exhibit10-1.htm


    
      

    

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      to Form 8-K

    Exhibit
      10.1

    
 

    PROVIDER
      AGREEMENT

                          
      


    BETWEEN

    


    STATE
      OF
      OHIO

    


    DEPARTMENT
      OF JOB AND FAMILY SERVICES

    


    AND

    


    WELLCARE
      OF OHIO, INC.

    


    Amendment
      No.
      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 Covered Families and Children (hereinafter
      referred to as “CFC”) 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/  Thad
                Bereday

            	
              DATE:
                1/4/08

            
	
              THAD
                BEREDAY,  SENIOR VICE PRESIDENT 

            	 
	 	 
	
              OHIO
                DEPARTMENT OF JOB AND FAMILY SERVICES:

              
              

            	 
	
              BY:  Helen
                Jones-Kelley

            	
              DATE:
                1/7/08

            
	
              HELEN
                E. JONES-KELLEY, DIRECTOR

            	 


    

     

    


    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

    

    


    APPENDIX
      C

    


    MCP
      RESPONSIBILITIES

    CFC
      ELIGIBLE
      POPULATION

    


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

    


     General
      Provisions

    


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

    


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

    


    3. The
      MCP must designate the
      following:

     

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

    


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

     

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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


    13. The
      MCP must notify the BMHC of
      the termination of an MCP panel
      provider that is   designated
      as the primary care
provider for 500
      or more of the MCP’s CFC members.
The
      MCP must provide notification within
      one working day of the MCP
 becoming aware of
      the
      termination.

    


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

    


    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
      of members and eligible individuals in accordance with the
      following:

     

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

    


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

    


    20.  The
      MCP must utilize a
      centralized database which records the special communication needs of all MCP
      members (i.e., those with limited English proficiency, limited
      reading proficiency,
      visual impairment, and
      hearing impairment) and the provision of related services
      (i.e., MCP materials in
      alternate format, oral interpretation, oral translation services,
      written translations of MCP
      materials, and sign language services).  This database
      must include all MCP member
      primary language information (PLI) as well as all other
      special communication needs
      information for MCP members, as indicated above, when
      identified by any source including
      but not limited to ODJFS, ODJFS selection services
      entity, MCP staff,
      providers, and
      members.  This centralized database must be readily
      available to MCP
      staff and
      be used in coordinating
      communication and services to members,
      including the selection
      of a PCP who speaks the
      primary language of an LEP
member,
      when such
      a provider
      is available. MCPs must share
      specific
      communication needs
      information with their 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 or other staff.  Furthermore,
      MCPs are prohibited from offering gifts of nominal value (i.e. clipboards,
      pens,
      coffee mugs, etc.) to CDJFS offices or managed
      care enrollment center (MCEC)
      staff, as these may influence an individual’s decision to select
      a
      particular MCP.

    


    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. New
      Member
      Materials

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

    


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

     

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


     

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

     

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

    


    25. Call
      -Center
      Standards

    The
      MCP must provide assistance to
      members through a member services toll-free call-in system pursuant to OAC
      rule
      5101:3-26-08.2(A)(1).  MCP member services staff must be available
      nationwide to provide assistance to members through the toll-free call-in system
      every Monday through Friday, at all times during the hours of 7:00 am to 7:00
      pm Eastern
      Time, exceptfor 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
      (24/7) toll-free call-in system, available nationwide, pursuant to OAC
      rule 5101:3-26-03.1(A)(6). The
      24/7 call-in system must be staffed by appropriately trained medical
      personnel. For the purposes of meeting this requirement, trained medical
      professionals are defined as physicians, physician assistants, licensed
      practical nurses, and registered nurses.

    


    MCPs
      must
      meet the current American Accreditation HealthCare Commission/URAC-designed
      Health Call Center Standards (HCC) for call center abandonment rate, blockage
      rate and average speed of answer. By the 10th
      of each
      month, MCPs must self-report their prior month performance in these three areas
      for their member services and 24/7
      toll-free call-in
      systems to ODJFS. ODJFS will inform the MCPs of any changes/updates to these
      URAC call center standards.

    


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

     

    26.      Notification
      of Optional MCP Membership

    


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

    - Indians
      who are members of
      federally-recognized tribes.

    - Children
      under 19 years of age who
      are:

    o Eligible
      for Supplemental Security
      Income under title XVI;

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

    o Receiving
      foster care of adoption
      assistance;

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

    


    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 and delivery payments as reported on the monthly remittance
      advice (RA).

    


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

    


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

    


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

    


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

    


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

    


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

       

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

    


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

    


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

    


    i.   Transition
      of
      Fee-For-Service Members

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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


    b. dental
      services that have not yet been
      received;

    


    c. vision
      services that have not yet been
      received;

    


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

    


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

    


    As
      soon as the MCP becomes aware of the
      member’s current fee-for-service authorization approval, the MCP must initiate
      contact with the authorized provider and member as applicable to ensure
      continuity of care.  The MCP must implement a plan to meet the
      member’s immediate and ongoing medical needs and, 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.

    


    iv. Reimburse
      out-of-panel providers that
      agree to provide the transition services at 100% of the current Medicaid
      fee-for-service provider rate for the service(s) identified in Section 29.i.
      (i., ii., and iii.) of this appendix.

    


    v. Document
      the provision of transition of
      services identified in Section 29.i. (i., ii., and iii.) of this appendix as
      follows:

    


    a. For
      non-panel providers, notification to
      the provider confirming the provider’s agreement/disagreement to provide the
      service and accept 100% of the current Medicaid fee-for-service rate as
      payment.  If the provider agrees, the distribution of the MCP’s
materials as outlined
      in
      Appendix G.3.e.

    


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

    


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

    


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

     

    30. Health
      Information System Requirements

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

    


    a. Health
      Information
      System

    


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

    


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

    


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

    


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

    


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

    


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

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

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

    


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

    


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

    


    b. Electronic
      Data Interchange and Claims Adjudication Requirements

    


    Claims
      Adjudication

    


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

    


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

     

    Electronic
      Data
      Interchange

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

    Health
      care claims;

    Health
      care claim status request and response;

    Health
      care payment and remittance status;

    Standard
      code sets;
      and

    National
      Provider Identifier
      (NPI).

    


    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 enter into the
      appropriate trading partner agreement and  implemented
      standard code
      sets.  If the MCP has obtained third-party certification  of
      HIPAA compliance for any of the items
      listed below, that certification may be  submitted
      in lieu of the MCP’s written
      verification for the applicable item(s).

    i. Trading
      Partner
      Agreements

    ii. Code
      Sets

    iii. Transactions

    


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

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

    c. Referral
      Certification and Authorization (ASC X12N 278)

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

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

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

    g. Health
      Plan Premium Payments (ASC X12N 820)

    h. Coordination
      of Benefits 

      

    Trading
      Partner Agreement
      with ODJFS

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

    


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

    


    c. Encounter
      Data Submission
      Requirements

     

    General
      Requirements

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

    


    · Institutional
      Claims - UB92 flat file

    · Noninstitutional
      Claims - National standard format

    · Prescription
      Drug Claims - NCPDP

    


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

    


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

    


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

    


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

    


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

    


    Acceptance
      Testing

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

    


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

    


    Encounter
      Data File
      Submission Procedures

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

    


    Timing
      of Encounter Data
      Submissions

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

    


    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.

    


    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.
 Delivery
      Payments

    


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

    


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

    


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

    


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

    


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

    


    Rejections

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

    


    Timing
      of Delivery
      Payments

    MCPs
      will
      be paid monthly for deliveries.  For example, payment for a delivery
      encounter submitted  with the required encounter data submission in March, will be
      reimbursed in  March. The delivery payment will cover any encounters
      submitted with the monthly encounter data submission regardless of the date
      of
      the encounter, but will not cover encounters that occurred over one year
      ago.

    


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

    


    Updating
      and Deleting
      Delivery Encounters

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

    


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

    


    Auditing
      of Delivery
      Payments

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

    


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

    


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

    


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

    


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

    


    36. Franchise
      Fee Assessment Requirements

     

    a. Each
      MCP is required to pay
      a franchise permit fee to ODJFS for each calendar  quarter as required by ORC Section
      5111.176.  The current  fee
      to be paid is an  amount
      equal to 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.

    


    37. Information
      Required for MCP Websites

    


    a.
 On-line
      ProviderDirectory–
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) within one working day of receipt.  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. 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

    CFC
      ELIGIBLE
      POPULATION

     

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

    


    General
      Provisions

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

     

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

    


    · 40%
      of statewide
      Covered Families and
      Children (CFC) eligible population;
      and/or

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

    · 40%
      of the CFC eligibles in any
      region with three
      MCPs.

    


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

    


    c. 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 entityprovides
      a full member roster (F) and a
      change roster (C) via HIPAA 834 compliant transactions.

    


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

    


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

    


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

    


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

    


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

    


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

    


    19. Communications

    


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


    


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

    


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

     

     

    
      
        

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          


          
            APPENDIX
              E

          

          
            


          

          
            RATE
              METHODOLOGY

          

          
            CFC
              ELIGIBLE POPULATION

             

             

             

          


          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          


          
            	 	
                    
                      Chase
                        Center/Circle

                    

                  
	
                    
                      111
                        Monument Circle

                    

                  
	
                    
                      Suite
                        601

                    

                  
	
                    
                      Indianapolis,
                        IN 46204-5128

                    

                  
	
                    
                      USA

                    

                  
	
                    
                      Tel    +1
                        317 639 1000

                    

                    
                      Fax   +1
                        317 639 1001

                    

                  
	
                    
                      milliman.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 RATE
                        DEVELOPMENT METHODOLOGY - COVERED FAMILIES AND
                        CHILDREN

                    


            

          

          
            


          

          
            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 Covered Families and Children (CFC) 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.

          

          
            


          

          
            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.

          

          
            


            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

          

           

          
            FINAL
              and CONFIDENTIAL

          

          
             

            SUMMARY
              OF
              METHODOLOGY

          

          
            


          

          
            ODJFS
              contracted with Milliman to
              develop the CY 2008 CFC actuarially sound capitation rates. The actuarially
              sound capitation rates were developed from historical claims and enrollment
              data
              for the fee for service (FFS) and managed care populations. The composite
              of the
              FFS and managed care populations are considered a comparable population
              to the
              population enrolled with the health plans. The historical experience
              was
              converted to a per member per month (PMPM) basis and stratified by
              region, age /
              gender rating group, 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 CFC populations.

          

          
            


          

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

          

          
            


          

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

          

          
            


          

          
            


          

          
            DETAILS
              OF
              METHODOLOGY


          

          
            


          

          
            I.    COVERED
              POPULATION

          

          
            


          

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

          

           

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

           

          FINAL
            and CONFIDENTIAL

          
            


          

          
            


          

          
            


          

          
            Table
              1

          

          
            


          

          
            STATE
              OF OHIO

          

          
            DEPARTMENT
              OF JOB AND FAMILY SERVICES

          

          
            Summary
              of Managed Care Eligible Population

          

          
            


          

          
            


          

          
            	
                    
                      Program
                        Assignment

                    

                  	
                    
                      Description

                    

                  
	
                    
                      PREG

                    

                  	
                    
                      Healthy
                        Start Pregnant Women

                    

                  
	
                    
                      PREGE

                    

                  	
                    
                      Healthy
                        Start Pregnant Women Expansion

                    

                  
	
                    
                      PREGEX

                    

                  	
                    
                      Healthy
                        Start Expedited Pregnant Women

                    

                  
	
                    
                      RPREGEX

                    

                  	
                    
                      Healthy
                        Start Expedited Pregnant Women RMF

                    

                  
	
                    
                      HSC

                    

                  	
                    
                      Healthy
                        Start Children

                    

                  
	
                    
                      HSCE

                    

                  	
                    
                      Healthy
                        Start Expansion <=150%

                    

                  
	
                    
                      RHSC

                    

                  	
                    
                      Healthy
                        Start Children RMF

                    

                  
	
                    
                      CHIP1

                    

                  	
                    
                      Healthy
                        Start CHIP 1 <=150%

                    

                  
	
                    
                      CHIP2

                    

                  	
                    
                      Healthy
                        Start CHIP 2 151-200%

                    

                  
	
                    
                      RCHIP1

                    

                  	
                    
                      Healthy
                        Start CHIP 1 <=150% RMF

                    

                  
	
                    
                      RCHIP2

                    

                  	
                    
                      Healthy
                        Start CHIP 2 151-200% RMF

                    

                  
	
                    
                      RCHSUP

                    

                  	
                    
                      Healthy
                        Family Child Support Extended RMF

                    

                  
	
                    
                      CHSUP

                    

                  	
                    
                      Healthy
                        Family Child Support Extended

                    

                  
	
                    
                      OWFFAM

                    

                  	
                    
                      Ohio
                        Works First Families - Cash

                    

                  
	
                    
                      ROWFFAM

                    

                  	
                    
                      Ohio
                        Works First Families - Cash RMF

                    

                  
	
                    
                      LIFAM

                    

                  	
                    
                      Low
                        Income Families

                    

                  
	
                    
                      RLIFAM

                    

                  	
                    
                      Low
                        Income Families RMF

                    

                  
	
                    
                      HYFAM

                    

                  	
                    
                      Healthy
                        Families (Expansion 7/00 Reduced 1/06)

                    

                  
	
                    
                      TRANS

                    

                  	
                    
                      Transitional

                    

                  
	
                    
                      LIIND

                    

                  	
                    
                      Low
                        Income Individuals

                    

                  
	
                    
                      RLIIND

                    

                  	
                    
                      Low
                        Income Individuals RMF

                    

                  


          

          
             

          

          
            Milliman
              extracted the eligible population information from historical data.
              The eligible
              population includes the Healthy Start and Healthy Families populations.
              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.

          

          
            


          

          
            


            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

          

          
            FINAL
              and CONFIDENTIAL

          

          
            


          

          
            


          

          
            Table
              2

          

          
            


          

          
            STATE
              OF OHIO

          

          
            DEPARTMENT
              OF JOB AND FAMILY SERVICES

          

          
            Categories
              of Service

          

          
            


          

          
            	
                    
                      Categories
                        of ServiceType
                        of Service

                    

                  	
                    
                      Service
                        Category

                    

                  	
                    
                      Utilization
                        Units

                    

                  	
                    
                      Classification
                        Basis

                    

                  
	
                    
                      Inpatient
                        Hospital

                    

                  	
                    
                      Medical/Surgical

                    

                  	
                    
                      Admits/Days

                    

                  	
                    
                      
                      

                    

                    
                      
                      

                    

                    
                      
                      

                    

                    
                       

                       

                      COS,
                        DRG

                    

                  
	
                    
                      MH/SA

                    

                  	
                    
                      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

                    

                  
	
                    
                      Periodic
                        Exams

                    

                  	 
	
                    
                      Emergency
                        Room Visits

                    

                  	
                    
                      Services

                    

                  
	
                    
                      Immunization
                        & 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

                    

                  


          

          
            


          

          
            


            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

          

          
             

            FINAL
              and CONFIDENTIAL

          

          
            


          

          
            


          

          
            III.           
              RATE GROUPS

          

          
            


          

          
            The
              CY
              2008 CFC capitation rates are segmented by region and rate group. Table
              3
              contains the rate groups
              used for the CFC population.  The non-delivery rate groups vary by
              age, gender, and program assignment.  The delivery rate group is determined
              based on the
              CFC Program Delivery Payment Reporting Procedures for ODJFS
              Managed Care Plans, effective September 7, 2005.

          

           

          
             

          

          
            


          

          
            Table
              3

          

          
            STATE
              OF OHIO

          

          
            DEPARTMENT
              OF JOB AND FAMILY SERVICES

          

          
            Rate
              Groups

          

          
            


          

          
            	
                    
                      Age/Gender
                        Groups

                    

                  	
                    
                      Benefit
                        Type

                    

                  	
                    
                      Population

                    

                  
	
                    
                      M/F
                        - <1

                    

                  	
                    
                      Non
                        - Delivery

                    

                  	
                    
                      Healthy
                        Start / Healthy Families

                    

                  
	
                    
                      M/F
                        - 1

                    

                  	
                    
                      Non
                        - Delivery

                    

                  	
                    
                      Healthy
                        Start / Healthy Families

                    

                  
	
                    
                      M/F
                        - 2 to 13

                    

                  	
                    
                      Non
                        - Delivery

                    

                  	
                    
                      Healthy
                        Start / Healthy Families

                    

                  
	
                    
                      M-
                        14 to 18

                    

                  	
                    
                      Non
                        - Delivery

                    

                  	
                    
                      Healthy
                        Start / Healthy Families

                    

                  
	
                    
                      F-
                        14 to 18

                    

                  	
                    
                      Non
                        – Delivery

                    

                  	
                    
                      Healthy
                        Start / Healthy Families

                    

                  
	
                    
                      M
                        -
                        19 to 44

                    

                  	
                    
                      Non
                        – Delivery

                    

                  	
                    
                      Healthy
                        Families

                    

                  
	
                    
                      F
                        -
                        19 to 44

                    

                  	
                    
                      Non
                        – Delivery

                    

                  	
                    
                      Healthy
                        Families

                    

                  
	
                    
                      M/F
                        - 45 to 64

                    

                  	
                    
                      Non
                        – Delivery

                    

                  	
                    
                      Healthy
                        Families

                    

                  
	
                    
                      F
                        -
                        19 to 64

                    

                  	
                    
                      Non
                        – Delivery

                    

                  	
                    
                      Healthy
                        Start

                    

                  
	
                    
                      F
                        -
                        All Ages

                    

                  	
                    
                      Delivery

                    

                  	
                    
                      Healthy
                        Start / Healthy Families

                    

                  


          

          
            


          

          
            IV.           
              DEVELOPMENT OF CY 2006 ADJUSTED FFS DATA

          

          
            


          

          
            a.           
              Historical Data Summaries

          

          
            


          

          
            The
              CY
              2008 CFC capitation rates were developed, in part, 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.


            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

          

          
            


          

          
            FINAL
              and CONFIDENTIAL

          

          
            


          

          
            


          

          
            The
              FFS
              data summaries represent historical experience for those services that
              re
              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 ODJFS
              defined category of service field, as shown in Table 4

          

          
            


          

          
            Table
              4

          

          
            


          

          
            STATE
              OF OHIO

          

          
            DEPARTMENT
              OF JOB AND FAMILY SERVICES

          

          
            Claims
              Excluded from the FFS Data Summaries

          

          
            


          

          
            	
                    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 SFY 2005 and twelve months of SFY 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
              FFS data summaries represent 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

          

          
            


            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

          

          
            FINAL
              and CONFIDENTIAL

          

          
            


          

          
            


          

          
            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.

          

          
            


          

          
            ODJFS
              has
              provided a listing of all program changes impacting the base experience
              data.  Table 5 summarizes the historical program changes that were
              reflected in the development of the CY 2008 capitation rates.

          

          
            


          

          
            


          

          
            Table
              5

          

          
            


          

          
            STATE
              OF OHIO

          

          
            DEPARTMENT
              OF JOB AND FAMILY SERVICES

          

          
            Historical
              Program Adjustments – FFS

          

          
            


          

          


          
            	
                    
                      Program
                        Adjustment

                    

                  	
                    
                      Effective
                        Date

                    

                  	
                    
                      Service
                        Category(s)

                    

                  	
                    
                      Rate
                        Group

                    

                  
	
                    
                      Inpatient
                        Market Basket Increase

                    

                  	
                    
                      1/1/2005

                    

                  	
                    
                      Inpatient
                        Hospital

                    

                  	
                    
                      All
                        Rate Groups (incl Delivery)

                    

                  
	
                    
                      Dental
                        Fee Schedule Reduction

                    

                  	
                    
                      1/1/2006

                    

                  	
                    
                      Dental

                    

                  	
                    
                      All
                        Rate Groups (incl. Delivery)

                    

                  
	
                    
                      Inpatient
                        Recalibration and Outlier Policy

                    

                  	
                    
                      1/1/2006

                    

                  	
                    
                      Inpatient

                    

                  	
                    
                      All
                        Rate Groups  (incl. Delivery)

                    

                  
	
                    
                      Pharmacy
                        Co-pay

                    

                    
                      ($2
                        Per Brand Prescription)

                    

                  	
                    
                      1/1/2006

                    

                  	
                    
                      Pharmacy

                    

                  	
                    
                      HF
                        M -19 to 44

                    

                  
	
                    
                      HF
                        F-19 to 44

                    

                  
	
                    
                      HF
                        M/F- 45 to 64

                    

                  
	
                    
                      Dental
                        Co-pay

                    

                    
                      ($3
                        Per Date of Service)

                    

                  	
                    
                      1/1/2006

                    

                  	
                    
                      Dental

                    

                  	
                    
                      HF
                        M -19 to 44

                    

                  
	
                    
                      HFF-19
                        to 44

                    

                  
	
                    
                      HF
                        M/F-45 to 64

                    

                  
	
                    
                      HSTF-19
                        to 64

                    

                  
	
                    
                      Vision
                        Exam Co-Pay ($2 Per Exam)

                    

                  	
                    
                      1/1/2006

                    

                  	
                    
                      Vision
                        / Optometric

                    

                  	
                    
                      HF
                        M-19 to 44

                    

                  
	
                    
                      HF
                        F-19 to 44

                    

                  
	
                    
                      HF
                        M/F-45 to 64

                    

                  
	
                    
                      HSTF-19
                        to 64

                    

                  
	
                    
                      Vision
                        Hardware Co-Pay ($1 Per Item)

                    

                  	
                    
                      1/1/2006

                    

                  	
                    
                      Vision
                        / Optometric

                    

                  	
                    
                      HFM-19
                        to 44

                    

                  
	
                    
                      HFF-19
                        to 44

                    

                  
	
                    
                      HF
                        M/F-45 to 64

                    

                  
	
                    
                      HSTF-19
                        to 64

                    

                  
	
                    
                      ER
                        Co-Pay

                    

                    
                      ($3
                        Per Non-Emergency Visit)

                    

                  	
                    
                      1/1/2006

                    

                  	
                    
                      Emergency
                        Room

                    

                  	
                    
                      HF
                        M -I9 to 44

                    

                  
	
                    
                      HF
                        F-19 to 44

                    

                  
	
                    
                      HF
                        M/F-45 to 64

                    

                  
	
                    
                      HSTF-19
                        to 64

                    

                  
	
                    
                      Dental
                        Benefit Reduction

                    

                  	
                    
                      1/1/2006

                    

                  	
                    
                      Dental

                    

                  	
                    
                      HFM-19
                        to 44

                    

                  
	
                    
                      HFF-19
                        to 44

                    

                  
	
                    
                      HF
                        M/F- 45 to 64

                    

                  
	
                    
                      HST
                        F – 19 to 64

                    

                  
	
                    
                      HSTF-19
                        to 64

                    

                  


          

          
            
              
                


                
                  
                    
                    

                  

                  
                    
                    

                    
                      

                    

                  

                  
                    
                    

                  

                

              

              
                FINAL
                  and CONFIDENTIAL

              

              
                


              

            

          

          
            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.

          

          
            


          

          
            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" file from ODJFS containing the additional
              adjustments.

          

          
            


          

          
            g.           
              Non-State Plan 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.           
              Historical Selection Adjustments

          

          
            


          

          
            Milliman
              applied a historical selection adjustment to the base FFS data to reflect
              that
              the base period contains a combination of FFS and managed care enrollment.
              The
              historical selection adjustment is intended to normalize the FFS experience
              to
              the morbidity level of the entire managed care eligible population
              and is
              similar in methodology to previous years.

          

          
            
              
                


                
                  
                    
                    

                  

                  
                    
                    

                    
                      

                    

                  

                  
                    
                    

                  

                

              

              
                FINAL
                  and CONFIDENTIAL

              

              
                


              

            

            i.           
              Trends/Inflation to CY 2006

          

          
            


          

          
            Milliman
              developed trend rates to progress the historical experience from SFY
              2005 and
              SFY 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 in the development
              of the CY
              2008 CFC 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.

          

          
            


          

          
            j.           
              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%.

          

          
            


          

          
            k.           
              Managed Care Adjustments

          

          
            


          

          
            Utilization
              and cost per service adjustments were developed for each rate group,
              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.

          

          
            


          

          
            Cost
              Per
              Service

          

          
            


          

          
            Milliman
              adjusted the cost per service amounts 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 benchmark 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.

          

          
            
              
                


                
                  
                    
                    

                  

                  
                    
                    

                    
                      

                    

                  

                  
                    
                    

                  

                

              

              
                FINAL
                  and CONFIDENTIAL

              

              
                


              

            

          

          
            V.           
              DEVELOPMENT OF CY 2006 ADJUSTED ENCOUNTER DATA

          

          
            


          

          
            a.           
              Historical Data Summaries

          

          
            


          

          
            
              	
                       

                    	
                      The
                        CY 2008 CFC capitation rates were developed, in part, using
                        Encounter
                        claims for two 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
              Encounter data summaries represent historical experience for 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 ODJFS defined category of service field, as
              shown in
              Section IV, Table 4.

          

          
            


          

          
            The
              historical data summaries for the base encounter experience reflect
              only region,
              county, health plan combinations with sufficient experience to be considered
              credible. As such, counties considered '"voluntary" and health plans
              with low
              enrollment were not included in the base data. Table 6 provides the
              region/county and health plan combinations contained in the capitation
              rate
              development.

          

          
            


          

          
            Table
              6

          

          
            


          

          
            STATE
              OF OHIO

          

          
            DEPARTMENT
              OF JOB AND FAMILY SERVICES

          

          
            Region/County
              and Health Plan Inclusions – Encounter

          

          


          
            	
                    
                      Region
                        - County

                    

                  	
                    
                      Health
                        Plans

                    

                  
	
                    
                      Central
                        - Franklin

                    

                  	
                    
                      Caresource;
                        Molina

                    

                  
	
                    
                      East
                        Central - Stark

                    

                  	
                    
                      Buckeye;
                        Caresource; Mediplan

                    

                  
	
                    
                      East
                        Central - Summit

                    

                  	
                    
                      Buckeye;
                        Caresource; Summacare

                    

                  
	 Northeast
                    - Cuyahoga    	Caresource;
                    Anthem/Qualchoice
	
                    
                      Northeast
                        - Lorain

                    

                  	
                    
                      Caresource;
                        Anthem/Qualchoice

                    

                  
	
                    
                      Northeast
                        Central - Mahoning

                    

                  	
                    
                      Caresource;
                        Gateway; Unison

                    

                  
	
                    
                      Northeast
                        Central - Trumbull

                    

                  	
                    
                      Caresource;
                        Gateway; Unison

                    

                  
	
                    
                      Northwest
                        - Lucas

                    

                  	
                    
                      Buckeye;
                        Paramount

                    

                  
	
                    
                      Southwest
                        - Butler

                    

                  	
                    
                      Amerigroup;
                        Caresource

                    

                  
	
                    
                      Southwest
                        - Hamilton

                    

                  	
                    
                      Amerigroup;
                        Caresource

                    

                  
	
                    
                      West
                        Central -
                        Clark

                    

                  	
                    
                      Caresource;
                        Molina

                    

                  
	
                    
                      West
                        Central - Montgomery

                    

                  	
                    
                      Caresource;
                        Molina

                    

                  


          


          
             

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

             

            FINAL
              and CONFIDENTIAL

          

          
            


          

          
            b.           
              Imputed Cost per Service

          

          
            


          

          
            Milliman
              applied a cost per service amount to the managed care encounter data
              to reflect
              the missing financial information in the base managed care encounter
              experience.
              The cost per service was applied by rate group on a statewide basis
              for all
              categories of service except for inpatient services. The cost per service
              was
              applied by rate group and region for inpatient services.

          

          
            


          

          
            Additionally,
              the cost per service was re-priced based on the mix/intensity of services
              included in the encounter base experience. The cost per service was
              developed
              from the Medicaid FFS reimbursement rates. In addition to reflecting
              the health
              plan mix of services, the cost per service was adjusted for other managed
              care
              factors as described below.

          

          
            


          

          
            c.           
              Completion Factors

          

          
            


          

          
            Milliman
              utilized 24 months of claims experience for the managed care 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 SFY
              2005 and
              twelve months of SFY 2006 claims experience. The claim completion factors
              were
              developed by service category based on utilization experience for the
              managed
              care population incurred and paid through May 2007.

          

          
            


          

          
            d.           
              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.

          

          
            


          

          
            ODJFS
              has
              provided a listing of all program changes impacting the base experience
              data.
              Section IV, Table 5 summarizes the historical program changes that
              were
              reflected in the development of the CY 2008 capitation rates.

          

          
            


          

          
            e.           
              Third-Party Liability and Fraud-Abuse Recoveries

          

          
            


          

          
            The
              cost
              reports submitted by the health plans contained information related
              to
              third-party liability and fraud-abuse recoveries.  Milliman calculated
              the average recoveries and applied the reduction to the base encounter
              data.

          

          
            


            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

          

          
            FINAL
              and CONFIDENTIAL

          

          
            



          

          
            f.           
              Non-State Plan Services

          

          
            


          

          
            CMS
              requires removal of non-state plan services from
              rate-setting.   The encounter data contains certain claims that
              are considered non-state plan services.   The health plan
              submitted cost reports were used as the source of information for the
              non-state
              plan service adjustments.

          

          
            


          

          
            g.           
              Historical Selection Adjustments

          

          
            


          

          
            Milliman
              applied a historical selection adjustment to the base encounter data
              to reflect
              that the base period contains a combination of FFS and managed care
              enrollment.
              The historical selection adjustment is intended to normalize the encounter
              experience to the morbidity level of the entire managed care eligible
              population.

          

          
            


          

          
            h.           
              Trends/Inflation to CY 2006

          

          
            


          

          
            Milliman
              developed trend rates to progress the historical experience from SFY
              2005 and
              SFY 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 in the development of the CY 2008 CFC 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.
              Generally, SFY 2006 was given 70% weight except where insufficient
              experience
              existed in either SFY 2005 or SFY 2006. In these situations, either
              SFY 2005 or
              SFY 2006 was given 100% credibility.

          

          
            


          

          
            j.           
              Managed Care Adjustments

          

          
            


          

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

          

          
            
              
                


                
                  
                    
                    

                  

                  
                    
                    

                    
                      

                    

                  

                  
                    
                    

                  

                

              

              
                FINAL
                  and CONFIDENTIAL

              

              
                



              

            

          

          
            Utilization


          

          
            


          

          
            Milliman
              adjusted the encounter utilization and cost per service to reflect
              changes
              anticipated in 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 utilization
              differential between an economic and efficiently managed plan and the
              encounter
              base experience.

          

          
            


          

          
            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.

          

          
            


          

          
            VI.           
              DEVELOPMENT OF CY 2006 ADJUSTED COST REPORT DATA

          

          
            


          

          
            a.           
              Historical Data Summaries

          

          
            


          

          
            The
              CY
              2008 CFC capitation rates were developed, in part, using health plan
              submitted
              cost reports for two calendar year (CY) periods:

          

          
            


          

          
            
              	
                      §  

                    	
                      CY
                        2005 (Incurred during the 12 months ending December 31, 2005
                        paid through
                        December 31, 2006).

                    


            

          

          
            
              	
                      §  

                    	
                      CY
                        2006 (Incurred during the 12 months ending December 31, 2006
                        paid through
                        December 31, 2007).

                    


            

          

          
            


          

          
            The
              historical data summaries for the base cost report experience reflect
              only
              region, county, health plan combinations with sufficient experience
              to be
              considered credible. As such, counties considered "voluntary" and health
              plans
              with low enrollment were not included in the base data. Table 7 provides
              the
              region/county and health plan combinations contained in the capitation
              rate
              development.

          

          
            


            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

          

          
             

            FINAL
              and CONFIDENTIAL

             

          

          
            
              	
                       

                    	
                      Table
                        7 

                    


            

          

          
            


          

          
            
              	
                       

                    	
                      STATE
                        OF OHIO 

                    


            

          

          
            
              	
                       

                    	
                      DEPARTMENT
                        OF JOB AND FAMILY SERVICES 

                    


            

          

          
            
              	
                       

                    	
                      Region/County
                        and Health Plan Inclusions – Cost Report


                    


            

          

          
             

          

          
            	
                    
                      Region
-
County

                    

                  	
                    
                      Health
                        Plans

                    

                  
	
                    
                      Central
                        - Franklin

                    

                  	
                    
                      Caresource;
                        Molina

                    

                  
	
                    
                      East
                        Central - Stark

                    

                  	
                    
                      Buckeye;
                        Caresource

                    

                  
	
                    
                      East
                        Central - Summit

                    

                  	
                    
                      Buckeye;
                        Caresource

                    

                  
	
                    
                      Northeast
                        - Cuyahoga

                    

                  	
                    
                      Caresource:
                        Anthem/Qualchoice

                    

                  
	
                    
                      Northeast
                        - Lorain

                    

                  	
                    
                      Caresource;
                        Anthem/Qualchoice

                    

                  
	
                    
                      Northeast
                        Central - Mahoning

                    

                  	
                    
                      Caresource;
                        Gateway; Unison

                    

                  
	
                    
                      Northeast
                        Central - Trumbull

                    

                  	
                    
                      Caresource;
                        Gateway; Unison

                    

                  
	
                    
                      Northwest
                        - Lucas

                    

                  	
                    
                      Buckeye;
                        Paramount

                    

                  
	
                    
                      Southwest
                        - Butler

                    

                  	
                    
                      Amerigroup;
                        Caresource

                    

                  
	
                    
                      Southwest
                        - Hamilton

                    

                  	
                    
                      Amerigroup;
                        Caresource

                    

                  
	
                    
                      West
                        Central - Clark

                    

                  	
                    
                      Caresource;
                        Molina

                    

                  
	
                    
                      West
                        Central - Montgomery

                    

                  	
                    
                      Caresource;
                        Molina

                    

                  


          

          
            


          

          
            b.  Completion
              Factors

          

          
            


          

          
            The
              cost
              reports contained claim experience incurred through December 31, 2006
              and paid
              through December 31, 2006, as well as health plan estimated 1BNR reserve
              amounts. Milliman reviewed the claims completion contained in the submitted
              cost
              reports for reasonableness. During this review, Milliman estimated
              a high and
              low completion percentage on a statewide basis. The claims completion
              implemented by the health plans in aggregate was within the range and,
              as such,
              no further adjustments were applied.


          

          
            


          

          
            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 CY 2006 experience. As such, an adjustment was applied
              to CY
              2005 to include the program change m all periods of the base experience
              data.

          

          
            


          

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

          

          
            
              
                


                
                  
                    
                    

                  

                  
                    
                    

                    
                      

                    

                  

                  
                    
                    

                  

                

              

              
                FINAL
                  and CONFIDENTIAL

              

              
                


              

            

            d.  Third-Party
              Liability and Fraud-Abuse Recoveries

          

          
            


          

          
            The
              cost
              reports submitted by the health plans contained information related
              to
              third-party liability and fraud-abuse recoveries.  Milliman calculated
              the average recoveries and applied the reduction to the base cost report
              data.

          

          
            


          

          
            e.   Non-State
              Plan Services

          

          


          
            CMS
              requires removal of non-state plan services from rate-setting. The
              cost report
              claims that are considered non-state plan services. The health plan
              submitted
              cost the source of information for the non-state plan service
              adjustments.

          

          
            


          

          
            
              f. 
Historical
                Selection
                Adjustments 



          

          
            Milliman
              applied a historical selection adjustment to the base cost report data
              to
              reflect that the base period contains a combination of FFS and managed
              care
              enrollment. The historical selection adjustment is intended to normalize
              the
              cost report experience to the morbidity level of the entire managed
              care
              eligible population.

          

          
            


          

          
            g.     Trends/Inflation
              to CY 2006

          

          
            


          

          
            Milliman
              developed trend rates to progress the historical experience from calendar
              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 in the development of the CY 2008 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.

          

          
            


          

          
            h.       Blend
              Base Experience Years

          

          
            


          

          
            The
              base
              CY 2005 year 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.  Generally, CY 2006 was given 70% weight except where
              insufficient experience existed in either CY 2005 or CY 2006.  In
              these situations, either CY 2005 or CY 2006 was given 100%
              credibility.

          

          
          

          
            
              
                


                
                  
                    
                    

                  

                  
                    
                    

                    
                      

                    

                  

                  
                    
                    

                  

                

              

              
                FINAL
                  and CONFIDENTIAL

              

              
                



              

            

          

          
            i.        Managed
              Care Adjustments

          

          
            


          

          
            Milliman
              adjusted the cost report experience data to reflect changes anticipated
              in the
              managed care environment.  The cost report base experience was
              adjusted using the same managed care adjustments as the base encounter
              data with
              the exception of the health plan provider contracting adjustment. The
              health
              plan rate of provider reimbursement is already included in the cost
              report base
              experience.

          

          
            


          

          
            Adjustments
              were developed for each rate group, service category, and
              region.

          

          
            


          

          
            VII.       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 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 rates.

          

          
            


          

          
            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 8 lists the program changes that were
              included in
              the CY 2008 capitation rate development.

          

          
          

          
            
              
                


                
                  
                    
                    

                  

                  
                    
                    

                    
                      

                    

                  

                  
                    
                    

                  

                

              

              
                FINAL
                  and CONFIDENTIAL

              

              
                


              

            

          

          
            Table
              8

          

          
            


          

          
            
              	
                       

                    	
                      STATE
                        OF OHIO 

                    


            

          

          
            
              	
                       

                    	
                      DEPARTMENT
                        OF JOB AND FAMILY SERVICES 

                    


            

          

          
            
              	
                       

                    	
                      Prospective
                        Program Adjustments 

                    


            

          

          
            


          

          
            	
                    Program
                      Adjustment

                  	
                    Effective
                      Date

                  	
                    Service
                      Category

                  	
                    Rate
                      Groups

                  
	
                    Nursing
                      Facility Fee Increase

                  	
                    7/1/2007

                    7/1/2008

                  	
                    Nursing
                      Facility

                  	
                    All
                      Rate Groups (excl. Delivery)

                  
	
                    Chiropractor
                      Benefit Restoration

                  	
                    1/1/2008

                  	
                    Miscellaneous
                      Services

                  	
                    HF
                      M – 19 to 44

                    HF
                      F – 19 to 44

                    HF
                      M/F – 45 to 64

                    HST
                      F – 19 to 64

                  
	
                    Independent
                      Psychologists Benefit Restoration

                  	
                    1/1/2008

                  	
                    Mental
                      Health / Substance Abuse

                  	
                    HF
                      M – 19 to 44

                    HF
                      F – 19 to 44

                    HF
                      M/F – 45 to 64

                    HST
                      F – 19 to 64

                  
	
                    Occupational
                      Therapy-Independent Provider Status

                  	
                    1/1/2008

                  	
                    Miscellaneous
                      Services

                  	
                    All
                      Rate Groups (excl. Delivery)

                  
	
                    Developmental
                      Therapies

                  	
                    1/1/2008

                  	
                    Miscellaneous
                      Services

                  	
                    HST
                      M/F - <
                      1

                  
	
                    Foster
                      Children Expansion

                  	
                    1/1/2008

                  	
                    All
                      Service Categories

                  	
                    HST
                      M – 14 to 18

                  
	
                    CHIP
                      III Expansion

                  	
                    1/1/2008

                  	
                    All
                      Service Categories

                  	
                    HST
                      F – 14 to 18

                    HF
                      M – 19 to 44

                    HF
                      F – 19 to 44

                    HST
                      F – 19 to 64

                    HST
                      M/F – 2 to 13

                  
	
                    Pregnant
                      Women Expansion

                  	
                    1/1/2008

                  	
                    All
                      Service Categories

                  	
                    HST
                      M – 14 to 18

                    HST
                      F – 14 to 18

                    HST
                      F – 19 to 64

                  
	
                    Improved
                      TPL Management

                  	
                    1/1/2008

                  	
                    All
                      Service Categories

                  	
                    Delivery

                    All
                      Rate Groups (incl. Delivery)

                  
	
                    Expedite
                      Managed Care Enrollment

                  	
                    1/1/2008

                  	
                    All
                      Service Categories

                  	
                    All
                      Rate Groups (incl. Delivery)

                  
	
                    Expedite
                      Newborn Enrollment

                  	
                    1/1/2008

                  	
                    All
                      Service Categories

                  	
                    HST
                      M/F - <
                      1

                  
	
                    Short
                      Term Nursing Facility Policy Change (consistent with ABD)

                  	
                    1/1/2008

                  	
                    Nursing
                      Facility

                  	
                    All
                      Rate Groups (excl. Delivery)

                  
	
                    Prior
                      Authorization Policy Change

                  	
                    1/1/2008

                  	
                    Pharmacy

                  	
                    All
                      Rate Groups (excl. Delivery)

                  
	
                    Prior
                      Authorization of Atypical Anti-Psychotic Medication

                  	
                    1/1/2008

                  	
                    Pharmacy

                  	
                    All
                      Rate Group (excl. Delivery)

                  


          

          
            
              
                


                
                  
                    
                    

                  

                  
                    
                    

                    
                      

                    

                  

                  
                    
                    

                  

                

              

              
                FINAL
                  and CONFIDENTIAL

              

              
                


              

            

          

          
            c.           
              Prospective Selection Adjustment

          

          
            


          

          
            Milliman
              adjusted the base experience data to reflect the morbidity of the entire
              managed
              care eligible population.  Subsequently, a prospective selection
              adjustment was deleloped to reflect that less than 100% of managed
              care
              eligibles will enroll in managed care.  Table 9 provides that taget
              managed care penetration used in the development of the CY 2008 capitation
              rates.

          

          
            


          

          
            


          

          
            Table
              9

          

          
            


          

          
            STATE
              OF OHIO

          

          
            DEPARTMENT
              OF JOB AND FAMILY SERVICES

          

          
            Prospective
              Selection Adjustments

          

          


          
            	
                    
                      Region

                    

                  	
                    
                      June
                        2007 MC Penetration

                    

                  	
                    
                      Target
                        MC Penetration

                    

                  
	
                    
                      Central

                    

                  	
                    
                      93.4%

                    

                  	
                    
                      95%

                    

                  
	
                    
                      East
                        Central

                    

                  	
                    
                      94.6%

                    

                  	
                    
                      95%

                    

                  
	
                    
                      Northeast

                    

                  	
                    
                      95.2%

                    

                  	
                    
                      95%

                    

                  
	
                    
                      Northeast
                        Central

                    

                  	
                    
                      75.8%

                    

                  	
                    
                      95%

                    

                  
	
                    
                      Northwest

                    

                  	
                    
                      94.5%

                    

                  	
                    
                      95%

                    

                  
	
                    
                      Southeast

                    

                  	
                    
                      94.9%

                    

                  	
                    
                      95%

                    

                  
	
                    
                      Southwest

                    

                  	
                    
                      93.6%

                    

                  	
                    
                      95%

                    

                  
	
                    
                      West
                        Central

                    

                  	
                    
                      94.0%

                    

                  	
                    
                      95%

                    

                  


          

          
            


          

          
            d.           
              Clinical Measures Adjustments

          

          
            


          

          
            Appendix
              M of the provider agreement between contracted health plans and ODJFS
              contains
              certain clinical measures that each health plan must achieve. The agreement
              stipulates that, at a minimum, the experience improvement must reduce
              the
              discrepancy between the ultimate target and the actual rate by a certain
              percentage. Milliman developed adjustments to the capitation rates
              to reflect
              this required improvement in performance based on the CY 2006 actual
              results.
              Table 10 illustrates the measures for which adjustment factors were
              applied by
              category of service and rate group.

             

          

          
            Table
              10

          

          
            


          

          
            STATE
              OF OHIO

          

          
            DEPARTMENT
              OF JOB AND FAMILY SERVICES

          

          
            Clinical
              Measures Adjustments

          

          
            


          

          
            	
                    Clinical
                      Measure Description

                  	
                    Measure

                  	
                    Service
                      Category

                  	
                    Rate
                      Groups

                  
	
                    Ongoing
                      Prenatal Care

                  	
                    80%
                      receive 81+% of expected visits

                  	
                    Office
                      Visits / Consults

                  	
                    HST
                      F – 14 to 18

                    HF
                      F – 19 to 44

                    HST
                      F – 19 to 64

                  
	
                    Postpartum
                      Care

                  	
                    80%
                      receive a visit

                  	
                    Obstetrics

                  	
                    HST
                      F – 14 to 18

                    HF
                      F – 19 to 44

                    HST
                      F – 19 to 64

                  
	
                    Well
                      Child Visits

                  	
                    80%
                      receive expected visits

                  	
                    Periodic
                      Exams

                  	
                    HST
                      M/F – <1

                    HST
                      M/F – 1

                    HST
                      M/F – 2 to 13

                    HST
                      F – 14 to 18

                    HST
                      M – 14 to 18

                  
	
                    Asthma
                      Medications

                  	
                    95%
                      receive appropriate medications

                  	
                    Pharmacy

                  	
                    HST
                      M/F – 2 to 13

                    HST
                      F – 14 to 18

                    HST
                      M – 14 to 18

                    HF
                      F – 19 to 44

                    HF
                      M – 19 to 44

                    HF
                      M/F – 45 to 64

                    HST
                      F – 19 to 64

                  
	
                    Annual
                      Dental Visits

                  	
                    60%
                      receive a visit

                  	
                    Dental

                  	
                    HST
                      M/F – 2 to 13

                    HST
                      F – 14 to 18

                    HST
                      M – 14 to 18

                  
	
                    Lead
                      Screening

                  	
                    80%
                      receive screening

                  	
                    Pathology
                      / Laboratory

                  	
                    HST
                      M/F – 1

                    HST
                      M/F – 2 to 13

                  


          

          
            


          

          e.           
            Delivery of Cesarean Section Rates

          


          Milliman
            reviewed the cesarean rates for both the FFS and managed care populations
            in the
            base period data summaries.  In the previous years, the capitation
            rates were adjusted to target a specific cesarean rate.  For 2008,
            Milliman did not adjust the regional cost summaries, up or down, to reflect
            a
            different cesarean rate.

          


          f.           
            Blend FFS / Encounter / Cost Report

          


          The
            FFS,
            encounter, and cost report data sets were projected to CY 2008 and composited
            to
            establish the CY 2008 total claims cost. The credibility between data
            sources
            was based upon the amount of managed care
            experience in the case data.  The encounter and cost report data
            sources were given equal weight in each region.

          
            
              


              
                
                  
                  

                

                
                  
                  

                  
                    

                  

                

                
                  
                  

                

              

            

            
              FINAL
                and CONFIDENTIAL

            

            
              
g.           
                Age/Gender Realignment

            

          

          


          
            Milliman
              developed the 2008 capitation rates by rate group and region. The resulting
              capitation rates by rate group were then adjusted within each region
              to realign
              the age/gender relativities among regions. The realignment maintains
              the
              composite capitation rates for each region and in aggregate while allowing
              for
              more consistent age/gender relativities.

          

          
            


          

          
            h.           
              Administrative Allowances

          

          
            


          

          
            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 actual health plan
              cost
              information contained in the cost reports as well as 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 11 provides the administrative cost allowance
              for
              each plan year.

          

          
             

            Table
              11

          

          
            


          

          
            STATE
              OF OHIO

          

          
            DEPARTMENT
              OF JOB AND FAMILY SERVICES

          

          
            Administrative
              Cost Allowance

          

          
             

            Non-Delivery

          

          


          
            	
                    
                      Plan
Year 

                    

                  	
                    
                      Guaranteed
                        %

                    

                  	
                    
                      At-Risk
                        %

                    

                  	
                    
                      Total
                        %

                    

                  
	
                    
                      Plan
                        Year 1 (1-12 Months)

                    

                  	
                    
                      12.5%

                    

                  	
                    
                      0.0%

                    

                  	
                    
                      12.5%

                    

                  
	
                    
                      Plan
                        Year 2 (13-24 Months)

                    

                  	
                    
                      11.5%

                    

                  	
                    
                      0.0%

                    

                  	
                    
                      11.5%

                    

                  
	
                    
                      Plan
                        Year 3 (25 + Months)

                    

                  	
                    
                      10.5%

                    

                  	
                    
                      1.0%

                    

                  	
                    
                      11.5%

                    

                  


          

          
            
              


              
                
                  
                  

                

                
                  
                  

                  
                    

                  

                

                
                  
                  

                

              

            

            
              FINAL
                and CONFIDENTIAL

            

            
              


            

          

          Delivery

          


          
            	
                    
                      Plan
                        Year

                    

                  	
                    
                      Guaranteed
                        %

                    

                  	
                    
                      At-Risk
                        %

                    

                  	
                    
                      Total
                        %

                    

                  
	
                    
                      Plan
                        Year 1 (142 Months)

                    

                  	
                    
                      6.0%

                    

                  	
                    
                      0.0%

                    

                  	
                    
                      6.0%

                    

                  
	
                    
                      Plan
                        Year 2 (13-24 Months)

                    

                  	
                    
                      5.0%

                    

                  	
                    
                      0.0%

                    

                  	
                    
                      5.0%

                    

                  
	
                    
                      Plan
                        Year 3 (25 + Months)

                    

                  	
                    
                      4.0%

                    

                  	
                    
                      1.0%

                    

                  	
                    
                      5.0%

                    

                  


          

          
            


          

          
            The
              administrative cost allowance percentages contained in Table 11 reflect
              a change
              from the 2007 methodology.

          

          
            


          

          
            i.           
              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.

          

          
            


          

          
            DATA
              RELIANCE

          

          
            


          

          
            In
              developing the CY 2008 CFC 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) 

                    
	 	MitaliGhatak
                      (ODJFS)
	 	Robert
                      Monks (ODJF1 )


            

          

          
             

          


          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          


          
            APPENDIX
              1

          

          
            


          

          
            Illustration
              of Rate Development Methodology

          

          
            


          

          
            [Graph]

             

             

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

          

          
            


          

          
            


          

          
            APPENDIX
              2

          

          
            


          

          
            STATE
              OF OHIO

          

          
            DEPARTMENT
              OF JOB AND FAMILY SERVICES

          

          
            Covered
              Families and Children – 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 Covered Families and Children
              managed
              care eligible populations. I have experience in the examination of
              financial
              calculations for Medicaid programs and meet the qualification standards
              for
              rendering this opinion.

          

          
            


          

          
            I
              reviewed the historical claims experience for reasonableness and consistency.
              I
              have developed certain actuarial assumptions and actuarial methodologies
              regarding the projection of healthcare expenditures into future periods.
              I have
              complied with the elements of the rate setting checklist 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. Damler

          

          
            Robert
              M.
              Damler, FSA

          

          
            Member,
              American Academy of Actuaries

          

          
            


          

          
            
              	
                       

                    	
                      December
                        4,
                        2007

                    


            

          


          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          


          
            


          

          
            


          

          
            


          

          
            


          

          
            


          

          
            APPENDIX
              3

          

          
             

             

            FINAL
              AND CONFIDENTIAL

          

          
            


          

          
            


          

          
            State
              of Ohio

          

          
            


          

          
            Department
              of Job and Family Services

          

          
            


          

          
            Capitation
              Rate Summary – Rate Group Level

          

          
            


          

          
            [Table]

          

          
            


          

          
            


          

          
            


          

          
            


          

          

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            



        

      

      
        	
                APPENDIX
                  F

              
	
                REGIONAL
                  RATES

              
	 	 	 	 	 	 	 	 	 	 	 	 
	
                1.  PREMIUM
                  RATES  WITHOUT THE AT-RISK PAYMENT AMOUNTS FOR 01/01/08 THROUGH
                  06/30/08 SHALL BE AS FOLLOWS:

              
	
                An
                  at-risk amount of 1% is applied
                  to the MCP rates.  The status of the at-risk amount is
                  determined in accordance with Appendix O, performance
                  incentives.

              
	 	 	 	 	 	 	 	 	 	 	 	 
	
                MCP:  WellCare
                  of Ohio,
                  Inc.

              	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	
                SERVICE

              	
                REGIONAL

              	
                HF/HST

              	
                HF/HST

              	
                HF/HST

              	
                HF/HST

              	
                HF/HST

              	
                HF

              	
                HF

              	
                HF

              	
                HST

              	
                Delivery

              
	
                ENROLLMENT

              	
                STATUS

              	
                Age
<
1

              	
                Age
                  1

              	
                Age
                  2-13

              	
                Age
                  14-18

              	
                Age
                  14-18

              	
                Age
                  19-44

              	
                Age
                  19-44

              	
                Age
                  45

              	
                Age
                  19-64

              	
                Payment

              
	
                AREA

              	 	 	 	 	
                Male

              	
                Female

              	
                Male

              	
                Female

              	
                and
                  over

              	
                Female

              	 
	
                Northeast

              	
                Mandatory

              	
                $537.65

              	
                $138.65

              	
                $93.78

              	
                $112.18

              	
                $156.32

              	
                $188.08

              	
                $287.97

              	
                $459.68

              	
                $356.04

              	
                $4,105.75

              
	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	
                List
                  of Eligible Assistance Groups
                  (AGs)

              	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	 Healthy
                Families: 	
                -  MA-C  Categorically
                  eligible due to TANF cash

                -  MA-T   Children
                  under 21

                -  MA-Y   Transitional
                  Medicaid

              
	 	 	 	 	 	 	 	 	 	 	 	 
	 Healthy
                Start: 	-  MA-P  Pregnant
                Women and Children
	 	 	 	 	 	 	 	 	 	 	 	 
	
                 For
                  the SFY 2008 contract
                  period, MCPs will be put at-risk for a portion of the premiums
                  received
                  for members in counties they served as of January 1, 2006, provided
                  the MCP has participated in the program for more than twenty-four
                  months.
                  

              	 
	
                          

              	 	 	 	 
	
                 MCPs
                  will be put at-risk for
                  a portion of the premiums received for members in counties they
                  began
                  serving after January 1, 2006, beginning with the MCP's
                  twenty-fifth month of membership in each county's region. 

              	 
	
                         

              	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	
                Page
                  1 of
                  3

              
	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	
                APPENDIX
                  F

              
	
                 REGIONAL
                  RATES

              
	 	 	 	 	 	 	 	 	 	 	 	 
	
                2.  AT-RISK
                  AMOUNTS
                  FOR  01/01/08 THROUGH 06/30/08 SHALL BE AS
                  FOLLOWS:

              
	
                An
                  at-risk amount of 1% is applied
                  to the MCP rates.  The status of the at-risk amount is
                  determined in accordance with Appendix O, performance
                  incentives.

              
	 	 	 	 	 	 	 	 	 	 	 	 
	
                MCP:  WellCare
                  of Ohio,
                  Inc.

              	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	
                SERVICE

              	
                REGIONAL

              	
                HF/HST

              	
                HF/HST

              	
                HF/HST

              	
                HF/HST

              	
                HF/HST

              	
                HF

              	
                HF

              	
                HF

              	
                HST

              	
                Delivery

              
	
                ENROLLMENT

              	
                STATUS

              	
                Age
<
1

              	
                Age
                  1

              	
                Age
                  2-13

              	
                Age
                  14-18

              	
                Age
                  14-18

              	
                Age
                  19-44

              	
                Age
                  19-44

              	
                Age
                  45

              	
                Age
                  19-64

              	
                Payment

              
	
                AREA

              	 	 	 	 	
                Male

              	
                Female

              	
                Male

              	
                Female

              	
                and
                  over

              	
                Female

              	 
	
                Northeast

              	
                Mandatory

              	
                $0.00

              	
                $0.00

              	
                $0.00

              	
                $0.00

              	
                $0.00

              	
                $0.00

              	
                $0.00

              	
                $0.00

              	
                $0.00

              	
                $0.00

              
	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	
                List
                  of Eligible Assistance Groups
                  (AGs)

                 

              	 	 	 	 	 	 	 	 	 
	 Healthy
                Families:	
                -  MA-C  Categorically
                  eligible due to TANF cash

                -  MA-T   Children
                  under 21

                -  MA-Y   Transitional
                  Medicaid

              
	 	 	 	 	 	 	 	 	 	 	 	 
	
                     

              	 	 	 	 	 	 	 
	 Healthy
                Start:   	-  MA-P   Pregnant
                Women and Children
	 	 	 	 	 	 	 	 	 	 	 	 
	
                 For
                  the SFY 2008 contract
                  period, MCPs will be put at-risk for a portion of the premiums
                  received
                  for members in counties they served as of January 1, 2006, provided
                  the MCP has participated in the program for more than twenty-four
                  months.
                  

              	 
	
                          

              	 	 	 	 
	
                 MCPs
                  will be put at-risk for
                  a portion of the premiums received for members in counties they
                  began
                  serving after January 1, 2006, beginning with the MCP's
                  twenty-fifth month of membership in each county's region. 

              	 
	
                       

              	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	
                Page
                  2 of
                  3

              
	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	
                APPENDIX
                  F

              
	
                 REGIONAL
                  RATES

              
	 	 	 	 	 	 	 	 	 	 	 	 
	
                3.  PREMIUM
                  RATES FOR
                  01/01/08 THROUGH 06/30/08 SHALL BE AS FOLLOWS:

              
	
                An
                  at-risk amount of 1% is applied
                  to the MCP rates.  The status of the at-risk amount is
                  determined in accordance with Appendix O, performance
                  incentives.

              
	 	 	 	 	 	 	 	 	 	 	 	 
	
                MCP:  WellCare
                  of Ohio,
                  Inc.

              	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	
                SERVICE

              	
                REGIONAL

              	
                HF/HST

              	
                HF/HST

              	
                HF/HST

              	
                HF/HST

              	
                HF/HST

              	
                HF

              	
                HF

              	
                HF

              	
                HST

              	
                Delivery

              
	
                ENROLLMENT

              	
                STATUS

              	
                Age
<
1

              	
                Age
                  1

              	
                Age
                  2-13

              	
                Age
                  14-18

              	
                Age
                  14-18

              	
                Age
                  19-44

              	
                Age
                  19-44

              	
                Age
                  45

              	
                Age
                  19-64

              	
                Payment

              
	
                AREA

              	 	 	 	 	
                Male

              	
                Female

              	
                Male

              	
                Female

              	
                and
                  over

              	
                Female

              	 
	
                Northeast

              	
                Mandatory

              	
                $537.65

              	
                $138.65

              	
                $93.78

              	
                $112.18

              	
                $156.32

              	
                $188.08

              	
                $287.97

              	
                $459.68

              	
                $356.04

              	
                $4,105.75

              
	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	
                List
                  of Eligible Assistance Groups
                  (AGs)

                 

              	 	 	 	 	 	 	 	 	 
	 Healthy
                Families:  	
                -  MA-C  Categorically
                  eligible due to TANF cash

                -  MA-T   Children
                  under 21

                -  MA-Y   Transitional
                  Medicaid

              
	
                                            

              	 	 	 	 	 	 	 	 
	 Healthy
                Start:      	-  MA-P   Pregnant
                Women and Children
	
                 

              	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	
                 For
                  the SFY 2008 contract
                  period, MCPs will be put at-risk for a portion of the premiums
                  received
                  for members in counties they served as of January 1, 2006, provided
                  the MCP has participated in the program for more than twenty-four
                  months.
                  

              	 
	
                         

              	 	 	 	 
	
                 MCPs
                  will be put at-risk for
                  a portion of the premiums received for members in counties they
                  began
                  serving after January 1, 2006, beginning with the MCP's
                  twenty-fifth month of membership in each county's region. 

              	 
	
                         

              	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	
                Page
                  3 of
                  3

              
	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 


      



    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

    

     

    


    APPENDIX
      G

    


    COVERAGE
      AND
      SERVICES

    CFC
      ELIGIBLE
      POPULATION

    


    1.         Basic
      Benefit
      Package

    


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

    


    · Inpatient
      hospital services

    · Outpatient
      hospital services

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

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

    · Laboratory
      and
      x-ray services

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

    · Family
      planning services and supplies

    · Home
      health
and private duty nursing
      services  

    · Podiatry

    · Chiropractic
      services

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

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

    · Prescription
      drugs

    · Ambulance
      and
      ambulette services

    · Dental
      services 

    · Durable
      medical equipment and medical supplies

    · Vision
      care
      services, including eyeglasses

    · Short-term
      rehabilitative stays in a nursing facility as specified in OAC rule
      5101:3-26-03

    · Hospice
      care

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

    


    2. Exclusions,
      Limitations and
      Clarifications

    


    a. Exclusions

    


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

    


    · Services
      or
      supplies that are not medically necessary

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

    · Organ
      transplants that are not covered by Medicaid

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

    · Infertility
      services for males or females

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

    ·
      Reversal of voluntary sterilization procedures

    · Plastic
      or cosmetic surgery that is
      not
      medically necessary*

    · Immunizations
      for travel outside of the United States

    · Services
      for
      the treatment of obesity unless medically necessary*

    · Custodial
      or
      supportive care not covered by
      Medicaid

    · Sex
      change
      surgery and related services

    · 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 are 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/psychologist/psychiatrist services, outpatient clinic services,
      general hospital outpatient psychiatric services, pre-hospitalization screening,
      diagnostic assessment (clinical evaluation), crisis intervention, psychiatric
      hospitalization in general hospitals (for all ages), and Medicaid-covered
      prescription drugs and laboratory services.  MCPs are not required
to cover partial hospitalization,
      or inpatient psychiatric care in a private or public free-standing psychiatric
      hospital. However, MCPs are required to cover the payment of physician services
      in a private or public free-standing psychiatric hospital when such services
      are
      billed independent of the
      hospital.     

    


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

    


    Where
      an
      MCP is responsible for providing substance abuse services for their members,
      the
      MCP is responsible for ensuring access to alcohol and other drug (AOD)
      urinalysis screening, assessment, counseling,
      physician/psychologist/psychiatrist AOD treatment services, outpatient clinic
      AOD treatment services, general hospital outpatient AOD treatment services,
      crisis intervention, inpatient detoxification services in a general hospital,
      and Medicaid-covered prescription drugs and laboratory services. MCPs are not
      required to cover outpatient detoxification 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.  MCPs must
 make their approved list of drugs covered only with  prior
 authorization available to members and providers, as outlined  in
      paragraphs 37(b) and (c) of Appendix C.

    


     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.

    


    b. Case
Management
      Programs

    


    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.  The MCP’s
      comprehensive case management program must also include a Children with Special
      Health Care Needs component as specified below.

    


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

    


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

    


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

    


    CSHCN
      are defined as children age 17 and
      under who are pregnant, and members under 21 years of age with one or more
      of
      the following:

    - Asthma

    - HIV/AIDS

    - A
      chronic physical, emotional or mental
      condition for which they are receiving treatment or
      counseling

    - Supplemental
      security income (SSI) for a
      health-related condition 

    - A
      current letter of approval from the
      Bureau of Children with Medical Handicaps (BCMH), Ohio Department of
      Health

    


     iii.     Comprehensive
      Case
      Management Program

      

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

    


    2.  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:

    


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

    


      b)
      existing members, 90 days from identifying their need for case
      management.

     

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

      

    a. Identification


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

     

    b. Assessment

    The
      MCP must arrange for or conduct a
      comprehensive assessment of the member’s physical and/or behavioral health
      condition(s) to confirm the results of a positive identification, and determine
      the 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
      physician.

    


    For
      CSHCN, the comprehensive assessment
      must include, at a minimum, the use of the ODJFS
      CSHCN Standard
      Assessment Tool.

          

    c. Care
      Treatment
      Plan

    


     The
      care treatment plan is defined by ODJFS as the one  developed by the MCP
      for the member.  The development of   the care treatment
      plan must be based on the comprehensive  health assessment and reflect the
      member's primary medical  diagnosis and health conditions, any
      co-morbidities, 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 insure the care
      treatment plan is adequately monitored  including the
      following:

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

    ·
Re-evaluation
      to
      determine if the care treatment plan is adequate to meet the member's 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 level with adjustment to the level of case management services
      provided.

    


    4.  Coordination
      of Care and
      Communication

    


    The
      MCP
      must provide case management services for:

    


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


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


    ·
adults
      whose health
      conditions warrant case management services.

    


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

    


     There
      should be an accountable point of contact (i.e., case manager) who can help
      obtain medically necessary care, assist with health-related services and
      coordinate care needs.  The MCP must arrange or provide for professional
      case management services that are performed collaboratively by a team of
      professionals appropriate for the member’s condition and health care
      needs.  At a minimum, the MCP’s 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 communication between service providers, the member,
      and the member’s family.  The MCP must have a provision to disseminate
      information to the member/caregiver concerning the health condition, types
      of
      services that may be  available, and how to access the
      services.

    


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

    


     iv.  Case
      Management Strategies

    


    The
      MCPmust follow best-practice
      and/or
      evidence based clinical guidelines when developing a member’s care treatment
      plan and coordinating the case management needs. 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.

    


    v.   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 manager, 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 care 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.

    


    vi.   Case
      Management Data
      Submission

    


     The
      MCP must submit a monthly electronic
      report  to the  Case
      Management System (CAMS) for all
      members who  are
      case managed by the MCP as outlined
      in the ODJFS
 Case
      Management File
      and Submission Specifications.   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
      10th
      business day of each
      month.

    


    The
MCP
      must also have
      an ODJFS-approved case
      management program which includes the items in Section
      3.b.  Each MCP
      should 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.

     

    c. Care
      Coordination with ODJFS-Designated
      Providers

    


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

    


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

    


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

    


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

    · The
      MCP’s prior authorization and
      referral procedures or the MCP’s website which includes this
      information;  

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


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


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

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

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


    


    d. Care
      coordination with Non-Contracting Providers

    


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

    


    e. Integration
      of Member
      Care

     

    The
      MCP must ensure that a discharge
      plan is in place to meet a member’s healthcare
      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.


    
 

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    APPENDIX
      H

    


    PROVIDER
      PANEL SPECIFICATIONS

    CFC
      ELIGIBLE
      POPULATION

    


    


    1.
       GENERAL
      PROVISIONS

    


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

    


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

    


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

    


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

    


    2. PROVIDER
      SUBCONTRACTING

    


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

    


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

    


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

    


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

    


    3. PROVIDER
      PANEL REQUIREMENTS

    


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

    


    a. Primary
      Care
      Providers (PCPs)

    


    Primary
      Care Provider (PCP) means an individual physician (M.D. or D.O.), certain
      physician group practice/clinic (Primary Care Clinics [PCCs]), or an advanced
      practice nurse (APN) as defined in ORC 4723.43 or advanced practice nurse group
      practice within an acceptable specialty, contracting with an MCP to provide
      services as specified in paragraph (B) of OAC rule 5101:
      3-26-03.1.  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.

    


    In
      determining whether an MCP has
      sufficient PCP capacity for a region, ODJFS considers aprovider
      who can serve as a PCP for 2000
      Medicaid MCP members as one full-time equivalent(FTE).

    


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

    


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

    


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

          

    The
      PCP requirement is based on an MCP
      having sufficient PCP capacity to serve 40%
      of the eligibles in the region if
      three MCPs are serving the region and 55% of the eligibles in the region if
      two
      MCPs are serving the region. At
      a minimum, each MCP must meet both
      the PCP FTE requirement for that region, and a ratio of one PCP FTEfor each 2,000 of their
      Medicaid members
      in that region.  MCPs must also satisfy a PCP geographic accessibility
      standard. ODJFS will match the PCP practice sites and the stated PCP capacity
      with the geographic location of the eligible population in that region (on
      a
      county-specific basis) and perform analysis using Geographic Information Systems
      (GIS) software. The analysis will be used to determine if at least 40% of the
      eligible population is located within 10 miles of PCP with available capacity
      in
      urban counties and 40% of the eligible population within 30 miles of a PCP
      with
      available capacity in rural counties. [Rural areas are defined pursuant to
      42
      CFR 412.62(f)(1)(iii).]

     

    In
      addition to the PCP FTE capacity requirement, MCPs must also contract with
      the
      specified number of pediatric
      PCPs for each region.  These pediatric PCPs
      will have their stated capacity  counted toward the PCP FTE
      requirement.

    


    A
      pediatric PCP must maintain
      a  general pediatric practice (e.g., a pediatric neurologist would not
      meet this definition unless this physician also operated a practice as a general
      pediatrician) at a site(s) located within the county/region and be listed as
      a
      pediatrician with the Ohio State Medical Board.  In addition, half of
      the required number of pediatric PCPs must also be certified by the American
      Board of Pediatrics.  The provider panel requirements for
      pediatricians are included in the practitioner charts in this
      appendix.

    


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

    


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

    


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

     

    Hospitals
      -
MCPs must contract with
      the
      number and type of hospitals specified by ODJFS for each county/region. In
      developing these hospital requirements, ODJFS considered, on a county-by-county
      basis, the population size and utilization patterns of the Covered Families
      and

    


    Children
      (CFC) consumers and integrated
      the existing utilization patterns into the hospital network requirements to
      avoid disruption of care.  For this reason, ODJFS may require that
      MCPs contract with out-of-state hospitals (i.e. Kentucky,
West
      Virginia, etc.).

    


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

    


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

    


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

    


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

    


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

    


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

    


    Dental
      Care
      Providers - MCPs must
      contract with the specified number of dentists. In order to assure
      sufficient access
      to adult MCP members, no more
      than two-thirds of the dentists used to meet the provider
      panel requirement may be
      pediatric dentists.

    


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

    


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

    


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

    


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

    


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

    


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

    


    Qualified
      Family Planning Providers
      (QFPPs) - All MCP members must be permitted to self-refer to family
      planning services provided by a QFPP.  A QFPP is defined as
      any public or not-for-profit health care provider that complies with Title
      X
      guidelines/standards, and receives

    


    either
      Title X funding or family planning funding from the Ohio Department of
      Health.  MCPs must reimburse all medically-necessary
      Medicaid-covered  family planning services provided to eligible
      members by a QFPP provider (including on-site pharmacy
      and
      diagnostic services) on a patient self-referral
      basis, regardless of the
      provider’s status as a panel or non-panel provider.  MCPs will be
      required to work with QFPPs in the region to develop mutually-agreeable HIPAA
      compliant policies and procedures to preserve patient/provider confidentiality,
      and conveypertinent
      information to the member’s PCP and/or MCP.

    


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

    


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

    


    4. PROVIDER
      PANEL
      EXCEPTIONS

    


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

    


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

    


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

    


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

    


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

    


    ODJFS
      will aggressively monitor
access to all services
      related to the approvalof
      a provider
      panel exception request through
      a variety of data sources, including: consumer satisfaction
      surveys; member
      appeals/grievances/complaints and state hearingnotifications/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
      tothe
      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 covered population.  For example, an MCP who serves CFC and ABD
      in the Central Region would have two provider directories, one for CFC and
      one
      for ABD. Once
      approved, this directory may be
      regularly updated with provider additions or deletions by the MCP without ODJFS
      prior-approval, however, copies of the revised directory (or inserts) must
      be
      submitted to ODJFS prior to distribution to members.

    


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

    


    Internet
      Provider Directory

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

    


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

    


    


     

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    



    WellCare

    


    APPENDIX
      J

    


    FINANCIAL
      PERFORMANCE

    CFC
      ELIGIBLE POPULATION

    


    1. SUBMISSION
      OF FINANCIAL STATEMENTS AND REPORTS

    


     MCPs
      must submit the following financial reports to ODJFS:

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


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

    


    


    2. FINANCIAL
      PERFORMANCE MEASURES AND STANDARDS

    


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

    


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

    


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

    


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

       

    Standard: For
      the
      financial report that covers calendar year 2008, a minimum net worth per member
      of $151.00, as determined from the annual Financial Statement submitted to
      ODI
      and the ODJFS.

    


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

    


    0.75
      if
      the MCP had a total membership of 100,000 or more during that calendar
      year

    


    0.90
      if
      the MCP had a total membership of less than 100,000 for that calendar
      year

    


    If
      the
      MCP did not receive Medicaid Managed Care Capitation payments during the
      preceding calendar year, then the NWPM standard for the MCP is the average
      Medicaid Managed Care capitation amount paid to Medicaid-contracting MCPs during
      the preceding calendar year, including delivery payments, but excluding the
      at-risk amount, multiplied by the applicable proportion above.

    


    b. Indicator: Administrative
      Expense Ratio

    


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

    


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

    


     c. Indicator: Overall
      Expense
      Ratio

    


    Definition: Overall
      Expense Ratio = The sum of the Administrative Expense  Ratio
      and the Medical Expense Ratio.

    


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

    


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

    


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

    


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

    


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

    


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

    


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

     

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

    


     d. Indicator: Days
      Cash on Hand

    


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

    


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

    


     e. Indicator: Ratio
      of Cash to Claims
      Payable

    


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

    


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

     

    3. REINSURANCE
      REQUIREMENTS

    


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

    


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

    


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

    


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

    


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

    


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

    


    c. the
      number of members covered by the MCP;

    


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

    


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

    


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

    


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

    


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

    


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

    


    4. PROMPT
      PAY REQUIREMENTS

    


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

    


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

    


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

    


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

    


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

    


    5. PHYSICIAN
      INCENTIVE PLAN DISCLOSURE REQUIREMENTS

    


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

    


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

    


    In
      accordance with 42 CFR 417.479 and 42 CFR 422.210, MCPs must maintain copies
      of
      the following required documentation and submit to ODJFS annually, no later
      than
      30 days after the close of the state fiscal year and upon any modification
      of
      the MCP’s physician incentive plan:

    


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

    


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

    


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

    


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

    


    6. NOTIFICATION
      OF REGULATORY ACTION

    


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

    

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

APPENDIX
      K

    
      


      QUALITY
        ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM

      AND

      EXTERNAL
        QUALITY REVIEW

      CFC
        ELIGIBLE POPULATION

      


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

       

      a.  PERFORMANCE
        IMPROVEMENT
        PROJECTS

      


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

      


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

      


      MCPs
        must
        initiate the following PIPs:

      


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

      


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

      


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

      


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

      


      b.    UNDER-
        AND
        OVER-UTILIZATION

      


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

      


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

      


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

      


      c.  SPECIAL
        HEALTH CARE
        NEEDS

      


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

      


      d.  SUBMISSION
        OF PERFORMANCE
        MEASUREMENT DATA

      


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

      


      Each
        MCP
        must also submit clinical performance measurement data as required by ODJFS
        that
        uses standard measures as specified by ODJFS.  MCPs are required to
        submit Health Employer Data Information Set (HEDIS) audited data for the
        following measures:

      


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

      ii. Child
        Immunization
        Status

      


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

      


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

      


      e.   QAPI
        PROGRAM
        SUBMISSION

      


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

      


      2.  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 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

      CFC
        ELIGIBLE
        POPULATION

      


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

      


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

      


      1.
        ENCOUNTER DATA

      


      For
        detailed descriptions of the
        encounter data quality measures below, see ODJFS
        Methods for
        Encounter Data Quality Measures for
        CFC and
        ABD.

      


      1.a.  Encounter
        Data Completeness

      


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

      


      1.a.i.
        Encounter Data Volume

      


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

      


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

      


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

       

      
        	
                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

                
                

              	
                July2007

              	
                August2007

              	
                SFY2008

              
	
                Qtr3
&Qtr
                  4  2004,
2005,
                  2006

                Qtr
                  1, Qtr 2
                  2007

              	
                October
2007

              	
                November
2007

              
	
                Qtr
                  4 2004,2005,
                  2006Qtr 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

      


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

      


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

      


      
        	
                Category

              	
                Measure
                  per 1,000/MM

              	
                Standard
                  for Dates of Service

                7/1/2003
thru
                  6/30/2004

              	
                Standard
                  for Dates of Service

                7/1/2004thru
                  6/30/2006

              	
                Standard
                  for Dates of
                  Service

                on
                  or after
                  7/1/2006

              	
                Description

              
	
                Inpatient
                  Hospital

              	
                Discharges

              	
                5.4

              	
                5.0

              	
                5.4

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

              
	
                Emergency
                  Department

              	
                Visits

              	
                51.6

              	
                51.4

              	
                50.7

              	
                Includes
                  physician and hospital emergency department encounters

              
	
                Dental

              	
                38.2

              	
                41.7

              	
                50.9

              	
                Non-institutional
                  and hospital dental visits

              
	
                Vision

              	
                11.6

              	
                11.6

              	
                10.6

              	
                Non-institutional
                  and hospital outpatient optometry and ophthalmology
                  visits

              
	
                Primary
                  and Specialist Care

              	
                220.1

              	
                225.7

              	
                233.2

              	
                Physician/practitioner
                  and hospital outpatient visits

              
	
                Ancillary
                  Services

              	
                144.7

              	
                123.0

              	
                133.6

              	
                Ancillary
                  visits

              
	
                Behavioral
                  Health

              	
                Service

              	
                7.6

              	
                8.6

              	
                10.5

              	
                Inpatient
                  and outpatient behavioral encounters

              
	
                Pharmacy

              	
                Prescriptions

              	
                388.5

              	
                457.6

              	
                492.2

              	
                Prescribed
                  drugs

              


      

      


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

      


      Interim
        Regional-Based
        Approach:

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

      


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

      


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

      


      Table
        3. Standards – Encounter Data Volume (Interim Regional-Based
        Approach)

      


      
        	
                Category

              	
                Measure
                  per 1,000/MM

              	
                Standard
                  for Dates of
                  Service

                on
                  or after
                  7/1/2006

              	
                Description

              
	
                Inpatient
                  Hospital

              	
                Discharges

              	
                2.7

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

              
	
                Emergency
                  Department

              	
                Visits

              	
                25.3

              	
                Includes
                  physician and hospital emergency department encounters

              
	
                Dental

              	
                25.5

              	
                Non-institutional
                  and hospital dental visits

              
	
                Vision

              	
                5.3

              	
                Non-institutional
                  and hospital outpatient optometry and ophthalmology
                  visits

              
	
                Primary
                  and Specialist Care

              	
                116.6

              	
                Physician/practitioner
                  and hospital outpatient visits

              
	
                Ancillary
                  Services

              	
                66.8

              	
                Ancillary
                  visits

              
	
                Behavioral
                  Health

              	
                Service

              	
                5.2

              	
                Inpatient
                  and outpatient behavioral encounters

              
	
                Pharmacy

              	
                Prescriptions

              	
                246.1

              	
                Prescribed
                  drugs

              


      

      


      


      Determination
        of
        Compliance:Performance is
        monitored once every quarter for the entire report period.  If the
        standard is not met for every service category in all quarters of the report
        period in either the
        county-based or interim regional-based approach, or both, then the MCP will be
        determined to be
        noncompliant for the report period.

      


      Penalty
        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.

      


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

      


      1.a.ii.
        Incomplete Outpatient Hospital Data

      


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

      


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

      


      Report
        Period:  For
        the SFY 2008
        and SFY 2009 contractperiods,
        performance will be evaluated
        using the report periods listed in
        1.a.i., Table 1.

      


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

      


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


      


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

      


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

       

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

      


      1.a.iii.
        Incomplete Data For Last Menstrual Period

      


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

      


      The
        occurrence code and date fields on the UB-92, which are “optional” fields, can
        also be used to submit the date of the LMP. These fields are described in
        Items
        32a & b, 33a & b, 34a & b, 35a & b of the “Inpatient Hospital”
and  “Outpatient Hospital UB-92 Claim Form Instructions.”

      


      An
        occurrence code value of  ‘10’ indicates that a LMP date
        was  provided. The actual date of the LMP would be given in the
‘Occurrence Date’ field.

      


      Measure: The
        percentage of
        recipients with a live birth during the report
        period where a “valid”
        LMP date was given on one or more of
        the recipient’s
        perinatal claims. If the LMP date is
        before the date of birth and there is a difference of between 119 and 315
        days
        between the date the recipient gave birth and the LMP date, then the LMP
        date
        will be considered a valid date.  The measure will be
        calculated per
        MCP (i.e., to include
        the MCP’s service area for the
        CFC.

      


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

      


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

      


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

      


      1.a.iv.
        Rejected Encounters

      


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

      


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

      


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

      


      Report
        Period:  For the
        SFY 2008 contract period, performance will be evaluated using the following
        report periods:  April - June 2007;
        July - September 2007; October -
        December 2007,
        January - March 2008, and 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, and 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 type in the ODJFS-specified
        medium
        performat for encounters
        submitted in SFY 2004 and thereafter. The measure will be
        calculated per
        MCP.

      


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

      


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

      


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

      


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

      


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


      


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

      


      
        	
                Third
                  through sixth months with
                  membership:         50%

              	
                 

              
	
                Seventh
                  through twelfth month with
                  membership:  25%

              	
                 

              


      

      


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

      


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

      


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

      


      1.a.v.
        Acceptance Rate

      


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

      


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

      


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

      


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

      


      
        	
                Third
                  through sixth month with
                  membership:

              	
                50
                  encounters per 1,000 MM for
                  NCPDP

              
	 	
                65
                  encounters per 1,000 MM for
                  NSF

              
	 	
                20
                  encounters per 1,000 MM for
                  UB-92

              
	 	 
	
                Seventh
                  through twelfth month of
                  membership:

              	
                250
                  encounters per 1,000 MM for
                  NCPDP

              
	 	
                350
                  encounters per 1,000 MM for
                  NSF

              
	 	
                100
                  encounters per 1,000 MM for
                  UB-92

              


      

      


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

      


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

      


      1.b.  Encounter
        Data
        Accuracy

      


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

      


      1.b.i.  Encounter
        Data
        Accuracy Studies

      


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

      


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

      


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

      


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

      


      Penalty
        for
        noncompliance: The MCP must
        participate in a detailed review of delivery payments made for deliveries
        during
        the report period.  Any duplicate or unvalidated delivery payments
        must be returned to ODJFS.

      


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

      


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

      


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

      


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

      


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

      


      Data
Quality
        Standard for
        Measure 2:   TBD
        for SFY 2008 and SFY 2009 based on study conducted in SFY 2007 (standard
        to be
        released in June, 2007).

      


      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 periods,
        performance will be evaluated using the report periods listed in 1.a.i.,
        Table
        1.

      


      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.v.) standards are based on encounters
        being
        submitted within this time frame.

      


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

      


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

      


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

      
         

        2.
          CASE MANAGEMENT DATA 

      

      
      

      


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

      


      2.a.   Case
        Management System Data Accuracy

      


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

      


      Measure:  The
        percentage of the MCP’s adult and children case management records in the
        Screening, Assessment, and Case Management System that have open case management
        date spans for members who have disenrolled from the MCP.

      


      Report
        Period: For the 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.

      


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

      


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

      


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

      


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

      


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

      


      2.b.  Timely
        Submission of Case Management Files

      


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

      


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

      
         

        3.
          EXTERNAL QUALITY REVIEW DATA 

      

       

      In
        accordance with federal law and regulations, ODJFS  is required to
        conduct an independent quality review of contracting managed care
        plans.  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 CFC members, including
        those who have case
        management needs.  The MCP must submit  a Members’
Designated PCP file every month.  Specialists may and should be
        identified as the PCP as appropriate for the member’s condition per the
        specialty types specified for the CFC population in ODJFS Member’s
        PCP Data
        File and Submission Specifications; however, no CFC member
        may have more
        than one PCP identified for a given month.

      


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

      


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

      


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

      


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

      


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

      


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

      


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

      


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

      


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

      


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

      


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

      


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

      


      


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

      


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

      


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

      


      5.
        APPEALS AND GRIEVANCES DATA

      


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

      


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

      


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

      


      6.  NOTES

      


      
        	
                6.a.

              	
                Penalties,
                  Including Monetary
                  Sanctions, for Noncompliance

              


      

      


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

      


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

      


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

      


      6.b.
        Combined Remedies

      


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

      


      6.c.  Membership
        Freezes

      


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

      


      6.d.  Reconsideration

      


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

      


      6.e.  Contract
        Termination, Nonrenewals, or Denials

      


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


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      



      APPENDIX
        M

      


      PERFORMANCE
        EVALUATION

      CFC
        ELIGIBLE
        POPULATION

      


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

      


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

      


      The
        statewide approach will be implemented beginning January 1, 2008.  Due
        to differences in data and reporting requirements, transition to statewide
        measurement will vary by performance measure. Given that the original intent
        of
        the SFY 2007 and SFY 2008
        Covered Families and Children Provider Agreements, Appendix M, was to
        transition to a regional-based system of evaluation, several performance
        measures have used regional-based results for performance monitoring.
        Regional-based performance monitoring will be discontinued for all measures
        in
        Appendix M for report periods from January, 2008 onward.  Unless
        otherwise noted, performance measures and standards (see Sections 1, 2, 3
        and 4
        of this appendix) will be applicable for all counties in which the MCP has
        membership as of February 1, 2006, until statewide measurement is
        implemented.

      


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

      


      1.  QUALITY
        OF CARE

      


      1.a.
        Independent External Quality
        Review

      


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

      


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

      


      Report
        Period:  Performance
        will be evaluated using the reviews conducted during SFY2008.

      


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

      


      1.b.  Children
        with Special Health Care Needs (CSHCN)

      


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

      


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

      


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

      


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

      


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

      


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

      


      County
        and
        Regional-Based Minimum
        Performance
        Standard: For
        the third and fourth quarters of SFY
        2007, a case management rate of 5.0%.  For the
        first and second
        quarters of SFY
        2008, a case management
        rate of
        5.0%.

      


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

      


      1.b.ii.
        Case Management of Children
(applicable to
        performance evaluation as of  January, 2008)

      


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

      


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

      


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

      


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

      


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

      


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

      


      1.b.iii.
        Case Management
        of
        Children with an ODJFS-Mandated Condition (applicable
        to performance
        evaluation through December 2007)

      


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

      


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

      


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

      


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

      


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

      


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

      


      County
        and
        Regional-Based Minimum
        Performance
        Standard for Measures 1 and 3: For the third and fourth
quarters
        of SFY 2007, a case management rate of 70%.  For the first and second
        quarters of SFY 2008, a case management rate of 70%.

      


      County
        and Regional-Based Minimum Performance Standard for Measure 2: For the third
        and
        fourth quarters of SFY 2007, a case management rate of 60%.  For the
        first and second quarters of SFY 2008, a case management rate of
        60%.

      


      Penalty
        for
        Noncompliance for Measures 1 and 2:  The first time an MCP
        is
        noncompliant with a standard for this measure, ODJFS will issue a Sanction
        Advisory informing the MCP that any future noncompliance instances with the
        standard for this measure will result in ODJFS imposing a monetary
        sanction.  Upon all subsequent measurements of performance, if an MCP
        is again determined to be noncompliant with the standard, ODJFS will impose
        a
        monetary sanction (see Section 5) of two percent of the current month’s premium
        payment. Monetary sanctions will not be levied for consecutive quarters that
        an
        MCP is determined to be noncompliant.  If an MCP is noncompliant for a
        subsequent quarter, new member selection freezes or a reduction of assignments
        will occur as outlined in Appendix N of the Provider Agreement.  Once the MCP is determined
        to be compliant with the standard and the violations/deficiencies are resolved
        to the satisfaction of ODJFS, the
        penalties will be lifted, if
        applicable, and monetary sanctions will be
        returned.  Note:  For the first reporting period during
        which regional results are used to evaluate performance, measures 1, 2, and
        3
        are reporting-only measures.  For SFY 2008, measure 3 is a
        reporting-only measure.

      


      1.b.iv.
        Case Management of Children
        with an ODJFS-Mandated Condition (applicable
        to performance
        evaluation as of  January 2008)

      


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

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

      


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

      


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

      


      Regional-Based
        Statewide Target for
        Measures 1 and 2:  For the third and fourth quarters of SFY
        2008, a case management rate of 70%.  For SFY 2009, a case management
        rate of 80%.

      


      Regional-Based
        Statewide Minimum
        Performance Standard for Measures 1 and  2:  The
        level of improvement must result in at least a 20% decrease in the difference
        between the target and the previous report period’s results.

      


      Penalty
        for Noncompliance for
        Measure  1:  The first time an MCP is noncompliant
        with a standard for this measure, ODJFS will issue a Sanction Advisory informing
        the MCP that any future noncompliance instances with the standard for this
        measure will result in ODJFS imposing a monetary sanction.  Upon all
        subsequent measurements of performance, if an MCP is again determined to
        be
        noncompliant with the standard, ODJFS will impose a monetary sanction (see
        Section 5) of two percent of the current month’s premium payment. Monetary
        sanctions will not be levied for consecutive quarters that an MCP is determined
        to be noncompliant.  If an MCP is noncompliant for a subsequent
        quarter, new member selection freezes or a reduction of assignments will
        occur
        as outlined in Appendix N of the Provider Agreement.  Once the MCP is
        determined to be compliant with the standard and the violations/deficiencies
        are
        resolved to the satisfaction of ODJFS, the penalties will be lifted, if
        applicable, and monetary sanctions will be returned. For SFY 2008 and SFY
        2009,
        measure 2 is a reporting-only measure.

      


      1.c.
        Clinical Performance
        Measures

      


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

      


      The
        clinical performance measures described below closely follow the National
        Committee for Quality Assurance’s Health Plan Employer Data and Information Set
        (HEDIS).  Minor adjustments to HEDIS measures are required to account
        for the differences between the commercial population and the Medicaid
        population, such as shorter
        and interrupted enrollment periods. NCQA may annually change its method for
        calculating a measure.  These changes can make it difficult to
        evaluate whether improvement occurred from a  prior
        year.  For this reason, ODJFS will use the same
        methods to calculate the baseline results and the results for the period
        in
        which the MCP is being held
        accountable.  For example, the same methods were being used to
        calculate calendar year  2005 results (the baseline
        period) and
        calendar year  2006 results.  The methods will be updated
        and a new baseline will be created during 2007 for
        calendar  year  2006 results.  These results will
        then serve as the baseline to evaluate whether improvement occurred from
        calendar  year 2006 to calendar year 2007. Clinical performance
        measure results will be calculated after a sufficient amount of time has
        passed
        after the end of the report period in order to allow for claims
        runout.  For a comprehensive description of the clinical performance
        measures below, see ODJFS
        Methods for
        Clinical Performance Measures
        for the
        CFC Managed
        Care
        Program.  Performance standards
        are
        subject to change based on the revision or update of NCQA
        methods or other national
        standards, methods or benchmarks.

      


      For
        an MCP which had membership as
        of February 1, 2006: MCP performance will be evaluated using an MCP’s
        county-based statewide result for the counties in which the MCP had membership
        as of February 1, 2006.  For reporting periods CY 2007 and CY 2008,
        targets and performance standards for Clinical Performance Measures
        in
        this Appendix (1.c.i – 1.c.vii) will be applicable to all counties in
        which MCPs had membership as of February 1, 2006.  The final reporting
        year for the counties in which an MCP had membership as of February 1, 2006,
        will be CY 2008.

      


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

      


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

      


      For
        measures requiring one year of baseline data, ODJFS will use the first full
        calendar year of data (CY 2007 - which may be adjusted based on the number
        of
        months of managed care membership) from all MCPs serving CFC membership to
        determine statewide minimum performance standards.  CY 2008 will be
        the first reporting year that MCPs will be held accountable to the statewide
        performance standards for one year measures, and penalties will be applied
        for
        noncompliance.

      


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

      


      Statewide
        performance measure results will be calculated after a sufficient amount
        of time
        has passed after the end of the report period in order to allow for claims
        runout.

      


      Report
        Period:  In order
        to adhere to the statewide expansion timeline, reporting periods may be adjusted
        based on the number of months of managed care membership.  For
        the SFY 2007 contract period,
        performance will be evaluated using the January - December
        2006 report
        period.  For the SFY 2008 contract period, performance will be
        evaluated using the January - December 2007 report period.  For
        the SFY 2009 contract period,
        performance will be evaluated using the January – December 2008 report
        period.

      


      1.c.i.  Perinatal
        Care – Frequency of Ongoing Prenatal Care

      


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

      


      County-Based
        Statewide
        Target:  At
        least 80% of the eligible
        population must receive 81% or more of the expected number of prenatal
        visits.

      


      County-Based
        Statewide Minimum
        Performance Standard:  The level of improvement must result in
        at least a 10% decrease in the difference between the target and the previous
        report period’s results. (For example, if last year’s results were 20%, then the
        difference between the target and last year’s results is 60%.  In this
        example, the standard is an improvement in performance of 10% of this difference
        or 6%. In this example, results of 26% or better would be compliant with
        the
        standard.)

      


      Regional-Based
        Statewide
        Target:  TBD

      


      Regional-Based
        Statewide Minimum
        Performance Standard:  TBD

      


      Action
        Required for
        Noncompliance:  Beginning
        SFY
        2007, if
        the standard is not met and the results
        are below 42% (44% for SFY 2009), the MCP is required to complete a
Corrective Action Plan to
        address the area of noncompliance.  If the standard is not met and the
        results are at or above 42% (44% for SFY 2009), ODJFS will issue a Quality
        Improvement Directive which will notify the MCP of noncompliance and may
        outline
        the steps that the MCP must take to improve the results.

      


      1.c.ii.  Perinatal
        Care -
        Initiation of Prenatal Care

      


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

      


      County-Based
        Statewide Target:
At least 90% of the eligible population initiate prenatal care within
        the
        specified time.

      


      County-Based  Statewide
        Minimum Performance Standard: The level of improvement must result in at
        least a 10% decrease in the difference between the target and the previous
        year’s results.

      


      Regional-Based
        Statewide
        Target:  TBD

      


      Regional-Based
        Statewide Minimum
        Performance Standard:  TBD

      


      Action
        Required for
        Noncompliance:  Beginning SFY 2007, 
        if the standard is not
        met and the
        results are below 71% (74% for SFY 2009), 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 71% (74% for SFY 2009), 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.  Perinatal
        Care - Postpartum Care

      


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

      


      County-Based Statewide
        Target: At least
        80% of the eligible population must receive a postpartum visit.

      


      County-Based
        Statewide Minimum
Performance
        Standard: The
        level of improvement must result in
        at least a 5% decrease in the difference between the target and the previous
        year’s results.

      


      Regional-Based
        Statewide
        Target:  TBD

      


      Regional-Based
        Statewide Minimum
        Performance Standard:  TBD

      


      Action
        Required for Noncompliance:
Beginning SFY 2007,  if the standard
        is not
        met and the results are below 48% (50% for SFY 2009), 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 48% (50% for SFY 2009),
        ODJFS will issue a Quality Improvement Directive which will notify the MCP
        of
        noncompliance and may outline the steps that the MCP must take to improve the
        results.

      


      1.c.iv.  Preventive
        Care for Children - Well-Child Visits

      


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

      


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

      


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

      


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

      


      County-Based
        Statewide
        Target:  At least 80% of the eligible children receive the
        expected number of well-child visits.

      


      County-Based  Statewide
        Minimum Performance Standard for Each of the Age Groups:  The
        level of improvement must result in at least a 10% decrease in the difference
        between the target and the previous year’s results.

      


      Regional-Based
        Statewide
        Target:  TBD

      


      Regional-Based
        Statewide Minimum
        Performance Standard for Each of the Age
        Groups:  TBD

      


      Action
        Required for Noncompliance
        (15 month old age group):  Beginning SFY 2007,  if
        the standard is not met and the results are below 34% (42% for SFY 2009),
        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
        34%
        (42% for SFY 2009), ODJFS will issue a Quality Improvement Directive which
        will
        notify the MCP of noncompliance and may outline the steps that the MCP must
        take
        to improve the results.

      


      Action
        Required for
Noncompliance (3-6
        year
        old age group):  Beginning SFY 2007,  if the standard
        is not met and the results are below 50% (57% for SFY 2009), the MCP is required
        to complete a Corrective Action Plan to address the area of noncompliance.
        If
        the standard is not met and the results are at or above 50% (57% for SFY
        2009),
        ODJFS will issue a Quality Improvement Directive which will notify the MCP
        of
        noncompliance and may outline the steps that the MCP must take to improve
        the
        results.

      


      Action
        Required
for
        Noncompliance (12-21
        year old age group):  Beginning SFY 2007, if the standard is
        not met and the results are below 30% (33% for SFY 2009), 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 30% (33% for SFY 2009),
        ODJFS will issue a Quality Improvement Directive which will notify the MCP
        of
        noncompliance and may outline the steps that the MCP must take to improve
        the
        results.

      


      1.c.v.   Use
        of Appropriate Medications for People with Asthma

      


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

      


      County-Based
        Statewide
        Target: At least 95% of the eligible population must receive the
        recommended medications.

      


      County-Based
        Statewide Minimum
        Performance Standard: The level of improvement must result in at least a
        10% decrease in the difference between the target and the previous year’s
        results.

      


      Regional-Based
        Statewide
        Target:  TBD

      


      Regional-Based
        Statewide Minimum
        Performance Standard:  TBD

      


      Action
        Required for Noncompliance:
Beginning SFY 2007,  if the standard
        is not
        met and the results are below 83% (84% for SFY 2009), 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 83% (84% for SFY 2009),
        ODJFS will issue a Quality Improvement Directive which will notify the MCP
        of
        noncompliance and may outline the steps that the MCP must take to improve
        the
        results.

      


      1.c.vi.  Annual
        Dental Visits

      


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

      


      County-Based
        Statewide
        Target:At
        least 60% of the eligible population
        receive a dental visit.

      


      County-Based
        Statewide Minimum
        Performance Standard: The level of improvement must result in at least a
        10% decrease in the difference between the target and the previous year’s
        results.

      


      Regional-Based
        Statewide
        Target:  TBD

      


      Regional-Based
        Statewide Minimum
        Performance Standard:  TBD

      


      Action
        Required for
        Noncompliance:  Beginning SFY 2007,  if the standard
        is not met and the results are below 40% (42% for SFY 2009), 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 40% (42% for SFY
        2009),
        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.  Lead
        Screening

      


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

      


      County-Based
        Statewide
        Target: At least 80% of the eligible population receive a blood lead
        screening.

      


      County-Based
        Statewide Minimum
        Performance Standard for Each of the Age Groups: The level of improvement
        must result in at least a 10% decrease in the difference between the target
        and
        the previous year’s results.

      


      Regional-Based
        Statewide
        Target:  TBD

      


      Regional-Based
        Statewide Minimum
        Performance Standard for Each of the Age
        Groups:  TBD

      


      Action
        Required for Noncompliance (1
        year olds): Beginning SFY 2007,  if the standard is not met and
        the results are below 45% the MCP is required to complete a Corrective Action
        Plan to address the area of noncompliance. If the standard is not met and
        the
        results are at or above 45%, ODJFS will issue a Quality Improvement Directive
        which will notify the MCP of noncompliance and may outline the steps that
        the
        MCP must take to improve the results.

      


      Action
        Required for Noncompliance (2
        year olds): Beginning SFY 2007, if the standard is not met and the
        results are below  28% the MCP is required to complete a Corrective
        Action Plan to address the area of noncompliance.  If the standard is
        not met and the results are at or above 28%, ODJFS will issue a Quality
        Improvement Directive which will notify the MCP of noncompliance and may
        outline
        the steps that the MCP must take to improve the results.

      


      2.  ACCESS

      


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

      


      2.a.
        PCP Turnover

      


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

      


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

      


      For
        an MCP which had membership as
        of February1, 2006:
MCP performance
        will be evaluated using an MCP’s county-based statewide
        result for the counties in which the MCP had membership as
        of  February 1, 2006.  The minimum performance standard in
        this Appendix (2.a)
        will be applicable to the MCP’s county-based statewide result for the counties
        in which the MCP had membership as of February 1, 2006.  The last
        reporting year using  the MCP’s county-based statewide result for the
        counties in which the MCP had membership as of February 1, 2006 for performance
        evaluation is CY 2007; the last reporting year using the MCP’s county-based
        statewide result for the counties in which the MCP had membership as of February
        1, 2006 for P4P (Appendix
        O) is CY 2008.

      


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

      


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

      


      Report
        Period: In order to
        adhere to the statewide expansion timeline, reporting periods may be adjusted
        based on the number of months of managed care membership.  For the SFY
        2007 contract period, performance will be evaluated using the January - December
        2006 report period.  For the SFY 2008 contract period, performance
        will be evaluated using the January - December 2007 report
        period.  For the SFY 2009 contract period, performance will be
        evaluated using the January - December 2008 report period.

      


      County-Based
        Statewide Minimum
        Performance Standard:  A maximum PCP Turnover rate of
        18%.

      Regional-Based
        Statewide Minimum
        Performance Standard:  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.
        Children’s Access to Primary Care

      


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

      


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

      


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

      


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

      


      Regional-Based
        Statewide
        Approach: MCPs will be evaluated statewide, using results for all active
        regions and counties (Mahoning and Trumbull) in which the MCP has membership.
        ODJFS will use the first two full calendar years of data (CY 2007 and CY
        2008 -
        which may be adjusted based on the number of months of managed care
        membership)  from all MCPs serving CFC membership as a
        baseline  to determine a statewide minimum performance
        standard.  CY 2009 will be the first reporting year that MCPs will be
        held accountable to the statewide performance standard for statewide reporting,
        and penalties will be applied for noncompliance.  Statewide
        performance measure results will be calculated after a sufficient amount
        of time
        has passed after the end of the report period in order to allow for claims
        runout.

      


      Report
        Period: In
        order
        to adhere to the statewide expansion timeline, reporting periods may be adjusted
        based on the number of months of managed care membership.  For the SFY
        2007 contract period, performance will be evaluated using the January - December
        2006 report period.  For
        the SFY 2008 contract period,
        performance
        will be evaluated using the January - December 2007 report
        period.  For the SFY 2009 contract period, performance will be
        evaluated using the January - December 2008 report period.

      


      County-Based Statewide
        Minimum Performance
        Standards:

      


      CY
        2006
        report period – 70% of children must receive a visit.

      CY
        2007 report period – 71% of children
        must receive a visit

      CY
        2008
        report period – 74% of children must receive a visit

      


      Regional-Based
        Statewide 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 age 20 and older who had an ambulatory or preventive-care
        visit.

      


      For
        an MCP which had membership as
        of February1, 2006:
MCP performance
        will be evaluated using an MCP’s county-based statewide
        result for the counties in which the MCP had membership as of February 1,
        2006.  The minimum performance standard in this Appendix (2.c) will be
        applicable to the MCP’s county-based statewide result for the counties in which
        the MCP had membership as of  February 1, 2006.  The last
        reporting year using  the MCP’s county-based statewide result for the
        counties in which the MCP had membership as of February 1, 2006 for performance
        evaluation is CY 2007; the last reporting year using the MCP’s county-based
        statewide result for the counties in which the MCP had membership as
        of  February 1, 2006 for P4P (Appendix
        O) is CY 2008.

      


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

      


      Regional-Based
        Statewide
        Approach:  MCPs will be evaluated statewide, using results for
        all active regions and counties (Mahoning and Trumbull) in which the MCP
        has
        membership. ODJFS will use the first full calendar year of data (CY 2007
        - which
        may be adjusted based on the number of months of managed care
        membership)  from all MCPs serving CFC membership as a baseline to
        determine a statewide minimum performance standard.  CY 2008 will be
        the first reporting year that MCPs will be held accountable to the statewide
        performance standard for statewide reporting, and penalties will be applied
        for
        noncompliance.  Statewide performance measure results will be
        calculated after a sufficient amount of time has passed after the end of
        the
        report period in order to allow for claims runout.

      


      Report
Period: In
        order
        to adhere to the statewide expansion timeline, reporting periods may be adjusted
        based on the number of months of managed care membership.  For the SFY
        2007 contract period, performance will be evaluated using the January - December
        2006 report period. For the SFY
        2008 contract period, performance will be evaluated using the January - December
        2007 report period.  For
        the SFY 2009 contract period,
        performance will be evaluated using the January - December 2008 report
        period.

      


      County-Based
        Statewide Minimum
        Performance Standards:

      CY
        2006
        report period – 63% of adults must receive a visit.

      CY
        2007
        report period – 63% of adults must receive a visit.

      CY
        2008
        report period – 63% of adults must receive a visit.

      


      Regional-Based
        Statewide 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.d.
        Members’ Access to Designated PCP

      


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

      


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

      


      Regional-Based
        Statewide Approach:
MCPs  will be evaluated statewide, using results for all active
        regions and counties (Mahoning and Trumbull) in which the MCP has
        membership.  ODJFS will use the first full calendar year of data (CY
        2007 - which may be adjusted based on the number of months of managed care
        membership) from all MCPs serving CFC membership as a baseline to determine
        a
        statewide minimum performance standard.  CY 2008 will be the first
        reporting year that MCPs will be held accountable to the performance standard
        and penalties will be applied for noncompliance.  Statewide
        performance measure results will be calculated after a sufficient amount
        of time
        has passed after the end of the report period in order to allow for claims
        runout.

      


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

      


      Regional-Based
        Statewide Minimum
        Performance Standard:
        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

      


      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.  For
        SFY 2007 and SFY 2008, performance in this
        category will be
        determined by the overall satisfaction score.  For a comprehensive
        description of the Consumer
        Satisfaction performance measure below, see ODJFS
        Methods for the Consumer
        Satisfaction Performance Measure for the CFC Program.

      


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

      


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

      


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

      


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

      


      Report
        Period: For the SFY
        2007
        contract period, performance will be evaluated using the results from the
        CY
        2007 consumer satisfaction survey.   For the SFY 2008 contract
        period, performance will be evaluated using the results from the CY 2008
        consumer satisfaction survey.  For the SFY 2009 contract period,
        performance will be evaluated using the results from the CY 2009 consumer
        satisfaction survey.

      


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

      


      Regional-Based
        Statewide Minimum Performance Standard: TBD

      


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

       

      4.
        ADMINISTRATIVE
        CAPACITY

      


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

      


      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 (applicable
        to performance
        evaluation through  SFY  2008 and P4P through SFY
        2007)

      


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

      


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

      


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

       

      Report
        Period:  For
        the SFY 2007 contract period, a baseline level of performance will be set
        using
        the January - June 2006 report period.  Results will be calculated for
        the reporting period of July - December 2006 and compared to the baseline
        results to determine if the minimum performance standard is met. For the
        SFY
        2008 contract period, a baseline level of performance will be set using the
        January - June 2007 report period.  Results will be calculated for the
        reporting period of July - December 2007 and compared to the baseline results
        to
        determine if the minimum performance standard is met

      


      County-Based  Statewide
        Target:
A maximum of  0.70% of the eligible population will have four
        or more ED visits during the reporting period.

      


      County-Based
        Statewide Minimum
        Performance Standard: The level of improvement must result in at least a
        10% decrease in the difference between the target and the baseline period
        results.

      


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

      


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

      


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

      


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

      


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

      


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

      


      Regional-Based
        Statewide Target:
A maximum of  TBD of the eligible population will have TBD or
        more targeted ED visits during the reporting period.

      


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

      


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

      


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

      


      5.b.
        Monetary
        Sanctions

      


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

      


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

      


      5.c. Combined
        Remedies

      


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

      


      5.d.
        Enrollment Freezes

      


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

      


      5.e.
        Reconsideration

      


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

      


      5.f.
        Contract Termination, Nonrenewals or Denials

      


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


      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      


      APPENDIX
        N

      


      COMPLIANCE
        ASSESSMENT SYSTEM 

      CFC
        ELIGIBLE POPULATION

      


      


      I.
        General Provisions of the Compliance Assessment System

      


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

      


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

      


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

      


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

      


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

      


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

      


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

      


      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)

              
	
                16-25
                  Points

              	
                CAP
                  + $5,000
                  fine

              
	
                26-50
                  Points

              	
                CAP
                  + $10,000
                  fine

              
	
                51-70
                  Points

              	
                CAP
                  + $20,000
                  fine

              
	
                71-100
                  Points

              	
                CAP
                  + $30,000
                  fine

              
	
                100+
                  Points

              	
                Proposed
                  Contract Termination

              


      

      


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

      


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

      


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

      


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

      


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

      


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

      


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

      


      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)

      CFC
        ELIGIBLE
        POPULATION

      


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

      


      To
        qualify for consideration of any P4P,
        MCPs must meet minimum performance standards established in Appendix M,
Performance
        Evaluationon selected
        measures, and achieve P4P standards established for selected Clinical
        Performance Measures.  For qualifying MCPs, higher performance
        standards for three measures must be reached to be awarded a portion of the
        at-risk amount and any additional P4P (see Sections 1 and 2).  An
        excellent and superior standard is set in this Appendix for each of the three
        measures.  Qualifying MCPs will be awarded a portion of the at-risk
        amount for each excellent standard met.  If an MCP meets all three
        excellent and superior standards, they may be awarded additional P4P (see
        Section 3).

      


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

      


      1.
        SFY 2007 P4P

      


      1.a.
        Qualifying Performance Levels

      


      To
        qualify for consideration of the SFY
        2007 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 Emergency
        Department Diversion and Clinical Performance Measures
        below.

      


      A
        detailed description of the
        methodologies for each measure can be found on the BMHC page of the ODJFS
        website.

      


      Measures
        for which the minimum
        performance standard for SFY 2007 established in Appendix M, Performance
        Evaluation, must be met to
        qualify for consideration of  P4P are
        as follows:

      


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

      


      Report
        Period: CY
        2006


      


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

      


      Report
        Period: CY
        2006

      


      3.  Adults’
Access
        to
        Preventive/Ambulatory Health Services (Appendix M, Section
        2.c.)

      


      Report
        Period: CY
        2006                                                    


      


      4.
        Overall Satisfaction with MCP
        (Appendix M, Section 3.)

      


      Report
        Period: The
        most recent consumer satisfaction
        survey completed prior to the end of the SFY 2007 contract
        period.

      


      For
        the EDD performance measure, the MCP
        must meet the  P4P standard
        for the report period of July -
        December, 2006 to be considered for SFY 2007 P4P.  The
        MCP meets the
P4P standard
        if one of two criteria are
        met.  The  P4P standard
        is a performance level of
        either:

      


      1)
        The minimum performance standard
        established in Appendix M, Section 4.b.; or

      


      2)
        The Medicaid benchmark of a
        performance level at or below 1.1%.

      


      For
        each clinical performance measure
        listed below, the
        MCP must meet the P4P standard to be considered for SFY 2007 P4P.  The
        MCP meets the P4P
        standard if one of two criteria are met.  The P4Pstandard
        is a performance level of
        either:

      


      1)
        The minimum performance standard
        established in Appendix M,
Performance
        Evaluation, for seven of
        the nine clinical performance measures listed below; or

      


      2)
        The Medicaid benchmarks for seven of
        the nine clinical performance measures listed below.  The Medicaid
        benchmarks are subject to change based on the revision or update of applicable
        national standards, methods or benchmarks.

      


      
        	
                
                

                Clinical
                  Performance Measure

              	
                Medicaid
                  Benchmark

              
	
                1.
                  Perinatal Care - Frequency of
                  Ongoing Prenatal Care

              	
                42%

              
	
                2.
                  Perinatal Care - Initiation of
                  Prenatal Care

              	
                71%

              
	
                3.
                  Perinatal Care - Postpartum
                  Care

              	
                48%

              
	
                4.
                  Well-Child Visits – Children
                  who turn 15 months old

              	
                34%

              
	
                5.
                  Well-Child Visits - 3, 4, 5, or
                  6, years old

                6.
                  Well-Child Visits - 12 through
                  21 years old

                7.
                  Use of Appropriate Medications
                  for People with Asthma

                8.
                  Annual Dental
                  Visits

                9.
                  Blood Lead – 1 year
                  olds

              	
                50%

                30%

                83%

                40%

                45%

              


      

      


      


      


      1.b.
        Excellent and Superior Performance
        Levels

      


      For
        qualifying MCPs as determined by
        Section 2.a., performance will be evaluated on the
        measures below to
        determine the status of the at-risk amount or any additional P4P that
        may be
        awarded.  Excellent and Superior standards
        are set for the three measures
        described below.  The standards are subject to change based on the
        revision or update of applicable national standards, methods or
        benchmarks.

      


      A
        brief description of these measures is
        provided in Appendix M, Performance
        Evaluation.  A
        detailed description of the methodologies for each measure can be found on
        the
        BMHC page of the ODJFS website.

      


      1.
        Case Management of Children (Appendix
        M, Section 1.b.ii.)

      


      Report
        Period: April - June
        2007

      


      Excellent
        Standard:
        5.5%

       

      Superior
        Standard:
        6.5%

      


      2.
        Use of Appropriate Medications for
        People with Asthma (Appendix M, Section 1.c.vi.)

      


      Report
        Period: CY
        2006

      


      Excellent
        Standard:
        86%

      


      Superior
        Standard:
        88%


      


      3.
        Adults’ Access to
        Preventive/Ambulatory Health Services (Appendix M, Section
        2.c.)

      


      Report
        Period: CY
        2006

      


      Excellent
        Standard:
        76%

      


      Superior
        Standard:
        83%

      


      1.c.
        Determining SFY 2007 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 Superior standards
        established in Section 1.b.
        herein, additional P4P may be awarded.  For MCPs receiving additional
        P4P, the amount in the P4P fund
        (see section 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.
        SFY 2008 P4P

      


      2.a.
        Qualifying Performance
        Levels

      


      To
        qualify for consideration of the SFY
        2008 P4P,
        an MCP’s performance level must meet
        the minimum performance standards set in Appendix M, Performance
        Evaluation, for the
        measures listed below.  A detailed description of the methodologies
        for each measure can be found on the BMHC page of the ODJFS
        website.

      


      Measures
        for which the minimum
        performance standard for SFY 2008 established in Appendix M, Performance
        Evaluation, must be met to
        qualify for consideration of  P4P are
        as follows:

      


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

      


      Report
        Period: CY
        2007

      


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

      


      Report
        Period: CY
        2007

      


      3.  Adults’
Access
        to
        Preventive/Ambulatory Health Services (Appendix M, Section
        2.c.)

      


      Report
        Period: CY
        2007                                                    


      


      4.
        Overall Satisfaction with MCP
        (Appendix M, Section 3.)

      


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

      


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

      


      1)
        The minimum performance standard
        established in Appendix M, Performance
        Evaluation, for seven of
        the nine clinical performance measures listed below; or

      


      2)
        The Medicaid benchmarks for seven of
        the nine clinical performance measures listed below.  The Medicaid
        benchmarks are subject to change based on the revision or update of applicable
        national standards, methods or benchmarks.

      


      


      
        	
                
                

                Clinical
                  Performance Measure

              	
                Medicaid
                  Benchmark

              
	
                1.
                  Perinatal Care - Frequency of
                  Ongoing Prenatal Care

              	
                42%

              
	
                2.
                  Perinatal Care - Initiation of
                  Prenatal Care

              	
                71%

              
	
                3.
                  Perinatal Care - Postpartum
                  Care

              	
                48%

              
	
                4.
                  Well-Child Visits – Children
                  who turn 15 months old

              	
                34%

              
	
                5.
                  Well-Child Visits - 3, 4, 5, or
                  6, years old

                6.
                  Well-Child Visits - 12 through
                  21 years old

                7.
                  Use of Appropriate Medications
                  for People with Asthma

                8.
                  Annual Dental
                  Visits

                9.
                  Blood Lead – 1 year
                  olds

              	
                50%

                30%

                83%

                40%

                45%

              


      

      


      2.b.
        Excellent and Superior Performance
        Levels

      


      For
        qualifying MCPs as determined by
        Section 2.a., performance will be evaluated on the measures below to determine
        the status of the at-risk amount or any additional P4P that
        may be
        awarded.  Excellent and Superior standards
        are set for the three measures
        described below.  The standards are subject to change based on the
        revision or update of applicable national standards, methods or
        benchmarks.

      


      A
        brief description of these measures is
        provided in Appendix M, Performance
        Evaluation.  A
        detailed description of the methodologies for each measure can be found on
        the
        BMHC page of the ODJFS website.

      


      1.
        Case Management of Children (Appendix
        M, Section 1.b.i.)

      


      Report
        Period: April - June
        2008

      


      Excellent
        Standard:
        5.5%

      


      Superior
        Standard:
        6.5%

      


      2.
        Use of Appropriate Medications for
        People with Asthma (Appendix M, Section 1.c.v.)

      


      Report
        Period: CY
        2007

      


      Excellent
        Standard:
        86%

      


      Superior
        Standard:
        88%


      


      3.
        Adults’ Access to
        Preventive/Ambulatory Health Services (Appendix M, Section
        2.c.)

      


      Report
        Period: CY
        2007

      


      Excellent
        Standard:
        76%

      


      Superior
        Standard:
        84%

      


      2.c.
        Determining SFY 2008
        P4P

      


      MCP’s
        reaching the minimum performance
        standards described in Section 2.a. herein, will be considered for P4P including
        retention of the at-risk
        amount and any additional P4P.  For
        each Excellent standard
        established in Section 2.b. herein, that an MCP meets, one-third of the at-risk
        amount may be retained.  For MCPs meeting all of the Excellent and
Superiorstandards
        established in Section 2.b.
        herein, additional P4P
may
        be
        awarded.  For MCPs receiving additional P4P,
        the amount in the P4P fund (see
        Section 3.) will be divided equally, up to the maximum additional amount,
        among
        all MCPs’ ABD and/or CFC programs receiving additional P4P.  The
        maximum additional
        amount to be awarded per plan, per program, per contract year is
        $250,000.  An MCP may receive up to $500,000 should both of the MCP’s
        ABD and CFC programs achieve the Superior Performance
        Levels.

      


      3.
        NOTES

      


      3.a.
        Transition from a county-based statewide to a regional-based statewide P4P
        system.

      


      The
        current county-based statewide P4P system will transition to a regional-based
        statewide system as managed care expands statewide.  The
        regional-based statewide approach will be fully phased in no later than SFY
        2010.  The regional-based statewide P4P system will be modeled after
        the county-based statewide system with adjustments to performance standards
        where appropriate.

      


      3.a.i.
        County-based statewide P4P system

      


      For
        MCPs
        in their first twenty-four months of Ohio Medicaid CFC Managed Care Program
        participation, the status of the at-risk amount will not be determined because
        compliance with many of the standards cannot be determined in an MCP’s first two
        contract years (see Appendix F., Rate Chart). In addition,
        MCPs in their first two contract years are not eligible for the additional
        P4P
        amount awarded for superior performance.

      


      Starting
        with the twenty-fifth month of participation in the program, a new MCP’s at-risk
        amount will be included in the P4P system. The determination of the status
        of
        this at-risk amount will be after at least three full calendar years of
        membership as many of the performance standards require three full calendar
        years to determine an MCP’s performance level.  Because of this
        requirement, more than 12 months of at-risk dollars may be included in an
        MCP’s
        first at-risk status determination depending on when an MCP starts with the
        program relative to the calendar year.

      


      During
        the transition to a regional-based statewide system (SFY 2006 through SFY
        2009),
        MCPs with membership as of  February 1, 2006 will continue in the
        county-based statewide P4P system until the transition is
        complete.  These MCPs will be put at-risk for a portion of the
        premiums received for members in counties they are serving as of February
        1,
        2006.

      


      3.a.ii.
        Regional-based statewide P4P system

      


      All
        MCPs will be included in the
        regional-based statewide P4P system.  The at-risk amount will
        be determined separately for each region an MCP serves.

      


      The
        status of the at-risk amount for counties not included in the county-based statewide
        P4P
        system will not be determined for the first twenty-four months of regional
        membership.  Starting with the twenty-fifth month of regional
        membership, the MCP’s at-risk amount will be included in the P4P system. The
        determination of the status of this at-risk amount will be after at least
        three
        full calendar years of regional membership as many of the performance standards
        require three full calendar years to determine an MCP’s performance level. Given
        that statewide expansion was not complete by December 31, 2006, ODJFS may
        adjust
        performance measure reporting periods based on the number of months an MCP
        has
        had regional membership. Because of this requirement, more than 12 months
        of
        at-risk dollars may be included in an MCP’s first regional at-risk status
        determination depending on when regional membership starts relative to the
        calendar year.  Regional premium payments for months prior to July
        2009 for members in counties included in the county-based statewide P4P system
        for the SFY 2009 P4P determination, will be excluded from the at-risk dollars
        included in the first regional-based statewide
        P4P determination.

      


      3.b.
        Determination of at-risk amounts and additional P4P payments

      


      For
        MCPs
        that have participated in the Ohio Medicaid Managed Care Program long enough
        to
        calculate performance levels for all of the performance measures included
        in the
        P4P system, determination of the status of an MCP’s at-risk amount will occur
        within six months of the end of the contract period.  Determination of
        additional P4P payments will be made at the same time the status of an MCP’s
        at-risk amount is determined.

      


      3.c.
        Contract Termination, Nonrenewals, or Denials

      


      Upon
        termination, nonrenewal or denial of an MCP contract, the at-risk amount
        paid to
        the MCP under the current provider agreement will be returned to
        ODJFS  in accordance with Appendix P., Terminations/Nonrenewals/Amendments,
        of the provider agreement.

      


      Additionally,
        in accordance with Article XI of the provider agreement, the return of the
        at-risk amount paid to the MCP under the current provider agreement will
        be a
        condition necessary for ODJFS’ approval of a provider agreement
        assignment.

      


      3.d.
        Report Periods

      


      The
        report period used in determining the MCP’s performance levels varies for each
        measure depending on the frequency of the report and the data
        source.  Unless otherwise noted, the most recent report or study
        finalized prior to the end of the contract period will be used in determining
        the MCP’s overall performance level for that contract
        period.