ohioamend1.htm


    Back to Form 8-K

    Exhibit 10.1

    
 

    
      PROVIDER
AGREEMENT

       

    

    
      BETWEEN

       

    

    
      STATE OF
OHIO

       

    

    
      DEPARTMENT
OF JOB AND FAMILY SERVICES

       

    

    
      AND

       

    

    
      WELLCARE
OF OHIO, INC.

       

    

    
      Amendment No.
1

    

    
       

      Pursuant
to Article IX.A. the Provider Agreement between the State of Ohio. Department of
Job and Family Services, (hereinafter referred to as "ODJFS") and WELLCARE OF
OHIO, INC. (hereinafter referred to as "MCP") for the Covered Families and
Children (hereinafter referred to as "CFC") population dated July 1, 2008. is
hereby amended as follows:

    

    
       

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

       

    

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

       

                   
The amendment contained herein shall be effective January 1,
2009.

    

    
      


    

    
      	
              WELLCARE
      OF OHIO, INC.

               

            	 
      
	
              BY: 
      /s/ Heath
      Schiesser                                                                                             
      

                      HEATH
      SCHIESSER, CHIEF EXECUTIVE OFFICER AND PRESIDENT

               

            	
              DATE: 12-19-08              
      

            
	
              OHIO
      DEPARTMENT OF JOB AND FAMILY SERVICES:

               

            	 
      
	
              BY: 
      /s/ Jan Allen,
      Director                                                                                         
      

                  
         JAN ALLEN, DIRECTOR 

               

            	
              DATE:
      12/30/08              
      

            


    

    
      

        
          
             


          

          
             


            
              

            

          

          
             


          

        

      

    

    
       

      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.


      

    

    
              

        
          
             


          

          
             


            
              

            

          

          
             


          

        



    

    
      Appendix
C

    

    
      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 planned services availability. If an
      MCP elects to provide additional services, the MCP must ensure to the
      satisfaction of ODJFS that the services are readily available and
      accessible to members who are eligible to receive them. Additional
      benefits must be made available to members for at least six (6) calendar
      months from date approved by
ODJFS.

              


      

    

    
      

        
          
             


          

          
             


            
              

            

          

          
             


          

        



    

    
      Appendix
C

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
3


    

    
       

      
        	
                 
      

              	
                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:

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
C

    

    
      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 (i.e., those special services
      arranged by the MCP as well as those services reported to the MCP which
      were arranged by the
provider).

              


      

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
C

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
5

       

    

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

    

    
       

      
        	
                21.

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

              


      

    

    
       

      
        	
                22.

              	
                Pursuant
      to OAC rules 5101:3-26-08 and 5101:3-26-08.2, the MCP is responsible for
      ensuring that all MCP marketing and member materials are prior approved by
      ODJFS before being used or shared with members. Member materials must be
      available in written format, but can be provided to the member in
      alternative formats (e.g., CD-rom) if specifically requested by the
      member, except as specified in OAC rule 5101:3-26-08.4. 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.

              


      

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
C

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
6

       

    

    
      
        	
                 
      

              	
                f.

              	
                MCP
      marketing representatives and other MCP staff are prohibited from offering
      eligible individuals the use of a portable device (laptop computer,
      cellular phone, etc.) to assist with the completion of an online
      application to select and/or change MCPs, as all enrollment activities
      must be completed by the
MCEC.

              


      

    

    
       

      
        	
                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.

              


      

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
C

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
7

       

    

    
      
        	
                 

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

              


      

    

    
       

      
        	
                 

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

              


      

    

    
       

      
        	
                 

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

              


      

    

    
       

      
        	
                 

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

              


      

    

    
       

      24.           New Member
Materials

       

    

    
                      Pursuant
to OAC rule 5101:3-26-08.2 (B)(3), MCPs must provide to each member or
assistance group, as applicable, an MCP identification (ID) card, a new member
letter, a

                     
 member handbook, a provider directory, and information on advance
directives.

    

    
       

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

    

    
       

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

    

    
       

                      c.
The member handbook, provider directory and advance directives information may
be mailed to the member separately from the ID card and new member letter. MCPs
will

                
     meet the timely receipt requirement for these materials
if they are mailed to the member within (twenty-four) 24 hours of the MCP
receiving the ODJFS produced monthly 

                     
membership roster (MMR). This is provided the materials are mailed via a method
with an expected delivery date of no more than five (5) days. If the member
handbook, 

                     
provider directory and advance directives information are mailed separately from
the ID card and new member letter and the MCP is unable to mail the materials
within twenty-

                     
four (24) hours, the member handbook, provider directory and advance directives
information must be mailed via a method that will ensure receipt by no later
than the effective 

                     
date of coverage. If the MCP mails the ID card and new member letter with the
other materials (e.g., member handbook, provider directory, and advance
directives), the MCP 

                      must
ensure that all
materials are mailed via a method that will ensure their receipt prior to the member’s
effective date of coverage.

    

    
      


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

                     
At least one of the staff members must receive the materials at their home
address.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
C

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
8

       

    

    
      25.           Call Center
Standards

    

    
       

                     
The MCP must provide assistance to members through a member services toll-free
call-in system pursuant to OAC rule 5101:3-26-08.2(A)(1). MCP member services
staff must 

                     
be available nationwide to provide assistance to members through the toll-free
call-in system every Monday through Friday, at all times during the hours of
7:00 am to 7:00 pm

                    
 Eastern Time, except for the following major holidays:

       

    

    
                                      
•     New Year’s Day

    

    
                                       •     Martin
Luther King’s Birthday

    

    
                                      
•     Memorial Day

    

    
                                      
•     Independence Day

    

    
                                      
•     Labor Day

    

    
                                      
•     Thanksgiving Day

    

    
                                       •     Christmas
Day

                                      
•     2
optional closure days: These days can be used independently or in combination
with any of the major holiday closures but cannot both be used within the
same

                                          
  closure period.  

                                            
Before
announcing any optional closure dates to members and/or staff, MCPs must receive
ODJFS prior-approval which verifies that the optional closure days 

                                            
meet the specified criteria.

    

    
       

      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.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
C

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
9

       

    

    
      26.       
   Notification of Optional MCP
Membership

    

    
      


                     
In order to comply with the terms of the ODJFS State Plan Amendment for the
managed care program (i.e., 42 CFR 438.50), MCPs in mandatory membership service
areas must 

                    
 inform new members that MCP membership is optional for certain
populations. Specifically, MCPs must inform any applicable pending member or
member that the following 

                    
 CFC populations are not required to select an MCP in order to receive
their Medicaid healthcare benefit and what steps they need to take if they do
not wish to be a member of

                    
 an MCP:

    

    
                         
-      Indians who are members of
federally-recognized tribes.

    

    
                         
-      Children under 19 years of age who
are:

    

    
                                      
o  Eligible for Supplemental Security Income under title
XVI;

    

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

    

    
                                      
o  Receiving foster care of adoption assistance;

      
                                        
o  Receiving services through the Ohio Department of Health’s Bureau
for Children with Medical Handicaps (BCMH) or any other family-centered,
community-based, 

                                            
coordinated care system that receives grant funds under section 501(a)(1)(D) of
title V, and is defined by the State in terms of either program participation or
special 

                                          
  health care needs.

         

      

    

    
      27.         
 HIPAA Privacy
Compliance Requirements

    

    
      


                    
 The Health Insurance Portability and Accountability Act (HIPAA) Privacy
Regulations at 45 CFR. § 164.502(e) and § 164.504(e) require ODJFS to have
agreements with MCPs

                
     as a means of obtaining satisfactory assurance
that the MCPs will appropriately safeguard all personal identified health
information. Protected Health Information (PHI) is

                    
 information received from or on behalf of ODJFS that meets the definition
of PHI as defined by HIPAA and the regulations promulgated by the United States
Department of 

                     
Health and Human Services, specifically 45 CFR 164.501, and any amendments
thereto. MCPs must agree to the following:

    

    
       

      
        	
                 
      

              	
                a.

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

              


      

    

    
       

      
        	
                 
      

              	
                b.

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

              


      

    

    
       

      
        	
                 
      

              	
                c.

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

              


      

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
C

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
10

       

    

    
      
        	
                 
      

              	
                d.

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

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


      

       

    

    
      
        	
                 
      

              	
                f.

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

              


      

    

    
       

      
        	
                 
      

              	
                g.

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

              


      

    

    
       

      
        	
                 
      

              	
                h.

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

              


      

    

    
       

      
        	
                 
      

              	
                i.

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

              


      

    

    
       

      
        	
                 
      

              	
                j.

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

              


      

    

    
       

      
        	
                28.

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

              


      

    

    
       

      29.           MCP Membership acceptance,
documentation and reconciliation

    

    
       

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


                                      
request additional information about the MCP.

    

    
       

      b.     
        Monthly Reconciliation of
Membership and Premiums: The MCP shall reconcile member
data as reported on the MCEC produced consumer contact record (CCR)


                                      
with the ODJFS-produced monthly member roster (MMR) and report to the ODJFS any
difficulties in interpreting
or reconciling information received. Membership

                                      
reconciliation questions must be identified and reported to the ODJFS prior to
the first of the month to assure that no member is left without coverage. The
MCP shall 

                                      
reconcile membership with premium payments and delivery payments as reported on
the monthly remittance advice (RA).

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
C

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
11

       

    

    
                                      
The MCP shall work directly with the ODJFS, or other ODJFS-identified entity, to
resolve any difficulties in interpreting or reconciling premium information.
Premium

                                    
  reconciliation questions must be identified within thirty (30) days of
receipt of the RA. Monthly reconciliation data must be submitted in the format
specified by

                                       ODJFS.

    

    
       

      
        	
                 
      

              	
                c.

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

              


      

    

    
       

      
        	
                 
      

              	
                d.

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

              


      

    

    
       

      
        	
                 
      

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

              


      

    

    
       

      
        
          
             


          

          
             


            
              

            

          

          
             


          

        

Appendix
C

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
12

       

    

    
      
                                       
When an MCP learns that a new member who was previously on Medicaid fee for
service was admitted prior to the effective date of enrollment and remains
an

                                         inpatient
on the effective date of enrollment, the enrolling MCP shall notify the
hospital/ inpatient facility and treating providers that the MCP may not
be the payer.

                                       
 The MCP shall work with hospital/inpatient facility, treating providers
and the ODJFS to assure that discharge planning assures continuity of care and
accurate

                                       
payment. Notwithstanding the MCP’s right to request a hospital deferment up to
six (6) months following the member’s effective date, when the enrolling MCP
learns

                                       
of a deferment-eligible hospitalization, the MCP shall notify the ODJFS and request the deferment
within five (5) business days of learning of the potential
deferment.

      

    

    
       

      
        	
                 
      

              	
                e.

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

              


      

    

    
       

      
        	
                 
      

              	
                f.

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

              


      

    

    
       

      
        	
                 
      

              	
                g.

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

              


      

    

    
       

      h.            
 Pending
Member

    

    
       

      
        	
                 
      

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

              


      

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
C

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
13

       

    

    
      i.         
    Transition of
Fee-For-Service Members

    

    
                      (Does
not apply to regions where members are not required to enroll in an
MCP)


    

    
       

      
        	
                 
      

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

              


      

    

    
      


                     
i.           
   Allow their new members that are transitioning from Medicaid
fee-for-service
to receive services from out-of-panel providers if the member or provider
contacts the 

                                      
MCP to discuss the scheduled health services in advance of the service date and
one of the following applies:

    

    
       

      
        	
                 
      

              	
                a.

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

              


      

    

    
       

      
        	
                 
      

              	
                b.

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

              


      

    

    
       

      
        	
                 
      

              	
                c.

              	
                The
      member has appointments within the initial month of MCP membership with
      specialty physicians that were scheduled prior tothe 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.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
C

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
14

    

     

    
      
        	
                 
      

              	
                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 and 2.b.v of Appendix G;

              
	 	 	 
	 	b.	dental
      services that have not yet been received;
	 	 	 
	 	c. 	vision
      services that have not yet been
received;


      

    

    
                                                                     

    

    
      
        	
                 
      

              	
                d.

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

              
	 	 	 
	 	 e.	
                private
      duty nursing (PDN) services. PDN services must be covered
      at the previously-authorized service level until the MCP conducts a
      medical necessity

                review
      and renders an authorization decision pursuant to OAC rule
      5101:3-26-03.1.

              


      

    

    
       

                                      
As soon as the MCP becomes aware of the member’s current fee-for-service
authorization approval, the MCP must initiate contact with the authorized
provider and 

    

    
                                      
member as applicable to ensure continuity of care. The MCP must implement a plan
to meet the member’s immediate and ongoing medical needs and, coordinate the


                                      
transfer of services to a panel provider, if appropriate. For organ, bone marrow
or hematapoietic stem cell transplants, MCPs must receive prior approval from
ODJFS 

                                       to
transfer services to a panel provider.

    

    
       

                                      
When an MCP medical necessity review results in a decision to reduce, suspend,
or terminate services previously authorized by fee-for-service Medicaid, the
MCP

                                     
 must notify the member of their state hearing rights no less than 15
calendar days prior to the effective date of the MCP’s proposed action, per rule
5101:3-26-08.4 of 

                                      
the Administrative Code.

    

    
       

                     
iv.           
 Reimburse out-of-panel providers that agree to provide the transition
services
at 100% of the current Medicaid fee-for-service provider rate for the service(s)


                                      
identified in Section 29.i. (i., ii., and iii.) of this
appendix.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
C

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
15

       

    

    
      
        	
                 

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

              


      

    

    
       

      
        	
                 

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

              


      

    

    
       

      
        	
                 

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

              


      

    

    
       

      
        	
                 

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

              


      

       

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

                                     
 relating to such services.

    

    
       

      30.          
Health Information System
Requirements

    

    
                     
The ability to develop and maintain information management systems capacity is
crucial to successful plan performance. ODJFS therefore requires MCPs to
demonstrate their 

                     
ongoing capacity in this area by meeting several related
specifications.

    

    


                   
a.             
Health
Information System                      

     

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

                Medicaid
      eligibility.

              
	 	 	 
	
                 

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

              
	 	 	 
	 	iii. 	
                 As
      required by 42 CFR 438.242(b)(2), each MCP must ensure that data received
      from providers is accurate and complete by verifying the accuracy
      and

                timeliness
      of reported data; screening the data for completeness, logic, and
      consistency; and collecting service information in standardized formats to
      the

                extent
      feasible and appropriate.

              


      

           

      
        
          
             


          

          
             


            
              

            

          

          
             


          

        

      

      


    

    
      Appendix
C

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
16


    

    
       

      
        	
                 

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

              


      

    

    
       

      
        	
                 

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

              


      

    

    
       

                                                      
a.            Before an
MCP may submit production files

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

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

      

    

    
       

    

    
                                                      
MCPs that change or modify information systems that are involved in producing
any type of electronically submitted files, either internally or by changing


                                                      
vendors, are required to submit to ODJFS for review and approval a transition
plan including the submission of test files in the ODJFS-specified formats.


                                                 
     Once an acceptable test file is submitted to ODJFS, as
determined solely by ODJFS, the MCP can return to submitting production files.
ODJFS will inform

                                                       MCPs
in writing when a test file is acceptable. Once an MCP’s new or modified
information system is operational, that
MCP will have up to ninety (90) days 

                                                      
to submit an acceptable test file and an acceptable production
file.

    

    
       

                                                      
Submission of test files can start before the new or modified information system
is in
production. ODJFS reserves the right to verify any MCP’s capability
to

                                                      
report elements in the minimum data set prior to executing the provider
agreement for the next contract period. Penalties for noncompliance with this


                                                      
requirement are specified in Appendix N, Compliance Assessment System of the
Provider Agreement.

    

    
      


                     
b.       
     Electronic Data Interchange and Claims
Adjudication Requirements 

       

                                      
Claims Adjudication

    

    
       

      
        	
                 
      

              	
                The
      MCP must have the capacity to electronically accept and adjudicate all
      claims to final status (payment or denial). Information on claims
      submission procedures 

                  
                    must
      be provided to non-contracting providers within thirty (30) days of a
      request.  MCPs
      must inform providers of its ability to electronically process and
      adjudicate

                  

                  
                    claims
      and the process for submission. Such information must be initiated by the
      MCP
      and not only in response to provider
  requests.

                  

                

              


      

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
C

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
17

    

    
      
        
           

        

      

    

    
      
        	
                 
      

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

              


      

    

    
      


                                      
Electronic Data
Interchange

    

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


                                      
transactions:

    

    
                                      
Health care
claims;
                                 Health
care claim status request and response;

                                      
Health
care payment and remittance status;

                                      
Standard
code sets; and

                                       National
Provider Identifier (NPI).

    

    
       

                                      
Each EDI transaction processed by the MCP shall be implemented in conformance
with the appropriate version of the transaction implementation guide, as
specified 

                                      
by applicable federal rule or regulation.

    

    
       

                                      
The MCP must have the capacity to accept the following transactions from the
Ohio Department of Job and Family services consistent with EDI
processing

                                     
 specifications in the transaction implementation guides and in conformance
with the 820 and 834 Transaction Companion Guides issued by
ODJFS:

    

    
       

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


    

    
       

                                      
ASC X12 834 - Benefit Enrollment and Maintenance.


    

    
       

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


                                       regulations.

       

    

    
                                      
Documentation of Compliance with
Mandated EDI Standards

                                     
 The capacity of the MCP and/or applicable trading partners and business
associates to electronically conduct claims processing and related transactions
in

                                    
  compliance with standards and effective dates mandated by HIPAA must be
demonstrated, to the satisfaction of ODJFS, as outlined
below.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
C

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
18

    

    
       

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

    

    
      


                                      
MCPs shall comply with the transaction standards and code sets for sending and
receiving applicable transactions as specified in 45 CFR Part 162 – Health
Insurance

                                      
Reform: Standards for Electronic Transactions (HIPAA regulations) In addition
the MCP must enter into the appropriate trading partner agreement and
implemented 

                                      
standard code sets. If the MCP has obtained third-party certification of HIPAA
compliance for any of the items listed below, that certification may be
submitted in lieu 

                                      
of the MCP’s written verification for the applicable item(s).

    

    
       

                                       i.           Trading
Partner Agreements

    

    
                                      
ii.          Code
Sets

    

    
                                      
iii.         Transactions

    

    
       

      
        	
                                                              
      

              	
                 a.

              	Health
      Care Claims or Equivalent Encounter Information (ASC X12N 837 & NCPDP
      5.1)
	 	 b.	Eligibility
      for a Health Plan (ASC X12N 270/271)
	 	 c.	Referral
      Certification and Authorization (ASC X12N 278)
	 	 d.	Health
      Care Claim Status (ASC X12N 276/277)
	 	 e.	Enrollment
      and Disenrollment in a Health Plan (ASC X12N 834)
	 	 f.	Health
      Care Payment and Remittance Advice (ASC X12N 835)
	 	 g.	Health
      Plan Premium Payments (ASC X12N 820)
	 	 h.	Coordination
      of Benefits


      

    

    
                                                      

    

    
                                     
 Trading Partner Agreement with
ODJFS

    

    
                                
      MCPs must complete and submit an EDI trading
partner agreement in a format specified by the ODJFS. Submission of the copy of
the trading partner agreement prior 

                                      
to entering into this Agreement may be waived at the discretion of ODJFS; if
submission prior to entering into this Agreement is waived, the trading partner


                                      
agreement must be
submitted at a subsequent date determined by ODJFS.

       

    

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


                                      
System, of the Provider Agreement.

    

    
      


                     
c.             Encounter Data Submission
Requirements

    

    
       

                                   
   General
Requirements

    

    
                              
        Each MCP must collect data on services
furnished to members through an encounter data system and must report encounter
data to the ODJFS. MCPs are required to

                                     
 submit this data
electronically to ODJFS on a monthly basis in the following standard
formats:

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
C

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
19

    

    
          

    

    
                                      
•      Institutional Claims - UB92 flat
file

    

    
                                      
•      Noninstitutional Claims - National
standard format

    

    
                                      
•      Prescription Drug Claims -
NCPDP


    

    
       

                              
        ODJFS relies heavily on encounter
data for monitoring MCP performance. The ODJFS uses encounter data to measure
clinical performance, conduct access and

                               
       utilization reviews,
reimburse MCPs for newborn deliveries and aid in setting MCP capitation rates.
For these reasons, it is important that encounter data is timely,

                                     
accurate, and complete.  Data
quality, performance measures and standards are described in the
Agreement.

    

    
       

                                   
   An encounter represents all of the services, including medical
supplies and medications, provided to a member of the MCP by a particular
provider, regardless of the

                                    
  payment arrangement
between the MCP and the provider. For example, if a member had an emergency
department visit and was examined by a physician, this would

                                     
 constitute two encounters,
one related to the hospital provider and one related to the physician provider.
However, for the purposes of calculating a utilization

                                     
 measure, this would be counted
as a
single emergency department visit. If a member visits their PCP and the PCP
examines the member and has laboratory procedures

                                     
 done within the office, then this is
one encounter
between the member and their PCP.

    

    
       

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

                                      each prescription
filled is a separate encounter.

    

    
       

                                     
Encounters include services paid for retrospectively through fee-for-service
payment arrangements, and prospectively through capitated arrangements.
Only

                                    
 encounters with services
(line items) that are paid by the MCP, fully or in part, and for which no
further payment is anticipated, are acceptable encounter data

                                    
 submissions, except for immunization
services. Immunization services submitted to the MCP must be submitted to ODJFS
if these services were paid for by another

                                    
 entity (e.g., free vaccine program).

    

    
       

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

                                      may
not be submitted
to ODJFS until they are paid. Penalties for noncompliance with this requirement
are specified in Appendix N, Compliance Assessment System

                                    
 of the Agreement.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
C

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
20

    

    
       

                                     
Acceptance
Testing

    

    
                            
         The MCP must have the
capability to report all elements in the Minimum Data Set as set forth in the
ODJFS Encounter Data Specifications and must submit a test file

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

    

    
       

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

    

    
      


                                     
Encounter Data File Submission
Procedures

    

    
                                     
A certification letter must accompany the submission of an encounter data file
in the ODJFS-specified medium. The certification letter must be signed by the
MCP’s

                                      Chief Executive
Officer (CEO), Chief Financial Officer (CFO), or an individual who has delegated
authority to sign for, and who reports directly to, the MCP’s CEO
or

                                      CFO.

    

    
       

                                
      Timing
of Encounter Data Submissions

    

    
                                 
     ODJFS recommends that MCPs submit encounters no more
than thirty-five (35) days after the end of the month in which they were paid.
For example, claims paid in 

                                  
    January are due March
5. ODJFS recommends that MCPs submit files in the ODJFS-specified medium by the
5th of each month. This will help to ensure that the

                                   
  encounters are included in the ODJFS
master file in the same month in which they were submitted.

    

    
       

                     
d.             Information Systems
Review

    

    
       

                                      ODJFS
or its designee may review the information system capabilities of each MCP,
before ODJFS enters into a provider agreement with a new MCP, when
a

                                      participating
MCP undergoes
a major information system upgrade or change, when there is identification of
significant information system problems, or at ODJFS’

                                     
discretion. Each MCP must participate
in the review. The review will assess the extent to which MCPs are capable of
maintaining a health information system including

                                     
producing valid encounter data, performance
measures, and other data necessary to support quality assessment and
improvement, as well as managing the care

                                     
delivered to its members.

    

    
       

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

    

    
       

      
        	
                                

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

              


      

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
C

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
21

       

    

    
                              
      
ii.          Review the
completed ISCA and accompanying documents;

    

    
       

      
        	
                                          
           iii.

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

              


      

    

    
       

      
        	
                                          
           iv.

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

              


      

    

    
       

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

    

    
       

                              
      
vi.         Examine MCP processes
for data transfers;

    

    
       

      
        	
                            
                     
         vii.

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

              


      

    

    
       

      
        	
                                               
      viii.

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

              


      

    

    
       

      
        	
                                      
               ix.

              	
                Assess
      the claims adjudication process and capabilities of the
    MCP.

              


      

    

    
       

      31.           Delivery
Payments

    

    
       

                     
MCPs will be reimbursed for paid deliveries that are identified in the submitted
encounters using the methodology outlined in the ODJFS Delivery Payment and
Reporting

                   
  Procedures document. 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. Delivery encounters
submitted by MCPs must be received by ODJFS no later than 460 days after the
last date of service.

                    
 Delivery encounters which are received by ODJFS after this time will be
denied payment. MCPs will receive notice of the payment denial on the remittance
advice.

    

    
       

                     
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.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
C

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
22

    

    
       

                      If
a physician and a hospital encounter is found for the same delivery, only one
payment will be made. The same is true for multiple births; if multiple delivery
encounters are

                    
 submitted, only one payment will be made. The method for reimbursing for
deliveries includes the delivery of stillborns where the MCP incurred costs
related to the delivery.

    

    
       

                     
Rejections

    

    
                      If
a delivery encounter is not submitted according to ODJFS specifications, it will
be rejected
and MCPs will receive this information on the exception report (or error
report)

                     
that
accompanies every file in the ODJFS-specified format. Tracking, correcting and
resubmitting
all rejected encounters is the responsibility of the MCP and is required
by

                      ODJFS.

    

    
      


                     
Timing of Delivery
Payments

                     
MCPs will be paid monthly for deliveries. For example, payment for a delivery
encounter submitted with the required encounter data submission in March, will
be reimbursed in

    

    
                     
March. The delivery payment will cover any encounters submitted with the monthly
encounter data submission regardless of the date of the encounter, but will not
cover

                    
 encounters that occurred over one year ago.

    

    
      


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

                     
remittance advice is in the same format as the capitation remittance
advice.

    

    
       

                      Updating and Deleting Delivery
Encounters

    

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

                      instructions
on updating and deleting delivery encounters.

    

    
      


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

                     
specifications (record/field CA0-31.0a).

    

    
       

                     
Auditing of Delivery
Payments

    

    
                     
A delivery payment audit will be conducted periodically. If medical records do
not substantiate that a delivery occurred related to the payment that was made,
then ODJFS will

                    
 recoup the delivery payment from the MCP. Also, if it is determined that
the encounter which triggered the delivery payment was not a paid encounter,
then ODJFS will recoup

                    
 the delivery payment.

    

    
       

      
        	
                32.

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

              


      

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
C

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
23

    

    
       

      
        	
                33.

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

              


      

    

    
       

      
        	
                34.

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

              


      

    

    
       

      
        	
                35.

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

              


      

    

    
       

      36.           Franchise Fee Assessment
Requirements

    

    
       

      
        	
                               
      a.

              	
                Each
      MCP is required to pay a franchise permit fee to ODJFS for each calendar
      quarter as required by ORC Section 5111.176. The current fee to be paid is
      an amount equal to 5.5 percent of the managed care premiums, minus
      Medicare premiums that the MCP received from any payer in the quarter to
      which the fee applies. Any premiums the MCP returned or refunded to
      members or premium payers during that quarter are excluded from the
      fee.

              


      

    

    
       

      
        	
                                b.

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

              


      

    

    
       

      
        	
                                c.

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

              


      

    

    
       

      
        	
                               
      d.

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

              


      

    

    
       

      37.           Information Required for MCP
Websites

    

    
       

      
        	
                                a.

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

              


      

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
C

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
24

       

    

    
      
        	
                               
      b.

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

              


      

    

    
       

                                      
The MCP member website must also include, at a minimum, the following
information which must be accessible to members and the general public without
any log-in 

                                       restrictions:
(1) MCP contact information, including the MCP’s toll-free member services phone
number, service hours, and closure dates; (2) a list of counties

                                     
 covered in the MCP’s service area; (3) the ODJFS-approved MCP member
handbook, recent newsletters and announcements; (4) the MCP’s on-line
provider

                                     
 directory as referenced in section 36(a) of this appendix; (5) the MCP’s
current preferred drug list (PDL), including an explanation of the list, which
drugs require prior

                                      
authorization (PA), and how to initiate a PA; and (6) the MCP’s current list of
drugs covered only with PA, how to initiate a PA, and the MCP’s policy for
covering

                                     
 name brand drugs. MCPs must ensure that all website member information and
materials are clearly labeled for CFC members and/or ABD members, as
applicable.

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

    

    
       

      
        	
                                c.

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

              


      

    

    
      


                                    
  The MCP provider website must also include, at a minimum, the following
information which must be accessible to providers and the general public without
any log-

                                      
in restrictions:
(1) MCP contact information, including the MCP’s designated contact for provider
issues; (2) a list of counties covered in the MCP’s service area;
(3)

                                     
 the MCP’s provider manual including the MCP's claims submission process,
as well as a list of services requiring prior authorization, recent newsletters
and

                                   
   announcements; (4) the MCP’s on-line provider directory as
referenced in section 36(a) of this appendix; (5) the MCP’s current PDL,
including an explanation of the

                                     
 list, which drugs require PA, and how to initiate a PA; and (6) the MCP’s
current list of drugs covered only with PA, how to initiate a PA, and the MCP’s
policy for 

                                      
covering name brand drugs. MCPs must ensure that all website information and
materials are clearly labeled for CFC members and/or ABD members, as
applicable.

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

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
C

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
25

       

    

    
      
        	
                38.

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

              


      

    

    
       

      
        	
                39.

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

              


      

    

    
       

      40.           Coordination of
Benefits

    

    
      


                     
When a claim is denied due to third party liability, the managed care plan must
timely share appropriate and available information regarding the third party to
the provider for

                    
 the purposes of coordination of benefits, including, but not limited to
third party liability information received from the Ohio Department of Job and
Family Services.

    

    
       

      
        	
                41.

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

              


      

    

    
       

      
        
          
             


          

          
             


            
              

            

          

          
             


          

        



    

    
      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.

              


      

    

    
       

      
        
          
             


          

          
             


            
              

            

          

          
             


          

        

Appendix
D

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
2

    

    
       

      
        	
                10.

              	
                On
      a monthly basis, ODJFS will provide MCPs with an electronic Provider
      Master File containing all the Ohio Medicaid fee-for-service providers,
      which includes their Medicaid Provider Number, as well as all providers
      who have been assigned a provider reporting number for current encounter
      data purposes. This file also includes National Provider Identifier (NPI)
      information where applicable.

              


      

    

    
       

      
        	
                11.

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

              


      

    

    
       

      
        	
                12.

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

              


      

    

    
       

      
        	
                13.

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

              


      

    

    
       

      14.           Consumer
information

    

    
       

      
        	
                                a.

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

              


      

    

    
       

      
        	
                                b.

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

              


      

    

    
       

      
        	
                                c.

              	
                If
      an MCP elects not to provide, reimburse, or cover a counseling service or
      referral service due to an objection to the service on moral or religious
      grounds, ODJFS will provide
      coverage and reimbursement for these services for the MCP’s members. 
      ODJFS
      will provide information on what services the MCP will not cover and how
      and
      where the MCP’s members may obtain these services in the applicable
      Consumer
      Guides.

              


      

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
D

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
3

    

    
      
        
           

        

      

    

    
      15.          
Membership Selection
and Premium Payment

    

    
       

      
        	
                                a.

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

              


      

    

    
      


                                      
The MCEC shall distribute the most current Consumer Guide that includes the
managed care program information as specified in 42 CFR 438.10, as well as
ODJFS 

                                     
 prior-approved MCP materials, such as solicitation brochures and provider
directories, to consumers who request additional materials.

    

    
       

        	
                               
      b.

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

              


      

    

    
       

      
        	
                                                     
      •

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

              
	                                  
         •  	70%
      of the CFC eligibles in any region with two MCPs; and/or
	                                     
      •  	55% of the CFC eligibles in any region with three MCPs


      

    

    
                                                                                   

    

    
                                      
Once an MCP meets one of these enrollment thresholds, the MCP will only be
permitted to receive the additional new membership (in the region or statewide,
as

                                      
applicable) through: (1) consumer-initiated enrollment; and (2) auto-assignments
which are based on previous enrollment in that MCP or based on an historical


                                      
provider relationship with a provider who is not on the panel of any other MCP
in that region. In the event that an MCP in a region meets one or more of these


                                      
enrollment thresholds, ODJFS, in their sole discretion, may not impose the
auto-assignment limitation and auto-assign members to the MCPs in that region as
ODJFS

                                      
deems appropriate.

    

    
       

      
        	
                                c
      .

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

              


      

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
D

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
4

    

    
       

                     
MCPs will be scored based on the following ten measures:

    

    
       

                  
    i.              MCP
Consumer Call Center (see Appendix C)

    

    
                                      
–         Average Speed of
Answer

    

    
                                      
–         Abandonment
Rate

    

    
               –         Blockage
rate          

    

    
                      
ii.             MCP
Provider Call Center (measurement and standards will match those set for the MCP
Consumer Call Center outlined in Appendix
C.      

                                     
 –         Average Speed of
Answer

    

    
                                      
–         Abandonment
Rate

                                      
–         Blockage
rate 

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

    

    
                                      
–         Average Time to Process
Non-Pharmacy Requests

                                      
–         Average
Time to Process Pharmacy Requests 

                      
iv.           Prompt Payment
of Claims (see Appendix J)

                                      
–         Percentage
of Claims Paid within 30days

                                      
–         Percentage
of Claims Paid within 90 days

    

    
       

                     
Each MCP will receive a point for meeting the established standard. If an MCP
meets the established standard for each measure, they will receive ten points.
For each region,

                    
 the MCP with the highest score will receive the performance-based
auto-assignments for the region. If there is a tie for the highest score, then
each tying MCP will be

                     
considered equal in the auto-assignment process. Scoring will take place
quarterly and applied to the auto-assignment process once the results are
finalized.

    

    
       

                     
On a regional basis, MCPs that have auto-assignment limitations in accordance
with 15(b) do not qualify for performance-based auto-assignments unless (1)
there are two

                    
 MCPs in the region, (2) the auto-assignment limited MCP received 10 points
and (3) the other MCP in the regional failed to receive 10 points. In this case,
the MCP with the

                    
 auto-assignment limitation shall receive auto-assignments in the amount of
10% of the performance based auto-assignments for every point the other MCP is
below 10 points 

                      (i.e.
if the other MCP has 7 points then the MCP would receive 30% (3 points *
10%)).

    

    
       

                      If
ODJFS implements a new enrollment freeze on an MCP as outlined in Appendix N,
the MCP will not receive any auto-assignments. Should ODJFS remove the new
enrollment 

                     
freeze, the MCP will not be entitled to receive performance based
auto-assignments until the next quarterly review is performed and implemented as
outlined in this section.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
D

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
5

       

    

    
      
        	
                                d.

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

              


      

    

    
       

      
        	
                                e.

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

              


      

    

    
       

      
        	
                                f.

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

              


      

    

    
       

      
        	
                               
      g.

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

              


      

    

    
       

      
        	
                                h.

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

              


      

    

    
       

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

    

    
       

      
        	
                17.

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

              


      

    

    
       

      
        	
                18.

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

              


      

    

    
       

      19.           Communications

    

    
       

        	
                               
      a.             
      ODJFS/BMHC:

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

              


      

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
D

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
6

    

    
       

    

    
                      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
F 

      REGIONAL
RATES

    

    
       

      1.
PREMIUM RATES WITHOUT THE AT-RISK PAYMENT AMOUNTS FOR 01/01/09 THROUGH 06/30/09
SHALL BE AS FOLLOWS: An
at-risk amount of 1% is applied to the MCP rates. The status of the at-risk
amount is determined in accordance with Appendix O, performance
incentives.

    

    
       

      MCP:
WellCare of Ohio, Inc.

    

     

    
      	
              
                SERVICE

              

              
                ENROLLMENT

              

              
                AREA

              

            	
              
                REGIONAL
      STATUS

              

            	
              
                HF/HST
      

                Age
      < 1

              

            	
              
                HF/HST
      

                Age
      1

              

            	
              
                HF/HST
      

                Age
      2-13

              

            	
              
                HF/HST

              

              
                Age
      14-18

              

              
                Male

              

            	
              
                HF/HST

              

              
                Age
      14-18

              

              
                Female

              

            	
              
                HF

              

              
                Age
      19-44

              

              
                Male

              

            	
              
                HF

              

              
                Age
      19-44

              

              
                Female

              

            	
              
                HF

              

              
                Age
      45

              

              
                and
      over

              

            	
              
                HST

              

              
                Age
      19-64

              

              
                Female

              

            	
              
                Delivery
      Payment

              

            
	
              
                Northeast

              

            	
              
                Mandatory

              

            	
              
                $560.36

              

            	
              
                $138.09

              

            	
              
                $98.52

              

            	
              
                $127.48

              

            	
              
                $171.11

              

            	
              
                $214.01

              

            	
              
                $318.30

              

            	
              
                $490.82

              

            	
              
                $395.17

              

            	
              
                $4,482.86

              

            
	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      


    

    
       

      List
of Eligible Assistance Groups (AGs)

    

    
       

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

    

    
                                   -
MA-T   Children under 21

    

    
                                       - MA-Y  Transitional
Medicaid

       

    

    
      Healthy
Start:         - MA-P Pregnant Women and
Children

    

    
       

      For the
SFY 2009 contract period, MCPs will be put at-risk for a portion of the premiums
received for members in regions they served as of January
1, 2006, provided the MCP has participated in the program for more than
twenty-four months. 

      MCPs will
be put at-risk for a portion of the premiums received for members in regions
they began serving after January 1, 2006, beginning with the
MCP's twenty-fifth month of membership in each region. The at-risk amount will
be determined separately for each region an MCP serves. WellCare's regions at
risk: Northeast.

    

    
      Page 1 of
3

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      APPENDIX
F 

      REGIONAL
RATES

       

    

    
                     
2. AT-RISK AMOUNTS FOR 01/01/09 THROUGH 06/30/09 SHALL BE AS FOLLOWS: An at-risk
amount of 1% is applied to the MCP rates. The status of the at-risk amount is
determined in accordance with Appendix O, performance
incentives.

    

    
      


      MCP:
WellCare of Ohio, Inc.

    

     

    
      	
              
                SERVICE

              

              
                ENROLLMENT

              

              
                AREA

              

            	
              
                REGIONAL
      STATUS

              

            	
              
                HF/HST
      

                Age
      < 1

              

            	
              
                HF/HST
      

                Age
      1

              

            	
              
                HF/HST
      

                Age
      2-13

              

            	
              
                HF/HST

              

              
                Age
      14-18

              

              
                Male

              

            	
              
                HF/HST

              

              
                Age
      14-18

              

              
                Female

              

            	
              
                HF

              

              
                Age
      19-44

              

              
                Male

              

            	
              
                HF

              

              
                Age
      19-44

              

              
                Female

              

            	
              
                HF

              

              
                Age
      45

              

              
                and
      over

              

            	
              
                HST

              

              
                Age
      19-64

              

              
                Female

              

            	
              
                Delivery
      Payment

              

            
	
              
                Northeast

              

            	
              
                Mandatory

              

            	
              
                $5.35

              

            	
              
                $1.32

              

            	
              
                $0.94

              

            	
              
                $1.22

              

            	
              
                $1.63

              

            	
              
                $2.04

              

            	
              
                $3.04

              

            	
              
                $4.68

              

            	
              
                $3.77

              

            	
              
                $42.77

              

            
	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      


    

    
       

      List
of Eligible Assistance Groups (AGs)

    

    
       

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

    

    
                                      
-   MA-T   Children under 21

    

    
                                      
-   MA-Y  Transitional Medicaid

    

    
       

      Healthy
Start:         - 
MA-P   Pregnant Women and Children

    

    
      


      For the
SFY 2009 contract period, MCPs will be put at-risk for a portion of the premiums
received for members in regions they served as of January
1, 2006, provided the MCP has participated in the program for more than
twenty-four months. 

      MCPs will
be put at-risk for a portion of the premiums received for members in regions
they began serving after January 1, 2006, beginning with the
MCP's twenty-fifth month of membership in each region. The at-risk amount will
be determined separately for each region an MCP serves. WellCare's regions at
risk: Northeast.

    

    
      Page 2 of
3

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      APPENDIX
F 

      REGIONAL
RATES

    

    
                     
3. PREMIUM RATES FOR 01/01/09 THROUGH 06/30/09 SHALL BE AS FOLLOWS: An at-risk
amount of 1% is applied to the MCP rates. The status of the at-risk amount is
determined in accordance with Appendix O, performance
incentives.

    

    
       

      MCP:
WellCare of Ohio, Inc.

    

     

    
      	
              
                SERVICE

              

              
                ENROLLMENT

              

              
                AREA

              

            	
              
                REGIONAL
      STATUS

              

            	
              
                HF/HST
      

                Age
      < 1

              

            	
              
                HF/HST
      

                Age
      1

              

            	
              
                HF/HST
      

                Age
      2-13

              

            	
              
                HF/HST

              

              
                Age
      14-18

              

              
                Male

              

            	
              
                HF/HST

              

              
                Age
      14-18

              

              
                Female

              

            	
              
                HF

              

              
                Age
      19-44

              

              
                Male

              

            	
              
                HF

              

              
                Age
      19-44

              

              
                Female

              

            	
              
                HF

              

              
                Age
      45

              

              
                and
      over

              

            	
              
                HST

              

              
                Age
      19-64

              

              
                Female

              

            	
              
                Delivery
      Payment

              

            
	
              
                Northeast

              

            	
              
                Mandatory

              

            	
              
                $565.71

              

            	
              
                $139.41

              

            	
              
                $99.46

              

            	
              
                $128.70

              

            	
              
                $172.74

              

            	
              
                $216.05

              

            	
              
                $321.34

              

            	
              
                $495.50

              

            	
              
                $398.94

              

            	
              
                $4,525.63

              

            
	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      	 
      


    

    
      


      List
of Eligible Assistance Groups (AGs)

    

    
      


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

    

    
                                       -   MA-T   Children
under 21

    

    
                                      
-   MA-Y  Transitional Medicaid

    

    
       

      Healthy
Start:         - 
MA-P   Pregnant Women and Children

    

    
       

      For the
SFY 2009 contract period, MCPs will be put at-risk for a portion of the premiums
received for members in regions they served as of January 1,
2006, provided the MCP has participated in the program for more than twenty-four
months. 

      MCPs will
be put at-risk for a portion of the premiums received for members in regions
they began serving after January 1, 2006, beginning with the
MCP's twenty-fifth month of membership in each region. The at-risk amount will
be determined separately for each region an MCP serves. WellCare's regions at
risk: Northeast.

    

    
      Page 3 of
3

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
G

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
1

    

    
      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, and any additional
services as specified in OAC rule 5101:3-26-03. For information on
Medicaid-covered services,

                    
 MCPs must refer to the ODJFS website. The following is a general list of
the benefits covered by the Ohio Medicaid fee-for-service
program:

    

    
       

                                      
•      Inpatient hospital
services

    

    
       

                                      
•      Outpatient hospital
services

    

    
      


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

    

    
       

      
        	
                                                
      •

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

              


      

    

    
       

                                      
•      Laboratory and x-ray
services

    

    
       

      
        	
                                                
      •

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

              


      

    

    
      


                                   
   •      Family planning
services and supplies

    

    
                                    

                                      
•      Home health and private duty nursing
services

    

    
       

                                      
•      Podiatry

      
      

    

    
                         
            
•      Chiropractic
services

    

    
       

      
        	
                                                
      •

              	
                Physical
      therapy, occupational therapy, developmental therapy and speech
      therapy

              


      

    

    
       

      
        	
                                                
      •

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

              


      

    

    
       

                                      
•      Prescription
drugs

    

    
       

                                      
•      Ambulance and ambulette
services

       

    

    
                                      
•      Dental
services


        
          
             


          

          
             


            
              

            

          

          
             


          

        

      

       

    

    
      Appendix
G

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
2

    

    
       

                                      
•      Durable medical equipment and
medical supplies

       

    

    
                                      
•      Vision care services, including
eyeglasses

       

    

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

       

    

    
                                      
•      Hospice care

       

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

    

     

    
      2.     Exclusions, Limitations and Clarifications

       

                                     
a.           Exclusions


    

    
       

                                                   
MCPs are not required to pay for Ohio Medicaid FFS program (Medicaid)
non-covered services, except as specified in OAC rule 5101:3-26-03. 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

              


      

    

    
       

      
        	
                                                              •

              	
                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*

       

    

    
                                                    •      Services
for the treatment of obesity unless medically necessary*

       

    

    
                                                   
•      Custodial or supportive care not
covered by Medicaid

       

    

    
                                                   
•      Sexual or marriage
counseling

       

    

    
                                                   
•      Acupuncture and biofeedback
services

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
G

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
3

       

    

    
                                                    
•      Services to find cause of death
(autopsy)


    

    
       

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

       

                                                    
•    
 Paternity testing

    

    
       

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

                                    
 otherwise directed by ODJFS.

    

    
       

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

    

    
      


       

                  
    b.          
 Limitations &
Clarifications

    

    


                                   
i.           
Member
Cost-Sharing

    
       

                                                   
As specified in OAC rules 5101:3-26-05(D) and 5101:3-26-12, MCPs are permitted
to impose the applicable member co-payment amount(s) for dental services,


                                                   
vision services, non-emergency emergency department services, or prescription
drugs, other than generic drugs. MCPs must notify ODJFS if they intend
to

                                                  
 impose a co-payment. ODJFS must approve the notice to be sent to the MCP’s
members and the timing of when the co-payments will begin to be imposed. If


                                                   
ODJFS determines that an MCP’s decision to impose a particular co-payment on
their members would constitute a significant change for those members,


                                                   
ODJFS may require the effective date of the co-payment to coincide with the
“Open Enrollment” month.

    

    
       

                                                   
Notwithstanding the preceding paragraph, MCPs must provide an ODJFS-approved
notice to all their members 90 days in advance of the date that the
MCP

                                                  
 will impose the co-payment. With the exception of member co-payments the
MCP has elected to implement in accordance with OAC rules 5101:3-26-05(D) and


                                                   
5101:3-26-12, the MCP’s payment constitutes payment in full for any covered
services and their subcontractors must not charge members or ODJFS any 


                                                   
additional co-payment, cost sharing, down-payment, or similar charge, refundable
or otherwise.

    

    
       

                                     
ii.           Abortion and
Sterilization

    

    
       

                                                   
The use of federal funds to pay for abortion and sterilization services is
prohibited unless the specific criteria found in 42 CFR 441 and OAC rules
5101:3-17-01

                                                  
 and 5101:3-21-01 are met. MCPs must verify that all of the information on
the required forms (JFS 03197, 03198, and 03199) is provided and that the
service

                                           
        meets the required criteria before
any such claim is paid.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
G

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
4

    

    
       

    

    
                                                   
Additionally, payment must not be made for associated services such as
anesthesia, laboratory tests, or hospital services if the abortion or
sterilization itself

                                                  
 does not qualify for payment. MCPs are responsible for educating their
providers on the requirements; implementing internal procedures including
systems 

                                                    edits
to ensure that claims are only paid once the MCP has determined if the
applicable forms are completed and the required criteria are met, as confirmed
by

                                                  
 the appropriate certification/consent forms; and for maintaining
documentation to justify any such claim payments.

    

    
       

                                      iii.          Behavioral Health
Services


    

    
       

                                             
      Coordination of
Services: MCPs must have a process to coordinate benefits
of and referrals to the publicly funded community behavioral health
system.

                                                  
 MCPs must
ensure that members have access to all medically-necessary behavioral health
services covered by the Ohio Medicaid FFS program and are

                                                    responsible
for coordinating those services with other medical and support services. MCPs
must notify members via the member handbook and provider

                                                
   directory of where and how to access behavioral health
services, including the ability to self-refer to mental health services offered
through ODMH

                                                  
 community mental
health centers (CMHCs) as well as substance abuse services offered through Ohio
Department of Alcohol and Drug Addiction Services

                                                  
 (ODADAS)-certified
Medicaid providers. Pursuant to ORC Section 5111.16, alcohol, drug addiction and
mental health services covered by Medicaid are not to

                                                  
 be paid by the
managed care program when the nonfederal share of the cost of those services is
provided by a board of alcohol, drug addiction, and mental

                                                  
 health services
or a state agency other than ODJFS. MCPs are also not responsible for providing
mental health services to persons between 22 and 64 years of

                                                  
 age while
residing in an institution for mental disease (IMD) as defined in Section
1905(i) of the Social Security Act.

    

    
       

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

                                                  
 through community providers.

    

    
       

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

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
G

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
5

       

    

    
                                              
     Where an MCP is responsible for providing MH services
for their members, the MCP is responsible for ensuring access to counselingand
psychotherapy,

                                                   
physician/psychologist/psychiatrist services, outpatient clinic services,
general hospital outpatient psychiatric services, pre-hospitalization
screening,

                                                    diagnostic
assessment (clinical evaluation), crisis intervention, psychiatric
hospitalization in general hospitals (for all ages), and
Medicaid-covered

                                                  
 prescription drugs and
laboratory services. MCPs are not required to cover partial hospitalization, or
inpatient psychiatric care in a private or public free-

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

                                                  
 when such
services are billed independent of the hospital. The payment of physician
services in an IMD is also covered by the MCPs, as long as the
member

                                                  
 is 21 years of
age and under or 65 years of age and older.

    

    
       

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

    

    
      


                                                    Where
an MCP is responsible for providing substance abuse services for their members,
the MCP is responsible for ensuring access to alcohol and other
drug

                                                  
 (AOD) urinalysis screening, assessment, counseling,
physician/psychologist/psychiatrist AOD treatment services, outpatient clinic
AOD treatment services,

                                            
       general hospital outpatient AOD treatment
services, crisis intervention, inpatient detoxification services in a general
hospital, and Medicaid-covered

                                                 
  prescription drugs and laboratory services. MCPs are not required to
cover outpatient detoxification, intensive outpatient programs (IOP) or
methadone

                                                  
 maintenance.

    

    
       

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

    

    
       

      
        	
                                                                
      •

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

              


      

    

    
      
        	
                                                                
      •

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

              


      

    

    
      
        	
                                                                
      • 

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

              


      

    

    
       

                                                     
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:

              


      

    

    
      
      

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
G

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
6

    

    
       

    

    
      
        	
                                                                             
      •

              	
                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;

              


      

    

    
      
        	
                                                                              •

              	
                MCPs
      are
      required to cover the payment of physician services in a private or public
      free­standing psychiatric hospital when such services are billed
      independent of the hospital.

              


      

    

    
       

      
        	
                 
      

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

                             
      service program, in accordance with OAC rule 5101:3-26-03(A) and
      (B).

              


      

    

    
       

                                                   
Pursuant to ORC Section 5111.172, MCPs may, subject to ODJFS approval, implement
strategies for the management of drug utilization. (see appendix
G.3.a).

    

    
       

      
        	
                                              
       v.

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

              


      

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
G

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
7

    

    
      


      3.         
   Health
Management Programs

    

    
       

                     
In an effort to improve access, quality, and continuity of care for MCP members,
each MCP must:


    

    
       

                    
       i.  Establish a primary care provider
(PCP) for each member and encourage the member to have an ongoing relationship
with the PCP. For this requirement, a primary care

                          
 provider as defined in OAC: 5101: 3-26-01 serves as the ongoing source of
primary and preventive care; assists with coordination of care as appropriate
for the member’s

                          
 health care needs; recommends referrals to specialists for the member;
triages the member appropriately; notifies the MCP of a member who may benefit
from care

                          
 management services; and participates in development of the Care
Management care treatment plan. The MCP must ensure the primary care provider
agrees to perform the

                          
 care coordination responsibilities as outlined in OAC: 5101:
3-26-03.1.

    

    
       

                           
ii.  Provide education and outreach to each member to emphasize the
importance of disease prevention and health/wellness promotion. The MCP must
encourage and

                          
 enable the member to make informed decisions about accessing and utilizing
health care services appropriately.

    

    
      


                           
iii. Direct and monitor coordination of care efforts for each member for medical
services delivered across the continuum of care. The MCP should incorporate
the

                          
 requirements in Sections 3 c, d, and e in its overall strategy for care
coordination.

    

    
       

                           
iv. Develop and implement a strategy to identify members who display risk
factors for developing a disease and/or who over-/under-utilize health care
services, and would

                          
 benefit from targeted outreach or education. For this requirement, the MCP
must implement mechanisms to identify such members and should include the
following

                          
 information sources: administrative data review (e.g., pharmacy claims,
emergency department claims, or inpatient hospital admissions), provider/self
referrals, telephone

                           
interviews, home visits, referrals resulting from internal MCP operations, and
data as reported by the MCEC during membership selection. Should the MCP
identify

                          
 members characterized as having an increased risk for developing a disease
or who inappropriately utilize health care services, the MCP must offer
education and outreach 

                           
initiatives (e.g., educational mailing) designed to mitigate the risk factors,
and prevent the member from requiring more progressive interventions, such as
care management

                          
 services.

    

    
       

                           
v. Implement Utilization Management Programs as outlined in Section 3.a to
maximize effectiveness of care provided to members.

    

    
       

                           
vi. Each MCP must implement a Care Management Program as outlined in Section 3.b
which coordinates and monitors the care for members with special health care
needs.

                          
 The Care Management Program must be designed to ensure the intensity of
interventions provided by the MCP corresponds to the member’s level of
need.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
G

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
8

    

    
       

                     
a.             Utilization Management
Programs

    

    
       

                                                   
General Provisions
- Pursuant to OAC rule 5101:3-26-03.1(A)(7), MCPs must implement a
utilization management (UM) program to maximize the effectiveness

                                                  
 of the care provided to members and may develop other UM programs, subject
to prior approval by ODJFS. For the purposes of this requirement, the
specific

                                                  
 UM programs which require ODJFS prior-approval are an MCP’s general
pharmacy program, a controlled substances and member management program,
and

                                                  
 any other program designed by the MCP with the purpose of redirecting or
restricting access to a particular service or service
location.

    

    
       

      
        	
                                                              i.

              	
                Pharmacy
      Programs - Pursuant to ORC Sec. 5111.172, MCPs may, subject to ODJFS
      prior-approval, implement strategies for the management of drug
      utilization. Pharmacy utilization management strategies may include
      developing preferred drug lists, requiring prior authorization for certain
      drugs, placing limitations on the type of provider and locations where
      certain medications may be administered, and developing and implementing a
      specialized pharmacy program to address the utilization of controlled
      substances, as defined in section 3719.01 of the Ohio Revised Code. MCPs
      may also implement a retrospective drug utilization review program
      designed to promote the appropriate clinical prescribing of covered
      drugs.

              


      

    

    
       

                                                               Drug
Prior Authorizations: MCPs must receive prior approval from ODJFS for the
medications that they wish to cover through prior authorization.
MCPs

                                                              
must establish their prior authorization system so that it does not
unnecessarily impede member access to medically-necessary
Medicaid-covered

                                                             
 services. MCPs must make their approved list of drugs covered only with
prior authorization available to members and providers, as outlined
in

                                                             
 paragraphs 37(b) and (c) of Appendix C.

    

    
       

                                                              
While MCPs may, with ODJFS approval,   require prior
authorization for the coverage of 2nd
generation antipsychotic drugs, MCPs must allow any

                                                             
 member to continue receiving a specific 2nd
generation antipsychotic drug if the member is stabilized on that particular
medication. The MCP must 

                                                             
 continue to cover that specific antipsychotic for the stabilized member
for as long as that medication continues to be effective for the member.
MCPs

                                                             
 must also collaborate with ODJFS in the retrospective review of 2nd
generation antipsychotic utilization.

    

    
       

                                                              
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.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
G

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
9

    

    
       

                                                              
Controlled Substances and Member Management Programs: MCPs may also, with ODJFS
prior approval, develop and implement Controlled Substances

    

    
                                                             
 and Member Management (CSMM) programs designed to address use of
controlled substances. Utilization management strategies may include
prior 

                                                             
 authorization as a condition of obtaining a controlled substance, as
defined in section 3719.01 of the Ohio Revised Code. CSMM strategies may
also 

                                                             
 include processes for requiring MCP members at high risk for fraud or
abuse involving controlled substances to have their controlled substances


                                                              
prescribed by a designated provider/providers and filled by a pharmacy, medical
provider, or health care facility designated by the program.

    

    
       

      
        	
                                                             
      ii.

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

              


      

    

    
      


                                                              
Each MCP must establish an ED diversion (EDD) program with the goal of
minimizing frequent ED utilization. The MCP’s EDD program must include
the

                                                       
       monitoring of ED utilization,
identification of frequent ED utilizers, and targeted approaches designed to
reduce avoidable ED utilization. MCP EDD

                                                            
  programs must, at a minimum, address those ED visits which could have
been prevented through improved education, access, quality or care

                                                             
 management approaches.

    

    
      


                                                              
Although there is often an assumption that frequent ED visits are solely the
result of a preference on the part of the member and education is
therefore

                                                              
the standard remedy, it is also important to ensure that a member’s frequent ED
utilization is not due to problems such as their PCP’s lack of

                                                             
 accessibility or
failure to make appropriate specialist referrals. The MCP’s EDD program must
therefore also include the identification of providers who

                                                             
 serve as PCPs for a substantial number of frequent ED utilizers and the
implementation of corrective action with these providers as so
indicated.

    

    
      


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

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
G

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
10


    

    
       

                     
b.             Care Management
Programs

    

    
      


                                  
   In accordance with 5101:3-26-03.1(A)(8), MCPs must offer and
provide care management services which coordinate and monitor the care of
members with special

                                 
    health care needs.

    

    
       

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


    

    
       

                                      ii.        The
MCP’s care management program must include, at a minimum, the following
components:


    

    
       

      
        	
                                                     
           a.

              	
                Identification
      Strategies

              


      

    

    
       

      
        	
                 
      

              	
                The
      MCP must implement mechanisms to identify members potentially eligible for
      care management services. These mechanisms must include an administrative
      data review of pharmacy claims, emergency department visits, and inpatient
      hospital admissions (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,
      home visits, or referrals resulting from internal MCP operations (e.g.,
      utilization management, 24/7 nurse advice line, member services,
      etc.).

              


      

    

    
       

                                                                 
Each MCP must incorporate identification strategies (i.e., mechanisms and
criteria) as specified in ODJFS Care Management Program
Requirements.

    

    
       

      
        	
                                                         
       b.

              	
                Risk Stratification
      Levels

              


      

    

    
       

      
        	
                 
      

              	
                The
      MCP must develop a strategy to assign members to low, medium, or high risk
      stratification levels based on the results of the identification and/or
      assessment processes. This will be a continual process and the risk levels
      will be adjusted based on the completion of the health assessment and the
      member’s demonstrated progress in meeting the goals of the care treatment
      plan. Each MCP must incorporate risk stratification levels as specified in
      ODJFS Care Management
      Program Requirements.

              


      

    

    
       

      
        	
                                                       
         c.

              	
                Health
      Assessment

              


      

    

    
       

      
        	
                 
      

              	
                Once
      a member has been identified by the MCP as being potentially eligible for
      care management, the MCP must arrange for, or conduct, a health assessment
      to determine the member’s need for care management services. The health
      assessment completed by the MCP will depend on the member’s initial
      assignment to a low-, medium-, or high-risk stratification level. ODJFS
      recognizes that the completion of an assessment may result in the
      assignment of the member to a different risk stratification level (i.e.,
      than the level originally assigned) or that the member may not demonstrate
      a need for care management
services.

              


      

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
G

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
11

       

                                                                
 For a member assigned to the low- or medium-risk stratification levels,
the MCP must, at a minimum, complete a health assessment based on a
review

                                                                
of administrative claims
data. The health assessment must be able to identify the severity of the
member’s condition/disease state, and must be

                                                                
 reviewed by a qualified health professional
appropriate for the member’s health condition. If an MCP opts to use a disease
management

                                                               
 methodology/algorithm to assign members to a risk stratification
level as part of the assessment, there must be clinical input to the development
of the

                                                                
algorithm.

       

                                                                
 For
members assigned to a high risk stratification level, the MCP must complete a
health assessment that is comprehensive and evaluates the

    

    
                                                                 
member’s medical condition(s),
including physical, behavioral, social, and psychological
needs.   The health assessment must also evaluate if
the

                                                               
  member has co-morbidities, or multiple complex
health care conditions. The goals of the assessment are to identify the member’s
existing and/or

                                                                
 potential health care needs and assess the member’s need
for care
management services. The health assessment for members assigned to the high risk


                                                                
stratification level must be completed by a physician, physician
assistant, RN, LPN,
licensed social worker, or a graduate of a two- or four-year allied

                                                                
health program. If the assessment is completed by a physician assistant, LPN,
licensed social
worker, or a graduate of a two- or four-year allied health

                                                                
 program, there should be oversight and monitoring by either a registered
nurse or physician.

    

    
       

                                                                
 The MCP must address the health assessment components as specified in
ODJFS Care Management Program
Requirements.

    

    
       

                                      
         
d.             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 health
assessment, and reflect the member’s health care needs. The care treatment plan
must also include specific provisions for periodic

                                                                
 reviews of the member's health
care needs. Periodic reviews may include administrative data reviews or
screening questions to alert appropriately

                                                               
 qualified MCP staff to update the health assessment
and the care treatment plan. The frequency of contact with the member must
correspond to the

                                                                
 member’s risk stratification level, and must include a provision
for two-way communication or feedback between the member and the
MCP.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
G

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
12

    

    
       

    

    
                                                              
   The member and the member's PCP must be actively involved in the
development of, and revisions to, the care treatment plan. The designated PCP
is

                                                                
 the provider, or specialist,
who will manage and coordinate the overall care for the member. Ongoing
communication regarding the status of the care

                                                                
 treatment
plan may be accomplished
between the MCP and the PCP's designee (i.e., qualified health professional).
Revisions to the clinical portion of

                                                                
 the care treatment plan should be completed
in consultation with the PCP.

    

    
       

                                               
              
   The elements of a care treatment plan include:

    

    
       

                                                     
           
(a)         Goals and actions that
address health care conditions identified in the health
assessment;

    

    
       

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

                                                                 
to the  health
care conditions identified in the health assessment;

    

    
       

                                                           
      (c)    
     Continuous review, revision and contact follow-up,
as needed, with members to insure the care treatment plan is adequately
monitored 

                                                                 
including the following:

    

     

    
      
        	
                                                                            •

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

              


      

    

    
      
        	
                                                                          
       •

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

              


      

    

    
                 


                                                 The
MCP must address care treatment plan components as specified in ODJFS Care Management Program
Requirements.

    

    
       

                                                 e.      
       Coordination of Care and
Communication

    

    
       

                                                   
              The
MCP must assign an accountable point of contact (i.e., care manager) who can
help obtain medically necessary care, assist with health-related

                                                              
   services and coordinate
care needs.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
G

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
13

    

    
       

                                                          
       The MCP must arrange or provide for
professional care management services that are performed collaboratively by a
team of professionals appropriate

                                                                
 for the member’s
condition and health care needs. The MCP’s care manager must attempt to
coordinate with the member’s care manager from other 

                                                                 
health systems. The MCP must have
a process to facilitate, maintain, and coordinate both care and communication
with the member, PCP, and other

                                                                
 service providers and care managers. The MCP must
also have a process to coordinate care for a member that is receiving services
from state sub-

                                                                 
recipient agencies as appropriate [e.g., the Ohio Department of Mental
Health (ODMH); the Ohio Department of Mental Retardation and

                                                                
 Developmental Disabilities (ODMR/DD); and the Ohio Department of Alcohol
and Drug Addiction
Services (ODADAS)]. The MCP must have a 

                                                                 
provision to disseminate information to the member/caregiver concerning the
health condition, types of services
that may be available, and how to 

                                                                 
access the services.

    

    
       

                                                
f.           
  Member
Enrollment in the Care Management Program

    

    
       

                                                
The MCP must assure and coordinate the placement of the member into the Care
Management Program–including the identification of the member’s need
for

                                                 care management
services, completion of the health assessment, and timely development of the
care treatment plan. This process must occur within the

                                                
following timeframes for:

    

    
      


                                         
      
a)             newly
enrolled members: 90 days from the effective date of enrollment for those
members who are identified as meeting the criteria for care

                                               
 management; and 

                                                 b)          
  existing members: 90 days from identifying their need for care
management.

    

    
       

                                       
         For members assigned to
the low or medium risk stratification levels, the MCP may choose to implement an
“opt out” process for members. MCPs that

                                                
implement an opt out
process must provide care management services to the member until the member
declines the initial offer to participate in the program. The

                                               
 opt out process must be clearly
defined in all member materials, and the MCP must have a documented process for
honoring any opt out requests. For members

                                               
 assigned to a low- or medium – level, the
MCP may obtain verbal or written confirmation of the member’s care management
status in the care management

                                               
 records. For members assigned to the high risk stratification
levels, the MCP must obtain written or verbal confirmation of the member’s care
management status

                                               
 in the care management record.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
G

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
14


    

    
       

                                               
 g.            
Provider and Member
Notifications

    

    
       

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

                                               
 enrollment into the care
management program. The MCP must develop, at a minimum, the following
notifications for members enrolled in the Care Management

                                               
 program:

       

    

    
      
        	
                                                                      
      1.

              	
                Member
      Enrollment in the Care Management Program: This must include a description
      of the opt-out process (if an MCP implements) for members in the low- and
      medium- risk stratification levels; contact information for the member’s
      care manager; and the care management services available to the
      member.

              


      

    

    
      
        	
                                                                      
      2.

              	
                Member
      Disenrollment from the Care Management Program: This notice must include
      the rationale for disenrolling the member from the care management
      program, (e.g., declines participation in the program, meets goals in care
      treatment plan, etc.) and information for the member to contact the MCP if
      future assistance is needed.

              


      

    

    
       

                                                
h.             Access to
Specialists

    

    
         

                                                            
     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.

    

    
       

                                                
i.            
  Care Management
Strategies

    

    
       

                                                              
   The MCP must follow best-practice and/or evidence based clinical
guidelines when developing interventions for the risk stratification levels, the
care

                                                                
 treatment plan and
coordinating the care management needs. The MCP must develop and implement
mechanisms to educate and equip providers and

                                                                
 care managers with evidence-based
clinical guidelines or best practice approaches to assist in providing a high
level of quality of care to members.

    

    
       

                                                
j.             
 Care Management
Program Staffing

       

                                                            
     The MCP must identify the staff that will be involved
in the operations of the care management program, including but not imited to:
care manager 

                                                                  supervisors,
care manager,
and administrative support staff. The MCP must identify the role and functions
of each care management staff member as

                                                                
 well as the educational requirements,
clinical licensure standards, certification and relevant experience with care
management standards and/or 

                                                                 
activities. The MCP must provide care manager
staff/member ratios based on the member risk stratification and different levels
of care being provided

                                                                 
to members.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
G

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
15

    

    
       

                                                
k.             
Information Technology
System for the Care Management Program


    

    
                            

                                                
The MCP’s information technology system for the Care Management Program must
maximize the opportunity for communication between the MCP, the PCP,
the

                                               
 member, and other
service providers and care managers. The MCP must have an integrated database
that allows MCP staff who may be contacted by a member

                                                
in care management
to have immediate access to, and review of, the most recent information with the
MCP’s information systems relevant to the case. The

                                                
integrated database may
include the following: administrative data, call center communications, service
authorizations, care treatment plans, health assessments, 

                                                
care management notes, and PCP
notes. The information technology system must also have the capability to share
relevant information with the member, the 

                                                
PCP, and other service providers and care managers.
The goal is to integrate information from a variety of sources in an effort to
facilitate care management

                                               
 needs for the member.

    

    
       

                                      
         
l.          
    Care Management Data
Submission

       

    

    
                                                                 
The MCP must submit a monthly electronic report to the Care Management System
(CAMS) for all members who are provided care management

                                                                
 services by the MCP
as outlined in the ODJFS Case
Management File and Submission Specifications.    In
order for a member to be submitted as care

                                                                
 managed in CAMS, the
MCP must complete the steps as outlined in Section ii.f: Enrollment in the Care
Management program. ODJFS, or its

                                                                
 designated entity, the external quality
review vendor, will validate on an annual basis the accuracy of the information
contained in CAMS with the

                                                                
 member’s care management record.

    

    
       

                                                                 
The CAMS files are due the 15th
calendar day of each month.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
G

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
16

       

    

    
                                                                
 The MCP must also have an ODJFS-approved care management program which
includes the items in this Section. Each MCP must implement an 

                                                                 
evaluation process
to review, revise and/or update the care management program on an annual basis.
If the evaluation process results in a revision to

                                                                
 identification strategies,
health assessment(s), and risk stratification strategies, then the MCP must
notify ODJFS in writing of the change, which
may
                                                          
 be subject to review and
approval by ODJFS.

    

    
       

                     
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);

              


      

    

    
      

        
          
             


          

          
             


            
              

            

          

          
             


          

        

Appendix
G

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
17

    

    
       

      
        	
                                                                        
      •

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

              


      

    

    
       

      
        	
                                                                         •

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

              


      

    

    
       

                     
d.             Care coordination with
Non-Contracting Providers

    

    
       

                                     
Per OAC rule 5101:3-26-05(A)(9), MCPs authorizing the delivery of services from
a provider who does not have an executed subcontract must ensure that they have a

                                    
 mutually agreed upon compensation amount for the authorized service and
notify the provider of the applicable provisions of paragraph D of OAC rule
5101:3-26-05.

                                     
This notice is provided when an MCP authorizes a non-contracting provider to
furnish services on a one-time or infrequent basis to an MCP member and must
include

                                    
 required ODJFS-model language and information. This notice must also be
included with the transition of services form sent to providers as outlined in
paragraph 29.h

                                     
of Appendix C.

    

    
       

                     
e.             Integration of Member
Care


    

    
       

                                     
The MCP must ensure that a discharge plan is in place to meet a member’s health
care needs following discharge from a nursing facility, and integrated into
the

                                    
 member’s continuum of care. The discharge plan must address the services
to be provided for the member and must be developed prior to the date of
discharge from

                                    
 the nursing facility. The MCP must ensure follow-up contact occurs with
the member, or authorized representative, within thirty (30) days of the
member’s discharge

                                    
 from the nursing facility to ensure that the member’s health care needs
are being met.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
H

    

    
      Covered
Families and Children (CFC) population

    

    
      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 Administrative Code rule requirements specific
to provider subcontracting and therefore cannot be modified except to add
personalizing information such as the MCP’s name.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
H

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
2

    

    
      


      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 Managed Care Provider Network
(MCPN), maintained by the Managed Care Enrollment Center (MCEC), or other
designated process. The MCPN is a centralized database system that maintains
information on the status of all MCP-submitted providers.

    

    
       

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

    

    
       

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

    

    
       

      3. 
           PROVIDER PANEL
REQUIREMENTS

       

    

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

    

    
       

      a.      
       Primary Care Providers
(PCPs)

    

    
       

      Primary
Care Provider (PCP) means an individual physician (M.D. or D.O.), certain
physician group practice/clinic (Primary Care Clinics [PCCs]), or an advanced
practice nurse (APN) as defined in ORC 4723.43 or advanced practice nurse group
practice within an acceptable specialty, contracting with an MCP to provide
services as specified in paragraph (B) of OAC rule 5101: 3-26-03.1. The APN
capacity can count up to 10% of the total requirement for the county. Acceptable
specialty types for PCPs include family/general practice, internal medicine,
pediatrics, and obstetrics/gynecology (OB/GYN). Acceptable PCCs include FQHCs,
RHCs and the acceptable group practices/clinics specified by ODJFS. As part of
their subcontract with an MCP, PCPs must stipulate the total Medicaid member
capacity that they can ensure for that individual MCP.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      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 MCPN
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.

    

    
      


      b.       
     Non-PCP Provider
Network

    

    
      


      In
addition to the PCP capacity requirements, each MCP is also required to maintain
adequate capacity in the remainder of its provider network within the following
categories: hospitals, dentists, pharmacies, vision care providers,
obstetricians/gynecologists (OB/GYNs), allergists, general surgeons,
otolaryngologists, orthopedists, certified nurse midwives (CNMs), certified
nurse practitioners (CNPs), federally qualified health centers (FQHCs)/rural
health centers (RHCs) and qualified family planning providers (QFPPs). CNMs,
CNPs, FQHCs/RHCs and QFPPs are federally-required provider
types.

    

    
       

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

    

    
      


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

    

    
       

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

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
H

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
5

    

    
       

    

    
      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
MCPN, 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 MCPN, or other system, count towards MCP
minimum panel requirements, and be listed in the MCPs’ provider directory.The
MCP must ensure a member’s access to CNM and CNP services if such providers are
practicing within the region.

    

    
       

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

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
H

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
6

    

     

    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 MCPN process, or other designated
process. Even if no FQHC/RHC is available within the region, MCPs must have
mechanisms in place to ensure coverage for FQHC/RHC services in the event that a
member accesses these services outside of the region.

    

    
      


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

    

    
       

        	
                                 •

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

              


      

    

    
       

      
        	
                                
      •

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

              


      

    

    
       

      
        	
                                 •             
      

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

              


      

    

    
       

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

    

    
       

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

    

    
       

      MCPs will
be required to work with QFPPs in the region to develop mutually-agreeable HIPAA
compliant policies and procedures to preserve patient/provider confidentiality,
and convey pertinent information to the member’s PCP and/or
MCP.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
H

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
7

    

    
       

    

    
      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 MCPN, 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

    

    
       

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

    

    
       

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

    

    
       

      5.         
  PROVIDER
DIRECTORIES

    

    
       

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

              


      

    

    
      
      

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
H Page 10

    

    
       

    

    
      
        •         
     MCPs must adequately and timely cover services
to an out-of-network provider if the MCP’s contracted provider panel is unable
to provide the services covered under the

                 
      MCP’s provider agreement. The MCP must cover the
out-of-network services for as long as the MCP network is unable to provide the
services. MCPs must coordinate with

                      
 the out-of-network provider with respect to payment and ensure that the
provider agrees with the applicable requirements.

      

    

    
       

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

    

    
       

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

    

    
       

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

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      North East Region - PCP
Capacity

    

    


     

    
      	 
      	
              
                Minimum
      PCP Capacity Requirements

              

            	 
      
	
              
                 

                PCPs

              

            	
              
                 

                Total
      Required

              

            	
                        
      

              Ashtabula 

            	
               
      

                       Cuyahoga     

            	
               
      

              Erie

            	
               
      

              Geauga

            	
               
      

              Huron

            	
               
      

              Lake

            	
               
      

              Lorain

            	
               
      

              Medina

            	
              
                Additional

              

              
                Required:

              

              
                In-Region
      *

              

            
	
              
                 

                Capacity 1

              

            	
              
                 

                98,212

              

            	
              
                 

                5,256

              

            	
              
                 

                66,564

              

            	
              
                 

                2,873

              

            	
              
                 

                1,111

              

            	
              
                 

                2,612

              

            	
              
                 

                5,210

              

            	
              
                 

                11,431

              

            	
              
                 

                3,155

              

            	 
      
	
              
                 

                FTEs

              

            	
              
                 

                49.11

              

            	
              
                 

                2.63

              

            	
              
                 

                33.28

              

            	
              
                 

                1.44

              

            	
              
                 

                0.56

              

            	
              
                 

                1.31

              

            	
              
                 

                2.61

              

            	
              
                 

                5.72

              

            	
              
                 

                1.58

              

            	 
      


    

    
       

       

      
        	 1  Based
      on an FTE of 2000 members	 


      

       

    

    
      * Must be
located within the region.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      North
East Central Region - PCP Capacity


    

     

    
      	 
      	
              
                Minimum PCP
      Capacity Requirements

              

            
	
              
                 

                 

                PCPs

              

            	
              
                 

                 

                Total

                Required

              

            	
               
      

               

              Columbiana    

            	
               
      

               

              Mahoning

            	
               
      

               

              Trumbull

            	
              
                Additional

              

              
                Required:

              

              
                In-Region
      *

              

            
	
              
                 

                Capacity
      1

              

            	
              
                 

                31,367

              

            	
              
                 

                5,281

              

            	
              
                 

                12,039

              

            	
              
                 

                9,047

              

            	
              
                 

                5,000

              

            
	
              
                 

                FTEs

              

            	
              
                 

                15.68

              

            	
              
                 

                2.64

              

            	
              
                 

                6.02

              

            	
              
                 

                4.52

              

            	
              
                 

                2.50

              

            


    

    
       

       

      
        
          	 1 Based on an
      FTE of 2000 members	 


        

         

      

    

    
      * Must be
located within the region.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      East
Central Region - PCP Capacity


    

     

    
      	 
      	 
      	
              
                Minimum
      PCP Capacity Requirements

              

            	 
      
	
              
                 

                 

                PCPs

              

            	
              
                 

                Total
      

                Required

              

            	
               
      

              Ashland

            	
               
      

              Carroll

            	
               
      

              Holmes

            	
               

              Portage
      

            	
               
      

              Richland

            	
               
      

              Stark

            	
               
      

              Summit

            	 
      Tuscarawas	
               
      

              Wayne

            	
              
                Additional

              

              
                Required:

              

              
                In-Region
      *

              

            
	
              
                Capacity
      1

              

            	
              
                55,006

              

            	
              
                1,732

              

            	
              
                1,226

              

            	
              
                794

              

            	
              
                4,329

              

            	
              
                5,363

              

            	
              
                14,376

              

            	
              
                20,279

              

            	
              
                3,616

              

            	
              
                3,291

              

            	 
      
	
              
                FTEs

              

            	
              
                27.50

              

            	
              
                0.87

              

            	
              
                0.61

              

            	
              
                0.40

              

            	
              
                2.16

              

            	
              
                2.68

              

            	
              
                7.19

              

            	
              
                10.14

              

            	
              
                1.81

              

            	
              
                1.65

              

            	 
      


    

    
       

       

      
        
          	 1 Based on an
      FTE of 2000 members	 


        

         

      

    

    
      * Must be
located within the region.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Central Region - PCP
Capacity

    

    


     

    
      	
              
                County

              

            	
              
                Capacity 1

              

            	
              
                FTEs

              

            
	 
      
	
              
                Total
      Required

              

            	
              
                100,253

              

            	
              
                50.13|

              

            
	
              
                Crawford

              

            	
              
                2,016

              

            	
              
                1.01

              

            
	
              
                Delaware

              

            	
              
                2,307

              

            	
              
                1.15

              

            
	
              
                Fairfield

              

            	
              
                4,698

              

            	
              
                2.35

              

            
	
              
                Fayette

              

            	
              
                1,341

              

            	
              
                0.67

              

            
	
              
                Franklin

              

            	
              
                55,101

              

            	
              
                27.55

              

            
	
              
                Hocking

              

            	
              
                1,672

              

            	
              
                0.84

              

            
	
              
                Knox

              

            	
              
                2,236

              

            	
              
                1.12

              

            
	
              
                Licking

              

            	
              
                5,897

              

            	
              
                2.95

              

            
	
              
                Logan

              

            	
              
                1,656

              

            	
              
                0.83

              

            
	
              
                Madison

              

            	
              
                1,378

              

            	
              
                0.69

              

            
	
              
                Marion

              

            	
              
                3,042

              

            	
              
                1.52

              

            
	
              
                Morrow

              

            	
              
                1,492

              

            	
              
                0.75

              

            
	
              
                Perry

              

            	
              
                2,263

              

            	
              
                1.13

              

            
	
              
                Pickaway

              

            	
              
                2,123

              

            	
              
                1.06

              

            
	
              
                Pike

              

            	
              
                2,116

              

            	
              
                1.06

              

            
	
              
                Ross

              

            	
              
                4,442

              

            	
              
                2.22

              

            
	
              
                Scioto

              

            	
              
                5,204

              

            	
              
                2.60

              

            
	
              
                Union

              

            	
              
                1,269

              

            	
              
                0.63

              

            


    

    
      


       

      
        	 1 Based on an
      FTE of 2000 members	 


      

       

    

    
      * Must be
located within the region.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      South East Region - PCP
Capacity

    

    


     

    
      	
              
                County

              

            	
              
                Capacity 1

              

            	
              
                FTEs

              

            
	 
      
	
              
                Total
      Required

              

            	
              
                42,412

              

            	
              
                21.21       |

              

            
	
              
                Athens

              

            	
              
                2,664

              

            	
              
                1.33

              

            
	
              
                Belmont

              

            	
              
                3,178

              

            	
              
                1.59

              

            
	
              
                Coshocton

              

            	
              
                1,840

              

            	
              
                0.92

              

            
	
              
                Gallia

              

            	
              
                1,918

              

            	
              
                0.96

              

            
	
              
                Guernsey

              

            	
              
                2,518

              

            	
              
                1.26

              

            
	
              
                Harrison

              

            	
              
                810

              

            	
              
                0.41

              

            
	
              
                Jackson

              

            	
              
                2,107

              

            	
              
                1.05

              

            
	
              
                Jefferson

              

            	
              
                3,418

              

            	
              
                1.71

              

            
	
              
                Lawrence

              

            	
              
                4,021

              

            	
              
                2.01

              

            
	
              
                Meigs

              

            	
              
                1,557

              

            	
              
                0.78

              

            
	
              
                Monroe

              

            	
              
                750

              

            	
              
                0.38

              

            
	
              
                Morgon

              

            	
              
                930

              

            	
              
                0.47

              

            
	
              
                Muskingum

              

            	
              
                5,304

              

            	
              
                2.65

              

            
	
              
                Noble

              

            	
              
                581

              

            	
              
                0.29

              

            
	
              
                Vinton

              

            	
              
                1,061

              

            	
              
                0.53

              

            
	
              
                Washington

              

            	
              
                2,755

              

            	
              
                1.38

              

            
	
              
                 

                 

                Additional
      Required:
      

                In-Region
      *

              

            	
              
                 

                 

                7,000

              

            	
              
                 

                 

                3.50

              

            


    

    
       

      
      

      
      

       

      
        	 1 Based on an
      FTE of 2000 members	 


      

       

      * Must be
located within the region.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      South West Region - PCP
Capacity

    

    


     

    
      	 
      	
              
                Minimum
      PCP Capacity Requirements

              

            	 
      
	
              
                 

                 

                PCPs

              

            	
              
                 

                Total
      

                Required

                 

              

            	
               
      

               

              Adams

            	
               

               

               Brown

            	
               
      

               

              Butler

            	
               

               

               Clermont

            	
               

               

               Clinton

            	
               

               

               Hamilton

            	
               
      

               

              Highland

            	
               
      

               

              Warren

            	
              
                Additional
      

                Required:
      In 

                  Region
      *

                

              

            
	
              
                 

              

            
	
              
                Capacity
      1

              

            	
              
                58,754

              

            	
              
                2,063

              

            	
              
                2,122

              

            	
              
                12,296

              

            	
              
                5,787

              

            	
              
                1,705

              

            	
              
                29,787

              

            	
              
                2,240

              

            	
              
                2,754

              

            	 
      
	
              
                FTEs

              

            	
              
                29.38

              

            	
              
                1.03

              

            	
              
                1.06

              

            	
              
                6.15

              

            	
              
                2.89

              

            	
              
                0.85

              

            	
              
                14.89

              

            	
              
                1.12

              

            	
              
                1.38

              

            	 
      


    

    
       

       

      
        	 1 Based on an
      FTE of 2000 members	 


      

       

      * Must be
located within the region.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      West
Central Region - PCP Capacity

    

    


     

    
      	 
      	
              
                Minimum
      PCP Capacity Requirements

              

            	 
      
	
              
                 

                 

                PCPs

              

            	
              
                 

                Total
      

                Required

              

            	
               
      

               

              Champaign

            	
               
      

               

              Clark

            	
               
      

               

              Darke

            	
               
      

               

              Greene

            	
               

               

              Miami

            	
               
      

               

              Montgomery

            	
               
      

               

              Preble

            	
               
      

               

              Shelby

            	
              
                 

                Additional

              

              
                Required:

              

              
                In-Region
      *

              

            
	
              
                Capacity
      1

              

            	
              
                42,784

              

            	
              
                1,472

              

            	
              
                7,225

              

            	
              
                1,476

              

            	
              
                4,347

              

            	
              
                2,550

              

            	
              
                22,751

              

            	
              
                1,541

              

            	
              
                1,422

              

            	 
      
	
              
                FTEs

              

            	
              
                21.39

              

            	
              
                0.74

              

            	
              
                3.61

              

            	
              
                0.74

              

            	
              
                2.17

              

            	
              
                1.28

              

            	
              
                11.38

              

            	
              
                0.77

              

            	
              
                0.71

              

            	 
      


    

    
      


      
      

       

      
        	 1 Based on an
      FTE of 2000 members	 


      

       

    

    
      * Must be
located within the region.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      North West Region - PCP
Capacity

    

    


     

    
      	
              
                County

              

            	
              
                Capacity 1

              

            	
              
                FTEs

              

            
	 	 	 
	 Total
      Required	
               68,540 

            	
               34.27

            
	
              
                Allen

              

            	
              
                4,262

              

            	
              
                2.13

              

            
	
              
                Auglaize

              

            	
              
                1,228

              

            	
              
                0.61

              

            
	
              
                Defiance

              

            	
              
                1,555

              

            	
              
                0.78

              

            
	
              
                Fulton

              

            	
              
                1,270

              

            	
              
                0.64

              

            
	
              
                Hancock

              

            	
              
                2,038

              

            	
              
                1.02

              

            
	
              
                Hardin

              

            	
              
                1,096

              

            	
              
                0.55

              

            
	
              
                Henry

              

            	
              
                894

              

            	
              
                0.45

              

            
	
              
                Lucas

              

            	
              
                24,752

              

            	
              
                12.38

              

            
	
              
                Mercer

              

            	
              
                821

              

            	
              
                0.41

              

            
	
              
                Ottawa

              

            	
              
                1,271

              

            	
              
                0.64

              

            
	
              
                Paulding

              

            	
              
                710

              

            	
              
                0.36

              

            
	
              
                Putnam

              

            	
              
                770

              

            	
              
                0.39

              

            
	
              
                Sandusky

              

            	
              
                2,142

              

            	
              
                1.07

              

            
	
              
                Seneca

              

            	
              
                2,128

              

            	
              
                1.06

              

            
	
              
                Van
      Wert

              

            	
              
                847

              

            	
              
                0.42

              

            
	
              
                Williams

              

            	
              
                1,478

              

            	
              
                0.74

              

            
	
              
                Wood

              

            	
              
                2,444

              

            	
              
                1.22

              

            
	
              
                Wyandot

              

            	
              
                634

              

            	
              
                0.32

              

            
	
              
                 

                Additional
      Required:
      

                In-Region
      *

              

            	
              
                 

                 

                18,200

              

            	
              
                 

                 

                9.10

              

            


    

    
       

       

    

    
      
        	 1 Based on an
      FTE of 2000 members	 


      

       

      * Must be
located within the region.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      WellCare

    

    
       

      APPENDIX
J


    

    
       

      FINANCIAL
PERFORMANCE 

      CFC
ELIGIBLE POPULATION

    

    
      


      1.        
   SUBMISSION OF FINANCIAL STATEMENTS AND
REPORTS

    

    
      


       

                     
MCPs must submit the following financial reports to ODJFS:

    

    
      


       

      
        	
                                a.

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

              


      

    

    
       

      
        	
                               
      b.

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

              


      

    

    
       

      
        	
                                c.

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

              


      

    

    
       

      
        	
                               
      d.

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

              


      

    

    
       

      
        	
                               
      e.

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

              


      

    

    
       

      
        	
                               
      f.

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

              


      

    

    
      


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

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
J

    

    
      Covered
Families and Children (CFC) population

    

    
      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 2009, a minimum net
      worth per member of $363.00, as determined from the annual Financial
      Statement

                                        
      submitted to ODI and the
ODJFS.

              


      

    

    
       

                                  
   The Net Worth Per Member (NWPM) standard is the Medicaid Managed
Care Capitation amount paid to the MCP during the preceding calendar year,
including

                                 
    delivery payments, but excluding the at-risk amount,
expressed as a per-member per-month figure, multiplied by the applicable
proportion below:

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
J

    

    
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Families and Children (CFC) population

    

    
      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

              
       enrollment 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).

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
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      Page
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If the financial statement is not submitted to ODI by the due date, the MCP
continues to be obligated to submit the report to ODJFS by ODI’s originally
specified due date

                    
 unless the MCP requests and is granted an extension by
ODJFS.

    

    
       

                   
  Failure to submit complete quarterly and annual Financial Statements on a
timely basis will be deemed a failure to meet the standards and will be subject
to the noncompliance

            
         penalties listed for indicators
2.a., 2.b., and 2.c., including the imposition of a new enrollment freeze. The
new enrollment 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

                     enrollment
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

    

    
      Covered
Families and Children (CFC) population

    

    
      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 $75,000 that covers 80% of inpatient costs in excess of the deductible amount
for non-

                      transplant
services.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
J

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
6

    

    
      


                
     Penalty for noncompliance: If it is determined
that an MCP failed to have reinsurance coverage, that an MCP’s deductible
exceeds $75,000.00 without approval from ODJFS, or

                
     that the MCP’s reinsurance for non-transplant services
covers less than 80% of inpatient costs in excess of the deductible incurred by
one member for one year without

              
       approval from ODJFS, then the MCP will be
required to pay a monetary penalty to ODJFS. The amount of the penalty will be
the difference between the estimated amount, as

                   
  determined by ODJFS, of what the MCP would have paid in premiums for the
reinsurance policy if it had been in compliance and what the MCP did actually
pay while it was

                    
 out of
compliance plus 5%. For example, if the MCP paid $3,000,000.00 in premiums
during the period of non-compliance and would have paid $5,000,000.00 if the
requirements

                    
 had been met, then the penalty would be $2,100,000.00.

    

    
       

                     
If it is determined that an MCP’s reinsurance for transplant services covers
less than 50% of inpatient costs incurred by one member for one year, the MCP
will be required to

                    
 develop a corrective action plan (CAP).

    

    
       

      
        	
                4.

              	
                PROMPT
      PAY REQUIREMENTS

              


      

    

    
       

                   
  In accordance with 42 CFR 447.46, MCPs must pay 90% of all submitted
clean claims within 30 days of the date of receipt and 99% of such claims within
90 days of the date of

                     
receipt, unless the MCP and its contracted provider(s) have established an
alternative payment schedule that is mutually agreed upon and described in their
contract. The

                    
 clean pharmacy
and non-pharmacy claims will be separately measured against the 30 and 90 day
prompt pay standards. The prompt pay requirement applies to the
processing

                    
 of both electronic
and paper claims for contracting and non-contracting providers by the MCP and
delegated claims processing entities.

    

    
       

                   
  The date of receipt is the date the MCP receives the claim, as indicated
by its date stamp on the claim. The date of payment is the date of the check or
date of electronic

                  
   payment transmission. A claim means a bill from a provider for
health care services that is assigned a unique identifier. A claim does not
include an encounter form.

    

    
      


                  
   A “claim” can include any of the following: (1) a bill for
services; (2) a line item of services; or (3) all services for one recipient
within a bill. A “clean claim” is a claim that can be

                 
    processed without obtaining additional information from the
provider of a service or from a third party.

    

    
      


                     
Clean claims do not include payments made to a provider of service or a third
party where the timing of the payment is not directly related to submission of a
completed claim

                    
 by the provider of service or third party (e.g., capitation). A clean
claim also does not include a claim from a provider who is under investigation
for fraud or abuse, or a claim

                    
 under review for medical necessity.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
J

    

    
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Families and Children (CFC) population

    

    
      Page
7

       

    

    
                   
  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 upon
request:


    

    
       

      
        	
                               
      a.

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

              


      

    

    
       

      
        	
                               
      b.

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

              


      

    

    
       

      
        	
                                c.

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

              


      

    

    
       

      
        	
                               
      d.

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

              


      

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
J

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
8

    

    
       

    

    
      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 enrollment
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 and complete 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.

    

    
       

              
       The MCPs will be required to participate in
a PIP collaborative beginning in SFY 2009, and as specified by ODJFS. A PIP
Collaborative is defined as a cooperative quality

                     
improvement effort by the MCP, ODJFS, and the EQRO to address a clinical or
non-clinical topic area relevant to the Medicaid managed care program, which is
designed to

                     
identify, develop, and implement standardized measures and statewide
interventions to optimize health outcomes for MCP members and improve
efficiencies related to health

                    
 care service delivery.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
K

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
2

    

    
      


       

                     
b.             HEALTH CARE SERVICE
UTILIZATION

    

    
       

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

                      annual
submission of the QAPI program to ODJFS.

    

    
       

           
          It should also be noted
that pursuant to the program integrity provisions outlined in Appendix I, MCPs
must monitor for the potential under-utilization of services by
their

                
     members in order to assure that all Medicaid-covered
services are being provided, as required. If any under-utilized services are
identified, the MCP must immediately

               
      investigate and correct the problem(s) which
resulted in such under-utilization of services.

    

    
      


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

                     
utilized.

    

    
      


                     
c.             SPECIAL HEALTH CARE
NEEDS

    

    
       

              
       Each MCP must have mechanisms in place to
assess the quality and appropriateness of care furnished to 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

                    
 Healthcare Effectiveness Data and 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 as specified by ODJFS. 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.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
K

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
3

    

    
       

                     
e.             QAPI PROGRAM
SUBMISSION

    

    
      


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

                    
 by ODJFS.

    

    
      


      2.
            EXTERNAL QUALITY
REVIEW

    

    
       

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

    

    
       

                     
a.            EQRO ADMINISTRATIVE
REVIEWS

    

    
      


                     
The EQRO will conduct annual focused administrative compliance assessments for
each MCP which will include, but not be limited to, the following domains as
specified by

                    
 ODJFS: member rights and services, QAPI program, case management, provider
networks, grievance system, coordination and continuity of care, and utilization
management.

                      In
addition, the EQRO will complete a comprehensive administrative compliance
assessment every three (3) years as required by 42 CFR 438.358 and specified by
ODJFS.

    

    
       

                     
In accordance with 42 CFR 438.360 and 438.362, MCPs with accreditation from a
national accrediting organization approved by the Centers for Medicare and
Medicaid Services

                
     (CMS) may request a non-duplication exemption from
certain specified components of the administrative review. ODJFS will inform the
MCPs when a non-duplication

               
      exemption may be requested.

    

    
       

                     
b.            EXTERNAL QUALITY REVIEW
PERFORMANCE

    

    
      


                     
In accordance with OAC 5101: 3-26-07, each MCP must participate in an annual
external quality review survey. If the EQRO cites a deficiency in performance,
the MCP will be 

                     
required to complete a Corrective Action Plan (e.g., ODJFS technical assistance
session) or Quality Improvement Directives depending on the severity of the
deficiency. (An

                    
 example of a deficiency is if an MCP fails to meet certain clinical or
administrative standards as supported by national evidence-based guidelines or
best practices.) Serious

                   
  deficiencies may result in immediate termination or non-renewal of the
provider agreement. These quality improvement measures recognize the importance
of ongoing MCP

                    
 performance improvement related to clinical care and service
delivery.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      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
care 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; care
management data; data used in the external quality review; members’ PCP data;
and appeal and grievance data.

    

    
       

      1.
ENCOUNTER DATA

    

    
      


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

    

    
       

      1.a.
Encounter Data Completeness

    

    
      


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

    

    
       

      1.a.i.
Encounter Data Volume

    

    
      


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

    

    
       

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

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
L

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
2

    

    
       

      Table
1. Report Periods for the SFY 2009 and 2010 Contract
Periods


    

     

    
      	
              
                Quarterly
      Report Periods

              

            	
              
                Data
      Source:

              

              
                Estimated
      Encounter

              

              
                Data
      File Update

                 

              

            	
              
                Quarterly
      Report 

                Estimated
      Issue Date

              

            	
              
                Contract
      Period

              

            
	
              
                 

                Qtr
      2 thru Qtr 4 2005,

              

              
                Qtr
      1 thru Qtr 4: 2006, 2007

              

              
                Qtr
      1 2008

              

            	
              
                 

                July
      2008

              

            	
              
                 

                August
      2008*

              

            	
              
                 

                 

                 

                 

                 

                 

                 

                SFY
      2009

              

            
	
              
                 

                Qtr
      3, Qtr 4: 2005,

              

              
                Qtr
      1 thru Qtr 4: 2006, 2007

              

              
                Qtr
      1, Qtr 2 2008

              

            	
              
                 

                October
      2008

              

            	
              
                 

                November
      2008*

              

            
	
              
                 

                Qtr
      4: 2005,

              

              
                Qtr
      1 thru Qtr 4: 2006, 2007

              

              
                Qtr
      1 thru Qtr 3: 2008

              

            	
              
                 

                January
      2009

              

            	
              
                 

                February
      2009*

              

            
	
              
                 

                Qtr
      1 thru Qtr 4: 2006, 2007, 2008

              

            	
              
                 

                April
      2009

              

            	
              
                 

                May
      2009

              

            
	
              
                 

                Qtr
      2 thru Qtr 4: 2006, Qtr 1 thru Qtr 4: 2007, 2008 Qtr 1
      2009

              

            	
              
                 

                July
      2009

              

            	
              
                 

                August
      2009

              

            	
              
                 

                 

                 

                 

                 

                 

                SFY
      2010

              

            
	
              
                 

                Qtr
      3, Qtr 4: 2006,

              

              
                Qtr
      1 thru Qtr 4: 2007, 2008

              

              
                Qtr
      1, Qtr 2: 2009

              

            	
              
                 

                October
      2009

              

            	
              
                 

                November
      2009

              

            
	
              
                 

                Qtr
      4: 2006,

              

              
                Qtr
      1 thru Qtr 4: 2007, 2008

              

              
                Qtr
      1 thru Qtr 3: 2009

              

            	
              
                 

                January
      2010

              

            	
              
                 

                February
      2010

              

            
	
              
                 

                Qtr
      1 thru Qtr 4: 2007, 2008, 2009

              

            	
              
                 

                April
      2010

              

            	
              
                 

                May
      2010

              

            


    

    
       

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

    

    
      


      *The
first three report periods for SFY 2009 will be consolidated into one report, to
be issued in February 2009. There will only be one compliance period associated
with this (combined) report period.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
L

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
3

    

    
       

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

    

    
       

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

    

    


     

    
      	
              
                Category

              

            	
              
                Measure
      per 1,000/MM

              

            	
              
                Standard
      for

              

              
                Dates
      of Service

              

              
                7/1/2003
      thru

              

              
                6/30/2004

              

            	
              
                Standard
      for

              

              
                Dates
      of Service

              

              
                7/1/2004
      thru

              

              
                6/30/2006

              

            	
              
                Standard
      for

              

              
                Dates
      of

              

              
                Service

              

              
                on
      or after

              

              
                7/1/2006

              

            	
              
                Description

              

            
	
              
                 

                Inpatient
      

                Hospital

                 

              

            	
              
                 

                Discharges

              

            	
              
                 

                5.4

              

            	
              
                 

                5.0

              

            	
              
                 

                5.4

              

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

              

            
	
              
                 

                Emergency
      

                Department

                 

              

            	
              
                 

                 

                 

                 

                 

                 

                 

                 

                Visits

              

            	
              
                51.6

              

            	
              
                51.4

              

            	
              
                50.7

              

            	
              
                Includes
      physician and hospital emergency department encounters

                 

              

            
	
              
                 

                Dental

              

            	
              
                38.2

              

            	
              
                41.7

              

            	
              
                50.9

              

            	
              
                Non-institutional
      and hospital dental visits

              

            
	
              
                 

                Vision

              

            	
              
                11.6

              

            	
              
                11.6

              

            	
              
                10.6

              

            	
              
                Non-institutional
      and hospital outpatient optometry and ophthalmology
      visits

              

            
	
              
                Primary
      and 

                Specialist
      Care

              

            	
              
                220.1

              

            	
              
                225.7

              

            	
              
                233.2

              

            	
              
                Physician/practitioner
      and hospital outpatient visits

              

            
	
              
                Ancillary
      

                Services

              

            	
              
                144.7

              

            	
              
                123.0

              

            	
              
                133.6

              

            	
              
                Ancillary
      visits

              

            
	
              
                Behavioral
      

                Health

              

            	
              
                Service

              

            	
              
                7.6

              

            	
              
                8.6

              

            	
              
                10.5

              

            	
              
                Inpatient
      and outpatient behavioral encounters

              

            
	
              
                Pharmacy

              

            	
              
                Prescriptions

              

            	
              
                388.5

              

            	
              
                457.6

              

            	
              
                492.2

              

            	
              
                Prescribed
      drugs

              

            


    

    
       

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

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
L

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
4

    

    
      


      Interim
Regional-Based Approach:

    

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

    

    
       

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

    

    
       

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

    

    
       

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

    

    


     

    
      	
              
                Category

              

            	
              
                Measure
      per 1,000/MM

              

            	
              
                Standard
      for

              

              
                Dates
      of

              

              
                Service

              

              
                on
      or after

              

              
                7/1/2006

              

            	
              
                Description

              

            
	
              
                Inpatient
      Hospital

              

            	
              
                Discharges

              

            	
              
                2.7

              

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

              

            
	
              
                Emergency
      Department

              

            	
              
                 

                 

                Visits

              

            	
              
                25.3

              

            	
              
                Includes
      physician and hospital emergency department
    encounters

              

            
	
              
                Dental

              

            	
              
                25.5

              

            	
              
                Non-institutional
      and hospital dental visits

              

            
	
              
                Vision

              

            	
              
                5.3

              

            	
              
                Non-institutional
      and hospital outpatient optometry and ophthalmology
      visits

              

            
	
              
                Primary
      and Specialist Care

              

            	
              
                116.6

              

            	
              
                Physician/practitioner
      and hospital outpatient visits

              

            
	
              
                Ancillary
      Services

              

            	
              
                66.8

              

            	
              
                Ancillary
      visits

              

            
	
              
                Behavioral
      Health

              

            	
              
                Service

              

            	
              
                5.2

              

            	
              
                Inpatient
      and outpatient behavioral encounters

              

            
	
              
                Pharmacy

              

            	
              
                Prescriptions

              

            	
              
                246.1

              

            	
              
                Prescribed
      drugs

              

            


    

    
      


      Regional-Based
Approach:

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
L

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
5

       

    

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

    

    
      


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

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
L

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
6

       

    

    
      Table
4. Standards – Encounter Data Volume (Regional-Based Approach

    

    
      	
              
                 

                Region

              

            	
              
                 

                Category

              

            	
              
                 

                Measure
      per 

                1,000/MM

              

            	
              
                Standard
      for

              

              
                Dates
      of Service on or after TBD (in Spring, 2009)

              

            	
              
                 

                Description

              

            
	
              
                 

                 

                 

                 

                 

                Central

              

            	
              
                 

                Inpatient
      Hospital

              

            	
              
                 

                Discharges

              

            	
              
                 

                TBD

              

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

              

            
	
              
                 

                Emergency
      Department

              

            	
              
                 

                 

                 

                Visits

              

            	
              
                 

                TBD

              

            	
              
                Includes
      physician and hospital emergency department
    encounters

              

            
	
              
                Dental

              

            	
              
                TBD

              

            	
              
                Non-institutional
      and hospital dental visits

              

            
	
              
                 

                Vision

              

            	
              
                 

                TBD

              

            	
              
                Non-institutional
      and hospital outpatient optometry and ophthalmology
      visits

              

            
	
              
                Primary
      & Specialist Care

              

            	
              
                TBD

              

            	
              
                Physician/practitioner
      and hospital outpatient visits

              

            
	
              
                Ancillary
      Services

              

            	
              
                TBD

              

            	
              
                Ancillary
      visits

              

            
	
              
                Behavioral
      Health

              

            	
              
                Service

              

            	
              
                TBD

              

            	
              
                Inpatient
      and outpatient behavioral encounters

              

            
	
              
                Pharmacy

              

            	
              
                Prescriptions

              

            	
              
                TBD

              

            	
              
                Prescribed
      drugs

              

            
	
              
                 

                 

                 

                 

                 

                East
      

                Central

              

            	
              
                Inpatient
      Hospital

              

            	
              
                Discharges

              

            	
              
                TBD

              

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

              

            
	
              
                Emergency
      Department

              

            	
              
                 

                 

                 

                Visits

              

            	
              
                TBD

              

            	
              
                Includes
      physician and hospital emergency department
    encounters

              

            
	
              
                Dental

              

            	
              
                TBD

              

            	
              
                Non-institutional
      and hospital dental visits

              

            
	
              
                Vision

              

            	
              
                TBD

              

            	
              
                Non-institutional
      and hospital outpatient optometry and ophthalmology
      visits

              

            
	
              
                Primary
      & Specialist Care

              

            	
              
                TBD

              

            	
              
                Physician/practitioner
      and hospital outpatient visits

              

            
	
              
                Ancillary
      Services

              

            	
              
                TBD

              

            	
              
                Ancillary
      visits

              

            
	
              
                Behavioral
      Health

              

            	
              
                Service

              

            	
              
                TBD

              

            	
              
                Inpatient
      and outpatient behavioral encounters

              

            
	
              
                Pharmacy

              

            	
              
                Prescriptions

              

            	
              
                TBD

              

            	
              
                Prescribed
      drugs

              

            
	
              
                 

                 

                 

                 

                 

                Northeast

              

            	
              
                Inpatient
      Hospital

              

            	
              
                Discharges

              

            	
              
                TBD

              

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

              

            
	
              
                Emergency
      Department

              

            	
              
                 

                 

                 

                Visits

              

            	
              
                TBD

              

            	
              
                Includes
      physician and hospital emergency department
    encounters

              

            
	
              
                Dental

              

            	
              
                TBD

              

            	
              
                Non-institutional
      and hospital dental visits

              

            
	
              
                Vision

              

            	
              
                TBD

              

            	
              
                Non-institutional
      and hospital outpatient optometry and ophthalmology
      visits

              

            
	
              
                Primary
      & Specialist Care

              

            	
              
                TBD

              

            	
              
                Physician/practitioner
      and hospital outpatient visits

              

            
	
              
                Ancillary
      Services

              

            	
              
                TBD

              

            	
              
                Ancillary
      visits

              

            
	
              
                Behavioral
      Health

              

            	
              
                Service

              

            	
              
                TBD

              

            	
              
                Inpatient
      and outpatient behavioral encounters

              

            
	
              
                Pharmacy

              

            	
              
                Prescriptions

              

            	
              
                TBD

              

            	
              
                Prescribed
      drugs

              

            
	
              
                 

                 

                 

                 

                 

                Northeast
      Central

              

            	
              
                Inpatient
      Hospital

              

            	
              
                Discharges

              

            	
              
                TBD

              

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

              

            
	
              
                Emergency
      Department

              

            	
              
                 

                 

                 

                Visits

              

            	
              
                TBD

              

            	
              
                Includes
      physician and hospital emergency department
    encounters

              

            
	
              
                Dental

              

            	
              
                TBD

              

            	
              
                Non-institutional
      and hospital dental visits

              

            
	
              
                Vision

              

            	
              
                TBD

              

            	
              
                Non-institutional
      and hospital outpatient optometry and ophthalmology
      visits

              

            
	
              
                Primary
      & Specialist Care

              

            	
              
                TBD

              

            	
              
                Physician/practitioner
      and hospital outpatient visits

              

            
	
              
                Ancillary
      Services

              

            	
              
                TBD

              

            	
              
                Ancillary
      visits

              

            
	
              
                Behavioral
      Health

              

            	
              
                Service

              

            	
              
                TBD

              

            	
              
                Inpatient
      and outpatient behavioral encounters

              

            
	
              
                Pharmacy

              

            	
              
                Prescriptions

              

            	
              
                TBD

              

            	
              
                Prescribed
      drugs

              

            


    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
L

    

    
      Covered
Families and Children (CFC) population

    

    
      Page 7

       

    

    
      	
              
                Region

              

            	
              
                Category

              

            	
              
                Measure
      per 

                1,000/MM

              

            	
              
                Standard
      for Dates of

              

              
                Service
      on or

              

              
                after

              

              
                TBD
      (in

              

              
                Spring,
      2009)

              

            	
              
                Description

              

            
	
              
                 

                 

                 

                 

                 

                North­west

              

            	
              
                Inpatient
      Hospital

              

            	
              
                Discharges

              

            	
              
                TBD

              

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

              

            
	
              
                Emergency
      Department

              

            	
              
                 

                 

                 

                Visits

              

            	
              
                TBD

              

            	
              
                Includes
      physician and hospital emergency department
    encounters

              

            
	
              
                Dental

              

            	
              
                TBD

              

            	
              
                Non-institutional
      and hospital dental visits

              

            
	
              
                Vision

              

            	
              
                TBD

              

            	
              
                Non-institutional
      and hospital outpatient optometry and ophthalmology
      visits

              

            
	
              
                Primary
      & Specialist Care

              

            	
              
                TBD

              

            	
              
                Physician/practitioner
      and hospital outpatient visits

              

            
	
              
                Ancillary
      Services

              

            	
              
                TBD

              

            	
              
                Ancillary
      visits

              

            
	
              
                Behavioral
      Health

              

            	
              
                Service

              

            	
              
                TBD

              

            	
              
                Inpatient
      and outpatient behavioral encounters

              

            
	
              
                Pharmacy

              

            	
              
                Prescriptions

              

            	
              
                TBD

              

            	
              
                Prescribed
      drugs

              

            
	
              
                 

                 

                 

                 

                 

                Southeast

              

            	
              
                Inpatient
      Hospital

              

            	
              
                Discharges

              

            	
              
                TBD

              

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

              

            
	
              
                Emergency
      Department

              

            	
              
                 

                 

                 

                Visits

              

            	
              
                TBD

              

            	
              
                Includes
      physician and hospital emergency department
    encounters

              

            
	
              
                Dental

              

            	
              
                TBD

              

            	
              
                Non-institutional
      and hospital dental visits

              

            
	
              
                Vision

              

            	
              
                TBD

              

            	
              
                Non-institutional
      and hospital outpatient optometry and ophthalmology
      visits

              

            
	
              
                Primary
      & Specialist Care

              

            	
              
                TBD

              

            	
              
                Physician/practitioner
      and hospital outpatient visits

              

            
	
              
                Ancillary
      Services

              

            	
              
                TBD

              

            	
              
                Ancillary
      visits

              

            
	
              
                Behavioral
      Health

              

            	
              
                Service

              

            	
              
                TBD

              

            	
              
                Inpatient
      and outpatient behavioral encounters

              

            
	
              
                Pharmacy

              

            	
              
                Prescriptions

              

            	
              
                TBD

              

            	
              
                Prescribed
      drugs

              

            
	
              
                 

                 

                 

                 

                 

                South­west

              

            	
              
                Inpatient
      Hospital

              

            	
              
                Discharges

              

            	
              
                TBD

              

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

              

            
	
              
                Emergency
      Department

              

            	
              
                 

                 

                 

                Visits

              

            	
              
                TBD

              

            	
              
                Includes
      physician and hospital emergency department
    encounters

              

            
	
              
                Dental

              

            	
              
                TBD

              

            	
              
                Non-institutional
      and hospital dental visits

              

            
	
              
                Vision

              

            	
              
                TBD

              

            	
              
                Non-institutional
      and hospital outpatient optometry and ophthalmology
      visits

              

            
	
              
                Primary
      & Specialist Care

              

            	
              
                TBD

              

            	
              
                Physician/practitioner
      and hospital outpatient visits

              

            
	
              
                Ancillary
      Services

              

            	
              
                TBD

              

            	
              
                Ancillary
      visits

              

            
	
              
                Behavioral
      Health

              

            	
              
                Service

              

            	
              
                TBD

              

            	
              
                Inpatient
      and outpatient behavioral encounters

              

            
	
              
                Pharmacy

              

            	
              
                Prescriptions

              

            	
              
                TBD

              

            	
              
                Prescribed
      drugs

              

            
	
              
                 

                 

                 

                 

                 

                West
      Central

              

            	
              
                Inpatient
      Hospital

              

            	
              
                Discharges

              

            	
              
                TBD

              

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

              

            
	
              
                Emergency
      Department

              

            	
              
                 

                 

                 

                Visits

              

            	
              
                TBD

              

            	
              
                Includes
      physician and hospital emergency department
    encounters

              

            
	
              
                Dental

              

            	
              
                TBD

              

            	
              
                Non-institutional
      and hospital dental visits

              

            
	
              
                Vision

              

            	
              
                TBD

              

            	
              
                Non-institutional
      and hospital outpatient optometry and ophthalmology
      visits

              

            
	
              
                Primary
      & Specialist Care

              

            	
              
                TBD

              

            	
              
                 Physician/practitioner
      and hospital outpatient visits

              

            
	
              
                Ancillary
      Services

              

            	
              
                TBD

              

            	
              
                Ancillary
      visits

              

            
	
              
                Behavioral
      Health

              

            	
              
                Service

              

            	
              
                TBD

              

            	
              
                Inpatient
      and outpatient behavioral encounters

              

            
	
              
                Pharmacy

              

            	
              
                Prescriptions

              

            	
              
                TBD

              

            	
              
                Prescribed
      drugs

              

            


    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
L

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
8

       

    

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

    

    
       

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

    

    
      


      1.a.ii.
Incomplete Outpatient Hospital Data

    

    
       

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

    

    
       

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

    

    
       

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

    

    
       

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

    

    
       

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

    

    
       

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

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
L

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
9

       

    

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

    

    
       

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

    

    
       

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

    

    
       

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

    

    
       

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

    

    
       

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

    

    
       

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

    

    
       

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

    

    
      


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

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
L

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
10

       

    

    
      1.a.iv.
Rejected Encounters

    

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

    

    
       

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

    

    
       

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

    

    
       

      Report Period: For the SFY
2009 contract period, performance will be evaluated using the following report
periods: July – September 2008; October - December 2008; January - March 2009;
and April – June 2009. For the SFY 2010 contract period, performance will be
evaluated using the following report periods: July - September 2009; October -
December 2009; January - March 2010; and April – June 2010.

    

    
       

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

    

    
       

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

    

    
       

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

    

    
      


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

    

    
       

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

    

    
       

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

    

    
       

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

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
L

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
11

    

    
      


              
         Third through sixth months with
membership:        50%

    

    
      


                       
Seventh through twelfth month with
membership:   25%

    

    
       

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

    

    
       

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

    

    
       

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

    

    
       

      1.a.v.
Acceptance Rate

    

    
       

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

    

    
       

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

    

    
       

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

    

    
       

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

    

    
      


                     
Third through sixth month with membership: 50 encounters per 1,000 MM for NCPDP


                                                                                                     
65
encounters per 1,000 MM for NSF 

                                                                                                     
20 encounters per 1,000 MM for UB-92

    

    
      


                     
Seventh through twelfth month of membership: 250 encounters per 1,000 MM for
NCPDP

    

    
                                                                                                          
350 encounters per 1,000 MM for NSF 

                                                                                                          
100 encounters per 1,000 MM
for UB-92

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
L

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
12

       

    

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

    

    
       

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

    

    
       

      1.b.
Encounter Data Accuracy

    

    
       

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

    

    
       

      1.b.i.
Encounter Data Accuracy Studies

    

    
       

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

    

    
       

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

    

    
      


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

    

    
       

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

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
L

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
13

       

    

    
      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. Two levels of analysis will be
conducted: one to evaluate encounter data completeness for which two rates will
be calculated and one to evaluate payment data accuracy. Payment completeness
and accuracy rates will be determined by aggregating data across claim types
(i.e., professional, institutional, and pharmacy) and stratifying data by file
type (i.e., header and detail).

    

    
       

      Encounter
Data Completeness (Level 1):

    

    
      Omission
Encounter Rate: The percentage of encounters in an MCP’s fully adjudicated
claims file not
present in the ODJFS encounter data files.

    

    
      


      Surplus
Encounter Rate: The percentage of encounters in the ODJFS encounter data files
not present in an MCP’s fully adjudicated claims files.

    

    
       

      Payment
Data Accuracy (Level 2):

    

    
      Payment
Error Rate: The percentage of matched encounters between the ODJFS encounter
data files and an
MCP’s fully adjudicated claims files where a payment amount discrepancy was
identified.

    

    
      


      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 study is initiated. This study is
conducted annually.

    

    
       

      Data
Quality Standard for Measure 2:

    

    
      For SFY
2009, this measure is reporting only. For SFY 2009, each MCP must implement a
Corrective Action Plan (CAP) which identifies interventions and a timeline for
resolving data quality issues related to payments per the direction of ODJFS
and/or the EQRO. Additional reports to ODJFS addressing targeted areas of
deficiencies and progress implementing data quality improvement activities may
be required.

    

    
       

      For SFY
2010:

    

    
      For Level
1: An omission encounter rate and a surplus encounter rate of no more than 11%
for both header
and detail records.

    

    
      For Level
2: A payment error rate of no more than 4%.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
L

    

    
      Covered
Families and Children (CFC) population 

      Page
14

       

    

    
      Penalty for Noncompliance:
Beginning SFY 2010, if an MCP is noncompliant with the standard for
either level 1 or level 2 for this measure, the MCP must implement a CAP which
identifies interventions and a timeline for resolving data quality issues
related to payments. Additional reports to ODJFS addressing targeted areas of
deficiencies and progress implementing data quality improvement activities may
be required. Upon all subsequent measurements of performance, if an MCP is again
determined to be noncompliant with the standard, ODJFS will impose a monetary
sanction (see Section 6) of one percent of the current month’s premium payment.
Once the MCP is performing at standard levels and violations/deficiencies are
resolved to the satisfaction of ODJFS, the money will be
refunded.

    

    
       

      1.b.ii.
Generic Provider Number Usage

    

    
       

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

    

    
       

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

    

    
      


      Data Quality Standard for Measure 1:
A maximum generic provider number usage rate of 10%.

    

    
       

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

    

    
       

      Penalty for noncompliance for
Measure 1: The first time an MCP is noncompliant with a standard for this
measure, ODJFS will issue a Sanction Advisory informing the MCP that any future
noncompliance instances with the standard for this measure will result in ODJFS
imposing a monetary sanction.

    

    
      


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

    

    
       

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

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
L

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
15

       

    

    
      Report Period for Measure 2:
For the SFY 2009 and SFY 2010 contract periods, performance will be evaluated
using the report periods listed in 1.a.i., Table 1. The Qtr. 3, CY 2008
reporting period (July – September, 2008) will be used to calculate the baseline
rate.

    

    
       

      Data Quality Standard for Measure2:
For SFY 2009, this measure is reporting only. For SFY 2010, the data
quality standard for this measure is to be determined (in Fall,
2009).

    

    
       

      Determination of Compliance for
Measure 2: Performance is monitored once every quarter for all report
periods on or after July 1, 2008. An initial instance of noncompliance means
that the result for the applicable report period was in compliance as determined
in the prior quarterly report,
or the instance of noncompliance is the first determination for an MCP’s
first quarter of measurement.

    

    
       

      Penalty for noncompliance with
Measure 2: The first time an MCP is noncompliant with a standard for this
measure, ODJFS will issue a Sanction Advisory informing the MCP that any future
noncompliance instances with the standard for this measure will result in ODJFS
imposing a monetary sanction.

    

    
       

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

    

    
       

      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.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
L

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
16

    

    
       

      2. 
          CARE MANAGEMENT
DATA

    

    
       

      ODJFS
designed a care management system (CAMS) in order to monitor MCP compliance with
program requirements specified in Appendix G, Coverage and Services. Each
MCP’s care management data submissions will be assessed for completeness and
accuracy. The MCP is responsible for submitting a care management file every
month. Failure to do so jeopardizes the MCP’s ability to demonstrate compliance
with care management requirements

    

    
       

      2.a.
Timely Submission of Care Management Files

    

    
       

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

    

    
       

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

    

    
      


      3. 
          EXTERNAL QUALITY
REVIEW DATA

    

    
       

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

    

    
       

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

    

    
       

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

    

    
       

      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.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
L

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
17

       

    

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

    

    
       

      4.           
MEMBERS’ PCP DATA

    

    
       

      The
designated PCP is the provider who will manage and coordinate the overall care
for CFC members, including those who have care 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

    

    
      


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

    

    
      


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

    

    
       

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

    

    
       

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

    

    
       

      Data Quality Standards: For
SFY 2009, the level of improvement must result in at least a 10% decrease in the
difference between the target and the previous report period’s results. For SFY
2010, 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.

    

    
      

        
          
             


          

          
             


            
              

            

          

          
             


          

        

Appendix
L

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
18

       

    

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

    

    
      


      5. 
          APPEALS AND
GRIEVANCES DATA

    

    
       

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

    

    
       

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

    

    
       

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

    

    
       

      6. 
          NOTES

    

    
       

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

    

    
      


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

    

    
       

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

    

    
      


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

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
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      Covered
Families and Children (CFC) population

    

    
      Page
19

       

    

    
      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.
Enrollment Freezes

    

    
       

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

    

    
       

      6.f.
Report and Compliance Periods

    

    
       

      ODJFS
reserves the right to revise report periods (and corresponding compliance
periods), as needed, due to unforeseen circumstances.

    

    
      


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

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
M

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
1

    

    
      APPENDIX
M

       

      
        PERFORMANCE
EVALUATION 

        CFC
ELIGIBLE POPULATION

      

    

    
      


       

      This
appendix establishes performance measures and minimum performance standards for
managed care plans (MCPs) in key program areas. The intent is to maintain
accountability for contract requirements. Performance measures and standards are
subject to change based on the revision or update of applicable national
measures, 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. All performance measures, as
specified in this appendix, will be calculated per MCP and include only members
in the CFC Medicaid managed care program.

    

    
       

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

    

    
       

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

    

    
       

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

    

    
       

      1.           
QUALITY OF CARE

    

    
       

      1.a.
Independent External Quality Review

    

    
       

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

    

    
       

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

    

    
       

      Report
Period: Performance will be evaluated using the reviews conducted during SFY
2009.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
M

    

    
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      Page
2

    

    
      


      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.
Members with Special Health Care Needs (MSHCN)

    

    
      


      In order
to ensure state compliance with the provisions of 42 CFR 438.208, the Bureau of
Managed Health Care established care management basic program requirements in
Appendix G, Coverage
and Services,
and corresponding performance measures and minimum performance standards as
described below. The purpose of these measures is to ensure appropriate care
management services are provided to MSHCN.

    

    
       

      1.b.i. Care Management of Children
(applicable to P4P
through SFY 2008)

    

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

    

    
      Report Period: For the SFY
2008 contract period: April – June 2008 (for P4P).

    

    
       

      County-Based Approach: 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
2008. A detailed description of the of excellent and superior standards
associated with this measure for P4P determination for SFY 2008 can be found in
Appendix O, Section 1.b.1.

    

    
       

      1.b.ii. Care Management of High Risk
Members (applicable to
performance evaluation beginning January
2009)

    

    
       

      Measure: The percent of high
risk members who have had at least three consecutive months of enrollment in one
MCP that are care managed.

    

    
       

      Report Period: For the SFY
2009 contract period: January – March 2009 (informational only), and April –
June 2009 (baseline – reporting only) report periods. For the SFY 2010 contract
period: July – September 2009, October – December 2009, January – March 2010,
and April – June 2010 report periods.

    

    
       

      Interim Regional-Based Statewide
Minimum Performance Standard: For SFY 2009, each MCP must submit a
quality improvement plan (QIP) which addresses the following: 1) strategies the
MCP will implement to identify members eligible for care management services,
including low, medium and high-risk stratification levels; and 2) strategies the
MCP will implement to ensure the MCP's information technology system is designed
to accept, integrate, and analyze data used to inform and support the MCP's Care
Management Program, including the MCP's process for submitting data to CAMS as
outlined in the file specifications. The MCP will be expected to incorporate the
QIP into the submission of its Care Management Program for ODJFS review and
approval as outlined in Appendix G.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
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Families and Children (CFC) population

    

    
      Page
3

    

    
       

      Regional-Based Statewide Approach:
Performance will be evaluated using a regional-based statewide approach
for all active regions in which the MCP has membership. ODJFS will use the April
– June 2009 report period as the baseline report period. July-September 2009
will be the first report period that MCPs will be held accountable to the
performance standard and penalties will be applied for
noncompliance.

    

    
       

      Regional-Based Statewide Target:
For SFY 2010, the target is a care management rate of
70%.

    

    
       

      Regional-Based Statewide Minimum
Performance Standard: For SFY 2010, the standard is a level of
improvement that is at least a 10% decrease in the difference between the target
and the previous report period’s results.

    

    
      


      Penalty for Noncompliance with the
Regional-Based Statewide Standard: Beginning SFY 2010, the first time an
MCP is noncompliant with a standard for this measure, ODJFS will issue a
Sanction Advisory informing the MCP that any future noncompliance instances with
the standard for this measure will result in ODJFS imposing a monetary sanction.
Upon all subsequent measurements of performance, if an MCP is again determined
to be noncompliant with the standard, ODJFS will impose a monetary sanction (see
Section 5) of two percent of the current month’s premium payment. Monetary
sanctions will not be levied for consecutive quarters that an MCP is determined
to be noncompliant. If an MCP is noncompliant for a subsequent quarter, new
member selection freezes or a reduction of assignments will occur as outlined in
Appendix N of the Provider Agreement. Once the MCP is determined to be compliant
with the standard and the violations/deficiencies are resolved to the
satisfaction of ODJFS, the penalties will be lifted, if applicable, and monetary
sanctions will be returned.

    

    
      


      1.b.iii.Care Management of Members
(applicable to
performance evaluation beginning January 2009)

    

    
       

      Measure: The average monthly
care management rate for members who have had at least three consecutive months
of enrollment in one MCP (including members assigned to low, medium, and high
risk stratification levels).

    

    
       

      Report Period: For the SFY
2009 contract period, January – March 2009 (informational only), and April –
June 2009 (baseline – reporting only) report periods. For the SFY 2010 contract
period, July – September 2009, October – December 2009, January – March 2010,
and April – June 2010 report periods.

    

    
       

      Interim Regional-Based Statewide
Minimum Performance Standard: For SFY 2009, each MCP must submit a
quality improvement plan (QIP) which addresses the following: 1) strategies the
MCP will implement to identify members eligible for care management services,
including low, medium, and high-risk stratification levels; and 2) strategies
the MCP will implement to ensure the MCP's information technology system is
designed to accept, integrate, and analyze data used to inform and support the
MCP's Care Management Program, including the MCP's process for submitting data
to CAMS as outlined in the file specifications. The MCP will be expected to
incorporate the QIP into the submission of its Care Management Program for ODJFS
review and approval as outlined in Appendix G.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
M

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
4

    

    
       

    

    
      Regional-Based Statewide Approach:
Performance will be evaluated using a regional-based statewide approach
for all active regions in which the MCP has membership. ODJFS will use the April
– June 2009 report period as the baseline report period to determine a minimum
performance standard and target. July-September 2009 will be the first report
period that MCPs will be held accountable to the performance standard and
penalties will be applied for noncompliance.

    

    
       

      Regional-Based Statewide Target:
For SFY 2010, the target is to be determined (in Fall,
2009).

    

    
      


      Regional-Based Statewide Minimum
Performance Standard: For SFY 2010, the standard is to be determined (in
Fall, 2009).

    

    
      


      Penalty for Noncompliance with the
Regional-Based Statewide Standard: Beginning SFY 2010, 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.c.
Clinical Performance Measures

    

    
      


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

    

    
       

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

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
M

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
5

    

    
      
      

    

    
      For an MCP which had membership as
of February 1, 2006: MCP performance will be evaluated using an MCP’s
county-based statewide result for the counties in which the MCP had membership
as of February 1, 2006. For reporting period CY 2008, the county-based statewide
targets and performance standards for the 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 evaluation) for
the counties in which an MCP had membership as of February 1, 2006, for one year
measures, was CY 2007. The final reporting year (for evaluation) for the
counties in which an MCP had membership as of February 1, 2006, for two year
measures, will be CY 2008. The final reporting year (for P4P) for the counties
in which an MCP had membership as of February 1, 2006, for both one and two year
measures, will be CY 2008.

    

    
       

      For any MCP which did not have
membership as of February 1, 2006: MCP Performance will
be evaluated using an MCP's regional-based statewide result for all active
regions and counties (Trumbull and Mahoning) in which the MCP has membership.
For reporting period CY 2008, ODJFS will evaluate MCP performance using interim
regional-based statewide minimum performance standards. ODJFS will evaluate MCP
performance using regional-based statewide targets and performance standards
beginning with reporting period CY 2009.

    

    
       

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

    

    
      


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

    

    
      


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

    

    
       

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

    

    
      

        
          
             


          

          
             


            
              

            

          

          
             


          

        

      

       

    

    
      Appendix
M

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
6

    

    
      


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

       

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

    

    
       

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

    

    
      


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

    

    
      


      Action Required for Noncompliance
with the County-Based Statewide Standard: For SFY 2009, if the standard
is not met and the results are below 44.0%, the MCP is required to complete a
Corrective Action Plan to address the area of noncompliance. If the standard is
not met and the results are at or above 44.0%, ODJFS will issue a Quality
Improvement Directive which will notify the MCP of noncompliance and may outline
the steps that the MCP must take to improve the results.

    

    
       

      Interim Regional-Based Statewide
Minimum Performance Standard: For SFY 2009, each MCP must implement a
quality improvement plan (QIP) which identifies areas needing quality
improvement, includes a root-cause analysis of the areas needing improvement,
and establishes strategies and implementation activities to achieve continuous
quality improvement for this measure. The QIP must be submitted to ODJFS for
review and implemented no later than May, 1, 2009.

    

    
       

      Regional-Based Statewide Target:
To be determined (in Spring, 2009).

    

    
      


      Regional-Based Statewide Minimum
Performance Standard: To be determined (in Spring,
2009).

    

    
       

      Action Required for Noncompliance
with the Regional-Based Statewide Standard: Beginning SFY 2010, if the
standard is not met and the results are below TBD% the MCP is required to
complete a Corrective Action Plan to address the area of noncompliance. If the
standard is not met and the results are at or above TBD%, ODJFS will issue a
Quality Improvement Directive which will notify the MCP of noncompliance and may
outline the steps that the MCP must take to improve the
results.

    

    
      


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

    

    
       

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

    

    
      


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

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
M

    

    
      Covered
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      Page
7

    

    
       

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

    

    
      


      Action Required for Noncompliance
with the County-Based Statewide Standard: For SFY 2009, if the standard
is not met and the results are below 74.0%, the MCP is required to complete a
Corrective Action Plan to address the area of noncompliance. If the standard is
not met and the results are at or above 74.0%, ODJFS will issue a Quality
Improvement Directive which will notify the MCP of noncompliance and may outline
the steps that the MCP must take to improve the results.

    

    
      


      Interim Regional-Based Statewide
Minimum Performance Standard: For SFY 2009, each MCP must implement a
quality improvement plan (QIP) which identifies areas needing quality
improvement, includes a root-cause analysis of the areas needing improvement,
and establishes strategies and implementation activities to achieve continuous
quality improvement for this measure. The QIP must be submitted to ODJFS for
review and implemented no later than May, 1, 2009.

    

    
       

      Regional-Based Statewide Target:
To be determined (in Spring, 2009).

    

    
       

      Regional-Based Statewide Minimum
Performance Standard: To be determined (in Spring,
2009).

    

    
      


      Action Required for Noncompliance
with the Regional-Based Statewide Standard: Beginning SFY 2010, if the
standard is not met and the results are below TBD% the MCP is required to
complete a Corrective Action Plan to address the area of noncompliance. If the
standard is not met and the results are at or above TBD%, ODJFS will issue a
Quality Improvement Directive which will notify the MCP of noncompliance and may
outline the steps that the MCP must take to improve the
results.

    

    
       

      1.c.iii.
Perinatal Care - Postpartum Care

    

    
      


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

    

    
      


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

    

    
       

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

    

    
       

      Action Required for Noncompliance
with the County-Based Statewide Standard: For SFY 2009, if the standard
is not met and the results are below 50.0%, the MCP is required to complete a
Corrective Action Plan to address the area of noncompliance. If the standard is
not met and the results are at or above 50.0%, ODJFS will issue a Quality
Improvement Directive which will notify the MCP of noncompliance and may outline
the steps that the MCP must take to improve the results.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
M

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
8

    

    
      


      Interim Regional-Based Statewide
Minimum Performance Standard: For SFY 2009, each MCP must implement a
quality improvement plan (QIP) which identifies areas needing quality
improvement, includes a root-cause analysis of the areas needing improvement,
and establishes strategies and implementation activities to achieve continuous
quality improvement for this measure. The QIP must be submitted to ODJFS for
review and implemented no later than May, 1, 2009.

    

    
       

      Regional-Based Statewide Target:
To be determined (in Spring, 2009).

    

    
       

      Regional-Based Statewide Minimum
Performance Standard: To be determined (in Spring,
2009).

    

    
      


      Action Required for Noncompliance
with the Regional-Based Statewide Standard: Beginning SFY 2010, if the
standard is not met and the results are below TBD%, the MCP is required to
complete a Corrective Action Plan to address the area of noncompliance. If the
standard is not met and the results are at or above TBD%, ODJFS will issue a
Quality Improvement Directive which will notify the MCP of noncompliance and may
outline the steps that the MCP must take to improve the
results.

    

    
       

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

    

    
      


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

    

    
       

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

       

    

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

       

    

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


    

    
       

      County-Based Statewide Target:
At least 80.0% of the eligible children receive the expected number of
well-child visits.

    

    
      


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

    

    
       

      Action Required for Noncompliance
with the County-Based Statewide Standard (15 month old age group): For SFY 2009, if the
standard is not met and the results are below 42.0%, the MCP is required to
complete a Corrective Action Plan to address the area of noncompliance. If the
standard is not met and the results are at or above 42.0%, ODJFS will issue a
Quality Improvement Directive which will notify the MCP of noncompliance and may
outline the steps that the MCP must take to improve the
results.

    

    
       

      Action Required for Noncompliance
with the County-Based Statewide Standard (3-6 year old age group): For SFY 2009, if the
standard is not met and the results are below 57.0%, the MCP is required to
complete a Corrective Action Plan to address the area of noncompliance. If the
standard is not met and the results are at or above 57.0%, ODJFS will issue a
Quality Improvement Directive which will notify the MCP of noncompliance and may
outline the steps that the MCP must take to improve the
results.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
M

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
9

    

    
      


      Action Required for Noncompliance
with the County-Based Statewide Standard (12-21 year old age group): For SFY 2009, if the
standard is not met and the results are below 33.0%, the MCP is required to
complete a Corrective Action Plan to address the area of noncompliance. If the
standard is not met and the results are at or above 33.0%, ODJFS will issue a
Quality Improvement Directive which will notify the MCP of noncompliance and may
outline the steps that the MCP must take to improve the
results.

    

    
      


      Interim Regional-Based Statewide
Minimum Performance Standard for Each of the Age Groups: For SFY 2009,
each MCP must implement a quality improvement plan (QIP) which identifies areas
needing quality improvement, includes a root-cause analysis of the areas needing
improvement, and establishes strategies and implementation activities to achieve
continuous quality improvement for this measure. The QIP must be submitted to
ODJFS for review and implemented no later than May, 1, 2009.

    

    
      


      Regional-Based Statewide Target:
To be determined (in Spring, 2009).

    

    
       

      Regional-Based Statewide Minimum
Performance Standard for Each of the Age Groups: To be determined (in
Spring, 2009).

    

    
      


      Action Required for Noncompliance
with the Regional-Based Statewide Standard (15 month old age group): Beginning SFY 2010,
if the standard is not met and the results are below TBD%, the MCP is required
to complete a Corrective Action Plan to address the area of noncompliance. If
the standard is not met and the results are at or above TBD%, ODJFS will issue a
Quality Improvement Directive which will notify the MCP of noncompliance and may
outline the steps that the MCP must take to improve the
results.

    

    
       

      Action Required for Noncompliance
with the Regional-Based Statewide Standard (3-6 year old age group): Beginning SFY 2010,
if the standard is not met and the results are below TBD% , the MCP is required
to complete a Corrective Action Plan to address the area of noncompliance. If
the standard is not met and the results are at or above TBD%, ODJFS will issue a
Quality Improvement Directive which will notify the MCP of noncompliance and may
outline the steps that the MCP must take to improve the
results.

    

    
       

      Action Required for Noncompliance
with the Regional-Based Statewide Standard (12-21 year old age group): Beginning SFY
2010, if the standard is not met and the results are below TBD%, the MCP is
required to complete a Corrective Action Plan to address the area of
noncompliance. If the standard is not met and the results are at or above TBD%,
ODJFS will issue a Quality Improvement Directive which will notify the MCP of
noncompliance and may outline the steps that the MCP must take to improve the
results.

    

    
      

        
          
             


          

          
             


            
              

            

          

          
             


          

        

Appendix
M

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
10

    

    
      


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

       

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

    

    
       

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

    

    
       

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

    

    
       

      Action Required for Noncompliance
with the County-Based Statewide Standard: For SFY 2009, if the standard
is not met and the results are below 84.0%, the MCP is required to complete a
Corrective Action Plan to address the area of noncompliance. If the standard is
not met and the results are at or above 84.0%, ODJFS will issue a Quality
Improvement Directive which will notify the MCP of noncompliance and may outline
the steps that the MCP must take to improve the results.

    

    
       

      Interim Regional-Based Statewide
Minimum Performance Standard: For SFY 2009, each MCP must implement a
quality improvement plan (QIP) which identifies areas needing quality
improvement, includes a root-cause analysis of the areas needing improvement,
and establishes strategies and implementation activities to achieve continuous
quality improvement for this measure. The QIP must be submitted to ODJFS for
review and implemented no later than May, 1, 2009.

    

    
       

      Regional-Based Statewide Target:
To be determined (in Spring, 2009).

    

    
       

      Regional-Based Statewide Minimum
Performance Standard: To be determined (in Spring,
2009).

    

    
      


      Action Required for Noncompliance
with the Regional-Based Statewide Standard: Beginning SFY 2010, if the
standard is not met and the results are below TBD%, the MCP is required to
complete a Corrective Action Plan to address the area of noncompliance. If the
standard is not met and the results are at or above TBD%, ODJFS will issue a
Quality Improvement Directive which will notify the MCP of noncompliance and may
outline the steps that the MCP must take to improve the
results.

    

    
       

      1.c.vi.
Annual Dental Visits

    

    
      


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

    

    
       

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

    

    
      


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

    

    
       

      Action Required for Noncompliance
with the County-Based Statewide Standard: For SFY 2009, if the standard
is not met and the results are below 42.0%, the MCP is required to complete a
Corrective Action Plan to address the area of noncompliance. If the standard is
not met and the results
are at or above 42.0%, ODJFS will issue a Quality Improvement Directive which
will notify the MCP of noncompliance and may outline the steps that the MCP must
take to improve the results.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
M

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
11

       

    

    
      Interim Regional-Based Statewide
Minimum Performance Standard: For SFY 2009, each MCP must implement a
quality improvement plan (QIP) which identifies areas needing quality
improvement, includes a root-cause analysis of the areas needing improvement,
and establishes strategies and implementation activities to achieve continuous
quality improvement for this measure. The QIP must be submitted to ODJFS for
review and implemented no later than May, 1, 2009.

    

    
      


      Regional-Based Statewide Target:
To be determined (in Spring, 2009).

    

    
      


      Regional-Based Statewide Minimum
Performance Standard: To be determined (in Spring,
2009).

    

    
      


      Action Required for Noncompliance
with the Regional-Based Statewide Standard: Beginning SFY 2010, if the
standard is not met and the results are below TBD%, the MCP is required to
complete a Corrective Action Plan to address the area of noncompliance. If the
standard is not met and the results are at or above TBD%, ODJFS will issue a
Quality Improvement Directive which will notify the MCP of noncompliance and may
outline the steps that the MCP must take to improve the
results.

    

    
       

      1.c.vii. Lead Screening (For 1 Year Olds and For 2 Year
Olds)

    

    
      


      The final
report period for these measures is CY 2008 (SFY 2009).

    

    
      


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

    

    
       

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

    

    
      


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

    

    
      


      Action Required for Noncompliance
with the County-Based Statewide Standard (1 year olds): Beginning SFY
2007, if the standard is not met and the results are below 45.0% the MCP is
required to complete a Corrective Action Plan to address the area of
noncompliance. If the standard is not met and the results are at or above 45.0%,
ODJFS will issue a Quality Improvement Directive which will notify the MCP of
noncompliance and may outline the steps that the MCP must take to improve the
results.

    

    
       

      Action Required for Noncompliance
with the County-Based Statewide Standard (2 year olds): Beginning SFY
2007, if the standard is not met and the results are below 28.0% the MCP is
required to complete a Corrective Action Plan to address the area of
noncompliance. If the standard is not met and the results are at or above 28.0%,
ODJFS will issue a Quality Improvement Directive which will notify the MCP of
noncompliance and may outline the steps that the MCP must take to improve the
results.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
M

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
12

    

    
      


      1.c.viii.
Lead Testing in Children

    

    
      


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

    

    
      


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

    

    
      


      Regional-Based Statewide Target:
To be determined (in Spring, 2009).

    

    
       

      Regional-Based Statewide Minimum
Performance Standard: To be determined (in Spring,
2009).

    

    
      


      Action Required for Noncompliance
with the Regional-Based Statewide Standard: Beginning SFY 2010, if the
standard is not met and the results are below TBD% the MCP is required to
complete a Corrective Action Plan to address the area of noncompliance. If the
standard is not met and the results are at or above TBD%, ODJFS will issue a
Quality Improvement Directive which will notify the MCP of noncompliance and may
outline the steps that the MCP must take to improve the
results.

    

    
       

      2.
ACCESS

    

    
      


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

    

    
      


      2.a.
PCP Turnover

    

    
      


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

    

    
       

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

    

    
       

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

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
M

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
13

    

    
       

    

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

    

    
      


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

    

    
       

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

    

    
      


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

    

    
       

      Interim Regional-Based Statewide
Minimum Performance Standard: For SFY 2009, each MCP must implement a
quality improvement plan (QIP) which identifies areas needing quality
improvement, includes a root-cause analysis of the areas needing improvement,
and establishes strategies and implementation activities to achieve continuous
quality improvement for this measure. The QIP must be submitted to ODJFS for
review and implemented no later than May, 1, 2009.

    

    
      


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

    

    
      


      Action Required for Noncompliance
with the Regional-Based Statewide Minimum Performance Standard: 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 (applicable to
performance evaluation through SFY 2010)

    

    
      


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

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
M

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
14

    

    
       

      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) 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 run
out.

    

    
       

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

    

    
      


      County-Based Statewide Minimum
Performance Standards:


      CY 2007
report period – 71.0% of children must receive a visit 

      CY 2008
report period – 74.0% of children must receive a visit

    

    
      


      Regional-Based Statewide Minimum
Performance Standards: 

      CY 2009
report period – To be determined (in Spring, 2009).

    

    
      


      Penalty for Noncompliance with the
County-Based and Regional-Based Statewide Minimum Performance Standards:
If an MCP
is noncompliant with the Minimum Performance Standard, the MCP must develop and
implement a corrective action plan.

    

    
       

      2.b.i. Children’s Access to Primary
Care (applicable to
performance evaluation as of SFY 2011)

    

    
      


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

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
M

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
15

    

    
       

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

    

    
       

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

    

    
       

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

    

    
       

      Regional-Based Statewide Minimum
Performance Standards: CY 2010 report period – To be determined (in
Spring, 2010).

    

    
       

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

    

    
      


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

    

    
      


      This
measure indicates whether adult members are accessing health
services.

    

    
      


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

    

    
       

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

    

    
      


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

    

    
       

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

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
M

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
16

    

    
       

    

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

    

    
       

      County-Based Statewide Minimum
Performance Standards: 

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

      CY 2008
report period – 63% of adults must receive a visit (P4P
only).

    

    
       

      Interim Regional-Based Statewide
Minimum Performance Standard: For SFY 2009, each MCP must implement a
quality improvement plan (QIP) which identifies areas needing quality
improvement, includes a root-cause analysis of the areas needing improvement,
and establishes strategies and implementation activities to achieve continuous
quality improvement for this measure. The QIP must be submitted to ODJFS for
review and implemented no later than May, 1, 2009.

    

    
       

      Regional-Based
Statewide Minimum Performance Standards:

    

    
      CY 2009
report period – 75% of adults must receive a visit (may be adjusted in Spring,
2009).

    

    
       

      Penalty for Noncompliance with the
Regional-Based Statewide Minimum Performance Standard: I f 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) 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. Statewide performance measure results will be
calculated after a sufficient amount of time has passed after the end of the
report period in order to allow for claims run out.

    

    
       

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

    

    evaluated
using the January - December 2009 report period.


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
M

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
17

    

    
      


      Interim Regional-Based Statewide
Minimum Performance Standard: For SFY 2009, each MCP must implement a
quality improvement plan (QIP) which identifies areas needing quality
improvement, includes a root-cause analysis of the areas needing improvement,
and establishes strategies and implementation activities to achieve continuous
quality improvement for this measure. The QIP must be submitted to ODJFS for
review and implemented no later than May, 1, 2009.

    

    
       

      Regional-Based
Statewide Minimum Performance Standard:

    

    
      CY 2009 –
A level of improvement must results in at least a 10% decrease in the
difference

    

    
      between
the target and the previous report period’s results.

    

    
       

      Regional-Based
Statewide Target:

    

    
      CY 2009 -
80.0% of members must have one (1) or more visits with designated
PCP.

    

    
       

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

    

    
       

      3.           
CONSUMER SATISFACTION

    

    
      


      In
accordance with federal requirements and in the interest of assessing enrollee
satisfaction with MCP performance, ODJFS conducts annual independent consumer
satisfaction surveys. Results are used to assist in identifying and correcting
MCP performance overall and in the areas of access, quality of care, and member
services. For SFY 2008 and SFY 2009, performance in this category will be
determined by the overall satisfaction score. ODJFS intends to change the
measure and standard used to evaluate performance in this category beginning
with SFY 2010. ODJFS will use results from the SFY 2009 survey as a baseline to
establish a measure and set a standard (in Fall, 2009). For a comprehensive
description of the Consumer Satisfaction performance measure below, see ODJFS Methods for the Consumer
Satisfaction Performance Measure for the CFC Program.

    

    
       

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

    

    
      


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

    

    
      

        
          
             


          

          
             


            
              

            

          

          
             


          

        

Appendix
M

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
18

    

    
      


      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 in which the MCP has
membership.

    

    
       

      Regional-Based Statewide Approach:
MCPs will be evaluated statewide, using results for all active regions in
which the MCP has membership. For performance evaluation, the first year to use
the statewide regional-based approach will be SFY 2009, using CY 2009 data. For
P4P (Appendix O), the first year to use the statewide regional-based approach
will be SFY 2010, using CY 2010 data.

    

    
       

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

    

    
      


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

    

    
      


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

    

    
      


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

    

    
       

      4.           
ADMINISTRATIVE CAPACITY

    

    
       

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

    

    
       

      4.a.
Compliance Assessment System

    

    
       

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

    

    
       

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

    

    
       

      Performance Standard: A
maximum of 15 points

    

    
      


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

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
M

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
19

    

    
      


      4.b. Emergency Department Diversion
(applicable to
performance evaluation through SFY 2008)

    

    
      


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

    

    
       

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

    

    
       

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

    

    
      


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

    

    
      


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

    

    
       

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

    

    
       

      Penalty for Noncompliance: If
the standard is not met 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 two or more targeted ED visits during the twelve month reporting
period.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
M

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
20

    

    
      


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

    

    
       

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

    

    
       

      Interim Regional-Based Statewide
Minimum Performance Standard: For SFY 2009, each MCP must implement a
quality improvement plan (QIP) which identifies areas needing quality
improvement, includes a root-cause analysis of the areas needing improvement,
and establishes strategies and implementation activities to achieve continuous
quality improvement for this measure. The QIP must be submitted to ODJFS for
review and implemented no later than May, 1, 2009.

    

    
      


      Regional-Based Statewide Target:
For SFY 2010, a maximum of 3.00% of the eligible population will have two
or more targeted ED visits during the reporting period.

    

    
      


      Regional-Based Statewide Minimum
Performance Standard: For SFY 2010, 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 with the
Regional-Based Statewide Minimum Performance Standard: If the standard is
not met, then the MCP must develop a corrective action plan, for which ODJFS may
direct the MCP to develop the components of their EDD program as specified by
ODJFS. If the standard is not met and the results are at or below a percent to
be determined, then the MCP must develop a Quality Improvement
Directive.

    

    
       

      5.           
NOTES

    

    
       

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

    

    
       

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

    

    
      


      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.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
M

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
21

    

    
      


      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.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 15.0% of
the MCP’s monthly capitation.

    

    
       

      5.c.Enrollment
Freezes

    

    
       

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

    

    
      


      5.d.Reconsideration

    

    
       

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

    

    
      


      5.e.Contract
Termination, Nonrenewals or Denials

    

    
      


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

    

    
       

      5.f.
Report and Compliance Periods

    

    
      


      ODJFS
reserves the right to revise report periods (and corresponding compliance
periods), as needed, due to unforeseen circumstances.

    

    
       

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

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      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 suspend 

                     
any further new member selections.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
N

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
2

    

    
       

    

    
                     
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. Quality Improvement Plan
(QIDs) - A quality improvement plan (QIP) is a written description of the
managed care plan's process to improve access and quality of care in
a

                   
  clinical or administrative topic area. A QIP consists of three
components: data analysis, root cause analysis, and the resulting quality
improvement initiative, including the

                    
 implementation and completion timeline. QIPs will be required when an MCP
must comply with Interim Performance Measure Standards as specified by
ODJFS.

    

    
       

                     
D. 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.).

    

    
       

                                     
D.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:

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
N

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
4

       

    

    
      
        	
                                          
                •

              	
                Violations
      which result in a member’s MCP selection or termination based on
      inaccurate provider panel information from the
  MCP.

              


      

    

    
      
        	
                                          
                •

              	
                Failure
      to provide member materials to new members in a timely
    manner.

              


      

    

    
      
        	
                                           
               •

              	
                Failure
      to comply with appeal, grievance, or state hearing
      requirements, including the failure to notify a member of their right to a
      state hearing when the MCP proposes to deny, reduce, suspend or terminate
      a Medicaid-covered service.

              


      

    

    
      
        	
                                          
                •

              	
                Failure
      to staff 24-hour call-in system with appropriate trained medical
      personnel.

              


      

    

    
      
        	
                                     
           
               •

              	
                Failure
      to meet the monthly call-center requirements for either the member
      services or the 24-hour call-in system
lines.

              


      

    

    
      
        	
                                          
                •

              	
                Provision
      of false, inaccurate or materially misleading information to health care
      providers, the MCP’s members, or any eligible
  individuals.

              

                                     •       
Use of unapproved marketing or member materials.

    

    
      
        	
                                              
            •  

              	
                Failure
      to appropriately notify ODJFS or members of provider panel
      terminations.

              


      

    

    
                                    
      •       
Failure to update website provider directories as required.

       

    

    
                                     
D.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.

              


      

    

    
       

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

    

    
      


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

    

    
      
 

                                   
  E.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.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
N

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
5

    

     

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

    

    
      


                           
          E.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.

    

    
      


                            
         E.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.

    

    
       

                     
F. 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.


    

    
       

                      G. 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

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
N

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
6

       

    

    
                     
H. New Enrollment 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 enrollment through consumer initiated selection or the assignment
process if: (1) the MCP has accumulated a total of 51 or more points during a
rolling 12-

                     
month period; (2) or the MCP fails to fully implement a CAP within the
designated time frame; or (3) circumstances exist which potentially jeopardize
the MCP’s members’

                    
access to care. [Examples of circumstances that ODJFS may consider as
jeopardizing member access to care include:

    

    
       

      
        	
                               
      -

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

              


      

    

    
       

      
        	
                               
      -

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

              


      

    

    
       

      
        	
                               
      -

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

              


      

    

    
       

      
        	
                               
      -

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

              


      

    

    
       

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

                     
requirements in 42 CFR 438.730.

    

    
       

                     
I. 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 enrollment volume.
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.

    

    
       

                      J. 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.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
N

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
7

    

    
       

                     
K. Specific Pre-Determined
Penalties

    

    
      


                             
        K.1. Adequate network-minimum provider panel
requirements - Compliance with
provider panel requirements will be assessed quarterly. Any deficiencies in
the

                                    
 MCP’s provider network
as specified in Appendix H of the Agreement or by ODJFS, will result in the
assessment of a $1,000 nonrefundable fine for each category

                                     
(practitioners, PCP capacity,
hospitals), for each county, and for each population (e.g., ABD, CFC). For
example if the MCP did not meet the following minimum panel 

                                      requirements,
the MCP would be
assessed (1) a $3,000 nonrefundable fine for the failure to meet CFC panel
requirements; and, (2) a $1,000 nonrefundable fine for the 

                                      failure
to meet ABD panel requirements).

    

    
                                                  
 •      practitioner requirements in
Franklin county for the CFC population

    

    
                                                  
 •      practitioner requirements in
Franklin county for the ABD population

    

    
                                                
   •      hospital requirements
in Franklin county for the CFC population 

    

    
                                                   
•      PCP capacity requirements in
Fairfield county for the CFC population

    

    
       

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

                     
identified resulting from provider panel noncompliance.

    

    
      


                              
       K.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

    

    
      


                                      K.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

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
N

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
8

    

    
       

                                                       
    o Annual delegation assessments

    

    
                                                     
      o Call center report

    

    
                                                      
     o Franchise fee documentation

    

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

                                                       
    o State hearing
notifications

       

    

    
                                                  
 •      Late required data
submissions

    

    
                                                           
o Appeals and grievances, case management, or PCP data

    

    
                                                   
•      Late required information
requests

    

    
                                                      
     o Automatic call distribution
reports

    

    
                                                   
        o Information/resolution
regarding consumer or provider complaint
o Just cause
or other coordination care request from ODJFS o Provider
panel

                                                          
 documentation 

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

    

    
      


                      
              
If an MCP determines that they will be unable to meet a program deadline or
data/documentation submission deadline, the MCP must submit a written request to
its 

                                      Contract Administrator
for an extension of the deadline, as soon as possible, but no later than 3 PM
EST on the date of the deadline in question. Extension requests

                                      should
only be  submitted
in situations where unforeseeable circumstances have occurred which make it
impossible for the MCP to meet an ODJFS-stipulated

                                    
 deadline and all such requests will be
evaluated upon this standard. Only written approval as may be granted by ODJFS
of a deadline extension will preclude the

                                    
 assessment of compliance action for untimely submissions.

    

    
       

                                    
 K.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.

    

    
       

                               
      K.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.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
N

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
9

    

    
       

                                
     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.

    

    
       

                           
          K.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.

              


      

    

    
       

                                 
    K.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.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
N

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
10

    

    
      


                                 
    K.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.

    

    
       

                           
          K.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.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
N

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
11

    

    
      
      

      
               
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

    

    
      Page
1

    

    
      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 of this appendix). 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 of this
appendix).

    

    
       

      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. The first regional-based statewide
P4P determination will be SFY 2010 and will include at-risk amounts from July,
2009 through June, 2010.

    

    
       

      1.
SFY 2008 P4P

    

    
       

      1.a.
Qualifying Performance Levels

    

    
       

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

    

    
       

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

    

    
       

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

       

    

    
                     
Report Period: CY 2007

       

    

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

       

    

    
                     
Report Period: CY 2007

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
O

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
2

    

    
      


      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 SFY 2008.

    

    
       

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

    

    
       

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

    

    
      


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

                  
 applicable national standards, methods or benchmarks.

    

    
       

    

    
      	 
      	
               

              Clinical Performance
      Measure

            	
              Medicaid
      

              Benchmark

            
	
               
      1.  

            	
              Perinatal
      Care - Frequency of Ongoing Prenatal Care

            	
              42%

            
	
              2.
        

            	
              Perinatal
      Care - Initiation of Prenatal Care

            	
              71%

            
	
              3.
        

            	
              Perinatal
      Care - Postpartum Care

            	
              48%

            
	
              4.
        

            	
              Well-Child
      Visits – Children who turn 15 months old

            	
              34%

            
	
              5.
        

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

            	
              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%

            


    

    
       

      1.b.
Excellent and Superior Performance Levels

    

    
      


      For
qualifying MCPs as determined by Section 1.a. of this appendix, performance will
be evaluated on the measures listed below to determine the status of the at-risk
amount and 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.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
O

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
3

    

    
      


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

    

    
              


                     
Report Period: April - June 2008

    

    
       

                     
Excellent Standard: 5.5% or the submission of a Proof of Action (POA)
delineating an active care management program from April, 2008 through June,
2008. This POA must be

                    
 determined sufficient by ODJFS.

    

    
      


                     
Superior Standard: 6.5%

       

    

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

    

    
      


                     
Report Period: CY 2007 

       

                      Excellent
Standard: 86% 

       

                    
 Superior Standard: 88%

    

    
      


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

       

    

    
                     
Report Period: CY 2007 

       

                  
   Excellent Standard:
76%

       

                 
    Superior Standard: 84%

    

    
       

      1.c.
Determining SFY 2008 P4P

    

    
       

      MCPs that
do not meet the minimum performance standards described in Section 1.a. herein,
will not be considered for P4P and must return to ODJFS one hundred percent of
their at-risk amount used in the SFY 2008 P4P determination. MCP’s reaching the
minimum performance standards described in Section 1.a. herein, will be
considered for P4P including retention of the at-risk amount and any additional
P4P. For each Excellent standard established in Section 1.b. herein, that an MCP
meets, one-third of the at-risk amount may be retained. For MCPs meeting all of
the Excellent and Superior standards established in Section 1.b. herein,
additional P4P may be awarded. For MCPs receiving additional P4P, the amount in
the P4P fund (see Section 3 of this appendix) 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.

    

    
      

        
          
             


          

          
             


            
              

            

          

          
             


          

        

Appendix
O

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
4

    

    
      


      
        2.
SFY 2009 P4P

        
          


          2.a.
Qualifying Performance Levels

           

        

      

      To
qualify for consideration of the SFY 2009 P4P, an MCP’s performance level must
meet the minimum performance standards set in Appendix M, Performance Evaluation, for
the measures listed below. A detailed description of the methodologies for each
measure can be found on the BMHC page of the ODJFS website.

    

    
      


      Measures
for which the minimum performance standard for SFY 2009 established in Appendix
M, Performance
Evaluation, must be met to qualify for consideration of P4P are as
follows:

    

    
       

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

       

    

    
                   
Report Period: CY 2008

    

    
       

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

       

    

    
                   
Report Period: CY 2008

    

    
       

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

    

    
       

                   
Report Period: CY 2008

       

    

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

    

    
       

                   
Report Period: The most recent consumer satisfaction survey completed
prior to the end of SFY 2009.

    

    
       

      For each
clinical performance measure listed below, the MCP must meet the P4P standard to
be considered for SFY 2009 P4P. The MCP meets the P4P standard if one of two
criteria is met. The P4P standard is a performance level of
either:

    

    
      


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

    

    
       

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

    

    
      

        
          
             


          

          
             


            
              

            

          

          
             


          

        

      

       

    

    
      Appendix
O

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
5

    

    
      


    

    
      	 
      	
               

              Clinical Performance
      Measure

            	
              Medicaid
      

              Benchmark

            
	
              1.  
      

            	
              Perinatal
      Care - Frequency of Ongoing Prenatal Care

            	
              44%

            
	
              2.  
      

            	
              Perinatal
      Care - Initiation of Prenatal Care

            	
              74%

            
	
              3.  
      

            	
              Perinatal
      Care - Postpartum Care

            	
              50%

            
	
              4.  
      

            	
               Well-Child
      Visits – Children who turn 15 months old

            	
              42%

            
	
              5.  
      

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

            	
              57%

            
	
              6.  
      

            	
              Well-Child
      Visits - 12 through 21 years old

            	
              33%

            
	
              7.  
      

            	
              Use
      of Appropriate Medications for People with Asthma

            	
              84%

            
	
              8.  
      

            	
              Annual
      Dental Visits

            	
              42%

            
	
              9.  
      

            	
              Blood
      Lead – 1 year olds

            	
              45%

            


    

    
      


      2.b.
Excellent and Superior Performance Levels

    

    
       

      For
qualifying MCPs as determined by Section 2.a. of this appendix, performance will
be evaluated on the measures listed below to determine the status of the at-risk
amount. 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.  Care
Management of High Risk Members (Appendix M, Section 1.b.ii.)

    

    
         

                   
Excellent Standard: The Interim Regional-Based Statewide Minimum
Performance Standard established in Appendix M, Section
1.b.ii.

    

    
                  


                   
Superior Standard: N/A

    

    
       

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

    

    
       

                   
Report Period: CY 2008 

      
      

                   
Excellent Standard: 86% 

       

                   
Superior Standard: 88%

       

    

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

    

    
       

                   
Report Period: CY 2008

       

                  
 Excellent
Standard: 77%

    

    
       

                   
Superior Standard: 84%

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
O

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
6

    

    
      


      2.c.
Determining SFY 2009 P4P

    

    
       

      MCPs that
do not meet the minimum performance standards described in Section 2.a. herein,
will not be considered for P4P and must return to ODJFS one hundred percent of
their at-risk amount used in the SFY 2009 P4P determination. MCPs reaching the
minimum performance standards described in Section 2.a. herein, will be
considered for P4P (retention of the at-risk amount). For each Excellent
standard established in Section 2.b. herein, that an MCP meets, one-third of the
at-risk amount used in the SFY 2009 P4P determination may be retained. No
additional P4P will be awarded in SFY 2009.

    

    
       

      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 implemented in SFY 2010. The regional-based statewide P4P
system will be modeled after the county-based statewide system with adjustments
to performance standards where appropriate.

    

    
      


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

    

    
       

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

    

    
       

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

    

    
       

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

    

    
      


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

    

    
       

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

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
O

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
7

    

    
       

      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. The first regional-based statewide P4P determination
will be SFY 2010 and will include at-risk amounts from July, 2009 through June,
2010.

    

    
       

      For MCPs
with membership in the NEC region, the first regional-based statewide P4P
determination (SFY 2010) will include at-risk dollars from Columbiana county
from March, 2010 through June, 2010 and at-risk dollars from Mahoning and
Trumbull counties from July, 2009 through June, 2010.

    

    
      


      Regional
premium payments at-risk for months prior to July, 2009, for counties not
included in the county-based statewide P4P determination, will be determined as
follows:

    

    
       

      MCPs
which meet the Interim Minimum Performance Standards set in Appendix M, Performance Evaluation, for
all of the measures listed in Table 1 below may retain one hundred percent of
their at-risk amount for months prior to July, 2009, for counties not included
in the county-based statewide P4P determination. MCPs which do not meet the
Interim Minimum Performance Standards set in Appendix M, Performance Evaluation, for
all of the measures listed in Table 1 below must return to ODJFS one hundred
percent of their at-risk amount for months prior to July, 2009, for counties not
included in the county-based statewide P4P determination. This determination
will be made by December 31, 2009.

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
O

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
8

    

    
      


      Table
1. Measures Used to Determine the Status of the At-Risk Amount for Months Prior
to July, 2009, for Counties Not Included in the County-Based Statewide P4P
System

    

    
      


      
        
          	
                  Measures

                
	
                  1.

                	
                  Care Management of High Risk
      Members

                
	
                  2.

                	
                  Care Management of
  Members

                
	
                  3.

                	
                  PCP Turnover

                
	
                  4.

                	
                  Adults' Access to Preventive/Ambulatory Health
      Services

                
	
                  5.

                	
                  Members Access to Designated
      PCP

                
	
                  6.

                	
                  Emergency Department
    Diversion

                
	
                  7.

                	
                  Perinatal Care - Frequency of Ongoing Prenatal
      Care

                
	
                  8.

                	
                  Perinatal Care - Initiation of Prenatal
      Care

                
	
                  9.

                	
                  Perinatal Care - Postpartum
      Care

                
	
                  10.

                	
                  Well Child Visits - 15 Months
      Old

                
	
                  11.

                	
                  Well Child Visits - 3, 4, 5, or 6 Years
      Old

                
	
                  12.

                	
                  Well Child Visits - 12 through 21 Years
      Old

                
	
                  13.

                	
                  Annual Dental Visits

                
	
                  14.

                	
                  Use of Appropriate Medications for People with
      Asthma

                


        

      

    

    
       

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

      

    

    
      


      Given
that unforeseen circumstances (e.g., revision or update of measure(s),
applicable national standards, methods or benchmarks, or issues related to
program implementation) may impact the determination of the status of an MCP’s
at-risk amount and any additional P4P payments, ODJFS reserves the right to
calculate an MCP’s at-risk amount (the status of which is determined in
accordance with this appendix) using a lesser percentage than that established
in Appendix F (Regional Rates) and to award additional P4P in an amount lesser
than that established in this appendix.

    

    
       

      For MCPs
that have participated in the Ohio Medicaid Managed Care Program long enough to
calculate performance levels for all of the performance measures included in the
P4P system, determination of the status of an MCP’s at-risk amount may occur
within six months of the end of the contract period. Where applicable,
determination of additional P4P payments will be made at the same time the
status of an MCP’s at-risk amount is determined. Given that unforeseen
circumstances may impact the determination of the status of an MCP’s at-risk
amount and any additional P4P payments, ODJFS reserves the right to revise the
time frame in which the determination will be made (i.e. the determination may
be made more than six months after the end of the contract
period).

    


    
      
         


      

      
         


        
          

        

      

      
         


      

    


    
      Appendix
O

    

    
      Covered
Families and Children (CFC) population

    

    
      Page
9

    

    
      


      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.
Measures and 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. ODJFS
reserves the right to revise P4P measures and report periods, as needed, due to
unforeseen circumstances. Unless otherwise noted, the most recent report or
study finalized prior to the end of the contract period may be used in
determining the MCP’s overall performance level for the current contract
period.