exv10w24w1



 





EXHIBIT 10.24.1



PROVIDER AGREEMENT



BETWEEN


STATE OF OHIO


DEPARTMENT OF JOB AND FAMILY SERVICES


AND


MOLINA HEALTHCARE 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 MOLINA HEALTHCARE 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.




	 	 	 	 	 
	 
	 	 	 	 
	MOLINA HEALTHCARE OF OHIO, INC:
	 
	 	 	 	 
	BY:
	 	/s/ Kathie Mancini
	 	DATE: 12/20/07
	 
	 	 	 	 
	 	 	KATHIE MANCINI, PRESIDENT      On behalf of Kathie Mancini
	 
	 	 	 	 
	OHIO DEPARTMENT OF JOB AND FAMILY SERVICES:
	 
	 	 	 	 
	BY:
	 	/s/ Helen E. Jones-Kelley
	 	DATE: 12/20/07
	 
	 	 	 	 
	 	 	HELEN E. JONES-KELLEY, DIRECTOR





 








 






Appendix C

Covered Families and Children (CFC) population

Page 1




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.




 









 











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Covered Families and Children (CFC) population

Page 2





	7.	 	Upon request by ODJFS, the MCP must submit information on the current status of their
company’s operations not specifically covered under this 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




 









 











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Covered Families and Children (CFC) population

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	 	 	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:




 









 











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Covered Families and Children (CFC) population

Page 4





	 	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




 









 











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Covered Families and Children (CFC) population

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	 	 	(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.




 









 











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	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




 









 











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	 	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, except for the following major holidays:






	 	•	 	New Year’s Day
	 
	 	•	 	Martin Luther King’s Birthday
	 
	 	•	 	Memorial Day




 









 











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	 	•	 	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




 









 











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	 	 	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






 











 





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	 	 	 	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.




 









 











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	 	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.




 









 











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	 	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




 









 











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	 	 	 	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;




 









 











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	 	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.




 









 











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	 	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:




 









 












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	 	a.	 	Before an MCP may submit production files
	 
	 	b.	 	Whenever an MCP changes the method or preparer of the electronic media; and/or
	 
	 	c.	 	When the ODJFS determines an MCP’s data submissions have an unacceptably high error rate.






	 	 	 	MCPs that change or modify information systems that are involved in producing any
type of electronically submitted files, either internally or by changing vendors,
are required to submit to ODJFS for review and approval a transition plan
including the submission of test files in the ODJFS-specified formats. Once an
acceptable test file is submitted to ODJFS, as determined solely by ODJFS, the MCP
can return to submitting production files. ODJFS will inform MCPs in writing when
a test file is acceptable. Once an MCP’s new or modified
information system is
operational, that MCP will have up to ninety (90) days to submit an acceptable
test file and an acceptable production file.
	 
	 	 	 	Submission of test files can start before the new or modified information system
is in production. ODJFS reserves the right to verify any MCP’s capability to
report elements in the minimum data set prior to executing the provider agreement
for the next contract period. Penalties for noncompliance with this requirement
are specified in Appendix N, Compliance Assessment System of the Provider
Agreement.






	 	b.	 	Electronic Data Interchange and Claims Adjudication Requirements






	 	 	 	Claims Adjudication 
	 
	 	 	 	The MCP must have the capacity to electronically accept and adjudicate all claims to final status
(payment or denial). Information on claims submission procedures must be provided to non-contracting providers
within thirty (30) days of a request. MCPs must inform providers of its ability to
electronically process and adjudicate claims and the process for submission. Such
information must be initiated by the MCP and not only in response to provider requests.
	 
	 	 	 	The MCP must notify providers who have submitted claims of claims status [paid,
denied, pended (suspended)] within one month of receipt. Such
notification be in the form of a claim payment/remittance advice produced on
a  routine monthly, or more frequent, basis.




 









 












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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



 









 





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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




 









 











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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.




 












 





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	 	 	 	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.






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






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






	 	ii.	 	Review the completed ISCA and accompanying documents;






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






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




 









 











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	 	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





 









 





Appendix C

Covered Families and Children (CFC) population

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	 	 	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).
	 










 









 











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	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 Provider Directory – MCPs must have an
internet-based provider directory available in the same format as their ODJFS-approved
provider directory, that allows members to electronically search for the MCP panel
providers based on name, provider type, geographic proximity, and population (as
specified in Appendix H). MCP provider directories must include all MCP-contracted
providers [except as specified by ODJFS] as well as certain ODJFS non-contracted
providers.
	 
	 	b.	 	On-line Member Website – MCPs must have a secure
internet-based website which is regularly updated to include the most current ODJFS
approved materials. The website at a minimum must include: (1) a list of the counties
that are covered










 









 











Appendix C

Covered Families and Children (CFC) population

Page 24





	 	 	 	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.





 









 





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Page 25





	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

Covered Families and Children (CFC)
population
 Page 1




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.





 









 





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Covered Families and Children (CFC)
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Page 2





	10.	 	On a monthly basis, ODJFS will provide MCPs with an electronic Master Provider File
containing all the Ohio Medicaid fee-for-service providers, which includes their Medicaid
Provider Number, as well as all providers who have been assigned a provider reporting number
for current encounter data purposes.
	 
	11.	 	It is the intent of ODJFS to utilize electronic commerce for many processes and procedures
that are now limited by HIPAA privacy concerns to FAX, telephone, or hard copy. The use of TLS
will mean that private health information (PHI) and the identification of consumers as
Medicaid recipients can be shared between ODJFS and the contracting MCPs via e-mail such as
reports, copies of letters, forms, hospital claims, discharge records, general discussions of
member-specific information, etc. ODJFS may revise data/information exchange policies and
procedures for many functions that are now restricted to FAX, telephone, and hard copy,
including, but not limited to, monthly membership and premium payment reconciliation requests,
newborn reporting, Just Cause disenrollment requests, information requests etc. (as specified
in Appendix C).
	 
	12.	 	ODJFS will immediately report to Center for Medicare and Medicaid Services (CMS) any breach
in privacy or security that compromises protected health information (PHI), when reported by
the MCP or ODJFS staff.
	 
	13.	 	Service Area Designation
	 
	 	 	Membership in a service area is mandatory unless ODJFS approves membership in the service
area for consumer initiated selections only. It is ODJFS’current intention to implement a
mandatory managed care program in service areas wherever choice and capacity allow and the
criteria in 42 CFR 438.50(a) are met.
	 
	14.	 	Consumer information






	 	a.	 	ODJFS or its delegated entity will provide membership notices,
informational materials, and instructional materials relating to members and eligible
individuals in a manner and format that may be easily understood. At least annually,
ODJFS or designee will provide MCP eligible individuals, including current MCP
members, with a Consumer Guide. The Consumer Guide will describe the managed care
program and include information on the MCP options in the service area and other
information regarding the managed care program as specified in 42 CFR 438.10.
	 
	 	b.	 	ODJFS will notify members or ask MCPs to notify members about significant
changes affecting contractual requirements, member services or access to providers.
	 
	 	c.	 	If an MCP elects not to provide, reimburse, or cover a counseling service
or referral service due to an objection to the service on moral or religious grounds,
ODJFS will provide coverage and reimbursement for these services for the MCP’s
members.





 









 





Appendix D

Covered Families and Children (CFC)
population 
Page 3





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






	15.	 	Membership Selection and Premium Payment 






	 	a.	 	The managed care enrollment center (MCEC): The ODJFS-contracted MCEC will
provide unbiased education, selection services, and community outreach for the
Medicaid managed care program. The MCEC shall operate a statewide toll-free telephone
center to assist eligible individuals in selecting an MCP or choosing a health care
delivery option.
	 
	 	 	 	The MCEC shall distribute the most current Consumer Guide that includes the
managed care program information as specified in 42 CFR 438.10, as well as ODJFS
prior-approved MCP materials, such as solicitation brochures and provider
directories, to consumers who request additional materials.
	 
	 	b.	 	Auto-Assignment Limitations – In order to 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.





 









 





Appendix D

Covered Families and Children (CFC)
population 
 Page 4





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


 

 









 





Appendix D

Covered Families and Children (CFC)
population 
Page 5






	 	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.



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 information presented.




Offices in principal Cities Worldwide




 









 





			
	 	 	 
	
	 	Mr. Jon Barley, Ph.D.

December 12, 2007

Page 2






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.



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 information presented.




 









 








			
	 	 	 
	
	 	Mr. Jon Barley, Ph.D.

December 12, 2007

Page 3






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.



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 information presented.




 









 








			
	 	 	 
	
	 	Mr. Jon Barley, Ph.D.

December 12, 2007

Page 4






FINAL and CONFIDENTIAL




Table 2




STATE OF OHIO

DEPARTMENT OF JOB AND FAMILY SERVICES

Categories of Service




	 	 	 	 	 	 	 
	Type of Service	 	Service Category	 	Utilization Units	 	Classification Basis
	Inpatient Hospital

	 	Medical/Surgical
	 	Admits/Days
	 	COS, DRG
	 

	 	MH/SA
	 	Admits/Days	 	 
	 

	 	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	 	 
	 

	 	Immunizations & Injections
	 	Services	 	 
	 

	 	Physical Medicine
	 	Services	 	 
	 

	 	Miscellaneous Services
	 	Line Items, Services	 	 
	 
	 	 	 	 	 	 
	Rad/Path/Lab

	 	Radiology
	 	Services
	 	COS, Revenue Code, Provider

	 

	 	Pathology/Laboratory
	 	Services	 	Type, Procedure
	 
	 	 	 	 	 	 
	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





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 information presented.




 









 





			
	 	 	 
	
	 	Mr. Jon Barley, Ph.D.

December 12, 2007

Page 5






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 TyoeType	 	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.



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 information presented.




 









 





			
	 	 	 
	
	 	Mr. Jon Barley, Ph.D.

December 12, 2007

Page 6






FINAL and CONFIDENTIAL



The FFS 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 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



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 information
presented.




 









 





			
	 	 	 
	
	 	Mr. Jon Barley, Ph.D.

December 12, 2007

Page 7






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




	 	 	 	 	 	 	 
	 	 	Effective	 	 	 	 
	Program Adjustment	 	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

HF F-19 to 44
	 

	 	 	 	 	 	HF M/F-45 to 64
	 

	 	 	 	 	 	HST F-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
	 

	 	 	 	 	 	HST F-19 to 64
	Vision Hardware Co-Pay

($1 Per Item)

	 	1/1/2006
	 	Vision /

Optometric
	 	HF M-19 to 44

HF F-19 to 44
	 

	 	 	 	 	 	HF M/F-45 to 64
	 

	 	 	 	 	 	HST F-19 to 64
	ER Co-Pay

($3 Per Non-Emergency Visit)

	 	1/1/2006
	 	Emergency Room
	 	HF M-19 to 44

HF F-19 to 44
	 

	 	 	 	 	 	HF M/F-45 to 64
	 

	 	 	 	 	 	HST F-19 to 64
	Dental Benefit Reduction

	 	1/1/2006
	 	Dental
	 	HF M-19 to 44
	 

	 	 	 	 	 	HF F-19 to 44
	 

	 	 	 	 	 	HF M/F-45 to 64
	 

	 	 	 	 	 	HST F-19 to 64





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 information presented.




 









 








			
	 	 	 
	
	 	Mr. Jon Barley, Ph.D.

December 12, 2007

Page 8






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.



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 information
presented.





 









 





			
	 	 	 
	
	 	Mr. Jon Barley, Ph.D.

December 12, 2007

Page 9






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 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.



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 information
presented.
















 





			
	     	 	 
	
	 	Mr. Jon Barley, Ph.D.

December 12, 2007

Page 10






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; Surnmacare
	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






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 information presented.




 









 








			
	     	 	 
	
	 	Mr. Jon Barley, Ph.D.

December 12, 2007

Page 11






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.



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 information presented.




 









 








			
	     	 	 
	
	 	Mr. Jon Barley, Ph.D.

December 12, 2007

Page 12






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.



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 information presented.




 









 








			
	     	 	 
	
	 	Mr. Jon Barley, Ph.D.

December 12, 2007

Page 13






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 the 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.



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 information presented.




 









 








			
	     	 	 
	
	 	Mr. Jon Barley, Ph.D.

December 12, 2007

Page 14






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 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.



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 information presented.




 









 








			
	     	 	 
	
	 	Mr. Jon Barley, Ph.D.

December 12, 2007

Page 15






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 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.




	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.



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 information presented.




 









 








			
	     	 	 
	
	 	Mr. Jon Barley, Ph.D.

December 12, 2007

Page 16






FINAL and CONFIDENTIAL





	i.	 	Managed Care Adjustments





Milllman 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.



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 information presented.




 









 








			
	     	 	 
	
	 	Mr. Jon Barley, Ph.D.

December 12, 2007

Page 17






FINAL and CONFIDENTIAL




Table 8




STATE OF OHIO

DEPARTMENT OF JOB AND FAMILY SERVICES

Prospective Program Adjustments




	 	 	 	 	 	 	 
	 	 	Effective	 	Service	 	 
	Program Adjustment	 	Date	 	Category(s)	 	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
	 

	 	 	 	 	 	HST F — 14 to 18
	CHIP III Expansion

	 	1/1/2008
	 	All Service Categories
	 	HF M — 19 to 44

HF F — 19 to 44
	 

	 	 	 	 	 	HST F — 19 to 64
	 

	 	 	 	 	 	HST M/F — 2 to l3
	 

	 	 	 	 	 	HST M — 14 to 18
	Pregnant Women Expansion

	 	1/1/2008
	 	All Service Categories
	 	HST F — 14 to 18
	 

	 	 	 	 	 	HST F — 19 to 64
	 

	 	 	 	 	 	Delivery
	Improved TPL Management

	 	1/1/2008
	 	All Service Categories
	 	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 Groups
(excl. Delivery)






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 information presented.




 









 








			
	     	 	 
	
	 	Mr. Jon Barley, Ph.D.

December 12, 2007

Page 18






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 developed to reflect
that less than 100% of managed care eligibles will enroll in managed care. Table 9 provides the
target 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




	 	 	 	 	 	 	 	 	 
	 	 	June 2007 MC	 	Target MC
	Region	 	Penetration	 	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.



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 information presented.




 









 








			
	     	 	 
	
	 	Mr. Jon Barley, Ph.D.

December 12, 2007

Page 19






FINAL and CONFIDENTIAL




Table 10




STATE OF OHIO

DEPARTMENT OF JOB AND FAMILY SERVICES

Clinical Measures Adjustments




	 	 	 	 	 	 	 
	Clinical Measure	 	 	 	Service	 	 
	Description	 	Measure	 	Category	 	Rate Groups
	Ongoing Prenatal
Care

	 	80% receive 81+% of
expected visits
	 	Office Visits / Consults
	 	HST F — 14 to l8

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 a screening
	 	Pathology / Laboratory
	 	HST M/F — 1
	 

	 	 	 	 	 	HST M/F — 2 to 13







	e.	 	Delivery Cesarean Section Rates





Milliman reviewed the cesarean rates for both the FFS and managed care populations in the base
period data summaries. In 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



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 information presented.



 









 





			
	     	 	 
	
	 	Mr. Jon Barley, Ph.D.

December 12, 2007

Page 20






FINAL and CONFIDENTIAL




care experience in the base data. The encounter and cost report data sources were given equal
weight in each region.




	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 Allowance





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






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 information presented.




 











 










Mr. Jon Barley, Ph.D.

December 12, 2007

Page 21




FINAL and CONFIDENTIAL




Delivery




	 	 	 	 	 	 	 	 	 	 	 	 	 
	Plan
Year
	 	Guaranteed %	 	At Risk %	 	Total %
	Plan Year 1 (1-12 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.




                    w w w w                    



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




Sincerely,









Robert M. Damler, FSA, MAAA

Principal and Consulting Actuary




RMD/mle

cc: Dan Hecht (ODJFS)

     Mitali Ghatak (ODJFS)

     Robert Monks (ODJFS)



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 information presented.




 









 










FINAL and CONFIDENTIAL




APPENDIX 1



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 information presented.




 









 










FINAL and CONFIDENTIAL








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 information presented.




 









 










FINAL and CONFIDENTIAL




APPENDIX 2



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 information presented.




 









 










FINAL and CONFIDENTIAL




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.









Robert M. Damler, FSA

Member, American Academy of Actuaries




	 
	December 4, 2007                                                            

	Date






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




 









 










FINAL and CONFIDENTIAL




APPENDIX 3



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 information presented.




 









 





FINAL AND CONFIDENTIAL




State of Ohio

Department of Job and Family Services

Capitation Rate Summary — Rate Group Level




	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	Projected	 	 	 	 	 	 	CY 2008	 	 	 	 	 	 	 
	 	 	 	 	CY 2008	 	 	 	 	 	 	Guaranteed	 	 	CY 2008 At	 	 	 	 
	Region	 	Rate Group	 	MMs/Deliveries	 	 	%of MMs	 	 	Rate	 	 	Risk Rate	 	 	CY 2008 Rate	 
	Central
	 	HF/HST <1 M+F	 	 	203,519	 	 	 	7.4	%	 	$	562.74	 	 	$	5.43	 	 	$	568.17	 
	Central
	 	HF/HST 1 M+F	 	 	158,456	 	 	 	5.8	%	 	 	145.11	 	 	 	1.40	 	 	 	146.51	 
	Central
	 	HF/HST 2-13 M+F	 	 	1,226,460	 	 	 	44.7	%	 	 	98.15	 	 	 	0.95	 	 	 	99.10	 
	Central
	 	HF/HST 14-18 F	 	 	163,216	 	 	 	5.9	%	 	 	163.61	 	 	 	1.58	 	 	 	165.19	 
	Central
	 	HF/HST 14-18 M	 	 	146,796	 	 	 	5.3	%	 	 	117.41	 	 	 	1.13	 	 	 	118.54	 
	Central
	 	HF 19-44 F	 	 	550,237	 	 	 	20.1	%	 	 	301.40	 	 	 	2.91	 	 	 	304.31	 
	Central
	 	HF 19-44 M	 	 	168,204	 	 	 	6.1	%	 	 	196.85	 	 	 	1.90	 	 	 	198.75	 
	Central
	 	HF 45+ M+F	 	 	65,409	 	 	 	2.4	%	 	 	481.13	 	 	 	4.64	 	 	 	485.77	 
	Central
	 	HST 19-64 F	 	 	61,713	 	 	 	2.2	%	 	 	372.66	 	 	 	3.59	 	 	 	376.25	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Central
	 	Composite Non-Delivery	 	 	2,744,010	 	 	 	 	 	 	$	202.36	 	 	$	1.95	 	 	$	204.31	 
	Central
	 	Delivery CFC	 	 	10,854	 	 	 	 	 	 	 	3,718.41	 	 	 	35.85	 	 	 	3,754.26	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Central
	 	Composite with Delivery	 	 	2,744,010	 	 	 	 	 	 	$	217.07	 	 	$	2.09	 	 	$	219.16	 
	East Central
	 	HF/HST <1 M+F	 	 	100,943	 	 	 	6.7	%	 	$	548.66	 	 	$	5.29	 	 	$	553.95	 
	East Central
	 	HF/HST 1 M+F	 	 	75,476	 	 	 	5.0	%	 	 	141.49	 	 	 	1.36	 	 	 	142.85	 
	East Central
	 	HF/HST 2-13 M+F	 	 	669,784	 	 	 	44.2	%	 	 	95.70	 	 	 	0.92	 	 	 	96.62	 
	East Central
	 	HF/HST 14-18 F	 	 	96,465	 	 	 	6.4	%	 	 	159.52	 	 	 	1.54	 	 	 	161.06	 
	East Central
	 	HF/HST 14-18 M	 	 	88,374	 	 	 	5.8	%	 	 	114.47	 	 	 	1.10	 	 	 	115.57	 
	East Central
	 	HF I9-44 F	 	 	320,982	 	 	 	21.2	%	 	 	293.86	 	 	 	2.83	 	 	 	296.69	 
	East Central
	 	HF 19-44 M	 	 	90,883	 	 	 	6.0	%	 	 	191.93	 	 	 	1.85	 	 	 	193.78	 
	East Central
	 	HF 45+ M+F	 	 	39,563	 	 	 	2.6	%	 	 	469.08	 	 	 	4.52	 	 	 	473.60	 
	East Central
	 	HST 19-64 F	 	 	33,888	 	 	 	2.2	%	 	 	363.34	 	 	 	3.50	 	 	 	366.84	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	East Central
	 	Composite Non-Delivery	 	 	1,516,358	 	 	 	 	 	 	$	196.72	 	 	$	1.90	 	 	$	198.62	 
	East Central
	 	Delivery CFC	 	 	6,386	 	 	 	 	 	 	 	3,952.33	 	 	 	38.11	 	 	 	3,990.44	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	East Central
	 	Composite with Delivery	 	 	1,516,358	 	 	 	 	 	 	$	213.36	 	 	$	2.06	 	 	$	215.42	 
	Northeast
	 	HF/HST <1 M+F	 	 	162,387	 	 	 	6.2	%	 	$	532.52	 	 	$	5.13	 	 	$	537.65	 
	Northeast
	 	HF/HST 1 M+F	 	 	130,937	 	 	 	5.0	%	 	 	137.33	 	 	 	1.32	 	 	 	138.65	 
	Northeast
	 	HF/HST 2-13 M+F	 	 	1,160,029	 	 	 	44.5	%	 	 	92.88	 	 	 	0.90	 	 	 	93.78	 
	Northeast
	 	HF/HST 14-18 F	 	 	180,843	 	 	 	6.9	%	 	 	154.83	 	 	 	1.49	 	 	 	156.32	 
	Northeast
	 	HF/HST 14-18 M	 	 	164,388	 	 	 	6.3	%	 	 	111.11	 	 	 	1.07	 	 	 	112.18	 
	Northeast
	 	HF 19-44 F	 	 	561,019	 	 	 	21.5	%	 	 	285.22	 	 	 	2.75	 	 	 	287.97	 
	Northeast
	 	HF 19-44 M	 	 	119,830	 	 	 	4.6	%	 	 	186.28	 	 	 	1.80	 	 	 	188.08	 
	Northeast
	 	HF 45+ M+F	 	 	78,748	 	 	 	3.0	%	 	 	455.29	 	 	 	4.39	 	 	 	459.68	 
	Northeast
	 	HST 19-64 F	 	 	50,934	 	 	 	2.0	%	 	 	352.64	 	 	 	3.40	 	 	 	356.04	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Northeast
	 	Composite Non-Delivery	 	 	2,609,115	 	 	 	 	 	 	$	189.57	 	 	$	1.83	 	 	$	191.40	 
	Northeast
	 	Delivery CFC	 	 	9,871	 	 	 	 	 	 	 	4,066.54	 	 	 	39.21	 	 	 	4,105.75	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Northeast
	 	Composite with Delivery	 	 	2,609,115	 	 	 	 	 	 	$	204.96	 	 	$	1.98	 	 	$	206.93	 
	Northeast Central
	 	HF/HST <1 M+F	 	 	42,798	 	 	 	6.2	%	 	$	575.16	 	 	$	5.55	 	 	$	580.71	 
	Northeast Central
	 	HF/HST 1 M+F	 	 	32,550	 	 	 	4.7	%	 	 	148.33	 	 	 	1.43	 	 	 	149.76	 
	Northeast Central
	 	HF/HST 2-13 M+F	 	 	306,477	 	 	 	44.2	%	 	 	100.32	 	 	 	0.97	 	 	 	101.29	 
	Northeast Central
	 	HF/HST 14-18 F	 	 	47,853	 	 	 	6.9	%	 	 	167.23	 	 	 	1.61	 	 	 	168.84	 
	Northeast
Central
	 	HF/HST 14-18 M	 	 	44,376	 	 	 	6.4	%	 	 	120.00	 	 	 	1.16	 	 	 	121.16	 
	Northeast Central
	 	HF 19-44 F	 	 	145,323	 	 	 	20.9	%	 	 	308.07	 	 	 	2.97	 	 	 	311.04	 
	Northeast Central
	 	HF 19-44 M	 	 	41,692	 	 	 	6.0	%	 	 	201.20	 	 	 	1.94	 	 	 	203.14	 
	Northeast Central
	 	HF 45+ M+F	 	 	18,583	 	 	 	2.7	%	 	 	491.75	 	 	 	4.74	 	 	 	496.49	 
	Northeast Central
	 	HST 19-64 F	 	 	14,085	 	 	 	2.0	%	 	 	380.88	 	 	 	3.67	 	 	 	384.55	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Northeast Central
	 	Composite Non-Delivery	 	 	693,737	 	 	 	 	 	 	$	203.51	 	 	$	1.96	 	 	$	205.47	 
	Northeast Central
	 	Delivery CFC	 	 	2,683	 	 	 	 	 	 	 	4,074.59	 	 	 	39.29	 	 	 	4,113.88	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Northeast Central
	 	Composite with Delivery	 	 	693,737	 	 	 	 	 	 	$	219.27	 	 	$	2.11	 	 	$	221.38	 
	Northwest
	 	hf/hst
<1 M+F	 	 	103,070	 	 	 	7.2	%	 	$	560.41	 	 	$	5.40	 	 	$	565.81	 
	Northwest
	 	HF/HST 1 M+F	 	 	76,773	 	 	 	5.4	%	 	 	144.52	 	 	 	1.39	 	 	 	145.91	 
	Northwest
	 	HF/HST 2-13 M+F	 	 	627,854	 	 	 	44.0	%	 	 	97.75	 	 	 	0.94	 	 	 	98.69	 
	Northwest
	 	HF/HST 14-18 F	 	 	91,028	 	 	 	6.4	%	 	 	162.94	 	 	 	1.57	 	 	 	164.51	 
	Northwest
	 	HF/HST 14-18 M	 	 	82,247	 	 	 	5.8	%	 	 	116.91	 	 	 	1.13	 	 	 	118.04	 
	Northwest
	 	HF 19-44 F	 	 	290,044	 	 	 	20.3	%	 	 	300.16	 	 	 	2.89	 	 	 	303.05	 
	Northwest
	 	HF 19-44 M	 	 	88,010	 	 	 	6.2	%	 	 	196.05	 	 	 	1.89	 	 	 	197.94	 
	Northwest
	 	HF 45+ M+F	 	 	32,963	 	 	 	2.3	%	 	 	479.14	 	 	 	4.62	 	 	 	483.76	 
	Northwest
	 	HST 19-64 F	 	 	36,142	 	 	 	2.5	%	 	 	371.11	 	 	 	3.58	 	 	 	374.69	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Northwest
	 	Composite Non-Delivery	 	 	1,428,131	 	 	 	 	 	 	$	201.79	 	 	$	1.95	 	 	$	203.74	 
	Northwest
	 	Delivery CFC	 	 	6,080	 	 	 	 	 	 	 	3,732.40	 	 	 	35.99	 	 	 	3,768.39	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Northwest
	 	Composite with Delivery	 	 	1,428,131	 	 	 	 	 	 	$	217.69	 	 	$	2.10	 	 	$	219.79	 






					
	 	 	 	 	 
	Appendix 3
	 	Milliman, Inc.
	 	Page 1







 












 






FINAL AND CONFIDENTIAL




State of Ohio




Department of Job and Family Services

Capitation Rate Summary — Rate Group Level




	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	Projected	 	 	 	 	 	 	CY 2008	 	 	 	 	 	 	 
	 	 	 	 	CY 2008	 	 	 	 	 	 	Guaranteed	 	 	CY 2008 At	 	 	 	 
	Region	 	Rate Group	 	MMs/Deliveries	 	 	% of MMs	 	 	Rate	 	 	Risk Rate	 	 	CY 2008 Rate	 
	Southeast
	 	HF/HST<1 M+F	 	 	54,113	 	 	 	5.6	%	 	$	569.55	 	 	$	5.49	 	 	$	575.04	 
	Southeast
	 	HF/HST 1 M+F	 	 	44,355	 	 	 	4.6	%	 	 	146.87	 	 	 	1.42	 	 	 	148.29	 
	Southeast
	 	HF/HST 2 -13 M+F	 	 	405,711	 	 	 	42.2	%	 	 	99.34	 	 	 	0.96	 	 	 	100.30	 
	Southeast
	 	HF/HST 14-18 F	 	 	60,544	 	 	 	6.3	%	 	 	165.59	 	 	 	1.60	 	 	 	167.19	 
	Southeast
	 	HF/HST 14-18 M	 	 	56,221	 	 	 	5.8	%	 	 	118.83	 	 	 	1.15	 	 	 	119.98	 
	Southeast
	 	HF 19-44 F	 	 	205,174	 	 	 	21.3	%	 	 	305.06	 	 	 	2.94	 	 	 	308.00	 
	Southeast
	 	HF 19-44 M	 	 	90,312	 	 	 	9.4	%	 	 	199.24	 	 	 	1.92	 	 	 	201.16	 
	Southeast
	 	HF 45+ M+F	 	 	27,036	 	 	 	2.8	%	 	 	486.93	 	 	 	4.70	 	 	 	491.63	 
	Southeast
	 	HST 19-64 F	 	 	18,943	 	 	 	2.0	%	 	 	377.17	 	 	 	3.64	 	 	 	380.81	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Southeast
	 	Composite Non-Delivery	 	 	962,409	 	 	 	 	 	 	$	202.86	 	 	$	1.96	 	 	$	204.82	 
	Southeast
	 	Delivery CFC	 	 	3,528	 	 	 	 	 	 	 	3,523.18	 	 	 	33.97	 	 	 	3,557.15	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Southeast
	 	Composite with Delivery	 	 	962,409	 	 	 	 	 	 	$	215.78	 	 	$	2.08	 	 	$	217.86	 
	Southwest
	 	HF/HST <1 M+F	 	 	136,292	 	 	 	8.2	%	 	$	601.16	 	 	$	5.80	 	 	$	606.96	 
	Southwest
	 	HF/HST 1 M+F	 	 	98,401	 	 	 	5.9	%	 	 	155.03	 	 	 	1.49	 	 	 	156.52	 
	Southwest
	 	HF/HST 2-13 M+F	 	 	761,118	 	 	 	45.6	%	 	 	104.86	 	 	 	1.01	 	 	 	105.87	 
	Southwest
	 	HF/HST 14-18 F	 	 	102,994	 	 	 	6.2	%	 	 	174.78	 	 	 	1.69	 	 	 	176.47	 
	Southwest
	 	HF/HST 14-18 M	 	 	88,400	 	 	 	5.3	%	 	 	125.43	 	 	 	1.21	 	 	 	126.64	 
	Southwest
	 	HF 19-44F	 	 	321,176	 	 	 	19.2	%	 	 	321.99	 	 	 	3.10	 	 	 	325.09	 
	Southwest
	 	HF 19-44 M	 	 	84,540	 	 	 	5.1	%	 	 	210.31	 	 	 	2.03	 	 	 	212.34	 
	Southwest
	 	HF 45+ M+F	 	 	34,189	 	 	 	2.0	%	 	 	513.98	 	 	 	4.96	 	 	 	518.94	 
	Southwest
	 	HST 19-64 F	 	 	42,884	 	 	 	2.6	%	 	 	398.11	 	 	 	3.84	 	 	 	401.95	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Southwest
	 	Composite Non-Delivery	 	 	1,669,994	 	 	 	 	 	 	$	216.72	 	 	$	2.09	 	 	$	218.81	 
	Southwest
	 	Delivery CFC	 	 	7,350	 	 	 	 	 	 	 	3,973.57	 	 	 	38.31	 	 	 	4,011.88	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Southwest
	 	Composite with Delivery	 	 	1,669,994	 	 	 	 	 	 	$	234.21	 	 	$	2.26	 	 	$	236.47	 
	West Central
	 	HF/HST < 1M+F	 	 	88,254	 	 	 	7.5	%	 	$	567.07	 	 	$	5.47	 	 	$	572.54	 
	West Central
	 	HF/HST 1 M+F	 	 	65,856	 	 	 	5.6	%	 	 	146.24	 	 	 	1.41	 	 	 	147.65	 
	West Central
	 	HF/HST 2-13 M+F	 	 	528,534	 	 	 	44.7	%	 	 	98.91	 	 	 	0.95	 	 	 	99,86	 
	West Central
	 	HF/HST 14-18 F	 	 	77,143	 	 	 	6.5	%	 	 	164.88	 	 	 	1.59	 	 	 	166.47	 
	West Central
	 	HF/HST 14-18 M	 	 	67,395	 	 	 	5.7	%	 	 	118.32	 	 	 	1.14	 	 	 	119.46	 
	West Central
	 	HF 19-44 F	 	 	234,878	 	 	 	19.9	%	 	 	303.73	 	 	 	2.93	 	 	 	306.66	 
	West Central
	 	HF-19-44 M	 	 	66,482	 	 	 	5.6	%	 	 	198.38	 	 	 	1.91	 	 	 	200.29	 
	West Central
	 	HF 45+ M+F	 	 	27,032	 	 	 	2.3	%	 	 	484.84	 	 	 	4.67	 	 	 	489.51	 
	West Centra!
	 	HST 19-64 F	 	 	27,422	 	 	 	2.3	%	 	 	375.53	 	 	 	3.62	 	 	 	379.15	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	West Central
	 	Composite Non-Delivery	 	 	1,182,996	 	 	 	 	 	 	$	203.36	 	 	$	1.96	 	 	$	205.32	 
	West Central
	 	Delivery CFC	 	 	4,916	 	 	 	 	 	 	 	4,301.21	 	 	 	41.47	 	 	 	4,342.68	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	West Central
	 	Composite with Delivery	 	 	1,182,996	 	 	 	 	 	 	$	221.24	 	 	$	2.13	 	 	$	223.37	 
	Statewide
	 	HF/HST <1 M+F	 	 	891,376	 	 	 	7.0	%	 	$	562.68	 	 	$	5.43	 	 	$	568.11	 
	Statewide
	 	HF/HST 1 M+F	 	 	682,804	 	 	 	5.3	%	 	 	144.95	 	 	 	1.40	 	 	 	146.35	 
	Statewide
	 	HF/HST 2- 13 M+F	 	 	5,685,967	 	 	 	44.4	%	 	 	97.92	 	 	 	0.94	 	 	 	98.86	 
	Statewide
	 	HF/HST 14-18F	 	 	820,086	 	 	 	6.4	%	 	 	163.00	 	 	 	1.57	 	 	 	164.57	 
	Statewide
	 	HF/HST 14-18 M	 	 	738,197	 	 	 	5.8	%	 	 	116.90	 	 	 	1.13	 	 	 	118.03	 
	Statewide
	 	HF 19-44 F	 	 	2,628,833	 	 	 	20.5	%	 	 	300.26	 	 	 	2.90	 	 	 	303.16	 
	Statewide
	 	HF 19-44 M	 	 	749,953	 	 	 	5.9	%	 	 	196.65	 	 	 	1.90	 	 	 	198.55	 
	Statewide
	 	HF 45 + M+F	 	 	323,523	 	 	 	2.5	%	 	 	478.04	 	 	 	4.61	 	 	 	482.65	 
	Statewide
	 	HST 19-64 F	 	 	286,011	 	 	 	2.2	%	 	 	372.59	 	 	 	3.59	 	 	 	376.18	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Statewide
	 	Composite Non-Delivery	 	 	12,806,750	 	 	 	100.0	%	 	$	201.09	 	 	$	1.94	 	 	 	203.03	 
	Statewide
	 	Delivery CFC	 	 	51,668	 	 	 	0.4	%	 	 	3,91.39	 	 	 	37.72	 	 	 	3,950.11	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Statewide
	 	Composite with Delivery	 	 	12,806,750	 	 	$	100.0	%	 	$	216.87	 	 	$	2.09	 	 	$	218.96	 






					
	 	 	 	 	 
	Appendix 3
	 	Milliman, Inc.
	 	Page 2






 









 










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




MCP: MOLINA HEALTHCARE OF OHIO, INC.




	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	SERVICE	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	HF/HST	 	HF/HST	 	HF	 	HF	 	HF	 	HST	 	 
	ENROLLMENT	 	REGIONAL	 	HF/HST	 	HF/HST	 	HF/HST	 	Age 14-18	 	Age 14-18	 	Age 19-44	 	Age 19-44	 	Age 45	 	Age 19-64	 	Delivery
	AREA	 	STATUS	 	Age < 1	 	Age 1	 	Age 2-13	 	Male	 	Female	 	Male	 	Female	 	and over	 	Female	 	Payment
	Central
	 	Mandatory	 	$	562.74	 	 	$	145.11	 	 	$	98.15	 	 	$	117.41	 	 	$	163.61	 	 	$	196.85	 	 	$	301.40	 	 	$	481.13	 	 	$	372.66	 	 	$	3,718.41	 
	Southeast
	 	Mandatory	 	$	575.04	 	 	$	148.29	 	 	$	100.30	 	 	$	119.98	 	 	$	167.19	 	 	$	201.16	 	 	$	308.00	 	 	$	491.63	 	 	$	380.81	 	 	$	3,557.15	 
	Southwest
	 	Mandatory	 	$	606.96	 	 	$	156.52	 	 	$	105.87	 	 	$	126.64	 	 	$	176.47	 	 	$	212.34	 	 	$	325.09	 	 	$	518.94	 	 	$	401.95	 	 	$	4,011.88	 
	West Central
	 	Mandatory	 	$	567.07	 	 	$	146.24	 	 	$	98.91	 	 	$	118.32	 	 	$	164.88	 	 	$	198.38	 	 	$	303.73	 	 	$	484.84	 	 	$	375.53	 	 	$	4,301.21	 






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



Per Appendix E, Rate Methodology, MCPs in the first two years of operation of the MC program are
not subject to an at-risk recovery amount.




   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.


   Molina’s regional counties at-risk: Clark, Franklin, Montgomery.





Page 4 of 6









 













APPENDIX F 
REGIONAL RATES




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




MCP: MOLINA HEALTHCARE OF OHIO, INC.




	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	SERVICE	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	HF/HST	 	HF/HST	 	HF	 	HF	 	HF	 	HST	 	 
	ENROLLMENT	 	REGIONAL	 	HF/HST	 	HF/HST	 	HF/HST	 	Age 14-18	 	Age 14-18	 	Age 19-44	 	Age 19-44	 	Age 45	 	Age 19-64	 	Delivery
	AREA	 	STATUS	 	Age < 1	 	Age 1	 	Age 2-13	 	Male	 	Female	 	Male	 	Female	 	and over	 	Female	 	Payment
	Central
	 	Mandatory	 	$	5.43	 	 	$	1.40	 	 	$	0.95	 	 	$	1.13	 	 	$	1.58	 	 	$	1.90	 	 	$	2.91	 	 	$	4.64	 	 	$	3.59	 	 	$	35.85	 
	Southeast
	 	Mandatory	 	$	0.00	 	 	$	0.00	 	 	$	0.00	 	 	$	0.00	 	 	$	0.00	 	 	$	0.00	 	 	$	0.00	 	 	$	0.00	 	 	$	0.00	 	 	$	0.00	 
	Southwest
	 	Mandatory	 	$	0.00	 	 	$	0.00	 	 	$	0.00	 	 	$	0.00	 	 	$	0.00	 	 	$	0.00	 	 	$	0.00	 	 	$	0.00	 	 	$	0.00	 	 	$	0.00	 
	West Central
	 	Mandatory	 	$	5.47	 	 	$	1.41	 	 	$	0.95	 	 	$	1.14	 	 	$	1.59	 	 	$	1.91	 	 	$	2.93	 	 	$	4.67	 	 	$	3.62	 	 	$	41.47	 






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



Per Appendix E, Rate Methodology, MCPs in the first two years of operation in the MC program are
not subject to an at-risk recovery amount.




   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.


   Molina’s regional
counties at-risk: Clark, Franklin,
Montgomery.





Page 5 of 6









 













APPENDIX F

 REGIONAL RATES




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




MCP: MOLINA HEALTHCARE OF OHIO, INC.




	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	SERVICE	 	 	 	 	 	 	 	 	 	HF/HST	 	HF/HST	 	HF	 	HF	 	HF	 	HST	 	 
	ENROLLMENT	 	REGIONAL	 	HF/HST	 	HF/HST	 	HF/HST	 	Age 14-18	 	Age 14-18	 	Age 19-44	 	Age 19-44	 	Age 45	 	Age 19-64	 	Delivery
	AREA	 	STATUS	 	Age < 1	 	Age 1	 	Age 2-13	 	Male	 	Female	 	Male	 	Female	 	and over	 	Female	 	Payment
	Central
	 	Mandatory	 	$	568.17	 	 	$	146.51	 	 	$	99.10	 	 	$	118.54	 	 	$	165.19	 	 	$	198.75	 	 	$	304.31	 	 	$	485.77	 	 	$	376.25	 	 	$	3,754.26	 
	Southeast
	 	Mandatory	 	$	575.04	 	 	$	148.29	 	 	$	100.30	 	 	$	119.98	 	 	$	167.19	 	 	$	201.16	 	 	$	308.00	 	 	$	491.63	 	 	$	380.81	 	 	$	3,557.15	 
	Southwest
	 	Mandatory	 	$	606.96	 	 	$	156.52	 	 	$	105.87	 	 	$	126.64	 	 	$	176.47	 	 	$	212.34	 	 	$	325.09	 	 	$	518.94	 	 	$	401.95	 	 	$	4,011.88	 
	West Central
	 	Mandatory	 	$	572.54	 	 	$	147.65	 	 	$	99.86	 	 	$	119.46	 	 	$	166.47	 	 	$	200.29	 	 	$	306.66	 	 	$	489.51	 	 	$	379.15	 	 	$	4,342.68	 






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



Per
Appendix E, Rate Methodology, MCPs in the first two years of operation in the MC program are not
subject to an at-risk recovery amount.




     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.


     Molina’s regional
counties at-risk: Clark, Franklin,
Montgomery.





Page 6 of 6









 








			
	 	 	 
	Appendix G 

Covered Families and Children (CFC) population 

Page l
	 	 






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 ( Medicaid-covered
services, MCPs must refer to the ODJFS website. The following is 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




 









 











			
	 	 	 
	Appendix G 

Covered Families and Children (CFC) population 

Page 2
	 	 







	 	•	 	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





 









 





			
	 	 	 
	Appendix G 

Covered Families and Children (CFC) population 

Page 3
	 	 







	 	•	 	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.



 









 





			
	 	 	 
	Appendix G 

Covered Families and Children (CFC) population 

Page 4
	 	 







	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.



 









 





			
	 	 	 
	Appendix G 

Covered Families and Children (CFC) population 

Page 5
	 	 







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.





 









 





			
	 	 	 
	Appendix G 

Covered Families and Children (CFC) population 

Page 6
	 	 







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




 









 











			
	 	 	 
	Appendix G

Covered Families and Children (CFC) population 

Page 7
	 	 







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






 











 




Appendix G

Covered Families and Children (CFC)
population
 Page 8





	 	 	 	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




 









 










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Covered Families and Children (CFC)
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	 	 	 	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



 









 




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	 	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.




 









 










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	 	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




 









 










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	 	•	 	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 MCP must 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





 









 




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	 	 	 	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
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.




 









 










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Covered Families and Children (CFC)
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	 	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).




 









 










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	 	d.	 	Care coordination with Non-Contracting Providers
	 
	 	 	 	Per OAC rule 5101:3-26-05(A)(9), MCPs authorizing the delivery of services from a
provider who does not have an executed subcontract must ensure that they have a mutually
agreed upon compensation amount for the authorized service and notify the provider of the
applicable provisions of paragraph D of OAC rule 5101:3-26-05. This notice is provided
when an MCP authorizes a non-contracting provider to furnish services on a one-time or
infrequent basis to an MCP member and must include required ODJFS-model language and
information. This notice must also be included with the transition of services form sent
to providers as outlined in paragraph 29.h of Appendix C.
	 
	 	e.	 	Integration of Member Care
	 
	 	 	 	The MCP must ensure that a discharge plan is in place to meet a member’s health care
needs following discharge from a nursing facility, and integrated into the member’s
continuum of care. The discharge plan must address the services to be provided for the
member and must be developed prior to the date of discharge from the nursing facility. The
MCP must ensure follow-up contact occurs with the member, or authorized representative,
within thirty (30) days of the member’s discharge from the nursing facility to ensure that
the member’s health care needs are being met.




 









 










Appendix H

Covered Families and Children (CFC)
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 Page 1




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




 









 







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Covered Families and Children (CFC)
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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.




2. 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.





 












 





Appendix H

Covered Families and Children (CFC) population

Page 3




Each PCP must have the capacity and agree to serve at least 50 Medicaid members at each practice
site in order to be approved by ODJFS as a PCP. The capacity-by-site requirement must be met for
all ODJFS-approved PCPs.



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



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



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



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



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



 









 





Appendix H

Covered Families and Children (CFC) population

Page 4




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.



 









 





Appendix H

Covered Families and Children (CFC) population

Page 5




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



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



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



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



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



Vision Care Providers - MCPs must contract with the specified number of
ophthalmologists/optometrists for each specified county/region , all of whom must maintain a
full-time practice at a site(s) located in the specified county/region. All ODJFS-approved vision
providers must regularly perform routine eye exams. (MCPs will be expected to contract with an
adequate number of ophthalmologists as part of their overall provider panel, but only



 









 





Appendix H

Covered Families and Children (CFC) population

Page 6




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



 









 





Appendix H

Covered Families and Children (CFC) population

Page 7




compliant policies and procedures to preserve patient/provider confidentiality, and convey
pertinent information to the member’s PCP and/or MCP.



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



Other Specialty Types (pediatricians, general surgeons, otolaryngologists, allergists, 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.



 









 





Appendix H

Covered Families and Children (CFC) population

Page 8




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



5. PROVIDER DIRECTORIES




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



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



The directory must also specify:




	•	 	provider address(es) and phone number(s);
	 
	•	 	an explanation of how to access providers (e.g. referral required vs. self-referral);
	 
	•	 	an indication of which providers are available to members on a self-referral basis
	 
	•	 	foreign-language speaking PCPs and specialists and the specific foreign language(s) spoken;
	 
	•	 	how members may obtain directory information in alternate formats that takes into
consideration the special needs of eligible individuals including but not limited to,
visually-limited, LEP, and LRP eligible individuals; and
	 
	•	 	any PCP or specialist practice limitations.





Printed Provider Directory 




Prior to receiving a provider agreement, all MCPs must develop a printed provider directory that
shall be prior-approved by ODJFS for each 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.



 









 





Appendix H

Covered Families and Children (CFC) population

Page 9




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



Internet Provider Directory 




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



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



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




 









 











Appendix H

Page 10




          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.



 









 





Molina




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);




 









 











Appendix J

Page 2





	 	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 $172.00, 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:






 









 






Appendix J

Page 3




	 	 	 	 	 
	 

	 	 	 	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




 









 








Appendix J

Page 4





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.






 









 






Appendix J

Page 5




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 $400,000
that covers 80% of inpatient costs in excess of the deductible amount for non-transplant
services.



 









 





Appendix J

Page 6





Molina has also been approved to delegate the responsibility for maintaining reinsurance
coverage for Molina members who are with Children’s Hospital and Physician Health Care Network
(CHPHN) to CHPHN. Molina must assure that CHPHN maintains a reinsurance policy and that this policy
covers at least 70% of inpatient costs incurred by one member in one year, in excess of CHPHN’s
$100,000.00 deductible.




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



 









 





Appendix J

Page 7





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.




 









 











Appendix J

Page 8





	 	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

Covered Families and Children (CFC) population

Page 1




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



 









 





Appendix K

Covered Families and Children (CFC) population

Page 2





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.




 









 











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Covered Families and Children (CFC) population

Page 3





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

Covered Families and Children

Page 1




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.




 









 








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




	 	 	 	 	 	 	 
	 	 	Data Source:	 	 	 	 
	 	 	Estimated Encounter	 	Quarterly Report	 	 
	Quarterly Report Periods	 	Data File Update	 	Estimated Issue Date	 	Contract Period
	Qtr 3 & Qtr 4 2004, 2005, 2006

Qtr 1 2007

	 	July 2007
	 	August 2007
	 	SFY 2008
	 
	 	 	 	 	 	 
	Qtr 3 & Qtr 4 2004, 2005, 2006 

Qtr 1, Qtr 2 2007

	 	October 2007
	 	November 2007	 	 
	 
	 	 	 	 	 	 
	Qtr 4 2004, 2005, 2006

Qtr 1 thru Qtr 3 2007

	 	January 2008
	 	February 2008	 	 
	 
	 	 	 	 	 	 
	Qtr 1 thru Qtr 4: 2005, 2006, 2007


	 	April 2008
	 	May 2008	 	 
	 
	 	 	 	 	 	 
	Qtr 2 thru Qtr 4 2005,

Qtr 1 thru Qtr 4: 2006, 2007

Qtr 1 2008

	 	July 2008
	 	August 2008
	 	SFY 2009
	 
	 	 	 	 	 	 
	Qtr 3, Qtr 4: 2005,

Qtr 1 thru Qtr 4: 2006, 2007 

Qtr 1, Qtr 2 2008

	 	October 2008
	 	November 2008	 	 
	 
	 	 	 	 	 	 
	Qtr 4: 2005,

Qtr 1 thru Qtr 4: 2006, 2007 

Qtr 1 thru Qtr 3: 2008

	 	January 2009
	 	February 2009	 	 
	 
	 	 	 	 	 	 
	Qtr 1 thru Qtr 4: 2006, 2007, 2008

	 	April 2009
	 	May 2009	 	 






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






 









 






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



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




	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	Standard for	 	 
	 	 	 	 	Standard for	 	Standard for	 	Dates of	 	 
	 	 	 	 	Dates of Service	 	Dates of Service	 	Service	 	 
	 	 	Measure per	 	7/1/2003 thru	 	7/1/2004 thru	 	on or after	 	 
	Category	 	1,000/MM	 	6/30/2004	 	6/30/2006	 	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

	 	 	 	 	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

	 	Visits
	 	 	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




 









 








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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)




	 	 	 	 	 	 	 	 	 
	 	 	 	 	Standard for	 	 
	 	 	 	 	Dates of	 	 
	 	 	 	 	Service	 	 
	 	 	Measure per	 	on or after	 	 
	Category	 	1,000/MM	 	7/1/2006	 	Description
	Inpatient Hospital

	 	Discharges
	 	 	2.7	 	 	General/acute care, excluding newborns and mental
health and chemical dependency services
	 
	 	 	 	 	 	 	 	 
	Emergency Department

	 	 	 	 	25.3	 	 	Includes physician and hospital emergency department
encounters
	 
	Dental

	 	 	 	 	25.5	 	 	Non-institutional and hospital dental visits
	 
	Vision

	 	Visits
	 	 	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






 









 






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



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



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




 









 








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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




 









 








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Covered Families and Children (CFC) population

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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 per format for encounters submitted in
SFY 2004 and thereafter. The measure will be calculated per MCP.



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



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



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



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




 









 








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




1.a.v. Acceptance Rate



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



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



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



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




 









 








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Covered Families and Children (CFC) population

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	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




 









 








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Covered Families and Children (CFC) population

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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.




 









 








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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.




 









 








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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.




 









 








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Covered Families and Children (CFC) population

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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.






 









 








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4. MEMBERS’ PCP DATA



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




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



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



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



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)




 









 








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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




 









 






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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.





 












 





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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.




 









 








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



Action Required for Deficiencies: For all reviews conducted during the contract period, if the EQRO
cites a deficiency in performance, the MCP will be required to complete a Corrective Action Plan or
Quality Improvement Directive depending on the severity of the deficiency. Serious deficiencies
may result in immediate termination or non-renewal of the 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 an active region
have at least 10,000 members during each month of the entire report period. Upon implementation of
regional-based evaluation for a particular county’s region, the county will be included in the
MCP’s regional-based result and will no longer be included in the MCP’s county-based statewide
result. [Example: The county-based statewide result for MCP AAA, which has contracts in the Central
and West Central regions, will include Franklin, Pickaway, Montgomery, Greene and Clark counties
(i.e., counties in which MCP AAA had managed care membership as of February 1, 2006). When regional-based evaluation is implemented for the Central
region, Franklin and Pickaway counties, along with all other counties in the region, will then be
included in the Central region results for MCP AAA; Montgomery, Greene, and Clark counties will
remain in the county-based statewide result for evaluation of MCP AAA until the West Central
regional-based approach is implemented.] The last report period using the MCP’s county-based
statewide result for the counties in which the MCP had membership as of February 1, 2006 for P4P
(Appendix O) is April-June 2009.



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




 









 








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Covered Families and Children (CFC) population

Page 3



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




 









 








Appendix M

Covered Families and Children (CFC) population

Page 4



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



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




 









 








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Covered Families and Children (CFC) population

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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%.




 









 








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Covered Families and Children (CFC) population

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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




 









 








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Covered Families and Children (CFC) population

Page 7



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.




 









 








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(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.




 









 








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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.




 









 








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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




 









 








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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




 









 








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are not adhering to the MCP’s standard of care. Therefore, this measure is used in conjunction with
the children and adult access measures to assess performance in the access category.



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



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



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




 









 








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Covered Families and Children (CFC) population

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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.




 









 








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



This measure indicates whether adult members are accessing health services.



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



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



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



Regional-Based Statewide Approach: MCPs will be evaluated statewide, using results for all active
regions and counties (Mahoning and Trumbull) in which the MCP has membership. ODJFS will use the
first full calendar year of data (CY 2007 — 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




 









 








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Covered Families and Children (CFC) population

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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




 









 








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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.




 









 








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Covered Families and Children (CFC) population

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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.




 









 








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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




 









 








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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

Covered Families and Children (CFC) population

Page 1




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



 









 





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Covered Families and Children (CFC) population

Page 2





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.



 









 





Appendix N

Covered Families and Children (CFC) population

Page 3





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




 









 











Appendix N

Covered Families and Children (CFC) population

Page 4





	 	 	 	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.



 









 





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Covered Families and Children (CFC) population

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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



 









 





Appendix N

Covered Families and Children (CFC) population

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as jeopardizing member access to care include:




	 	–	 	the MCP has been found by ODJFS to be noncompliant with the prompt payment or the
non-contracting provider payment requirements;
	 
	 	–	 	the MCP has been found by ODJFS to be noncompliant with the provider panel requirements
specified in Appendix H of the Agreement;
	 
	 	–	 	the MCP’s refusal to comply with a program requirement after ODJFS has directed the MCP to
comply with the specific program requirement; or
	 
	 	–	 	the MCP has received notice of proposed or implemented adverse action by the Ohio
Department of Insurance.]






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




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




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




J. Specific Pre-Determined Penalties




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



 









 





Appendix N

Covered Families and Children (CFC) population

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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




 









 











Appendix N

Covered Families and Children (CFC) population

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	 	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.



 









 





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Covered Families and Children (CFC) population

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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.



 









 





Appendix N

Covered Families and Children (CFC) population

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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

Covered Families and Children (CFC) population

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APPENDIX O




PAY-FOR PERFORMANCE (P4P)

CFC ELIGIBLE POPULATION



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



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



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




1. SFY 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



 









 





Appendix O

Covered Families and Children (CFC) population

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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 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.




	 	 	 	 	 
	 	 	Medicaid
	Clinical Performance Measure	 	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
	 	 	50      	%
	6. Well-Child Visits — 12 through 21 years old
	 	 	30      	%
	7. Use of Appropriate Medications for People with Asthma
	 	 	83      	%
	8. Annual Dental Visits
	 	 	40      	%
	9. Blood Lead — 1 year olds
	 	 	45      	%






 









 






Appendix O

Covered Families and Children (CFC) population

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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




 









 








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Covered Families and Children (CFC) population

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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 SFY2008.


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



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



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




 









 








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Covered Families and Children (CFC) population

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	 	 	Medicaid
	Clinical Performance Measure	 	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
	 	 	50      	%
	6. Well-Child Visits — 12 through 21 years old
	 	 	30      	%
	7. Use of Appropriate Medications for People with Asthma
	 	 	83      	%
	8. Annual Dental Visits
	 	 	40      	%
	9. Blood Lead — 1 year olds
	 	 	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%



 









 





Appendix O

Covered Families and Children (CFC) population

Page 6





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
Superior standards established in Section 2.b. herein, additional P4P may be awarded. For MCPs
receiving additional P4P, the amount in the P4P fund (see Section 3.) will be divided equally, up
to the maximum additional amount, among all MCPs’ ABD and/or CFC programs receiving additional P4P.
The maximum additional amount to be awarded per plan, per program, per contract year is $250,000.
An MCP may receive up to $500,000 should both of the MCP’s ABD and CFC programs achieve the
Superior Performance Levels.




3. NOTES




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



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




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



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



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



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




 









 








Appendix O

Covered Families and Children (CFC) population

Page 7




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.