exhibit10-2.htm


    
      
        

      

    

    Back
      to Form 8-K

    Exhibit
      10.2

     

    


    


    PROVIDER
      AGREEMENT

                          
      


    BETWEEN

    


    STATE
      OF
      OHIO

    


    DEPARTMENT
      OF JOB AND FAMILY SERVICES

    


    AND

    


    WELLCARE
      OF OHIO, INC.

    


    Amendment
      No.
      1

    


    Pursuant
      to Article IX.A. the Provider Agreement between the State of Ohio, Department
      of
      Job and Family Services, (hereinafter referred to as “ODJFS”) and WELLCARE OF
      OHIO, INC.  (hereinafter
      referred to as “MCP”) for the Aged, Blind or Disabled (hereinafter referred to
      as “ABD”) population dated July 1, 2007, is hereby amended as
      follows:

     

    1.           
      Appendices C, D, E, F, G, H, J, K, L, M, N and O are modified as
      attached.

     

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

     

    The
      amendment contained herein shall be effective January 1,
      2008. 

    


    


    
      	
              WELLCARE
                OF OHIO, INC.

            	
               

               

            
	
              BY:  /s/  TODD
                S. FARHA

            	DATE:
              12/19/07
	
              TODD
                S. FARHA, PRESIDENT AND CEO

            
	 
	 
	
              OHIO
                DEPARTMENT OF JOB AND FAMILY SERVICES:

              
              

            
	
              BY:
                /s/ HELEN E.
                JONES-KELLEY

            	
              DATE:
                12/26/07

            
	
              HELEN
                E. JONES-KELLEY, 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.

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

    a. Maintain
      written policies and procedures that meet the requirements for advance
      directives, as set forth in 42 CFR Subpart I of part 489.

     

    b. Maintain
      written policies and procedures concerning advance directives with respect
      to
      all adult individuals receiving medical care by or through the MCP to ensure
      that the  MCP:

     

    i. Provides
      written information to all adult members concerning:

     

    a. the
      member’s rights under state law to make decisions concerning their medical care,
      including the right to accept or refuse medical or surgical treatment and the
      right to formulate advance
      directives.  (In meeting this requirement, MCPs must utilize form JFS
      08095 entitled You
      Have the
      Right, or
      include the
      text from JFS 08095 in their ODJFS-approved member
      handbook).

     

    b. the
      MCP’s policies concerning the implementation of those rights including a clear
      and precise statement of any limitation regarding the implementation of advance
      directives as a matter of conscience;

     

    c. any
      changes in state law
      regarding
      advance directives as soon as possible but no later than ninety (90) days
      after the proposed effective date of the change; and

     

    d. the
      right to file complaints concerning noncompliance with the advance directive
      requirements with the Ohio Department of Health.

     

    ii. Provides
      for education of staff concerning the MCP’s policies and procedures on advance
      directives;

    iii. Provides
      for community education regarding advance directives directly or in concert
      with
      other providers or entities;

    iv. Requires
      that the member’s medical record document whether or not the member has executed
      an advance directive; and

    v. Does
      not condition the provision of care, or otherwise discriminate against a member,
      based on whether the member has executed an advance
      directive.

     

    24. NewMember
      Materials

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

     

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

     

    b.
      The ID card and new member letter must be mailed together to the member via
      a
 method that will ensure their receipt prior to the member’s effective date
      of coverage.

     

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

     

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

     

    25. Call CenterStandards

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


    ·      
      New Year’s Day 

    ·      
      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.

     

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

     

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

     

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

     

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

     

    26.       Notification
      of Optional MCP Membership

     

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

     

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

     

    27. HIPAA
      Privacy Compliance Requirements

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

    29. MCP
      Membership acceptance, documentation and
      reconciliation

     

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

      

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

     

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

     

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

     

    d.
       Hospital/Inpatient Facility Deferment: When an MCP learns of a currently
      hospitalized member’s intent to disenroll through the CCR or the 834, the
      disenrolling MCP must notify the hospital/inpatient facility and treating
      providers as well as the enrolling MCP of the change in enrollment within five
      (5) business days of receipt of the CCR or 834. The disenrolling MCP must notify
      the inpatient facility that it will remain responsible for the inpatient
      facility charges through the date of discharge; and must notify the treating
      providers that it will remain responsible for provider charges through the
      date
      of disenrollment.

     

    When
      the enrolling MCP learns through the disenrolling MCP, through ODJFS
      or other means, that a new member who was previously enrolled with another
      MCP was admitted prior to the effective date of enrollment and remains an
      inpatient on the effective date of enrollment, the enrolling MCP shall
      contact the hospital/inpatient facility within five (5) business days of
      learning of the hospitalization.  The enrolling MCP shall verify that
      it is responsible for all medically necessary Medicaid covered services
      from the effective date of MCP membership, including treating provider
      services related to the inpatient stay; the  enrolling MCP must
      reiterate that the admitting/disenrolling MCP remains responsible for the
      hospital/inpatient facility charges through the date
      of discharge.  The enrolling MCP shall work with the
      hospital/inpatient facility to  facilitate discharge planning and authorize
      services as needed.

     

    When
      an MCP learns that a new member who was previously on Medicaid fee for
  service was admitted prior to the effective date of enrollment and
      remains an inpatient on the effective date of enrollment, the enrolling MCP
      shall notify the hospital/ inpatient facility and treating providers
      that the MCP may not be the payer. The MCP shall work with
      hospital/inpatient facility, treating providers and  the ODJFS to
      assure that discharge planning assures continuity of care and accurate
      payment. Notwithstanding the MCP’s right to request a hospital deferment up to
      six (6) months following the member’s effective date, when the enrolling MCP
      learns of a deferment-eligible hospitalization, the MCP shall notify the
      ODJFS
      and request the deferment within five (5) business days
      of  learning of the potential deferment.

     

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

     

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

     

    g.  Pending
      Member: If
a
      pending member (i.e., an
      eligible
      individual subsequent to plan selection or
      assignment, but
      prior to
      their membership effective date) contacts
      the selected
      MCP,  the MCP
      must
      provide any membership information requested,
      including but
      not limited
      to, assistance in determining
      whether the
      current
      medications
      require prior
      authorization. The
      MCP must
      also ensure
      that any
      care coordination (e.g., PCPselection, prescheduled
      services and transition
      of services)
      information provided by the
      pending
member
      is
logged
      in
      the MCP’s
      system
      and forwarded
      to
      the appropriate MCP staff for
      processing as
      required.  MCPs may confirm
      any information provided on
      the CCR
      at this
      time.  Such communication
      does not constitute confirmation
      of membership.  MCPs
      are prohibited from initiating
      contact with
      a
      pending member. Upon
      receipt of
      the 834, the  MCP
      may contact
      a pending member to confirm information provided on the
      CCR or the
      834, assist with care coordination and transition of care, and
      inquire if
      the pending member has any membership questions.

     

     h. Transition
      of Fee-For-Service Members:
Providing
      care
      coordination, access to preventive and specialized care, case management,
      member services, and education with minimal disruption to members’ established
      relationships with providers and existing care treatment plans is critical
      for
      members transitioning from Medicaid fee-for-service to managed
      care.  MCPs must develop
      and
      implement a transition plan that outlines how the MCP will effectively address
      the unique care coordination issues of members in their first three months
      of
      MCP membership and how the various MCP departments will coordinate and share
      information regarding these new members. The transition plan must include at
      a
      minimum:

     

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

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

     

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

     

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

     

    ii. Strategies
      for how each new member will obtain care therapies from  appropriate
      sources of care as an MCP member. The MCP’s strategies  must
      include at
      a minimum:

     

    a. Allowing
      their
      new members that are transitioning from Medicaid fee-for-service
      to receive services from out-of-panel providers if the
      member or
      provider contacts the MCP to discuss the scheduled health services in advance
      of
      the service date and one of the following applies:

     

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

     

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

     

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

     

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

     

    v. The
      member has
      been released from the hospital within thirty (30) days prior
      to MCP
      enrollment and is following
      a
      treatment plan.

     

    If
      contacted by
      the member, the MCP must contact the provider’s office as expeditiously as the
      situation warrants to confirm that the service(s) meets the above
      criteria.

     

    b.
Allowing
      their
      new members that are transitioning from Medicaid fee-for-service
      to continue receiving home care services (i.e., nursing, aide, and skilled
      therapy services) and private duty nursing (PDN) services if the member or
      provider contacts the MCP
      to discuss
      the health services in advance of the service date.  These services
      must be covered from the date of the member or provider contact at the current
      service level, and with the current provider, whether a panel or out-of-panel
      provider, until the MCP conducts
      a
      medical necessity review and renders an authorization decision pursuant to
      OAC
      rule 5101:3-26-03.1.  As soon as the MCP becomes aware of the member’s
      current home care services, the MCP must initiate contact with the current
      provider and member as applicable to ensure continuity of care and coordinate
      a
      transfer of services to a panel provider, if
      appropriate.

     

    c. Honoring
      any
      current fee-for-service prior authorization to allow their
      new
      members that are transitioning from Medicaid fee-for-service to receive services
      from the authorized provider, whether a panel
      or
      out-of-panel provider, for the following approved
      services:

     

     i. an
      organ, bone
      marrow, or hematapoietic stem cell transplant
      pursuant to OAC rule 5101:3-2-07.1;

     

    ii. dental
      services
      that have not yet been received;

     

    iii. vision
      services
      that have not yet been received;

     

    iv. durable
      medical
      equipment (DME) that has not yet been received.  Ongoing
      DME services and supplies are to be covered by the MCP as previously-authorized
      until the MCP conducts a medical necessity review and renders an authorization
      decision pursuant to OAC rule 5101:3-26-03.1.

     

    v.  private
      duty
      nursing (PDN) services.  PDN services must be
      covered at
      the previously-authorized service level until the MCP conducts a medical
      necessity review and renders an authorization decision pursuant to OAC rule
      5101:3-26-03.1.

     

    As
      soon as the
      MCP becomes aware of the member’s current fee-for-service authorization
      approval, the MCP must initiate contact with the authorized provider and member
      as applicable to ensure continuity of care.  The MCP must implement a
      plan to meet the member’s immediate and ongoing medical needs and, with the
      exception of organ, bone marrow, or hematapoietic stem cell transplants,
      coordinate the transfer of services to a panel provider, if
      appropriate.

     

    When
      an MCP
      medical necessity review results in a decision to reduce, suspend, or terminate
      services previously authorized by fee-for-service Medicaid, the MCP must notify
      the member of their state hearing rights no less than 15 calendar days prior
      to
      the effective date of the MCP’s proposed action, per rule 5101:3-26-08.4 of the
      Administrative Code.

     

    d. Reimbursing
      out-of-panel providers that agree to provide the transition
      services at 100% of the current Medicaid fee-for-service  provider
      rate
      for the service(s) identified in Section 29.h.ii.(a., b.,  and
      c.) of this
      appendix.

     

    e. Documenting
      the
      provision of transition services identified in Section
      29.h.ii.(a., b., and c.) of this appendix as follows:

     

    i. For
      non-panel
      providers, notification to the provider  confirming
      the
      provider’s agreement/disagreement to  provide
      the
      service and accept 100% of the current  Medicaid
      fee-for-service rate as payment.  If the provider agrees,
      the
      distribution of the MCP’s materials
      as
      outlined in
      Appendix
      G.4.e.

     

    ii. Notification
      to
      the member of the non-panel provider’s  agreement
      /disagreement to provide the service.  If the provider
      disagrees, notification to the member of the MCP’s
      availability to assist with locating a provider as expeditiously
      as the member’s health condition warrants.

     

    iii. For
      panel
      providers, notification to the provider and member
      confirming the MCP’s responsibility to cover the  service.

     

    MCPs
      must use
      the ODJFS-specified model language for the provider and  member
      notices and maintain documentation of all member and/or provider contacts
      relating to such services.

      

    f. Implementing
      a drug transition of care process that prevents drug access problems for new
      members that are transitioning from Medicaid fee-for-service
      (FFS).  Such a process would involve the MCP covering at least one
      prescription fill or refill without prior authorization (PA) of any covered
      prescription drug not requiring PA by FFS.  For new members that are
      transitioning from FFS who utilize ongoing medications for chronic conditions
      the MCP must educate the member about how to continue to access drugs for their
      chronic condition before the MCP may implement PA requirements for that member’s
      specific ongoing medication.  The MCP’s process for covering the
      prescription fill or refill without PA must be based on one of the following
      approaches:

     

    i.
      the MCP covers without PA all prescriptions written within the two months prior
      to the effective date of MCP enrollment that do not require PA by Medicaid
      fee-for-service; or

     

    ii.
      the MCP covers without PA for at least the initial 30 days of the member’s MCP
      membership all prescriptions that do not require PA by Medicaid
      fee-for-service.

     

    For
      any new member transitioning from FFS who utilizes ongoing medications for
      chronic conditions the MCP may require subsequent PA for those drugs once the
      MCP has educated the member about the importance of working with their physician
      to discuss initiating a PA request to continue the current medication and the
      option of using alternative medications that may be available without
      PA.  Written member notices must use ODJFS-specified model language
      and be ODJFS-approved.  Verbal member education may be done in place
      of written education but must contain the same information as a written notice
      and must follow a call script that contains ODJFS-specified model language
      and
      be ODJFS-approved.

     

    For
      those new members who are not utilizing ongoing medications for chronic
      conditions, no additional drug PA education is required beyond the MCP’s general
      new member education that includes what drugs require MCP
      PA.

     

    MCPs
      must receive ODJFS approval prior to implementing their transition of care
      drug
      PA process.  An MCP’s proposal must document how the MCP
      will:

     

    i.  implement
      one of the above options to ensure that members transitioning from FFS receive
      at least one prescription fill or refill without PA of any covered prescription
      drug not requiring PA by FFS; and

     

    ii.
      identify new members that are transitioning from FFS who utilize ongoing
      medications for chronic conditions and provide timely education to the member
      about how to continue to access drugs for their chronic condition before the
      MCP
      will implement PA requirements for that member’s specific ongoing
      medication.

     

    MCPs
      who have not received ODJFS approval for their transition of care drug PA
      process must not require PA of any prescription drug that does not require
      PA by
      Medicaid fee-for-service for the initial three months of a member’s MCP
      membership.

     

    g. Covering
      antipsychotic medications for new members as well as current members as
      stipulated in Appendix G(3)(a)(i).

     

    30. Health
      Information System Requirements

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

     

     a. Health
      Information System

     

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

     

    ii. As
      required by
      42 CFR 438.242(b)(1), each MCP must collect data on member and provider
      characteristics and on services furnished to its
      members.

     

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

     

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

     

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

     

    a. Before
      an MCP
      may submit production files ODJFS-specified formats;
      and/or

    b. Whenever
      an MCP
      changes the method or preparer of the electronic media;
      and/or

    c. When
      the ODJFS
      determines an MCP’s data submissions havean
      unacceptably
      high error rate.

     

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

     

    Submission
      of
      test files can start before the new or modified information system is
      in production.  ODJFS reserves
      the right to verify any MCP’s capability
      to
      report elements in the minimum data set prior to executing the provider
      agreement for the next contract period. Penalties for noncompliance with this
      requirement are specified in Appendix N, Compliance Assessment
      System of the Provider Agreement.

     

    b. Electronic
      Data Interchange and Claims Adjudication Requirements

     

      Claims
      Adjudication

     

    The
      MCP must have the capacity to electronically accept and adjudicate all claims
       to final status (payment or denial).  Information on claims
      submission procedures  must be provided to non-contracting providers within
thirty
      (30) days of a request.   MCPs must inform providers of
      its ability to electronically process and adjudicate  claims and the
      process for submission.  Such
      information must be initiated by the  MCP
      and not
      only in response to provider requests.

     

     The
      MCP must
      notify providers who have submitted claims of claims status [paid,  denied,
      pended (suspended)]
      within one month of receipt.  Such notification may  be in the
      form of a claim payment/remittance advice produced on a routine  monthly,
      or more frequent, basis.

     

    Electronic
      Data Interchange

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

      Health
      care claims;

      Health
      care claim status request and response;

      Health
      care
      payment and remittance status;

      Standard
      code
      sets; and   

      National
      Provider Identifier (NPI).

     

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

     

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

     

     ASC
      X12 820 - Payroll Deducted and Other Group Premium Payment for  Insurance
      Products; and

     

     ASC
      X12 834 - Benefit Enrollment and Maintenance.

     

     The
      MCP shall comply with the HIPAA mandated EDI transaction standards and
 code sets no later than the required compliance dates as set forth in the
      federal  regulations.

     

      Documentation
      of Compliance with Mandated EDI Standards

     The
      capacity of the MCP and/or applicable trading partners and business
 associates to electronically conduct claims processing and related
      transactions in  compliance
      with
      standards and effective dates mandated by HIPAA must be  demonstrated,
      to the satisfaction of ODJFS, as outlined below.

     

    Verification
      of Compliance with HIPAA (Health Insurance Portability and  Accountability
      Act of 1995)

    MCPs
      shall
      comply with the transaction standards and code sets for sending and  receiving
      applicable transactions as specified
      in 45
      CFR Part 162 – Health  Insurance
      Reform:  Standards for Electronic
      Transactions (HIPAA  regulations)
      In
       addition
      the MCP must enterinto
      the
      appropriate trading partner
      agreement and  implemented
      standard
      code
      sets.  If the MCP has obtained
      third-party certification  of
      HIPAA
      compliance for any of the items  listed
      below,
 that
      certification may  be
      submitted
      in lieu of
      the MCP’s written verification
      for the applicable  item(s).

       

    i. Trading
      Partner
      Agreements

    ii. Code
      Sets

    iii. Transactions

     

    a. Health
      Care Claims or Equivalent Encounter Information (ASC
      X12N 837 & NCPDP 5.1)

    b. Eligibility
      for a Health Plan (ASC X12N 270/271)

    c. Referral
      Certification and Authorization (ASC X12N 278)

    d. Health
      Care Claim Status (ASC X12N 276/277)

    e. Enrollment
      and Disenrollment in a Health Plan (ASC  X12N 834)

    f. Health
      Care Payment and Remittance Advice (ASC X12N 835)

    g. Health
      Plan Premium Payments (ASC X12N 820)

    h. Coordination
      of Benefits 

      

    Trading
      Partner Agreement with ODJFS

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

     

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

     

    c. Encounter
      Data Submission Requirements

     

    General
      Requirements

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

     

    ·    Institutional
      Claims - UB92 flat file

    ·    Noninstitutional
      Claims - National standard format

    ·    Prescription
      Drug Claims - NCPDP

     

    ODJFS
      relies heavily on encounter data for monitoring MCP performance. The ODJFS
      uses
      encounter data to measure clinical performance, conduct access and utilization
      reviews, reimburse MCPs for newborn deliveries and
      aid in
      setting

     

    MCP
      capitation rates.  For these reasons, it is important that encounter
      data is timely, accurate, and complete. Data quality,
performance
      measures and standards are described in the
      Agreement.

     

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

     

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

     

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

     

    All
      other services that are unpaid or paid in part and for which the MCP anticipates
      further payment (e.g., unpaid services rendered during a delivery of a newborn)
      may not be submitted to ODJFS until they are paid. Penalties for noncompliance
      with this requirement are specified in Appendix N, Compliance
      Assessment System of the Agreement.

     

    Acceptance
      Testing

    The
      MCP must have the capability to report all elements in the Minimum Data Set
      as
      set forth in the ODJFS Encounter Data Specifications and must submit a test
      file
      in the ODJFS-specified medium in the required formats prior to contracting
      or
      prior to an information systems replacement or update.

     

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

     

    Encounter
      Data File Submission Procedures

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

     

    Timing
      of Encounter Data Submissions

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

     

    d. Information
      Systems Review

     

    ODJFS
      or its designee may review the information system capabilities of each MCP
      before ODJFS enters into a provider agreement with a new MCP, when a
      participating MCP undergoes a major information system upgrade or
      change,  when there is identification of significant information
      system problems, or at ODJFS’ discretion. Each MCP must participate in the
      review. The review will assess the extent to which MCPs are capable of
      maintaining a health information system including producing valid encounter
      data, performance measures, and other data necessary to support quality
      assessment and improvement, as well as managing the care delivered to its
      members.

     

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

     

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

     

    ii. Review
      the
      completed ISCA and accompanying documents;

     

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

     

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

     

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

     

    vi.
      Examine MCP
      processes for data transfers;

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

    35. Franchise
      Fee
      Assessment Requirements

     

    a. Each
      MCP is required to pay a franchise permit fee to ODJFS for each calendar
 quarter
      as
      required by ORC Section 5111.176.  The current  fee
      to be paid
      is an  amount
      equal to
      41⁄2 percent of the managed care premiums, minus Medicare  premiums
      that
      the MCP received from any payer in the quarter to which the fee  applies.  Any
      premiums the MCP returned or refunded to members or premium  payers
      during
      that quarter are excluded from the fee.

     

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

     

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

     

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

     

    36. Information
      Required for MCP Websites

     

    a.
 On-line
      Provider Directory–
MCPs
      must
      have an internet-based provider directory
      available in the same format as their ODJFS-approved provider directory,
      that
      allows  members
      to
      electronically search for the MCP panel providers
      based
      on name, provider type, geographic proximity, and population
      (as
      specified in Appendix H).  MCP provider directories must
      include all
      MCP-contracted providers [except as specified by ODJFS] as well as
      certain ODJFS
      non-contracted providers.

     

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

     

    c. On-line
      Provider Website –
MCPs
      must have a secure internet-based website for contracting providers where
      they will be able to confirm a consumer’s MCP enrollment and through this
      website (or through e-mail process) allow providers    to
      electronically submit and receive responses to prior authorization
      requests.   This website must also include: (1) a list of the
      counties that are covered in their service area; (2) the MCP’s provider
      manual; (3) MCP contact information; (4) a link to the MCP’s on-line
      provider directory as referenced in section 37(a) of this appendix; (5) the
      MCP’s current PDL list, including an explanation of the list,  which
      drugs require PA, and the PA process; (6) the MCP’s current list
      of  drugs covered only with PA, the PA process, and the MCP’s policy
      for covering    generic for brand-name drugs.  MCPs
      must ensure that all provider materials designated specifically for CFC
      and/or ABD consumers (i.e. the MCP’s provider  manual) are clearly
      labeled as such; and (7) information regarding the availability of
      expedited prior authorization requests, as well as the information that
      is required from that provider in order to substantiate an expedited prior
 authorization request.

     

    ODJFS
      may require MCPs to include additional information on the provider website,
      as needed.

     

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

     

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

     

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

     

    41. Coordination
      of Benefits

     

     When
      a claim is denied due to third party liability, the managed care plan must
      timely  share appropriate and available information regarding the third
      party to the provider for  the purposes of coordination of benefits,
      including, but not  limited to third party liability  information
      received from the Ohio Department of Job and  Family
      Services.

    


    


    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    APPENDIX
      D

    


    ODJFS
      RESPONSIBILITIES

    ABD
      ELIGIBLE
      POPULATION

    


    The
      following are ODJFS responsibilities or clarifications that are not otherwise
      specifically stated in OAC Chapter 5101: 3-26 or elsewhere in the ODJFS-MCP
      provider agreement.

     

    General
      Provisions

     

    1. ODJFS
      will provide MCPs with an opportunity  to review and comment on the
      rate-setting time line and proposed rates, and proposed changes to the OAC
      program rules or the provider agreement.

     

    2. ODJFS
      will notify MCPs of managed
      care program policy and procedural changes and, whenever possible, offer
      sufficient time for comment and implementation.

     

    3. ODJFS
      will provide regular opportunities for MCPs to receive program updates and
      discuss program
      issues with ODJFS staff.

     

    4. ODJFS
      will provide technical assistance sessions where MCP attendance and
      participation is required. ODJFS will also provide optional technical assistance
      sessions to MCPs, individually or as a group.

     

    5. ODJFS
      will provide MCPs with an annual MCP Calendar of Submissions outlining major
      submissions and due dates.

     

    6. ODJFS
      will identify contact staff, including the Contract Administrator, selected
      for
      each MCP.

     

    7. ODJFS
      will recalculate the minimum
      provider panel specifications  if ODJFS determines that significant
      changes have occurred in the availability of specific provider types and the
      number and composition of the eligible population.

     

    8. ODJFS
      will recalculate the
      geographic accessibility standards, using the geographic information systems
      (GIS) software, if ODJFS determines that significant changes have occurred
      in
      the availability of specific provider types and the number and composition
      of
      the eligible population and/or the ODJFS provider panel
      specifications.

     

    9. On
      a monthly basis, ODJFS will
      provide MCPs with an electronic file containing their MCP’s provider panel as
      reflected in the ODJFS Provider Verification System (PVS) database, or
      other designated system.

     

    10. On
      a monthly basis, ODJFS will
      provide MCPs with an electronic Master Provider File containing all the Ohio
      Medicaid fee-for-service providers, which includes their Medicaid Provider Number,
      as well as all
      providers who have been assigned a provider reporting number for current encounter
      data
      purposes.

     

    11. It
      is the intent of ODJFS to
      utilize electronic commerce for many processes and  procedures
      that are now limited by
      HIPAA privacy concerns to FAX, telephone, or hard copy.  The use of
      TLS will mean that private health information (PHI) and the identification
      of
      consumers as Medicaid recipients can be shared between ODJFS and the contracting
      MCPs via e-mail such as reports, copies of letters, forms, hospital claims,
      discharge records, general discussions of member-specific information, etc.
      ODJFS may revise data/information exchange policies and procedures for many
      functions that are now restricted to FAX, telephone, and hard copy, including,
      but not limited to, monthly membership and premium payment reconciliation
      requests, newborn reporting, Just Cause disenrollment requests, information
      requests etc. (as specified in Appendix C).

     

    12. ODJFS
      will immediately report to
      Center for Medicare and Medicaid Services (CMS) any breach
      in privacy or security that
      compromises protected health information (PHI), when reported
      by the MCP or ODJFS
      staff.

     

    13. Service
      Area Designation

    Membership
      in a service area is
mandatory unless
      ODJFS approves membership in
      the service area for
      consumer initiated selections only. It is ODJFS’ current
intention
      to implement a mandatory
managed
      care program in
      service areas wherever choice
      and capacity allow and the criteria in 42 CFR 438.50(a) are
      met.

     

    14. Consumer
      information

     

    a. ODJFS,
or
      its delegated entity, will
      provide membership notices,
      informational materials, and instructional materials relating to members and
      eligible individuals in a manner and format that may be easily understood.
      At
      least annually, ODJFS or designee
      will provide
      MCP eligible individuals, including current MCP members, with a Consumer Guide. The Consumer Guide
      will describe the managed  care program and include information on the
      MCP options in the service area and
      other  information  regarding the managed care program as
      specified in 42 CFR 438.10.

     

    b. ODJFS
      will notify members or ask MCPs to notify members about significant changes
      affecting contractual requirements, member services or access to
      providers.

     

    c. If
      an MCP elects not to provide, reimburse, or cover a counseling service or
      referral service due to an objection to the service on moral or religious
      grounds, ODJFS will provide coverage and reimbursement for these services for
      the MCP’s members.

     

    ODJFS
      will provide information on what services the MCP will not cover and how and
      where the MCP’s members may obtain these services in the applicable Consumer
      Guides.

     

    15. Membership
      Selection and Premium Payment

     

    a. The
      managed care enrollment center
      (MCEC): The
      ODJFS-contracted MCEC
will
      provide unbiased
      education, selection services, and community outreach for the Medicaid
managed care
program.  The
      MCEC shall
      operate a statewide toll-free
      telephone center to assist eligible individuals in selecting an MCP or choosing
      a health care delivery option.

      

     The
      MCEC shall
      distribute the most current
      Consumer Guide that includes the managed care program
      information as specified in 42 CFR 438.10, as well as ODJFS prior-approved
      MCP
      materials, such as solicitation brochures and provider directories, to consumers
      who request additional materials.

     

    b. Auto-Assignment
      Limitations – In order
      to promote market and program stability, ODJFS may limit an MCP’s
      auto-assignments if they meet any of the following enrollment
      thresholds:

     

    ·  40%
      of statewideAged,
      Blind, or Disabled (ABD)
      managed care eligibles; and/or

    ·  60%
      of the ABD managed care
      eligibles in any
      region with two MCPs;
      and/or

    ·  40%
      of the ABD managed care
      eligibles in any
      region with three MCPs.

     

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

     

    c. Consumer
      Contact
      Record (CCR):  ODJFS or their
      designated entity shall forward CCRs to MCPs on no less than a weekly
      basis.  The
      CCRs are a record of each consumer-initiated MCP enrollment, change, or
      termination, and each
      MCEC initiated MCP
      assignment processed through the MCEC.  The
      CCR contains
      information that is not included on the monthly member
      roster.

     

    d. Monthly
      member roster (MR):
      ODJFS verifies managed care plan enrollment on a monthly
      basis via the monthly
      membership roster.  ODJFS or its designated entity provides
      a full member roster (F)
      and a change roster (C) via HIPAA 834 compliant transactions.

     

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

     

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

     

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

     

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

     

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

     

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

     

    19.   Communications

     

    a. ODJFS/BMHC:
      The Bureau of Managed Health Care
      (BMHC) is  responsible
      for the oversight of
      the MCPs’ provider agreements with     ODJFS.
      Within the BMHC,
a specific Contract
      Administrator (CA)
 has
      been assigned to each
      MCP.  Unless expressly directed  otherwise,
      MCPs shall first contact
      their designated CA for  questions/assistance
      related to
      Medicaid and/or the MCP’s  program
      requirements
      /responsibilities. If their CA is not available  and
      the MCP needs immediate
      assistance, MCP staff should  request
      to speak to a supervisor
      within the Contract Administration Section.  MCPs
      should
      take all necessary and appropriate steps to ensure all MCP staff are aware
      of,
      and follow, this communication process.

     

    b. ODJFS
      contracting entities:  ODJFS-contracting
      entities should never be contacted by the MCPs unless the MCPs have been
      specifically  instructed
      by ODJFS to
      contact the ODJFS contracting
      entity  directly.

     

    c. MCP
      delegated entities: In
      that MCPs are ultimately responsible for meeting  program
      requirements, the BMHC will
      not discuss MCP issues  with
      the MCPs’ delegated entities
      unless the applicable MCP is  also
      participating in the
      discussion.  MCP delegated entities, with the applicable    MCP
      participating, should only
      communicate with the specific CA assigned to that
      MCP.

     

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    
      APPENDIX
        E

    

    
      


      RATE
        METHODOLOGY ABD ELIGIBLE POPULATION

    

    


    


    


    


    


    


    


    


    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

     

    


    
      


    

    
       

      Chase
        Center/Circle

    

    
      111
        Monument Circle

    

    
      Suite
        601

    

    
      Indianapolis,
        IN
        46204-5128

    

    
      USA

       

    

    
      Tel
        +1317 639 1000 

      Fax
        +1317 639 1001

    

    
       

      rniliiman.com

    

    
       

      FINAL
        and CONFIDENTIAL

    

     

    
       

      December
        12, 2007

    

    
       

       

      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:   CY
        2008 CAPITATION RATE DEVELOPMENT - AGED. BLIND, OR
        DISABLED

    

    
       

      Dear
        Jon:

    

    
       

      Milliman,
        Inc. (Milliman) was retained by the State of Ohio, Department of Job and
        Family
        Services (ODJFS) to develop the calendar year 2008 actuarially sound capitation
        rates for the Aged, Blind, or Disabled (ABD) Risk Based Managed Care (RBMC)
        program. This letter provides the documentation for the actuarially sound
        capitation rates.

    

    
       

      LIMITATIONS

    

    
       

      The
        information contained in this letter, including the enclosures, has been
        prepared for the State of Ohio, Department of Job and Family Services and
        their
        consultants and advisors. It is our understanding that the information contained
        in this letter may be utilized in a public document. To the extent that the
        information contained in this letter is provided to third parties, the letter
        should be distributed in its entirety. Any user of the data must possess
        a
        certain level of expertise in actuarial science and healthcare modeling so
        as
        not to misinterpret the data presented.

    

    
       

      Milliman
        makes no representations or warranties regarding the contents of this letter
        to
        third parties. Likewise, third parties are instructed that they are to place
        no
        reliance upon this letter prepared for ODJFS by Milliman that would result
        in
        the creation of any duty or liability under any theory of law by Milliman
        or its
        employees to third parties. Other parties receiving this letter must rely
        upon
        their own experts in drawing conclusions about the capitation rates,
        assumptions, and trends.

    

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


     

    
       

      Jon
        Barley, Ph.D.

    

    
      December
        12, 2007

    

    
      Page
        2

    

    
       

      FINAL
        and CONFIDENTIAL

    

    
       

      The
        information contained in this letter was prepared as documentation of the
        actuarially sound capitation rates for Medicaid managed care organization
        health
        plans in the State of Ohio. The information may not be appropriate for any
        other
        purpose.

    

    
       

      SUMMARY
        OF METHODOLOGY

    

    
       

      ODJFS
        contracted with Milliman to develop the CY 2008 ABD actuarially sound capitation
        rates. The actuarially sound capitation rates were developed from historical
        claims and enrollment data for the fee for service (FFS) population. The
        FFS
        population is considered a comparable population to the population to be
        enrolled with the health plans. The historical experience was converted to
        a per
        member per month (PMPM) basis and stratified by region and category of service.
        The historical experience was trended forward using projected trend rates
        to a
        center point of July 1, 2008 for the 2008 calendar year contract period.
        The
        historical experience was adjusted to reflect adjustments to the utilization
        and
        average cost per service that would be expected in a managed care
        environment.

    

    
       

      Appendix
        1 contains a chart outlining the methodology that was used to develop the
        CY
        2008 capitation rates for the ABD populations.

    

    
       

      Appendix
        2 contains the actuarial certification regarding the actuarial soundness
        of the
        capitation rates.

    

    
       

      Appendix
        3 contains the CY 2008 capitation rates by region, including the segmentation
        of
        the administrative cost allowance between guaranteed and at-risk
        components.

    

    
       

      DETAILS
        OF METHODOLOGY

    

    
       

      I.           
        COVERED POPULATION

    

    
       

      The
        CY 2008 ABD capitation rates have been developed using historical experience
        from the FFS population. The historical experience was developed for the
        population eligible for managed care enrollment based on age and program
        assignment. The program assignments shown in Table 1 were included in the
        development of the capitation rates.

    

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    
      Mr.
        Jon Barley, Ph.D.

    

    
      December
        12, 2007

    

    
      Page
        3

    

    
       

      FINAL
        and CONFIDENTIAL

    

    
       

      Table
        I

    

    
       

      STATE
        OF OHIO

    

    
      DEPARTMENT
        OF JOB AND FAMILY SERVICES

    

    
      Summary
        of Managed Care Eligible Population

    

     

    
      	
              
                Program
                  Assignment

              

            	
              
                Description

              

            
	
              
                AGED

              

            	
              
                Aged

              

            
	
              
                RAGED

              

            	
              
                Aged
                  as defined on RMF

              

            
	
              
                BLIND

              

            	
              
                Blind

              

            
	
              
                RBLIND

              

            	
              
                Blind
                  as defined on RMF

              

            
	
              
                DISABLED

              

            	
              
                Disabled

              

            
	
              
                RDISABLED

              

            	
              
                Disabled
                  as defined on RMF

              

            
	
              
                RESMED

              

            	
              
                Residential
                  State Supplement &
                  Medicaid

              

            


    

    
       

      Milliman
        extracted the eligible population information from historical data. The eligible
        population includes the adult ABD population excluding: retro-active periods,
        back-dated periods, institutionalized, waiver, spend-down, Medicare
        dual-eligibles, and long-term nursing facility recipients. Adults are defined
        based on age greater than or equal to 21 during the base experience period.
        Long-term nursing facility was defined as stays lasting past the last day
        of the
        month following the admission to the nursing
        facility.

    

    
       

      If
        a member was ineligible during a month, all claims and eligibility for the
        month
        were excluded from the actuarial models.

       

    

    
      II.CATEGORY
        OF SERVICE DEFINITIONS

    

    
       

      The
        categories of service listed in Table 2 describe the actuarial model service
        groupings. The units associated with the categories have been indicated.
        Further, the primary method of classifying the claims has been
        provided.

       

    

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


     

     

    
       

      Mr.
        Jon Barley, Ph.D.

    

    
      December
        12, 2007

    

    
      Page
        4

    

    
       

      FINAL
        and CONFIDENTIAL

    

    
       

      Table
        2

       

      STATE
        OF OHIO

    

    
      DEPARTMENT
        OF JOB AND FAMILY SERVICES

    

    
      Categories
        of Service

      
 

      
        
          	
                  
                    Type
                      of Service

                  

                	
                  
                    Service
                      Category

                  

                	
                  
                    Utilization
                      Units

                  

                	
                  
                    Classification
                      Basis

                  

                
	
                  
                    Inpatient
                      Hospital

                  

                	
                  
                    Medical/Surgical

                  

                	
                  
                    Admits/Days

                  

                	
                  
                    COS,
                      DRG

                  

                
	 	
                  
                    MH/SA

                  

                	
                  
                    Admits/Days

                  

                
	 	
                  
                    Maternity
                      Delivery

                  

                	
                  
                    Admits/Days

                  

                
	 	
                  
                    Well
                      Newborn

                  

                	
                  
                    Admits/Days

                  

                
	 	
                  
                    Maternity
                      Non-Deliveries

                  

                	
                  
                    Admits/Days

                  

                
	 	
                  
                    Nursing
                      Facility

                  

                	
                  
                    Admits/Days

                  

                
	 	
                  
                    Other
                      Inpatient

                  

                	
                  
                    Admits/Days

                  

                
	
                  
                    Outpatient
                      Hospital

                  

                	
                  
                    Emergency
                      Room

                  

                	
                  
                    Claims

                  

                	
                  
                    COS,
                      Revenue Code

                  

                
	 	
                  
                    Surgery/ASC

                  

                	
                  
                    Services

                  

                
	 	
                  
                    Cardiovascular

                  

                	
                  
                    Services

                  

                
	 	
                  
                    PT/ST/OT

                  

                	
                  
                    Services

                  

                
	 	
                  
                    Clinic

                  

                	
                  
                    Services

                  

                
	 	
                  
                    Other

                  

                	
                  
                    Services

                  

                
	
                  
                    Professional

                  

                	
                  
                    Inpatient/Outpatient
                      Surgery

                  

                	
                  
                    Services

                  

                	
                  
                    COS,
                      Provider Type, Procedure, Modifier

                  

                
	 	
                  
                    Anesthesia

                  

                	
                  
                    Line
                      Items

                  

                
	 	
                  
                    Obstetrics

                  

                	
                  
                    Services

                  

                
	 	
                  
                    Office
                      Visits/Consults

                  

                	
                  
                    Services

                  

                
	 	
                  
                    Hospital
                      Inpatient Visits

                  

                	
                  
                    Services

                  

                
	 	
                  
                    Emergency
                      Room Visits

                  

                	
                  
                    Services

                  

                
	 	
                  
                    Immunizations
                      & Injections

                  

                	
                  
                    Services

                  

                
	 	
                  
                    Physical
                      Medicine

                  

                	
                  
                    Services

                  

                
	 	
                  
                    Miscellaneous
                      Services

                  

                	
                  
                    Line
                      Items, Services

                  

                
	
                  
                    Rad/Path/Lab

                  

                	
                  
                    Radiology

                  

                	
                  
                    Services

                  

                	
                  
                    COS,
                      Revenue Code, Provider Type, Procedure

                  

                  
                    
                    

                  

                  
                    
                    

                  

                
	 	
                  
                    Pathology/Laboratory

                  

                	
                  
                    Services

                  

                
	
                  
                    Ancillaries

                  

                	
                  
                    MH/SA

                  

                	
                  
                    Services

                  

                	
                  
                    COS,
                      Provider Type, Procedure

                  

                
	 	
                  
                    FQHC/RHF/OP
                      Health Facility

                  

                	
                  
                    Services

                  

                	
                  
                    COS

                  

                
	 	
                  
                    Pharmacy

                  

                	
                  
                    Line
                      Items

                  

                	
                  
                    COS

                  

                
	 	
                  
                    Dental

                  

                	
                  
                    Services

                  

                	
                  
                    COS

                  

                
	 	
                  
                    Vision

                  

                	
                  
                    Services

                  

                	
                  
                    COS,
                      Provider Type, Procedure

                  

                
	 	
                  
                    Home
                      Health

                  

                	
                  
                    Line
                      Items

                  

                	
                  
                    COS

                  

                
	 	
                  
                    Non-Emergent
                      Transportation

                  

                	
                  
                    Line
                      Items

                  

                	
                  
                    COS

                  

                
	 	
                  
                    Ambulance

                  

                	
                  
                    Line
                      items

                  

                	
                  
                    COS,
                      Procedure Code

                  

                
	 	
                  
                    Supplies
                      and DME

                  

                	
                  
                    Line
                      Items

                  

                	
                  
                    COS,
                      Provider Type, Procedure

                  

                
	 	
                  
                    Miscellaneous
                      Services

                  

                	
                  
                    Line
                      Items

                  

                	
                  
                    COS

                  

                


        


        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        




    

    


    
      Mr.
        Jon Barley, Ph.D. 

      December
        12, 2007

    

    
      Page
        5

    

    
       

      FINAL
        and CONFIDENTIAL

    

    
       

      III.       RATE
        GROUPS

    

    
       

      The
        CY 2008 ABD capitation rates will be risk adjusted using the Chronic Illness
        and
        Disability Payment System (CDPS). As such, the ABD capitation rates are provided
        in one single rate group. Further information regarding the CDPS risk adjustment
        is contained in a later section as well as documented in detail in other
        correspondence provided by Milliman,

    

    
       

      IV.        DEVELOPMENT
        OF CY 2006 ADJUSTED FFS DATA

    

    
       

      As
        discussed in other sections of this document, several adjustments were applied
        to the base FFS data to develop the CY 2008 capitation rates. The following
        outlines each of the adjustments applied to the base FFS
        data.

    

    
       

      a.           
        Historical Data Summaries

    

    
       

      The
        CY 2008 ABD capitation rates were developed using FFS claims for two state
        fiscal year (SFY) periods:

    

    
       

      
        	
                §  

              	
                SFY
                  2005 (Incurred during the 12 months ending June 30, 2005 paid through
                  May
                  31, 2007).

              


      

    

    
       

      
        	
                §  

              	
                SFY
                  2006 (Incurred during the 12 months ending June 30, 2006 paid through
                  May
                  31, 2007).

              


      

    

    
       

      The
        claims data was provided by ODJFS from the data warehouse. The experience
        was
        stratified into geographic region based on the member's county of
        residence.

    

    
       

      The
        reimbursement amounts captured on the FFS actuarial models reflect the amount
        paid by ODJFS, net of third party liability recoveries and member co-payment
        amounts. The reimbursement amounts have not been adjusted for payments made
        outside the claims processing system. These amounts are discussed later in
        the
        documentation.

    

    
       

      The
        FFS historical experience was adjusted to include only those services that
        are
        included in the capitation payment. Services that are not covered under the
        capitation payment have been excluded from the experience. The excluded services
        were identified by the state-assigned Category of Service field, as shown
        in
        Table 3.

    

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    
      Mr.
        Jon Barley, Ph.D.

    

    
      December
        12, 2007

    

    
      Page
        6

    

    
       

      FINAL
        and CONFIDENTIAL

    

    
       

      Table
        3

    

    
       

      STATE
        OF OHIO

      DEPARTMENT
        OF JOB AND FAMILY SERVICES

    

    
      FFS
        Claim Exclusions

    

    
 

    
      
        	
                
                  COS
                    Field Value

                

              	
                
                  Description

                

              
	
                
                  08

                

              	
                
                  PACE

                

              
	
                
                  13

                

              	
                
                  ICF/MR
                    Public

                

              
	
                
                  18

                

              	
                
                  ICF/MR
                    Private

                

              
	
                
                  35

                

              	
                
                  Core
                    Services

                

              
	
                
                  36

                

              	
                
                  Home
                    Care Facilitator Services

                

              
	
                
                  41

                

              	
                
                  Mental
                    Health Services

                

              
	
                
                  42

                

              	
                
                  Mental
                    Retardation

                

              
	
                
                  46

                

              	
                
                  Model
                    50 Waiver Services

                

              
	
                
                  58

                

              	
                
                  HMO
                    Services

                

              
	
                
                  59

                

              	
                
                  Mental
                    Health Support Services

                

              
	
                
                  60

                

              	
                
                  Mental
                    Retardation Support Services

                

              
	
                
                  63

                

              	
                
                  PPO
                    Services

                

              
	
                
                  64

                

              	
                
                  Passport

                

              
	
                
                  66

                

              	
                
                  Passport
                    Waiver III

                

              
	
                
                  67

                

              	
                
                  OBRA
                    MR/DD Waiver

                

              
	
                
                  80

                

              	
                
                  Alcohol
                    and Drug Abuse

                

              
	
                
                  82

                

              	
                
                  Department
                    of Education

                

              
	
                
                  84

                

              	
                
                  ODADAS

                

              


      

       

    

    
      b.            
        Completion Factors

    

    
       

      Milliman
        utilized 24 months of claims experience for the FFS population that was incurred
        through June 2006 and paid through May 2007 (eleven months of run-out). Milliman
        applied claim completion factors to the twelve months of fiscal year 2005
        and
        twelve months of fiscal year 2006 claims experience. The claim completion
        factors were developed by service category based on claims experience for
        the
        FFS population incurred and paid through May
        2007.

    

    
       

      c.            
        Historical Program Adjustments

    

    
       

      The
        base experience data represents a historical time period from which projections
        were developed. Certain program changes have occurred during and subsequent
        to
        the base data time period. The program adjustments were estimated and applied
        to
        the portion of the base experience data prior to the program change effective
        date. For example, a program change implemented on January 1. 2006 will only
        be
        reflected in the second half of SFY 2006. As such, an adjustment was applied
        to
        all of SFY 2005 and half of SFY 2006 to include the program change in all
        periods of the base experience data.

    

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    
      Mr.
        Jon Barley, Ph.D.

    

    
      December
        12, 2007

    

    
      Page
        7

    

    
       

      FINAL
        and CONFIDENTIAL

    

    
       

      ODJFS
        has provided a listing of all program changes impacting the base experience
        data. Table 4 summarizes the historical program changes that were reflected
        in
        the development of the CY 2008 capitation
        rates.

    

    
       

      Table
        4

    

    
       

      STATE
        OF OHIO

    

    
      DEPARTMENT
        OF JOB AND FAMILY SERVICES

    

    
      Historical
        Program Adjustments - FFS

    

    
 

    
      
        	
                
                  Program
                    Adjustment

                

              	
                
                  Effective
                    Date

                

              	
                
                  Service
                    Category(s)

                

              
	
                
                  Inpatient
                    Market Basket Increase

                

              	
                
                  1/1/2005

                

              	
                
                  Inpatient
                    Hospital

                

              
	
                
                  Dental
                    Fee Schedule Reduction

                

              	
                
                  1/1/2006

                

              	
                
                  Dental

                

              
	
                
                  Inpatient
                    Recalibration and Outlier Policy

                

              	
                
                  1/1/2006

                

              	
                
                  Inpatient

                

              
	
                
                  Pharmacy
                    Co-pay ($2 Per Brand Prescription)

                

              	
                
                  1/1/2006

                

              	
                
                  Pharmacy

                

              
	
                
                  Dental
                    Co-pay ($3 Per Date of Service)

                

              	
                
                  1/1/2006

                

              	
                
                  Dental

                

              
	
                
                  Vision
                    Exam Co-Pay ($2 Per Exam)

                

              	
                
                  1/1/2006

                

              	
                
                  Vision
                    / Optometric

                

              
	
                
                  Vision
                    Hardware Co-Pay ($ 1 Per Item)

                

              	
                
                  1/1/2006

                

              	
                
                  Vision
                    / Optometric

                

              
	
                
                  ER
                    Co-Pay ($3 Per Non-Emergency Visit)

                

              	
                
                  1/1/2006

                

              	
                
                  Emergency
                    Room

                

              
	
                
                  Dental
                    Benefit Reduction

                

              	
                
                  1/1/2006

                

              	
                
                  Dental

                

              


      

    

    
       

      d.           
        Third-Party Liability

    

    
       

      The
        FFS experience was calculated using the net paid claim data from the FFS
        data
        provided by ODJFS. The paid amounts reflect a reduction for the amounts paid
        by
        third party carriers. Additionally, Milliman reduced the FFS experience to
        reflect third party liability recoveries following payment of claims. The
        reduction represents the average third party liability recovery rate received
        by
        the state under the "pay-and-chase" recovery program for each base year.
        It is
        expected that the health plans will collect the third party liability recoveries
        for managed care enrolled individuals.

    

    
       

      e.           
        Fraud and Abuse

    

    
       

      The
        FFS experience was calculated using the net paid claim data from the FFS
        data
        provided by ODJFS. Milliman reduced the FFS experience to reflect fraud and
        abuse recoveries following payment of claims. The reduction represents the
        average fraud and abuse recovery rate received by the state for each, base
        year.
        It is expected that the health plans will pursue fraud and abuse detection
        activities for managed care enrolled
        individuals.

    

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    
      Mr.
        Jon Barley,
        Ph.D.

    

    
      December  12,
        2007

    

    
      Page
        8

    

    
       

      FINAL
        and CONFIDENTIAL

    

    
       

      f.            
        Gross Adjustments

    

    
       

      The
        FFS experience was calculated using the net paid claim data from the FFS
        data
        provided by ODJFS. Milliman adjusted the FFS experience to reflect
        payments/refunds occurring outside of normal claim adjudication. Milliman
        received a "gross adjustments" tile from ODJFS containing the additional
        adjustments.

    

    
       

      g.            
        Non-State Flan Services

    

    
       

      CMS
        requires removal of non-state plan services from rate-setting. The FFS data
        does
        not contain any such services. As such, no adjustment was applied to the
        base
        FFS data for non-state plan services.

    

    
       

      h.           
        Trends/Inflation to CY 2006

    

    
       

      Milliman
        developed trend rates to progress the historical experience from state fiscal
        years 2005 and 2006 forward to a common center point (CY 2006). Milliman
        reviewed historical experience and performed linear regression on the experience
        data to develop trend rates by category of service for both utilization and
        unit
        cost. Additionally, Milliman reviewed the resulting trends with internal
        data
        sources to develop the trends used to develop the CY 2008 ABD capitation
        rates.

    

    
       

      The
        base experience data was normalized for artificial program adjustments prior
        to
        the trend rate development. Milliman did not consider items such as fee schedule
        changes or benefit modifications as standard components of trend. Removing
        the
        impact of historical changes allows for transparent inclusion of prospective
        program changes for future periods.

    

    
       

      i.            
        Blend Base Experience Years

    

    
       

      Each
        of the base experience years was trended to CY 2006. At this point, each
        base
        year was on a comparable basis and could be aggregated. The weighting was
        developed with the intention of placing more credibility on the most recent
        experience and is consistent with the CY 2007 methodology. Specifically,
        SFY
        2005 received a weight of 30% and SFY 2006 received a weight of
        70%.

    

    
       

      j.            
        Managed Care Adjustments

    

    
       

      Utilization
        and cost per service adjustments were developed for each service category
        and
        region.

    

    
       

      Utilization

    

    
       

      Milliman
        adjusted the FFS utilization and cost per service to reflect the managed
        care
        environment. After reviewing utilization benchmarks in the Milliman Medicaid
        Guidelines (Guidelines)
        as well as other sources, Milliman calculated percentage adjustments
        to
        reflect the utilization differential between an economic and efficiently
        managed
        plan and the FFS base experience.

    

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    
      Mr.
        Jon Barley, Ph.D.

    

    
      December
        12, 2007

    

    
      Page
        9

    

    
       

      FINAL
        and CONFIDENTIAL

    

    
       

       

    

    
       

      Cost
        Per Service

    

    
       

      Milliman
        adjusted the average reimbursement rates to reflect changes in the mix /
        intensity of services due to the management of health care. The reimbursement
        rate changes were also developed following a review of benchmarks in the
Guidelines
        as well as other sources.

    

    
       

      In
        addition to the intensity adjustments applied to the cost per service amounts,
        Milliman also included adjustments to reflect the health plan contracted
        rates
        with providers in the managed care adjustments.

    

    
       

      V.           
        CY 2006 ADJUSTED BASE DATA TO CY 2008 CAPITATION
        RATES

    

    
       

      The
        adjusted CY 2006 utilization and cost per service rates are trended forward
        to
        CY 2008 and adjusted for prospective program changes that will be effective
        for
        the CY 2008 contract period. The resulting PMPM, after trend and prospective
        program changes establishes the regional adjusted claim cost for the health
        plans in CY 2008. The administrative cost allowance and franchise fee components
        are applied to the adjusted claim cost to develop the CY 2008 capitation
        rate.

    

    
       

      a.           
        Trend to CY 2008

    

    
       

      The
        trend rates that were used to progress the CY 2006 experience forward to
        the CY
        2008 rating period were developed from the historical experience, the experience
        from other Medicaid managed care programs, and our actuarial judgment. The
        trend
        rates include a component for utilization and unit cost by major category
        of
        service.

    

    
       

      b.           
        Prospective Program Adjustments

    

    
       

      The
        SFY 2008/2009 Budget contains several program changes that impacted the
        development of the capitation rates. The program changes include items such
        as
        provider fee changes, benefit changes, and administrative changes. Adjustments
        to the CY 2006 experience were developed for each item based on its expected
        impact to the prospective claims cost. Table 5 lists the program changes
        that
        were included in the CY 2008 capitation rate
        development.

       

       

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    
       

      Mr.
        Jon Barley, Ph.D.

    

    
      December
        12, 2007

    

    
      Page
        10

    

    
       

      FINAL
        and CONFIDENTIAL

    

    
       

      Table
        5

    

    
       

      STATE
        OF OHIO

    

    
      DEPARTMENT
        OF JOB AND FAMILY SERVICES

    

    
      Prospective
        Program Adjustments

       

    

    
      
        	
                
                  Program
                    Adjustment

                

              	
                
                  Effective
                    Date

                

              	
                
                  Service
                    Category(s)

                

              
	
                
                  Nursing
                    Facility Fee Increase

                

              	
                
                  7/1/2007

                

              	
                
                  Nursing
                    Facility

                

              
	
                
                  7/1/2008

                

              
	
                
                  Chiropractor
                    Benefit Restoration

                

              	
                
                  1/1/2008

                

              	
                
                  Miscellaneous
                    Services

                

              
	
                
                  Independent
                    Psychologists Benefit Restoration

                

              	
                
                  1/1/2008

                

              	
                
                  Mental
                    Health / Substance Abuse

                

              
	
                
                  Occupational
                    Therapy-Independent Provider Status

                

              	
                
                  1/1/2008

                

              	
                
                  Miscellaneous
                    Services

                

              
	
                
                  Improved
                    TPL Management

                

              	
                
                  1/1/2008

                

              	
                
                  All
                    Service Categories

                

              
	
                
                  Prior
                    Authorization Policy Change

                

              	
                
                  1/1/2008

                

              	
                
                  Pharmacy

                

              
	
                
                  Prior
                    Authorization of Atypical Anti-Psychotic Medication

                

              	
                
                  1/1/2008

                

              	
                
                  Pharmacy

                

              


      

       

    

    
      c.           
        Prospective Selection Adjustment

    

    
       

      Milliman
        adjusted the CY 2006 experience to reflect the expected penetration of managed
        care in CY 2008. Table 6 provides the target managed care penetration used
        in
        the development of the CY 2008 capitation
        rates.

    

    
       

      Table
        6

    

    
       

      STATE
        OF OHIO

    

    
      DEPARTMENT
        OF JOB AND FAMILY SERVICES

    

    
      Prospective
        Selection Adjustments

       

      

        
          
            	
                    
                      Region

                    

                  	
                    
                      June
                        2007 MC Penetration

                    

                  	
                    
                      Target
                        MC Penetration

                    

                  
	
                    
                      Central

                    

                  	
                    
                      89.5%

                    

                  	
                    
                      93%

                    

                  
	
                    
                      East
                        Central

                    

                  	
                    
                      88.8%

                    

                  	
                    
                      93%

                    

                  
	
                    
                      Northeast

                    

                  	
                    
                      89.7%

                    

                  	
                    
                      93%

                    

                  
	
                    
                      Northeast
                        Central

                    

                  	
                    
                      0.0%

                    

                  	
                    
                      93%

                    

                  
	
                    
                      Northwest

                    

                  	
                    
                      87.6%

                    

                  	
                    
                      93%

                    

                  
	
                    
                      Southeast

                    

                  	
                    
                      92.3%

                    

                  	
                    
                      93%

                    

                  
	
                    
                      Southwest

                    

                  	
                    
                      86.0%

                    

                  	
                    
                      93%

                    

                  
	
                    
                      West
                        Central

                    

                  	
                    
                      87.7%

                    

                  	
                    
                      93%

                    

                  


          

        

      

    

     

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    
      Mr.
        Jon Barley. Ph.D. 

    

    
      December
        12, 2007 

      Page
        11

    

    
       

      FINAL
        and CONFIDENTIAL

    

    
       

      d.           
        Administrative Allowance

    

    
       

      Milliman
        included an administrative cost allowance in the development of the actuarially
        sound capitation rates for CY 2008. The administrative cost allowance contains
        provision for administrative expenses, profit/contingency, and surplus
        contribution and was calculated as a percentage of the capitation rate prior
        to
        the franchise fee. As such, the pre-franchise fee capitation rate will be
        determined by dividing the projected managed care claim cost by one minus
        the
        administrative cost allowance. By determining the pre-franchise fee capitation
        rate in this manner, the administrative allowance may be expressed as a
        percentage of the pre-franchise fee capitation rate. Milliman developed the
        administrative cost allowance following a review of cost information from
        other
        representative Medicaid managed care
        organizations.

    

    
       

      For
        health plans in plan year 3 or later, 1% of the administrative component
        will be
        at-risk and contingent upon performance requirements defined in the ODJFS
        provider agreements. Table 7 provides the administrative cost allowance for
        each
        plan year.

    

    
       

      Table
        7

    

    
       

      STATE
        OF OHIO

    

    
      DEPARTMENT
        OF JOB AND FAMILY SERVICES

    

    
      Administrative
        Cost Allowance

    

    
 

    
      
        	
                
                  Plan
                    Year

                

              	
                
                  Guaranteed
                    %

                

              	
                
                  At-Risk
                    %

                

              	
                
                  Total  %

                

              
	
                
                  Plan
                    Year 1 (1-12 Months)

                

              	
                
                  11.5%

                

              	
                
                  0.0%

                

              	
                
                  11.5%

                

              
	
                
                  Plan
                    Year 2 (13-24 Months)

                

              	
                
                  10.5%

                

              	
                
                  0.0%

                

              	
                
                  10.5%

                

              
	
                
                  Plan
                    Year 3 (25 + Months)

                

              	
                
                  9.5%

                

              	
                
                  1.0%

                

              	
                
                  10.5%

                

              


      

    

    
       

      The
        administrative cost allowance percentages contained in Table 7 reflect a
        change
        from the 2007 methodology.

    

    
       

      e.           
        Franchise Fee

    

    
       

      Milliman
        included a franchise fee component in the development of the actuarially
        sound
        capitation rates for CY 2008. The franchise fee was calculated as a percentage
        of the capitation rates. Therefore, the capitation rate will be determined
        by
        dividing the pre-franchise fee capitation rate by one minus the franchise
        fee
        component. By determining the pre-franchise fee capitation rate in this manner,
        the franchise fee may be expressed as a percentage of the capitation rate.
        The
        franchise fee component is 4.5% of the capitation
        rate.

       

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    
       

      Mr.
        Jon Barley, Ph.D.

    

    
      December
        12, 2007

    

    
      Page
        12

    

    
       

      FINAL
        and CONFIDENTIAL

    

    
      VI. 
        CDPS
        RISK ADJUSTMENT

    

     

    
       

      The
        methodology described in this correspondence was used to develop the base
        capitation rates for CY 2008 for each region. Milliman will then apply the
        Chronic Illness and Disability Payment System (CDPS) to adjust the actuarially
        sound base capitation rates for the ABD population on a regional basis for
        each
        health plan. The CDPS risk adjustment will be updated each six month period
        for
        existing regions and plans. For the initial period of managed care within
        a
        region and plan, a monthly risk score will be developed for the first three
        months.

    

    
       

      The
        next anticipated risk score update will be January 1, 2008. The CDPS risk
        scores
        will be developed for ABD recipients enrolled in managed care during December
        2007 using diagnosis information from claims incurred in calendar year 2006
        with
        paid dates between January 1, 2006 and June 30, 2007. Health plan and region
        specific prevalence reports will be provided with the updated risk
        scores.

    

    
       

      DATA
        RELIANCE

    

    
       

      In
        developing the CY 2008 ABD capitation rates, we have relied upon certain
        data
        and information from ODJFS. While limited review was performed for
        reasonableness, the data and information was accepted without audit. To the
        extent that the data and information was not accurate or complete, the values
        shown in this letter will need to be revised.

    

    
       

      ♦♦♦♦

    

    
       

      If
        you have any questions regarding the enclosed information, please do not
        hesitate to contact me at
        (317)  524-3512.

    

    
       

      Sincerely,

    

    
       

    

    
      /s/
        Robert M. Damler

    

    
      Robert
        M. Damler, FSA, MAAA

    

    
      Principal
        and Consulting Actuary

    

    
       

      RMD/mle

    

    
      
        	
              	
                cc: 

              	
                Dan
                  Hecht (ODJFS) 

                Mitali
                  Ghatak (ODJFS)

                Robert
                  Monks (ODJFS)

              


      

    

    
       

    

    
 

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    
      FINAL
        and CONFIDENTIAL 

    

    
       

      APPENDIX
        1

    

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    
       

       

    

     

     

    
       

      FINAL
        and CONFIDENTIAL

    

     

    
       

      Illustration
        of Rate Development Methodology

       

      [Graph]

    

    
       

      
        
        



    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    
                                                                                           
        FINAL and CONFIDENTIAL

    

    
       

      APPENDIX
        2

    

    
       

    

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


     

    
       

      FINAL
        and CONFIDENTIAL

    

    
       

    

    
       

    

    
      STATE
        OF OHIO

    

    
      DEPARTMENT
        OF JOB AND FAMILY SERVICES

    

    
      Aged,
        Blind, or Disabled - CY 2008 Capitation Rates

    

    
       

      Actuarial
        Certification

    

    
       

      I,
        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. I was retained by the State of Ohio, Department
        of Job and Family Services to perform an actuarial review and certification
        regarding the development of the capitation rates to be effective for calendar
        year 2008. The capitation rates were developed for the Aged, Blind, or Disabled
        managed care eligible populations. I have experience in the examination of
        financial calculations for Medicaid programs and meet the qualification
        standards for rendering this opinion.

    

    
       

      I
        reviewed the historical claims experience for reasonableness and consistency.
        I
        have developed certain actuarial assumptions and actuarial methodologies
        regarding the projection of healthcare expenditures into future periods.
        I have
        complied with the elements of the rate setting checklist CMS developed for
        its
        Regional Offices regarding 42 CFR 438.6(c) for capitated Medicaid managed
        care
        plans.

    

    
       

      The
        capitation rates provided with this certification are effective for a one-year
        rating period beginning January 1, 2008 through December 31, 2008. At the
        end of
        the one-year period, the capitation rates will be updated for calendar year
        2009. The update may be based on fee-for-service experience, managed care
        utilization and trend experience, policy and procedure changes, and other
        changes in the health care market. A separate certification will be provided
        with the updated rates.

    

    
       

      The
        capitation rates provided with this certification are considered actuarially
        sound, defined as:

    

    
       

      
        	
                •  

              	
                the  capitation
                  rates have been
                  developed  in  accordance  with  generally  accepted  actuarial
                  principles and practices;

              


      

    

    
      
        	
                •  

              	
                the
                  capitation rates are appropriate for the populations to be covered,
                  and
                  the services to be furnished under the contract; and,

              
	•  	the
                capitation rates meet the requirements of 42 CFR
                438.6(c).


      

    

    
       

    

    
      This
        actuarial certification has been based on the actuarial methods, considerations,
        and analyses promulgated
        from time to time through the Actuarial Standards of Practice by the Actuarial
        Standards

    

    
       

      Board.

    

    
       

       

    

    
      /s/
        Robert M. Dalmer_

    

    
      Robert
        M. Damler, FSA

    

    
      Member,
        American Academy of Actuaries

    

    
       

      December
        4, 2007

    

    
      Date

    

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    
       

    

    
       

      FINAL
        and CONFIDENTIAL

    

     

    
       

      APPENDIX
        3

       

    

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


     

    
       

      FINAL
        AND CONFIDENTIAL

    

    
       

      State
        of Ohio

    

    
      Department
        of Job and Family Services

    

    
      CY2008
        ABD Capitation Rate Development

    

     

    
      	 	 	
              
                Projected
                  CY

              

            	 	 	
              
                CY
                  2008

              

            	 	 	 	 	 	 	 
	 	 	
              
                2008
                  Member

              

            	 	 	
              
                Guaranteed

              

            	 	 	
              
                CY
                  2008 At

              

            	 	 	 	 
	
              
                Region

              

            	 	
              
                Months

              

            	 	 	
              
                Rate

              

            	 	 	
              
                Risk
                  Rate

              

            	 	 	
              
                CY
                  2008 Rate

              

            	 
	
              
                Central

              

            	 	 	
              284,169

            	 	 	 	$1,101.26	 	 	 	$10.62	 	 	 	$1,111.88	 
	
              
                East
                  Central

              

            	 	 	149,045	 	 	 	1,091.21	 	 	 	10.52	 	 	 	1,101.73	 
	
              
                Northeast

              

            	 	 	287,103	 	 	 	1,099.46	 	 	 	10.60	 	 	 	1,110.06	 
	
              
                Northeast
                  Central

              

            	 	 	85,309	 	 	 	1,098.34	 	 	 	10.59	 	 	 	1,108.93	 
	
              
                Northwest

              

            	 	 	137,407	 	 	 	1,107.94	 	 	 	10.68	 	 	 	1,118.62	 
	
              
                Southeast

              

            	 	 	152,735	 	 	 	981.68	 	 	 	9.47	 	 	 	991.15	 
	
              
                Southwest

              

            	 	 	174,390	 	 	 	1,120.61	 	 	 	10.80	 	 	 	1,131.41	 
	
              
                West
                  Central

              

            	 	 	123,260	 	 	 	1,133.13	 	 	 	10.93	 	 	 	1,144.06	 
	
              
                Statewide

              

            	 	 	1,393,418	 	 	 	$1,092.43	 	 	 	$10.53	 	 	 	$1,102.96	 


    

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


     

    
      Appendix
        F

       

    

    
       

      
        	
                 

              	
                PREMIUM
                  RATES WITHOUT THE AT-RISK PAYMENT AMOUNTS FOR 01/01/08 THROUGH
                  06/30/08
                  

                 

                MCP's
                  premiums will be at-risk starting the 25th month of the ABD Medicaid
                  Managed Care Program participation.


              


      

    

    
       

      MCP:  WellCare
        of Ohio, Inc.

    

     

    
      	
              
                Service
                  Enrollment
                  Area

              

            	Risk
              Adjusted Rate	
              At-Risk
                Amounts

            
	
              
                Northeast
                  Region

              

            	
              
                $1,125.45

              

            	
              
                $0.00

              

            


    

    
       

       

       

      
        	 List
                of Eligible Assistance Groups
                (AGs)	 
	 Aged,
                Blind or
                Disabled:   	MA-A
                Aged
	 	 MA-B
                Blind
                
	 	 MA-D
                Disabled


      

    

    
                                                        


    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    



    


    APPENDIX
      G

    


    COVERAGE
      AND SERVICES

    ABD
      ELIGIBLE
      POPULATION

    


    1.
Basic
      Benefit
      Package

    


    Pursuant
      to OAC rule 5101:3-26-03(A), with limited exclusions (see section G.2 of this
      appendix), MCPs must ensure that members have access to medically-necessary
      services covered by the Ohio Medicaid fee-for-service (FFS)
      program.  For information on Medicaid-covered services, MCPs must
      refer to the
      ODJFS website. The following is a general list of the benefits pertinent to
      the
      ABD population covered by the MCPs:

    


    ·      
      Inpatient hospital services

    ·      
      Outpatient hospital services

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


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

    ·      
      Laboratory and x-ray services

    ·      
      Family planning services and supplies

    ·      
      Home health and private duty
      nursing services 

    ·      
      Podiatry

    ·      
      Physical therapy, occupational therapy, and speech therapy

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

    ·      
      Prescription drugs

    ·      
      Ambulance and ambulette services

    ·      
      Dental services

    ·      
      Durable medical equipment and medical supplies

    ·      
      Vision care services, including
      eyeglasses


    ·      
      Nursing facility stays as
      specified in OAC rule 5101:3-26-03


    ·      
      Hospice care

    ·      
      Behavioral health services (see section G.2.b.iii of this appendix)

    ·      
      Chiropractic services

    


    2. Exclusions,
      Limitations and
      Clarifications

    


    a. Exclusions

    


    MCPs
      are
      not required to pay for Ohio Medicaid FFS program (Medicaid) non-covered
      services. For information regarding Medicaid noncovered services, MCPs must
      refer to the ODJFS website. The following is a general list of the services
      not
      covered by the Ohio Medicaid fee-for-service program:

    


    ·      
      Services or supplies that are not medically necessary

    ·      
      Experimental services and procedures, including drugs and equipment, not covered
      by Medicaid

    ·      
      Organ transplants that are not covered by Medicaid

    ·      
      Abortions, except in the case of a reported rape, incest, or when medically
      necessary to save the life of the mother

    ·      
      Infertility services for males or females

    ·      
      Voluntary sterilization if under 21 years of age or legally incapable of
      consenting to the procedure

    ·      
      Reversal of voluntary sterilization procedures

    ·      
      Plastic or cosmetic surgery
      that is not
      medically necessary*

    ·      
      Immunizations for travel outside of the United States

    ·      
      Services for the treatment of obesity unless medically necessary*

    ·      
      Custodial or supportive care not
      covered by Medicaid

    ·      
      Sex change surgery and related services

    ·      
      Sexual or marriage counseling

    ·      
      Acupuncture and biofeedback services

    ·      
      Services to find cause of death (autopsy)

    ·      
      Comfort items in the hospital (e.g., TV or phone)

    ·      
      Paternity testing

    


    MCPs
      are
      also not required to pay for non-emergency services or supplies received without
      members following the directions in their MCP member handbook, unless otherwise
      directed by ODJFS.

    


      *These
      services
      could be deemed medically necessary if medical complications/conditions in
      addition to the obesity or physical imperfection are present.

    


    b. Limitations
&
      Clarifications

     

    i. Member
      Cost-Sharing

    


    As
      specified in OAC rules 5101:3-26-05(D) and  5101:3-26-12, MCPs
      are permitted to impose the applicable member co-payment amount(s) for dental
      services, vision services, non-emergency emergency department services, or
      prescription drugs, other than generic drugs. MCPs must notify ODJFS if they
      intend to impose a co-payment.  ODJFS must approve the notice to be
      sent to the MCP’s members and the timing of when the co-payments will begin to
      be imposed.  If ODJFS determines that an MCP’s decision to impose a
      particular co-payment on their members would constitute a significant change
      for
      those members, ODJFS may require the effective date of the co-payment to
      coincide with the “Open
      Enrollment” month.

    


    Notwithstanding
      the preceding paragraph, MCPs must provide an ODJFS-approved notice to all
      their
      members 90 days in advance of the date that the MCP will impose the co-payment.
      With the exception of member co-payments the MCP has elected to implement in
      accordance with OAC rules 5101:3-26-05(D) and  5101:3-26-12, the MCP’s payment
      constitutes payment in full for any covered services and their subcontractors
      must not charge members or ODJFS any additional co-payment, cost sharing,
      down-payment, or similar charge, refundable or otherwise.

    


    ii. Abortion
      and
      Sterilization

    


    The
      use
      of federal funds to pay for abortion and sterilization services is prohibited
      unless the specific criteria found in 42 CFR 441 and OAC rules 5101:3-17-01
      and
      5101:3-21-01 are met.  MCPs must verify that all of the information on
      the required forms (JFS 03197, 03198, and 03199) is provided and that the
      service meets the required criteria before any such claim is paid.

     

    Additionally,
      payment must not be made for associated services such as anesthesia, laboratory
      tests, or hospital services if the abortion or sterilization itself does not
      qualify for payment.  MCPs are responsible for educating their
      providers on the requirements; implementing internal procedures including
      systems edits to ensure that claims are only paid once the MCP has determined
      if
      the applicable forms are completed and the required criteria are met, as
      confirmed by the appropriate certification/consent forms; and for maintaining
      documentation to justify any such claim payments.

    


    iii. Behavioral
      Health
      Services

    


    Coordination
      of Services:  MCPs must have a process
      to
      coordinate benefits of and referrals to the publicly funded community behavioral
      health system. MCPs must ensure
      that
      members have access to all medically-necessary behavioral health services
      covered by the Ohio Medicaid FFS program and are responsible for coordinating
      those services with other medical and support services.  MCPs must
      notify members via the member handbook and provider directory of where and
      how
      to access behavioral health services, including the ability to self-refer to
      mental health services offered through ODMH community mental health
      centers (CMHCs) as well as substance abuse services offered through Ohio
      Department of Alcohol and Drug Addiction Services (ODADAS)-certified Medicaid
      providers. Pursuant to ORC Section 5111.16, alcohol, drug addiction and mental
      health services covered by Medicaid are not to be paid by the managed care
      program when the nonfederal share of the cost of those services is provided
      by a
      board of alcohol, drug addiction, and mental health services or a
      state agency
      other than ODJFS.  MCPs are also not responsible for providing mental
      health services to persons between 22 and 64 years of age while residing
      in an institution for mental disease (IMD) as defined in Section 1905(i) of
      the
      Social Security Act.

    


    MCPs
      must provide
      Medicaid-covered behavioral health
      services
      for members who are unable to timely access services or unwilling to access
      services through community providers.

    


    Mental
      Health
      Services: There are a number of Medicaid-covered mental health (MH) services available
      through
ODMH CMHCs.

    


    Where
      an
      MCP is responsible for providing MH services for their members, the MCP is
      responsible for ensuring access to counseling and psychotherapy,
      physician/psychiatrist services, outpatient clinic services, general hospital
      outpatient psychiatric services, pre-hospitalization screening, diagnostic
      assessment (clinical evaluation), crisis intervention, psychiatric
      hospitalization in general hospitals (for all ages), and Medicaid-covered
      prescription drugs and laboratory services.  MCPs are not required to
      cover partial hospitalization, or inpatient psychiatric care in a private or public
      free-standing psychiatric
      hospital.  However, MCPs are required to cover the payment of
      physician services in a private or public free-standing psychiatric hospital
      when such services are billed independent of the hospital.

    


    Substance
      Abuse
      Services:  There are a number of Medicaid-covered substance
      abuse services available through ODADAS-certified Medicaid
      providers.

    


    Where
      an
      MCP is responsible for providing substance abuse services for their members,
      the
      MCP is responsible for ensuring access to alcohol and other drug (AOD)
      urinalysis screening, assessment, counseling, physician/psychiatrist AOD
      treatment services, outpatient clinic AOD treatment services, general hospital
      outpatient AOD treatment services, crisis intervention, inpatient detoxification
      services in a general hospital, and Medicaid-covered prescription drugs and
      laboratory services. MCPs are not required to cover outpatient detoxification
      and methadone maintenance.

    


    Financial
Responsibility
      for Behavioral Health Services:  MCPs are responsible
      for the
      following:

    ·   payment
      of Medicaid-covered prescription
      drugs prescribed by an ODMH CMHC or ODADAS-certified provider when obtained
      through an MCP’s panel pharmacy;


    ·   payment
      of Medicaid-covered services
      provided by an MCP’s panel laboratory when referred by an ODMH CMHC or
      ODADAS-certified provider;


    ·   payment
      of all other Medicaid-covered
      behavioral health services obtained through providers other than those who
      are
      ODMH CMHCs or ODADAS-certified providers when arranged/authorized by the
      MCP.

    


    Limitations:

    ·   Pursuant
      to ORC Section 5111.16,
      alcohol, drug addiction and mental health services covered by Medicaid are
      not
      to be paid by the managed care program when the nonfederal share of the cost
      of
      those services is provided by a board of alcohol, drug addiction, and mental
      health services or a state agency other than ODJFS.  As part of this
      limitation:

    ·   MCPs
      are not responsible for paying for
      behavioral health services provided through ODMH CMHCs and ODADAS-certified
      Medicaid providers;


    ·   MCPs
      are not responsible for payment of
      partial hospitalization (mental health), inpatient psychiatric care in a private
      or public free-standing inpatient psychiatric hospital, outpatient
      detoxification, intensive outpatient programs (IOP) (substance abuse) or
      methadone maintenance.


    ·    However,
      MCPs are required to cover the
      payment of physician services in a private or public free-standing psychiatric
      hospital when such services are billed independent of the
      hospital.

    


    iv. Pharmacy
      Benefit:  In providing the Medicaid pharmacy benefit to their
      members, MCPs must cover the same
      drugs covered by the Ohio Medicaid
      fee-for-service program.

     

    MCPs
      may
      establish a preferred drug list for members and providers which includes a
      listing of the drugs that they prefer to have prescribed. Preferred drugs
      requiring prior authorization approval must be clearly indicated as
      such.  Pursuant to ORC §5111.172, ODJFS may approve MCP-specific
      pharmacy program utilization management strategies (see appendix
      G.3.a).

    


    v. Organ
      Transplants: MCPs
      must ensure coverage for organ
 transplants
      and related services in
      accordance with OAC 5101-3-2- 07.1
      (B)(4)&(5).  Coverage
      for all organ transplant services, except  kidney
      transplants, is contingent upon
      review and recommendation  by
      the “Ohio Solid Organ Transplant
      Consortium” based on  criteria
      established by Ohio organ
      transplant surgeons and
 authorization
      from the ODJFS prior
      authorization unit.  Reimbursement
      for bone marrow transplant
      and hematapoietic  stem
      cell transplant services, as
      defined in OAC 3701:84-01, is  contingent
      upon review and
      recommendation by the “Ohio  Hematapoietic
      Stem Cell Transplant
      Consortium” again based on criteria established
      by Ohio experts
      in the field of bone marrow
 transplant.  While
      MCPs may
      require prior authorization for these  transplant services,
      the
      approval criteria would be limited to  confirming the consumer is being
      considered and/or has been  recommended for a transplant by either
      consortium and authorized  by ODJFS.  Additionally, in accordance
      with OAC 5101:3-2-03  (A)(4) all services related to organ donations are
      covered for the  donor recipient when the consumer is Medicaid
      eligible. 

    


    3. Care
      Coordination

    


    a. Utilization
      Management  Programs

    


    General
      Provisions -
      Pursuant to OAC rule 5101:3-26-03.1(A)(7), MCPs must implement a utilization
      management (UM) program to maximize the effectiveness of the care provided
      to
      members and may develop other UM programs, subject to prior approval by
      ODJFS.  For the purposes of this requirement, the specific UM programs which
      require ODJFS prior-approval are an MCP’s general pharmacy program, a controlled
      substances and member management program, and any other program designed by
      the
      MCP with the purpose of redirecting or restricting access to a particular
      service or service location.

    


    i. Pharmacy
      Programs -
      Pursuant to ORC Sec. 5111.172 and OAC  rule 5101:3-26-03(A) and (B), MCPs
      may, subject to ODJFS prior- approval, implement strategies for the
      management of  pharmacy utilization.  Pharmacy utilization
      management strategies  may include developing preferred drug lists,
      requiring prior  authorization for certain drugs, placing limitations on
      the type of  provider and locations where certain medications may be
 administered, and developing and implementing a specialized  pharmacy
      program to address the utilization of controlled  substances, as defined in
      section 3719.01 of the Ohio Revised
 Code.              

                 

    Drug
      Prior
      Authorizations: MCPs must receive prior approval from  ODJFS for the
      medications that they wish to cover through prior
 authorization.  MCPs must establish their prior authorization
 system so that it does not unnecessarily impede member access to
 medically-necessary Medicaid-covered services.  As outlined in
 paragraph 29(i)(ii)(f) of Appendix C, MCPs must adhere to  specific
      prior-authorization limitations to assist with the  transition of new ABD
      members from FFS Medicaid. MCPs must  make their approved list of drugs
      covered only with prior  authorization available to members and providers,
      as outlined in  paragraphs 36(b) and (c) of Appendix C.

    


    Beginning
      January 1, 2008, MCPs may require prior authorization for  the coverage of
      antipsychotic  drugs with ODJFS approval.  MCPs  must,
      however, allow any member to continue receiving a specific  antipsychotic
      drug if the member is stabilized on that particular
 medication.  The MCP must continue to cover that specific drug
      for the  stabilized member for as long as that medication continues to be
 effective for the member.  MCPs may also implement a drug
      utilization review program designed to promote the appropriate clinical
 prescribing of antipsychotic drugs.  This can be accomplished
      through  the MCP’s retrospective analysis of drug claims to identify
      potential  inappropriate use and provide education to those providers who
      are  outliers to acceptable standards for prescribing/dispensing
 antipsychotic drugs.

    


    MCPs
      must comply with the provisions of
      1927(d)(5) of the Social Security Act, 42 USC 1396r-8(k)(3), and
      OAC rule 5101:3-26- 03.1
      regarding the timeframes for prior authorization of covered outpatient
      drugs.

    


    Controlled
      Substances and
      Member Management Programs: MCPs  may also, with ODJFS prior
      approval, develop and implement  Controlled Substances and Member
      Management (CSMM)  programs designed to address use of controlled
      substances. Utilization management strategies may include prior
      authorization  as a condition of obtaining a controlled substance, as
      defined in  section 3719.01 of the Ohio Revised Code.  CSMM
      strategies may  also include processes for requiring MCP members at high
      risk for  fraud or abuse involving controlled substances to have their
 narcotic medications prescribed by a designated provider/providers
 and filled by a pharmacy, medical provider, or health care facility
 designated by the program.

    


    ii. Emergency
      Department
      Diversion (EDD) – MCPs must
      provide
   access to services in a way that assures access to
      primary, specialist and  urgent care in the most appropriate settings
      and that    minimizes frequent, preventable utilization of
      emergency department (ED) services. OAC rule 5101:3-26-03.1(A)(7)(d) requires MCPs to
      implement the ODJFS-required emergency department diversion (EDD) program for
      frequent utilizers.

    


     Each
      MCP must establish an ED diversion  (EDD) program with the goal of
      minimizing frequent ED utilization. The MCP’s EDD program must include the
      monitoring of ED utilization, identification of frequent ED utilizers, and
      targeted approaches designed to reduce avoidable ED utilization. MCP EDD
      programs must, at a minimum, address those ED visits which could have been
      prevented through improved education, access, quality or care management
      approaches.

    


    Although
      there is often an assumption that frequent ED visits are solely the result
      of a
      preference on the part of the member and education is therefore the standard
      remedy, it is also
      important to ensure that a member’s frequent ED utilization is not due to
      problems such as their PCP’s lack of accessibility or failure to make
      appropriate specialist referrals.  The MCP’s EDD program must
      therefore also include the identification of providers who serve as PCPs for
      a
      substantial number of frequent ED utilizers and the implementation of corrective
      action with these providers as so indicated.

    


    This
      requirement does not replace the MCP’s responsibility to inform and educate all
      members regarding the appropriate use of the ED.

    


    MCPs
      must
      also implement the ODJFS-required emergency department diversion (EDD) program
      for frequent users.  In that ODJFS has developed the parameters for an
      MCP’s EDD program, it therefore does not require ODJFS prior approval
      (Moved).

    


    b. Integration
      of Member Care

     

    The
      MCP must ensure that a discharge
      plan is in place to meet a member’s  health
      care needs following discharge
      from a nursing facility, and integrated into the member’s continuum
      of care.   The discharge plan must address the services
      to be provided for
      the member and must be developed prior to the date of
      discharge from the
      nursing facility.  The MCP must ensure follow-up contact
      occurs with the
      member, or authorized representative, within
      thirty (30) days
      of the member’s discharge from the nursing facility
      to ensure that
      the member’s health care needs are being met.

    


    c. Care
      Coordination with
      ODJFS-Designated Providers

    


    Per
      OAC
      rule 5101:3-26-03.1(A)(4), MCPs are required to share specific information
      with
      certain ODJFS-designated non-contracting providers in order to ensure that
      these
      providers have been supplied with specific information needed to coordinate
      care
      for the MCP’s  members.  Within the first month of
      operation, after an MCP has obtained a provider agreement, the MCP must
      provide to the ODJFS-designated providers (i.e., ODMH Community Mental Health
      Centers, ODADAS-certified Medicaid providers, FQHCs/RHCs, QFPPs, CNMs, CNPs
      [if
      applicable], and hospitals) a quick reference information packet which
      includes the following:

    


    i. A
      brief cover letter explaining the
      purpose of the mailing; and

    


    ii. A
      brief summary document that includes the following
      information:

    


    ·   Claims
      submission information including the MCP’s Medicaid provider number for each
      region;   

    ·   The
      MCP’s prior authorization and referral procedures or the MCP’s
      website;  

    ·   A
      picture of the MCP’s member identification card (front and back);

    ·   Contact
      numbers and/or website location for obtaining information for eligibility
      verification, claims processing, referrals/prior authorization, and information
      regarding the MCP’s behavioral health administrator;

    ·  A
      listing of the MCP’s major pharmacy chains and the contact number for the MCP’s
      pharmacy benefit administrator (PBM);

    ·  A
      listing of the MCP’s laboratories and radiology providers; and

    ·  A
      listing of the MCP’s contracting behavioral health providers and how to access
      services through them (this information is only to be provided to
      non-contracting community mental health and substance abuse
      providers).

    


    d. Care
      coordination with Non-Contracting Providers

    


    Per
      OAC
      rule 5101:3-26-05(A)(9), MCPs authorizing the delivery of  services
      from a provider who does not have an executed subcontract must ensure that they have a mutually
      agreed
      upon compensation amount for the authorized service and notify the provider
      of
      the applicable provisions of paragraph D of OAC rule
      5101:3-26-05.  This notice is provided when an MCP authorizes a
      non-contracting provider to furnish services on a one-time or infrequent
      basis to an MCP member and must include required ODJFS-model language and
      information. This notice must also be included with the transition of services
      form sent to providers as outlined in paragraph 29.h. of Appendix
      C.

    


    4. Case
      Management

    


    In
      accordance with 5101:3-26-03.1(A)(8),
      MCPs must offer and provide comprehensive case
      management services which
      coordinate and monitor the care of members with specific diagnoses, or who
      require high-cost and/or extensive services.

    


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

    


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

    


    i.
      newly
      enrolled members – 90 days from the effective date of enrollment;
      and

    


    ii.
      existing members – 90 days from identifying their need for case
      management.

    


    c. The
      MCP’s comprehensive case management program must include, at a minimum, the
      following components:

    


    i. Identification
      –

    The
      MCP
      must have mechanisms in place to identify members potentially eligible for
      case
      management services.  These mechanisms must include an administrative
      data review (e.g. diagnosis, cost threshold, and/or service utilization) and
      may
      also include telephone interviews; provider/self-referrals; information as
      reported by the Managed Care Enrollment Center (MCEC) during membership
      selection; or
      home visits.

    


    ii. Assessment
      -

    The
      MCP must arrange for or conduct a
      comprehensive assessment of the member’s physical and/or behavioral health
      condition(s) to confirm the results of a positive identification, and to
      determine the need for case management services.    The
      goals of the assessment are to identify the member’s existing and/or potential
      health care needs and assess the member’s need for case management
      services.

    


    The
      assessment must be completed by a
      physician, physician assistant, RN, LPN, licensed social worker, or a graduate
      of a two or four year allied health program.  If the assessment is
      completed by another medical professional, there should be oversight and
      monitoring by either a registered nurse or a physician.

    


    The
      MCP must have a process to inform
      members and their PCPs that
      they have been identified as meeting the criteria for case management, including
      their enrollment into case management services.

    


    The
      MCP must develop a strategy to
      assign members to risk stratification levels, based on the member’s
      comprehensive needs assessment.

    


    iii.  Care
      Treatment Plan –

    The
      care treatment plan is defined by
      ODJFS as the one developed by the MCP for the member.

    


    The
      development of the care treatment
      plan must be based on the comprehensive health assessment and reflect the
      member’s primary medical diagnosis and health conditions, any comorbidities, and
      the member’s psychological, behavioral health and community support
      needs.  The care treatment plan must also include specific provisions
      for periodic reviews (i.e.,
      no less than semi-annually) of the member’s condition and
      appropriate updates to the plan.  The member and the member’s PCP must
      be actively involved in the development of and revisions to the care treatment
      plan.  The designated PCP is the provider, or specialist, who will
      manage and
      coordinate the overall care for the member.  Ongoing communication
      regarding the status of the care treatment plan may be accomplished between
      the
      MCP and the PCP’s designee (i.e., qualified health
      professional).  Revisions to the clinical portion of the care
      treatment plan should be completed in consultation with the
      PCP.

    


    The
      elements of a comprehensive care treatment plan include:

       

    Goals
      and
      actions that address medical, social, behavioral and psychological
      needs;

    


    Member
      level interventions, (i.e., referrals and making appointments) that assist
      members in obtaining services, providers and programs;

    


    Continuous
      review, revision and contact follow-up, as needed, to ensure the
      care treatment plan is adequately monitored including the
      following:

    


    ·  Documentation
      that services are provided in accordance with the care treatment
      plan;

    ·  Re-evaluation
      to determine if the care treatment plan is adequate to meet the member's current
      needs;

    ·  Identification
      of gaps between recommended care and actual care provided;

    ·  A
      change
      in needs or status from the re-evaluation that requires revisions to the care
      treatment plan;

    ·  Active
      participation by the member or representative in the care treatment plan
      development;

    ·  Monitoring
      of specific service delivery including service utilization; and

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

    


    iv.    Coordination
      of Care and Communication

    There
      should be an accountable point of contact at the MCP for each member in case
      management who can help obtain medically necessary care, assist with
      health-related services and coordinate care needs, including behavioral
      health.  The MCP must
      arrange or provide for professional case management services that are performed
      collaboratively by a team ofprofessionals
      appropriate for the
      member’s condition and health care needs.  At a minimum, the MCP’s
      case manager must attempt to coordinate with the member’s case manager from
      other health systems, including behavioral health.  The MCP must have
      a process to facilitate, maintain, and coordinate both care and communication
      with the member, PCP, and other service providers and case
      managers.  The MCP must also have a process to coordinate care for a
      member that is receiving services from state sub-recipient agencies as
      appropriate [e.g., the Ohio Department of Mental Health (ODMH); the Ohio
      Department of Mental Retardation and Developmental Disabilities (ODMR/DD);
      and
      the Ohio Department of Alcohol and Drug Addiction Services
      (ODADAS)].

    


    The
      MCP must have a provision to
      disseminate information to the member/caregiver concerning the health condition,
      types of services that may be available, and how to access
      services.

    


    The
      MCP
      must implement mechanisms to notify all Members with Special Health Care Needs
      of their right to directly access a specialist.  Such access may be
      assured through, for example, a standing referral or an approved number of
      visits, and documented in the care treatment plan.

    


    v. ODJFS
      Targeted Case Management
      Conditions:

    The
      MCP must,
      at a minimum, case manage members with
      the following physical and behavioral health conditions:

    ·  Congestive
      Heart
      Failure

    ·  Coronary
      Artery
      Disease

    ·  Non-Mild
      Hypertension

    ·  Diabetes

    ·  Chronic
      Obstructive Pulmonary
      Disease

    ·  Asthma

    ·  Severe
      mental
      illness

    ·  High
      risk or high cost substance abuse
      disorders

    ·  Severe
      cognitive and/or developmental
      limitation

    


    The
      MCP
      must also case manage any member enrolled in an MCP’s CSMM as specified in
      section G(3)(a)(i).

    


    The
      MCP should also focus on all members
      whose health conditions warrant case management services and should not limit
      these services only to members with these conditions (e.g., cystic fibrosis,
      cerebral palsy and sickle cell anemia).

    


    Refer
      to Appendix
      M
for the performance
      measures and standards related to case management.

    


    vi. Case
      Management Program
      Staffing

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

    


    vii. Case
      Management
      Strategies

    The
      MCP must follow best-practice and/or
      evidence based clinical guidelines when devising a member’s care treatment plan
      and coordinating the case management needs.  If an MCP uses a disease
      management methodology to identify and/or stratify members in need of case
      management services, the methods must be validated by scientific research and/or
      nationally accepted in the health care industry.

    


    The
      MCP must develop and implement
      mechanisms to educate and equip providers and case managers with evidence-based
      clinical
      guidelines or best practice approaches to assist in providing a high level
      of
      quality of care to members.

    


    viii.
      Information Technology System
      for
      Case Management

    The
      MCP’s information technology system
      for its case management program must maximize the opportunity for communication
      between the plan, PCP, the member, and other service providers and case
      managers.  The MCP must have an integrated database that allows MCP
      staff that may be contacted by a member in case management to have immediate
      access to, and review of, the most recent information with the MCP’s information
      systems relevant to the case.  The integrated database may include the
      following: administrative data, call center communications, service
      authorizations, care treatment plans, patient assessments, case management
      notes, and PCP notes.  The information technology system must also
      have the capability to share relevant information with the member, the PCP,
      and
      other service providers and case managers.

    


    ix.
      Data Submission

    The
      MCP must submit a monthly electronic
      report to the Case
      Management System (CAMS) for all members that are case managed.  In
      order for a member to be submitted as case managed in CAMS, the MCP
      must:  (1)  complete the identification process, a
      comprehensive health needs assessment and development of a care treatment plan
      for the member; and (2) document the member's written or verbal confirmation
      of
      his/her case management status in the case management record.  ODJFS,
      or its designated entity, the external quality review vendor, will validate
      on
      an annual basis the accuracy of the information contained in CAMS with the
      member's case management record.  The
      CAMS files are due the
      10thbusiness
      day of each
      month.

    


    d. Annual
      Case Management Program Submission

    


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

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    APPENDIX
      H

    


    PROVIDER
      PANEL SPECIFICATIONS

    ABD
      ELIGIBLE
      POPULATION

    


    
      	
              1.

            	
              GENERAL
                PROVISIONS

            


    

    


    MCPs
      must
provide or arrange for the
      delivery of all medically necessary, Medicaid-covered health services, as well
      as assure that they meet all applicable provider panel requirements for their
      entire designated
      service area.  The
      ODJFS provider panel requirements are specified in the charts included with
      this
      appendix and must be met prior to the MCP receiving a provider agreement with
      ODJFS.  The MCP must remain in compliance with these requirements for
      the duration of the provider agreement.

    


    If
      an MCP is unable to provide the
      medically necessary, Medicaid-covered services through their contracted provider
      panel, the MCP must ensure access to these services on an as needed
      basis. For
      example, if an MCP meets
the gastroenterologist
      requirement but a member is unable to obtain a timely appointment from a
      gastroenterologist on the MCP’s provider panel, the MCP will be required to
      secure an appointment from a panel gastroenterologist or arrange for an
      out-of-panel referral to a gastroenterologist.

    


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

    


    In
      developing the provider panel requirements, ODJFS considered, on a
      county-by-county basis, the population size and utilization patterns of the
      Aged, Blind or Disabled (ABD)
      consumers, as well as the potential availability of the designated provider
      types.  ODJFS has integrated existing utilization patterns into the
      provider network requirements to avoid disruption of care.  Most
      provider panel requirements are county-specific but in certain circumstances,
      ODJFS requires providers to be located anywhere in the region.
      Although all provider types
      listed in this appendix are required provider types, only those listed on the
      attached charts must be submitted for ODJFS prior approval.

    


    2.           
      PROVIDER SUBCONTRACTING

    


    Unless
      otherwise specified in this appendix or OAC rule 5101:3-26-05, all MCPs are required to enter
      into
      fully-executed subcontracts with their providers.  These subcontracts
      must include
      a baseline contractual
      agreement, as well as the appropriate ODJFS-approved Model Medicaid Addendum.
      The Model Medicaid Addendum incorporates all applicable Ohio
      Administrative Code rule requirements specific to provider subcontracting and
      therefore cannot be modified except to add personalizing information such as
      the
      MCP’s name.

    


    ODJFS
      must prior approve all MCP providers in the ODJFS- required provider type
      categories before they can begin to provide services to that MCP’s
      members.  MCPs may not employ or contract with providers excluded from
      participation in Federal health care programs under either section 1128 or
      section 1128A of the Social Security Act.  As part of the prior
      approval process,  MCPs
      must submit  documentation verifying that all necessary contract
      documents have been appropriately completed.  ODJFS will verify the
      approvability of the submission and process this information using the ODJFS
      Provider Verification System (PVS), or other designated process.  The PVS is a centralized
      database system that maintains information on the status of all MCP-submitted
      providers.

    


    Only
      those providers who meet the
      applicable criteria specified in this document, and as determined by ODJFS,
      will
      be approved by ODJFS.   MCPs must credential/recredential
      providers in accordance with the standards specified by the National Committee
      for Quality Assurance (or receive approval from ODJFS to use an alternate
      industry standard) and must have completed the credentialing review before
      submitting any provider to ODJFS for approval.  Regardless of whether
      ODJFS has approved a provider, the MCP must ensure that the provider has met
      all
      applicable credentialing criteria before the provider can render services to
      the
      MCP’s members.

    


    MCPs
      must
      notify ODJFS of the addition and deletion of their contracting providers as
      specified in OAC rule 5101:3-26-05, and must notify ODJFS within one working
      day
      in instances where the MCP has identified that they are not in compliance with
      the provider panel requirements specified in this appendix.

    


    3.           
      PROVIDER
      PANEL REQUIREMENTS

    


    The
      provider network criteria that must be met by each MCP are as
      follows:

    


    a.           
      Primary Care
      Providers (PCPs)

    


    Primary
      Care Provider (PCP) means an individual physician (M.D. or D.O.), certain
      physician group practice/clinic (Primary Care Clinics [PCCs]), or an advanced
      practice nurse (APN) as defined in ORC 4723.43 or advanced practice nurse group
      practice within an acceptable specialty, contracting with an MCP to provide
      services as specified in paragraph (B) of OAC rule 5101:
      3-26-03.1.  Acceptable specialty types for PCPs include family/general
      practice, internal medicine, pediatrics, and obstetrics/gynecology
      (OB/GYN).  Acceptable
      PCCs include FQHCs, RHCs
      and the acceptable group practices/clinics specified by ODJFS.  As part
      of their subcontract with an MCP, PCPs
      must stipulate the total Medicaid member capacity that they can ensure for
      that
      individual MCP.  Each PCP must have the capacity and agree to serve at
      least 50 Medicaid members at each practice site in order to be approved by
      ODJFS
      as a PCP.  The capacity-by-site
      requirement must be met
      for all ODJFS-approved PCPs.

    


    ODJFS
      reviews the capacity totals for
      each PCP to determine if they appear excessive. DJFS
      reserves the right to request
      clarification from an MCP for any PCP whose total stated capacity
      for all MCP networks added
      together exceeds 2000 Medicaid members (i.e., 1 FTE). ODJFS may allow
      up to an additional 750 member
      capacity for each nurse practitioner
      or physician’s assistant
      that is used to provide clinical support for a PCP.

    


    For
      PCPs
      contracting with more than one MCP, the MCP must ensure that the capacity figure
      stated by the PCP in their subcontract reflects only the capacity the PCP
      intends to provide for that one MCP. ODJFS utilizes each approved PCP’s capacity
      figure to determine if an MCP meets the provider panel requirements and this
      stated capacity figure does not prohibit a PCP from actually having a caseload
      that exceeds the capacity figure indicated in their subcontract.

    


    ODJFS
      expects that
      MCPs will need to
      utilize specialty physicians to serve as PCPs for some special needs
      members.  In these
      situations it will not be necessary for the MCP to submit these
specialists to the PVS database, or other system, as PCPs, however,
      they
      must be submitted to PVS, or other system, as the appropriate required provider
      type.  Also, in some situations (e.g., continuity of care) a PCP may
      only want to serve a very small number of members for an MCP.  In
      these situations it will not be necessary for the MCP to submit these PCPs
      to
      ODJFS for prior approval.  These PCPs will not be included in the
      ODJFS PVS database, or other system and therefore may not appear as PCPs in
      the
      MCP’s provider directory.  These PCPs will, however, need to execute a
      subcontract with the MCP which includes the appropriate Model Medicaid
      Addendum.

    


    The
      PCP requirement is based on an MCP
      having sufficient PCP capacity to serve 40% of
      the eligibles in the
      region if
      three MCPs are serving the region and
      55% of the eligibles in the region if two MCPs are serving the
      region.  Each
      MCP must meet the PCP minimum FTE
      requirement for that region.  MCPs must also satisfy a PCP geographic
      accessibility standard. ODJFS will match the PCP practice sites and the stated
      PCP capacity with the geographic location of the eligible population in that
      region (on a county-specific basis) and perform analysis using Geographic
      Information Systems (GIS) software. The analysis will be used to determine
      if at
      least 40% of the eligible population is located within 10 miles of a PCP with
      available capacity in urban
      counties and 40% of the eligible population within 30 miles of a PCP with
      available capacity in rural counties. [Rural areas are defined pursuant to
      42
      CFR 412.62(f)(1)(iii).]

    


    Until
      July 1, 2008, MCPs may only use PCPs who are individual physicians (M.D. or
      D.O.), physician group practices, or PCCs to meet capacity and FTE
      requirements.

    


    b.           
      Non-PCP Provider
      Network

    


    In
      addition to the PCP capacity requirements, each MCP is also required to maintain
      adequate capacity in the remainder of its provider network within the following
      categories:  hospitals, cardiovascular, dentists,
      gastroenterology, nephrology, neurology, oncology, physical medicine, podiatry,
      psychiatry, urology, vision care providers, obstetricians/gynecologists
      (OB/GYNs), allergists, general surgeons, otolaryngologists, orthopedists,
      federally qualified health centers (FQHCs)/rural health centers (RHCs) and
      qualified family planning providers (QFPPs). CNMs,
      CNPs, FQHCs/RHCs and QFPPs are
      federally-required provider types.

    


    All
      Medicaid-contracting MCPs must provide all medically-necessary Medicaid-covered
      services to their members and therefore their complete provider network will
      include many other additional specialists and provider types.  MCPs
      must ensure that all non-PCP network providers follow community standards in
      the
      scheduling of routine appointments (i.e., the amount of time members must wait
      from the time of their request to the first available time when the visit can
      occur).

    


    Although
      there are currently no capacity requirements for the non-PCP required provider
      types, MCPs are required to ensure that adequate access is available to members
      for all required provider types.  Additionally, for certain non-PCP
      required provider types, MCPs must ensure that these providers maintain a
      full-time practice at a site(s) located in the
      specified county/region
      (i.e., the ODJFS-specified
      county within the region or anywhere within the region if no particular county
      is specified).  A full-time practice is defined as one where the
      provider is available to patients at their practice site(s) in the specified
      county/region for at least 25 hours a week. ODJFS will monitor access to
      services through a variety of data sources, including:  consumer
      satisfaction surveys; member appeals/grievances/complaints and state hearing
      notifications/requests; clinical quality studies; encounter data volume;
      provider complaints, and clinical performance measures.

    


    Hospitals
      -
MCPs must contract with
      the
      number and type of hospitals specified by ODJFS for each county/region. In
      developing these hospital
      requirements, ODJFS considered, on a county-by-county basis, the population
      size
      and utilization patterns of the Aged, Blind or Disabled (ABD) consumers and integrated
      the existing
      utilization patterns into the hospital network requirements to avoid disruption
      of care.  For this reason, ODJFS may require that MCPs contract with
      out-of-state hospitals (i.e. Kentucky,
West
      Virginia, etc.).

    


    For
      each Ohio hospital,
      ODJFS utilizes the hospital’s
      most current Annual Hospital Registration and Planning Report, as filed with
      the
      Ohio Department of Health, in verifying types of services that hospital
      provides.  Although ODJFS has the authority, under certain situations,
      to obligate a non-contracting hospital to provide non-emergency hospital
      services to an MCP’s members, MCPs must still contract with the specified number
      and type of hospitals unless ODJFS approves a provider panel exception (see
      Section 4 of this appendix – Provider Panel Exceptions).

    


    If
      an
      MCP-contracted hospital elects not to provide specific Medicaid-covered hospital
      services because of an objection on moral or religious grounds, the MCP must
      ensure that these hospital services are available to its members through another
      MCP-contracted hospital in the specified
      county/region.

    


    OB/GYNs-
      MCPs must contract with the
      specified  number of OB/GYNs for each county/region, all of whom must
      maintain a full-time obstetrical practice at a site(s) located in the
specified
      county/region.  Only MCP-contracting OB/GYNs with current
      hospital delivery privileges at a hospital under contract with the MCP in the
      region can be submitted to the PVS, or other system, count towards MCP minimum
      panel requirements, and be listed in the MCPs’ provider directory.

    


    Certified
      Nurse Midwives (CNMs)
and
      Certified Nurse Practitioners (CNPs) - MCPs must ensure access to CNM
      and CNP services in
      the region if such provider types are present within the
      region.  The
      MCP may contract directly with the CNM
      or CNP providers, or with a physician or other provider entity who is able
      to
      obligate the participation of a CNM or CNP.  If an MCP does not
      contract for CNM or CNP services and such providers are present within the
      region, the MCP will be required to allow members to receive CNM or CNP services
      outside of the MCP’s provider network.

    


    Only
      CNMs
      with hospital delivery privileges at a hospital under contract to the MCP in
      the
      region can be submitted to the PVS, or other system, count towards MCP minimum
      panel requirements, and be listed in the MCPs’ provider directory. The MCP must ensure a member’s access to CNM
      and CNP services if such providers are practicing within the
      region.

    


    Vision
      Care Providers - MCPs
      must contract with the specified number of ophthalmologists/optometrists
      for each
specified
      county/region, all
      of whom must maintain a full-time
      practice at a site(s) located in the specified county/region. All ODJFS-approved
      vision providers must regularly perform routine eye exams. (MCPs
      will be expected to contract with
      an adequate number of ophthalmologists as part of their overall provider panel,
      but only ophthalmologists who regularly perform routine eye exams can be used
      to
      meet the vision care provider panel requirement.) If optical dispensing
      is not
      sufficiently available in a region through the MCP’s contracting
      ophthalmologists/optometrists, the MCP must
      separately
contract with an adequate
      number of optical dispensers located in the region.

    


    Dental
      Care
      Providers - MCPs must
      contract with the specified number of dentists.

    


    Federally
      Qualified Health
      Centers/Rural Health Clinics(FQHCs/RHCs) - MCPs are
      required to ensure member access
      to any  federally qualified health center or rural health clinic
      (FQHCs/RHCs), regardless of contracting status.  Contracting FQHC/RHC
      providers must be submitted for ODJFS approval via the PVS process, or
      other designated process. Even if
      no FQHC/RHC is available within the region, MCPs must have mechanisms in place
      to ensure coverage for FQHC/RHC services in the event that a member accesses
      these services outside of the region. 

    


    In
      order
      to ensure that any FQHC/RHC has the ability
      to
      submit a claim to ODJFS for the state’s supplemental payment, MCPs must offer
      FQHCs/RHCs reimbursement pursuant to the following:

    


    
      	
               

            	
              •

            	
              MCPs
                must provide expedited reimbursement on a service-specific basis
                in an
                amount no less than the payment made to other providers for the same
                or
                similar service. 

            


    

    


    
      	
               

            	
              •

            	
              If
                the MCP has no comparable service-specific rate structure, the MCP
                must
                use the regular Medicaid
                fee-for-service payment schedule for non-FQHC/RHC providers.
                

            


    

    


    
      	
               

            	
              •

            	
              MCPs
                must make all efforts to pay FQHCs/RHCs as quickly as possible and
                not
                just attempt to pay these claims within the prompt pay time frames.
                

            


    

    


    MCPs
      are
      required to educate their staff and providers on the need to assure member
      access to FQHC/RHC services.

    


    Qualified
      Family Planning Providers
      (QFPPs) - All MCP members must be permitted to self-refer to family
      planning services provided by a QFPP.  A QFPP is defined as
      any public or not-for-profit health care provider that complies with Title
      X
      guidelines/standards, and receives either Title X funding or family planning
      funding from the Ohio Department of Health.  MCPs must reimburse all
      medically-necessary Medicaid-covered  family planning services
      provided to eligible members by a QFPP provider (including on-site pharmacy
      and
      diagnostic services) on a patient self-referral
      basis, regardless of the
      provider’s status as a panel or non-panel provider.  MCPs will be
      required to work with QFPPs in the region to develop mutually-agreeable HIPAA
      compliant policies and procedures to preserve patient/provider
      confidentiality, and convey pertinent information to the member’s PCP and/or
      MCP.

    


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

    


    Other
      Specialty
      Types(general
      surgeons,
      otolaryngologists, orthopedists, cardiologists, gastroenterologists,
      nephrologists, neurologists, oncologists, podiatrists, physiatrists,
      psychiatrists, and urologists ) - MCPs must contract
      with the specified
      number of all other ODJFS designated specialty provider types. In order to
      be
      counted toward meeting the provider panel requirements, these specialty
      providers must maintain a full-time practice at a site(s) located within the
      specified county/region. Only contracting general surgeons, orthopedists,
      otolaryngologists, cardiologists, gastroenterologists,
      nephrologists, neurologists, oncologists, podiatrists, physiatrists,
      psychiatrists, and urologists with admitting privileges at a hospital
under
      contract with the MCP in the region can be submitted to the PVS, or other
      system, count towards MCP minimum panel requirements, and be listed in the
      MCPs’
provider directory.

    


    4.           
      PROVIDER PANEL
      EXCEPTIONS

    


    ODJFS
      may specify provider panel
      criteria for a service area that deviates from that specified in this appendix
      if:

    


    
      	
               

            	
              -

            	
              the
                MCP presents sufficient
                documentation to ODJFS to verify that they have been unable to meet
                or
                maintain certain provider panel requirements in a particular service
                area
                despite all reasonable efforts on their part to secure such a contract(s),
                and

            


    

    


    
      	
               

            	
              -

            	
              if
                notified by ODJFS, the
                provider(s) in
                question fails to provide a reasonable argument why they would not
                contract with the MCP, and

            


    

    


    
      	
               

            	
              -

            	
              the
                MCP presents sufficient
                assurances to ODJFS that their members will have adequate access
                to the
                services in question.

            


    

    


    If
      an MCP is unable to contract with or
      maintain a sufficient number of providers to meet the ODJFS-specified provider
      panel criteria, the MCP may request an exception to these criteria by submitting
      a provider panel exception request as specified by ODJFS.  ODJFS will
      review the exception request and determine whether the MCP has sufficiently
      demonstrated that all reasonable efforts were made to obtain contracts with
      providers of the type in question and that they will be able to provide access
      to the services in question.

    


    ODJFS
      will aggressively monitor access
      to all services related
      to
the approval of
      a provider
      panel exception request through
      a variety of data sources, including: consumer satisfaction
      surveys; member
      appeals/grievances/complaints and state hearing notifications/requests;
      member
      just-cause for termination requests; clinical quality studies; encounter
      data volume; provider
      complaints, and clinical performance measures.  ODJFS approval of a
      provider panel exception request does not exempt the MCP from assuring access
      to
      the services in question.  If ODJFS determines that an MCP has not
      provided sufficient access to these services, the MCP may be subject to
      sanctions.

    


    
      	
              5.

            	
              PROVIDER
                DIRECTORIES

            


    

    


    MCP
      provider directories must include
      all MCP-contracted providers [except as specified by ODJFS] as well as certain
      non-contracted providers.  At the time of ODJFS’ review, the
      information listed in the MCP’s provider directory for all ODJFS-required
      provider types specified on the attached charts must exactly match the data
      currently on file in the ODJFS PVS, or other designated
      process.

    


    MCP
      provider directories must utilize a
      format specified by ODJFS. Directories may be region-specific or include
      multiple regions, however, the providers within the directory must be divided
      by
      region, county, and provider type, in that order.

    


    The
      directory must also specify:

    


    
      	
               

            	
              •

            	
              provider
                address(es) and phone
                number(s);

            


    

    
      	
               

            	
              •

            	
              an
                explanation of how to access
                providers (e.g. referral required vs.
                self-referral);

            


    

    
      	
               

            	
              •

            	
              an
                indication of which providers
                are available to members on a self-referral basis;

            


    

    
      	
               

            	
              •

            	
              foreign-language
                speaking PCPs and
                specialists and the specific foreign language(s) spoken;
                

            


    

    
      	
               

            	
              •

            	
              how
                members may obtain directory information in alternate formats that
                takes
                into consideration the special needs of eligible individuals including
                but
                not limited to, visually-limited, LEP, and LRP eligible individuals;
                and
                

            


    

    
      	
               

            	
              •

            	
              any
                PCP or specialist practice limitations.


            


    

    


    Printed
      Provider Directory

    Prior
      to receiving a provider agreement,
      all MCPs must develop a printed provider directory that shall be prior-approved
      by ODJFS for each population.  For example, an MCP who serves CFC and
      ABD in the Central Region would have two provider directories, one for CFC
      and
      one for ABD.  Once approved, this directory may be regularly updated
      with provider
      additions or deletions by the MCP without ODJFS prior-approval, however, copies
      of the revised directory (or inserts) must be submitted to ODJFS prior to
      distribution to members.

    


    On
      a quarterly basis, MCPs must
create
      an insert to each printed directory
      that lists those providers
deleted
      from the MCP’s provider
      panel during the previous three months.  Although this insert does not
      need to be prior approved by ODJFS, copies of the insert must be submitted
      to
      ODJFS two weeks prior to distribution to members.

    


    Internet
      Provider Directory

    MCPs
      are required to have an
      internet-based provider directory available in the same format as their
      ODJFS-approved printed directory.  This internet directory must allow
      members to electronically
      search for MCP panel providers based on name, provider type, and geographic
      proximity, and population (e.g. CFC and/or ABD).  If an MCP has one
      internet-based directory for multiple populations, each provider must include
      a
      description of which population they serve.

    


    The
      internet directory may be updated at
      any time to include providers who are not
one
      of the ODJFS-required provider types
      listed on the charts included with this appendix.  ODJFS-required
      providers must
be
      added to the internet directory
      within one week of the MCP’s notification of ODJFS-approval of the provider via
      the Provider Verification process.  Providers being deleted from the
      MCP’s panel must be deleted
      from the internet directory
      within one week of notification from the provider to the MCP. These
      deleted providers must be included
      in the inserts to the MCP’s provider directory referenced
      above.

    


    
      	
              6
                .

            	
              FEDERAL
                ACCESS
                STANDARDS

            


    

    


    MCPs
      must
      demonstrate that they are in compliance with the following federally
      defined  provider panel access standards as required by 42 CFR
      438.206:

    


    In
      establishing and maintaining their provider panel, MCPs must consider the
      following:

    


    
      	
              •

            	
              The
                anticipated Medicaid membership. 

            


    

    
      	
              •

            	
              The
                expected utilization of services, taking into consideration the
                characteristics and health care needs of specific Medicaid populations
                represented in the MCP. 

            


    

    
      	
              •

            	
              The
                number and types (in terms of training, experience, and specialization)
                of
                panel providers required to deliver the contracted
                Medicaid services. 

            


    

    
      	
              •

            	
              The
                geographic location of panel providers and Medicaid members, considering
                distance, travel time, the means of transportation ordinarily used
                by
                Medicaid members, and whether the location provides physical access
                for
                Medicaid members with disabilities.


            


    

    
      	
              •

            	
              MCPs
                must adequately and timely cover services to an out-of-network provider
                if
                the MCP’s contracted provider panel is unable to provide the services
                covered under the MCP’s provider agreement.  The MCP must cover
                the out-of-network services for as long as the MCP network is unable
                to
                provide the services. MCPs must coordinate
                with the out-of-network provider with respect to payment and ensure
                that
                the provider agrees with the applicable requirements.

            


    

    


    Contracting
      providers must offer hours of operation that are no less than the hours of
      operation offered to commercial members or comparable to Medicaid
      fee-for-service, if the provider serves only Medicaid members.  MCPs
      must ensure that services are available 24 hours a day, 7 days a week, when
      medically necessary.  MCPs must establish mechanisms to ensure that
      panel providers comply with timely access
      requirements, and
      must take corrective action
      if there is failure to comply.

    


    In
      order
      to demonstrate adequate provider panel capacity and services, 42 CFR 438.206
      and
      438.207 stipulates that the MCP must submit documentation to ODJFS, in a format
      specified by ODJFS, that demonstrates it offers an appropriate range of
      preventive, primary care and specialty services adequate for the anticipated
      number of members in the service
      area, while maintaining a provider panel that is sufficient in number,
      mix, and geographic distribution to meet the needs of the number of members
      in
      the service
      area.

    


    This
      documentation of assurance of adequate capacity and services must be submitted
      to ODJFS no less frequently than at the time the MCP enters into a contract
      with
      ODJFS; at any time there is a significant change (as defined by
      ODJFS)  in the MCP’s operations that would affect adequate capacity
      and services (including changes in services, benefits, geographic service or
      payments); and at any time there is enrollment of a new population in the
      MCP.

     

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    



    APPENDIX
      K

    


    QUALITY
      ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM

    AND

    EXTERNAL
      QUALITY
      REVIEW

    ABD
      ELIGIBLE
      POPULATION

    


    1.    As
      required by federal regulation, 42 CFR 438.240, each managed care plan (MCP)
      must have an ongoing Quality Assessment and Performance Improvement Program
      (QAPI) that is annually prior-approved by the Ohio Department of Job and Family
      Services (ODJFS).  The program must include the following
      elements:

    


    a.  PERFORMANCE
      IMPROVEMENT
      PROJECTS

    


    Each
      MCP
      must conduct performance improvement projects (PIPs), including those specified
      by ODJFS.  PIPs must achieve, through periodic measurements and
      intervention, significant and sustained improvement in clinical and non-clinical
      areas which are expected to have a favorable effect on health outcomes and
      satisfaction.  MCPs must adhere to ODJFS PIP content and format
      specifications.

    


    All
      ODJFS-specified PIPs must be prior-approved by ODJFS.  As part of the
      external quality review organization (EQRO) process, the EQRO will assist MCPs
      with conducting PIPs by providing technical assistance and will annually
      validate the PIPs.  In addition, the MCP must annually submit to ODJFS
      the status and results of each PIP.

    


    ODJFS
      will identify the clinical and/or
      non-clinical study topics for the SFY 2009 Provider
      Agreement.  Initiation of the PIPs will begin in the second year of
      participation in the ABD Medicaid managed care program.

    


    b.    UNDER-
      AND
      OVER-UTILIZATION

    


    Each
      MCP
      must have mechanisms in place to detect under- and over-utilization of health
      care services.  The MCP must specify the mechanisms used to monitor
      utilization in its annual submission of the QAPI program to ODJFS.

    


    It
      should
      also be noted that pursuant to the program integrity provisions outlined in
      Appendix I, MCPs must monitor for the potential under-utilization of services
      by
      their members in order to assure that all Medicaid-covered services are being
      provided, as required.  If any under-utilized services are identified,
      the MCP must immediately investigate and correct the problem(s) which resulted
      in such under-utilization of services.

    


    The
      MCP must conduct an ongoing
      review of service denials and must monitor utilization on an ongoing basis
      in
      order to identify services which may be under-utilized.

    


    c.  SPECIALHEALTH
      CARE
      NEEDS

    


    Each
      MCP
      must have mechanisms in place to assess the quality and appropriateness of
care furnished to members with
      special
      health care needs.  The MCP must specify the mechanisms used in its
      annual submission of the QAPI program to ODJFS.

    


    d.  SUBMISSION OF
      PERFORMANCE MEASUREMENT DATA

    


    Each
      MCP
      must submit clinical performance measurement data as required by ODJFS that
      enables ODJFS to calculate standard measures.  Refer to Appendix M
“Performance Evaluation” for a more comprehensive description of the clinical
      performance measures.

    


    Each
      MCP
      must also submit clinical performance measurement data as required by ODJFS
      that
      uses standard measures as specified by ODJFS.  MCPs will be required
      to submit Health Employer Data Information Set (HEDIS) audited data for measures
      that will be identified by ODJFS for the SFY 2009 Provider
      Agreement.

    


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

    


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

    


    e.   QAPI
      PROGRAM
      SUBMISSION

    


    Each
      MCP
      must implement an evaluation process to review, revise, and/or update the
QAPI
      program.  The MCP must annually submit its QAPI program for review and
      approval by ODJFS.

     

    2.  EXTERNAL
      QUALITY
      REVIEW

    


    In
      addition to the following
      requirements, MCPs must participate in external quality review activities as
      outlined in OAC 5101:3-26-07.

     

    a.
EQRO
      ADMINISTRATIVE REVIEWS

    


    The
EQRO
      will conduct annual
      focused administrative
      compliance assessments
      for each MCP which will
      include, but not be limited to, the
      following domains as specified by ODJFS:  member rights and services,
      QAPI program, case
      management, provider
networks, grievance
      system, coordination and continuity of care, and
      utilization management.  In addition, the EQRO will complete a
      comprehensive administrative compliance assessment every three (3) years as
      required by 42 CFR 438.358 and specified by ODJFS.

    


    In
      accordance with 42 CFR 438.360 and
      438.362, MCPs with
      accreditation from a national accrediting organization approved by the Centers
      for Medicare and Medicaid Services (CMS) may request a non-duplication exemption
      from certain specified components of the administrative
      review.  Non-duplication exemptions may not be requested for SFY 2008.

    


    b.  EXTERNAL
      QUALITY
      REVIEW PERFORMANCE

    


    In
      accordance with OAC rule
      5101:3-26-07, each MCP must participate in an annual
      external quality review
      survey.  If the EQRO cites a deficiency in performance, the MCP will
      be required to complete a Corrective Action Plan (e.g., ODJFS technical
      assistance session) or Quality
      Improvement Directives depending
      on the severity of the deficiency.  (An example of a deficiency is if
      an MCP fails to meet certain clinical or administrative standards as supported
      by national evidence-based guidelines or best
      practices.)  Serious  deficiencies may result in immediate
      termination or non-renewal of the provider agreement.  These quality
      improvement measures recognize the importance of ongoing MCP performance
      improvement related to clinical care and service delivery.

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    


    APPENDIX
      L

    


    DATA
      QUALITY

    ABD
      ELIGIBLE
      POPULATION

    


    A
      high level of performance on the data
      quality measures established in this appendix is crucial in order for the Ohio
      Department of Job and Family Services (ODJFS) to determine the value of the
      Aged, Blind or Disabled
      (ABD) Medicaid Managed
      Health Care programand
      to evaluate Medicaid consumers’
access to and quality of services. Data collected from MCPs are used in key
      performance assessments such as the external quality review, clinical
      performance measures, utilization review, care coordination and case management,
      and in determining incentives.  The data will also be used in
      conjunction with the cost reports in setting the premium payment
      rates.  The
      following measures, as specified in this appendix, will be calculated per MCP
      and include all Ohio Medicaid members receiving services from the MCP (i.e.,
      Covered Families and Children (CFC) and ABD membership, if
      applicable):  Incomplete Outpatient Hospital
      Data,
Rejected
      Encounters, Acceptance
      Rate, Encounter Data
      Accuracy, and Generic Provider Number Usage. 

    


    Data
      sets
      collected from MCPs with data quality standards include: encounter data; case
      management data; data used in the external quality review; members’ PCP data;
      and appeal and grievance data.

    


    1.
      ENCOUNTER DATA

    


    For
      detailed descriptions of the
      encounter data quality measures below, see ODJFS
      Methods for
the
      ABD
      and CFC Medicaid Managed Care Programs DataQuality
      Measures.

    


    1.a.  Encounter
      Data Completeness

    


    Each
      MCP’s encounter data submissions will be assessed for
      completeness.  The MCP is responsible for collecting information from
      providers and reporting the data to ODJFS in accordance with program
      requirements established in Appendix C, MCP
      Responsibilities.  Failure to do so jeopardizes the MCP’s
      ability to demonstrate compliance with other performance standards.

    


    1.a.i.
      Encounter Data Volume

    


    Measure:  The
      volume measure for each
      service category, as listed in Table 2 below, is the rate of utilization (e.g.,
      discharges, visits) per 1,000 member months (MM) for the ABD
      program. The measure will be
      calculated per
      MCP.

    


    Report
      Period:  The
      report periods for the SFY
      2008 and
      SFY 2009 contract periods are listed
      in Table
      1. below.

    


    Table
      1. Report Periods for the
      SFY  2008 and
      2009 Contract Periods

     

    
      	
              Report
                Period

            	
              Data
                Source:

              Estimated
                Encounter  Data File Update

            	
              Quarterly
                Report

              Estimated
                Issue
                Date

            	
              Contract
                Period

            
	
              Qtr
                1 2007

            	
              July
                2007

            	
              August
                2007

            	
              SFY  2008

              
              

            
	
              Qtr
                1, Qtr 2
                2007

            	
              October
                2007

            	
              November2007

            
	
              Qtr
                1 thru Qtr 3
                2007

            	
              January
                2008

            	
              February
                2008

            
	
              Qtr
                1 thru Qtr 4
                2007

            	
              April
 2008

            	
              May 2008

            
	
              Qtr
                1 thru Qtr 4 2007, Qtr 1
                2008

            	
              July
                2008

            	
              August
                2008

            	
              SFY
                2009

            
	
              Qtr
                1 thru Qtr 4
                2007,

              Qtr
                1, Qtr 2
                2008

            	
              October
                2008

            	
              November
                2008

            
	
              Qtr
                1 thru Qtr 4
                2007,

              Qtr
                1 thru Qtr 3
                2008

            	
              January
                2009

            	
              February
                2009

            
	
              Qtr
                1 thru Qtr 4
                2007,

              Qtr
                1 thru Qtr 4
                2008

               

            	
              April
                2009

            	
              May
                2009

            
	 Qtr1
              = January to March    Qtr2 = April to
              June    Qtr3
              = July to  September    Qtr 4 = October
              to December


    

    


    Data
      Quality
      Standard:  The
      utilization rate for all service categories listed in Table 2 must be equal
      to
      or greater than the interim
standards
      established in Table 2. below (Interim
      Standards - Encounter Data
      Volume).

    


    Statewide
      Approach:  Prior
      to establishment of
statewide
      minimum
      performance standards,
ODJFS
      will evaluate MCP
      performance using the interim standards for Encounter data volume. ODJFS will use the first
      four quarters
      of data (i.e., full calendar year quarters) from all MCPs serving ABD program membership
      to determine statewide
      minimum encounter volume data quality standards.


    


    Table
      2. Interim
Standards–
Encounter
      Data Volume

    


    
      	
              Category

            	
              Measure
                per 1,000/MM

            	
              Standard
                for Dates of
                Service

              on
                or after 1/1/2007

            	
              Description

            
	
              Inpatient
                Hospital

            	
              Discharges

            	
              2.7

            	
              General/acute
                care, excluding newborns and mental health and chemical dependency
                services

            
	
              Emergency
                Department

            	
              Visits

            	
              25.3

            	
              Includes
                physician and hospital emergency department encounters

            
	
              Dental

            	
              25.5

            	
              Non-institutional
                and hospital dental visits

            
	
              Vision

            	
              5.3

            	
              Non-institutional
                and hospital outpatient optometry and ophthalmology
                visits

            
	
              Primary
                and Specialist Care

            	
              116.6

            	
              Physician/practitioner
                and hospital outpatient visits

            
	
              Ancillary
                Services

            	
              66.8

            	
              Ancillary
                visits

            
	
              Behavioral
                Health

            	
              Service

            	
              5.2

            	
              Inpatient
                and outpatient behavioral encounters

            
	
              Pharmacy

            	
              Prescriptions

            	
              246.1

            	
              Prescribed
                drugs

            


    

    


    Determination
      of
      Compliance: Performance is
      monitored once every quarter for the entire report period.  If the
      standard is not met for every service category in all quarters of the report
      period, then the MCP will be determined to be noncompliant for the report
      period.

    


    Penalty
      for
      noncompliance:  The first time an MCP is noncompliant with a
      standard for this measure, ODJFS will issue a Sanction Advisory informing the
      MCP that any future noncompliance instances with the standard for this measure
      will result in ODJFS imposing a monetary sanction. Upon all subsequent
      measurements of performance, if an MCP is again determined to be noncompliant
      with the standard, ODJFS will impose a monetary sanction (see Section 6.) of
      two
      percent of the current month’s premium payment.  Monetary
      sanctions will
      not be levied for
      consecutive quarters
      that an MCP is determined to be
      noncompliant.  If an MCP is noncompliant for three consecutive quarters, membership
      will
      be frozen. Once
      the MCP is determined to be
      compliant with the standard and the violations/deficiencies are resolved to
      the
      satisfaction of ODJFS, the penalties will be lifted, if applicable, and monetary
      sanctions will be returned.

    


    1.a.ii.Incomplete
      Outpatient Hospital Data

    


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

    


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

    


    Report
      Period: The report periods for
      the  SFY 2008 and SFY 2009 contract periods are listed
      in  Table 3. below.

     

    Table
      3. Report Periods
      for the SFY 2008 and 2009 Contract Periods 

     

    
      	
              Quarterly
                Report
                Periods

            	
              Data
                Source:

              Estimated
                Encounter  Data File Update

            	
              Quarterly
                Report

              Estimated
                Issue
                Date

            	
              Contract
                Period

            
	
              Qtr  3
                &  Qtr 4  2004,  2005,
                2006

              Qtr
                1  2007

            	
              July
                2007

            	
              August
                2007

            	
              SFY
                2008

            
	
              Qtr
                3 & Qtr 4 2004, 2005,
                2006

              Qtr
                1, Qtr 2
                2007

            	
              October
                2007

            	
              November
                2007

            
	
              Qtr
                4 2004, 2005,
                2006

              Qtr
                1 thru Qtr 3
                2007

            	
              January
                2008

            	
              February
                2008

            
	
               Qtr
                1 thru Qtr 4: 2005, 2006,
                2007

            	
              April
                2008

            	
              May
                2008

            
	
              Qtr
                2 thru Qtr 4
                2005,

              Qtr
                1 thru Qtr 4: 2006,
                2007

              Qtr
                1 2008

            	
              July
                2008

            	
              August
                2008

            	
              SFY
                2009

            
	
              Qtr
                3, Qtr 4:
                2005,

              Qtr
                1 thru Qtr 4: 2006,
                2007

              Qtr
                1, Qtr 2
                2008

            	
              October
                2008

            	
              November
                2008

            
	
              Qtr
                4: 2005,

              Qtr
                1 thru Qtr 4: 2006,
                2007

              Qtr
                1 thru Qtr 3:
                2008

            	
              January
                2009

            	
              February
                2009

            
	
              
              

              Qtr
                1 thru Qtr 4: 2006, 2007,
                2008

            	
              April
                2009

            	
              May
                2009

            


    

    Qtr1
      = January to March    Qtr2
      = April to June    Qtr3
      = July to September    Qtr4
      = October to
      December

    


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

    


    Determination
      of
      Compliance: Performance is
      monitored once every quarterfor all report
      periods.

    For
      quarterly reports that are issued on
      or after July 1, 2007, an MCP will be determined to be noncompliant for the
      quarter if the standard is not met in any report period and the initial instance
      of noncompliance in a report period is determined on or after July 1,
      2007.  An initial instance of noncompliance means that the result for
      the applicable report period was in compliance as determined in the prior
      quarterly report, or the instance of noncompliance is the first determination
      for an MCP’s first quarter of measurement.

    


    Penalty
      for
      noncompliance:  The first time an MCP is noncompliant with a
      standard for this measure, ODJFS will issue a Sanction Advisory informing the
      MCP that any future noncompliance instances with the standard for this measure
      will result in ODJFS imposing a monetary sanction.

    


    Upon
      all
      subsequent quarterly measurements of performance, if an MCP is again determined
      to be noncompliant with the standard, ODJFS will impose a monetary sanction
      (see
      Section 6) of one percent
      of the current month’s premium payment.  Once the MCP is performing at
      standard levels and violations/deficiencies are resolved to the satisfaction
      of
      ODJFS, the money will be refunded.

    


    1.a.iii.  Rejected
      Encounters

    


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

    


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

    


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

    


    Report
      Period:  For the
      SFY 2008 contract period, performance will be evaluated using the following report
      periods July
      - September 2007; October -
      December 2007;  January - March 2008; April – June 2008. For
      the SFY 2009 contract period,
      performance will be evaluated using the following report periods July -
      September 2008; October - December 2008;  January - March 2009; April
– June 2009.

    


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

     

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

    


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

    


    Penalty
      for noncompliance
      with
the
      Data
      Quality Standardfor
      measure
1:  The
      first time
      an MCP is noncompliant with a standard for this measure, ODJFS will issue a
      Sanction Advisory informing the MCP that any future noncompliance instances
      with
      the standard for this measure will result in ODJFS imposing a monetary sanction.
      Upon all subsequent measurements of performance, if an MCP is again determined
      to be noncompliant with the standard, ODJFS will impose a monetary sanction
      (see
      Section 6.) of one percent of the current month’s premium
      payment.  The monetary sanction will be applied for each file type
      in the ODJFS-specified medium per
      format that is determined to be out of compliance.

    


    Once
      the
      MCP is performing at standard levels and violations/deficiencies are resolved
      to
      the satisfaction of ODJFS, the money will be refunded.

    


    Measure
      2 only applies to
      MCPs that have had Medicaid membership for one year or less.

    


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

    


    Report
      Period: The report period
      for Measure 2 is monthly.  Results are calculated and performance is
      monitored monthly. The first reporting month begins with the third month of
      enrollment.

    


    Data
      Quality Standard for
      measure
2:  The data
      quality standard is a maximum encounter data rejection rate for each file in the ODJFS-specified
      medium per
      format as follows:

    


    Third
      through sixth month with
      membership:  
50%

    


    Seventh
      through twelfth month with
      membership:  25%

    


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

    


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

    


    Penalty
      for Noncompliance
      with the
Data
      Quality
      Standardfor
      measure
2:  If
      the MCP is determined to be noncompliant for either standard, ODJFS will impose
      a monetary sanction of one percent
      of the MCP’s current month’s
      premium  payment.  The monetary sanction
      will
      be applied for each file type  in the ODJFS-specified medium per
      format that is determined to be out of compliance.  The monetary sanction
      will be applied
      only once per file type
per
      compliance
      determination period and will not exceed a total of two percent of the MCP’s
      current month’s premium payment.  Once the MCP
      is performing at standard levels and violations/deficiencies are resolved to
      the
      satisfaction of ODJFS, the money will be refunded.  Special
      consideration will be made for MCPs with less than 1,000 members.

    


    1.a.iv.  Acceptance
      Rate

    


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

    


    Measure:  The
      rate
      of encounters that
      are submitted to ODJFS
      and accepted (i.e. accepted encounters
      per 1,000 member months).  The
      measure will be calculated per
      MCP.

    


    Report
      Period:  The
      report period for this measure is monthly.  Results are calculated and
      performance is monitored monthly. The first reporting month begins with the
      third month of enrollment.

    


    Data
      Quality
      Standard:  The data quality standard is a monthly minimum
      accepted rate of encounters for each file in the ODJFS-specified
      medium
      per format as follows:

    


    
      	
              Third
                through sixth month with
                membership:

            	 
	 	
              50
                encounters per 1,000 MM for
                NCPDP

            
	 	
              65
                encounters per 1,000 MM for
                NSF

            
	 	
              20
                encounters per 1,000 MM for
                UB-92

            


    

    


    
      	
              Seventh
                through twelfth month
                of membership:

            	 
	 	
              250
                encounters per 1,000 MM for
                NCPDP

            
	 	
              350
                encounters per 1,000 MM for
                NSF

            
	 	
              100
                encounters per 1,000 MM for
                UB-92

            


    

    


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

    


    Penalty
      for
      Noncompliance:  If the MCP is determined to be noncompliant
      with the standard, ODJFS will impose a monetary sanction of one percent of
      the
      MCP’s current month’s premium payment.  The monetary sanction will be
      applied
      for each file type  in the ODJFS-specified medium per format that is
      determined to be out of compliance. The monetary sanction
      will be applied
      only once per file
      type per
      compliance determination period and
      will not exceed a total of two percent ofthe
      MCP’s current month’s premium
      payment.  Once the MCP is performing at standard levels and
      violations/deficiencies are resolved to the satisfaction of ODJFS, the money
      will be refunded.  Special consideration will be
      made for
      MCPs with less than 1,000 members.

    


    1.a.v.
      Informational Encounter Data
      Completeness Measure

    


    The
‘Incomplete
      Data for Last Menstrual
      Period’ measure is informational only for the ABD
      population.  Although there is no minimum performance standard for
      this measure, results will be reported and used as one component in monitoring
      the quality of data submitted to ODJFS by the MCPs.

    


    1.b.  Encounter
      Data
      Accuracy

    


    As
      with data completeness, MCPs are
      responsible for assuring the collection and submission of accurate data to
      ODJFS.  Failure to do so jeopardizes MCPs’ performance, credibility
      and, if not corrected, will be assumed to indicate a failure in actual
      performance.

    


    1.b.i.  Encounter
      Data
Accuracy Study

    


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

    


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

    


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

    


    Data
      Quality
      Standard for Measure:   TBD for SFY 2008 and
      SFY 2009.

    


    Penalty
      for
      Noncompliance:  The
      first time an MCP is noncompliant
      with a standard for this measure, ODJFS will issue a Sanction Advisory informing
      the MCP that any future noncompliance instances with the standard for this
      measure will result in ODJFS imposing a monetary sanction.

    


    Upon
      all subsequent measurements of
      performance, if an MCP is again determined to be noncompliant with the standard,
      ODJFS will impose a monetary sanction (see Section 6.)
      of one percent
      of the current month’s premium
      payment.  Once the MCP is performing at standard levels and
      violations/deficiencies are resolved to the satisfaction of ODJFS, the money
      will be refunded.

    


    1.b.ii.  Generic
      Provider Number Usage

    


    Measure:
      This measure is the
      percentage of non-pharmacy encounters with the generic provider
      number.  Providers submitting claims which do not have an MMIS
      provider number must be submitted to ODJFS with the generic provider number
      9111115.  The measure will be calculated per MCP.

    


    All
      other
      encounters are required to have the MMIS provider number of the servicing
      provider.  The report period for this measure
      is  quarterly.

    


    Report
      Period:  For
      the SFY 2008 and SFY 2009 contract
      period, performance will be evaluated using the report periods listed in
      1.a.iii., Table 3.

    


    Data
      Quality Standard: A
      maximum generic provider
number
usage
      rate of 10%.

    


    Determination
      of
      Compliance: Performance is
monitored
      once every
      quarter for all report periods.  For
      quarterly reports that are issued on
      or after July 1, 2007, an MCP will be determined to be noncompliant for the
      quarter if the standard is not met in any report period and the initial instance
      of noncompliance in a report period is determined on or after July 1,
      2007.  An initial instance of noncompliance means that the result for
      the applicable report period was in compliance as determined in the prior
      quarterly report, or the instance of noncompliance is the first determination
      for an MCP’s first quarter of measurement.

    


    Penalty
      for
      noncompliance:   The first time an MCP is noncompliant
      with a standard for this measure, ODJFS will issue a Sanction Advisory informing
      the MCP that any future noncompliance instances with the standard for this
      measure will result in ODJFS imposing a monetary sanction. Upon all subsequent
      measurements of performance, if an MCP is again determined to be noncompliant
      with the standard, ODJFS will impose a monetary sanction (see Section 6.) of
      three percent of the current month’s premium payment.  Once the MCP is
      performing at standard levels and violations/deficiencies are resolved to the
      satisfaction of ODJFS, the money will be refunded.

    


    1.c.
      Timely Submission of Encounter Data

    


    1.c.i.  Timeliness

    


    ODJFS
      recommends submitting encounters no later than thirty-five days after the end
      of
      the month in which they were paid.  ODJFS does not monitor standards
      specifically for timeliness, but the minimum claims volume (Section 1.a.i.)
      and
      the rejected encounter (Section 1.a.iv.) standards are based
      on
      encounters being submitted within this time frame.

    


    1.c.ii.  Submission
      of Encounter Data Files
      in the ODJFS-specified medium per
      format

    


    Information
      concerning the proper submission of encounter data may be obtained from the
      ODJFS Encounter Data File
      Submission Specifications document.  The MCP must submit a
      letter of certification, using the form required by ODJFS, with each
      encounter data file in the
      ODJFS-specified medium per format.

    


    The
      letter of certification must be signed by the MCP’s Chief Executive Officer
      (CEO), Chief Financial Officer (CFO), or an individual who has delegated
      authority to sign for, and who reports directly to, the MCP’s CEO or
      CFO.

    
       

      2.
        CASE MANAGEMENT DATA 



    ODJFS
      designed a case management system
      (CAMS) in order to monitor MCP compliance with program requirements
      specified in Appendix G, Coverage and
      Services.  Each MCP’s case management data submissions will be
      assessed for completeness and accuracy.   The MCP is responsible
      for submitting a case
      management file every
      month.  Failure to do so jeopardizes the MCP’s
      ability to demonstrate compliance
      with case management
requirements.   For
      detailed descriptions of the case management measures below, see ODJFS
      Methods for
      the ABD  and CFC Medicaid Managed Care Programs Data Quality
      Measures.

    


    2.a.   Case
      Management System Data Accuracy

    


    2.a.i.
      Open Case Management Spans for
      Disenrolled Members (this measure will
      be discontinued
      as of January 2008)

    


    Measure:  The
      percentage of the MCP’s case management records in
      CAMS for the ABD
      program that have open case
      management date spans for members who have disenrolled from the
      MCP.

    


    Report
      Period: For
      the third and fourth
      quarters of SFY 2007, January
–
March
      2007, and April – June
      2007 report periods. For
      the  SFY
      2008 contract period,  July – September
      2007, and October
–
December
      2007 report
      periods.

    


    Data
      Quality
      Standard:  A rate of open case management spans for disenrolled
      members of no more than 1.0%.

    


    Statewide Approach:  MCPs
      will be evaluated using
      a statewide resultspecific
      for the ABD program,
      including all regions in which an MCP has ABD membership.  An
      MCP will not
      be evaluated until the MCP has at least 3,000 ABD members
      statewide. As
      the ABD Medicaid managed care program
      expands statewide and regions become active in different months, statewide
      results will include
      every region in which an MCP has
      membership [Example:  MCP AAA has: 6,000 members in the South West
      region beginning in January 2007; 7,000 members in the West Central
      regionbeginning
      in February 2007; and 8,000
      members in the South East region beginning in March 2007. MCP AAA’s statewide
      results for the April-June 2007 report period will include data for the South
      West, West Central, and South East regions.] 

    


    Penalty
      for
      noncompliance:   If an MCP is noncompliant with the
      standard, then the ODJFS will issue a Sanction Advisory informing the MCP that
      a
      monetary sanction will be imposed if the MCP is noncompliant for any future
      report periods.  Upon all subsequent semi-annual measurements of
      performance, if an MCP is again determined to be noncompliant with the standard,
      ODJFS will impose a monetary sanction of one-half of one percent of the current
      month’s premium payment. Once the MCP is performing at standard levels and
      violations/deficiencies are resolved to the satisfaction of ODJFS, the money
      will be refunded.

    


    2.b.  Timely
      Submission of Case Management Files

    


    Data
      Quality Submission
      Requirement: The MCP must submit Case Management files on a monthly basis
      according to the specifications established in ODJFS’ Case Management File and
      Submission Specifications.

    


    Penalty
      for noncompliance:
      See Appendix N, Compliance
      Assessment System, for the
      penalty for noncompliance with this requirement.

    
       

      3.
        EXTERNAL QUALITY REVIEW DATA 



    In
      accordance with federal law and regulations, ODJFS  is required to
      conduct an independent quality review of contracting managed care
      plans.  The OAC rule 5101:3-26-07(C) requires MCPs  to
      submit data and information as requested by ODJFS or its designee for the annual
      external quality review.

    


    Two
      information sources are integral to these studies: encounter data and medical
      records. Because encounter data is used to draw samples for these studies,
      quality must be sufficient to ensure valid sampling.

    


    An
      adequate number of  medical records must then be retrieved from
      providers and submitted to ODJFS or its designee in order to generalize results
      to all applicable members.  To aid MCPs in achieving the required
      medical record submittal rate, ODJFS will give at least an eight week period
      to
      retrieve and submit medical records.

     

    3.a.
      Independent External Quality Review

    


    Measure:  The
      percentage of requested records for
      a study conducted by the External Quality Review Organization (EQRO) that are
      submitted by the managed care plan.

    


    Report
      Period:  The
      report period is one year. Results are calculated and performance is monitored
      annually.  Performance is measured with each review.

    


    Data
      Quality Standard: A
      minimum record submittal rate of 85% for each clinical measure.

    


    Penalty
      for noncompliance for Data
      Quality Standard:  For each study that is completed during this
      contract period, if an MCP is noncompliant with the standard, ODJFS will impose
      a non-refundable $10,000 monetary sanction.

    


    4.  MEMBERS’
      PCP DATA

    


    The
      designated PCP is the
provider who will manage
      and coordinate the overall care for ABD members including those who have case
      management needs.  The MCP must submit  a Members’
Designated PCP file every month.  Specialists may and should be
      identified as the PCP as appropriate for the member’s
      condition per the specialty
      types specified for the ABD population in ODJFS Member’s
      PCP Data
      File and Submission Specifications; however, no ABD member
      may have more
      than one PCP identified for
      a given month. 

    


    4.a.  Timely
      submission of Member’s PCP Data

    


    Data
      Quality Submission
      Requirement:  The MCP must submit a Members’ Designated PCP
      Data files on a monthly basis according to the specifications established in
      ODJFS Member’s
      PCP Data File and
      Submission Specifications.

    


    Penalty
      for
      noncompliance:  See Appendix N, Compliance
      Assessment
      System, for the penalty for noncompliance with this
      requirement.

    


    4.b.  Designated
      PCP for newly enrolled members (applicable
      for report periods prior
      to January 2008)

    


    Measure:  The
      percentage of MCP’s newly enrolled
      members who were designated a PCP by their effective date of
      enrollment.

    


    Report
      Periods:  For
      the third and fourth
      quarters
      of SFY 2007 contract period, performance will be evaluated quarterly using
      the
      January – March 2007 and April – June 2007 report periods. For the SFY 2008
      contract period, performance will be evaluated quarterly using the
      July-September 2007, and October–
December 2007 report
      periods.

    


    Data
      Quality
      Standard:  A
      minimum rate of  65% of new members with PCP designation by their
      effective date of enrollment for quarter 3 and quarter 4 of SFY
      2007.  A
      minimum rate of 75% of new members
      with PCP designation by their effective date of enrollment for quarter 1 and
      quarter 2 of SFY 2008.

    


    Statewide
      Approach:  MCPs
      will be evaluated using a statewide result, including all regions in which
      an
      MCP has ABD membership.  An MCP will not be evaluated until the
      MCP has at least 3,000 ABD members statewide.

    


    Penalty
      for
      noncompliance:  If an MCP is noncompliant
      with the
      standard, ODJFS will impose a monetary sanction of one-half of one percent of the
      current month’s premium
      payment.  Once the MCP is performing at standard levels and
      violations/deficiencies are resolved to the satisfaction of ODJFS, the money
      will be refunded.  As stipulated in OAC
      rule
      5101:3-26-08.2, each new member must have a designated primary care
      provider (PCP) prior to their
      effective date of coverage.  Therefore, MCPs are subject to additional
      corrective action measures
      under Appendix N, Compliance Assessment System, for failure to meet this
      requirement.

    


    4.b.i.  Designated
      PCP for
      newly enrolled members (applicable for report
      periods after
      December 2007)

    


    Measure:  The
      percentage of MCP’s newly enrolled members who were designated a PCP by their
      effective date of enrollment.

    


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

    


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

    


    Statewide
      Approach:  MCPs will be evaluated using a statewide result,
      including all regions in which an MCP has ABD membership.  An MCP will
      not be evaluated until the MCP has at least 3,000 ABD members
      statewide.

    


    Penalty
      for
      noncompliance:  If an MCP is noncompliant with the standard,
      ODJFS will impose a monetary sanction of one-half of one percent of the current
      month’s premium payment.  Once the MCP is performing at standard
      levels and violations/deficiencies are resolved to the satisfaction of ODJFS,
      the money will be refunded.  As stipulated in OAC rule 5101:3-26-08.2,
      each new member must have a designated primary care provider (PCP) prior to
      their effective date ofcoverage.  Therefore,
      MCPs are subject to additional corrective action measures under Appendix N,
      Compliance Assessment System, for failure to meet this requirement.

     

    5.
      APPEALS AND GRIEVANCES DATA

    


    Pursuant
      to OAC rule 5101:3-26-08.4, MCPs are required to submit information at least
      monthly to ODJFS regarding appeal and grievance activity.  ODJFS
      requires these submissions to be in an electronic data file format pursuant
      to
      the Appeal File and Submission
      Specifications and Grievance File and
      Submission
      Specifications.

    


    The
      appeal data file and the grievance data file must include all appeal and
      grievance activity, respectively, for the previous month, and must be submitted
      by the ODJFS-specified due date.  These data files must be submitted
      in the ODJFS-specified format and with the ODJFS-specified filename in order
      to
      be successfully processed.

    


    Penalty
      for
      noncompliance:  MCPs who fail to submit their monthly
      electronic data files to the ODJFS by the specified due date or who fail to
      resubmit, by no later than the end of that month, a file which meets the data
      quality requirements will be subject to penalty as stipulated under the Compliance Assessment System
      (Appendix
      N).

    


    6.  NOTES

     

    
      6.a.  
Penalties,
        Including Monetary
        Sanctions, for Noncompliance



    Penalties
      for noncompliance with standards outlined in this appendix, including monetary
      sanctions, will be imposed as the results are finalized.  With the
      exception of  Sections
      1.a.i., 1.a.iii.,
      1.a.iv., 1.a.v.,
      and 1.b.ii no
      monetary sanctions described in
      this appendix will be imposed if the MCP is in its
      first
      contract year of Medicaid program participation.  Notwithstanding the
      penalties specified in this Appendix, ODJFS reserves the right to apply the
      most
      appropriate penalty to the area of deficiency identified when an MCP is
      determined to be noncompliant with a standard.  Monetary penalties for
      noncompliance with any individual measure,  as determined in this
      appendix,  shall not exceed $300,000 during each
      evaluation.

    


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

    


    Any
      monies collected through the imposition of such a sanction will be returned
      to
      the MCP (minus any applicable collection fees owed to the Attorney General’s
      Office, if the MCP has been delinquent in submitting payment) after the MCP
      has
      demonstrated full compliance with the particular program requirement and the
      violations/deficiencies are resolved to the satisfaction of ODJFS.  If
      an MCP does not comply within two years of the date of notification of
      noncompliance, then the monies will not be refunded.

    


    6.b.
      Combined Remedies

    


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

    


    6.c.  Membership
      Freezes

    


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

    


    6.d.  Reconsideration

    


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

    


    6.e.  Contract
      Termination, Nonrenewals, or Denials

    


    Upon
      termination either by the MCP or ODJFS, nonrenewal, or denial of an MCP provider
      agreement, all previously collected refundable monetary sanctions will be
      retained by ODJFS.

     

    

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      


      APPENDIX
        M

      


      PERFORMANCE
        EVALUATION

      ABD
        ELIGIBLE
        POPULATION

      


      This
        appendix establishes minimum performance standards for
        managed care
        plans (MCPs) in key program areas, under the Agreement.  Standards
        are subject to
        change based on the revision or update of applicable national standards,
        methods, benchmarks,
        or other factors as deemed
        relevant.  Performance will be
        evaluated in the categories of Quality of Care, Access, Consumer Satisfaction,
        and Administrative Capacity.  Each performance measure has an
        accompanying minimum performance standard. MCPs with performance levels below
        the minimum performance standards will be required to take corrective
        action. All
        performance measures, as specified
        in this appendix, will be calculated per MCP and include only members in
        the ABD
        Medicaid managed
care
        program.

       

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

      


      1.  QUALITY
        OF CARE

      


      1.a.
        Independent External Quality
        Review

      


      In
        accordance with federal law and
        regulations, state Medicaid agencies must annually provide for an external
        quality review of the quality outcomes and timeliness of, and access to,
        services provided by Medicaid-contracting MCPs [(42 CFR
        438.204(d)].  The external review assists the state in assuring MCP
        compliance with program requirements and facilitates the collection of accurate
        and reliable information concerning MCP performance.

      


      Measure:  The
        independent
        external quality reviewcovers a review of
        clinical and
        non-clinical performance as outlined in Appendix K.

      


      Report
        Period:  Performance
        will be evaluated using the reviews conducted during SFY 2008.

      


      Action
        Required for
        Deficiencies:  For all reviews conducted during the contract period,
        if the EQRO cites a deficiency in performance the MCP will be required to
        complete a Corrective Action Plan or Quality Improvement Directive, depending
        on
        the severity of the deficiency. Serious deficiencies may result in immediate
        termination or non-renewal of the Agreement.

      


      1.b.  Members
        with Special Health Care Needs (MSHCN)

      


      Given
        the substantial proportion of
        members with chronic conditions and co-morbidities in the ABD population,
        one of
        the quality of care initiatives of the ABD Medicaid managed
care
        program focuses on case
        management.  In order to ensure state compliance with  the
        provisions of 42 CFR 438.208, the
        Bureau of Managed Health Care
        established Members with Special Health Care Needs (MSHCN) basic program
        requirements as set
        forth in Appendix G,
Coverage
        and
        Services of the
Agreement,  and
        corresponding minimum
        performance standards as described below. The purpose of these measures is
        to
        provide appropriate and targeted case management services to MSHCN who have
        specific diagnoses and/or who require high-cost or extensive
        services.  Given
        the expedited schedule for implementing the ABD Medicaid managed care program,
        coupled with the challenges facing a new Medicaid program in the State of
        Ohio,
        the minimum performance standards for
        the case management requirements for MSHCN are phased in throughout SFY 2007
        and
        SFY 2008.  The minimum standards for these performance measures will
        be fully phased in by no later than SFY 2009.  For detailed
        methodologies of each measure, see ODJFS
        Methods for
        the ABD Medicaid Managed Care Program’s Case Management Performance
        Measures.

      


      1.b.i
Case
Management
        of
        Members

      


      Measure:
        The average monthly
        case
management rate for
        members
        who have at least three months of consecutive enrollment in one MCP.

      


      Report
        Period: For
        the SFY 2007 contract period, April
– June 2007 report period. For
        the SFY 2008 contract
        period,  July – September 2007, October
– December 2007,
        January – March 2008, and April – June 2008 report periods. For the SFY 2009 contract
        period,  July – September 2008, October – December 2008, January –
March 2009, and April – June 2009 report periods.

      


      Statewide
        Approach:  MCPs
        will be evaluated using a statewide result, including all regions in which
        an
        MCP has membership.  An MCP will not be evaluated until the MCP has at
        least 3,000 members statewide who have had at least three months of continuous
        enrollment during each month of the entire report period.  As the ABD
        Medicaid managed care program expands statewide and regions become active
        in
        different months, statewide results will include every region in which an
        MCP
        has membership [Example:  MCP AAA has: 6,000 members in the South West
        region beginning in January 2007; 7,000 members in the West Central region
        beginning in February 2007; and 8,000 members in the South East region beginning
        in March 2007.  MCP AAA’s statewide results for the April-June 2007
        report period will include case management rates for all members who meet
        minimum continuous enrollment criteria for this measure in: the South West
        region for April 2007’s monthly rate calculation; the South West
        and  West Central regions for May 2007’s monthly rate calculation; and
        the South West, West Central, and South East regions for June 2007’s monthly
        rate calculation.]

      


      Statewide
        Target:  For the first and second quarters of SFY 2008, a case
        management rate of 30%.  For the third and fourth quarters of SFY
        2008, a case management rate of 35%.  For the first and second
        quarters of SFY 2009, a case management rate of 40%.  For the third
        and fourth quarters of SFY 2009, a case management rate of 45%.

      


      Statewide
        Minimum Performance
        Standard:  The level of improvement must result in at least a
        20% decrease in the difference between the target and the previous report
        period’s results.

      


      Penalty
        for
        Noncompliance: The
        first time an MCP is noncompliant
        with a standard for this measure, ODJFS will issue a Sanction Advisory informing
        the MCP that any future noncompliance instances with the standard for this
        measure will result in ODJFS imposing a monetary sanction.  Upon all
        subsequent measurements of performance, if an MCP is again determined to
        be
        noncompliant with the standard, ODJFS will impose a monetary sanction (see
        Section 5) of two percent of the current month’s premium payment. Monetary
        sanctions will not be levied for consecutive quarters that an MCP is determined
        to be noncompliant.  If an MCP is noncompliant for a subsequent
        quarter, new member selection freezes or a reduction of assignments will
        occur
        as outlined in Appendix N of the Provider Agreement. Once
        the MCP is performing at standard
        levels and the violations/deficiencies are resolved to the satisfaction of
        ODJFS, the penalties
        will be lifted, if applicable,
        and monetary sanctions will be returned.

      


      1.b.ii.
        Case Management of Members with
        an ODJFS-Mandated Condition

      


      Measure
        1:  The percent
        of members with a positive identification through an ODJFS administrative
        review
        of data for the ODJFS-mandated case management condition
        of  asthma who
        have had at least three consecutive
        months of enrollment in one MCP that are case
        managed.

      


      Measure
        2:  The percent
        of members with a positive identification through an ODJFS administrative
        review
        of data for the ODJFS-mandated case management condition
        of  chronic
        obstructive pulmonary disease who
        have had at least three consecutive
        months of enrollment in one MCP that are case
        managed.

      


      Measure
        3:  The percent
        of members with a positive identification through an ODJFS administrative
        review
        of data for the ODJFS-mandated case management condition
        of  congestive
        heart failure   who
        have had at least three
        consecutive months of enrollment in one MCP that are case
        managed.

      


      Measure
        4:  The
        percent of members with a positive identification through an ODJFS
        administrative review of data for the ODJFS mandated case management condition
        of behavioral health who have had at least three consecutive months of
        enrollment in one MCP that are case managed.

      


      Measure
        5:  The
        percent of members with a positive identification through an ODJFS
        administrative review of data for the ODJFS-mandated case management condition
        of  diabetes who have had at least three consecutive months of
        enrollment in one MCP that are case managed.

      


      Measure
        6:  The
        percent of members with a positive identification through an ODJFS
        administrative review of data for the ODJFS-mandated case management condition
        of  non-mild hypertension who have had at least three consecutive
        months of enrollment in one MCP that are case managed.

      


      Measure
        7:  The
        percent of members with a positive identification through an ODJFS
        administrative review of data for the ODJFS-mandated case management condition
        of  coronary arterial disease who have had at least three consecutive
        months of enrollment in one MCP that are case managed.

      


      Report
        Periods for Measures 1-
        7:   For the SFY 2007 contract period April – June 2007
        report periods.  For the SFY 2008 contract period,  July – September
        2007, October – December 2007, January – March 2008, and April – June 2008
        report periods.  For the SFY 2009 contract
        period,  July – September 2008, October – December 2008, January –
March 2009, and April – June 2009 report periods. 

      


      Statewide
Approach:  MCPs
        will be evaluated using
        a statewide result, including all regions in which an MCP has
        membership.  An MCP will not be evaluated until the MCP has at least
        3,000 members statewide who have had at least three months of continuous
        enrollment during each month of the entire report period.  As the ABD
        Medicaid managed care programs expands statewide and regions become active
        in
        different months, statewide results will include every region in which an
        MCP
        has membership [Example:  MCP AAA has: 6,000 members in the South West
        region beginning in January 2007; 7,000 members in the West Central region
        beginning in February 2007; and 8,000 members in the South East region beginning
        in March 2007.  MCP AAA’s statewide results
        for the
        April-June 2007 report period will include case management rates for all
        members
        in the South West, West Central, and South East regions who are identified
        through the administrative data review as having a mandated condition and
        are
        continuously enrolled for at least three consecutive months in one
        MCP.]

      


      Statewide
        Target for Measures 1, 2,
        3, 5, 6, and 7:  For the first and second quarters of SFY 2008,
        a case management rate of 60%.  For the third and fourth quarters of
        SFY 2008, a case management rate of 65%.  For SFY 2009, a case
        management rate of 75%.

      


      Statewide
        Minimum Performance
        Standard:  The level of improvement must result in at least a
        20% decrease in the difference between the target and the previous report
        period’s results.

      


      Statewide
        Target for Measure
        4:  For the first and second quarters of SFY 2008, a case
        management rate of 30%.  For the third and fourth quarters of SFY
        2008, a case management rate of 35%.  For SFY 2009, the case
        management rate is TBD.

      


      Statewide
        Minimum Performance
        Standard:  The level of improvement must result in at least a
        20% decrease in the difference between the target and the previous report
        period’s results.

      


      Penalty
        for
        Noncompliance for
Measures
        1-7:  The first
        time an MCP is noncompliant with a standard for this measure, ODJFS will
        issue a
        Sanction Advisory informing the MCP that any future noncompliance instances
        with
        the standard for this measure will result in ODJFS imposing a monetary
        sanction.  Upon all subsequent measurements of performance, if an MCP
        is again determined to be noncompliant with the standard, ODJFS will impose
        a
        monetary sanction (see Section 5) of two percent of the current month’s premium
        payment. Monetary sanctions will not be levied for consecutive quarters that
        an
        MCP is determined to be noncompliant.  If an MCP is noncompliant for a
        subsequent quarter, new member selection freezes or a reduction of assignments
        will occur as outlined in Appendix N of the Provider Agreement. Once
        the MCP is performing at
standard levels and
        the
        violations/deficiencies are resolved to the satisfaction of ODJFS, the
        penalties will be lifted, if
        applicable, and monetary sanctions will be returned.

      


      1.c.
        Clinical Performance
        Measures

      


      MCP
        performance will be assessed based on the analysis of submitted encounter
        data
        for each year. For certain measures, standards are established; the
        identification of these standards is not intended to limit the assessment
        of
        other indicators for performance improvement activities.  Performance
        on multiple measures will be assessed and reported to the MCPs and others,
        including Medicaid consumers.

      


      The
        clinical performance measures described below closely follow the National
        Committee for Quality Assurance’s
(NCQA)
        Health Plan
        Employer Data and Information Set (HEDIS).  NCQA may annually change
        its method for calculating a measure.  These changes can make it
        difficult to evaluate whether improvement occurred from a  prior
        year.  For this reason, ODJFS will use the same
        methods to calculate the baseline results and the results for the period
        in
        which the MCP is being held
        accountable.  For example, the same methods are used
        to calculate calendar year  2008 results
        (the baseline period) and
        calendar year  2009 results.  The methods will be updated
        and a new baseline will be created during  2009 for
        calendar  year 2010  results.  These results will
        then serve as the baseline to evaluate whether improvement occurred from
        calendar  year 2009 to calendar year  2010. 
        Clinical performance measure results
        will be calculated after a sufficient amount of time has passed after the
        end of
        the report period in order to allow for claims runout.  For a
        comprehensive description of the clinical performance measures below, see
        ODJFS
        Methods for Clinical Performance Measures, ABD
Medicaid
        Managed
        Care Program.  Performance standards
        are subject to
        change, based
        on the revision or update of NCQA
        methods or other national
        standards, methods or benchmarks.

      


      MCPs
        will be evaluated using a statewide
        result, including all regions in which an MCP has
        membership.  ODJFS will use the
        first calendar year
        of an MCP’s ABD managed care program membership as
        the baseline year (i.e.,
        CY2007).  The
        baseline year will be
        used to determine performance standards and targets; baseline data will
come
        from a combination of
        FFS claims data and MCP encounter
        data.  For those
        performance measures that require two calendar years of baseline data, the
        additional calendar year (i.e., the calendar year prior to the first calendar
        year of ABD managed care program
        membership, i.e.,
        CY2006)
        data will come
        from FFS claims data. 

      


      An
        MCP’s second calendar
        year of
        ABD managed care program membership
(i.e., CY2008)
will
        be the initial report period of
        evaluation for performance measures that require one calendar year of
baseline
        data(i.e., CY2007),
        and for performance measures that
        require two calendar years
of
        baseline data (i.e.,
        CY2006and
        CY2007).

      


      Report
        Period:  For the
        SFY 2008 contract
        period, performance will be
        evaluated using the January - December 2007 report
        period and may be adjusted
        based on the number
        of months of ABD managed care membership.  For the SFY 2009
contract
        period, performance will be
        evaluated using the January - December 2008 report
        period.

      


      1.c.i.  Congestive
        Heart
        Failure (CHF) – Inpatient Hospital
Discharge
        Rate

      


      Measure:  The
        number
        of  acute inpatient hospital discharges in the reporting year
        where the
        principal diagnosis was CHF, per thousand member
        months, for members
        who had a
        diagnosisof CHF in the year
        prior to the reporting year.

      


      Target:  TBD

      


      Minimum
        Performance
        Standard:  The
        level of improvement must result in at least a TBD% decrease
        in the difference between the
        target and the previous report period’s results. (For example, if last year’s
        results were TBD%,
then
        the difference between
        the target and last year’s results is TBD%.  In
        this example, the
        standard is an improvement in performance of TBD%
        of this difference or TBD%.
        In this example, results of
TBD%
        or better would be compliant with the
        standard.)

      


      


      Action
        Required for
        Noncompliance:  If the standard is
        not met and the
        results are below TBD%,
        the MCP is required to complete a
Corrective Action Plan  to address the area of
        noncompliance.  If the standard is not met and the results are at or
        above TBD%,  ODJFS will
        issue a Quality Improvement Directive which will notify the MCP of noncompliance
        and may outline the steps that the MCP must take to improve the
        results.

      


      1.c.ii.  Congestive
        Heart
        Failure (CHF) – Emergency Department (ED) Utilization Rate

      


      Measure:  The
        number of emergency department
visits
        inthe reporting year
        where the primary
        diagnosis was CHF, per
        thousand member months,
for
        members who had
a diagnosis of
 CHF
        in the year prior to the
        reporting year.

      


      Target:  TBD

      


      Minimum
        Performance
        Standard:  The
        level of improvement must result in at least a TBD%
        decrease in the difference between the
        target and the previous report period’s results.

      


      Action
        Required for
Noncompliance:  If
        the standard is not met and the results are below TBD%,  the MCP is
        required to complete a Corrective Action Plan  to address the area of
        noncompliance.  If the standard is not met and the results are at or
        above TBD%,  ODJFS will issue a Quality Improvement Directive which
        will notify the MCP of noncompliance and may outline the steps that the MCP must
        take to
        improve the results.

      


      1.c.iii.
Congestive
        Heart Failure (CHF) –
Cardiac Related Hospital
Readmission

      


      Measure:  The
rateof
        cardiac related readmissions
during the reporting
        period
for members who had
        a diagnosis of CHF
        in the year prior to the
        reporting period.  A readmission is defined as a cardiac related
        admission that occurs within 30 days of  a prior cardiac related
        admission.

      


      Target:  TBD.

      


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

      


      Action
        Required for
        Noncompliance:  If
        the standard is not met and the
        results are below TBD%,  the
        MCP is required to
        complete a Corrective Action Plan 
        to address the area of noncompliance.
        If the standard is not met and the results are at or above TBD%,  ODJFS
        will issue a Quality
        Improvement Directive which will notify the MCP of noncompliance and may
        outline
        the steps that the MCP must take to improve the results.

      


      1.c.iv.  Coronary
        Artery Disease
        (CAD) – Inpatient HospitalDischarge
        Rate

      


      Measure:  The
        number
        of  acute inpatient hospital discharges in the reporting year
        where the primary
        diagnosis was CAD,  per thousand member
        months,
        for members who had
a
        diagnosis of  CAD in the year prior
        to
        the reporting year.

      


      Target:  TBD

      


      Minimum
        Performance
        Standard:  The
        level of improvement must result in at least a TBD%
        decrease in the difference between the
        target and the previous report period’s results.

      


      Action
        Required for
        Noncompliance:  If the standard is
        not met and the
        results are below TBD%,  the
        MCP is required to
        complete a Corrective Action Plan 
        to address the area of
        noncompliance. If
        the standard is not met and the
        results are at or above TBD%,
        ODJFS will issue a Quality
        Improvement Directive which will notify the MCP of noncompliance and may
        outline
        the steps that the MCP must take to improve the results.

      


      1.c.v.  Coronary
        Artery Disease
        (CAD) – Emergency Department (ED) Utilization Rate

      


      Measure:  The
        number
        of  emergency department visitsin the reporting year
        where the
        principal diagnosis was CAD,  per thousand member
        months,
        for members who had a
        diagnosisof CAD in the year
        prior to the reporting year.

      


      Target:  TBD

      


      Minimum
        Performance
        Standard:  The
        level of improvement must result in at least a TBD%
        decrease in the difference between the
        target and the previous report period’s results.

      


      Action
        Required for
        Noncompliance:  If the standard is
        not met and the
        results are below TBD%,  the
        MCP is required to
        complete a Corrective Action Plan  to
        address the area of
        noncompliance.  If
        the standard is not met and the
        results are at or above TBD%,  ODJFS
        will issue a Quality
        Improvement Directive which will notify the MCP of noncompliance and may
        outline
        the steps that the MCP must take to improve the results.

      


      1.c.vi.
Coronary
        Artery Disease (CAD) –
Cardiac Related Hospital
Readmission

      


      Measure:  The
rate
of
        cardiac related readmissions
in the reporting year
        for members who had
        a diagnosis of
        CAD in the year prior to the
        reporting year.  A
        readmission is defined as
        a cardiac related admission that occurs within 30 days of  a prior
        cardiac related admission.

      


      Target:  TBD.


      


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

      


      Action
        Required for
        Noncompliance:  If
        the standard is not met and the
        results are below TBD%,  the
        MCP is required to
        complete a Corrective Action
        Plan  to
        address the area of noncompliance. If
        the standard is not met and the results are at or above TBD%,  ODJFS
        will issue a Quality
        Improvement Directive which will notify the MCP of noncompliance and may
        outline
        the steps that the MCP must take to improve the results.

      


      1.c.vii.
        Coronary Artery Disease (CAD) –
Beta Blocker Treatment
        after Heart Attack

      


      The
        evaluation report period for this
        measure is CY 2008 only.

      


      Measure:  The
        percentage of members 35
years of
        age and older as of December
        31st
        of the
        reporting year who were hospitalized
        from January 1 – December 24th
        of the reporting year
        with
        a diagnosis of acute myocardial infarction (AMI) and who received an ambulatory
        prescription for beta blockers within seven days of
        discharge.

      


      Target:  TBD.

      


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

      


      Action
        Required for
        Noncompliance:  If
        the standard is not met and the
        results are below TBD%,  the
        MCP is required to
        complete a Corrective Action Plan  
        to address the area of noncompliance.
        If the standard is not met and the results are at or above TBD%,  ODJFS
        will issue a Quality
        Improvement Directive which will notify the MCP of noncompliance and may
        outline
        the steps that the MCP must take to improve the results.

      


      1.c.viii.  Persistence
        of Beta
        Blocker Treatment after Heart Attack

      


      The
        initial report period of evaluation
        for this measure is CY 2009.  This measure will replace the
Coronary Artery Disease
        (CAD) – Beta Blocker Treatment after Heart Attack measure (1.c.vii.) in the P4P
        for SFY 2010.

      


      Measure:  The
        percentage of members 35
        years of age and older as of December 31stof
        the reporting year who were
        hospitalized and discharged alive from July 1 of the year prior to the reporting
        year to June 30 of the measurement year with a diagnosis of acute myocardial
        information  (AMI) and who received persistent beta-blocker treatment
        for six months after discharge.

      


      Target:  TBD.

      


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

      


      Action
        Required for
        Noncompliance:  If the standard is
        not met and the
        results are below TBD%, the MCP is required to complete a Corrective Action
        Plan  to
        address the area of noncompliance. If
        the standard is not met and the results are at or above TBD%, ODJFS will
        issue a
        Quality Improvement Directive which will notify the MCP of noncompliance
        and may
        outline the steps that the MCP must take to improve the
        results.

      
         

        1.c.ix.
          Coronary Artery Disease (CAD) –
Cholesterol Management for Patients with Cardiovascular Conditions/LDL-C
          Screening Performed

      

      
      

      


      Measure:  The
        percentage of members
        who had a diagnosis
of 
CAD
        in the year
        prior to the reporting year, who were enrolled for at least 11 months in
        the
        reporting year, and
who
        received a lipid
        profile during the reporting year.

      


      Target:  TBD.

      


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

      


      Action
        Required for
        Noncompliance:  If
        the standard is not met and the
        results are below TBD%,  the
        MCP is required to
        complete a Corrective Action Plan to address the area
        of noncompliance. If
        the standard is not met and the results are at or above TBD%,  ODJFS
        will issue a Quality
        Improvement Directive which will notify the MCP of noncompliance and may
        outline
        the steps that the MCP must take to improve the results.

      


      1.c.x.  Hypertension  –
        Inpatient Hospital
        Discharge Rate

      


      Measure:  The
        number
        of  acute inpatient hospital dischargesin the reporting year
        where the primary
        diagnosis was non-mild hypertension,  per thousand member
        months,
        for members who had a
        diagnosis of non-mild
        hypertension in the year prior to the reporting year.

      


      Target:  TBD

      


      Minimum
        Performance
        Standard:  The
        level of improvement must result in at least a TBD%
        decrease in the difference between the
        target and the previous report period’s results.

      


      Action
        Required for
        Noncompliance:  If the standard is
        not met and the
        results are below TBD%,  the
        MCP is required to
        complete a Corrective Action Plan to address the area of
        noncompliance. If
        the standard is not met and the results are at or above TBD%,
        ODJFS will issue a Quality
        Improvement Directive which will notify the MCP of noncompliance and may
        outline
        the steps that the MCP must take to improve the results.

       

      1.c.xi.  Hypertension
–
Emergency
        Department (ED) Utilization Rate

      


      Measure:  The
        number
        of  emergency department visitsin the reporting year
        where the
        principal diagnosis was non-mild hypertension, per
        thousand member months, for members
        who had a diagnosis
of
        non-mild
        hypertension  in the year prior to the reporting
        year.

      


      Target:  TBD

      


      Minimum
        Performance
        Standard:  The
        level of improvement must result in at least a TBD%
        decrease in the difference between the
        target and the previous report period’s results.

      


      Action
        Required for
        Noncompliance:  If the standard is
        not met and the
        results are below TBD%,
        the MCP is required to complete a
Corrective Action Plan  to
        address the area of noncompliance.
 If
        the standard is not met and the
        results are at or above TBD%,  ODJFS
        will issue a Quality
        Improvement Directive which will notify the MCP of noncompliance and may
        outline
        the steps that the MCP must take to improve the results.

      


      1.c.xii.  Diabetes  –
        Inpatient Hospital
        Discharge Rate

      


      Measure:  The
        number of acute inpatient
        hospital discharges
in the reporting year
        where
        the principal diagnosis was diabetes, per thousand
        member months, for members
identified as diabetic
        in
the year prior
        to the reporting
        year.

      


      Target:  TBD

      


      Minimum
        Performance
        Standard:  The
        level of improvement must result in at least a TBD%
        decrease in the difference between the
        target and the previous report period’s results.

      


      Action
        Required for
        Noncompliance:  If the standard is
        not met and the
        results are below TBD%,  the
        MCP is required to
complete a Corrective Action Plan  to address the area of
        noncompliance.  If the standard is not met and the results are at or
        above TBD%,  ODJFS will
        issue a Quality Improvement Directive which will notify the MCP of noncompliance
        and may outline the steps that the MCP must take to improve the
        results.

      


      1.c.xiii.  Diabetes
–
Emergency
        Department (ED) Utilization Rate

      


      Measure:  The
        number of
        emergency department visits
in the reporting year
        where
        the primary  diagnosis was diabetes, per
        thousand member months, for members
identified as
        diabetic  in the
        year prior to the reporting year.

      


      Target:  TBD

      


      Minimum
        Performance
        Standard:  The
        level of improvement must result in at least a TBD%
        decrease in the difference between the
        target and the previous report period’s results.

      


      Action
        Required for
        Noncompliance:  If the standard is
        not met and the
        results are below TBD%,
        the MCP is required to complete a
Corrective Action Plan  to
        address the area of
        noncompliance. If
        the standard is not met and the
        results are at or above TBD%,  ODJFS
        will issue a Quality
        Improvement Directive which will notify the MCP of noncompliance and may
        outline
        the steps that the MCP must take to improve the results.

      


      1.c.xiv.  Diabetes
–
Eye
        Exam

      


      Measure:   The
        percentage of
diabetic members who
        were enrolled for at least 11 months
        during the reporting year, who received one or more retinal or dilated eye
        exams
        from an ophthalmologist or optometrist during the reporting
        year.

      


      Target:TBD.

      


      Minimum
        Performance
        Standard: The
        level of improvement must result in
        at least a TBD%  increase  in
        the
        difference between the target and the previous year’s
        results.

      


      Action
        Required for
        Noncompliance:  If the standard is
        not met and the
        results are below TBD%,  the
        MCP is required to
        complete a Corrective Action Plan to
        address the area of noncompliance. If
        the standard is not met and the results are at or above TBD%,  ODJFS
        will issue a Quality
        Improvement Directive which will notify the MCP of noncompliance and may
        outline
        the steps that the MCP must take to improve the results.

      


      1.c.xv.  Chronic
        Obstructive
        Pulmonary Disease  (COPD) – Inpatient Hospital
        Discharge Rate

      


      Measure:  The
        number
        of  acute inpatient hospital discharges in the reporting year
        where the primary
        diagnosis was COPD,  per thousand member
        months,
for
        members who had a diagnosis of
 COPD
        in the year prior to the
        reporting year.

      


      Target:  TBD

      


      Minimum
        Performance
        Standard:  The
        level of improvement must result in at least a TBD%
        decrease in the difference between the
        target and the previous report period’s results.

      


      Action
        Required for
        Noncompliance:  If the standard is
        not met and the
        results are below TBD%,  the
        MCP is required to
        complete a Corrective Action Plan  to
        address the area of
        noncompliance. If
        the standard is not met and the
        results are at or above TBD%,  ODJFS
        will issue a Quality
        Improvement Directive which will notify the MCP of noncompliance and may
        outline
        the steps that the MCP must take to improve the results.

       

      1.c.xvi.  Chronic
        Obstructive
        Pulmonary Disease  (COPD) – Emergency Department (ED) Utilization
        Rate

       

      Measure:  The
        number
        of  emergency department visits in the reporting year
        where the
        principal diagnosis was COPD,  per thousand member
        months,
        for members who had a
        diagnosis of
 COPD  in the year prior to
        the reporting
        year.

      


      Target:  TBD

      


      Minimum
        Performance
        Standard:  The
        level of improvement must result in at least a TBD%
        decrease in the difference between the
        target and the previous report period’s results.

      


      Action
        Required for
        Noncompliance:  If the standard is
        not met and the
        results are below TBD%,  the
        MCP is required to
        complete a Corrective Action Plan  to
        address the area of noncompliance.
If
        the standard is not met and the
        results are at or above TBD%,  ODJFS
        will issue a Quality
        Improvement Directive which will notify the MCP of noncompliance and may
        outline
        the steps that the MCP must take to improve the results.

      


      1.c.xvii.  Asthma
–
Inpatient Hospital
        Discharge Rate

      


      Measure:  The
        number of acute
        inpatient hospital discharges in the reporting year
        where the primary
        diagnosis was asthma, per
        thousand member months, for
        members with persistent asthma.

      


      Target:  TBD

      


      Minimum
        Performance
        Standard:  The
        level of improvement must result in at least a TBD%
        decrease in the difference between the
        target and the previous report period’s results.

      


      Action
        Required for
        Noncompliance:  If the standard is
        not met and the
        results are below TBD%,  the
        MCP is required to
        complete a Corrective Action Plan  to
        address the area of noncompliance.
 If
        the standard is not met and the
        results are at or above TBD%,  ODJFS
        will issue a Quality
        Improvement Directive which will notify the MCP of noncompliance and may
        outline
        the steps that the MCP must take to improve the results.

      
         

        1.c.xviii.  Asthma
–
Emergency
          Department (ED) Utilization Rate

      

      
      

      


      Measure:  The
        number
        of  emergency department visits in the reporting year
        where the
        principal diagnosis was asthma,  per thousand member
        months,
for members with persistent
        asthma.

      


      Target:  TBD

      


      Minimum
        Performance
        Standard:  The
        level of improvement must result in at least a TBD%
        decrease in the difference between the
        target and the previous report period’s results.

      


      Action
        Required for
        Noncompliance:  If the standard is
        not met and the
        results are below TBD%,  the
        MCP is required to
        complete a Corrective Action Plan   to
        address the area of
        noncompliance. If
        the standard is not met and the
        results are at or above TBD%,  ODJFS
        will issue a Quality
        Improvement Directive which will notify the MCP of noncompliance and may
        outline
        the steps that the MCP must take to improve the results.

      
         

        1.c.xix.  Asthma
–
Use
          of Appropriate
          Medications for People with Asthma

      

       

      Measure:  The
        percentage of members
        with persistent asthma who received prescribed medications acceptable as
        primary
        therapy for long-term control of asthma.

      


      Target:  TBD

      


      Minimum
        Performance
        Standard:  The
        level of improvement must result in at least a TBD%
        decrease in the difference between the
        target and the previous report period’s results.

      


      Action
        Required for
        Noncompliance:  If the standard is
        not met and the
        results are below TBD%,
        the MCP is required to
complete a Corrective Action Plan  to address the area of
        noncompliance.   If the standard is not met and the results are
        at or above TBD%, ODJFS will issue
        a Quality Improvement Directive which will notify the MCP of noncompliance
        and
        may outline the steps that the MCP must take to improve the
        results.

      


      1.c.xx.
        Mental Health, Severely
        Mentally Disabled (SMD) – Inpatient Hospital
        Discharge Rate

      


      Measure:  The
        number
        of  acute inpatient hospital discharges in the reporting year
where
        the primary diagnosis
        was SMD, per thousand member
        months, for members who
        had a primary diagnosis
        of SMD in the year prior
        to the reporting
        year.

      


      Target:  TBD

      


      Minimum
        Performance
        Standard:  The
        level of improvement must result in at least a TBD%
        decrease in the difference between the
        target and the previous report period’s results.

      


      Action
        Required for
        Noncompliance:  If the standard is
        not met and the
        results are below TBD%,
        the MCP is required to complete a
Corrective Action Plan  to
        address the area of noncompliance.
 If
        the standard is not met and the
        results are at or above TBD%,
        ODJFS will issue a Quality
        Improvement Directive which will notify the MCP of noncompliance and may
        outline
        the steps that the MCP must take to improve the results.

       

      
        1.c.xxi.  Mental
          Health, Severely
          Mentally Disabled (SMD) – Emergency
          Department Utilization Rate

      

      
      

      


      Measure:  The
        number
        of  emergency department visits in the reporting year
where
        the primary diagnosis
        was SMD, per thousand member
        months, for members who had
        a primary diagnosis of SMD in the year prior to the reporting
        year.

      


      Target:  TBD

      


      Minimum
        Performance
        Standard:  The
        level of improvement must result in at least a TBD%
        decrease in the difference between the
        target and the previous report period’s results.

      


      Action
        Required for
        Noncompliance:  If the standard is
        not met and the
        results are below TBD%,  the
        MCP is required to
        complete a Corrective Action Plan  to
        address the area of
        noncompliance. If
        the standard is not met and the
        results are at or above TBD%,
        ODJFS will issue a Quality
        Improvement Directive which will notify the MCP of noncompliance and may
        outline
        the steps that the MCP must take to improve the results.

       

      
        1.c.xxii.  Follow-up
          After Hospitalization for
          Mental Illness

      

      
      

      


      Measure:  The
        percentage of discharges
        for members enrolled from the date of discharge through 30 days after discharge,
        who were hospitalized for treatment of  selected mental health
        disorders and

      


      who
had
        a follow-up visit (i.e.,
were seen on an outpatient
        basis or were in intermediate treatment with a mental health
        provider) within:

      1)
        30 Days of discharge,
        and

      2)
        7 Days of
        discharge.

      


      Target:  TBD.

      


      Minimum
        Performance
        Standard For
        Each
        Measure:  The
        level of improvement must result in
        at least a TBD%  decrease
        in the difference
        between the target and the previous year’s results.

      


      Action
        Required for
        Noncompliance
        (Follow-up visits
        within 30 days of discharge):  If
        the standard is not met and the
        results are below TBD%,  the
        MCP is required to
        complete a Corrective Action Plan to
        address the area of noncompliance. If
        the standard is not met and the results are at or above TBD%, ODJFS
        will issue a Quality Improvement
        Directive which will notify the MCP of noncompliance and may outline the
        steps
        that the MCP must take to improve the results.

      


      Action
        Required for
        Noncompliance (Follow-up visits within 7 days of
        discharge):  If
        the standard is not met and the results are below TBD%, the MCP is required
        to
        complete a Corrective Action Plan to
        address the area of noncompliance. If
        the standard is not met and the results are at or above TBD%, ODJFS will
        issue a
        Quality Improvement Directive which will notify the MCP of noncompliance
        and may
        outline the steps that the MCP must take to improve the results.


      


      1.c.xxiii.
        Mental Health, Severely
        Mentally Disabled (SMD) – SMD Related Hospital
        Readmission

      


      Measure:  The
        number of SMD related
        readmissions for members who
        had a diagnosis
        of SMD in the year prior to
        the reporting year. A
        readmission is defined as a SMD
        related admission that occurs within 30 days of  a prior SMD related
        admission.

      Target:  TBD.

      


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

      


      Action
        Required for
        Noncompliance:  If
        the standard is not met and the
        results are below TBD%,  the
        MCP is required to
        complete a Corrective Action Plan to address the area
        of noncompliance. If
        the standard is not met and the results are at or above TBD%,  ODJFS
        will issue a Quality
        Improvement Directive which will notify the MCP of noncompliance and may
        outline
        the steps that the MCP must take to improve the results.

      


      1.c.xxiv.  Substance
        Abuse –
Inpatient Hospital
        Discharge Rate

      


      Measure:  The
        number of acute
        inpatient hospital discharges in the reporting year
where
        the primary diagnosis
        was alcohol and other drug
        abuse or dependence (AOD), per thousand member months, for members who
        had, in
        the year prior to the reporting year,
        a diagnosis of AOD and
        one of the following:
        AOD-related acute inpatient admission or two AOD related Emergency Department
        visits.

      


      Target:  TBD

      


      Minimum
        Performance
        Standard:  The
        level of improvement must result in at least a TBD%
        decrease in the difference between the
        target and the previous report period’s results.

      


      Action
        Required for
        Noncompliance:  If the standard is
        not met and the
        results are below TBD%,  the
        MCP is required to
        complete a Corrective Action Plan  to address the area of
        noncompliance. If
        the standard is not met and the
        results are at or above TBD%,
        ODJFS will issue a Quality
        Improvement Directive which will notify the MCP of noncompliance and may
        outline
        the steps that the MCP must take to improve the results.

       

      
        1.c.xxv. Substance
          Abuse – Emergency Department
          Utilization
          Rate

Measure:  The
        number
        of  emergency department visits in the reporting year
where
        the principal diagnosis was AOD,
        per thousand member months, for members who had, in the year
        prior to the
        reporting year, a diagnosis of AOD and
        one of the following:
        AOD-related acute inpatient admission or two AOD related Emergency Department
        visits .

      


      Target:  TBD

      


      Minimum
        Performance
        Standard:  The
        level of improvement must result in at least a TBD%
        decrease in the difference between the
        target and the previous report period’s results.

      


      Action
        Required for
        Noncompliance:  If the standard is
        not met and the
        results are below TBD%,
        the MCP is required to complete a
Corrective Action Plan  to
        address the area of
        noncompliance. If
        the standard is not met and the
        results are at or above TBD%,
        ODJFS will issue a Quality
        Improvement Directive which will notify the MCP of noncompliance and may
        outline
        the steps that the MCP must take to improve the results.

      


      1.c.xxvi.
        Substance Abuse – Inpatient Hospital
        Readmission Rate

      


      Measure:  The
        number of AOD related
        readmissions in
        the reporting year for members who
        had, in the year prior to the
        reporting year, a diagnosis of AOD and
        one of the following:
        AOD-related acute inpatient admission or two AOD related Emergency Department
        visits. A readmission is
        defined as an
        AOD-related admission that
        occurs within 30 days of  a prior AOD-related admission.

      


      Target:  TBD.

      


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

      


      Action
        Required for
        Noncompliance:  If
        the standard is not met and the
        results are below TBD%,  the
        MCP is required to
        complete a Corrective Action
        Plan  to
        address the area of noncompliance. If
        the standard is not met and the results are at or above TBD%,  ODJFS
        will issue a Quality
        Improvement Directive which will notify the MCP of noncompliance and may
        outline
        the steps that the MCP must take to improve the results.

      


      1.c.xxvii.
        Informational Clinical Performance
        Measures

      


      The
        clinical performance measures listed
        in Table 1 are informational only.  Although there are no performance
        targets or minimum performance standards for these measures, results will
        be
        reported and used as one component  in assessing the quality of care
        provided by MCPs to the ABD managed care population.

      


      Table
        1. Informational Clinical
        Performance Measures

       

      
        	
                Condition

              	
                Informational
                  Performance Measure

              
	
                CHF

              	
                Discharge
                  rate with age group
                  breakouts

              
	
                CAD

              	
                Discharge
                  rate with age group
                  breakouts

              
	
                Hypertension

              	
                Discharge
                  rate with age group
                  breakouts

              
	
                Diabetes

              	
                Discharge
                  rate with age group
                  breakouts

              
	
                Comprehensive
                  Diabetes Care
                  (CDC)/HbA1c testing

              
	
                CDC/kidney
                  disease
                  monitored

              
	
                CDC/LDL-C
                  screening
                  performed

              
	
                COPD

              	
                Discharge
                  rate with age group
                  breakouts

              
	
                Use
                  of Spirometry Testing in the
                  Assessment and Diagnosis of COPD

              
	
                Asthma

              	
                Discharge
                  rate with age group
                  breakouts

              
	
                Mental
                  Health
                  (SMD)

              	
                Discharge
                  rate with age group
                  breakouts

              
	
                Antidepressant
                  Medication
                  Management

              
	
                Substance
                  Abuse

              	
                Discharge
                  rate with age group
                  breakouts

              
	
                Initiation
                  and Engagement of
                  Alcohol and Other Drug Dependence
                  Treatment

              


      

      


      2.  ACCESS

      


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

      


      2.a.
        PCP Turnover

      


      A
        high
        PCP turnover rate may affect continuity of care and may signal poor management
        of providers.  However, some turnover may be expected when MCPs end
        contracts with  providers  who are not adhering to the MCP’s standard of
        care.  Therefore, this measure is used in conjunction with the adult
        access and designated PCP measures to assess performance in the access
        category.

      


      Measure:
        The percentage of
        primary care providers affiliated with the MCP as of the beginning of the
        measurement year who were not affiliated with the MCP as of the end of the
        year.

      


      Statewide
        Approach:
MCPs will be evaluated
        using a statewide result, including all regions in which an MCP has
        membership.  ODJFS will use the
        first calendar year
        of ABD managed care program membership as the baseline year (i.e., CY2007).
        The
        baseline year will be used to determine a minimum statewide performance
        standard.  An MCP’s second calendar year of ABD managed care program
        membership (i.e., CY2008) will be the initial report period of evaluation,
        and
        penalties will be applied for noncompliance.

      


      Report
        Period: For the SFY 2008 contract
        period, a
        baseline level of performance will be established using the CY 2007
        report period (and may be adjusted
        based on the number of months of ABD managed care
        membership).  For
        the SFY 2009 contract period, performance will be evaluated using the CY
2008
        report period.  The first
        reporting period in which MCPs will be held accountable to the performance
        standards will be the SFY
        2009 contract
        period.

      


      Minimum
        Performance
        Standard:  A maximum PCP Turnover rate of TBD.

      


      Action
        Required for
        Noncompliance:  MCPs are required to perform a causal analysis
        of the high PCP turnover rate and assess the impact on timely access to health
        services, including continuity of care.  If access has been reduced or
        coordination of care affected, then the MCP must develop and implement a
        corrective action plan to address
        the
        findings. 

      


      2.b.  Adults’
Access
        to
        Designated PCP

      


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

      


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

      


      Statewide
        Approach: MCPs will be
        evaluated using a statewide result, including all regions in which an MCP
        has
        membership.  ODJFS will use the
        first calendar year of ABD managed care program
        membership as
        the baseline year (i.e.,
        CY2007). The
        baseline year will be used
to determine a minimum
        statewide performance standard.  An MCP’s second calendar year of ABD
        managed care program membership (i.e.,
        CY2008)
        will be the initial report period of
        evaluation, and penalties will be applied for noncompliance.

      


      Report
        Period:  For the
        SFY 2008 contract period, performance will be evaluated using the January
        -
        December 2007 report period (and may be adjusted
        based on the number
        of months of ABD managed care membership).  For the SFY 2009 contract
        period, performance will be evaluated using the January - December 2008 report
        period.  The first reporting period in which MCPs will be held
        accountable to the performance standards will be the SFY 2009 contract period.

      


      Minimum
        Performance Standards:
        TBD

      


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

      


      2.c.
        Adults’ Access to Preventive/Ambulatory Health Services

      


      This
        measure indicates whether adult members are accessing health
        services.

      


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

      


      Statewide
        Approach: MCPs will be
        evaluated using a statewide result, including all regions in which an MCP
        has
        membership.  ODJFS will use the
        first calendar year
        of ABD managed care program membership as the baseline year (i.e., CY2007).
        The
        baseline year will be used to determine
        a minimum statewide
        performance standard.  An MCP’s second calendar year of ABD managed
        care program membership (i.e., CY2008) will be the initial report period
        of
        evaluation, and penalties will be applied for noncompliance.

      


      Report
        Period:  For the
        SFY 2008 contract period, performance will be evaluated using the January
        -
        December 2007 report period(and may be adjusted
        based on the number
        of months of ABD managed care membership).  For the SFY 2009 contract
        period,
performance will be
        evaluated using the January - December 2008 report period.  The first
        reporting period in which MCPs will be held accountable to the performance
        standards will be the SFY
        2009 contract
period.

      


      Minimum
        Performance Standards:
        TBD

      


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

      


      3.
        CONSUMER SATISFACTION

      


      MCPs
        will be evaluated using a statewide
        result, including all regions in which an MCP has
        membership.

      


      In
        accordance with federal requirements and in the interest of assessing enrollee
        satisfaction with MCP performance, ODJFS annually conducts independent
        consumer satisfaction surveys. Results are used to assist in identifying
        and
        correcting MCP performance overall and in the areas of access, quality of
        care,
        and member services.  Results from the SFY 2009
evaluation
        will be used to set a
        standard.  For the SFY 2009
        contract period, this measure is
        a reporting only measure.  SFY 2010 will be the first contract period
        in which MCPs will be held accountable to the performance standards for this
        measure.

      


      Measure: TBD.
        The results of this measure are
        reported annually.

      


      Report
        Period: For
        the SFY 2009 contract period, the measure
        is under review and
        the report period has not been determined.

      


      Minimum
        Performance Standard: TBD.

      


      Penalty
        for
        noncompliance:  If an MCP is determined noncompliant with the
        Minimum Performance Standard, then the MCP must develop a corrective action
        plan
        and provider agreement renewals
        may be affected.

      


      4.
        ADMINISTRATIVE CAPACITY

      


      The
        ability of an MCP to meet
        administrative requirements has been found to be both an indicator of current
        plan performance and a predictor of future performance.  Deficiencies
        in administrative capacity make the accurate assessment of performance in
        other
        categories difficult, with findings uncertain.  Performance in this
        category will be determined by the Compliance
Assessment
        System,  and
        the emergency department diversion
        program.  For a comprehensive description of the Administrative Capacity
        performance
        measures below, see ODJFS
        Methods
for the ABD
        Medicaid Managed
        Care Program Administrative Capacity Performance Measure,
        which are incorporated in this
        Appendix.

      


      4.a.
        Compliance Assessment
        System

      


      Measure:  The
        number of points accumulated during
        a rolling 12-month period through the Compliance
        Assessment System.

      


      Report
        Period: For
        the SFY 2008 and SFY 2009 contract
        periods, performance will be evaluated using a rolling 12-month report
        period.

      


      Performance
        Standard:  A
        maximum of 15 points

      


      Penalty
        for
        Noncompliance: Penalties
        for points are established in Appendix N, Compliance
        Assessment System.

      


      4.b.
        Emergency Department
        Diversion

      


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

      


      Measure:
        The percentage of
        members who had TBD
        targeted ED visits during the twelve month reporting period.

      


      Statewide
        Approach: MCPs will be
        evaluated using a statewide result, including all regions in which an MCP
        has
        membership.  ODJFS will use the first calendar year of ABD managed care membership
        as the
        baseline year (i.e.,
        CY2007). The
        baseline year will be used
to determine a minimum
        statewide performance standard and a target.  The number of members
        with an ED visit
        used to calculate the measure for the baseline year will be adjusted based
        on
        the number of months of ABD managed care membership in the baseline
        year.   An
        MCP’s second calendar year of ABD managed care program membership (i.e.,
        CY2008)
        will be the initial report period
of
        evaluation, and penalties will be
        applied for noncompliance.

      


      Report
        Period:  For
        the SFY 2008 contract
        period, a baseline level of
        performance will be established using the CY 2007 report
        period (and may be adjusted
        based on the number
        of months of ABD managed care membership).  For the SFY 2009
contract
        period, results will be
        calculated for the reporting period of CY2008 and
        compared to the CY2007 baseline
        results to determine if the
        minimum performance standard is met.

      


      Target: TBD

      


      Minimum
        Performance Standard: TBD

      


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

      


      5.
        Notes

      


      Given
        that unforeseen circumstances
        (e.g., revision or update
        of applicable national standards, methods or benchmarks, or issues related
        to program
        implementation) may impact
        performance assessment
        as specified in Sections 1
        through 4,  ODJFS
        reserves the right to apply the
        most appropriate penalty to the area of deficiency identified with any
        individual measure, notwithstanding the penalties specified in this
        Appendix.

      


      5.a.
        Monetary
        Sanctions

      


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

      


      Refundable
        monetary sanctions will be
        based on the capitation payment for the month of  the cited deficiency
        and will be due within 30 days of notification by ODJFS to the MCP of the
        amount.  Any monies collected through the imposition of such a
        sanction would be returned to the MCP (minus any applicable collection fees
        owed
        to the Attorney General’s Office, if the MCP has been delinquent in submitting
        payment) after they have demonstrated improved performance in accordance
        with
        this appendix.  If
        an MCP does not
        comply within two years of the date of notification of noncompliance, then
        the
        monies will not be refunded.  

      


      5.b.
        Combined
        Remedies

      


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

      


      5.c.
        Enrollment
        Freezes

      


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

      


      5.d.
        Reconsideration

      


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

      


      5.e.
        Contract Termination, Nonrenewals
        or Denials

      


      Upon
        termination, nonrenewal or denial
        of an MCP contract, all
        monetary sanctions collected under this appendix will be retained by ODJFS.
        The
        at-risk amount paid to the MCP under the current provider agreement will
        be
        returned to ODJFS  in accordance with Appendix P, Terminations,
        of  the provider
        agreement.

      



      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      


      APPENDIX
        N

      


      COMPLIANCE
        ASSESSMENT SYSTEM 

      ABD
        ELIGIBLE POPULATION

      


      


      I.
        General Provisions of the Compliance Assessment System

      


      A.
        The
Compliance Assessment System
        (CAS) is designed
        to improve the
        quality of each managed care plan’s (MCP’s) performance through actions taken by
        the Ohio Department of Job and Family Services (ODJFS) to address identified
        failures to meet program requirements.  This appendix applies to the
        MCP specified in the baseline of this MCP Provider Agreement (hereinafter referred to as
        the
        Agreement).

      


      B.
        The
CAS assesses
        progressive remedies with
        specified values (e.g., points, fines, etc.) assigned for certain documented
        failures to satisfy the deliverables required by Ohio Administrative
        Code (OAC) rule or
the Agreement.  Remedies
        are progressive based upon the
        severity of the violation, or a repeated pattern of violations. The CAS
        allows the accumulated point total to
        reflect patterns of less serious violations as well as less frequent, more
        serious violations.

      


      C.
        The
CAS focuses on clearly
        identifiable deliverables and sanctions/remedial actions are only assessed
        in
        documented and verified instances of noncompliance.  The CAS
        does not include categories which
        require subjective assessments or which are not within the MCPs
        control.

      


      D.
        The
        CAS does not replace ODJFS’ ability to require corrective action plans (CAPs)
        and  program improvements, or to impose any of the sanctions specified
        in OAC rule 5101:3-26-10, including the proposed termination, amendment,
        or
        nonrenewal of the MCP’s Provider Agreement.

      


      E.
        As
        stipulated in OAC rule 5101:3-26-10(F), regardless of whether ODJFS imposes
        a
        sanction, MCPs are required to initiate corrective action for any MCP program
        violations or deficiencies as soon as they are identified by the MCP or
        ODJFS.

      


      F.
        In addition to the remedies imposed
        in Appendix N, remedies related to areas of financial performance,
data
        quality,and
performance
        management may also be imposed
        pursuant to
        Appendices J, L, and M respectively, of the Agreement.

      


      G.
        If
        ODJFS determines that an MCP has violated any of the requirements of sections
        1903(m) or 1932 of the Social Security Act which are not specifically identified
        within the CAS, ODJFS may, pursuant to the provisions of OAC rule
        5101:3-26-10(A), notify the MCP’s members that they may terminate from the MCP
        without cause and/or suspend any further new member selections.

      


      H.
        For
        purposes of the CAS, the date that ODJFS first becomes aware of an MCP’s program
        violation is considered the date on which the violation
        occurred.  Therefore, program violations that technically reflect
        noncompliance from the previous compliance term will be subject to remedial
        action under CAS at the time that ODJFS first becomes aware of this
        noncompliance.

      


      I.
        In
        cases where an MCP contracted healthcare provider is found to have violated
        a
        program requirement (e.g., failing to provide adequate contract termination
        notice, marketing to potential members, inappropriate member billing, etc.),
        ODJFS will not assess points if: (1) the MCP can document that they provided
        sufficient notification/education to providers of applicable program
        requirements and prohibited activities; and (2) the MCP takes immediate and
        appropriate action to correct
        the
        problem and to ensure that it does not happen again to the satisfaction of
        ODJFS.  Repeated incidents will be reviewed to determine if the MCP
        has a systemic problem in this area, and if so, sanctions/remedial actions
        may
        be assessed, as determined by ODJFS.

      


      J.
        All
        notices of noncompliance will be issued in writing via email and facsimile
        to
        the identified MCP contact.

      


      II.
        Types of Sanctions/Remedial Actions

      


      ODJFS
        may
        impose the following types of sanctions/remedial actions, including, but
        not
        limited to, the items listed below.  The following are examples of
        program violations and their related penalties.  This list is not all
        inclusive.  As with any instance of noncompliance, ODJFS retains the
        right to use their sole discretion to determine the most appropriate penalty
        based on the severity of the offense, pattern of repeated noncompliance,
        and
        number of consumers affected.  Additionally, if an MCP has received
        any previous written correspondence regarding their duties and obligations
        under
        OAC rule or the Agreement, such notice may be taken into consideration when
        determining penalties and/or remedial actions.

      


      A.
        Corrective Action Plans
        (CAPs)– A CAP is a structured activity/process implemented by the MCP to
        improve identified operational deficiencies.

      


      MCPs
        may
        be required to develop CAPs for any instance of noncompliance, and CAPs are
        not
        limited to actions taken in this Appendix.  All CAPs requiring ongoing
        activity on the part of an MCP to ensure their compliance with a program
        requirement remain in effect for twenty-four months.

      


      In
        situations where ODJFS has already determined the specific action which must
        be
        implemented by the MCP or if the MCP has failed to submit a CAP, ODJFS may
        require the MCP to comply with an ODJFS-developed or “directed”
CAP.

      


      In
        situations where a penalty is assessed for a violation an MCP has previously
        been assessed a CAP (or any penalty or any other related written
        correspondence), the MCP may be assessed escalating penalties.

      


      B.
        Quality Improvement Directives (QIDs) –  A QID is a general
        instruction that directs  the MCP to implement a quality improvement
        initiative to improve identified  administrative or clinical
        deficiencies.  All QIDs remain in effect for twelve months from
 the date of implementation.

      


      MCPs
        may
        be required to develop QIDs for any instance of noncompliance.

      


       In
        situations where ODJFS has already determined the specific action which must
        be
 implemented by the MCP or if the MCP has failed to submit a QID, ODJFS may
        require  the MCP to comply with an ODJFS-developed or “directed”
QID.

      


       In
        situations where a penalty is assessed for a violation an MCP has previously
        been  assessed a QID (or any penalty or any other related written
        correspondence), the MCP  may be assessed escalating
        penalties.

      


      C.
        Points - Points
        will accumulate over a rolling 12-month schedule.  Each month, points
        that are more than 12-months old will expire.  Points will be tracked
        and monitored separately for each Agreement the MCP concomitantly holds with
        the
        BMHC, beginning with the commencement of this Agreement (i.e., the MCP will
        have
        zero points at the onset of this Agreement).

      


      No
        points
        will be assigned for any violation where an MCP is able to document that
        the
        precipitating circumstances were completely beyond their control and could
        not
        have been foreseen (e.g., a construction crew 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. 

      

      


      C.2.
        10 Points --
        Failures to meet program requirements, including but not limited to, actions
        which could affect the ability of the MCP to deliver or the consumer to access covered
        services, as determined by ODJFS.  Examples include, but are not
        limited to, the following:

      


      
        •Discrimination
          among members on the basis of their health status or need for health care
          services (this includes any practice that would reasonably be expected
          to
          encourage termination or discourage selection by individuals whose medical
          condition indicates probable need for substantial future medical services).
          

      

      
        •Failure
          to assist a member in accessing needed services in a timely manner after
          request
          from the member. 

      

      
        •Failure
          to provide medically-necessary Medicaid covered services to members.


      

      
        •Failure
          to process prior authorization requests within the prescribed time frames.
          

      

      
         

      

      D.
        Fines– Refundable
        or nonrefundable fines may be assessed as a penalty separate to or in
        combination with other sanctions/remedial actions.

      


      D.1.
        Unless otherwise
        stated, all fines are nonrefundable.

      


      D.2.
        Pursuant to procedures as established
        by ODJFS,
        refundable and nonrefundable monetary sanctions/assurances must be remitted
        to
        ODJFS within thirty (30) days of receipt of the invoice by the
        MCP.  In addition, per Ohio Revised Code Section 131.02, payments not
        received within forty-five (45) days will be certified to the Attorney General’s
        (AG’s) office. MCP payments certified to the AG’s office will be assessed the
        appropriate collection fee by the AG’s office.

      


      D.3.
        Monetary
        sanctions/assurances imposed by ODJFS will be based on the most recent premium
        payments.

      


      D.4.
        Any monies
        collected through the imposition of a refundable fine will be returned to
        the
        MCP (minus any applicable collection fees owed to the Attorney General’s Office
        if the MCP has been delinquent in submitting payment) after they have
        demonstrated full compliance, as determined by ODJFS, with the particular
        program requirement.  If an MCP does not comply within one (1) year of
        the date of notification of noncompliance involving issues of case management
        and two (2) years of the date of notification of noncompliance in issues
        involving encounter data, then the monies will not be refunded.

      


      D.5.
        MCPs are
        required to submit a written request for refund to ODJFS at the time they believe is appropriate before
        a refund
        of monies will be considered.

      


      E.
        Combined Remedies
        - Notwithstanding any other action ODJFS may take under this Appendix, ODJFS
        may
        impose a combined remedy which will address all areas of noncompliance if
        ODJFS
        determines, in its sole discretion, that (1) one systemic problem is responsible
        for multiple areas of noncompliance and/or (2) that there are a number of
        repeated instances of noncompliance with the same program
        requirement.

      


      F.
        Progressive
        Remedies - Progressive remedies will be based on the number of points
        accumulated at the time of the
        most recent incident.  Unless specifically otherwise indicated
        in this appendix, all fines are nonrefundable.  The designated fine
        amount will be assessed when the number of accumulated points falls within
        the
        ranges specified below:

      


      0
        -15
        Points   Corrective
        Action Plan (CAP)

      
        16-25Points   CAP
          + $5,000
          fine

      

      
        26-50Points   CAP
          + $10,000
          fine

      

      
        51-70
          Points   CAP
          + $20,000
          fine

      

      
        71-100
          Points   CAP
          + $30,000
fine

      

      100+
        Points   Proposed Contract Termination

      


      G.
        New Member Selection
        Freezes - Notwithstanding any other penalty or point assessment that
        ODJFS may impose on the MCP under this Appendix, ODJFS may prohibit an MCP
        from
        receiving new membership through consumer initiated selection or the assignment
        process if: (1) the MCP has accumulated a total of 51 or more points during
        a
        rolling 12-month period; (2) or
        the MCP fails to fully implement a CAP within the designated time frame;
        or  (3) circumstances exist which potentially jeopardize the MCP’s
        members’ access to care.  [Examples of circumstances that ODJFS may
        consider as jeopardizing member access to care include:

      


      - the
        MCP has been found by ODJFS to be
        noncompliant with the prompt payment or the non-contracting provider payment
         requirements;

      - the
        MCP has been found by ODJFS to be
        noncompliant with the provider panel requirements specified in Appendix H
        of the
        Agreement;


      - the
        MCP’s refusal to comply with a
        program requirement after ODJFS has directed the MCP to comply with the specific
        program requirement; or

      - the
        MCP has received notice of proposed
        or implemented adverse action by the Ohio Department of
        Insurance.]

      


      Payments
        provided for under the
        Agreement will be denied for new enrollees, when and for so long as, payments
        for those enrollees are denied by CMS in accordance with the requirements
        in 42
        CFR 438.730.

      


      H.
        Reduction of Assignments
– ODJFS has sole discretion over how member auto-assignments are
        made.  ODJFS may reduce the number of assignments an MCP receives to
        assure program stability within a region or if ODJFS determines that the
        MCP
        lacks sufficient capacity to meet the needs of the increased volume in
        membership.  Examples of circumstances which ODJFS may determine
        demonstrate a lack of sufficient capacity include, but are not limited to
        an
        MCP’s failure to: maintain an adequate provider network; repeatedly provide new
        member materials by the member’s effective date; meet the minimum call center
        requirements; meet the minimum performance standards for identifying and
        assessing children with special health care needs and members needing case
        management services; and/or provide complete and accurate appeal/grievance,
        member’s PCP and CAMS data files.

      


      I.
        Termination, Amendment,
        or Nonrenewal of MCP Provider Agreement - ODJFS can at any time move to
        terminate, amend or deny renewal of a provider agreement.  Upon such
        termination, nonrenewal, or denial of an MCP provider agreement, all previously
        collected monetary sanctions will be retained by ODJFS.

      


      J.
        Specific Pre-Determined
        Penalties

      


      I.1.
        Adequate network-minimum provider panel requirements- Compliance with provider
        panel
        requirements will be assessed quarterly.  Any deficiencies in
        the MCP’s provider network as specified in Appendix H of the Agreement or by
        ODJFS, will result in the assessment of a $1,000 nonrefundable fine for each
        category (practitioners, PCP capacity, hospitals), for each county, and for
        each
        population (e.g., ABD, CFC).  For example if the MCP did not meet the
        following minimum panel requirements, the MCP would be assessed (1) a $3,000
        nonrefundable fine for the failure to meet CFC panel requirements; and, (2)
        a
        $1,000 nonrefundable fine for the failure to meet ABD panel
        requirements).

      
        ·
practitioner
          requirements in Franklin county for the CFC population 

      

      
        ·
practitioner
          requirements in Franklin county for the ABD population 

      

      
        ·
hospital
          requirements in Franklin county for the CFC population 

      

      
        ·
PCP
          capacity requirements in Fairfield county for the CFC population


      

      


      In
        addition to the pre-determined penalties, ODJFS may assess additional penalties
        pursuant to this Appendix (e.g. CAPs, points, fines) if member specific access
        issues are identified resulting from provider panel noncompliance.

      


      J.2.
        Geographic Information
        System - Compliance with the Geographic Information System (GIS)
        requirements will be assessed semi-annually.  Any failure to meet GIS
        requirements as specified in Appendix H of the Agreement will result a $1,000
        nonrefundable fine for each county and for each population (e.g., ABD, CFC,
        etc.).  For example if the MCP did not meet GIS requirements in the
        following counties, the MCP would be assessed (1) a nonrefundable $2,000
        fine
        for the failure to meet GIS requirements for the CFC population and (2) a
        $1,000
        nonrefundable fine for the failure to meet GIS requirements for the ABD
        population.

      
        ·
GIS
          requirements in Franklin county for the CFC population 

      

      
        ·
GIS
          requirements in Fairfield county for the CFC population 

      

      
        ·
GIS
          requirements in Franklin county for the ABD population 

      

      


      J.3.
        Late Submissions
        - All required submissions/data and documentation requests must be received
        by
        their specified deadline and must represent the MCP in an honest and forthright
        manner.  Failure to provide ODJFS with a required submission or any
        data/documentation requested by ODJFS will result in the assessment of a nonrefundable fine of $100
        per day,
        unless the MCP requests and is granted an extension by
        ODJFS.  Assessments for late submissions will be done
        monthly.  Examples of such program violations include, but are not
        limited to:

      


      
        ·
Late
          required
          submissions

      

      
        o
          Annual
          delegation
          assessments

      

      
        o
          Call
          center
          report

      

      
        o
          Franchise
          fee
          documentation

      

      
        o
          Reinsurance
          information  (e.g., prior approval of
          changes)

      

      
        o
          State
          hearing
          notifications

      

      
         

        ·Late
          required data
          submissions

      

      
        o
          Appeals
          and grievances, case management,
          or PCP
          data

      

      
         

        ·Late
          required information
          requests

      

      
        o
          Automatic
          call distribution
          reports

      

      
        o
          Information/resolution
          regarding
          consumer or provider complaint

      

      
        o
          Just
          cause or other coordination care
          request from ODJFS

      

      
        o
          Provider
          panel documentation 

      

      
        o
          Failure
          to provide ODJFS with a required submission after ODJFS has notified the
          MCP
          that the prescribed deadline for that submission has passed 

      

      


      If
        an MCP
determines that they will
        be
        unable to meet a program deadline or data/documentation submission deadline,
        the
        MCP must submit a written request to its Contract Administrator
        for an extension of
        the
        deadline, as soon as possible, but no later than 3 PM EST on the date of
        the
        deadline in question. Extension requests should only be submitted in situations
        where unforeseeable circumstances have
        occurred which make it impossible
        for the MCP to
        meet an ODJFS-stipulated deadline and all such requests will be evaluated
        upon
        this standard.  Only
        written approval as may
        be granted by ODJFS of a deadline extension will preclude the assessment
        of
        compliance action for untimely submissions.

      


      J.4.
        Noncompliance with
        Claims Adjudication Requirements - If ODJFS finds that an MCP is unable
        to (1) electronically accept and adjudicate claims to final status and/or
        (2)
        notify providers of the status of their submitted claims, as stipulated in
        Appendix C of the Agreement, ODJFS will assess the MCP with a monetary sanction
        of $20,000 per day for the period of noncompliance.

      


      If
        ODJFS
        has identified specific instances where an MCP has failed to take the necessary
        steps to comply with the requirements specified in Appendix C of the Agreement
        for (1) failing to notify non-contracting providers of procedures for claims
        submissions when requested and/or (2) failing to notify contracting and
        non-contracting providers of the status of their submitted claims, the MCP
        will
        be assessed 5 points per incident of noncompliance.

      


      J.5.
        Noncompliancewith
        Prompt
        Payment:- Noncompliance
        with the prompt pay requirements as specified in Appendix J of the Agreement
        will result in progressive penalties.  The first violation during
a rolling 12-month
        period
will result in the
        submission of quarterly
        prompt pay and monthly
        status reports to ODJFS until the next quarterly report is due.  The
        second violation during
a
        rolling 12-month period will result in the
        submission of
        monthly status reports and a refundable fine equal to 5% of the MCP’s
        monthly premium payment or $300,000, whichever is less.  The
        refundable fine will be applied in lieu of a nonrefundable fine and the money
        will be refunded by ODJFS
        only
        after the MCP complies with the required standards for two (2) consecutive
        quarters.  Subsequent violations
        will
        result in an enrollment freeze.

       

      If
        an MCP is found to have not been in
        compliance with the prompt pay requirements for any time period for which
        a
        report and signed attestation have been submitted representing the MCP as
        being
        in compliance, the MCP will
        be subject to an enrollment freeze of not less
        than three (3) months
        duration.

      


      J.6.
        Noncompliance with
        Franchise Fee Assessment Requirements - In accordance with ORC Section
        5111.176, and in addition to the imposition of any other penalty, occurrence
        or
        points under this Appendix, an MCP that does not pay the franchise permit
        fee in
        full by the due date is subject to any or all of the following:

      


      
        ·
          A
          monetary penalty in the amount of $500 for each day any part of the fee
          remains
          unpaid, except the penalty will
          not exceed an amount equal to 5 % of the total fee that was due for the
          calendar
          quarter for which the penalty was imposed;

      

      


      
        ·
          Withholdings
          from future ODJFS
          capitation payments.  If an MCP fails to pay the full amount of its
          franchise fee when due, or the full amount of the imposed penalty, ODJFS
          may
          withhold an amount equal to the remaining amount due from any future ODJFS
          capitation payments. ODJFS will return all withheld capitation payments
          when the
          franchise fee amount has been paid in full;

      

      


      
        ·
          Proposed
          termination or non-renewal of
          the MCP’s Medicaid provider agreement may occur if the
          MCP:

      

      
        a.Fails
          to pay its franchise permit fee or
          fails to pay the fee promptly;

      

      
        b.Fails
          to pay a penalty imposed under
          this Appendix or fails to pay the penalty promptly;

      

      
        c.Fails
          to cooperate with an audit
          conducted in accordance with ORC Section 5111.176.

      

      


      J.7.
        Noncompliance with
        Clinical Laboratory Improvement Amendments - Noncompliance with CLIA
        requirements as specified by ODJFS will result in the assessment of a
        nonrefundable $1,000 fine for each violation.

      


      J.8.
        Noncompliance with
        Abortion and Sterilization Payment - Noncompliance with abortion and
        sterilization requirements as specified by ODJFS will result in the assessment
        of a nonrefundable $2,000 fine for each documented
        violation.  Additionally, MCPs must take all appropriate action to
        correct each ODJFS-documented violation.

      


      J.9.
        Refusal to
        Comply
        with Program Requirements - If ODJFS has instructed
        an MCP that they
        must comply with a specific program requirement and the MCP refuses, such
        refusal constitutes documentation that the MCP is no longer operating in
        the
        best interests of the MCP’s members or the state of Ohio and ODJFS will move to
        terminate or nonrenew the MCP’s provider agreement.

      


      III.
        Request
        for Reconsiderations

      


      MCPs
        may request a reconsideration of
        remedial action taken under the CAS for
        penalties that include points,
        fines, reductions in assignments and/or selection freezes.  Requests
        for reconsideration must be submitted on the ODJFS required form as
        follows:

      


      A.
        MCPs notified of ODJFS’ imposition of
        remedial  action taken under the CAS will have ten
        (10) working days from
        the date of receipt
        of the facsimile to request
        reconsideration, although ODJFS will impose enrollment
        freezes based on an access to care
        concern concurrent with initiating notification to the
        MCP.  Any information
        that the MCP would like reviewed as part of the reconsideration request must
        be
        submitted at the time of submission of the reconsideration request, unless
        ODJFS
        extends the time frame in writing.

      


      B.
        All requests for reconsideration must
        be submitted by either facsimile transmission or overnight mail to the Chief,
        Bureau of Managed Health Care, and received by ODJFS by the tenth business
        day after receipt of the
        faxed notification of the imposition of the remedial action by
        ODJFS.

      


      C.
        The
        MCP will be responsible for verifying timely receipt of all reconsideration
        requests.  All requests for reconsideration must explain in detail why
        the specified remedial action
        should not be imposed.  The MCP’s justification for reconsideration
        will be limited to a review of the written material submitted by the
        MCP.  The Bureau Chief will review all correspondence and materials
        related to the violation in question in making the final reconsideration
        decision.

      


      D.
        Final decisions or requests for
        additional information will be made by ODJFS within ten (10) business days
        of
        receipt of the request for reconsideration.

      


      E.
        If additional information is
        requested by ODJFS, a final reconsideration decision will be made within
        three
        (3) business days of the due date for the submission.  Should ODJFS
        require additional time in rendering the final reconsideration decision,
        the MCP
        will be notified of such in writing.

      


      F.
        If a reconsideration request is
        decided, in whole or in part, in favor of the MCP, both the penalty and the
        points associated
        with the incident, will be
        rescinded or reduced, in the sole discretion of ODJFS.  The MCP may
        still be required to submit a CAP if ODJFS, in its sole discretion, believes
        that a CAP is still warranted under the circumstances.


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      


      APPENDIX
        O

      


      PAY-FOR-PERFORMANCE
        (P4P)

      ABD
        ELIGIBLE
        POPULATION

      


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

      


      To
        qualify for consideration of any
P4P,
        MCPs must meet minimum performance
        standards established in Appendix M, Performance
        Evaluation on selected
        measures, and achieve P4P
standards
        established for
        selected Clinical Performance Measures, as set forth herein
        below.  For qualifying MCPs, higher performance standards for three
        measures must be reached to be awarded a portion of the at-risk amount and
        any
        additional P4P (see
        Sections 1).  An
        excellent and superior standard is set in this Appendix for each of the three
        measures.  Qualifying MCPs will be awarded a portion of the at-risk
        amount for each excellent standard met.  If an MCP meets all three
        excellent and superior standards, they may be awarded additional P4P (see
        Section 2).

      


      ODJFS
        will use the first calendar year
        of an MCP’s ABD managed care program membership as the baseline year (i.e.,
        CY2007).  The baseline year will be used to determine performance
        standards and targets; baseline data may come from a combination of FFS claims
        data and MCP encounter data.  As many of the performance measures used
        in the determination of P4P
require
        two calendar years
        of baseline data, the additional calendar year (i.e., the calendar year prior
        to
        the first calendar year of ABD managed care program membership, [i.e., CY2006])
        data will come from FFS
        claims.

      


      An
        MCP’s second calendar year of ABD
        managed care program membership (i.e., CY2008) will be the initial report
        period
        of evaluation for performance measures that require one calendar year of
        baseline data (i.e., CY2007), and for performance measures that require two
        calendar years of baseline data (i.e., CY2006 and CY2007).  CY2008
        will be the initial report period upon which compliance with the performance
        standards will be determined.  SFY 2009
        will become the first year an MCP’s
        performance level for P4Pcan
        be determined.

      


      1.
        SFY 2009 P4P

      


      1.a.
        Qualifying Performance
        Levels

      


      To
        qualify for consideration of the SFY
        2009 P4P, an MCP’s performance level must:

      


      1)
        Meet the minimum performance
        standards set in Appendix M, Performance
        Evaluation, for the
        measures listed below; and

      


      2)  Meet
        the  P4P
        standards established for the
        Clinical Performance Measures below.

       

      
        ·
          A
          detailed description of the
          methodologies for each measure can be found on the BMHC page of the ODJFS
          website.

      

      


      Measures
        for which the minimum
        performance standard for SFY 2009 established in Appendix M, Performance
        Evaluation, must be met to
        qualify for consideration of incentives are as follows:

      


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

      


      Report
        Period: CY
        2008

      


      2.  Adults’
Access
        to
        Preventive/Ambulatory Health Services (Appendix M, Section
        2.c.)

      


      Report
        Period: CY
        2008                                                      


      


      For
        each clinical performance measure
        listed below, the MCP must meet the P4P standard
        to be considered for SFY 2009
P4P.  The
        MCP meets the P4P
        standard if one of two criteria is met.  The P4P standard is a
        performance level of either:

      


      1)
        The minimum performance standard
        established in Appendix M, Performance
        Evaluation, for five of
        eight clinical performance measures listed below; or

      


      2)
        The Medicaid benchmarks for five of
        eight clinical performance measures listed below.  The Medicaid
        benchmarks are subject to change based on the revision or update of applicable
        national standards, methods or benchmarks.

       

      
        	 	
                
                

                Clinical
                  Performance Measure

              	
                Medicaid

                Benchmark

              
	
                CHF:
Inpatient HospitalDischarge
                  Rate

              	
                TBD 

              
	
                1.
CAD:
                  Beta-Blocker Treatment after
                  Heart Attack (AMI -related admission)

              	
                TBD

              
	
                2.
CAD:
                  Cholesterol Management for
                  Patients with Cardiovascular Conditions/LDL-C screening
                  performed

              	
                TBD

              
	
                3.
Hypertension:
Inpatient HospitalDischarge
                  Rate

              	
                TBD

              
	
                4.
Diabetes:
                  Comprehensive Diabetes
                  Care (CDC)/Eye exam

              	
                TBD

              
	
                5.
COPD:
Inpatient HospitalDischarge
                  Rate

              	
                TBD

              
	
                6.
Asthma:
                  Use of Appropriate
                  Medications for People with Asthma

              	
                TBD

              
	
                7.
Mental
                  Health: Follow-up After
                  Hospitalization for Mental Illness

              	
                TBD

              


      

      


      1.b.
        Excellent and Superior Performance
        Levels

      


      For
        qualifying MCPs as determined by
        Section 1.a.. herein, performance will be evaluated on the measures below
        to
        determine the status of the at-risk amount or any additional P4P
        that may be awarded.  Excellent and
Superior
standards
        are set for the three measures
        described below.  The standards are subject to change based on the
        revision or update of applicable national standards, methods or
        benchmarks.

      


      A
        brief description of these measures is
        provided in Appendix M, Performance
        Evaluation.  A
        detailed description of the methodologies for each measure can be found on
        the
        BMHC page of the ODJFS website.

      


      1.
        Case Management of Members (Appendix
        M, Section
        1.b.i)

      


      Report
        Period: April – June
        2009

      


      Excellent
        Standard:  TBD

      


      Superior
        Standard:  TBD

      


      2.
Comprehensive
        Diabetes Care (CDC)/Eye
        exam (Appendix M, Section
        1.c.xiv.)

      


      Report
        Period: CY
        2008

      


      Excellent
        Standard:
        TBD

      


      Superior
        Standard:
        TBD

      


      3.
        Adults’ Access to
        Preventive/Ambulatory Health Services (Appendix M, Section
        2.c.)

      


      Report
        Period: CY
        2008

      


      Excellent
        Standard:
        TBD

      


      Superior
        Standard:
        TBD

      


      1.c.
        Determining SFY 2009
        P4P

      


      MCPs
reaching
        the minimum performance
        standards described in Section 1.a. herein, will be considered for P4P including
        retention of the at-risk amount and any additional P4P.  For each
        Excellent standard established in Section 1.b. herein,  that an MCP
        meets, one-third of the at-risk amount may be retained.  For MCPs
        meeting all of the Excellent and Superiorstandards
        established in Section 1.b.
        herein, additional P4P may be awarded.  For MCPs receiving additional
        P4P, the amount in the P4P fund
        (see section 2.) will be divided
        equally, up to the maximum
        additional amount,
        among all MCPs’ABD and/or CFC
        programs receiving
        additional P4P.  The maximum additional amount to be awarded per plan,
        per program, per contract year is $250,000.  An MCP may receive up to
        $500,000 should both of the MCP’s ABD and CFC programs achieve the Superior
        Performance Levels.

      


      2.
        NOTES

      


      2.a. Initiation
        of the P4P
        System

      


      For
        MCPs in their first twenty-four (24)
        months of Ohio Medicaid ABD Managed Care Program participation, the status
        of
        the at-risk amount will not be determined because compliance with many of
        the
        standards in the ABD program cannot be determined in an MCP’s first two contract
        years
        (see Appendix F., Rate
        Chart). In addition, MCPs
        in their first two (2) contract years in the ABD program are not eligible
        for
        the additional P4P
amount
        awarded for
        superior
        performance.

      


      Starting
        with the twenty-fifth
        (25th)
        month of participation in the ABD
        program, the MCP’s at-risk amount will be included in
        the  P4P
system.  The
        determination of the status of this at-risk amount will occur after two (2)
        calendar years of ABD membership. Because
        of this requirement, the number
        of months of at-risk dollars to be included in an MCP’s first at-risk status
        determination may vary depending on when an MCP starts with the ABD program
        relative to the calendar year.

      


      2.b.
        Determination of at-risk amounts
        and additional P4P payments

      


      For
        MCPs that have participated in the
        Ohio Medicaid ABD Managed Care Program long enough to calculate performance
        levels for all of the performance measures included in the P4P system,
        determination of the status of
        an MCP’s at-risk amount will occur within six (6) months of the end of the
        contract period.  Determination of additional P4P payments
        will be made at the same time
        the status of an MCP’s at-risk amount is determined.

      


      2.c.
        Statewide P4P
        system

      


      All
        MCPs will be included in a statewide
        P4P system for the ABD program.  The at-risk amount will be determined
        using a statewide result for all regions in which an MCP serves ABD
        membership.

      


      2.d.
        Contract Termination, Nonrenewals,
        or Denials

      


      Upon
        termination, nonrenewal or denial of an MCP contract, the at-risk amount
        paid to
        the MCP under the current provider agreement will be returned to
        ODJFS  in accordance with Appendix P., Terminations/Nonrenewals/Amendments,
        of the provider agreement.

      


      Additionally,
        in accordance with Article
        XI of the provider agreement, the return of the at-risk amount paid to the
        MCP
        under the current provider agreement will be a condition necessary for ODJFS’
approval of a provider agreement assignment.

      


      2.e.
        Report Periods

      


      The
        report period used in determining
        the MCP’s performance levels varies for each measure depending on the
        frequency of the report and the data source.  Unless otherwise noted,
        the most recent report or study finalized prior to the end of the contract
        period will be used in determining the MCP’s overall performance level for that
        contract period.