
1
1
1
1
3
2
1
5
 
1 All required providers must be located within the region.
                               
2 Additional required providers may be located anywhere within the region.
                     
3 Preferred Providers are the additional provider contracts that must be secured
in order for the MCP to receive bonus points.
             
4 Half of this number must be certified by the American Board of Pediatrics.
                           
5 No more than two-thirds of this number can be pediatric dentists.
                             

 
 

--------------------------------------------------------------------------------

 
 
South West - Practitioners
 
 
Minimum Provider Panel Requirements
Provider Types
Total Required Providers1
Adams
Brown
Butler
Clermont
Clinton
Hamilton
Highland
Warren
Additional Required Providers2
Pediatricians4
59
   
7
2
1
39
   
10
OB/GYNs
16
 
1
2
1
1
9
 
1
1
Vision
21
   
3
1
1
11
1
1
3
General Surgeons
13
   
2
1
1
7
 
1
1
Otolaryngologist
6
   
1
   
3
 
1
1
Allergists
7
         
4
   
3
Orthopedists
9
   
2
   
5
   
2
Dentists5
50
1
1
10
4
1
26
2
2
3
                     
1 All required providers must be located within the region.
               
2 Additional required providers may be located anywhere within the region.
3 Preferred Providers are the additional provider contracts that must be secured
in order for the MCP to receive bonus points.
4 Half of this number must be certified by the American Board of Pediatrics.
5 No more than two-thirds of this number can be pediatric dentists.
                       

 
 

--------------------------------------------------------------------------------

 
 
West Central - Practitioners
 
 
Minimum Provider Panel Requirements
Provider Types
Total Required Providers1
Champaign
Clark
Darke
Greene
Miami
Montgomery
Preble
Shelby
Additional Required Providers2
Pediatricians4
36
 
2
 
3
1
22
   
8
OB/GYNs
12
 
2
 
1
1
6
 
1
1
Vision
20
 
2
1
2
2
10
 
1
2
General Surgeons
10
 
2
 
2
1
3
   
2
Otolaryngologist
7
 
1
     
3
   
3
Allergists
4
         
2
   
2
Orthopedists
5
     
1
 
2
   
2
Dentists5
38
1
5
1
3
3
20
 
1
4
                     
1 All required providers must be located within the region.
               
2 Additional required providers may be located anywhere within the region.
3 Preferred Providers are the additional provider contracts that must be secured
in order for the MCP to receive bonus points.
4 Half of this number must be certified by the American Board of Pediatrics.
5 No more than two-thirds of this number can be pediatric dentists.
 

 
 

--------------------------------------------------------------------------------

 
 
North West - Practitioners
 
 
 Minimum Provider Panel Requirements
Provider Types
Total Required Providers1
Allen
Auglaize
Defiance
Fulton
Hancock
Hardin
Henry
Lucas
Mercer
Ottawa
Paulding
Putnam
Sandusky
Seneca
Van Wert
Williams
Wood
Wyandot
Additional Required Providers2
Pediatricians4
45
4
     
1
   
23
       
1
   
1
2
 
13
OB/GYNs
13
2
     
1
   
5
       
1
1
   
1
 
2
Vision
18
2
1
1
 
1
   
7
1
     
1
   
1
2
 
1
General Surgeons
13
2
     
1
   
4
       
1
   
1
2
 
2
Otolaryngologist
7
1
     
1
   
2
                   
3
Allergists
3
1
           
1
                   
1
Orthopedists
7
2
     
1
   
2
       
1
     
1
   
Dentists5
45
4
1
1
1
2
1
1
20
1
1
 
1
2
2
1
1
2
1
2
                                         
1 All required providers must be located within the region.
                           
2 Additional required providers may be located anywhere within the region.
                       
3 Preferred Providers are the additional provider contracts that must be secured
in order for the MCP to receive bonus points.
           
4 Half of this number must be certified by the American Board of Pediatrics.
                       
5 No more than two-thirds of this number can be pediatric dentists.
                           

 
 

--------------------------------------------------------------------------------

Appendix I
Covered Families and Children (CFC) population    
 
APPENDIX I

PROGRAM INTEGRITY
CFC ELIGIBLE POPULATION

MCPs must comply with all applicable program integrity requirements, including
those specified in 42 CFR 455 and 42 CFR 438 Subpart H.

1.             Fraud and Abuse Program:
In addition to the specific requirements of OAC rule 5101:3-26-06, MCPs must
have a program that includes administrative and management arrangements or
procedures, including a mandatory compliance plan to guard against fraud and
abuse.  The MCP’s compliance plan must designate staff responsibility for
administering the plan and include clear goals, milestones or objectives,
measurements, key dates for achieving identified outcomes, and explain how the
MCP will determine the compliance plan’s effectiveness.

In addition to the requirements in OAC rule 5101:3-26-06, the MCP’s compliance
program which safeguards against fraud and abuse must, at a minimum,
specifically address the following:

 
a.
Employee education about false claims recovery:  In order to comply with Section
6032 of the Deficit Reduction Act of 2005 MCPs must, as a condition of receiving
Medicaid payment, do the following:

 
i.
establish and make readily available to all employees, including the MCP’s
management, the following written policies regarding false claims recovery:

 
a.
detailed information about the federal False Claims Act and other state and
federal laws related to the prevention and detection of fraud, waste, and abuse,
including administrative remedies for false claims and statements as well as
civil or criminal penalties;

 
b.
the MCP’s policies and procedures for detecting and preventing fraud, waste, and
abuse; and

 
c.
the laws governing the rights of employees to be protected as whistleblowers.

 
ii.
include in any employee handbook the required written policies regarding false
claims recovery;

 
1

--------------------------------------------------------------------------------

Appendix I
Covered Families and Children (CFC) population    
 
 
iii.
establish written policies for any MCP contractors and agents that provide
detailed information about the federal False Claims Act and other state and
federal laws related to the prevention and detection of fraud, waste, and abuse,
including administrative remedies for false claims and statements as well as
civil or criminal penalties,; the laws governing the rights of employees to be
protected as whistleblowers; and the MCP’s policies and procedures for detecting
and preventing fraud, waste, and abuse.  MCPs must make such information readily
available to their subcontractors; and

 
 
iv.
disseminate the required written policies to all contractors and agents, who
must abide by those written policies.

 
 
b.
Monitoring for fraud and abuse The MCP’s program which safeguards against fraud
and abuse must specifically address the MCP’s prevention, detection,
investigation, and reporting strategies in at least the following areas:

 
i.
Embezzlement and theft – MCPs must monitor activities on an ongoing basis to
prevent and detect activities involving embezzlement and theft (e.g., by staff,
providers, contractors, etc.) and respond promptly to such violations.

 
ii.
Underutilization of services – MCPs must monitor for the potential
underutilization of services by their members in order to assure that all
Medicaid-covered services are being provided, as required.  If any underutilized
services are identified, the MCP must immediately investigate and, if indicated,
correct the problem(s) which resulted in such underutilization of services.

   The MCP’s monitoring efforts must, at a minimum, include the following
activities:  a) an annual review of their prior authorization procedures to
determine that 
   they do not unreasonably limit a member’s access to Medicaid-covered
services; b) an annual review of the procedures providers are to follow in
appealing the
   MCP’s denial of a prior authorization request to determine that the process
does not unreasonably limit a member’s access to Medicaid-covered services; and
c)
   ongoing monitoring of MCP service denials and utilization in order to
identify services which may be underutilized.

 
iii.
Claims submission and billing – On an ongoing basis, MCPs must identify and
correct claims submission and billing activities which are potentially
fraudulent including, at a minimum, double-billing and improper coding, such as
upcoding and bundling.

 
2

--------------------------------------------------------------------------------

Appendix I
Covered Families and Children (CFC) population    
 
 
c.
Reporting MCP fraud and abuse activities:  Pursuant to OAC rule 5101:3-26-06,
MCPs are required to submit annually to ODJFS a report which summarizes the
MCP’s fraud and abuse activities for the previous year in each of the areas
specified above.  The MCP’s report must also identify any proposed changes to
the MCP’s compliance plan for the coming year.

 
 
d.
Reporting fraud and abuse:  MCPs are required to promptly report all instances
of provider fraud and abuse to ODJFS and member fraud to the CDJFS.  The MCP, at
a minimum, must report the following information on cases where the
MCP’s  investigation has revealed that an incident of fraud and/or abuse has
occurred:
 

 
i.
provider’s name and Medicaid provider number or provider reporting number (PRN);

ii.           source of complaint;

iii.           type of provider;

iv.           nature of complaint;

v.           approximate range of dollars involved, if applicable;

vi.           results of MCP’s investigation and actions taken;

vii.           name(s) of other agencies/entities (e.g., medical board, law
enforcement)notified by MCP; and

 
viii.
legal and administrative disposition of case, including actions taken by law
enforcement officials to whom the case has been referred.

 
 
e.
Monitoring for prohibited affiliations:  The MCP’s policies and procedures for
ensuring that, pursuant to 42 CFR 438.610, the MCP will not knowingly have a
relationship with individuals debarred by Federal Agencies, as specified in
Article XII of the Agreement.

 
3

--------------------------------------------------------------------------------

Appendix I
Covered Families and Children (CFC) population    

2.           Data Certification:
Pursuant to 42 CFR 438.604 and 42 CFR 438.606, MCPs are required to provide
certification as to the accuracy, completeness, and truthfulness of data and
documents submitted to ODJFS which may affect MCP payment.

 
a.
MCP Submissions:  MCPs must submit the appropriate ODJFS-developed certification
concurrently with the submission of the following data or documents:

i.             Encounter Data [as specified in the Data Quality Appendix
(Appendix L)]

 
ii.
Prompt Pay Reports [as specified in the Fiscal Performance Appendix (Appendix
J)]

 
iii.
Cost Reports [as specified in the Fiscal Performance Appendix (Appendix J)]

 
                        iv.           Case Management Data [as specified in the
Data Quality Appendix
                       (Appendix L)]
 
 
b.
Source of Certification:  The above MCP data submissions must be certified by
one of the following:

i.             The MCP’s Chief Executive Officer;

ii.            The MCP’s Chief Financial Officer, or

 
iii.
An individual who has delegated authority to sign for, or who reports directly
to, the MCP’s Chief Executive Officer or Chief Financial Officer.

       ODJFS may also require MCPs to certify as to the accuracy, completeness,
and truthfulness of additional submissions.
 
4

--------------------------------------------------------------------------------

Appendix J
Covered Families and Children (CFC) population 
 
WellCare

APPENDIX J

FINANCIAL PERFORMANCE
CFC ELIGIBLE POPULATION

1.            SUBMISSION OF FINANCIAL STATEMENTS AND REPORTS

MCPs must submit the following financial reports to ODJFS:

 
a.
The National Association of Insurance Commissioners (NAIC) quarterly and annual
Health Statements (hereafter referred to as the “Financial Statements”), as
outlined in Ohio Administrative Code (OAC) rule 5101:3-26-09(B).  The Financial
Statements must include all required Health Statement filings, schedules and
exhibits as stated in the NAIC Annual Health Statement Instructions including,
but not limited to, the following sections:  Assets, Liabilities, Capital and
Surplus Account, Cash Flow, Analysis of Operations by Lines of Business,
Five-Year Historical Data, and the Exhibit of Premiums, Enrollment and
Utilization.  The Financial Statements must be submitted to BMHC even if the
Ohio Department of Insurance (ODI) does not require the MCP to submit these
statements to ODI.  A signed hard copy and an electronic copy of the reports in
the NAIC-approved format must both be provided to ODJFS;

 
b.
Hard copies of annual financial statements for those entities who have an
ownership interest totaling five percent or more in the MCP or an indirect
interest of five percent or more, or a combination of direct and indirect
interest equal to five percent or more in the MCP;

 
c.
Annual audited Financial Statements prepared by a licensed independent external
auditor as submitted to the ODI, as outlined in OAC rule 5101:3-26-09(B);

 
d.
Medicaid Managed Care Plan Annual Ohio Department of Job and Family Services
(ODJFS) Cost Report and the auditor’s certification of the cost report, as
outlined in OAC rule 5101:3-26-09(B);

 
e.
Medicaid MCP Annual Restated Cost Report for the prior calendar year.  The
restated cost report shall be audited upon BMHC request;

 
 
f.
Annual physician incentive plan disclosure statements and disclosure of and
changes to the MCP’s physician incentive plans, as outlined in OAC rule
5101:3-26-09(B);

 
                g.            Reinsurance agreements, as outlined in OAC rule
5101:3-26-09(C);

 
h.
Prompt Pay Reports, in accordance with OAC rule 5101:3-26-09(B). A hard copy and
an electronic copy of the reports in the ODJFS-specified format must be provided
to ODJFS;

 
1

--------------------------------------------------------------------------------

Appendix J
Covered Families and Children (CFC) population 
 
 
i.
Notification of requests for information and copies of information released
pursuant to a tort action (i.e., third party recovery), as outlined in OAC rule
5101:3-26-09.1;

 
j.
Financial, utilization, and statistical reports, when ODJFS requests such
reports, based on a concern regarding the MCP’s quality of care, delivery of
services, fiscal operations or solvency, in accordance with OAC rule
5101:3-26-06(D);

 
k.
In accordance with ORC Section 5111.76 and Appendix C, MCP Responsibilities,
MCPs must submit ODJFS-specified franchise fee reports in hard copy and
electronic formats pursuant to ODJFS specifications.

 
2.            FINANCIAL PERFORMANCE MEASURES AND STANDARDS

This Appendix establishes specific expectations concerning the financial
performance of MCPs.  In the interest of administrative simplicity  and
nonduplication of areas of the ODI authority, ODJFS’  emphasis is on the
assurance of access to and quality of care. ODJFS will focus only on a limited
number of indicators and related standards to monitor plan performance.  The
three indicators and standards for this contract period are identified below,
along with the calculation methodologies.  The source for each indicator will be
the NAIC Quarterly and Annual Financial Statements.

Report Period: Compliance will be determined based on the annual Financial
Statement.

a.             Indicator:               Net Worth as measured by Net Worth Per
Member

 
Definition:
Net Worth = Total Admitted Assets minus Total Liabilities divided by Total
Members across all lines of business

 
Standard:
For the financial report that covers calendar year 2008, a minimum net worth per
member of $363.00, as determined from the annual Financial Statement submitted
to ODI and the ODJFS.

The Net Worth Per Member (NWPM) standard is the Medicaid Managed Care Capitation
amount paid to the MCP during the preceding calendar year, including delivery
payments, but excluding the at-risk amount, expressed as a per-member per-month
figure, multiplied by the applicable proportion below:

0.75 if the MCP had a total membership of 100,000 or more during that calendar
year 0.90 if the MCP had a total membership of less than 100,000 for that
calendar year.  If the MCP did not receive Medicaid Managed Care Capitation
payments during the preceding calendar year, then the NWPM standard for the MCP
is the average Medicaid Managed Care capitation amount paid to
Medicaid-contracting MCPs during the preceding calendar year, including delivery
payments, but excluding the at-risk amount, multiplied by the applicable
proportion above.

2

--------------------------------------------------------------------------------

Appendix J
Covered Families and Children (CFC) population 
          
       b.           Indicator:               Administrative Expense Ratio

 
Definition:
Administrative Expense Ratio = Administrative Expenses minus Franchise Fees
divided by Total Revenue minus Franchise Fees.

 
Standard:
Administrative Expense Ratio not to exceed 15%, as determined from the annual
Financial Statement submitted to ODI and ODJFS.

 
c.             Indicator:              Overall Expense Ratio

Definition:            Overall Expense Ratio = The sum of the Administrative
Expense Ratio and the Medical Expense Ratio.
 
Administrative Expense Ratio = Administrative Expenses minus Franchise Fees
divided by Total Revenue minus Franchise Fees.

Medical Expense Ratio = Medical Expenses divided by Total Revenue minus
Franchise Fees.

 
Standard:
Overall Expense Ratio not to exceed 100% as determined from the annual Financial
Statement submitted to ODI and ODJFS.

 
Penalty for noncompliance: Failure to meet any standard on 2.a., 2.b., or 2.c.
above will result in ODJFS requiring the MCP to complete a corrective action
plan (CAP) and specifying the date by which compliance must be
demonstrated.  Failure to meet the standard or otherwise comply with the CAP by
the specified date will result in a new membership freeze unless ODJFS
determines that the deficiency does not potentially jeopardize access to or
quality of care or affect the MCP’s ability to meet administrative requirements
(e.g., prompt pay requirements).  Justifiable reasons for noncompliance may
include one-time events (e.g., MCP investment in information system products).

If the financial statement is not submitted to ODI by the due date, the MCP
continues to be obligated to submit the report to ODJFS by ODI’s originally
specified due date unless the MCP requests and is granted an extension by ODJFS.
 
3

--------------------------------------------------------------------------------

Appendix J
Covered Families and Children (CFC) population 
 
Failure to submit complete quarterly and annual Financial Statements on a timely
basis will be deemed a failure to meet the standards and will be subject to the
noncompliance penalties listed for indicators 2.a., 2.b., and 2.c., including
the imposition of a new membership freeze.  The new membership freeze will take
effect at the first of the month following the month in which the determination
was made that the MCP was non-compliant for failing to submit financial reports
timely.

In addition, ODJFS will review two liquidity indicators if a plan demonstrates
potential problems in meeting related administrative requirements or the
standards listed above.  The two standards, 2.d and 2.e, reflect ODJFS’ expected
level of performance.  At this time, ODJFS has not established penalties for
noncompliance with these standards; however, ODJFS will consider the MCP’s
performance regarding the liquidity measures, in addition to indicators 2.a.,
2.b., and 2.c., in determining whether to impose a new membership freeze, as
outlined above, or to not issue or renew a contract with an MCP.  The source for
each indicator will be the NAIC Quarterly and annual Financial Statements.

Long-term investments that can be liquidated without significant penalty within
24 hours, which a plan would like to include in Cash and Short-Term Investments
in the next two measurements, must be disclosed in footnotes on the NAIC
Reports.  Descriptions and amounts should be disclosed.  Please note that
“significant penalty” for this purpose is any penalty greater than 20%. Also,
enter the amortized cost of the investment, the market value of the investment,
and the amount of the penalty.

d.            Indicator:               Days Cash on Hand

 
Definition:
Days Cash on Hand = Cash and Short-Term Investments divided by (Total Hospital
and Medical Expenses plus Total Administrative Expenses) divided by 365.

 
Standard:
Greater than 25 days as determined from the annual Financial Statement submitted
to ODI and ODJFS.

e.             Indicator:              Ratio of Cash to Claims Payable

 
Definition:
Ratio of Cash to Claims Payable = Cash and Short-Term Investments divided by
claims Payable (reported and unreported).

 
Standard:
Greater than 0.83 as determined from the annual Financial Statement submitted to
ODI and ODJFS.

 
 
4

--------------------------------------------------------------------------------

Appendix J
Covered Families and Children (CFC) population 

3.            REINSURANCE REQUIREMENTS

Pursuant to the provisions of OAC rule 5101:3-26-09 (C), each MCP must carry
reinsurance coverage from a licensed commercial carrier to protect against
inpatient-related medical expenses incurred by Medicaid members.

The annual deductible or retention amount for such insurance must be specified
in the reinsurance agreement and must not exceed $75,000.00, except as provided
below.  Except for transplant services, and as provided below, this reinsurance
must cover, at a minimum, 80% of inpatient costs incurred by one member in one
year, in excess of $75,000.00.

For transplant services, the reinsurance must cover, at a minimum, 50% of
inpatient transplant related costs incurred by one member in one year, in excess
of $75,000.00.

An MCP may request a higher deductible amount and/or that the reinsurance cover
less than 80% of inpatient costs in excess of the deductible amount.  If the MCP
does not have more than 75,000 members in Ohio, but does have more than 75,000
members between Ohio and other states, ODJFS may consider alternate reinsurance
arrangements.  However, depending on the corporate structures of the Medicaid
MCP, other forms of security may be required in addition to reinsurance.  These
other security tools may include parental guarantees, letters of credit, or
performance bonds. In determining whether or not the request will be approved,
the ODJFS may consider any or all of the following:

 
a.
whether the MCP has sufficient reserves available to pay unexpected claims;

 
b.
the MCP’s history in complying with financial indicators 2.a., 2.b., and 2.c.,
as specified in this Appendix.

 
    c.            the number of members covered by the MCP;

 
d.
how long the MCP has been covering Medicaid or other members on a full risk
basis.

 
    e.             risk based capital ratio greater than 2.5 calculated from the
last annual ODI financial statement.

 
f.
scatter diagram or bar graph from the last calendar year that shows the number
of reinsurance claims that exceeded the current reinsurance deductible.

 
    The MCP has been approved  to have a reinsurance policy with a deductible
amount of  $75,000 that covers 80% of inpatient costs in excess of the
deductible amount 
                for non- transplant services.
 
5

--------------------------------------------------------------------------------

Appendix J
Covered Families and Children (CFC) population 
 
Penalty for noncompliance: If it is determined that an MCP failed to have
reinsurance coverage, that an MCP’s deductible exceeds $75,000.00 without
approval from ODJFS, or that the MCP’s reinsurance for non-transplant services
covers less than 80% of inpatient costs in excess of the deductible incurred by
one member for one year without approval from ODJFS, then the MCP will be
required to pay a monetary penalty to ODJFS.  The amount of the penalty will be
the difference between the estimated amount, as determined by ODJFS, of what the
MCP would have paid in premiums for the reinsurance policy if it had been in
compliance and what the MCP did actually pay while it was out of compliance plus
5%.  For example, if the MCP paid $3,000,000.00 in premiums during the period of
non-compliance and would have paid $5,000,000.00 if the requirements had been
met, then the penalty would be $2,100,000.00.

If it is determined that an MCP’s reinsurance for transplant services covers
less than 50% of inpatient costs incurred by one member for one year, the MCP
will be required to develop a corrective action plan (CAP).
 
 4.   
PROMPT PAY REQUIREMENTS
 

In accordance with 42 CFR 447.46, MCPs must pay 90% of all submitted clean
claims within 30 days of the date of receipt and 99% of such claims within 90
days of the date of receipt, unless the MCP and its contracted provider(s) have
established an alternative payment schedule that is mutually agreed upon and
described in their contract.  The clean pharmacy and non-pharmacy claims will be
separately measured against the 30 and 90 day prompt pay standards.  The prompt
pay requirement applies to the processing of both electronic and paper claims
for contracting and non-contracting providers by the MCP and delegated claims
processing entities.

The date of receipt is the date the MCP receives the claim, as indicated by its
date stamp on the claim.  The date of payment is the date of the check or date
of electronic payment transmission.  A claim means a bill from a provider for
health care services that is assigned a unique identifier.  A claim does not
include an encounter form.

A “claim” can include any of the following:  (1) a bill for services; (2) a line
item of services; or (3) all services for one recipient within a bill.  A “clean
claim” is a claim that can be processed without obtaining additional information
from the provider of a service or from a third party.

Clean claims do not include payments made to a provider of service or a third
party where the timing of the payment is not directly related to submission of a
completed claim by the provider of service or third party (e.g., capitation).  A
clean claim also does not include a claim from a provider who is under
investigation for fraud or abuse, or a claim under review for medical necessity.

Penalty for noncompliance:  Noncompliance with prompt pay requirements will
result in progressive penalties to be assessed on a quarterly basis, as outlined
in Appendix N of the Provider Agreement.

 
6

--------------------------------------------------------------------------------

Appendix J
Covered Families and Children (CFC) population 
 
5.            PHYSICIAN INCENTIVE PLAN DISCLOSURE REQUIREMENTS

MCPs must comply with the physician incentive plan requirements stipulated in 42
CFR 438.6(h).  If the MCP operates a physician incentive plan, no specific
payment can be made directly or indirectly under this physician incentive plan
to a physician or physician group as an inducement to reduce or limit medically
necessary services furnished to an individual.

If the physician incentive plan places a physician or physician group at
substantial financial risk [as determined under paragraph (d) of 42 CFR 422.208]
for services that the physician or physician group does not furnish itself, the
MCP must assure that all physicians and physician groups at substantial
financial risk have either aggregate or per-patient stop-loss protection in
accordance with paragraph (f) of 42 CFR 422.208, and conduct periodic surveys in
accordance with paragraph (h) of 42 CFR 422.208.

In accordance with 42 CFR 417.479 and 42 CFR 422.210, MCPs must maintain copies
of the following required documentation and submit to upon request:

 
a.
A description of the types of physician incentive arrangements the MCP has in
place which indicates whether they involve a withhold, bonus, capitation, or
other arrangement.  If a physician incentive arrangement involves a withhold or
bonus, the percent of the withhold or bonus must be specified.

 
b.
A description of information/data feedback to a physician/group on their: 1)
adherence to evidence-based practice guidelines; and  2) positive and/or
negative care variances from standard clinical pathways that may impact outcomes
or costs.  The feedback information may be used by the MCP for activities such
as physician performance improvement projects that include incentive programs or
the development of quality improvement initiatives.

 
c.
A description of the panel size for each physician incentive plan.  If patients
are pooled, then the pooling method used to determine if substantial financial
risk exists must also be specified.

 
d.
If more than 25% of the total potential payment of a physician/group is at risk
for referral services, the MCP must maintain a copy of the results of
the required patient satisfaction survey and documentation verifying that the
physician or physician group has adequate stop-loss protection, including the
type of coverage (e.g., per member per year, aggregate), the threshold amounts,
and any coinsurance required for amounts over the threshold.

 
6.           NOTIFICATION OF REGULATORY ACTION

Any MCP notified by the ODI of proposed or implemented regulatory action must
report such notification and the nature of the action to ODJFS no later than one
working day after receipt from ODI.  The ODJFS may request, and the MCP must
provide, any additional information as necessary to assure continued
satisfaction of program requirements.  MCPs may request that information related
to such actions be considered proprietary in accordance with established ODJFS
procedures.  Failure to comply with this provision will result in an immediate
membership freeze.
 
 
7

--------------------------------------------------------------------------------

Appendix K
Covered Families and Children (CFC) population   

APPENDIX K
 
QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM
AND
EXTERNAL QUALITY REVIEW
CFC 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.

MCPs must initiate the following PIPs:

 
i.
Non-clinical Topic:  Identifying children/members with special health care
needs.

ii.           Clinical Topic:  Well-child visits during the first 15 months of
life.

iii.          Clinical Topic:  Percentage of members aged 2-21 years that access
dental care   services.

Initiation of PIPs will begin in the second year of participation in the
Medicaid managed care program.
 
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.
 
1

--------------------------------------------------------------------------------

Appendix K
Covered Families and Children (CFC) population   
 
It should also be noted that pursuant to the program integrity provisions
outlined in Appendix I, MCPs must monitor for the potential under-utilization of
services by their members in order to assure that all Medicaid-covered services
are being provided, as required.  If any under-utilized services are identified,
the MCP must immediately investigate and correct the problem(s) which resulted
in such under-utilization of services.
 
In addition the MCP must conduct an ongoing review of service denials and must
monitor utilization on an ongoing basis in order to identify services which may
be under-utilized.

c.           SPECIAL HEALTH CARE NEEDS

Each MCP must have mechanisms in place to assess the quality and appropriateness
of care furnished to children/members with special health care needs.  The MCP
must specify the mechanisms used in its annual submission of the QAPI program to
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 are required to
submit Health Employer Data Information Set (HEDIS) audited data for the
following measures:

 
i.
Well Child Visits in the First 15 Months of Life

                              ii.               Child Immunization Status
 
The measures must have received a “report” designation from the HEDIS certified
auditor and must be specific to the Medicaid population.  Data must be submitted
annually and in an electronic format.  Data will be used for MCP clinical
performance monitoring and will be incorporated into comparative reports
developed by the EQRO.

Initiation of submission of performance data will begin in the second year of
participation in the Medicaid managed care program.
 
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

--------------------------------------------------------------------------------

Appendix K
Covered Families and Children (CFC) population   
 
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.  ODJFS will inform the MCPs
when a non-duplication exemption may be requested.

b.           EXTERNAL QUALITY REVIEW PERFORMANCE

In accordance with OAC 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.
 
 
3

--------------------------------------------------------------------------------

Appendix L
Covered Families and Children (CFC) population   

APPENDIX L

DATA QUALITY
CFC 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 Medicaid Managed Health Care Program and
to evaluate Medicaid consumers’ access to and quality of services. Data
collected from MCPs are used in key performance assessments such as the external
quality review, clinical performance measures, utilization review, care
coordination and case management, and in determining incentives.  The data will
also be used in conjunction with the cost reports in setting the premium payment
rates.  The following measures, as specified in this appendix, will be
calculated per MCP and include all Ohio Medicaid members receiving services from
the MCP (i.e., Covered Families and Children (CFC) and Aged, Blind, or Disabled
(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 Encounter Data Quality Measures for CFC and ABD.

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).

Report Period:  The report periods for the SFY 2009 and SFY 2010 contract
periods are listed in Table 1. below.
 
 
1

--------------------------------------------------------------------------------

Appendix L
Covered Families and Children (CFC) population   
 
Table 1. Report Periods for the SFY 2009 and 2010 Contract Periods
Quarterly Report Periods
Data Source:
Estimated Encounter  Data File Update
Quarterly Report
Estimated Issue Date
Contract Period
 
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
Qtr 2 thru Qtr 4: 2006,
Qtr 1 thru Qtr 4: 2007, 2008
Qtr 1 2009
July 2009
August 2009
SFY 2010
Qtr 3, Qtr 4: 2006,
Qtr 1 thru Qtr 4: 2007, 2008
Qtr 1, Qtr 2: 2009
October 2009
November 2009
Qtr 4: 2006,
Qtr 1 thru Qtr 4: 2007, 2008
Qtr 1 thru Qtr 3: 2009
January 2010
February 2010
Qtr 1 thru Qtr 4: 2007, 2008, 2009
April 2010
May 2010

Qtr1 = January to March                                                        
Qtr2 = April to June                                              Qtr3 = July to
SeptemberQtr4 = October to December
 
 
2

--------------------------------------------------------------------------------

Appendix L
Covered Families and Children (CFC) population   

Table 2. Standards – Encounter Data Volume (County-Based Approach)

Data Quality Standard, County-Based Approach:  The standards in Table 2 apply to
the MCP’s county-based results (see County-Based Approach below).  The
utilization rate for all service categories listed in Table 2 must be equal to
or greater than the standard established in Table 2 below.

Category
Measure per 1,000/MM
Standard for Dates of Service
7/1/2003 thru 6/30/2004
Standard for Dates of Service
7/1/2004 thru 6/30/2006
Standard for Dates of Service
on or after 7/1/2006
Description
Inpatient Hospital
Discharges
5.4
5.0
5.4
General/acute care, excluding newborns and mental health and chemical dependency
services
Emergency Department
Visits
51.6
51.4
50.7
Includes physician and hospital emergency department encounters
Dental
38.2
41.7
50.9
Non-institutional and hospital dental visits
Vision
11.6
11.6
10.6
Non-institutional and hospital outpatient optometry and ophthalmology visits
Primary and Specialist Care
220.1
225.7
233.2
Physician/practitioner and hospital outpatient visits
Ancillary Services
144.7
123.0
133.6
Ancillary visits
Behavioral Health
Service
7.6
8.6
10.5
Inpatient and outpatient behavioral encounters
Pharmacy
Prescriptions
388.5
457.6
492.2
Prescribed drugs

 
County-Based Approach:  All counties with managed care membership as
of  February 1, 2006, will be included in a county-based encounter data volume
measure until regional evaluation is implemented for the county’s applicable
region..  Upon implementation of  regional-based evaluation for a particular
county’s region, the county will be included in the MCP’s regional-based results
and will no longer be included in the MCP’s county-based results. County-based
results will be determined by MCP (i.e., one utilization rate per service
category for all applicable counties) and must be equal to or greater than the
standards established in Table 2 above.  [Example: The county-based result for
MCP AAA, which has contracts in the Central and West Central regions, will
include Franklin, Pickaway, Montgomery, Greene and Clark counties (i.e.,
counties with managed care membership as of February 1, 2006).  When the
regional-based evaluation is implemented for the Central region, Franklin and
Pickaway counties, along with all other counties in the region, will then be
included in the Central region results for MCP AAA; Montgomery, Greene, and
Clark counties will remain in the county-based results for MCP AAA until the
West Central regional measure is implemented.]
 
3

--------------------------------------------------------------------------------

Appendix L
Covered Families and Children (CFC) population
 
Interim Regional-Based Approach:
Prior to the transition to the regional-based approach, encounter data volume
will be evaluated by MCP, by region, using an interim approach.  All regions
with managed care membership will be included in results for an interim
regional-based encounter data volume measure until regional evaluation is
implemented for the applicable region (see Regional-Based Approach
below).  Encounter data volume will be evaluated by MCP ( i.e., one utilization
rate per service category for all counties in the region).  The utilization rate
for all service categories listed in Table 3 must be equal to or greater than
the standard established in Table 3 below.  The standards listed in Table 3
below are based on utilization data for counties with managed care membership as
of February 1, 2006, and have been adjusted to accommodate estimated differences
in utilization for all counties in a region, including counties that did not
have membership as of February 1, 2006.

Prior to implementation of the regional-based approach, an MCP’s encounter data
volume will be evaluated using the county-based approach and the interim
regional-based approach.  A county with managed care membership as of February
1, 2006, will be included in both the County-Based approach and the Interim
Regional-Based approach until regional evaluation is implemented for the
county’s applicable region.

Data Quality Standard, Interim Regional-Based Approach:  The standards in Table
3 apply to the MCP’s interim regional-based results.  The utilization rate for
all service categories listed in Table 3 must be equal to or greater than the
standard established in Table 3 below.
 
Table 3.                      Standards – Encounter Data Volume (Interim
Regional-Based Approach)

Category
Measure per 1,000/MM
Standard for Dates of Service
on or after 7/1/2006
Description
Inpatient Hospital
Discharges
2.7
General/acute care, excluding newborns and mental health and chemical dependency
services
Emergency Department
Visits
25.3
Includes physician and hospital emergency department encounters
Dental
25.5
Non-institutional and hospital dental visits
Vision
5.3
Non-institutional and hospital outpatient optometry and ophthalmology visits
Primary and Specialist Care
116.6
Physician/practitioner and hospital outpatient visits
Ancillary Services
66.8
Ancillary visits
Behavioral Health
Service
5.2
Inpatient and outpatient behavioral encounters
Pharmacy
Prescriptions
246.1
Prescribed drugs

 
Regional-Based Approach:
Transition to the regional-based approach will occur by region, after the first
four quarters (i.e., full calendar year quarters) of regional
membership.  Encounter data volume will be evaluated by MCP, by region (i.e.,
one utilization rate per service category for all counties in the region), after
determination of the regional-based data quality standards.  ODJFS will use the
first four quarters of data (i.e., full calendar year quarters) from all MCPs
serving in an active region to determine minimum encounter volume data quality
standards for that region.

The utilization rate for all service categories listed in Table 4 must be equal
to or greater than the standard established in Table 4 below.  The standards
listed in Table 4 below are based on utilization data for regions and have been
adjusted to accommodate estimated differences in utilization for all counties in
a region, including counties that did not have membership as of February 1,
2006.
 
4

--------------------------------------------------------------------------------

Appendix L
Covered Families and Children (CFC) population
 
Table 4. Standards – Encounter Data Volume (Regional-Based Approach)
Region
Category
Measure per 1,000/MM
Standard for Dates of Service
on or after 7/1/2007
Description
Central
Inpatient Hospital
Discharges
TBD
General/acute care, excluding newborns and mental health and chemical dependency
services
Emergency Department
Visits
TBD
Includes physician and hospital emergency department encounters
Dental
TBD
Non-institutional and hospital dental visits
Vision
TBD
Non-institutional and hospital outpatient optometry and ophthalmology visits
Primary & Specialist Care
TBD
Physician/practitioner and hospital outpatient visits
Ancillary Services
TBD
Ancillary visits
Behavioral Health
Service
TBD
Inpatient and outpatient behavioral encounters
Pharmacy
Prescriptions
TBD
Prescribed drugs
East Central
Inpatient Hospital
Discharges
TBD
General/acute care, excluding newborns and mental health and chemical dependency
services
Emergency Department
 
 
 
Visits
TBD
Includes physician and hospital emergency department encounters
Dental
TBD
Non-institutional and hospital dental visits
Vision
TBD
Non-institutional and hospital outpatient optometry and ophthalmology visits
Primary & Specialist Care
TBD
Physician/practitioner and hospital outpatient visits
Ancillary Services
TBD
Ancillary visits
Behavioral Health
Service
TBD
Inpatient and outpatient behavioral encounters
Pharmacy
Prescriptions
TBD
Prescribed drugs
Northeast
Inpatient Hospital
Discharges
TBD
General/acute care, excluding newborns and mental health and chemical dependency
services
Emergency Department
 
 
 
Visits
TBD
Includes physician and hospital emergency department encounters
Dental
TBD
Non-institutional and hospital dental visits
Vision
TBD
Non-institutional and hospital outpatient optometry and ophthalmology visits
Primary & Specialist Care
TBD
Physician/practitioner and hospital outpatient visits
Ancillary Services
TBD
Ancillary visits
Behavioral Health
Service
TBD
Inpatient and outpatient behavioral encounters
Pharmacy
Prescriptions
TBD
Prescribed drugs
Northeast Central
Inpatient Hospital
Discharges
TBD
General/acute care, excluding newborns and mental health and chemical dependency
services
Emergency Department
 
 
 
Visits
TBD
Includes physician and hospital emergency department encounters
Dental
TBD
Non-institutional and hospital dental visits
Vision
TBD
Non-institutional and hospital outpatient optometry and ophthalmology visits
Primary & Specialist Care
TBD
Physician/practitioner and hospital outpatient visits
Ancillary Services
TBD
Ancillary visits
Behavioral Health
Service
TBD
Inpatient and outpatient behavioral encounters
Pharmacy
Prescriptions
TBD
Prescribed drugs

 
 
5

--------------------------------------------------------------------------------

Appendix L
Covered Families and Children (CFC) population   
 
Region
Category
Measure per 1,000/MM
Standard for Dates of Service
on or after 7/1/2007
Description
North-west
Inpatient Hospital
Discharges
TBD
General/acute care, excluding newborns and mental health and chemical dependency
services
Emergency Department
 
 
 
Visits
TBD
Includes physician and hospital emergency department encounters
Dental
TBD
Non-institutional and hospital dental visits
Vision
TBD
Non-institutional and hospital outpatient optometry and ophthalmology visits
Primary & Specialist Care
TBD
Physician/practitioner and hospital outpatient visits
Ancillary Services
TBD
Ancillary visits
Behavioral Health
Service
TBD
Inpatient and outpatient behavioral encounters
Pharmacy
Prescriptions
TBD
Prescribed drugs
Southeast
Inpatient Hospital
Discharges
TBD
General/acute care, excluding newborns and mental health and chemical dependency
services
Emergency Department
 
 
 
Visits
TBD
Includes physician and hospital emergency department encounters
Dental
TBD
Non-institutional and hospital dental visits
Vision
TBD
Non-institutional and hospital outpatient optometry and ophthalmology visits
Primary & Specialist Care
TBD
Physician/practitioner and hospital outpatient visits
Ancillary Services
TBD
Ancillary visits
Behavioral Health
Service
TBD
Inpatient and outpatient behavioral encounters
Pharmacy
Prescriptions
TBD
Prescribed drugs
South-west
Inpatient Hospital
Discharges
TBD
General/acute care, excluding newborns and mental health and chemical dependency
services
Emergency Department
 
 
 
Visits
TBD
Includes physician and hospital emergency department encounters
Dental
TBD
Non-institutional and hospital dental visits
Vision
TBD
Non-institutional and hospital outpatient optometry and ophthalmology visits
Primary & Specialist Care
TBD
Physician/practitioner and hospital outpatient visits
Ancillary Services
TBD
Ancillary visits
Behavioral Health
Service
TBD
Inpatient and outpatient behavioral encounters
Pharmacy
Prescriptions
TBD
Prescribed drugs
West Central
Inpatient Hospital
Discharges
TBD
General/acute care, excluding newborns and mental health and chemical dependency
services
Emergency Department
 
 
 
Visits
TBD
Includes physician and hospital emergency department encounters
Dental
TBD
Non-institutional and hospital dental visits
Vision
TBD
Non-institutional and hospital outpatient optometry and ophthalmology visits
Primary & Specialist Care
TBD
Physician/practitioner and hospital outpatient visits
Ancillary Services
TBD
Ancillary visits
Behavioral Health
Service
TBD
Inpatient and outpatient behavioral encounters
Pharmacy
Prescriptions
TBD
Prescribed drugs

 
6

--------------------------------------------------------------------------------

Appendix L
Covered Families and Children (CFC) population 
 
Determination of Compliance: Performance is monitored once every quarter for the
entire report period.  If the standard is not met for every service category in
all quarters of the report period in either the county-based, interim
regional-based, or regional-based approach, 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

Since July 1, 1997, MCPs have been required to provide both the revenue code and
the HCPCS code on applicable outpatient hospital encounters. ODJFS will be
monitoring, on a quarterly basis, the percentage of hospital encounters which
contain  a revenue code and CPT/HCPCS code. A CPT/HCPCS code must accompany
certain revenue center codes. These codes are listed in Appendix B of Ohio
Administrative Code rule 5101:3-2-21 (fee-for-service outpatient hospital
policies) and in the methods for calculating the completeness measures.

Measure: The percentage of outpatient hospital line items with certain revenue
center codes, as explained above, which had an accompanying valid procedure
(CPT/HCPCS) code.  The measure will be calculated per MCP.

Report Period:  For the SFY 2009 and SFY 2010 contract periods, performance will
be evaluated using the report periods listed in 1.a.i., Table 1.

Data Quality Standard: The data quality standard is a minimum rate of 95%.

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.
 
7

--------------------------------------------------------------------------------

Appendix L
Covered Families and Children (CFC) population
 
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.      Incomplete Data For Last Menstrual Period

As outlined in ODJFS Encounter Data Specifications, the last menstrual period
(LMP) field is a required encounter data field. It is discussed in Item 14 of
the “HCFA 1500 Billing Instructions.” The date of the LMP is essential for
calculating the clinical performance measures and allows the ODJFS to adjust
performance expectations for the length of a pregnancy.

The occurrence code and date fields on the UB-92, which are “optional” fields,
can also be used to submit the date of the LMP. These fields are described in
Items 32a & b, 33a & b, 34a & b, 35a & b of the “Inpatient Hospital” and
“Outpatient Hospital UB-92 Claim Form Instructions.”
 
An occurrence code value of  ‘10’ indicates that a LMP date was  provided. The
actual date of the LMP would be given in the ‘Occurrence Date’ field.
Measure: The percentage of recipients with a live birth during the report period
where a “valid” LMP date was given on one or more of the recipient’s perinatal
claims. If the LMP date is before the date of birth and there is a difference of
between 119 and 315 days between the date the recipient gave birth and the LMP
date, then the LMP date will be considered a valid date.  The measure will be
calculated per MCP (i.e., to include the MCP’s service area for the CFC.

Report Period:   For the SFY 2009 contract period, performance will be evaluated
using the January - December  2008 report period.  For the SFY  2010 contract
period, performance will be evaluated using the January - December  2009 report
period.

Data Quality Standard: The data quality standard is a minimum rate of 80%.

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.
 

 
8

--------------------------------------------------------------------------------

Appendix L
Covered Families and Children (CFC) population   
 
1.a.iv. Rejected Encounters

Encounters submitted to ODJFS that are incomplete or inaccurate are rejected
and  reported back to the MCPs on the Exception Report.  If an MCP does not
resubmit rejected encounters, ODJFS’ encounter data set will be incomplete.

Measure 1 only applies to MCPs that have had Medicaid membership for more than
one year.

Measure 1:  The percentage of encounters submitted to ODJFS that are
rejected.  The measure will be calculated per MCP.

Report Period:  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.  For the SFY 2010 contract
period, performance will be evaluated using the following report periods July -
September 2009; October - December  2009;  January - March  2010;  April –
June  2010.

Data Quality Standard for measure 1:  Data Quality Standard 1 is a maximum
encounter data rejection rate of 10% for each file type in the ODJFS-specified
medium per format for encounters submitted in SFY 2004 and thereafter. The
measure will be calculated per MCP.

Determination of Compliance:  Performance is monitored once every quarter.
Compliance determination with the standard applies only to the quarter under
consideration and does not include performance in previous quarters.

Penalty for noncompliance with the Data Quality Standard for 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.
 
9

--------------------------------------------------------------------------------

Appendix L
Covered Families and Children (CFC) population
 
Data Quality Standard for measure 2:  The data quality standard is a maximum
encounter data rejection rate for each file type in the ODJFS-specified medium
per format as follows:

Third through sixth months with membership:  50%

Seventh through twelfth month with membership:  25%

Files in the ODJFS-specified medium per format that are totally rejected will
not be considered in the determination of noncompliance.

Determination of Compliance:  Performance is monitored once every
month.  Compliance determination with the standard applies only to the month
under consideration and does not include performance in previous quarters.

Penalty for Noncompliance with the Data Quality Standard for 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.v. Acceptance Rate

This measure only applies to MCPs that have had Medicaid membership for one year
or less.

Measure: The rate of encounters that are submitted to ODJFS and accepted
(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 type 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
 
10

--------------------------------------------------------------------------------

Appendix L
Covered Families and Children (CFC) population
 
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 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.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 Studies

Measure 1:  The focus of this accuracy study will be on delivery
encounters.  Its primary purpose will be to verify that MCPs submit encounter
data accurately and  to ensure only one payment is made per delivery.  The rate
of appropriate payments will be determined by comparing a sample of delivery
payments to the medical record.  The measure will be calculated per MCP (i.e.,
to include the MCP’s entire service area for the CFC membership.

Report Period:  In order to provide timely feedback on the accuracy rate of
encounters, the report period will be the most recent from when the measure is
initiated.  This measure is conducted annually.

Medical records retrieval from the provider and submittal to ODJFS or its
designee is an integral component of the validation process.  ODJFS has
optimized the sampling to minimize the number of records required.  This
methodology requires a high record submittal rate.  To aid MCPs in achieving a
high submittal rate, ODJFS will give at least an 8 week period to retrieve and
submit medical records as a part of the validation process.  A record submittal
rate will be calculated as a percentage of all records requested for the study.

Data Quality Standard 1 for Measure 1: For results that are finalized during the
contract year, the accuracy rate for encounters generating delivery payments is
100%.
 
11

--------------------------------------------------------------------------------

Appendix L
Covered Families and Children (CFC) population
 
Penalty for noncompliance: The MCP must participate in a detailed review of
delivery payments made for deliveries during the report period.  Any duplicate
or unvalidated delivery payments must be returned to ODJFS.

Data Quality Standard 2 for Measure 1:  A minimum record submittal rate of 85%.

Penalty for noncompliance:  For all encounter data accuracy studies that are
completed during this contract period, if an MCP is noncompliant with the
standard, ODJFS will impose a non-refundable $10,000 monetary sanction.

Measure 2:  This accuracy study will compare the accuracy and completeness of
payment data stored in  MCPs’ claims systems during the study period to payment
data submitted to and accepted by ODJFS. The measure will be calculated per
MCP.  

Payment information found in MCPs’ claims systems for paid claims that does not
match payment information found on a corresponding encounter will be counted as
omissions.

Report Period:  In order to provide timely feedback on the omission rate of
encounters, the report period will be the most recent from when the measure is
initiated.  This measure is conducted annually.

Data Quality Standard for Measure 2:   For SFY 2009 and SFY 2010, to be
determined.

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 1: This measure is the percentage of institutional (UB-92) and
professional (NSF) encounters with the generic provider number in the Medicaid
Provider Number field.  Providers submitting claims which do not have an MMIS
provider number in the Medicaid Provider Number field must be submitted to ODJFS
with the generic provider number (i.e. 9111115).  The measure will be calculated
per MCP. The report period for this measure is quarterly.

Report Period for Measure 1:  For the SFY 2009 and SFY 2010 contract periods,
performance will be evaluated using the report periods listed in 1.a.i., Table
1.
 
12

--------------------------------------------------------------------------------

Appendix L
Covered Families and Children (CFC) population
 
Data Quality Standard for Measure 1: A maximum generic provider number usage
rate of 10%.

Determination of Compliance for Measure 1: 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 for 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 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.

Measure 2: This measure is the percentage of pharmacy encounters with the
generic provider number in the “Prescribing Provider ID” field.  Providers
submitting claims which do not have an MMIS provider number in the “Prescribing
Provider ID” field must be submitted to ODJFS with the generic provider number
(i.e. 9111115).  The measure will be calculated per MCP.  The report period for
this measure is quarterly.

Report Period for Measure 2:  For the SFY 2009 and SFY 2010 contract periods,
performance will be evaluated using the report periods listed in 1.a.i., Table
1.

Data Quality Standard for Measure 2:  To be determined.

Determination of Compliance for Measure 2: Performance is monitored once every
quarter for all report periods on or after July 1, 2008.  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 with Measure 2 :   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.
 
13

--------------------------------------------------------------------------------

Appendix L
Covered Families and Children (CFC) population
 
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.v.) 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 and Submission Specifications document.  The
MCP must submit a letter of certification, using the form required by ODJFS,
with each encounter data file in the ODJFS-specified medium per format.

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 CSHCN requirements.   For detailed descriptions of
the case management measures below, see ODJFS Methods for Case Management 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 adult and children case management records
in the Screening, Assessment, and Case Management System that have open case
management date spans for members who have disenrolled from the MCP.

Report Period: For the SFY 2008 contract period, July – September 2007, and
October – December 2007.
 
Statewide and Regional Data Quality Standard:  A rate of open case management
spans for disenrolled members of no more than 1.0%.
 
14

--------------------------------------------------------------------------------

Appendix L
Covered Families and Children (CFC) population
 
For an MCP which had membership as of February 1, 2006:  Performance will be
evaluated using: 1) region-based results for any active region in which all
selected MCPs had at least 10,000 members during each month of the entire report
period; and/or 2) the statewide result for all counties that were not included
in the region-based results, but in which the MCP had managed care membership as
of February 1, 2006.

For any MCP which did not have membership as of February 1, 2006: Performance
will begin to be evaluated using region-based results for any active region  in
which all selected MCPs had at least 10,000 members during each month of the
entire report period.

Regional-Based Approach: MCPs will be evaluated by region, using results for all
counties included in the region.

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.  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.
 
 
15

--------------------------------------------------------------------------------

Appendix L
Covered Families and Children (CFC) population   

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 CFC 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 CFC population in ODJFS Member’s PCP Data
File and Submission Specifications; however, no CFC 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 file 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.
 
16

--------------------------------------------------------------------------------

Appendix L
Covered Families and Children (CFC) population
 
4.b.          Designated PCP for newly enrolled members (only 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 SFY 2008 contract period, performance will be evaluated
using the July-September 2007, and October – December 2007 report periods.

Data Quality Standard:  SFY 2007 will be informational only. A minimum rate of
75% of new members with PCP designation by their effective date of enrollment
for quarter one and quarter two of SFY 2008.

Statewide Approach:  MCPs will be evaluated using a statewide result, including
all active regions and counties (Mahoning and Trumbull) in which an MCP has CFC
membership.

Penalty for noncompliance:  If an MCP is noncompliant with the standard, ODJFS
will impose a monetary sanction of one-half of one percent the current month’s
premium payment.  Once the MCP is performing at standard levels and
violations/deficiencies are resolved to the satisfaction of ODJFS, the money
will be refunded.  As stipulated in OAC rule 5101:3-26-08.2, each new member
must have a designated primary care 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 (only 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.

Statewide Approach:  MCPs  will be evaluated using their statewide result,
including all active regions and counties (Mahoning and Trumbull) in which an
MCP has CFC membership.

Report Periods:  For the SFY 2009 contract period, performance will be evaluated
annually using CY 2008.  For the SFY 2010 contract period, performance will be
evaluated annually using CY 2009.

Data Quality Standards:  For SFY 2009, a minimum rate of 85% of new members with
PCP designation by their effective date of enrollment.  For SFY 2010, a minimum
rate of 85% of new members with PCP designation by their effective date of
enrollment.

Penalty for noncompliance:  If an MCP is noncompliant with the standard, ODJFS
will impose a monetary sanction of one-half of one percent the current month’s
premium payment.  Once the MCP is performing at standard levels and
violations/deficiencies are resolved to the satisfaction of ODJFS, the money
will be refunded.  As stipulated in OAC rule 5101:3-26-08.2, each new member
must have a designated primary care 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.
 
17

--------------------------------------------------------------------------------

Appendix L
Covered Families and Children (CFC) population
 
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.v., 1.a.iv, 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 period.

Refundable monetary sanctions will be based on the premium payment in the month
of  the cited deficiency and due within 30 days of notification by ODJFS to the
MCP of the amount.

Any monies collected through the imposition of such a sanction will be returned
to the MCP (minus any applicable collection 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.
 
18

--------------------------------------------------------------------------------

Appendix L
Covered Families and Children (CFC) population
 
6.b.          Combined Remedies

If ODJFS determines that one systemic problem is responsible for multiple
deficiencies, ODJFS may impose a combined remedy which will address all areas of
deficient performance.  The total fines assessed in any one month will not
exceed 15% of the MCP’s monthly premium payment.

6.c.          Membership Freezes

MCPs found to have a pattern of repeated or ongoing noncompliance may be subject
to a membership freeze.

6.d.          Reconsideration

Requests for reconsideration of monetary sanctions and enrollment freezes may be
submitted as provided in Appendix N, Compliance Assessment System.

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.

 
19

--------------------------------------------------------------------------------

Appendix M
Covered Families and Children (CFC) population   
 
APPENDIX M

PERFORMANCE EVALUATION
CFC ELIGIBLE POPULATION

This appendix establishes minimum performance standards for managed care plans
(MCPs) in key program areas.  The intent is to maintain accountability for
contract requirements.  Standards are subject to change based on the revision or
update of applicable national standards, methods or benchmarks.  Performance
will be evaluated in the categories of Quality of Care, Access, Consumer
Satisfaction, and Administrative Capacity.  Each performance measure has an
accompanying minimum performance standard. MCPs with performance levels below
the minimum performance standards will be required to take corrective action.

With the statewide expansion of the Ohio Medicaid Managed Care Program for the
Covered Families and Children (CFC) population nearly complete, evaluation of
performance will transition to a statewide approach encompassing all members who
meet the criteria specified per the given methodology for each measure (i.e.,
measures will include members in any county who meet criteria per the given
methodology as opposed to only those members with managed care membership as of
February 1, 2006).

The statewide approach was implemented beginning January 1, 2008.  Unless
otherwise noted, performance measures and standards (see Sections 1, 2, 3 and 4
of this appendix) will be applicable for all counties in which the MCP has
membership as of February 1, 2006, until statewide measurement is implemented.

Selected measures in this appendix will be used to determine pay-for-performance
(P4P) as specified in Appendix O, Pay for Performance.

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 review covers 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.
 
1

--------------------------------------------------------------------------------

Appendix M
Covered Families and Children (CFC) population 
 
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
provider agreement.
 
1.b.           Children with Special Health Care Needs (CSHCN)

In order to ensure state compliance with  the provisions of 42 CFR 438.208, the
Bureau of Managed Health Care established Children with Special Health Care
Needs (CSHCN) basic program requirements in Appendix G, Coverage and
Services,  and corresponding minimum performance standards as described below.
The purpose of these measures is to provide appropriate and targeted case
management services to CSHCN.

1.b.i.         Case Management of Children (applicable to performance evaluation
through December 2007 and P4P through SFY 2009)

Measure: The average monthly case management rate for children under 21 years of
age.

Report Period: For the SFY 2008 contract period:  July – September 2007 and
October – December 2007 (for evaluation); and April – June 2008 (for P4P) report
periods. For the SFY 2009 contract period: April – June 2009 (for P4P) report
periods.

County-Based Approach:  MCPs with managed care membership as of February 1, 2006
will be evaluated  using their county-based statewide result until regional
evaluation is implemented for the county’s applicable region.  The county-based
statewide result will include data for all counties in which the MCP had
membership as of February 1, 2006 that are not included in any regional-based
result.  Regional-based results will not be used for evaluation until all
selected MCPs in an active region have at least 10,000 members during each month
of the entire report period.  Upon implementation of regional-based evaluation
for a particular county’s region, the county will be included in the MCP’s
regional-based result and will no longer be included in the MCP’s county-based
statewide result. [Example: The county-based statewide result for MCP AAA, which
has contracts in the Central and West Central regions, will include Franklin,
Pickaway, Montgomery, Greene and Clark counties (i.e., counties in which MCP AAA
had managed care membership as of February 1, 2006).  When regional-based
evaluation is implemented for the Central region, Franklin and Pickaway
counties, along with all other counties in the region, will then be included in
the Central region results for MCP AAA; Montgomery, Greene, and Clark counties
will remain in the county-based statewide result for evaluation of MCP AAA until
the West Central regional-based approach is implemented.] The last report period
using the MCP’s county-based statewide result for the counties in which the MCP
had membership as of February 1, 2006 for P4P (Appendix O) is April-June
2009.  A detailed description of the of excellent and superior standards
associated with this measure for P4P determination for SFY 2008 and SFY 2009 can
be found in Appendix O, Section 1.b1 and Section 2.b1.

Regional-Based Approach:   MCPs will be evaluated by region, using results for
all counties included in the region.  Performance will begin to be evaluated
using regional-based results for any active region in which all selected MCPs
had at least 10,000 members during each month of the entire report period.
 
2

--------------------------------------------------------------------------------

Appendix M
Covered Families and Children (CFC) population 
 
County and Regional-Based Minimum Performance Standard: For the third and fourth
quarters of SFY 2007, a case management rate of 5.0%.  For the first and second
quarters of SFY 2008, a case management rate of 5.0%.

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 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.b.ii.        Case Management of Children (applicable to performance evaluation
as of  January, 2008 and P4P as of SFY 2010)

Measure: The average monthly case management rate for children under 21 years of
age.

Report Period: For the SFY 2008 contract period, 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. For the SFY 2010 contract period,  July – September 2009,
October – December 2009, January – March 2010, and April – June 2010 report
periods.

Regional-Based Statewide Approach:  Performance will be evaluated using a
regional-based statewide approach for all active regions and counties (Mahoning
and Trumbull) in which the MCP has membership.

Regional-Based Statewide Target:  For the third and fourth quarters of SFY 2008,
a case management rate of 5.0%.  For SFY 2009, a case management rate of
5.0%.  For SFY 2010, a case management rate of 5.0%.

Regional-Based 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 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.
 
3

--------------------------------------------------------------------------------

Appendix M
Covered Families and Children (CFC) population 
 
1.b.iii.      Case Management of Children with an ODJFS-Mandated Condition
(applicable to performance evaluation through December 2007)

Measure 1:  The percent of  children under 21 years of age with a positive
identification through an ODJFS administrative review of data for the
ODJFS-mandated case management condition of  asthma that are case managed.

Measure 2:  The percent of  children age 17 and under with a positive
identification through an ODJFS administrative review of data for the
ODJFS-mandated case management condition of teenage pregnancy that are case
managed.

Measure 3:  The percent of  children under 21 years of age with a positive
identification through an ODJFS administrative review of data for the
ODJFS-mandated case management condition of HIV/AIDS that are case managed.

Report Periods for Measures 1, 2, and 3: For the SFY 2008 contract period, July
– September 2007 and October – December 2007 report periods.

County-Based Approach:  MCPs with managed care membership as of February 1, 2006
will be evaluated using their county-based statewide result until regional
evaluation is implemented for the county’s applicable region.  The county-based
statewide result will include data for all counties in which the MCP had
membership as of February 1, 2006 that are not included in any regional-based
result.  Regional-based results will not be used for evaluation until all
selected MCPs in an active region have at least 10,000 members during each month
of the entire report period.  Upon implementation of regional-based evaluation
for a particular county’s region, the county will be included in the MCP’s
regional-based result and will no longer be included in the MCP’s county-based
statewide result. [Example: The county-based statewide result for MCP AAA, which
has contracts in the Central and West Central regions, will include Franklin,
Pickaway, Montgomery, Greene and Clark counties (i.e., counties in which MCP AAA
had managed care membership as of February  1, 2006).  When regional-based
evaluation is implemented for the Central region, Franklin and Pickaway
counties, along with all other counties in the region, will then be included in
the Central region results for MCP AAA; Montgomery, Greene, and Clark counties
will remain in the county-based statewide result for evaluation of MCP AAA until
the West Central regional-based approach is implemented.]

Regional-Based Approach: MCPs will be evaluated by region, using results for all
counties included in the region.  Performance will begin to be evaluated using
regional-based results for any active region in which all selected MCPs had at
least 10,000 members during each month of the entire report period.
 
4

--------------------------------------------------------------------------------

Appendix M
Covered Families and Children (CFC) population 
 
County and Regional-Based Minimum Performance Standard for Measures 1 and 3: For
the third and fourth quarters of SFY 2007, a case management rate of 70%.  For
the first and second quarters of SFY 2008, a case management rate of 70%.

County and Regional-Based Minimum Performance Standard for Measure 2: For the
first and second quarters of SFY 2008, a case management rate of 60%.

Penalty for Noncompliance for Measures 1 and 2:  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 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.  Note:  For the first reporting period
during which regional results are used to evaluate performance, measures 1, 2,
and 3 are reporting-only measures.  For SFY 2008, measure 3 is a reporting-only
measure.
 
1.b.iv.       Case Management of Children with an ODJFS-Mandated
Condition (applicable to performance evaluation as of January 2008)

Measure 1:  The percent of  children under 21 years of age with a positive
identification through an ODJFS administrative review of data for the
ODJFS-mandated case management condition of  asthma that are case managed.

Measure 2:  The percent of children under 21 years of age with a positive
identification through an ODJFS administrative review of data for the
ODJFS-mandated case management condition of HIV/AIDS that are case managed.

Report Periods for Measures 1 and 2:   For the SFY 2008 contract period, 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.  For the SFY 2010 contract period, July –
September 2009, October – December 2009, January – March 2010, and April – June
2010 report periods.

Regional-Based Statewide Approach: Performance will be evaluated using a
regional-based statewide approach for all active regions and counties (Mahoning
and Trumbull) in which the MCP has membership.
 
5

--------------------------------------------------------------------------------

Appendix M
Covered Families and Children (CFC) population 

Regional-Based Statewide Target for Measures 1 and 2:  For the third and fourth
quarters of SFY 2008, a case management rate of 70.0%.  For SFY 2009, a case
management rate of 80.0%.  For SFY 2010, a case management rate of 80.0%.

Regional-Based Statewide Minimum Performance Standard for Measures 1
and  2:  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 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 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 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. For SFY 2008 and SFY 2009, measure 2 is a
reporting-only measure.

1.c.           Clinical Performance Measures
 
MCP performance will be assessed based on the analysis of submitted encounter
data for each year. For certain measures, standards are established; the
identification of these standards is not intended to limit the assessment of
other indicators for performance improvement activities.  Performance on
multiple measures will be assessed and reported to the MCPs and others,
including Medicaid consumers.
 
The clinical performance measures described below closely follow the National
Committee for Quality Assurance’s Healthcare Effectiveness Data and Information
Set (HEDIS).  Minor adjustments to HEDIS measures are required to account for
the differences between the commercial population and the Medicaid population,
such as shorter and interrupted enrollment periods. NCQA may annually change its
method for calculating a measure.  These changes can make it difficult to
evaluate whether improvement occurred from a  prior year.  For this reason,
ODJFS will use the same methods to calculate the baseline results and the
results for the period in which the MCP is being held accountable.  For example,
the same methods were being used to calculate calendar year  2005 results (the
baseline period) and calendar year  2006 results.  The methods will be updated
and a new baseline will be created during 2007 for calendar  year  2006
results.  These results will then serve as the baseline to evaluate whether
improvement occurred from calendar  year 2006 to calendar year 2007. 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 for the CFC 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.
 
6

--------------------------------------------------------------------------------

Appendix M
Covered Families and Children (CFC) population 
 
For an MCP which had membership as of February 1, 2006: MCP performance will be
evaluated using an MCP’s county-based statewide result for the counties in which
the MCP had membership as of February 1, 2006.  For reporting period CY 2008,
targets and performance standards for Clinical Performance Measures in this
Appendix (1.c.i – 1.c.vii) will be applicable to all counties in which MCPs had
membership as of February 1, 2006.  The final reporting year for the counties in
which an MCP had membership as of February 1, 2006, will be CY 2008.

For any MCP which did not have membership as of February 1, 2006:  Performance
will be evaluated using a regional-based statewide approach for all active
regions and counties (Trumbull and Mahoning) in which the MCP has membership.

Regional-Based Statewide Approach: MCPs will be evaluated statewide, using
results for all active regions and counties (Mahoning and Trumbull) in which the
MCP has membership.

For measures requiring one year of baseline data, ODJFS will use the first full
calendar year of data (CY 2007) from all MCPs serving CFC membership.  CY 2008
will be the first reporting year that MCPs will be held accountable to the
statewide performance standards for one year measures, and penalties will be
applied for noncompliance.

For measures requiring two years of baseline data, ODJFS will use the first two
full calendar years of data (CY 2007 and CY 2008) from all MCPs serving CFC
membership to determine statewide minimum performance standards.  CY 2009 will
be the first reporting year that MCPs will be held accountable to the statewide
performance standards for two year measures, and penalties will be applied for
noncompliance.

Statewide 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.

Report Period:  In order to adhere to the statewide expansion timeline,
reporting periods.  For the SFY 2008 contract period, performance will be
evaluated using the January - December 2007 report period.  For the SFY 2009
contract period, performance will be evaluated using the January - December 2008
report period.  For the SFY 2010 contract period, performance will be evaluated
using the January – December 2009 report period.
 
1.c.i.         Perinatal Care – Frequency of Ongoing Prenatal Care

Measure:  The percentage of enrolled women with a live birth during the year who
received the expected number of prenatal visits.  The number of observed versus
expected visits will be adjusted for length of enrollment.

County-Based Statewide Target:  At least 80.0% of the eligible population must
receive 81.0% or more of the expected number of prenatal visits.
 
7

--------------------------------------------------------------------------------

Appendix M
Covered Families and Children (CFC) population 
 
County-Based Statewide Minimum Performance Standard:  The level of improvement
must result in at least a 10.0% decrease in the difference between the target
and the previous report period’s results. (For example, if last year’s results
were 20.0%, then the difference between the target and last year’s results is
60.0%.  In this example, the standard is an improvement in performance of 10.0%
of this difference or 6.0%. In this example, results of 26.0% or better would be
compliant with the standard.)

Regional-Based Statewide Target:  To be determined.

Regional-Based Statewide Minimum Performance Standard: To be determined.

Action Required for Noncompliance:  Beginning SFY 2009, if the standard is not
met and the results are below 44.0% (49.0% for SFY 2010), 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 44.0% (49.0% for SFY 2010),
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.        Perinatal Care - Initiation of Prenatal Care

Measure:    The percentage of enrolled women with a live birth during the year
who had a prenatal visit within 42 days of enrollment or by the end of the first
trimester for those women who enrolled in the MCP during the early stages of
pregnancy.

County-Based Statewide Target: At least 90.0% of the eligible population
initiates prenatal care within the specified time.

County-Based Statewide Minimum Performance Standard: The level of improvement
must result in at least a 10.0% decrease in the difference between the target
and the previous year’s results.

Regional-Based Statewide Target: To be determined.

Regional-Based Statewide Minimum Performance Standard: To be determined.

Action Required for Noncompliance:  Beginning SFY 2009,  if the standard is not
met and the results are below 74.0%(77.0% for SFY 2010), 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 74.0% (77.0% for SFY 2010),
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.
 
8

--------------------------------------------------------------------------------

Appendix M
Covered Families and Children (CFC) population 
 
1.c.iii.      Perinatal Care - Postpartum Care

Measure:   The percentage of women who delivered a live birth who had a
postpartum visit on or between 21 days and 56 days after delivery.

County-Based Statewide Target: At least 80.0% of the eligible population must
receive a postpartum visit.

County-Based Statewide Minimum Performance Standard: The level of improvement
must result in at least a 5.0% decrease in the difference between the target and
the previous year’s results.

Regional-Based Statewide Target:  To be determined.

Regional-Based Statewide Minimum Performance Standard: To be determined.

Action Required for Noncompliance: SFY 2009,  if the standard is not met and the
results are below 50.0% (54.0% for SFY 2010), 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 50.0% (54.0% for SFY 2010), 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.       Preventive Care for Children - Well-Child Visits

Measure:  The percentage of children who received the expected number of
well-child visits adjusted by age and enrollment. The expected number of visits
is as follows:

Children who turn 15 months old: six or more well-child visits.

Children who were 3, 4, 5, or 6, years old: one or more well-child visits.

Children who were 12 through 21 years old: one or more well-child visits.

County-Based Statewide Target:  At least 80.0% of the eligible children receive
the expected number of well-child visits.
County-Based  Statewide Minimum Performance Standard for Each of the Age
Groups:  The level of improvement must result in at least a 10.0% decrease in
the difference between the target and the previous year’s results.

Regional-Based Statewide Target:  To be determined.

Regional-Based Statewide Minimum Performance Standard for Each of the Age
Groups: To be determined.
 
9

--------------------------------------------------------------------------------

Appendix M
Covered Families and Children (CFC) population 
 
Action Required for Noncompliance (15 month old age group):  Beginning SFY
2009,  if the standard is not met and the results are below 42.0% (47.0% for SFY
2010), 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 42.0% (47.0% for SFY 2010), ODJFS will issue a Quality Improvement
Directive which will notify the MCP of noncompliance and may outline the steps
that the MCP must take to improve the results.
 
Action Required for Noncompliance (3-6 year old age group):  Beginning SFY
2009,  if the standard is not met and the results are below 57.0% (63.0% for SFY
2010), 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 57.0% (63.0% for SFY 2010), ODJFS will issue a Quality Improvement
Directive which will notify the MCP of noncompliance and may outline the steps
that the MCP must take to improve the results.
 
Action Required for Noncompliance (12-21 year old age group):  Beginning SFY
2009, if the standard is not met and the results are below 33.0% (35.0% for SFY
2010), 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 33.0% (35.0% for SFY 2010), 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.         Use of Appropriate Medications for People with Asthma

Measure: The percentage of members with persistent asthma who were enrolled for
at least 11 months with the plan during the year and who received prescribed
medications acceptable as primary therapy for long-term control of asthma.

County-Based Statewide Target: At least 95.0% of the eligible population must
receive the recommended medications.

County-Based Statewide Minimum Performance Standard: The level of improvement
must result in at least a 10.0% decrease in the difference between the target
and the previous year’s results.

Regional-Based Statewide Target:  To be determined.

Regional-Based Statewide Minimum Performance Standard: To be determined.
 
10

--------------------------------------------------------------------------------

Appendix M
Covered Families and Children (CFC) population 
 
Action Required for Noncompliance: Beginning SFY 2009,  if the standard is not
met and the results are below 84.0% (86.0% for SFY 2010), 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 84.0% (86.0% for SFY 2010),
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.vi.       Annual Dental Visits

Measure: The percentage of enrolled members age 4 through 21 who were enrolled
for at least 11 months with the plan during the year and who had at least one
dental visit during the year.

County-Based Statewide Target: At least 60.0% of the eligible population
receives a dental visit.

County-Based Statewide Minimum Performance Standard: The level of improvement
must result in at least a 10.0% decrease in the difference between the target
and the previous year’s results.
 
Regional-Based Statewide Target:  To be determined.

Regional-Based Statewide Minimum Performance Standard: To be determined.

Action Required for Noncompliance:  Beginning SFY 2009,  if the standard is not
met and the results are below 42.0% (43.0% for SFY 2010), 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 42.0% (43.0% for SFY 2010),
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.
 
11

--------------------------------------------------------------------------------

Appendix M
Covered Families and Children (CFC) population 
 
1.c.vii.      Lead Screening (For 1 Year Olds and For 2 Year Olds)

The final report period for these measures is CY 2008.

Measure: The percentage of one and two year olds who received a blood lead
screening by age group.

County-Based Statewide Target: At least 80.0% of the eligible population
receives a blood lead screening.

County-Based Statewide Minimum Performance Standard for Each of the Age Groups:
The level of improvement must result in at least a 10.0% decrease in the
difference between the target and the previous year’s results.

Regional-Based Statewide Target:  To be determined.

Regional-Based Statewide Minimum Performance Standard for Each of the Age
Groups: To be determined.

Action Required for Noncompliance (1 year olds): Beginning SFY 2007,  if the
standard is not met and the results are below 45.0% 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 45.0%, 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 (2 year olds): Beginning SFY 2007, if the
standard is not met and the results are below  28.0% 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 28.0%, 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.
 
 
12

--------------------------------------------------------------------------------

Appendix M
Covered Families and Children (CFC) population 

1.c.viii.     Lead Testing in Children

The initial report period for this measure is CY 2009 (SFY 2010).  This measure
will replace the
Lead Screening for 1 Year Olds and for 2 Year Olds the P4P for SFY 2010.

Measure: The percentage of children who have turned two years of age during the
reporting year who have received one lead test on or before their second
birthday.

Regional-Based Statewide Target:  To be determined.

Regional-Based Statewide Minimum Performance Standard: To be determined.

Action Required for Noncompliance: Beginning SFY 2010,  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.

2.              ACCESS

Performance in the Access category will be determined by the following measures:
Primary Care Provider (PCP) Turnover, Children’s Access to Primary Care, Adults’
Access to Preventive/Ambulatory Health Services, and Members’ Access to
Designated PCP.  For a comprehensive description of the access performance
measures below, see ODJFS Methods for Access Performance Measures for the CFC
Managed Care Program.

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 children and
adult access 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.

For an MCP which had membership as of February 1, 2006: MCP performance will be
evaluated using an MCP’s county-based statewide result for the counties in which
the MCP had membership as of  February 1, 2006.  The minimum performance
standard in this Appendix (2.a) will be applicable to the MCP’s county-based
statewide result for the counties in which the MCP had membership as of February
1, 2006.  The last reporting year using  the MCP’s county-based statewide result
for the counties in which the MCP had membership as of February 1, 2006 for
performance evaluation is CY 2007; the last reporting year using the MCP’s
county-based statewide result for the counties in which the MCP had membership
as of February 1, 2006 for P4P (Appendix O) is CY 2008.
 
13

--------------------------------------------------------------------------------

Appendix M
Covered Families and Children (CFC) population 

For any MCP which did not have membership as of February 1, 2006:  Performance
will be evaluated using a regional-based statewide approach for all active
regions and counties (Mahoning and Trumbull) in which the MCP has membership.

Regional-Based Statewide Approach:  MCPs will be evaluated statewide, using
results for all regions and counties (Mahoning and Trumbull) in which the MCP
has membership. ODJFS will use the first full calendar year of data (CY 2007)
from all MCPs serving CFC membership as a baseline to determine a statewide
minimum performance standard.  CY 2008 will be the first reporting year that
MCPs will be held accountable to the statewide performance standard for
statewide reporting, 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.  For the SFY 2009 contract
period, performance will be evaluated using the January - December 2008 report
period.  For the SFY 2010 contract period, performance will be evaluated using
the January - December 2008 report period.

County-Based Statewide Minimum Performance Standard:  A maximum PCP Turnover
rate of 18.0%.
Regional-Based Statewide Minimum Performance Standard:  To be determined.

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.i.         Children’s Access to Primary Care (applicable to performance
evaluation through SFY 2010)

 This measure indicates whether children aged 12 months to 11 years are
accessing PCPs for sick or well-child visits.

Measure: The percentage of members age 12 months to 11 years who had a visit
with an MCP PCP-type provider.

For an MCP which had membership as of February 1, 2006: MCP performance will be
evaluated using an MCP’s county-based statewide result for the counties in which
the MCP had membership as of February 1, 2006.  The minimum performance standard
in this Appendix (2.b) will be applicable to the MCP’s county-based statewide
result for the counties in which the MCP had membership as of February 1,
2006.  The last reporting year using the MCP’s county-based statewide result for
the counties in which the MCP had membership as of February 1, 2006 is CY 2008.
 
14

--------------------------------------------------------------------------------

Appendix M
Covered Families and Children (CFC) population 
 
For any MCP which did not have membership as of February 1, 2006:  Performance
will be evaluated using a regional-based statewide approach for all active
regions and counties (Mahoning and Trumbull) in which the MCP has membership.
 
Regional-Based Statewide Approach: MCPs will be evaluated statewide, using
results for all active regions and counties (Mahoning and Trumbull) in which the
MCP has membership. ODJFS will use the first two full calendar years of data (CY
2007 and CY 2008)  from all MCPs serving CFC membership as a baseline  to
determine a statewide minimum performance standard.  CY 2009 will be the first
reporting year that MCPs will be held accountable to the statewide performance
standard for statewide reporting, and penalties will be applied for
noncompliance.  Statewide 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.

Report Period: For the SFY 2008 contract period, performance will be evaluated
using the January - December 2007 report period.  For the SFY 2009 contract
period, performance will be evaluated using the January - December 2008 report
period.  For the SFY 2010 contract period, performance will be evaluated using
the January – December 2009 report period.

County-Based Statewide Minimum Performance Standards:
CY 2007 report period – 71.0% of children must receive a visit
CY 2008 report period – 74.0% of children must receive a visit

Regional-Based Statewide Minimum Performance Standards:
CY 2009 report period – To be determined.
 
2.b.ii.       Children’s Access to Primary Care (applicable to performance
evaluation as of SFY 2011)

This measure indicates whether children aged 12 months to 19 years are accessing
PCPs for sick or well-child visits.

Measure: The percentage of members age 12 months to 19 years who had a visit
with an MCP PCP-type provider.

Regional-Based Statewide Approach: MCPs will be evaluated statewide, using
results for all active regions and counties in which the MCP has membership.
ODJFS will use CY 2008 and CY 2009  data from all MCPs serving CFC membership as
a baseline  to determine a statewide minimum performance standard.  CY
2010  will be the first reporting year that MCPs will be held accountable to the
statewide performance standard for statewide reporting, and penalties will be
applied for noncompliance.  Statewide 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 run out.

Report Period:   For the SFY 2011 contract period, performance will be evaluated
using the January - December 2010 report period.

Regional-Based Statewide Minimum Performance Standards: CY 2010 report period –
To be determined.

Penalty for Noncompliance:  If an MCP is noncompliant with the Minimum
Performance Standard, then the MCP must develop and implement a corrective
action plan.
 
15

--------------------------------------------------------------------------------

Appendix M
Covered Families and Children (CFC) population 
 
2.c.           Adults’ Access to Preventive/Ambulatory Health Services

This measure indicates whether adult members are accessing health services.

Measure: The percentage of members age 20 and older who had an ambulatory or
preventive-care visit.

For an MCP which had membership as of February 1, 2006: MCP performance will be
evaluated using an MCP’s county-based statewide result for the counties in which
the MCP had membership as of February 1, 2006.  The minimum performance standard
in this Appendix (2.c) will be applicable to the MCP’s county-based statewide
result for the counties in which the MCP had membership as of February 1,
2006.  The last reporting year using the MCP’s county-based statewide result for
the counties in which the MCP had membership as of February 1, 2006 for
performance evaluation is CY 2007; the last reporting year using the MCP’s
county-based statewide result for the counties in which the MCP had membership
as of February 1, 2006 for P4P (Appendix O) is CY 2008.

For any MCP which did not have membership as of February 1, 2006:  Performance
will be evaluated using a regional-based statewide approach for all active
regions and counties (Mahoning and Trumbull) in which the MCP has membership.

Regional-Based Statewide Approach:  MCPs will be evaluated statewide, using
results for all active regions and counties (Mahoning and Trumbull) in which the
MCP has membership. ODJFS will use the first full calendar year of data (CY
2007) from all MCPs serving CFC membership as a baseline to determine a
statewide minimum performance standard.  CY 2008 will be the first reporting
year that MCPs will be held accountable to the statewide performance standard
for statewide reporting, and penalties will be applied for
noncompliance.  Statewide 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.

Report Period: For the SFY 2008 contract period, performance will be evaluated
using the January - December 2007 report period.  For the SFY 2009 contract
period, performance will be evaluated using the January - December 2008 report
period.  For the SFY 2010 contract period, performance will be evaluated using
the January - December 2009 report period.

County-Based Statewide Minimum Performance Standards:
CY 2007 report period – 63.0% of adults must receive a visit.
CY 2008 report period – 63.0% of adults must receive a visit (P4P only).

Regional-Based Statewide Minimum Performance Standards:
CY 2008 report period – To be determined. (Evaluation only)
CY 2009 report period –To be determined

Penalty for Noncompliance:  If an MCP is noncompliant with the Minimum
Performance Standard, then the MCP must develop and implement a corrective
action plan.
 
 
16

--------------------------------------------------------------------------------

Appendix M
Covered Families and Children (CFC) population 

 
2.d.           Members’ Access to Designated PCP

The MCP must encourage and assist CFC members without a designated primary care
provider (PCP) to establish such a relationship, so that a designated PCP can
coordinate and manage a member’s health care needs.  This measure is to be used
to assess MCPs’ performance in the access category.

Measure:  The percentage of members who had a visit through members’ designated
PCPs.

Regional-Based Statewide Approach: MCPs will be evaluated statewide, using
results for all active regions and counties (Mahoning and Trumbull) in which the
MCP has membership.  ODJFS will use the first full calendar year of data (CY
2007) from all MCPs serving CFC membership as a baseline to determine a
statewide minimum performance standard.  CY 2008 will be the first reporting
year that MCPs will be held accountable to the performance standard and
penalties will be applied for noncompliance.  Statewide 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.

Report Period:  For the SFY 2009 contract period, performance will be evaluated
using the January - December 2008 report period.  For the SFY 2010 contract
period, performance will be evaluated using the January - December 2009 report
period.

Regional-Based Statewide Minimum Performance Standard:
CY 2008 – To be determined.
CY 2009 – To be determined

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

In accordance with federal requirements and in the interest of assessing
enrollee satisfaction with MCP performance, ODJFS conducts annual 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.  For SFY 2008, performance in this category will be
determined by the overall satisfaction score.  For a comprehensive description
of the Consumer Satisfaction performance measure below, see ODJFS Methods for
the Consumer Satisfaction Performance Measure for the CFC Program.
 
17

--------------------------------------------------------------------------------

Appendix M
Covered Families and Children (CFC) population 

Measure: Overall Satisfaction with MCP: The average rating of the respondents to
the Consumer Satisfaction Survey who were asked to rate their overall
satisfaction with their MCP.  The results of this measure are reported annually.

For an MCP which had membership as of February 1, 2006: MCP performance will be
evaluated using an MCP’s county-based statewide result for the counties in which
the MCP had membership as of February 1, 2006.  The minimum performance standard
in this Appendix (3.) will be applicable to the MCP’s county-based statewide
result for the counties in which the MCP had membership as of February 1,
2006.   For performance evaluation, the last year to use the county-based
statewide approach for the counties in which the MCP had membership as of
February 1, 2006 will be SFY 2008, using CY 2008 data.  For P4P (Appendix
O),  the last year to use the county-based statewide approach for the counties
in which the MCP had membership as of February 1, 2006 will be SFY 2009, using
CY 2009 data.

For any MCP which did not have membership as of February 1, 2006:  Performance
will be evaluated using a regional-based statewide approach for all active
regions and counties (Mahoning and Trumbull)  in which the MCP has membership.

Regional-Based Statewide Approach: MCPs will be evaluated statewide, using
results for all active regions and counties (Mahoning and Trumbull) in which the
MCP has membership.  ODJFS will use the first full calendar year of data (CY
2008 adult and child survey results) from all MCPs serving CFC membership as a
baseline to establish a measure and determine a minimum statewide performance
standard.  For performance evaluation, the first year to use the statewide
regional-based approach will be SFY 2009, using CY 2009 data.  For
P4P  (Appendix O),  the first year to use the statewide regional-based approach
will be SFY 2010, using CY 2010 data.

Report Period: For the SFY 2008 contract period, performance will be evaluated
using the results from the CY 2008 consumer satisfaction survey.  For the SFY
2009 contract period, performance will be evaluated using the results from the
CY 2009 consumer satisfaction survey.   For the SFY 2010 contract period,
performance will be evaluated using the results from the CY 2010 consumer
satisfaction survey.

County-Based Statewide Minimum Performance Standard:  An average score of no
less than 7.0.

Regional-Based Statewide 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 Administrative Capacity Performance Measure for
the CFC Managed Care Program.
 
18

--------------------------------------------------------------------------------

Appendix M
Covered Families and Children (CFC) population 
 
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 2009 contract period, 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 (applicable to performance
evaluation through  SFY  2008)

Managed care plans must provide access to services in a way that assures access
to primary and urgent care in the most effective settings and minimizes
inappropriate utilization of emergency department (ED) services.  MCPs are
required to identify high utilizers of ED services and implement action plans
designed to minimize inappropriate ED utilization.

Measure:  The percentage of members who had four or more ED visits during the
six month reporting period.

For an MCP which had membership as of February 1, 2006: MCP performance will be
evaluated using an MCP’s county-based statewide result for the counties in which
the MCP had membership as of February 1, 2006.  The minimum performance standard
and the target in this Appendix (4.b) will be applicable to the MCP’s
county-based statewide result for the counties in which the MCP had membership
as of February 1, 2006.  The last reporting period using  the MCP’s county-based
statewide result for the counties in which the MCP had membership as of February
1, 2006 for performance evaluation is July-December 2007; the last reporting
period using the MCP’s county-based statewide result for the counties in which
the MCP had membership as of February 1, 2006 for P4P (Appendix O) is
July-December 2006.

Report Period:  For the SFY 2008 contract period, a baseline level of
performance will be set using the January - June 2007 report period.  Results
will be calculated for the reporting period of July - December 2007 and compared
to the baseline results to determine if the minimum performance standard is met.
 
19

--------------------------------------------------------------------------------

Appendix M
Covered Families and Children (CFC) population 
 
County-Based  Statewide Target: A maximum of  0.70% of the eligible population
will have four or more ED visits during the reporting period.

County-Based Statewide Minimum Performance Standard: The level of improvement
must result in at least a 10.0% decrease in the difference between the target
and the baseline period results.

Penalty for Noncompliance:  If the standard is not met and the results are above
1.1%, then the MCP must develop a corrective action plan, for which ODJFS may
direct the MCP to develop the components of their EDD program as specified by
ODJFS.  If the standard is not met and the results are at or below 1.1%, then
the MCP must develop a Quality Improvement Directive.

4.b.i.         Emergency Department Diversion (applicable to performance
evaluation as of SFY 2009)

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 a number to be determined or more
targeted ED visits during the twelve month reporting period.

Regional-Based Statewide Approach: MCPs will be evaluated statewide, using
results for all active regions and counties (Mahoning and Trumbull) in which the
MCP has membership.  ODJFS will use the first  full calendar year of data (CY
2007) from all MCPs serving CFC membership as the first baseline reporting year
for statewide reporting and  to determine a statewide minimum performance
standard and target.  CY 2008 will be the first reporting year that MCPs will be
held accountable to the performance standard and penalties will be applied for
noncompliance.

Report Period: For the SFY 2009 contract period, January – December 2008.  For
the SFY 2010 contract period, January – December 2008.

Regional-Based Statewide Target: A maximum number to be determined of the
eligible population will have a number to be determined or more targeted ED
visits during the reporting period.

Regional-Based Statewide Minimum Performance Standard: The level of improvement
must result in at least a percent to be determined decrease in the difference
between the target and the baseline period results.

Penalty for Noncompliance:  If the standard is not met and the results are above
a percent to be determined, then the MCP must develop a corrective action plan,
for which ODJFS may direct the MCP to develop the components of their EDD
program as specified by ODJFS.  If the standard is not met and the results are
at or below a percent to be determined, then the MCP must develop a Quality
Improvement Directive.

 
20

--------------------------------------------------------------------------------

Appendix M
Covered Families and Children (CFC) population 
 
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.           Report Periods

Unless otherwise noted, the most recent report or study finalized prior to the
end of the contract period will be used in determining the MCP’s performance
level for that contract period.

5.b.           Monetary Sanctions

Penalties for noncompliance with individual standards in this appendix will be
imposed as the results are finalized. Penalties for noncompliance with
individual standards for each period of compliance, as determined in this
appendix, will not exceed $250,000.

Refundable monetary sanctions will be based on the capitation payment in the
month of the cited deficiency and due within 30 days of notification by ODJFS to
the MCP of the amount.  Any monies collected through the imposition of such a
sanction would be returned to the MCP (minus any applicable collection fees owed
to the Attorney General’s Office, 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.c.           Combined Remedies

If ODJFS determines that one systemic problem is responsible for multiple
deficiencies, ODJFS may impose a combined remedy which will address all areas of
deficient performance.  The total fines assessed in any one month will not
exceed 15.0% of the MCP’s monthly capitation.

5.d.           Enrollment Freezes

MCPs found to have a pattern of repeated or ongoing noncompliance may be subject
to an enrollment freeze.

5.e.           Reconsideration

Requests for reconsideration of monetary sanctions and enrollment freezes may be
submitted as provided in Appendix N, Compliance Assessment System.
 
5.f.            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.
 
 
21

--------------------------------------------------------------------------------

Appendix N
Covered Families and Children (CFC) population   
 
APPENDIX N

COMPLIANCE ASSESSMENT SYSTEM
CFC 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.
 
1

--------------------------------------------------------------------------------

Appendix N
Covered Families and Children (CFC) population
 
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.
 
2

--------------------------------------------------------------------------------

Appendix N
Covered Families and Children (CFC) population
 
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 severs 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.

 
3

--------------------------------------------------------------------------------

Appendix N
Covered Families and Children (CFC) population   
 
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.
 
4

--------------------------------------------------------------------------------

Appendix N
Covered Families and Children (CFC) population   
 
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)
 
16-25 Points
CAP + $5,000 fine
 
26-50 Points
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.]

 
5

--------------------------------------------------------------------------------

Appendix N
Covered Families and Children (CFC) population   
 
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.
 
6

--------------------------------------------------------------------------------

Appendix N
Covered Families and Children (CFC) population   
 
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

 
7

--------------------------------------------------------------------------------

Appendix N
Covered Families and Children (CFC) population   
 
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. Noncompliance with Prompt Payment: - Noncompliance with the prompt pay
requirements as specified in Appendix J of the Agreement will result in
progressive penalties.  The first violation during 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.
 
8

--------------------------------------------------------------------------------

Appendix N
Covered Families and Children (CFC) population   
 
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.
 
9

--------------------------------------------------------------------------------

Appendix N
Covered Families and Children (CFC) population   

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.
 
 
10

--------------------------------------------------------------------------------

Appendix O
Covered Families and Children (CFC) population   

APPENDIX O

PAY-FOR PERFORMANCE (P4P)
CFC ELIGIBLE POPULATION

This Appendix establishes P4P for managed care plans (MCPs) to improve
performance in specific areas important to the Medicaid MCP members.  P4P
include the at-risk amount included with the monthly premium payments (see
Appendix F, Rate Chart), and possible additional monetary rewards up to
$250,000.

To qualify for consideration of any 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.  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 and 2).  An excellent and superior standard
is set in this Appendix for each of the three measures.  Qualifying MCPs will be
awarded a portion of the at-risk amount for each excellent standard met.  If an
MCP meets all three excellent and superior standards, they may be awarded
additional P4P (see Section 3).

Prior to the transition to a regional-based statewide P4P system (SFY 2006
through SFY 2009), the county-based statewide P4P system (sections 1 and 2 of
this Appendix) will apply to MCPs with membership as of February 1, 2006.  Only
counties with membership as of February 1, 2006 will be used to calculate
performance levels for the county-based statewide P4P system.

1.             SFY 2008 P4P

1.a.          Qualifying Performance Levels

To qualify for consideration of the SFY 2008 P4P, an MCP’s performance level
must meet the minimum performance standards set in Appendix M, Performance
Evaluation, for the measures listed 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 2008 established in
Appendix M, Performance Evaluation, must be met to qualify for consideration of
P4P are as follows:

1.  PCP Turnover (Appendix M, Section 2.a.)

Report Period: CY 2007

2. Children’s Access to Primary Care (Appendix M, Section 2.b.)

Report Period: CY 2007

3.  Adults’ Access to Preventive/Ambulatory Health Services (Appendix M, Section
2.c.)
 
                Report Period: CY 2007
                                                
1

--------------------------------------------------------------------------------

Appendix O
Covered Families and Children (CFC) population   
 
4. Overall Satisfaction with MCP (Appendix M, Section 3.)

Report Period: The most recent consumer satisfaction survey completed prior to
the end of SFY 2008.

For each clinical performance measure listed below, the MCP must meet the P4P
standard to be considered for SFY 2008 P4P.  The MCP meets the P4P standard if
one of two criteria are met.  The P4P standard is a performance level of either:

1) The minimum performance standard established in Appendix M, Performance
Evaluation, for seven of the nine clinical performance measures listed below; or

2) The Medicaid benchmarks for seven of the nine clinical performance measures
listed below.  The Medicaid benchmarks are subject to change based on the
revision or update of applicable national standards, methods or benchmarks.
 
 
Clinical Performance Measure
Medicaid
Benchmark
1. Perinatal Care - Frequency of Ongoing Prenatal Care
42%
2. Perinatal Care - Initiation of Prenatal Care
71%
3. Perinatal Care - Postpartum Care
48%
4. Well-Child Visits – Children who turn 15 months old
34%
5. Well-Child Visits - 3, 4, 5, or 6, years old
6. Well-Child Visits - 12 through 21 years old
7. Use of Appropriate Medications for People with Asthma
8. Annual Dental Visits
9. Blood Lead – 1 year olds
50%
30%
83%
40%
45%

 
1.b.          Excellent and Superior Performance Levels

For qualifying MCPs as determined by Section 1.a., 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.
 
2

--------------------------------------------------------------------------------

Appendix O
Covered Families and Children (CFC) population   
 
1. Case Management of Children (Appendix M, Section 1.b.i.)

Report Period: April - June 2008
 
Excellent Standard: 5.5%

Superior Standard: 6.5%
 
2. Use of Appropriate Medications for People with Asthma (Appendix M, Section
1.c.v.)

Report Period: CY 2007

Excellent Standard: 86%

Superior Standard: 88%
 
3. Adults’ Access to Preventive/Ambulatory Health Services (Appendix M, Section
2.c.)

Report Period: CY 2007

Excellent Standard: 76%

Superior Standard: 84%

1.c.          Determining SFY 2008 P4P

MCP’s 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 Superior standards established in Section
1.b. herein, additional P4P may be awarded.  For MCPs receiving additional P4P,
the amount in the P4P fund (see Section 3.) 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.
 
3

--------------------------------------------------------------------------------

Appendix O
Covered Families and Children (CFC) population   
 
2.             SFY 2009 P4P

2.a.         Qualifying Performance Levels

To qualify for consideration of the SFY 2009 P4P, an MCP’s performance level
must meet the minimum performance standards set in Appendix M, Performance
Evaluation, for the measures listed 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
P4P are as follows:
 
1.  PCP Turnover (Appendix M, Section 2.a.)

Report Period: CY 2008

2. Children’s Access to Primary Care (Appendix M, Section 2.b.)

Report Period: CY 2008

3.  Adults’ Access to Preventive/Ambulatory Health Services (Appendix M, Section
2.c.)

Report Period: CY 2008                                                      

4. Overall Satisfaction with MCP (Appendix M, Section 3.)

Report Period: The most recent consumer satisfaction survey completed prior to
the end of SFY 2009.

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 seven of the nine clinical performance measures listed below; or

2) The Medicaid benchmarks for seven of the nine clinical performance measures
listed below.  The Medicaid benchmarks are subject to change based on the
revision or update of applicable national standards, methods or benchmarks.
 
4

--------------------------------------------------------------------------------

Appendix O
Covered Families and Children (CFC) population   
 
 
Clinical Performance Measure
                    Medicaid
                   Benchmark
 
1. Perinatal Care - Frequency of Ongoing Prenatal Care
                        44%
 
2. Perinatal Care - Initiation of Prenatal Care
                        74%
 
3. Perinatal Care - Postpartum Care
                        50%
 
4. Well-Child Visits – Children who turn 15 months old
                        42%
 
5. Well-Child Visits - 3, 4, 5, or 6, years old
6. Well-Child Visits - 12 through 21 years old
7. Use of Appropriate Medications for People with Asthma
8. Annual Dental Visits
9. Blood Lead – 1 year olds
                        57%
                        33%
                        84%
                        42%
                        45%
 

 
 
2.b.          Excellent and Superior Performance Levels

For qualifying MCPs as determined by Section 2.a., performance will be evaluated
on the measures below to determine the status of the at-risk amount or any
additional 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 Children (Appendix M, Section 1.b.i.)

Report Period: April - June 2009

Excellent Standard: To be determined.

Superior Standard: To be determined.

2. Use of Appropriate Medications for People with Asthma (Appendix M, Section
1.c.v.)

Report Period: CY 2008

Excellent Standard: To be determined.

Superior Standard: To be determined.
 
3. Adults’ Access to Preventive/Ambulatory Health Services (Appendix M, Section
2.c.)

Report Period: CY 2008

Excellent Standard: 77%

Superior Standard: 84%
 
5

--------------------------------------------------------------------------------

Appendix O
Covered Families and Children (CFC) population   
 
2.c.          Determining SFY 2008 P4P

MCP’s reaching the minimum performance standards described in Section 2.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 2.b.
herein, that an MCP meets, one-third of the at-risk amount may be retained.  For
MCPs meeting all of the Excellent and Superior standards established in Section
2.b. herein, additional P4P may be awarded.  For MCPs receiving additional P4P,
the amount in the P4P fund (see Section 3.) 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.
 
3.             NOTES

3.a.          Transition from a county-based statewide to a regional-based
statewide P4P system.

The current county-based statewide P4P system will transition to a
regional-based statewide system as managed care expands statewide.  The
regional-based statewide approach will be fully phased in no later than SFY
2010.  The regional-based statewide P4P system will be modeled after the
county-based statewide system with adjustments to performance standards where
appropriate.

3.a.i.       County-based statewide P4P system

For MCPs in their first twenty-four months of Ohio Medicaid CFC Managed Care
Program participation, the status of the at-risk amount will not be determined
because compliance with many of the standards cannot be determined in an MCP’s
first two contract years (see Appendix F., Rate Chart). In addition, MCPs in
their first two contract years are not eligible for the additional P4P amount
awarded for superior performance.

Starting with the twenty-fifth month of participation in the program, a new
MCP’s at-risk amount will be included in the P4P system. The determination of
the status of this at-risk amount will be after at least three full calendar
years of membership as many of the performance standards require three full
calendar years to determine an MCP’s performance level.  Because of this
requirement, more than 12 months of at-risk dollars may be included in an MCP’s
first at-risk status determination depending on when an MCP starts with the
program relative to the calendar year.

During the transition to a regional-based statewide system (SFY 2006 through SFY
2009), MCPs with membership as of  February 1, 2006 will continue in the
county-based statewide P4P system until the transition is complete.  These MCPs
will be put at-risk for a portion of the premiums received for members in
counties they are serving as of February 1, 2006.
 
6

--------------------------------------------------------------------------------

Appendix O
Covered Families and Children (CFC) population   
 
3.a.ii.      Regional-based statewide P4P system

All MCPs will be included in the regional-based statewide P4P system.  The
at-risk amount will be determined separately for each region an MCP serves.

The status of the at-risk amount for counties not included in the county-based
statewide P4P system will not be determined for the first twenty-four months of
regional membership.  Starting with the twenty-fifth month of regional
membership, the MCP’s at-risk amount will be included in the P4P system. The
determination of the status of this at-risk amount will be after at least three
full calendar years of regional membership as many of the performance standards
require three full calendar years to determine an MCP’s performance level. Given
that statewide expansion was not complete by December 31, 2006, ODJFS may adjust
performance measure reporting periods based on the number of months an MCP has
had regional membership. Because of this requirement, more than 12 months of
at-risk dollars may be included in an MCP’s first regional at-risk status
determination depending on when regional membership starts relative to the
calendar year.  Regional premium payments for months prior to July 2009 for
members in counties included in the county-based statewide P4P system for the
SFY 2009 P4P determination, will be excluded from the at-risk dollars included
in the first regional-based statewide P4P determination.
 
3.b.          Determination of at-risk amounts and additional P4P payments

Given that unforeseen circumstances (e.g., revision or update of applicable
national standards, methods or benchmarks, or issues related to program
implementation) may impact the determination of the status of an MCP’s at-risk
amount and any additional P4P payments,  ODJFS reserves the right to calculate
an MCP’s at-risk amount (the status of which is determined in accordance with
this appendix) using a lesser percentage than that established in Appendix F
(Regional Rates) and to award additional P4P in an amount lesser than that
established in this appendix.

For MCPs that have participated in the Ohio Medicaid Managed Care Program long
enough to calculate performance levels for all of the performance measures
included in the P4P system, determination of the status of an MCP’s at-risk
amount will occur within six months of the end
of the contract period.  Determination of additional P4P payments will be made
at the same time the status of an MCP’s at-risk amount is determined.

3.c.         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.

3.d.          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.

 
7

--------------------------------------------------------------------------------

Appendix P
Covered Families and Children (CFC) population   

APPENDIX P

MCP TERMINATIONS/NONRENEWALS/AMENDMENTS
ABD ELIGIBLE POPULATION

Upon termination either by the MCP or ODJFS, nonrenewal or denial of an MCP’s
provider agreement, all previously collected refundable monetary sanctions will
be retained by ODJFS.

1 .            MCP-INITIATED TERMINATIONS/NONRENEWALS

If an MCP provides notice of the termination/nonrenewal of their provider
agreement to ODJFS, pursuant to Article VIII of the agreement, the MCP will be
required to submit the following to ODJFS:
                a.  
Refundable Monetary Assurance and the At-Risk Amount

The MCP will be required to submit a refundable monetary assurance. This
monetary assurance will be held by ODJFS until such time that the MCP has
submitted all outstanding monies owed, data files, and reports, including, but
not limited to, grievance, appeal, encounter and cost report data related
to time periods through the final date of service under the MCP’s provider
agreement.  The monetary assurance must be in an amount of either $50,000 or 5 %
of the capitation amount paid by ODJFS in the month the termination/nonrenewal
notice is issued, whichever is greater.

The MCP must also return to ODJFS the at-risk amount paid to the MCP under the
current provider agreement.  The amount to be returned will be based on actual
MCP membership for preceding months and estimated MCP membership through the end
date of the contract.  MCP membership for each month between the month the
termination/nonrenewal is issued and the end date of the provider agreement will
be estimated as the MCP membership for the month the termination/nonrenewal is
issued. Any over payment will be determined by comparing actual to estimated MCP
membership and will be returned to the MCP following the end date of the
provider agreement.

The MCP must remit the monetary assurance and the at-risk amount in the
specified amounts via separate electronic fund transfers (EFT) payable to
Treasurer of State, State of Ohio(ODJFS).  The MCP should contact their Contract
Administrator to verify the correct amounts required for the monetary assurance
and the at-risk amount and obtain an invoice number prior to submitting the
monetary assurance and the at-risk amount.  Information from the invoices must
be included with each EFT to ensure monies are deposited in the appropriate
ODJFS Fund account.  In addition, the MCP must send copies of the EFT bank
confirmations and copies of the invoices to their Contract Administrator.

If the monetary assurance and the at-risk amount are not received as specified
above, ODJFS will withhold the MCP’s next month’s capitation payment until such
time that ODJFS receives documentation that the monetary assurance and the
at-risk amount are received by the Treasurer of State. If within one year of the
date of issuance of the invoice, an MCP does not submit all outstanding monies
owed and required submissions, including, but not limited to, grievance, appeal,
encounter and cost report data related to time periods through the final date of
service under the MCP’s provider agreement, the monetary assurance will not be
refunded to the MCP.
 
1

--------------------------------------------------------------------------------

Appendix P
Covered Families and Children (CFC) population 
 
b.            Data Files
               In order to assist members with continuity of care, the MCP must
create data files to be shared with each newly enrolling MCP.  The data files
will be provided in
               a consistant format specified by ODJFS and may include
information on the following:  case management, prior authorizations, inpatient
facility stays, PCP
               assignments, and pregnant members.  The timeline for providing
these files will be at the discretion of ODJFS.  The terminating MCP will be
responsible for ensuring
               the accuracy and data quality of the files.
 
 
c.
Notification

 
i.
Provider Notification

The MCP must notify contracted providers at least 55 days prior to the effective
date of termination.  The provider notification must be approved by ODJFS prior
to distribution.

ii.           Member Notification
The MCP must notify their members of the termination at least 45 days in advance
of the effective date of termination. The member notification must  be approved
by ODJFS prior to distribution.
 
iii.           Prior Authorization Re-Direction Notification
The MCP must create two notices to assist members and providers with prior
authorization requests received and/or approved during the last month of
membership. The first notice is for prior authorization requests for services to
be provided after the effective date of termination; this notice will direct
members and providers to contact the enrolling MCP.  The second notice is for
prior authorization requests for services to be provided before and after the
effective date of termination.  The MCP must utilize ODJFS model language to
create the notices and receive approval by ODJFS prior to distribution.  The
notices will be mailed to the provider and copied to the member for all requests
received during the last month of MCP membership.
 
2.             ODJFS-INITIATED TERMINATIONS

If ODJFS initiates the proposed termination, nonrenewal or amendment of an MCP’s
provider
agreement  pursuant to OAC rule 5101:3-26-10 and the MCP appeals that proposed
action, the MCP’s provider agreement will be extended through the issuance of an
adjudication order in the MCP’s appeal under the R.C. Chapter 119.
 
2

--------------------------------------------------------------------------------

Appendix P
Covered Families and Children (CFC) population 
 
During this time, the MCP will continue to accrue points and be assessed
penalties for each
subsequent compliance assessment occurrence/violation under Appendix N of the
provider agreement.  If the MCP exceeds 69 points, each subsequent point accrual
will result in a $15,000 nonrefundable fine.
 
Pursuant to OAC rule 5101:3-26-10(H), if ODJFS has proposed the termination,
nonrenewal, denial or amendment of a provider agreement, ODJFS may notify the
MCP's members of this proposed action and inform the members of their right to
immediately terminate their membership with that MCP without cause.  If ODJFS
has proposed the termination, nonrenewal, denial or amendment of   a provider
agreement and access to medically-necessary covered services is jeopardized,
ODJFS may propose to terminate the membership of all of the MCP's members.  The
appeal process for reconsideration of the proposed termination of members is as
follows:

·
All notifications of such a proposed MCP membership termination will be made by
ODJFS via certified or overnight mail to the identified MCP Contact.

·
MCPs notified by ODJFS of such a proposed MCP membership termination will have
three working days from the date of receipt to request reconsideration.

·
All reconsideration requests must be submitted by either facsimile transmission
or overnight mail to the Deputy Director, Office of Ohio Health Plans, and
received by 3PM Eastern Time (ET) on the third working day following receipt of
the ODJFS notification of termination. The address and fax number to be used in
making these requests will be specified in the ODJFS notification of termination
document.

·
The MCP will be responsible for verifying timely receipt of all reconsideration
requests.  All requests must explain in detail why the proposed MCP membership
termination is not justified.  The MCP’s justification for reconsideration will
be limited to a review of the written material submitted by the MCP.

 
·
A final decision or request for additional information will be made by the
Deputy Director within three working days of receipt of the request for
reconsideration.   Should the Deputy Director require additional time in
rendering the final reconsideration decision, the MCP will be notified of such
in writing.

·
The proposed MCP membership termination will not occur while an appeal is under
review and pending the Deputy Director’s decision.  If the Deputy Director
denies the appeal, the MCP membership termination will proceed at the first
possible effective date.  The date may be retroactive if the ODJFS determines
that it would be in the best interest of the members.

 
3

--------------------------------------------------------------------------------