Exhibit 10.1


    
      

    

    Back
      to Form 8-K

     

    Exhibit
      10.1

     

     

    


    PROVIDER
      AGREEMENT

    


    BETWEEN
      STATE OF
      OHIO

    DEPARTMENT
      OF JOB AND FAMILY SERVICES AND

    WELLCARE
      OF OHIO, INC.

    Amendment
      No. 2

     

    Pursuant
      to Article IX.A. the Provider Agreement between the State of Ohio, Department
      of
      Job and Family Services, (hereinafter referred to as "ODJFS") and WELLCARE
      OF
      OHIO, INC. (hereinafter referred to as "MCP") for the Aged, Blind or Disabled
      (hereinafter referred to as "ABD") population dated December 1, 2006, is hereby
      amended as follows:

    


    1.
      Appendix C is modified as attached.

    


    2.
      All
      other terms of the provider agreement are hereby affirmed.

    


    


    The
      amendment contained herein shall be effective March 1, 2007.

    


     

    
      	
              WELLCARE
                OF OHIO, INC.:

            	 	 	 
	
              BY:
                

            	
              /s/
                Todd S. Farha

            	 	
              DATE:

            	
              2/19/2007

            
	 	
              TODD
                S. FARHA, PRESIDENT & CEO

               

            	 	 	 
	
              OHIO
                DEPARTMENT OF JOB AND FAMILY SERVICES:

            	 	 	 
	
              BY:

            	
              /s/
                Helen E. Jones-Kelly

            	 	
              DATE:

            	  2/27/2007
	 	
              HELEN
                E. JONES-KELLY, DIRECTOR

            	 	 	 


    

    


    
 

    
      
        
        

      

      
        
        

        
        

      

      
        
        

      

    

    


    APPENDIX
      C

     

    MCP
      RESPONSIBILITIES ABD ELIGIBLE POPULATION

     

    The
      MCP
      must meet on an ongoing basis, all program requirements specified in Chapter
      5101:3-26 of the Ohio Administrative Code (OAC) and the Ohio Department of
      Job
      and Family Services (ODJFS) - MCP Provider Agreement. The following are MCP
      responsibilities that are not otherwise specifically stated in OAC rule
      provisions or elsewhere in the MCP provider agreement, but are required by
      ODJFS.

     

    General
      Provisions

     

    1.
      The
      MCP agrees to implement program modifications as soon as reasonably possible
      or
      no later than the required effective date, in response to changes in applicable
      state and federal laws and regulations.

     

    2.
      The
      MCP must submit a current copy of their Certificate of Authority (COA) to ODJFS
      within 30 days of issuance by the Ohio Department of Insurance.

     

    3.
      The
      MCP must designate the following:

     

    a.
      A
      primary contact person (the Medicaid Coordinator) who will dedicate a majority
      of their time to the Medicaid product line and coordinate overall communication
      between ODJFS and the MCP. ODJFS may also require the MCP to designate contact
      staff for specific program areas. The Medicaid Coordinator will be responsible
      for ensuring the timeliness, accuracy, completeness and responsiveness of all
      MCP submissions to ODJFS.

     

    b.
      A
      provider relations representative for each service area included in their ODJFS
      provider agreement. This provider relations representative can serve in this
      capacity for only one service area (as specified in Appendix H).

     

    If
      an MCP
      serves both the CFC and ABD populations, they are not required to designate
      a
      separate provider relations representative or Medicaid Coordinator for each
      population group.

     

    4.
      All
      MCP employees are to direct all day-to-day submissions and communications to
      their ODJFS-designated Contract Administrator unless otherwise notified by
      ODJFS.

     

    5.
      The
      MCP must be represented at all meetings and events designated by ODJFS as
      requiring mandatory attendance.

     

    6.
      The
      MCP must have an administrative office located in Ohio.

     

    


    


    Appendix
      C

    Page
      2

    


    7.
      Upon
      request by ODJFS, the MCP must submit information on the current status of
      their
      company's operations not specifically covered under this Agreement (for example,
      other product lines, Medicaid contracts in other states, NCQA accreditation,
      etc.) unless otherwise excluded by law.

     

    8.
      The
      MCP must have all new employees trained on applicable program requirements,
      and
      represent, warrant and certify to ODJFS that such training occurs, or has
      occurred.

     

    9.
      If an
      MCP determines that it does not wish to provide, reimburse, or cover a
      counseling service or referral service due to an objection to the service on
      moral or religious grounds, it must immediately notify ODJFS to coordinate
      the
      implementation of this change. MCPs will be required to notify their members
      of
      this change at least thirty (30) days prior to the effective date. The MCP's
      member handbook and provider directory, as well as all marketing materials,
      will
      need to include information specifying any such services that the MCP will
      not
      provide.

     

    10.
      For
      any data and/or documentation that MCPs are required to maintain, ODJFS may
      request that MCPs provide analysis of this data and/or documentation to ODJFS
      in
      an aggregate format, such format to be solely determined by ODJFS.

     

    11.
      The
      MCP is responsible for determining medical necessity for services and supplies
      requested for their members as specified in OAC rule 5101:3-26-03.
      Notwithstanding such responsibility, ODJFS retains the right to make the final
      determination on medical necessity in specific member situations.

     

    12.
      In
      addition to the timely submission of medical records at no cost for the annual
      external quality review as specified in OAC rule 5101:3-26-07, the MCP may
      be
      required for other purposes to submit medical records at no cost to ODJFS and/or
      designee upon request.

     

    13.
      The
      MCP must notify their Contract Administrator of the termination of an MCP panel
      provider that is designated as the primary care physician for ≥100
      of the MCP's ABD members. The MCP must provide notification within one working
      day of the MCP becoming aware of the termination.

     

    14.
      Upon
      request by ODJFS, MCPs may be required to provide written notice to members
      of
      any significant change(s) affecting contractual requirements, member services
      or
      access to providers.

     

    15.
      MCPs
      may elect to provide services that are in addition to those covered under the
      Ohio Medicaid fee-for-service program. Before MCPs notify potential or current
      members of the availability of these services, they must first notify ODJFS
      and
      advise ODJFS of such planned services availability. If an MCP elects to provide
      additional services, the MCP

     

    Appendix
      C 

    Page
      3

    


    must
      ensure to the satisfaction of ODJFS that the services are readily available
      and
      accessible to members who are eligible to receive them.

     

    a.
      MCPs
      are required
      to make transportation available to any member that must travel
      thirty (30) miles or more from their home to receive a medically-necessary
      Medicaid-covered service. If the MCP offers transportation to their members
      as
      an additional benefit and this transportation benefit only covers a limited
      number of trips, the required transportation listed above may not be counted
      toward this trip limit.

     

    b.
      Additional benefits may not vary by county within a region except out of
      necessity for transportation arrangements (e.g., bus versus cab). MCPs approved
      to serve consumers in more than one region may vary additional benefits between
      regions.

     

    c.
      MCPs
      must give ODJFS and members ninety (90) days prior notice when decreasing or
      ceasing any additional benefit(s). When it is beyond the control of the MCP,
      as
      demonstrated to ODJFS' satisfaction, ODJFS must be notified within one (1)
      working day.

     

    16.
      MCPs
      must comply with any applicable Federal and State laws that pertain to member
      rights and ensure that its staff adhere to such laws when furnishing services
      to
      its membrs. MCPs shall include a requirement in its contracts with affiliated
      providers that such providers also adhere to applicable Federal and State laws
      when providing services to members.

     

    17.
      MCPs
      must comply with any other applicable Federal and State laws (such as Title
      VI
      of the Civil rights Act of 1964, etc.) and other laws regarding privacy and
      confidentiality, as such may be applicable to this Agreement.

     

    18.
      Upon
      request, the MCP will provide members and potential members with a copy of
      their
      practice guidelines.

     

    19.
      The
      MCP is responsible for promoting the delivery of services in a culturally
      competent manner, as solely determined by ODJFS, to all members, including
      those
      with limited English proficiency (LEP) and diverse cultural and ethnic
      backgrounds.

     

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

     

    Appendix
      C

    Page
      4

    


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

     

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

     

    20.
      The
      MCP must utilize a centralized database which records the special communication
      needs of all MCP members (i.e., those with limited English proficiency, limited
      reading proficiency, visual impairment, and hearing impairment) and the
      provision of related services (i.e., MCP materials in alternate format, oral
      interpretation, oral translation services, written translations of MCP
      materials, and sign language services). This database must include all MCP
      member primary language information (PLI) as well as all other special
      communication needs information for MCP members, as indicated above, when
      identified by any source including but not limited to ODJFS, ODJFS selection
      services entity, MCP staff, providers, and members. This centralized database
      must be readily available to MCP staff and be used in coordinating communication
      and services to members, including the selection of a PCP who speaks the primary
      language of an LEP member, when such a provider is available. MCPs must share
      member specific communication needs information with their providers [e.g.,
      PCPs, Pharmacy Benefit Managers (PBMs), and Third Party Administrators (TPAs)],
      as applicable. MCPs must submit to ODJFS, upon request, detailed information
      regarding the MCP's members with special communication needs, which could
      include individual member names, their specific communication need, and any
      provision of special services to members (i.e., those special services arranged
      by the MCP as well as those services reported to the MCP which were arranged
      by
      the provider).


     

    


    Appendix
      C

    Page
      5

     

    Additional
      requirements specific to
      providing assistance to hearing-impaired, vision-impaired, limited reading
      proficient (LRP), and LEP members and eligible individuals are found in OAC
      rules 5101:3-26-03.1, 5101:3-26-05(D), 5101:3-26-05.1(A), 5101:3-26-08, and
      5101-3-26-08.2.

     

    21.
      The
      MCP is responsible for ensuring that all member materials use easily understood
      language and format. The determination of what materials comply with this
      requirement is in the sole discretion of ODJFS.

     

    22.
      Pursuant to OAC rules 5101:3-26-08 and 5101:3-26-08.2, the MCP is responsible
      for ensuring that all MCP marketing and member materials are prior approved
      by
      ODJFS before being used or shared with members. Marketing and member materials
      are defined as follows:

     

    a.
      Marketing materials are those items produced in any medium, by or on behalf
      of
      an MCP, including gifts of nominal value (i.e., items worth no more than
      $15.00), which can reasonably be interpreted as intended to market to eligible
      individuals.

     

    b.
      Member
      materials are those items developed, by or on behalf of an MCP, to fulfill
      MCP
      program requirements or to communicate to all members or a group ofmembers.
      Member health education materials that are produced by a source other than
      the
      MCP and which do not include any reference to the MCP are not considered to
      be
      member materials.

     

    c.
      All
      MCP marketing and member materials must represent the MCP in an honest and
      forthright manner and must not make statements which are inaccurate, misleading,
      confusing, or otherwise misrepresentative, or which defraud eligible individuals
      or ODJFS.

     

    d.
      All
      MCP marketing cannot contain any assertion or statement (whether written or
      oral) that the MCP is endorsed by CMS, the Federal or State government or
      similar entity.

     

    e.
      MCPs
      must establish positive working relationships with the CDJFS offices and must
      not aggressively solicit from local Directors, MCP County Coordinators, or
      or
      other staff. Furthermore, MCPs are prohibited from offering gifts of nominal
      value (i.e. clipboards, pens, coffee mugs, etc.) to CDJFS offices or SSE staff,
      as these may influence an individual's decision to select a particular
      MCP.

     

    23.
      Advance Directives - All MCPs must comply with the requirements specified in
      42
      CFR 422.128. At a minimum, the MCP must:

     

    a.
      Maintain written policies and procedures that meet the requirements for
      advance

    


    


    Appendix
      C 

    Page
      6

    


    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.

     

    Appendix
      C 

    Page
      7

     

    24.
      New
      Member Materials

    Pursuant
      to OAC rule 5101:3-26-08.2 (B)(3), MCPs must provide to each member an MCP
      identification (ID) card, a new member letter, a member handbook, a provider
      directory, and information on advance directives.

     

    a.
      MCPs
      must use the model language specified by ODJFS for the new member
      letter.

     

    b.
      The ID
      card and new member letter must be mailed together to the member via a method
      that will ensure its receipt prior to the member's effective date of coverage.
      No other materials may be included with this mailing.

     

    c.
      The
      member handbook, provider directory and advance directives information must
      be
      mailed separately from the ID card and new member letter. MCPs will meet the
      timely receipt requirement for these materials if they are mailed to the member
      within twenty-four (24) hours of the MCP receiving the ODJFS-produced monthly
      membership roster (MMR). This is provided the materials are mailed via a method
      with an expected delivery date of five (5) days. If the MCP is unable to mail
      the materials within twenty-four (24) hours, the materials must be mailed via
      a
      method that will ensure receipt by no later than the effective date of
      coverage.

     

    d.
      MCPs
      must designate two (2) MCP staff members to receive a copy of the new member
      materials on a monthly basis in order to monitor the timely receipt of these
      materials. At least one of the staff members must receive the materials at
      their
      home address.

     

    25.
      Call
      Center Standards

    The
      MCP
      must provide assistance to members through a member services toll-free call-in
      system pursuant to OAC rule 5101:3-26-08.2(A)(1). MCP member services staff
      must
      be available nationwide to provide assistance to members through the toll-free
      call-in system every Monday through Friday, at 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

     

    Appendix
      C

    Page
      8

    


    used
      within the same closure period. Before announcing any optional closure dates
      to
      members and/or staff, MCPs must receive ODJFS prior-approval which verifies
      that
      the optional closure days meet the specified criteria.

     

    If
      a
      major holiday falls on a Saturday, the MCP member services line may be closed
      on
      the preceding Friday. If a major holiday falls on a Sunday, the member services
      line may be closed on the following Monday. MCP member services closure days
      must be specified in the MCP's member handbook, member newsletter, or other
      some
      general issuance to the MCP's members at least thirty (30) days in advance
      of
      the closure.

     

    The
      MCP
      must also provide access to medical advice and direction through a centralized
      twenty-four-hour, seven day, toll-free call-in system, available nationwide,
      pursuant to OAC rule 5101:3-26-03.1(A)(6). The twenty-four (24)/7 hour call-in
      system must be staffed by appropriately trained medical personnel. For the
      purposes of meeting this requirement, trained medical professionals are defined
      as physicians, physician assistants, licensed practical nurses, and registered
      nurses.

     

    MCPs
      must
      meet the current American Accreditation HealthCare Commission/URAC-designed
      Health Call Center Standards (HCC) for call center abandonment rate, blockage
      rate and average speed of answer. By the 10th
      of each
      month, MCPs must self-report their prior month performance in these three areas
      for their member services and twenty-four (24) hour toll-free call-in systems
      to
      ODJFS. ODJFS will inform the MCPs of any changes/updates to these URAC call
      center standards.

     

    MCPs
      are
      not permitted to delegate grievance/appeal functions [Ohio Administrative Code
      (OAC) rule 5101:3-26-08.4(A)(9)]. Therefore, the member services call center
      requirement may not be met through the execution of a Medicaid Delegation
      Subcontract Addendum or Medicaid Combined Services Subcontract
      Addendum.

     

    26.
      Notification
      of Optional MCP Membership

     

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

    -  Indians
      who are members of federally-recognized tribes, except as permitted under
      42 C.F.R
      438.50(d)(21).

    


    


    Appendix
      C

    Page
      9

    


    27.
      HIPAA
      Privacy Compliance Requirements

     

    The
      Health Insurance Portability and Accountability Act (HIPAA) Privacy Regulations
      at 45 CFR. § 164.502(e) and § 164.504(e) require ODJFS to have agreements with
      MCPs as a means of obtaining satisfactory assurance that the MCPs will
      appropriately safeguard all personal identified health information. Protected
      Health Information (PHI) is information received from or on behalf of ODJFS
      that
      meets the definition of PHI as defined by HIPAA and the regulations promulgated
      by the United States Department of Health and Human Services, specifically
      45
      CFR 164.501, and any amendments thereto. MCPs must agree to the
      following:

     

    a.
      MCPs
      shall not use or disclose PHI other than is permitted by this Agreement or
      required by law.

     

    b.
      MCPs
      shall use appropriate safeguards to prevent unauthorized use or disclosure
      of
      PHI.

     

    c.
      MCPs
      shall report to ODJFS any unauthorized use or disclosure of PHI of which it
      becomes aware. Any breach by the MCP or its representatives of protected health
      information (PHI) standards shall be immediately reported to the State HIPAA
      Compliance Officer through the Bureau of Managed Health Care. MCPs must provide
      documentation of the breach and complete all actions ordered by the HIPAA
      Compliance Officer.

     

    d.
      MCPs
      shall ensure that all its agents and subcontractors agree to these same PHI
      conditions and restrictions.

     

    e.
      MCPs
      shall make PHI available for access as required by law.

     

    f.
      MCP
      shall make PHI available for amendment, and incorporate amendments as
      appropriate as required by law.

     

    g.
      MCPs
      shall make PHI disclosure information available for accounting as required
      by
      law.

     

    h.
      MCPs
      shall make its internal PHI practices, books and records available to the
      Secretary of Health and Human Services (HHS) to determine
      compliance.

     

    i.
      Upon
      termination of their agreement with ODJFS, the MCPs, at ODJFS' option, shall
      return to ODJFS, or destroy, all PHI in its possession, and keep no copies
      of
      the information, except as requested by ODJFS or required by law.

     

    j.
      ODJFS
      will propose termination of the MCP's provider agreement if ODJFS determines
      that the MCP has violated a material breach under this section of the agreement,
      unless inconsistent with statutory obligations of ODJFS or the
      MCP.

     

    Appendix
      C

    Page
      10


     

    28.
      Electronic
      Communications -
      MCPs are
      required to purchase/utilize Transport Layer Security (TLS) for all e-mail
      communication between ODJFS and the MCP. The MCP's e-mail gateway must be able
      to support the sending and receiving of e-mail using Transport Layer Security
      (TLS) and the MCP's gateway must be able to enforce the sending and receiving
      of
      email via TLS.

     

    29.
      MCP
      Membership acceptance, documentation and reconciliation

     

    a.
      Selection
      Services Contractor:
      The MCP
      shall provide to the selection services contractor (SSC) ODJFS prior-approved
      MCP materials and directories for distribution to eligible individuals who
      request additional information about the MCP.

     

    b.
      Monthly
      Reconciliation of Membership and Premiums: 
      The
      MCP
      shall reconcile member data as reported on the SSC-produced consumer contact
      record (CCR) with the ODJFS-produced monthly member roster (MMR) and report
      to
      the ODJFS any difficulties in interpreting or reconciling information received.
      Membership reconciliation questions must be identified and reported to the
      ODJFS
      prior to the first of the month to assure that no member is left without
      coverage. The MCP shall reconcile membership with premium payments reported
      on
      the monthly remittance advice (RA).

     

    The
      MCP
      shall work directly with the ODJFS, or other ODJFS-identified entity, to resolve
      any difficulties in interpreting or reconciling premium information. Premium
      reconciliation questions must be identified within thirty (30)days of receipt
      of
      the RA.

     

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

     

    d.
      Hospital
      Deferment Requests:
      When the
      MCP learns of a new member's hospitalization that is eligible for deferment
      prior to that member's discharge, the MCP shall notify the hospital and treating
      providers of the potential that the MCP may not be the payer. The MCP shall
      work
      with hospitals, providers and ODJFS to assure that discharge planning assures
      continuity of care and accurate payment. Notwithstanding the MCP's right to
      request a hospital deferment up to six (6) months following the member's
      effective date, when the MCP learns of a

     

    


    Appendix
      C

    Page
      11

    


    


    deferment-eligible
      hospitalization, the MCP shall make every effort to notify ODJFS and request
      the
      deferment as soon as possible. When the MCP is notified by ODJFS of a potential
      hospital deferment, the MCP must make every effort to respond to ODJFS within
      ten (10) business days of the receipt of the deferment information.

     

    e.
      Just
      Cause Requests:
      The MCP
      shall follow procedures as specified by ODJFS in assisting the ODJFS in
      resolving member requests for member-initiated requests affecting
      membership.

     

    f.
      Eligible
      Individuals:
      If an
      eligible individual contacts the MCP, the MCP must provide any MCP-specific
      managed care program information requested. The MCP must not attempt to assess
      the eligible individual's health care needs. However, if the eligible individual
      inquires about continuing/transitioning health care services, MCPs shall provide
      an assurance that all MCPs must cover all medically necessary Medicaid-covered
      health care services and assist members with transitioning their health care
      services.

     

    g.
      Pending
      Member If
      a
      pending member (i.e., an eligible individual subsequent to plan selection but
      prior to their membership effective date) contacts the selected MCP, the MCP
      must provide any membership information requested, including but not limited
      to,
      assistance in determining whether the current medications require prior
      authorization. The MCP must also ensure that any care coordination (e.g., PCP
      selection, transition of services) information provided by the pending member
      is
      logged in the MCP's system and forwarded to the appropriate MCP staff for
      processing as required. MCPs may confirm any information provided on the CCR
      at
      this time. Such communication does not constitute confirmation of membership.
      MCPs are prohibited from initiating contact with a pending member.

     

    h.
      Transition
      of Fee-For-Service Members Providing
      care coordination, access to preventive and specialized care, case management,
      member services, and education with minimal disruption to members' established
      relationships with providers and existing care treatment plans is critical
      for
      members transitioning from Medicaid fee-for-service to managed care. MCPs
      must:

     

    i.
      Develop a transition plan that outlines how the MCP will effectively address
      the
      unique care coordination issues for members in their first three months of
      MCP
      membership that includes at a minimum:

    


    Appendix
      C 

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      12

     

    ii.
      An
      effective outreach process to identify each
      new
      member's existing and/or potential health care needs that results in a new
      member profile that includes, but is not limited to identification
      of:

     

    a.
      Health
      care needs, including those services received through state sub-recipient
      agencies [e.g., the Ohio Department of Mental Health (ODMH), the Ohio Department
      of Mental Retardation and Developmental Disabilities (ODMR/DD), and the Ohio
      Department of Alcohol and Drug Addiction Services (ODADAS);

     

    b.
      Existing sources of care (i.e., primary physicians, specialists, case
      manager(s), ancillary and other care givers); and

     

    c.
      Current care therapies for all aspects of health care services, including
      scheduled health care appointments, planned and/or approved surgeries (inpatient
      or outpatient), ancillary or medical therapies, prescribed drugs, approved
      home
      health care, scheduled lab/radiology tests, necessary/approved durable medical
      equipment, supplies and needed/approved transportation
      arrangements.

     

    iii.
      Strategies for how each new member will obtain care therapies from appropriate
      sources of care as an MCP member including reported scheduled health services
      as
      described in Section 28.i.(ii-iv) of this Appendix.

     

    iv.
      Allow
      their new members that are transitioning from Medicaid fee-for-service to
      receive services from out-of-panel providers if the members contact the MCP
      to
      discuss the scheduled health services in advance of the service date and one
      of
      the following applies:

     

    a.
      The
      member has appointments within the initial three months of the MCP membership
      with a primary physician or specialty physicians that were scheduled prior
      to
      the effective date of the MCP membership;

     

    b.
      The
      member has been approved to receive an organ, bone marrow, or hematapoietic
      stem
      cell transplant pursuant to OAC rule 5101:3-2-07.1;

     

    Appendix
      C 

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      13

    


    c.
      The
      member is in her third trimester of pregnancy and has an established
      relationship with an obstetrician and/or delivery hospital;

     

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

     

    e.
      The
      member is receiving ongoing chemotherapy or radiation treatment;

     

    f.
      The
      member has been released from the hospital within the last thirty (30) days
      and
      is following a treatment plan;

     

    g.
      The
      member has been pre-certified to receive durable medical equipment (DME) which
      has not yet been received.

     

    v.
      Reimburse out-of-panel providers that agree to provide the transition services
      identified in section 28.i.section ii at 100% of the current Medicaid
      fee-for-service provider rate for the service(s).

     

    vi.
      Document the provision of transition services as follows:

     

    a.
      As
      expeditiously as the situation warrants, contact the provider's offices via
      telephone to confirm that the service(s) meets the above criteria.

     

    b.
      For
      services that meet the above criteria, inform the provider that the MCP is
      sending a form for signature to document that they accept/do not accept the
      terms for the provision of the services and copy the member on the
      form.

     

    c.
      If the
      provider agrees to the terms, notify the member and provider of the MCP's
      authorization and ensure that the MCP's claims processing system will not deny
      the claim payment because the provider is out-of-panel. MCPs must include their
      non-contracting provider materials as outlined in Appendix G.4.e with the
      provider notice.

     

    d.
      If the
      provider does not agree to the terms, notify the member and assist the member
      with locating a provider as expeditiously as the member's condition
      warrants.

    


    


    Appendix
      C 

    Page
      14

     

    e.
      Use
      the ODJFS-specified model language for the provider and member
      notices.

     

    f.
      Maintain documentation of all member and/or provider contacts relating to such
      out-of-panel services, including but not limited to telephone calls and
      letters.

     

    vii.
      Not
      require prior-authorization of any prescription drug that does not require
      prior
      authorization by Medicaid fee-for-service for the initial three months of a
      member's MCP membership. Additionally, all atypical anti-psychotic drugs, that
      do not require prior authorization by Medicaid fee-for-service, must be exempted
      from prior authorization requirements for all MCP ABD members through December
      2007, after which time ODJFS will re-evaluate the continuation of this pharmacy
      utilization strategy.

     

    30.
      Health
      Information System Requirements

    The
      ability to develop and maintain information management systems capacity is
      crucial to successful plan performance. ODJFS therefore requires MCPs to
      demonstrate their ongoing capacity in this area by meeting several related
      specifications.

     

    a.
      Health
      Information System

     

    i.
      As
      required by 42 CFR 438.242(a), each MCP must maintain a health information
      system that collects, analyzes, integrates, and reports data. The system must
      provide information on areas including, but not limited to, utilization,
      grievances and appeals, and MCP membership terminations for other than loss
      of
      Medicaid eligibility.

     

    ii.
      As
      required by 42 CFR 438.242(b)(l), each MCP must collect data on member and
      provider characteristics and on services furnished to its members.

     

    iii.
      As
      required by 42 CFR 438.242(b)(2), each MCP must ensure that data received from
      providers is accurate and complete by verifying the accuracy and timeliness
      of
      reported data; screening the data for completeness, logic, and consistency;
      and
      collecting service information in standardized formats to the extent feasible
      and appropriate.

     

    Appendix
      C 

    Page
      15

     

    iv.
      As
      required by 42 CFR
      438.242(b)(3), each MCP must make all collected data available upon request
      by
      ODJFS or the Center for Medicare and Medicaid Services (CMS).

     

    v.
      Acceptance testing of any data that is electronically submitted to ODJFS is
      required:

     

    a.
      Before
      an MCP may submit production files 

    b.
      Whenever an MCP changes the method or 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.

     

    
      Appendix
        C 

      Page
        16

    

    


    Electronic
      Data Interchange

    The
      MCP
      shall comply with all applicable provisions of HIPAA including electronic data
      interchange (EDI) standards for code sets and the following electronic
      transactions:

    Health
      care claims;

    Health
      care claim status request and response;

    Health
      care payment and remittance status; and Standard code sets.

     

    Each
      EDI
      transaction processed by the MCP shall be implemented in conformance with the
      appropriate version of the transaction implementation guide, as specified by
      applicable federal rule or regulation.

     

    The
      MCP
      must have the capacity to accept the following transactions from the Ohio
      Department of Job and Family services consistent with EDI processing
      specifications in the transaction implementation guides and in conformance
      with
      the 820 and 834 Transaction Companion Guides issued by ODJFS:

     

    ASC
      XI 2
      820 - Payroll Deducted and Other Group Premium Payment for Insurance Products;
      and

     

    ASC
      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 submit written verification to ODJES for transaction standards
      and

     

    Appendix
      C 

    Page
      17


    


    code
      sets
      specified in 45 CFR Part 162 - Health Insurance Reform: Standards for Electronic
      Transactions (HIPAA regulations), that the MCP has established the capability
      of
      sending and receiving applicable transactions in compliance with the HIPAA
      regulations. The written verification shall specify the date that the MCP has:
      1) achieved capability for sending and/or receiving the following transactions,
      2) entered into the appropriate trading partner agreements, and 3) implemented
      standard code sets. If the MCP has obtained third-party certification of HIPAA
      compliance for any of the items listed below, that certification may be
      submitted in lieu of the MCP's written verification for the applicable
      item(s).

     

    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 X 12N 276/277) 

    e.
      Enrollment and Disenrollment in a Health Plan (ASC X12N 834) f. Health Care
      Payment and Remittance Advice (ASC X12N 835)

    g.
      Health
      Plan Premium Payments (ASC X12N 820) 

    h.
      Coordination of Benefits

     

    Trading
      Partner Agreement with ODJFS

    MCPs
      must
      complete and submit an EDI trading partner agreement in a format specified
      by
      the ODJFS. Submission of the copy of the trading partner agreement prior to
      entering into this Agreement may be waived at the discretion of
      ODJFS;

    if
      submission prior to entering into the Agreement is waived, the trading partner
      agreement must be submitted at a subsequent date determined by
      ODJFS.

     

    Noncompliance
      with the EDI and claims adjudication requirements will result in the imposition
      of penalties, as outlined in Appendix N, Compliance Assessment System, of the
      Provider Agreement.

     

    c.
      Encounter
      Data Submission Requirements

     

    General
      Requirements

    Each
      MCP
      must collect data on services furnished to members through an encounter data
      system and must report encounter data to the ODJFS. MCPs are required to submit
      this data electronically to ODJFS on a monthly basis in the following standard
      formats:

    


    Appendix
      C 

    Page
      18

     

    •
      Institutional Claims - UB92 flat file

    •
      Noninstitutional Claims - National standard format

    •
      Prescription Drug Claims - NCPDP

     

    ODJFS
      relies heavily on encounter data for monitoring MCP performance. The ODJFS
      uses
      encounter data to measure clinical performance, conduct access and utilization
      reviews, reimburse MCPs for newborn deliveries and aid in setting MCP capitation
      rates. For these reasons, it is important that encounter data is timely,
      accurate, and complete. Data quality, performance measures and standards are
      described in the Agreement.

     

    An
      encounter represents all of the services, including medical supplies and
      medications, provided to a member of the MCP by a particular provider,
      regardless of the payment arrangement between the MCP and the provider. (For
      example, if a member had an emergency department visit and was examined by
      a
      physician, this would constitute two encounters, one related to the hospital
      provider and one related to the physician provider. However, for the purposes
      of
      calculating a utilization measure, this would be counted as a single emergency
      department visit. If a member visits their PCP and the PCP examines the member
      and has laboratory procedures done within the office, then this is one encounter
      between the member and their PCP.)

     

    If
      the
      PCP sends the member to a lab to have procedures performed, then this is two
      encounters; one with the PCP and another with the lab. For pharmacy encounters,
      each prescription filled is a separate encounter.

     

    Encounters
      include services paid for retrospectively, through fee-for-service payment
      arrangements, and prospectively. through capitated arrangements. Only encounters
      with services (line items) that are paid by the MCP, fully or in part, and
      for
      which no further payment is anticipated, are acceptable encounter data
      submissions.

     

    All
      other
      services that are unpaid or paid in part and for which the MCP anticipates
      further payment (e.g., unpaid services rendered during a delivery of a new-born)
      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

    


    


    Appendix
      C

    Page
      19

    


    test
      file
      in the ODJFS-specified medium in the required formats prior to contracting
      or
      prior to an information systems replacement or update.

     

    Acceptance
      testing of encounter data is required as specified in Section 29(a)(v) of this
      Appendix.

     

    Encounter
      Data File Submission Procedures

    A
      certification letter must accompany the submission of an encounter data file
      in
      the ODJFS-specified medium. The certification letter must be signed by the
      MCP's
      Chief Executive Officer (CEO), Chief Financial Officer (CFO), or an individual
      who has delegated authority to sign for, and who reports directly to, the MCP's
      CEO or CFO.

     

    No
      more
      than two production files in the ODJFS-specified medium per format (e.g., NSF)
      should be submitted each month. If it is necessary for an MCP to submit more
      than two production files in the ODJFS-specified medium for a particular format
      in a month, they must request and receive permission to do so from their
      designated Contract Administrator.

     

    Timing
      of Encounter Data Submissions

    ODJFS
      recommends that MCPs submit encounters no more than thirty-five (35) days after
      the end of the month in which they were paid. (For example, claims paid in
      January are due March 5.) ODJFS recommends that MCPs submit files in the
      ODJFS-specified medium by the 5th of each month. This will help to ensure that
      the encounters are included in the ODJFS master file in the same month in which
      they were submitted.

     

    d.
      Information
      Systems Review

     

    Every
      two
      (2) years, and before ODJFS enters into a provider agreement with a new MCP,
      ODJFS or designee may review the information system capabilities of each MCP.
      Each MCP must participate in the review, except as specified below. The review
      will assess the extent to which MCPs are capable of maintaining a health
      information system including producing valid encounter data, performance
      measures, and other data necessary to support quality assessment and
      improvement, as well as managing the care delivered to its members.

     

    The
      following activities, at a minimum, will be carried out during the review.
      ODJFS
      or its designee will:

     

    i.
      Review
      the Information Systems Capabilities Assessment (ISCA) forms, as developed
      by
      CMS; which the MCP will be required to complete.

    


    Appendix
      C

    Page
      20

    


    


    ii.
      Review the completed ISCA and accompanying documents;

     

    iii.
      Conduct interviews with MCP staff responsible for completing the ISCA, as well
      as staff responsible for aspects of the MCP's information systems
      function;

     

    iv.
      Analyze the information obtained through the ISCA, conduct follow-up interviews
      with MCP staff, and write a statement of findings about the MCP's information
      system.

     

    v.
      Assess
      the ability of the MCP to link data from multiple sources;

     

    vi.
      Examine MCP processes for data transfers;

     

    vii.
      If
      an MCP has a data warehouse, evaluate its structure and reporting
      capabilities;

     

    viii.
      Review MCP processes, documentation, and data files to ensure that they comply
      with state specifications for encounter data submissions; and

     

    ix.
      Assess the claims adjudication process and capabilities of the MCP.

     

    As
      noted
      above, the information system review may be performed every two years. However,
      if ODJFS or its designee identifies significant information system problems,
      then ODJFS or its designee may conduct, and the MCP must participate in, a
      review the following year, or in such a timeframe as ODJFS, in their sole
      discretion, deems appropriate to ensure accuracy and efficiency of the MCP
      health information system.

     

    If
      an MCP
      had an assessment performed of its information system through a private sector
      accreditation body or other independent entity within the two years preceding
      the time when ODJFS or its designee will be conducting its review, and has
      not
      made significant changes to its information system since that time, and the
      information gathered is the same as or consistent with the ODJFS or its
      designee's proposed review, as determined by the ODJFS, then the MCP will not
      required to undergo the IS review. The MCP must provide ODJFS or its designee
      with a copy of the review that was performed so that ODJFS can determine whether
      or not the MCP will be required to participate in the IS review. MCPs who are
      determined to be exempt from the IS review must participate in subsequent
      information system reviews, as determined by ODJFS.

     

    Appendix
      C 

    Page
      21

     

    31.
      If
      the MCP will be using the Internet functions that will allow approved users
      to
      access member information (e.g., eligibility verification), the MCP must receive
      prior written approval from ODJFS that verifies that the proper safeguards,
      firewalls, etc., are in place to protect member data.

     

    32.
      MCPs
      must receive prior written approval from ODJFS before adding any information
      to
      their website that would require ODJFS prior approval in hard copy form (e.g.,
      provider listings, member handbook information).

     

    33.
      Pursuant to 42 CFR 438.106(b), the MCP acknowledges that it is prohibited from
      holding a member liable for services provided to the member in the event that
      the ODJFS fails to make payment to the MCP.

     

    34.
      In
      the event of an insolvency of an MCP, the MCP, as directed by ODJFS, must cover
      the continued provision of services to members until the end of the month in
      which insolvency has occurred, as well as the continued provision of inpatient
      services until the date of discharge for a member who is institutionalized
      when
      insolvency occurs.

     

    35.
      Franchise
      Fee Assessment Requirements

     

    a.
      Each
      MCP is required to pay a franchise permit fee to ODJFS for each calendar quarter
      as required by ORC Section 5111.176. The current fee to be paid is an amount
      equal to 4'/2 percent of the managed care premiums, minus Medicare premiums
      that
      the MCP received from any payer in the quarter to which the fee applies. Any
      premiums the MCP returned or refunded to members or premium payers during that
      quarter are excluded from the fee.

     

    b.
      The
      franchise fee is due to ODJFS in the ODJFS-specified format on or before the
      30th day following the end of the calendar quarter to which the fee
      applies.

     

    c.
      At the
      time the fee is submitted, the MCP must also submit to ODJFS a completed form
      and any supporting documentation pursuant to ODJFS specifications.

     

    d.
      Penalties for noncompliance with this requirement are specified in Appendix
      N,
      Compliance Assessment System of the Provider Agreement and in ORC Section
      5111.176.

     

    36.
      Information
      Required for MCP Websites

     

    a.
      On-line
      Provider Directory
      - MCPs
      must have an internet-based provider directory available in the same format
      as
      their ODJFS-approved provider


    


    Appendix
      C

    Page
      22


    


    directory,
      that allows members to electronically search for the MCP panel providers based
      on name, provider type, geographic proximity, and population (as specified
      in
      Appendix H). MCP provider directories must include all MCP-contracted providers
      [except as specified by ODJFS] as well as certain ODJFS non-contracted
      providers.

     

    b.
      On-line
      Member Website
      - MCPs
      must have a secure internet-based website

    which
      is
      regularly updated to include the most current ODJFS approved materials. The
      website at a minimum must include: (1) a list of the counties that are covered
      in their service area; (2) the ODJFS-approved MCP member handbook, recent
      newsletters/announcements, MCP contact information including member services
      hours and closures; (3) the MCP provider directory as referenced in section
      36(a) of this appendix; (4) the MCP's current preferred drug list (PDL),
      including an explanation of the list, which drugs require prior authorization
      (PA), and the PA process; (5) the MCP's current list of drugs covered only
      with
      PA, the PA process, and the MCP's policy for covering generic for brand-name
      drugs; and (6) the ability for members to submit
      questions/comments/grievances/appeals/etc, and receive a response (members
      must
      be given the option of a return e-mail or phone call). Responses regarding
      questions or comments are expected within one working day of receipt, whereas
      responses regarding grievances and appeals must be within the timeframes
      specified in OAC rule 5101:3-26-08.4. MCPs must ensure that all member materials
      designated specifically for CFC and/or ABD consumers (i.e. the MCP member
      handbook) are clearly labeled as such. The MCP's member website cannot be used
      as the only means to notify members of new and/or revised MCP information (e.g.,
      change in holiday closures, change in additional benefits, revisions to approved
      member materials etc.). ODJFS may require MCPs to include additional information
      on the member website, as needed.

     

    c.
      On-line
      Provider Website -
      MCPs
      must have a secure internet-based website for providers where they will be
      able
      to confirm a consumer's MCP enrollment and through this website (or through
      e-mail process) allow providers to electronically submit and receive responses
      to prior authorization requests. This website must also include: (1) a list
      of
      the counties that are covered in their service area; (2) the MCP's provider
      iTianual.;(3) MCP contact information; (4) a link to the MCP's on-line provider
      directory as referenced in section 36(a) of this appendix; (5) the MCP's current
      PDL list, including an explanation of the list, which drugs require PA, and
      the
      PA process; and (6) the MCP's current list of drugs covered only with PA, the
      PA
      process, and the MCP's policy for covering generic for brand-name drugs. MCPs
      must ensure that all provider materials designated specifically for CFC and/or
      ABD consumers (i.e. The MCP's provider manual) are clearly labeled as such.
      ODJFS may require MCPs to include additional information on the provider
      website, as needed.


    


    Appendix
      C 

    Page
      23

     

    37.
      MCPs
      must provide members with a printed version of their PDL and PA lists, upon
      request.

     

    38.
      MCPs
      must not use, or propose to use , any offshore programming or call center
      services in fulfilling the program requirements.

     

    39.
      PCP
      Feedback
      - The
      MCP must have the administrative capacity to offer feedback to individual
      providers on their: 1) adherence to evidence-based practice guidelines; and
      2)
      positive and negative care variances from standard clinical pathways that may
      impact outcomes or costs. In addition, the feedback information may be used
      by
      the MCP for activities such as physician performance improvement projects that
      include incentive programs or the development of quality improvement
      programs.