Document:

exv10w25w1

 

EXHIBIT
10.25.1

PROVIDER AGREEMENT

BETWEEN

STATE OF OHIO

DEPARTMENT OF JOB AND FAMILY SERVICES

AND

MOLINA HEALTHCARE OF OHIO, INC

Amendment No. 1

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

	1.	 	Appendices C, D, E, F, G, H, J, K, L, M, N and O are modified as attached.
	 
	2.	 	All other terms of the provider agreement are hereby affirmed.
	 
	 	 	The amendment contained herein shall be effective January 1, 2008.

MOLINA HEALTHCARE OF OHIO, INC:

	 	 	 	 	 	 	 	 	 	 	 
	BY:

	 	/s/ KATHIE MANCINI
 

KATHIE MANCINI, PRESIDENT
	 	 	 	DATE:
	 12/20/07
 

	 	 
	On behalf of Kathie Mancini

	 
	 	 	 	 	 	 	 	 	 	 
	OHIO DEPARTMENT OF JOB AND FAMILY SERVICES:	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	BY:

	 	/s/ HELEN E. JONES-KELLEY
 

HELEN E. JONES-KELLEY, DIRECTOR
	 	 	 	DATE:
	 12/26/07
 

	 	 

 

 

Appendix C

Aged, Blind or Disabled population

Page 1

APPENDIX C

MCP RESPONSIBILITIES

ABD ELIGIBLE POPULATION

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

General Provisions

	1.	 	The MCP agrees to implement program modifications as soon as reasonably possible or no later
than the required effective date, in response to changes in applicable state and federal laws
and regulations.
	 
	2.	 	The MCP must submit a current copy of their Certificate of Authority (COA) to ODJFS within 30
days of issuance by the Ohio Department of Insurance.
	 
	3	 	The MCP must designate the following:

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

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

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

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

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

 

 

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

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

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

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

	10.	 	For any data and/or documentation that MCPs are required to maintain, ODJFS may request that
MCPs provide analysis of this data and/or documentation to ODJFS in an aggregate format, such
format to be solely determined by ODJFS.
	 
	11.	 	The MCP is responsible for determining medical necessity for services and supplies requested
for their members as specified in OAC rule 5101:3-26-03. Notwithstanding such responsibility, ODJFS
retains the right to make the final determination on medical necessity in specific member
situations.
	 
	12.	 	In addition to the timely submission of medical records at no cost for the annual external
quality review as specified in OAC rule 5101:3-26-07, the MCP may be required for other purposes to
submit medical records at no cost to ODJFS and/or designee upon request.
	 
	13.	 	The MCP must notify the BMHC of the termination of an MCP panel provider that is designated as
the primary care provider for 100 or more of the MCP’s ABD members. The MCP must provide
notification within one working day of the MCP becoming aware of the termination.
	 
	14.	 	Upon request by ODJFS, MCPs may be required to provide written notice to
members of any significant change(s) affecting contractual requirements, member services or access
to providers.

 

 

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

	 	a.	 	MCPs are required to make transportation available to any member requesting transportation
when they must travel thirty (30) miles or more from their home to receive a medically-necessary
Medicaid-covered service. If the MCP offers transportation to their members as an additional
benefit and this transportation benefit only covers a limited number of trips, the required
transportation listed above may not be counted toward this trip limit.
	 
	 	b.	 	Additional benefits may not vary by county within a region except out of necessity for
transportation arrangements (e.g., bus versus cab). MCPs approved to serve consumers in more than
one region may vary additional benefits between regions.
	 
	 	c.	 	MCPs must give ODJFS and members ninety (90) days prior notice when decreasing or ceasing
any additional benefit(s). When it is beyond the control of the MCP, as demonstrated to ODJFS’
satisfaction, ODJFS must be notified within one (1) working day.

	16.	 	MCPs must comply with any applicable Federal and State laws that pertain to member rights and
ensure that its staff adheres to such laws when furnishing services to its members. MCPs shall
include a requirement in its contracts with affiliated providers that such providers also adhere to
applicable Federal and State laws when providing services to members.
	 
	17.	 	MCPs must comply with any other applicable Federal and State laws (such as Title VI of the
Civil rights Act of 1964, etc.) and other laws regarding privacy and confidentiality, as such may
be applicable to this Agreement.
	 
	18.	 	Upon request, the MCP will provide members and potential members with a copy of their practice
guidelines.
	 
	19.	 	The MCP is responsible for promoting the delivery of services in a culturally competent manner,
as solely determined by ODJFS, to all members, including those with limited English proficiency
(LEP) and diverse cultural and ethnic backgrounds.

 

 

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

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

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

 

 

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	 	 	Managers (PBMs), and Third Party Administrators (TPAs)], as applicable. MCPs must submit to
ODJFS, upon request, detailed information regarding the MCP’s members with special communication
needs, which could include individual member names, their specific communication need, and any
provision of special services to members (i.e., those special services arranged by the MCP as well
as those services reported to the MCP which were arranged by the provider).
	 
	 	 	Additional requirements specific to providing assistance to hearing-impaired, vision-
impaired, limited reading proficient (LRP), and LEP members and eligible individuals are found in
OAC rules 5101:3-26-03.1, 5101:3-26-05(D), 5101:3-26-05.1(A), 5101:3-26-08, and 5101-3-26-08.2.
	 
	21.	 	The MCP is responsible for ensuring that all member materials use easily understood language
and format. The determination of what materials comply with this requirement is in the sole
discretion of ODJFS.
	 
	22.	 	Pursuant to OAC rules 5101:3-26-08 and 5101:3-26-08.2, the MCP is responsible for ensuring that
all MCP marketing and member materials are prior approved by ODJFS before being used or shared with
members. Marketing and member materials are defined as follows:

	 	a.	 	Marketing materials are those items produced in any medium, by or on behalf of an MCP,
including gifts of nominal value (i.e., items worth no more than $15.00), which can reasonably be
interpreted as intended to market to eligible individuals.
	 
	 	b.	 	Member materials are those items developed, by or on behalf of an MCP, to fulfill MCP
program requirements or to communicate to all members or a group of members. Member health
education materials that are produced by a source other than the MCP and which do not include any
reference to the MCP are not considered to be member materials.
	 
	 	c.	 	All MCP marketing and member materials must represent the MCP in an honest and forthright
manner and must not make statements which are inaccurate, misleading, confusing, or otherwise
misrepresentative, or which defraud eligible individuals or ODJFS.
	 
	 	d.	 	All MCP marketing cannot contain any assertion or statement (whether written or oral) that
the MCP is endorsed by CMS, the Federal or State government or similar
entity.
	 
	 	e.	 	MCPs must establish positive working relationships with the CDJFS offices and must not
aggressively solicit from local Directors, MCP County Coordinators, or

 

 

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	 	 	 	other staff. Furthermore, MCPs are prohibited from offering gifts of nominal value (i.e.
clipboards, pens, coffee mugs, etc.) to CDJFS offices or managed care enrollment center (MCEC)
staff, as these may influence an individual’s decision to select a particular MCP.

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

	 	a.	 	Maintain written policies and procedures that meet the requirements for advance
directives, as set forth in 42 CFR Subpart I of part 489.
	 
	 	b.	 	Maintain written policies and procedures concerning advance directives with respect to
all adult individuals receiving medical care by or through the MCP to ensure that the MCP:

	 	i.	 	Provides written information to all adult members concerning:

	 	a.	 	the member’s rights under state law to make decisions concerning their medical
care, including the right to accept or refuse medical or surgical treatment and the right
to formulate advance directives. (In meeting this requirement,
MCPs must utilize form JFS 08095 entitled You Have the Right, or
include the text from JFS 08095 in their ODJFS-approved member
handbook).
	 
	 	b.	 	the MCP’s policies concerning the implementation of those rights including a clear
and precise statement of any limitation regarding the implementation of advance directives
as a matter of conscience;
	 
	 	c.	 	any changes in state law regarding advance directives as soon as possible but no
later than ninety (90) days after the proposed effective date of the change; and
	 
	 	d.	 	the right to file complaints concerning noncompliance with the advance directive
requirements with the Ohio Department of Health.

	 	ii.	 	Provides for education of staff concerning the MCP’s policies and procedures on
advance directives;
	 
	 	iii.	 	Provides for community education regarding advance directives directly or in concert
with other providers or entities;

 

 

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	 	iv.	 	Requires that the member’s medical record document whether or not the member has executed
an advance directive; and
	 
	 	v.	 	Does not condition the provision of care, or otherwise discriminate against a member, based
on whether the member has executed an advance directive.

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

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

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

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

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

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

 

 

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	 	 	Eastern Time, except for the following major holidays:

	 	•	 	New Year’s Day
	 
	 	•	 	Martin Luther King’s Birthday
	 
	 	•	 	Memorial Day
	 
	 	•	 	Independence Day
	 
	 	•	 	Labor Day
	 
	 	•	 	Thanksgiving Day
	 
	 	•	 	Christmas Day
	 
	 	•	 	2 optional closure days: These days can be used independently or in combination
with any of the major holiday closures but cannot both be used within the same
closure period. Before announcing any optional closure dates to members and/or
staff, MCPs must receive ODJFS prior-approval which verifies that the optional
closure days meet the specified criteria.

	 	 	If a major holiday falls on a Saturday, the MCP member services line may be closed on the preceding
Friday. If a major holiday falls on a Sunday, the member services line may be closed on the
following Monday. MCP member services closure days must be specified in the MCP’s member handbook,
member newsletter, or other some general issuance to the MCP’s members at least thirty (30) days in
advance of the closure.
	 
	 	 	The MCP must also provide access to medical advice and direction through a centralized
twenty-four-hour, seven day, toll-free call-in system, available nationwide, pursuant to OAC rule
5101:3-26-03.1(A)(6). The twenty-four (24)/7 hour call-in system must be staffed by appropriately
trained medical personnel. For the purposes of meeting this requirement, trained medical
professionals are defined as physicians, physician assistants, licensed practical nurses, and
registered nurses.
	 
	 	 	MCPs must meet the current American Accreditation HealthCare Commission/URAC-designed Health Call
Center Standards (HCC) for call center abandonment rate, blockage rate and average speed of answer.
By the 10th of each month, MCPs must self-report their prior month performance in these
three areas for their member services and twenty-four (24) hour toll-free call-in systems to ODJFS.
ODJFS will inform the MCPs of any changes/updates to these URAC call center standards.
	 
	 	 	MCPs are not permitted to delegate grievance/appeal functions [Ohio Administrative Code (OAC) rule
5101:3-26-08.4(A)(9)]. Therefore, the member services call center requirement may not be met
through the execution of a Medicaid Delegation Subcontract Addendum or Medicaid Combined Services
Subcontract Addendum.

 

 

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

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

	27.	 	HIPAA Privacy Compliance Requirements

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

	 	a.	 	MCPs shall not use or disclose PHI other than is permitted by this Agreement or required
by law.
	 
	 	b.	 	MCPs shall use appropriate safeguards to prevent unauthorized use or disclosure of PHI.
	 
	 	c.	 	MCPs shall report to ODJFS any unauthorized use or disclosure of PHI of which it becomes
aware. Any breach by the MCP or its representatives of protected health information (PHI) standards
shall be immediately reported to the State HIPAA Compliance Officer through the Bureau of Managed
Health Care. MCPs must provide documentation of the breach and complete all actions ordered by the
HIPAA Compliance Officer.
	 
	 	d.	 	MCPs shall ensure that all its agents and subcontractors agree to these same PHI
conditions and restrictions.
	 
	 	e.	 	MCPs shall make PHI available for access as required by law.

 

 

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	 	f.	 	MCP shall make PHI available for amendment, and incorporate amendments as appropriate as
required by law.
	 
	 	g.	 	MCPs shall make PHI disclosure information available for accounting as required by law.
	 
	 	h.	 	MCPs shall make its internal PHI practices, books and records available to the Secretary of Health and Human Services (HHS) to determine compliance.
	 
	 	i.	 	Upon termination of their agreement with ODJFS, the MCPs, at ODJFS’ option, shall return
to ODJFS, or destroy, all PHI in its possession, and keep no copies of the information,
except as requested by ODJFS or required by law.
	 
	 	j.	 	ODJFS will propose termination of the MCP’s provider agreement if ODJFS determines that
the MCP has violated a material breach under this section of the agreement, unless
inconsistent with statutory obligations of ODJFS or the MCP.

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

	 	a.	 	Selection Services Contractor: The MCP shall provide to the MCEC ODJFS prior-approved MCP
materials and directories for distribution to eligible individuals who request additional
information about the MCP.
	 
	 	b.	 	Monthly Reconciliation of Membership and Premiums: The MCP shall reconcile member data as
reported on the MCEC produced consumer contact record (CCR) with the ODJFS-produced monthly member
roster (MMR) and report to the ODJFS any difficulties in interpreting or reconciling information
received.
Membership reconciliation questions must be identified and reported to the ODJFS
prior to the first of the month to assure that no member is left without coverage.
The MCP shall reconcile membership with premium payments reported on the monthly
remittance advice (RA).
	 
	 	 	 	The MCP shall work directly with the ODJFS, or other ODJFS-identified entity, to resolve any
difficulties in interpreting or reconciling premium information.
Premium reconciliation questions must be identified within thirty (30) days of
receipt of the RA.

 

 

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	 	c.	 	Monthly Premiums: The MCP must be able to receive monthly premiums in a method specified by
ODJFS. (ODJFS monthly prospective premium issue dates are provided in advance to the MCPs.) Various
retroactive premium payments and recovery of premiums paid (e.g., retroactive terminations of
membership, deferments, etc.,) may occur via any ODJFS weekly remittance.
	 
	 	d.	 	Hospital/Inpatient Facility Deferment: When an MCP learns of a currently hospitalized member’s
intent to disenroll through the CCR or the 834, the disenrolling MCP must notify the
hospital/inpatient facility and treating providers as well as the enrolling MCP of the change in
enrollment within five (5) business days of receipt of the CCR or 834. The disenrolling MCP must
notify the inpatient facility that it will remain responsible for the inpatient facility charges
through the date of discharge; and must notify the treating providers that it will remain
responsible for provider charges through the date of disenrollment.
	 
	 	 	 	When the enrolling MCP learns through the disenrolling MCP, through ODJFS or other means, that
a new member who was previously enrolled with another MCP was admitted prior to the effective date
of enrollment and remains an inpatient on the effective date of enrollment, the enrolling MCP shall
contact the hospital/inpatient facility within five (5) business days of learning of the
hospitalization. The enrolling MCP shall verify that it is responsible for all medically necessary
Medicaid covered services from the effective date of MCP membership, including treating provider
services related to the inpatient stay; the enrolling MCP must reiterate that the
admitting/disenrolling MCP remains responsible for the hospital/inpatient facility charges through
the date of discharge. The enrolling MCP shall work with the hospital/inpatient facility to
facilitate discharge planning and
authorize services as needed.
	 
	 	 	 	When an MCP learns that a new member who was previously on Medicaid fee for service was
admitted prior to the effective date of enrollment and remains an inpatient on the effective date
of enrollment, the enrolling MCP shall notify the hospital/ inpatient facility and treating
providers that the MCP may not be the payer. The MCP shall work with hospital/inpatient facility,
treating providers and the ODJFS to assure that discharge planning assures continuity of care and
accurate payment. Notwithstanding the MCP’s right to request a hospital deferment up to six (6)
months following the member’s effective date, when the enrolling MCP learns of a deferment-eligible
hospitalization, the MCP shall notify the ODJFS and request the deferment within five (5) business
days of learning of the potential deferment.
	 
	 	e.	 	Just Cause Requests: The MCP shall follow procedures as specified by ODJFS in assisting the
ODJFS in resolving member requests for member-initiated requests affecting membership.

 

 

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	 	f.	 	Eligible Individuals: If an eligible individual contacts the MCP, the MCP must provide any
MCP-specific managed care program information requested. The MCP must not attempt to assess the
eligible individual’s health care needs. However, if the eligible individual inquires about
continuing/transitioning health care services, MCPs shall provide an assurance that all MCPs must
cover all medically necessary Medicaid-covered health care services and assist members with
transitioning their health care services.
	 
	 	g.	 	Pending Member
	 
	 	 	 	If a pending member (i.e., an eligible individual subsequent to plan selection or
assignment, but prior to their membership effective date) contacts the selected MCP, the
MCP must provide any membership information requested, including but not limited to,
assistance in determining whether the current medications require prior authorization. The
MCP must also ensure that any care coordination (e.g., 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.
	 
	 	h.	 	Transition of Fee-For-Service Members
	 
	 	 	 	Providing care coordination, access to preventive and specialized care, case management,
member services, and education with minimal disruption to members’ established
relationships with providers and existing care treatment plans is critical for members
transitioning from Medicaid fee-for-service to managed care. MCPs must develop and
implement a transition plan that outlines how the MCP will effectively address the unique
care coordination issues of members in their first three months of MCP membership and how
the various MCP departments will coordinate and share information regarding these new
members. The transition plan must include at a minimum:

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

	 	a.	 	Health care needs, including those services received through state

 

 

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	 	 	 	sub-recipient agencies [e.g., the Ohio Department
of Mental Health (ODMH), the Ohio Department of Mental Retardation and Developmental Disabilities
(ODMR/DD), the Ohio Department of Alcohol and Drug Addiction Services (ODADAS) and the Ohio
Department of Aging (ODA)];
	 
	 	b.	 	Existing sources of care (i.e., primary physicians, specialists, case
manager(s), ancillary and other care givers); and
	 
	 	c.	 	Current care therapies for all aspects of health care services,
including scheduled health care appointments, planned and/or approved
surgeries (inpatient or outpatient), ancillary or medical therapies,
prescribed drugs, home health care services, private duty nursing (PDN),
scheduled lab/radiology tests, necessary durable medical equipment,
supplies and needed/approved transportation arrangements.

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

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

	 	i.	 	The member has appointments within the initial three months of the MCP membership with a
primary care provider_or specialty physician that was scheduled prior to the effective date of the
MCP membership;
	 
	 	ii.	 	The member is in her third trimester of pregnancy and has an established
relationship with an obstetrician and/or delivery hospital;
	 
	 	iii.	 	The member has been scheduled for an inpatient or 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);
	 
	 	iv.	 	The member is receiving ongoing chemotherapy or radiation
treatment; or

 

 

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

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

	 	i.	 	an organ, bone marrow, or hematapoietic stem cell transplant
pursuant to OAC rule 5101:3-2-07.1;
	 
	 	ii.	 	dental services that have not yet been received;
	 
	 	iii.	 	vision services that have not yet been received;
	 
	 	iv.	 	durable medical equipment (DME) that has not yet been
received. Ongoing DME services and supplies are to be covered by
the MCP as previously-authorized until the MCP conducts a medical
necessity review and renders an authorization decision pursuant to OAC rule
5101:3-26-03.1.

 

 

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

	 	 	 	As soon as the MCP becomes aware of the member’s current
fee-for-service authorization approval, the MCP must initiate
contact with the authorized provider and member as applicable to
ensure continuity of care. The MCP must implement a plan to meet
the member’s immediate and ongoing medical needs and, with the
exception of organ, bone marrow, or hematapoietic stem cell
transplants, coordinate the transfer of services to a panel
provider, if appropriate.
	 
	 	 	 	When an MCP medical necessity review results in a decision to
reduce, suspend, or terminate services previously authorized by
fee-for-service Medicaid, the MCP must notify the member of their
state hearing rights no less than 15 calendar days prior to the
effective date of the MCP’s proposed action, per rule
5101:3-26-08.4 of the Administrative Code.
	 
	 	d.	 	Reimbursing out-of-panel providers that agree to provide the transition
services at 100% of the current Medicaid fee-for-service provider rate for the
service(s) identified in Section 29.h.ii.(a., b., and c.) of this appendix.
	 
	 	e.	 	Documenting the provision of transition services identified in Section
29.h.ii.(a., b., and c.) of this appendix as follows:

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

 

 

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	 	 	 	MCP’s availability to assist with locating a provider as expeditiously as the
member’s health condition warrants.
	 
	 	iii.	 	For panel providers, notification to the provider and member confirming the MCP’s
responsibility to cover the service.

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

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

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

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

 

 

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	 	 	 	For those new members who are not utilizing ongoing medications
for chronic conditions, no additional drug PA education is
required beyond the MCP’s general new member education that
includes what drugs require MCP PA.
	 
	 	 	 	MCPs must receive ODJFS approval prior to implementing their
transition of care drug PA process. An MCP’s proposal must
document how the MCP will:

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

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

	 	 	 	MCPs who have not received ODJFS approval for their transition of
care drug PA process must not require PA of any prescription drug
that does not require PA by Medicaid fee-for-service for the
initial three months of a member’s MCP membership.
	 
	 	g.	 	Covering antipsychotic medications for new members as well as current members as stipulated
in Appendix G(3)(a)(i).

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

	 	a.	 	Health Information System

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

 

 

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	 	ii.	 	As required by 42 CFR 438.242(b)(1), each MCP must collect data on member and provider
characteristics and on services furnished to its members.
	 
	 	iii.	 	As required by 42 CFR 438.242(b)(2), each MCP must ensure that data received from
providers is accurate and complete by verifying the accuracy and timeliness of reported data;
screening the data for completeness, logic, and consistency; and collecting service information in
standardized formats to the extent feasible and appropriate.
	 
	 	iv.	 	As required by 42 CFR 438.242(b)(3), each MCP must make all collected data available upon
request by ODJFS or the Center for Medicare and Medicaid Services (CMS).
	 
	 	v.	 	Acceptance testing of any data that is electronically submitted to
ODJFS is required:

	 	a.	 	Before an MCP may submit production files
	 
	 	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.

 

 

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	 	b.	 	Electronic Data Interchange and Claims Adjudication Requirements
	 
	 	 	 	Claims Adjudication
	 
	 	 	 	The MCP must have the capacity to electronically accept and adjudicate all claims to
final status (payment or denial). Information on claims submission procedures must be
provided to non-contracting providers within thirty (30) days of a request. MCPs must
inform providers of its ability to electronically process and adjudicate claims and the
process for submission. Such information must be initiated by the MCP and not only in
response to provider requests.
	 
	 	 	 	The MCP must notify providers who have submitted claims of claims status [paid,
denied, pended (suspended)] within one month of receipt. Such notification may be in the
form of a claim payment/remittance advice produced on a routine monthly, or more frequent,
basis.
	 
	 	 	 	Electronic Data Interchange
	 
	 	 	 	The MCP shall comply with all applicable provisions of HIPAA including electronic data
interchange (EDI) standards for code sets and the following electronic transactions:
	 
	 	 	 	Health care claims; 

Health care claim status request and response; 

Health care payment and remittance status;

Standard code sets; and

	 
	 	 	 	National Provider Identifier (NPI).
	 
	 	 	 	Each EDI transaction processed by the MCP shall be implemented in conformance with the
appropriate version of the transaction implementation guide, as specified by applicable
federal rule or regulation.
	 
	 	 	 	The MCP must have the capacity to accept the following transactions from the Ohio
Department of Job and Family services consistent with EDI processing specifications in the
transaction implementation guides and in conformance with the 820 and 834 Transaction
Companion Guides issued by ODJFS:
	 
	 	 	 	ASC X12 820 — Payroll Deducted and Other Group Premium Payment for Insurance Products;
and
	 
	 	 	 	ASC X12 834 — Benefit Enrollment and Maintenance.
	 
	 	 	 	The MCP shall comply with the HIPAA mandated EDI transaction standards and

 

 

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	 	 	 	code sets no later than the required compliance
dates as set forth in the federal regulations.
	 
	 	 	 	Documentation of Compliance with Mandated EDI Standards
	 
	 	 	 	The capacity of the MCP and/or applicable trading partners and business associates to
electronically conduct claims processing and related transactions in compliance with
standards and effective dates mandated by HIPAA must be demonstrated, to the satisfaction
of ODJFS, as outlined below.
	 
	 	 	 	Verification of Compliance with HIPAA (Health Insurance Portability and Accountability
Act of 1995)
	 
	 	 	 	MCPs shall comply with the transaction standards and code sets for sending and
receiving applicable transactions as specified in 45 CFR Part 162 – Health Insurance
Reform: Standards for Electronic Transactions (HIPAA regulations) In addition the MCP must
enter into the appropriate trading partner agreement and implemented standard code sets. If
the MCP has obtained third-party certification of HIPAA compliance for any of the items
listed below, that certification may be submitted in lieu of the MCP’s written verification
for the applicable item(s).

	 	i.	 	Trading Partner Agreements
	 
	 	ii.	 	Code Sets
	 
	 	iii.	 	Transactions

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

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

 

 

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	 	 	 	Noncompliance with the EDI and claims adjudication requirements will result in the
imposition of penalties, as outlined in Appendix N, Compliance Assessment System, of the
Provider Agreement.
	 
	 	c.	 	Encounter Data Submission Requirements
	 
	 	 	 	General Requirements
	 
	 	 	 	Each MCP must collect data on services furnished to members through an encounter
data system and must report encounter data to the ODJFS. MCPs are required to
submit this data electronically to ODJFS on a monthly basis in the following
standard formats:

	 	•	 	Institutional Claims — UB92 flat file
	 
	 	•	 	Noninstitutional Claims — National standard format
	 
	 	•	 	Prescription Drug Claims — NCPDP

	 	 	 	ODJFS relies heavily on encounter data for monitoring MCP performance. The ODJFS
uses encounter data to measure clinical performance, conduct access and utilization
reviews, reimburse MCPs for newborn deliveries and aid in setting
	 
	 	 	 	MCP capitation rates. For these reasons, it is important that encounter data is
timely, accurate, and complete. Data quality, performance measures and standards
are described in the Agreement.
	 
	 	 	 	An encounter represents all of the services, including medical supplies and
medications, provided to a member of the MCP by a particular provider, regardless
of the payment arrangement between the MCP and the provider. (For example, if a
member had an emergency department visit and was examined by a physician, this
would constitute two encounters, one related to the hospital provider and one
related to the physician provider. However, for the purposes of calculating a
utilization measure, this would be counted as a single emergency department visit.
If a member visits their PCP and the PCP examines the member and has laboratory
procedures done within the office, then this is one encounter between the member
and their PCP.)
	 
	 	 	 	If the PCP sends the member to a lab to have procedures performed, then this is two
encounters; one with the PCP and another with the lab. For pharmacy encounters,
each prescription filled is a separate encounter.
	 
	 	 	 	Encounters include services paid for retrospectively, through fee-for-service
payment arrangements, and prospectively, through capitated arrangements. Only
encounters with services (line items) that are paid by the MCP, fully or in part,
and for which no further payment is anticipated, are acceptable encounter data submissions.

 

 

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	 	 	 	All other services that are unpaid or paid in part and for which the MCP
anticipates further payment (e.g., unpaid services rendered during a delivery of a
newborn) may not be submitted to ODJFS until they are paid. Penalties for
noncompliance with this requirement are specified in Appendix N, Compliance
Assessment System of the Agreement.
	 
	 	 	 	Acceptance Testing
	 
	 	 	 	The MCP must have the capability to report all elements in the Minimum Data Set as
set forth in the ODJFS Encounter Data Specifications and must submit a test file in
the ODJFS-specified medium in the required formats prior to contracting or prior to
an information systems replacement or update.
	 
	 	 	 	Acceptance testing of encounter data is required as specified in Section 29(a)(v) of this
Appendix.
	 
	 	 	 	Encounter Data File Submission Procedures
	 
	 	 	 	A certification letter must accompany the submission of an encounter data file in
the ODJFS-specified medium. The certification letter must be
signed by the MCP’s Chief Executive Officer (CEO), Chief Financial Officer (CFO),
or an individual who has delegated authority to sign for, and who reports directly
to, the MCP’s CEO or CFO.
	 
	 	 	 	Timing of Encounter Data Submissions
	 
	 	 	 	ODJFS recommends that MCPs submit encounters no more than thirty-five (35) days
after the end of the month in which they were paid. (For example, claims paid in
January are due March 5.) ODJFS recommends that MCPs submit files in the
ODJFS-specified medium by the 5th of each month. This will help to ensure that the
encounters are included in the ODJFS master file in the same month in which they
were submitted.
	 
	 	d.	 	Information Systems Review
	 
	 	 	 	ODJFS or its designee may review the information system capabilities of each MCP
before ODJFS enters into a provider agreement with a new MCP, when a participating
MCP undergoes a major information system upgrade or change, when there is
identification of significant information system problems, or at ODJFS’ discretion.
Each MCP must participate in the review. The review will assess the extent to which
MCPs are capable of maintaining a health information system including producing
valid encounter data, performance measures, and other data necessary to support
quality assessment and improvement, as well as managing the care delivered to its
members.

 

 

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

	 	i.	 	Review the Information Systems Capabilities Assessment (ISCA) forms, as developed by CMS;
which the MCP will be required to complete.
	 
	 	ii.	 	Review the completed ISCA and accompanying documents;
	 
	 	iii.	 	Conduct interviews with MCP staff responsible for completing the ISCA, as well as staff
responsible for aspects of the MCP’s information systems function;
	 
	 	iv.	 	Analyze the information obtained through the ISCA, conduct
follow-up interviews with MCP staff, and write a statement of findings about the MCP’s
information system.
	 
	 	v.	 	Assess the ability of the MCP to link data from multiple sources;
	 
	 	vi.	 	Examine MCP processes for data transfers;
	 
	 	vii.	 	If an MCP has a data warehouse, evaluate its structure and reporting capabilities;
	 
	 	viii.	 	Review MCP processes, documentation, and data files to ensure that they comply with
state specifications for encounter data submissions; and
	 
	 	ix.	 	Assess the claims adjudication process and capabilities of the MCP.

	31.	 	If the MCP will be using the Internet functions that will allow approved users to access member
information (e.g., eligibility verification), the MCP must receive prior written approval from
ODJFS that verifies that the proper safeguards, firewalls, etc., are in place to protect member
data.
	 
	32.	 	MCPs must receive prior written approval from ODJFS before adding any information to their
website that would require ODJFS prior approval in hard copy form (e.g., provider listings, member
handbook information).
	 
	33.	 	Pursuant to 42 CFR 438.106(b), the MCP acknowledges that it is prohibited from holding a member
liable for services provided to the member in the event that the ODJFS fails to make payment to the
MCP.

 

 

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

	 	a.	 	Each MCP is required to pay a franchise permit fee to ODJFS for each calendar quarter as
required by ORC Section 5111.176. The current fee to be paid is an amount equal to 41/2 percent of
the managed care premiums, minus Medicare premiums that the MCP received from any payer in the
quarter to which the fee applies. Any premiums the MCP returned or refunded to members or premium
payers during that quarter are excluded from the fee.
	 
	 	b.	 	The franchise fee is due to ODJFS in the ODJFS-specified format on or before the 30th day
following the end of the calendar quarter to which the fee applies.
	 
	 	c.	 	At the time the fee is submitted, the MCP must also submit to ODJFS a completed
form and any supporting documentation pursuant to ODJFS specifications.
	 
	 	d.	 	Penalties for noncompliance with this requirement are specified in Appendix N, Compliance
Assessment System of the Provider Agreement and in ORC Section
5111.176.

	36.	 	Information Required for MCP Websites

	 	a.	 	On-line Provider Directory – MCPs must have an internet-based provider directory available
in the same format as their ODJFS-approved provider directory, that allows members to
electronically search for the MCP panel providers based on name, provider type, geographic
proximity, and population (as specified in Appendix H). MCP provider directories must include all
MCP-contracted providers [except as specified by ODJFS] as well as certain ODJFS non-contracted
providers.
	 
	 	b.	 	On-line Member Website – MCPs must have a secure internet-based website which is regularly
updated to include the most current ODJFS approved materials. The website at a minimum must
include: (1) a list of the counties that are covered in their service area; (2) the ODJFS-approved
MCP member handbook, recent newsletters/announcements, MCP contact information including member
services hours and closures; (3) the MCP provider directory as referenced in section 36(a) of this
appendix; (4) the MCP’s current preferred drug list (PDL),

 

 

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	 	 	 	including an explanation of the list, which drugs
require prior authorization (PA), and the PA process; (5) the MCP’s current list of drugs covered
only with PA, the PA process, and the MCP’s policy for covering generic for brand-name drugs; and
(6) the ability for members to submit questions/comments/grievances/appeals/etc. and receive a
response (members must be given the option of a return e-mail or phone call). Responses regarding
questions or comments are expected within one working day of receipt, whereas responses regarding
grievances and appeals must be within the timeframes specified in OAC rule 5101:3-26-08.4. MCPs
must ensure that all member materials designated specifically for CFC and/or ABD consumers (i.e.
the MCP member handbook) are clearly labeled as such. The MCP’s member website cannot be used as
the only means to notify members of new and/or revised MCP information (e.g., change in holiday
closures, change in additional benefits, revisions to approved member materials etc.). ODJFS may
require MCPs to include additional information on the member website, as needed.
	 
	 	c.	 	On-line Provider Website – MCPs must have a secure internet-based website for contracting
providers where they will be able to confirm a consumer’s MCP enrollment and through this website
(or through e-mail process) allow providers to electronically submit and receive responses to prior
authorization requests. This website must also include: (1) a list of the counties that are covered
in their service area; (2) the MCP’s
provider manual;(3) MCP contact information; (4) a link to the MCP’s on-line provider directory as
referenced in section 37(a) of this appendix; (5) the MCP’s current PDL list, including an
explanation of the list, which drugs require PA, and the PA process; (6) the MCP’s current list of
drugs covered only with PA, the PA process, and the MCP’s policy for covering generic for
brand-name drugs. MCPs must ensure that all provider materials designated specifically for CFC
and/or ABD consumers (i.e. the MCP’s provider manual) are clearly labeled as such; and (7)
information regarding the availability of expedited prior authorization requests, as well as the
information that is required from that provider in order to substantiate an expedited prior
authorization request.
	 
	 	 	 	ODJFS may require MCPs to include additional information on the provider website, as needed.

	38.	 	MCPs must provide members with a printed version of their PDL and PA lists, upon request.
	 
	39.	 	MCPs must not use, or propose to use , any offshore programming or call center services in
fulfilling the program requirements.

 

 

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	40.	 	PCP Feedback – The MCP must have the administrative capacity to offer feedback to individual
providers on their: 1) adherence to evidence-based practice guidelines; and 2) positive and
negative care variances from standard clinical pathways that may impact outcomes or costs. In
addition, the feedback information may be used by the MCP for activities such as provider
performance improvement projects that include incentive programs or the development of quality
improvement programs.
	 
	41.	 	Coordination of Benefits
	 
	 	 	When a claim is denied due to third party liability, the managed care plan must timely share
appropriate and available information regarding the third party to the provider for the purposes of
coordination of benefits, including, but not limited to third party liability information received
from the Ohio Department of Job and Family Services.

 

 

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APPENDIX D

ODJFS RESPONSIBILITIES

ABD ELIGIBLE POPULATION

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

General Provisions

	1.	 	ODJFS will provide MCPs with an opportunity to review and comment on the rate-setting time
line and proposed rates, and proposed changes to the OAC program rules or the provider
agreement.
	 
	2.	 	ODJFS will notify MCPs of managed care program policy and procedural changes and, whenever
possible, offer sufficient time for comment and implementation.
	 
	3.	 	ODJFS will provide regular opportunities for MCPs to receive program updates and discuss
program issues with ODJFS staff.
	 
	4.	 	ODJFS will provide technical assistance sessions where MCP attendance and participation is
required. ODJFS will also provide optional technical assistance sessions to MCPs, individually
or as a group.
	 
	5.	 	ODJFS will provide MCPs with an annual MCP Calendar of Submissions outlining major
submissions and due dates.
	 
	6.	 	ODJFS will identify contact staff, including the Contract Administrator, selected for each
MCP.
	 
	7.	 	ODJFS will recalculate the minimum provider panel specifications if ODJFS determines that
significant changes have occurred in the availability of specific provider types and the
number and composition of the eligible population.
	 
	8.	 	ODJFS will recalculate the geographic accessibility standards, using the geographic
information systems (GIS) software, if ODJFS determines that significant changes have occurred
in the availability of specific provider types and the number and composition of the eligible
population and/or the ODJFS provider panel specifications.
	 
	9.	 	On a monthly basis, ODJFS will provide MCPs with an electronic file containing their MCP’s
provider panel as reflected in the ODJFS Provider Verification System (PVS) database, or other
designated system.

 

 

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Page 2

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

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

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

 

 

Appendix D

Aged, Blind or Disabled (ABD) population

Page 3

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

	15.	 	Membership Selection and Premium Payment

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

	 	•	 	40% of statewide Aged, Blind, or Disabled (ABD) managed care eligibles;and/or
	 
	 	•	 	60% of the ABD managed care eligibles in any region with two MCPs; and/or
	 
	 	•	 	40% of the ABD managed care eligibles in any region with three MCPs.

	 	 	 	Once an MCP meets one of these enrollment thresholds, the MCP will only be permitted
to receive the additional new membership (in the region or statewide, as applicable)
through: (1) consumer-initiated enrollment; and (2) auto-assignments which are based
on previous enrollment in that MCP or an historical provider relationship with a
provider who is not on the panel of any other MCP in that region. In the event that
an MCP in a region meets one or more of these enrollment thresholds, ODJFS, may not
impose the auto-assignment limitation and auto-assign members to the MCPs in that
region as ODJFS deems appropriate.
	 
	 	c.	 	Consumer Contact Record (CCR): ODJFS or their designated entity shall forward CCRs to MCPs
on no less than a weekly basis. The CCRs are a record of each consumer-initiated MCP enrollment,
change, or termination, and each MCEC

 

 

Appendix D

Aged, Blind or Disabled (ABD) population

Page 4

	 	 	 	initiated MCP assignment processed through the MCEC. The CCR contains information that is not
included on the monthly member roster.
	 
	 	d.	 	Monthly member roster (MR): ODJFS verifies managed care plan enrollment on a monthly basis
via the monthly membership roster. ODJFS or its designated entity provides a full member roster (F)
and a change roster (C) via HIPAA 834 compliant transactions.
	 
	 	e.	 	Monthly Premiums: ODJFS will remit payment to the MCPs via an electronic funds transfer
(EFT), or at the discretion of ODJFS, by paper warrant.
	 
	 	f.	 	Remittance Advice: ODJFS will confirm all premium payments paid to the MCP during the month
via a monthly remittance advice (RA), which is sent to the MCP the week following state cut-off.
ODJFS or its designated entity provides a record of each payment via HIPAA 820 compliant
transactions.
	 
	 	g.	 	MCP Reconciliation Assistance: ODJFS will work with an MCP-designated contact(s) to
resolve the MCP’s member and newborn eligibility inquiries, and premium inquiries/discrepancies and
to review/approve hospital deferment requests.

	16.	 	ODJFS will make available a website which includes current program information.
	 
	17.	 	ODJFS will regularly provide information to MCPs regarding different aspects of MCP performance
including, but not limited to, information on MCP-specific and statewide external quality review
organization surveys, focused clinical quality of care studies, 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

 

 

Appendix D

Aged, Blind or Disabled (ABD) population

Page 5

	 	 	 	Section. MCPs should take all necessary and appropriate steps to ensure all MCP staff
are aware of, and follow, this communication process.
	 
	 	b.	 	ODJFS contracting entities: ODJFS-contracting entities should never be contacted by the
MCPs unless the MCPs have been specifically instructed by ODJFS to contact the ODJFS
contracting entity directly.
	 
	 	c.	 	MCP delegated entities: In that MCPs are ultimately responsible for meeting program
requirements, the BMHC will not discuss MCP issues with the MCPs’ delegated entities unless the
applicable MCP is also participating in the discussion. MCP delegated entities, with the
applicable MCP participating, should only communicate with the specific CA assigned to that MCP.

 

 

APPENDIX E

RATE METHODOLOGY

ABD ELIGIBLE POPULATION

 

 

			
	
	 	Chase Center/Circle

111 Monument Circle

Suite 601

Indianapolis, IN 46204-5128

USA

Tel +1 317 639 1000

Fax +1 317 639 1001

milliman.com

FINAL and CONFIDENTIAL

December 12,2007

Mr. Jon Barley, Ph.D., Bureau Chief

Bureau of Managed Health Care

Ohio Department of Job and Family Services

Lazarus Building

50 West Town St., Suite 400

Columbus, OH 43215

RE:
CY 2008 CAPITATION RATE DEVELOPMENT — AGED, BLIND, OR DISABLED

Dear Jon:

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

LIMITATIONS

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

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

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

Offices
in Principal Cities Worldwick

 

 

			
	
	 	Mr. Jon Barley, Ph.D.

December 12, 2007

Page 2

FINAL and CONFIDENTIAL

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

SUMMARY OF METHODOLOGY

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

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

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

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

DETAILS OF METHODOLOGY

I. COVERED POPULATION

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

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

 

 

			
	
	 	Mr. Jon Barley, Ph.D.

December 12, 2007

Page 3

FINAL and CONFIDENTIAL

Table 1

STATE OF OHIO

DEPARTMENT OF JOB AND FAMILY SERVICES

Summary of Managed Care Eligible Population

	 	 	 
	Program Assignment	 	Description
	AGED

	 	Aged
	RAGED

	 	Aged as defined on RMF
	BLIND

	 	Blind
	RBLIND

	 	Blind as defined on RMF
	DISABLED

	 	Disabled
	RDISABLED

	 	Disabled as defined on RMF
	RESMED

	 	Residential State Supplement & Medicaid

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

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

II. CATEGORY OF SERVICE DEFINITIONS

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

 

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

 

 

			
	
	 	Mr. Jon Barley, Ph.D.

December 12, 2007

Page 4

FINAL and CONFIDENTIAL

Table 2

STATE OF OHIO

DEPARTMENT OF JOB AND FAMILY SERVICES

Categories of Service

	 	 	 	 	 	 	 
	Type of Service	 	Service Category	 	Utilization Units	 	Classification Basis
	Inpatient Hospital

	 	Medical/Surgical
	 	Admits/Days
	 	 
	 

	 	MH/SA
	 	Admits/Days	 	 
	 

	 	Maternity Delivery
	 	Admits/Days	 	 
	 

	 	Well Newborn
	 	Admits/Days	 	COS, DRG
	 

	 	Maternity Non-Deliveries
	 	Admits/Days	 	 
	 

	 	Nursing Facility
	 	Admits/Days	 	 
	 

	 	Other Inpatient
	 	Admits/Days	 	 
	 
	 	 	 	 	 	 
	Outpatient Hospital

	 	Emergency Room
	 	Claims
	 	 
	 

	 	Surgery/ASC
	 	Services	 	 
	 

	 	Cardiovascular
	 	Services	 	COS, Revenue Code
	 

	 	PT/ST/OT
	 	Services	 	 
	 

	 	Clinic
	 	Services	 	 
	 

	 	Other
	 	Services	 	 
	 
	 	 	 	 	 	 
	Professional

	 	Inpatient/Outpatient Surgery
	 	Services
	 	 
	 

	 	Anesthesia
	 	Line Items	 	 
	 

	 	Obstetrics
	 	Services	 	 
	 

	 	Office Visits/Consults
	 	Services	 	COS, Provider Type,
Procedure, 
	 

	 	Hospital Inpatient Visits
	 	Services	 	Modifier
	 

	 	Emergency Room Visits
	 	Services	 	 
	 

	 	Immunizations & Injections
	 	Services	 	 
	 

	 	Physical Medicine
	 	Services	 	 
	 

	 	Miscellaneous Services
	 	Line Items, Services	 	 
	 
	 	 	 	 	 	 
	Rad/Path/Lab

	 	Radiology
	 	Services
	 	COS, Revenue Code, Provider

	 

	 	Pathology/Laboratory
	 	Services	 	Type, Procedure
	 
	 	 	 	 	 	 
	Ancillaries

	 	MH/SA
	 	Services
	 	COS, Provider Type, Procedure
	 

	 	FQHC/RHF/OP Health Facility
	 	Services
	 	COS
	 

	 	Pharmacy
	 	Line Items
	 	COS
	 

	 	Dental
	 	Services
	 	COS
	 

	 	Vision
	 	Services
	 	COS, Provider Type, Procedure
	 

	 	Home Health
	 	Line Items
	 	COS
	 

	 	Non-Emergent Transportation
	 	Line Items
	 	COS
	 

	 	Ambulance
	 	Line Items
	 	COS, Procedure Code
	 

	 	Supplies and DME
	 	Line Items
	 	COS, Provider Type, Procedure
	 

	 	Miscellaneous Services
	 	Line Items
	 	COS

 

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

 

 

			
	
	 	Mr. Jon Barley, Ph.D.

December 12, 2007

Page 5

FINAL and CONFIDENTIAL

III. RATE GROUPS

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

IV. DEVELOPMENT OF CY 2006 ADJUSTED FFS DATA

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

a.
Historical Data Summaries

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

	 	§	 	SFY 2005 (Incurred during the 12 months ending June 30, 2005 paid through May 31, 2007).
	 
	 	§	 	SFY 2006 (Incurred during the 12 months ending June 30, 2006 paid through May 31, 2007).

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

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

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

 

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

 

 

			
	
	 	Mr. Jon Barley, Ph.D.

December 12, 2007

Page 6

FINAL and CONFIDENTIAL

Table 3

STATE OF OHIO

DEPARTMENT OF JOB AND FAMILY SERVICES

FFS Claim Exclusions

	 	 	 
	COS Field Value	 	Description
	08

	 	PACE
	13

	 	ICF/MR Public
	18

	 	ICF/MR Private
	35

	 	Core Services
	36

	 	Home Care Facilitator Services
	41

	 	Mental Health Services
	42

	 	Mental Retardation
	46

	 	Model 50 Waiver Services
	58

	 	HMO Services
	59

	 	Mental Health Support Services
	60

	 	Mental Retardation Support Services
	63

	 	PPO Services
	64

	 	Passport
	66

	 	Passport Waiver III
	67

	 	OBRA MR/DD Waiver
	80

	 	Alcohol and Drug Abuse
	82

	 	Department of Education
	84

	 	ODADAS

b. Completion Factors

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

c. Historical Program Adjustments

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

 

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

 

 

			
	
	 	Mr. Jon Barley, Ph.D.

December 12, 2007

Page 7

FINAL and CONFIDENTIAL

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

Table 4

STATE OF OHIO

DEPARTMENT OF JOB AND FAMILY SERVICES

Historical Program Adjustments — FFS

	 	 	 	 	 	 	 	 	 
	Program Adjustment	 	Effective Date	 	Service Category(s)
	Inpatient Market Basket Increase
	 	 	1/1/2005	 	 	Inpatient Hospital
	Dental Fee Schedule Reduction
	 	 	1/1/2006	 	 	Dental
	Inpatient Recalibration and Outlier Policy
	 	 	1/1/2006	 	 	Inpatient
	Pharmacy Co-pay ($2 Per Brand Prescription)
	 	 	1/1/2006	 	 	Pharmacy
	Dental Co-pay ($3 Per Date of Service)
	 	 	1/1/2006	 	 	Dental
	Vision Exam Co-Pay ($2 Per Exam)
	 	 	1/1/2006	 	 	Vision / Optometric
	Vision Hardware Co-Pay ($1 Per Item)
	 	 	1/1/2006	 	 	Vision / Optometric
	ER Co-Pay ($3 Per Non-Emergency Visit)
	 	 	1/1/2006	 	 	Emergency Room
	Dental Benefit Reduction
	 	 	1/1/2006	 	 	Dental

d. Third-Party Liability

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

e. Fraud and Abuse

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

 

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

 

 

			
	
	 	Mr. Jon Barley, Ph.D.

December 12, 2007

Page 8

FINAL and CONFIDENTIAL

f. Gross Adjustments

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

g. Non-State Plan Services

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

h. Trends/Inflation to CY 2006

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

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

i. Blend Base Experience Years

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

j. Managed Care Adjustments

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

Utilization

Milliman adjusted the FFS utilization and cost per service to reflect the managed care environment.
After reviewing utilization benchmarks in the Milliman Medicaid Guidelines (Guidelines) as well as
other

 

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

 

 

			
	
	 	Mr. Jon Barley, Ph.D.

December 12, 2007

Page 9

FINAL and CONFIDENTIAL

sources, Milliman calculated percentage adjustments to reflect the utilization differential between
an economic and efficiently managed plan and the FFS base experience.

Cost Per Service

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

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

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

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

a. Trend to CY 2008

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

b. Prospective Program Adjustments

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

 

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

 

 

			
	
	 	Mr. Jon Barley, Ph.D.

December 12, 2007

Page 10

FINAL and CONFIDENTIAL

Table 5

STATE OF OHIO

DEPARTMENT OF JOB AND FAMILY SERVICES

Prospective Program Adjustments

	 	 	 	 	 	 	 	 	 
	 	 	Effective	 	 
	Program Adjustment	 	Date	 	Service Category(s)
	Nursing Facility Fee Increase
	 	 	7/1/2007	 	 	Nursing Facility
	 
	 	 	7/1/2008	 	 	 	 	 
	Chiropractor Benefit Restoration
	 	 	1/1/2008	 	 	Miscellaneous Services
	Independent Psychologists Benefit Restoration
	 	 	1/1/2008	 	 	Mental Health / Substance Abuse
	Occupational Therapy-Independent Provider Status
	 	 	1/1/2008	 	 	Miscellaneous Services
	Improved TPL Management
	 	 	1/1/2008	 	 	All Service Categories
	Prior Authorization Policy Change
	 	 	1/1/2008	 	 	Pharmacy
	Prior Authorization of Atypical Anti-Psychotic Medication
	 	 	1/1/2008	 	 	Pharmacy

c. Prospective Selection Adjustment

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

Table 6

STATE OF OHIO

DEPARTMENT OF JOB AND FAMILY SERVICES

Prospective Selection Adjustments

	 	 	 	 	 	 	 	 	 
	 	 	June 2007 MC	 	Target MC
	Region	 	Penetration	 	Penetration
	Central
	 	 	89.5	%	 	 	93	%
	East Central
	 	 	88.8	%	 	 	93	%
	Northeast
	 	 	89.7	%	 	 	93	%
	Northeast Central
	 	 	0.0	%	 	 	93	%
	Northwest
	 	 	87.6	%	 	 	93	%
	Southeast
	 	 	92.3	%	 	 	93	%
	Southwest
	 	 	86.0	%	 	 	93	%
	West Central
	 	 	87.7	%	 	 	93	%

 

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

 

 

			
	
	 	Mr. Jon Barley, Ph.D.

December 12, 2007

Page 11

FINAL and CONFIDENTIAL

d. Administrative Allowance

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

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

Table 7

STATE OF OHIO

DEPARTMENT OF JOB AND FAMILY SERVICES

Administrative Cost Allowance

	 	 	 	 	 	 	 	 	 	 	 	 	 
	Plan Year	 	Guaranteed %	 	At-Risk %	 	Total %
	Plan Year 1 (1-12 Months)

	 	 	11.5	%	 	 	0.0	%	 	 	11.5	%
	Plan Year 2 (13-24 Months)

	 	 	10.5	%	 	 	0.0	%	 	 	10.5	%
	Plan Year 3 (25 + Months)

	 	 	9.5	%	 	 	1.0	%	 	 	10.5	%

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

e. Franchise Fee

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

 

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

 

 

			
	
	 	Mr. Jon Barley, Ph.D.

December 12, 2007

Page 12

FINAL and CONFIDENTIAL

VI. CDPS RISK ADJUSTMENT

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

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

DATA RELIANCE

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

                    
   u  
 u  
 u  
 u  
                    

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

Sincerely,

Robert M. Damler, FSA, MAAA

Principal and Consulting Actuary

RMD/mle

cc: Dan Hecht (ODJFS)

     Mitali Ghatak (ODJFS)

     Robert Monks (ODJFS)

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

 

 

			
	
	 	FINAL and CONFIDENTIAL

APPENDIX 1

 

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

 

 

FINAL and CONFIDENTIAL

	SFY 2005/2006 Fee For Service

	incomplete Data
Adjustments (Service
Category)

	Historical Program
Adjustments (Service
Category)

	Trend to CY 2006 Adjustments

	(Service Category)

	Blend Base Years

	CY 2006 Utilization, Cost Per Service., and Per Member Per Month

	Blended CY 2006 Fee For Service

	Managed Care Adjustments
(Region. Service
Category)

	Prospective Program
Adjustments (Service
Category)

	Trend
to CY 2008
Adjustments (Service
Category)

	CY 2008 Utilization, Cost Per Service, and Per Member Per Month

	Administrative Cost Allowance

	Franchise Fee

	CY 2008 Base Capitation Rates

	C’DPS Risk Adjustment

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

 

 

			
	
	 	FINAL and CONFIDENTIAL

APPENDIX 2

 

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

 

 

			
	
	 	FINAL and CONFIDENTIAL

STATE OF OHIO

DEPARTMENT OF JOB AND FAMILY SERVICES

Aged, Blind, or Disabled — CY 2008 Capitation Rates

Actuarial Certification

I, Robert M. Damler, am a Principal and Consulting Actuary with the firm of Milliman, Inc. I am a
Fellow of the Society of Actuaries and a Member of the American Academy of Actuaries. I was
retained by the State of Ohio, Department of Job and Family Services to perform an actuarial
review and certification regarding the development of the capitation rates to be effective for
calendar year 2008. The capitation rates were developed for the Aged, Blind, or Disabled managed
care eligible populations. I have experience in the examination of financial calculations for
Medicaid programs and meet the qualification standards for rendering this opinion.

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

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

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

	 	•	 	the capitation rates have been developed in accordance with generally accepted
actuarial principles and practices;
	 
	 	•	 	the capitation rates are appropriate for the populations to be covered, and the
services to be furnished under the contract; and,
	 
	 	•	 	the capitation rates meet the requirements of 42 CFR 438.6(c).

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

Robert M. Damler, FSA                                    

Member, American Academy of Actuaries

December 4,
2007                                                

Date

 

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

 

 

			
	
	 	FINAL and CONFIDENTIAL

APPENDIX 3

 
 

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

 

 

FINAL AND CONFIDENTIAL

State of Ohio

Department of Job and Family Services

CY2008 ABD Capitation Rate Development

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	Projected CY	 	CY 2008	 	 	 	 
	 	 	2008 Member	 	Guaranteed	 	CY 2008 At	 	 
	Region	 	Months	 	Rate	 	Risk Rate	 	CY 2008 Rate
	Central
	 	 	284,169	 	 	$	1,101.26	 	 	$	10.62	 	 	$	1,111.88	 
	East Central
	 	 	149,045	 	 	 	1,091.21	 	 	 	10.52	 	 	 	1,101.73	 
	Northeast
	 	 	287,103	 	 	 	1,099.46	 	 	 	10.60	 	 	 	1,110.06	 
	Northeast
Central
	 	 	85,309	 	 	 	1,098.34	 	 	 	10.59	 	 	 	1,108.93	 
	Northwest
	 	 	137,407	 	 	 	1,107.94	 	 	 	10.68	 	 	 	1,118.62	 
	Southeast
	 	 	152,735	 	 	 	981.68	 	 	 	9.47	 	 	 	991.15	 
	Southwest
	 	 	174,390	 	 	 	1,120.61	 	 	 	10.80	 	 	 	1,131.41	 
	West Central
	 	 	123,260	 	 	 	1,133.13	 	 	 	10.93	 	 	 	1,144.06	 
	Statewide
	 	 	1,393,418	 	 	$	1,092.43	 	 	$	10.53	 	 	$	1,102.96	 

	 	 	 	 	 
	Appendix 3	 	Milliman, Inc.	 	Page 1

 

 

Appendix F

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

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

MCP: Molina Healthcare of Ohio, Inc.

	 	 	 	 	 
	Service	 	 	 	 
	Enrollment	 	Risk Adjusted	 	At-Risk
	Area	 	Rate	 	Amounts
	Central Region

	 	$1,057.00
	 	$0.00
	Southeast Region
	 	$962.08
	 	$0.00
	Southwest Region
	 	$1,075.63
	 	$0.00
	West Central
	 	$1,094.20
	 	$0.00

List of Eligible Assistance Groups (AGs)

	 	 	 
	Aged, Blind or Disabled:

	 	MA-A Aged
	 

	 	MA-B Blind
	 

	 	MA-D Disabled

 

 

Appendix G

Aged, Blind or Disabled (ABD) population

Page 1

APPENDIX G

COVERAGE AND SERVICES

ABD ELIGIBLE POPULATION

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

	 	•	 	Inpatient hospital services
	 
	 	•	 	Outpatient hospital services
	 
	 	•	 	Rural health clinics (RHCs) and Federally qualified health centers (FQHCs)
	 
	 	•	 	Physician services whether furnished in the physician’s office,
the covered person’s home, a hospital, or elsewhere
	 
	 	•	 	Laboratory and x-ray services
	 
	 	•	 	Family planning services and supplies
	 
	 	•	 	Home health and private duty nursing services
	 
	 	•	 	Podiatry
	 
	 	•	 	Physical therapy, occupational therapy, and speech therapy
	 
	 	•	 	Nurse-midwife, certified family nurse practitioner, and
certified pediatric nurse practitioner services
	 
	 	•	 	Prescription drugs
	 
	 	•	 	Ambulance and ambulette services
	 
	 	•	 	Dental services
	 
	 	•	 	Durable medical equipment and medical supplies
	 
	 	•	 	Vision care services, including eyeglasses

 

 

Appendix G

Aged, Blind or Disabled (ABD) population

Page 2

	 	•	 	Nursing facility stays as specified in OAC rule 5101:3-26-03
	 
	 	•	 	Hospice care
	 
	 	•	 	Behavioral health services (see section G.2.b.iii of this appendix)
	 
	 	•	 	Chiropractic services

	2.	 	Exclusions, Limitations and Clarifications

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

	 	•	 	Services or supplies that are not medically necessary
	 
	 	•	 	Experimental services and
procedures, including drugs and equipment, not covered by
Medicaid
	 
	 	•	 	Organ transplants that are not covered by Medicaid
	 
	 	•	 	Abortions, except in the case of a
reported rape, incest, or when medically necessary to save the life
of the mother
	 
	 	•	 	Infertility services for males or females
	 
	 	•	 	Voluntary sterilization if under 21 years
of age or legally incapable of consenting to the procedure
	 
	 	•	 	Reversal of voluntary sterilization procedures
	 
	 	•	 	Plastic or cosmetic surgery that is not medically necessary*
	 
	 	•	 	Immunizations for travel outside of the United States
	 
	 	•	 	Services for the treatment of obesity unless medically necessary*
	 
	 	•	 	Custodial or supportive care not covered by Medicaid
	 
	 	•	 	Sex change surgery and related services
	 
	 	•	 	Sexual or marriage counseling

 

 

Appendix G

Aged, Blind or Disabled (ABD) population

Page 3

	 	•	 	Acupuncture and biofeedback services
	 
	 	•	 	Services to find cause of death (autopsy)
	 
	 	•	 	Comfort items in the hospital (e.g., TV or phone)
	 
	 	•	 	Paternity testing

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

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

	 	b.	 	Limitations & Clarifications

	 	i.	 	Member Cost-Sharing
	 
	 	 	 	As specified in OAC rules 5101:3-26-05(D) and 5101:3-26-12, MCPs are
permitted to impose the applicable member co-payment amount(s) for
dental services, vision services, non-emergency emergency department
services, or prescription drugs, other than generic drugs. MCPs must
notify ODJFS if they intend to impose a co-payment. ODJFS must
approve the notice to be sent to the MCP’s members and the timing of
when the co-payments will begin to be imposed. If ODJFS determines
that an MCP’s decision to impose a particular co-payment on their
members would constitute a significant change for those members,
ODJFS may require the effective date of the co-payment to coincide
with the “Open Enrollment” month.
	 
	 	 	 	Notwithstanding the preceding paragraph, MCPs must provide an
ODJFS-approved notice to all their members 90 days in advance of the
date that the MCP will impose the co-payment. With the exception of
member co-payments the MCP has elected to implement in accordance
with OAC rules 5101:3-26-05(D) and 5101:3-26-12, the MCP’s payment
constitutes payment in full for any covered services and their
subcontractors must not charge members or ODJFS any additional
co-payment, cost sharing, down-payment, or similar charge, refundable
or otherwise.

 

 

Appendix G

Aged, Blind or Disabled (ABD) population

Page 4

	 	ii.	 	Abortion and Sterilization
	 
	 	 	 	The use of federal funds to pay for abortion and sterilization
services is prohibited unless the specific criteria found in 42 CFR
441 and OAC rules 5101:3-17-01 and 5101:3-21-01 are met. MCPs must
verify that all of the information on the required forms (JFS 03197,
03198, and 03199) is provided and that the service meets the
required criteria before any such claim is paid.
	 
	 	 	 	Additionally, payment must not be made for associated services such
as anesthesia, laboratory tests, or hospital services if the abortion
or sterilization itself does not qualify for payment. MCPs are
responsible for educating their providers on the requirements;
implementing internal procedures including systems edits to ensure
that claims are only paid once the MCP has determined if the
applicable forms are completed and the required criteria are met, as
confirmed by the appropriate certification/consent forms; and for
maintaining documentation to justify any such claim payments.
	 
	 	iii.	 	Behavioral Health Services
	 
	 	 	 	Coordination of Services: MCPs must have a process to
coordinate benefits of and referrals to the publicly funded community
behavioral health system. MCPs must ensure that members have access
to all medically-necessary behavioral health services covered by the
Ohio Medicaid FFS program and are responsible for coordinating those
services with other medical and support services. MCPs must notify
members via the member handbook and provider directory of where and
how to access behavioral health services, including the ability to
self-refer to mental health services offered through ODMH community
mental health centers (CMHCs) as well as substance abuse services
offered through Ohio Department of Alcohol and Drug Addiction
Services (ODADAS)-certified Medicaid providers. Pursuant to ORC
Section 5111.16, alcohol, drug addiction and mental health services
covered by Medicaid are not to be paid by the managed care program
when the nonfederal share of the cost of those services is provided
by a board of alcohol, drug addiction, and mental health services or
a state agency other than ODJFS. MCPs are also not responsible for
providing mental health services to persons between 22 and 64 years
of age while residing in an institution for mental disease (IMD) as
defined in Section 1905(i) of the Social Security Act.
	 
	 	 	 	MCPs must provide Medicaid-covered behavioral health services for
members who are unable to timely access services or unwilling

 

 

Appendix G

Aged, Blind or Disabled (ABD) population

Page 5

	 	 	 	to access services through community providers.
	 
	 	 	 	Mental Health Services: There are a number of
Medicaid-covered mental health (MH) services available through ODMH
CMHCs.
	 
	 	 	 	Where an MCP is responsible for providing MH services for their
members, the MCP is responsible for ensuring access to counseling and
psychotherapy, physician/psychiatrist services, outpatient clinic
services, general hospital outpatient psychiatric services,
pre-hospitalization screening, diagnostic assessment (clinical
evaluation), crisis intervention, psychiatric hospitalization in
general hospitals (for all ages), and Medicaid-covered prescription
drugs and laboratory services. MCPs are not required to cover partial
hospitalization, or inpatient psychiatric care in a private or public
free-standing psychiatric hospital. However, MCPs are required to
cover the payment of physician services in a private or public
free-standing psychiatric hospital when such services are billed
independent of the hospital.
	 
	 	 	 	Substance Abuse Services: There are a number of
Medicaid-covered substance abuse services available through
ODADAS-certified Medicaid providers.
	 
	 	 	 	Where an MCP is responsible for providing substance abuse services
for their members, the MCP is responsible for ensuring access to
alcohol and other drug (AOD) urinalysis screening, assessment,
counseling, physician/psychiatrist AOD treatment services, outpatient
clinic AOD treatment services, general hospital outpatient AOD
treatment services, crisis intervention, inpatient detoxification
services in a general hospital, and Medicaid-covered prescription
drugs and laboratory services. MCPs are not required to cover
outpatient detoxification and methadone maintenance.
	 
	 	 	 	Financial Responsibility for Behavioral Health Services:
MCPs are responsible for the following:

	 	•	 	payment of
Medicaid-covered prescription drugs prescribed by an ODMH
CMHC or ODADAS-certified provider when obtained through an
MCP’s panel pharmacy;
	 
	 	•	 	payment of
Medicaid-covered services provided by an MCP’s panel
laboratory when referred by an ODMH CMHC or
ODADAS-certified provider;
	 
	 	•	 	payment of all other
Medicaid-covered behavioral health services obtained through
providers other than those who are ODMH CMHCs or
ODADAS-certified providers when

 

 

Appendix G

Aged, Blind or Disabled (ABD) population

Page 6

	 	 	 	arranged/authorized by the MCP.

	 	 	 	Limitations:

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

	 	•	 	MCPs are
not responsible for paying for behavioral health
services provided through ODMH CMHCs and
ODADAS-certified Medicaid providers;
	 
	 	•	 	MCPs are
not responsible for payment of partial
hospitalization (mental health), inpatient
psychiatric care in a private or public
free-standing inpatient psychiatric hospital,
outpatient detoxification, intensive outpatient
programs (IOP) (substance abuse) or methadone
maintenance.
	 
	 	•	 	However,
MCPs are required to cover the payment of physician
services in a private or public free-standing
psychiatric hospital when such services are billed
independent of the hospital.

	 	iv.	 	Pharmacy Benefit: In providing the
Medicaid pharmacy benefit to their members, MCPs must cover the same
drugs covered by the Ohio Medicaid fee-for-service program.
	 
	 	 	 	MCPs may establish a preferred drug list for members and providers
which includes a listing of the drugs that they prefer to have
prescribed. Preferred drugs requiring prior authorization approval
must be clearly indicated as such. Pursuant to ORC §5111.172, ODJFS
may approve MCP-specific pharmacy program utilization management
strategies (see appendix G.3.a).
	 
	 	v.	 	Organ Transplants: MCPs must ensure
coverage for organ transplants and related services in accordance with
OAC 5101-3-2-07.1 (B)(4)&(5). Coverage for all organ transplant
services, except kidney transplants, is contingent upon review and
recommendation by the “Ohio Solid Organ Transplant Consortium” based
on criteria established by Ohio organ transplant surgeons and
authorization from the ODJFS prior authorization unit. Reimbursement
for bone marrow transplant and hematapoietic stem cell transplant
services, as defined in OAC 3701:84-01, is contingent upon review
and recommendation by the “Ohio

 

 

Appendix G

Aged, Blind or Disabled (ABD) population

Page 7

	 	 	 	Hematapoietic Stem Cell Transplant Consortium” again based on
criteria established by Ohio experts in the field of bone marrow
transplant. While MCPs may require prior authorization for these
transplant services, the approval criteria would be limited to
confirming the consumer is being considered and/or has been
recommended for a transplant by either consortium and authorized by
ODJFS. Additionally, in accordance with OAC 5101:3-2-03 (A)(4) all
services related to organ donations are covered for the donor
recipient when the consumer is Medicaid eligible.

	 	3.	 	Care Coordination

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

	 	i.	 	Pharmacy Programs — Pursuant to ORC Sec. 5111.172 and OAC
rule 5101:3-26-03(A) and (B), MCPs may, subject to ODJFS
prior-approval, implement strategies for the management of pharmacy
utilization. Pharmacy utilization management strategies may include
developing preferred drug lists, requiring prior authorization for
certain drugs, placing limitations on the type of provider and
locations where certain medications may be administered, and
developing and implementing a specialized pharmacy program to address
the utilization of controlled substances, as defined in section
3719.01 of the Ohio Revised Code.
	 
	 	 	 	Drug Prior Authorizations: MCPs must receive prior approval
from ODJFS for the medications that they wish to cover through prior
authorization. MCPs must establish their prior authorization system
so that it does not unnecessarily impede member access to
medically-necessary Medicaid-covered services. As outlined in
paragraph 29(i)(ii)(f) of Appendix C, MCPs must adhere to specific
prior-authorization limitations to assist with the transition of new
ABD members from FFS Medicaid. MCPs must make their approved list of
drugs covered only with prior authorization available to members and
providers, as outlined in paragraphs 36(b) and (c) of Appendix C.

 

 

Appendix G

Aged, Blind or Disabled (ABD) population

Page 8

	 	 	 	Beginning January 1, 2008, MCPs may require prior authorization for
the coverage of antipsychotic drugs with ODJFS approval. MCPs must,
however, allow any member to continue receiving a specific
antipsychotic drug if the member is stabilized on that particular
medication. The MCP must continue to cover that specific drug for the
stabilized member for as long as that medication continues to be
effective for the member. MCPs may also implement a drug utilization
review program designed to promote the appropriate clinical
prescribing of antipsychotic drugs. This can be accomplished through
the MCP’s retrospective analysis of drug claims to identify potential
inappropriate use and provide education to those providers who are
outliers to acceptable standards for prescribing/dispensing
antipsychotic drugs.
	 
	 	 	 	MCPs must comply with the provisions of 1927(d)(5) of the Social
Security Act, 42 USC 1396r-8(k)(3), and OAC rule 5101:3-26-03.1
regarding the timeframes for prior authorization of covered outpatient
drugs.
	 
	 	 	 	Controlled Substances and Member Management Programs: MCPs may
also, with ODJFS prior approval, develop and implement Controlled
Substances and Member Management (CSMM) programs designed to address
use of controlled substances. Utilization management strategies may
include prior authorization as a condition of obtaining a controlled
substance, as defined in section 3719.01 of the Ohio Revised Code.
CSMM strategies may also include processes for requiring MCP members
at high risk for fraud or abuse involving controlled substances to
have their narcotic medications prescribed by a designated
provider/providers and filled by a pharmacy, medical provider, or
health care facility designated by the program.
	 
	 	ii.	 	Emergency Department Diversion
(EDD) — MCPs must provide access to services in a way that assures
access to primary, specialist and urgent care in the most appropriate
settings and that minimizes frequent, preventable utilization of
emergency department (ED) services. OAC rule 5101:3-26-03.1(A)(7)(d)
requires MCPs to implement the ODJFS-required emergency department
diversion (EDD) program for frequent utilizers.

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

 

 

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	 	 	 	access, quality or care management approaches.
	 
	 	 	 	Although there is often an assumption that frequent ED visits are solely the
result of a preference on the part of the member and education is therefore
the standard remedy, it is also important to ensure that a member’s frequent
ED utilization is not due to problems such as their PCP’s lack of
accessibility or failure to make appropriate specialist referrals. The MCP’s
EDD program must therefore also include the identification of providers who
serve as PCPs for a substantial number of frequent ED utilizers and the
implementation of corrective action with these providers as so indicated.
	 
	 	 	 	This requirement does not replace the MCP’s responsibility to inform and
educate all members regarding the appropriate use of the ED.
	 
	 	 	 	MCPs must also implement the ODJFS-required emergency department diversion
(EDD) program for frequent users. In that ODJFS has developed the
parameters for an MCP’s EDD program, it therefore does not require ODJFS
prior approval (Moved).
	 
	 	b.	 	Integration of Member Care
	 
	 	 	 	The MCP must ensure that a discharge plan is in place to meet a member’s
health care needs following discharge from a nursing facility, and
integrated into the member’s continuum of care. The discharge plan must
address the services to be provided for the member and must be developed
prior to the date of discharge from the nursing facility. The MCP must
ensure follow-up contact occurs with the member, or authorized
representative, within thirty (30) days of the member’s discharge from the
nursing facility to ensure that the member’s health care needs are being
met.
	 
	 	c.	 	Care Coordination with ODJFS-Designated Providers
	 
	 	 	 	Per OAC rule 5101:3-26-03.1(A)(4), MCPs are required to share specific
information with certain ODJFS-designated non-contracting providers in order
to ensure that these providers have been supplied with specific information
needed to coordinate care for the MCP’s members. Within the first month of
operation, after an MCP has obtained a provider agreement, the MCP must
provide to the ODJFS-designated providers (i.e., ODMH Community Mental
Health Centers, ODADAS-certified Medicaid providers, FQHCs/RHCs, QFPPs,
CNMs, CNPs [if applicable], and hospitals) a quick reference information
packet which includes the following:

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

 

 

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

	 	•	 	Claims submission information
including the MCP’s Medicaid provider number for each region;
	 
	 	•	 	The MCP’s prior authorization and
referral procedures or the MCP’s website;
	 
	 	•	 	A picture of the MCP’s member identification card (front and back);
	 
	 	•	 	Contact numbers and/or website location
for obtaining information for eligibility verification, claims
processing, referrals/prior authorization, and information
regarding the MCP’s behavioral health administrator;
	 
	 	•	 	A listing of the MCP’s major
pharmacy chains and the contact number for the MCP’s pharmacy
benefit administrator (PBM);
	 
	 	•	 	A listing of the MCP’s laboratories and radiology providers; and
	 
	 	•	 	A listing of the MCP’s contracting
behavioral health providers and how to access services through them
(this information is only to be provided to non-contracting
community mental health and substance abuse providers).

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

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

 

 

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	 	a.	 	Each MCP must inform all members and contracting providers of the MCP’s case
management services.
	 
	 	b.	 	The MCP must assure and coordinate the placement of the member into case
management — including identification of the member’s need for case management
services, completion of the comprehensive health needs assessment, and timely
development of a care treatment plan. This process must occur within the
following timeframes for:
	 
	 	 	 	i.   newly enrolled members – 90 days from the effective date of enrollment; and
	 
	 	 	 	ii.  existing members – 90 days from identifying their need for case management.
	 
	 	c.	 	The MCP’s comprehensive case management program must include, at a
minimum, the following components:

	 	i.	 	Identification –
	 
	 	 	 	The MCP must have mechanisms in place to identify members potentially eligible for
case management services. These mechanisms must include an administrative data
review (e.g. diagnosis, cost threshold, and/or service utilization) and may also
include telephone interviews; provider/self-referrals; information as reported by
the Managed Care Enrollment Center (MCEC) during membership selection; or home
visits.
	 
	 	ii.	 	Assessment -
	 
	 	 	 	The MCP must arrange for or conduct a comprehensive assessment of the member’s
physical and/or behavioral health condition(s) to confirm the results of a positive
identification, and to determine the need for case management services. The goals of
the assessment are to identify the member’s existing and/or potential health care
needs and assess the member’s need for case management services.
	 
	 	 	 	The assessment must be completed by a physician, physician assistant, RN, LPN,
licensed social worker, or a graduate of a two or four year allied health program.
If the assessment is completed by another medical professional, there should be
oversight and monitoring by either a registered nurse or a physician.
	 
	 	 	 	The MCP must have a process to inform members and their PCPs that they have been
identified as meeting the criteria for case management, including their enrollment
into case management services.
	 
	 	 	 	The MCP must develop a strategy to assign members to risk stratification levels,
based on the member’s comprehensive needs assessment.
	 
	 	iii.	 	Care Treatment Plan –
	 
	 	 	 	The care treatment plan is defined by ODJFS as the one developed by the MCP for the
member.

 

 

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	 	 	 	The development of the care treatment plan must be based on the comprehensive health
assessment and reflect the member’s primary medical diagnosis and health conditions,
any comorbidities, and the member’s psychological, behavioral health and community
support needs. The care treatment plan must also include specific provisions for
periodic reviews (i.e., no less than semi-annually) of the member’s condition and
appropriate updates to the plan. The member and the member’s PCP must be actively
involved in the development of and revisions to the care treatment plan. The
designated PCP is the provider, or specialist, who will manage and coordinate the
overall care for the member. Ongoing communication regarding the status of the care
treatment plan may be accomplished between the MCP and the PCP’s designee (i.e.,
qualified health professional). Revisions to the clinical portion of the care
treatment plan should be completed in consultation with the PCP.
	 
	 	 	 	The elements of a comprehensive care treatment plan include:
	 
	 	 	 	Goals and actions that address medical, social, behavioral and psychological
needs;
	 
	 	 	 	Member level interventions, (i.e., referrals and making appointments) that
assist members in obtaining services, providers and programs;
	 
	 	 	 	Continuous review, revision and contact follow-up, as needed, to ensure the care
treatment plan is adequately monitored including the following:

	 	•	 	Documentation that services are provided in accordance
with the care treatment plan;
	 
	 	•	 	Re-evaluation to determine if the care treatment plan is
adequate to meet the member’s current needs;
	 
	 	•	 	Identification of gaps between recommended care and actual care provided;
	 
	 	•	 	A change in needs or status from the re-evaluation that
requires revisions to the care treatment plan;
	 
	 	•	 	Active participation by the member or representative in the
care treatment plan development;
	 
	 	•	 	Monitoring of specific service delivery including service utilization; and
	 
	 	•	 	Re-evaluation of a member’s risk stratification level with
adjustment to the level of case management services provided.

	 	iv.	 	Coordination of Care and Communication
	 
	 	 	 	There should be an accountable point of contact at the MCP for each member in case
management who can help obtain medically necessary care, assist with health-related
services and coordinate care needs, including behavioral health. The MCP must
arrange or provide for professional case management services that are performed
collaboratively by a team of professionals appropriate for the member’s condition
and health care needs. At a minimum, the MCP’s case manager must attempt to
coordinate with the member’s case manager from other

 

 

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	 	 	 	health systems, including behavioral health. The MCP must have a process to
facilitate, maintain, and coordinate both care and communication with the member,
PCP, and other service providers and case managers. The MCP must also have a process
to coordinate care for a member that is receiving services from state sub-recipient
agencies as appropriate [e.g., the Ohio Department of Mental Health (ODMH); the Ohio
Department of Mental Retardation and Developmental Disabilities (ODMR/DD); and the
Ohio Department of Alcohol and Drug Addiction Services (ODADAS)].
	 
	 	 	 	The MCP must have a provision to disseminate information to the member/caregiver
concerning the health condition, types of services that may be available, and how to
access services.
	 
	 	 	 	The MCP must implement mechanisms to notify all Members with Special Health Care
Needs of their right to directly access a specialist. Such access may be assured
through, for example, a standing referral or an approved number of visits, and
documented in the care treatment plan.
	 
	 	v.	 	ODJFS Targeted Case Management Conditions
	 
	 	 	 	The MCP must, at a minimum, case manage members with the following physical
and behavioral health conditions:

	 	•	 	Congestive Heart Failure
	 
	 	•	 	Coronary Artery Disease
	 
	 	•	 	Non-Mild Hypertension
	 
	 	•	 	Diabetes
	 
	 	•	 	Chronic Obstructive Pulmonary Disease
	 
	 	•	 	Asthma
	 
	 	•	 	Severe mental illness
	 
	 	•	 	High risk or high cost substance abuse disorders
	 
	 	•	 	Severe cognitive and/or developmental limitation

	 	 	 	The MCP must also case manage any member enrolled in an MCP’s CSMM as specified in
section G(3)(a)(i).
	 
	 	 	 	The MCP should also focus on all members whose health conditions warrant case
management services and should not limit these services only to members with these
conditions (e.g., cystic fibrosis, cerebral palsy and sickle cell anemia).
	 
	 	 	 	Refer to Appendix M for the performance measures and standards related to case
management.
	 
	 	vi.	 	Case Management Program Staffing
	 
	 	 	 	The MCP must identify the staff that will be involved in the operations of the case
management program, including but not limited to: case manager supervisors, case
managers, and administrative support staff. The MCP must identify the role and
functions of each case management staff member as well as the educational

 

 

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	 	 	 	requirements, clinical licensure standards, certification and relevant experience
with case management standards and/or activities. The MCP must provide case manager
staff/member ratios based on the member risk stratification and different levels of
care being provided to members.
	 
	 	vii.	 	Case Management Strategies
	 
	 	 	 	The MCP must follow best-practice and/or evidence based clinical guidelines when
devising a member’s care treatment plan and coordinating the case management needs.
If an MCP uses a disease management methodology to identify and/or stratify members
in need of case management services, the methods must be validated by scientific
research and/or nationally accepted in the health care industry.
	 
	 	 	 	The MCP must develop and implement mechanisms to educate and equip providers
and case managers with evidence-based clinical guidelines or best practice
approaches to assist in providing a high level of quality of care to members.
	 
	 	viii.	 	Information Technology System for Case Management
	 
	 	 	 	The MCP’s information technology system for its case management program must
maximize the opportunity for communication between the plan, PCP, the member, and
other service providers and case managers. The MCP must have an integrated database
that allows MCP staff that may be contacted by a member in case management to have
immediate access to, and review of, the most recent information with the MCP’s
information systems relevant to the case. The integrated database may include the
following: administrative data, call center communications, service authorizations,
care treatment plans, patient assessments, case management notes, and PCP notes. The
information technology system must also have the capability to share relevant
information with the member, the PCP, and other service providers and case managers.
	 
	 	ix.	 	Data Submission

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

	 	d.	 	Annual Case Management Program Submission
	 
	 	 	 	The MCP must have an ODJFS-approved case management program which includes the items
in Section 4. Each MCP must implement an evaluation process

 

 

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to review, revise and/or update the case management program. The MCP must annually
submit its case management program for review and approval by ODJFS. Any subsequent
changes to an approved case management program description must be submitted to
ODJFS in writing for review and approval prior to implementation.

 

 

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APPENDIX H

PROVIDER PANEL SPECIFICATIONS

ABD ELIGIBLE POPULATION

	1. GENERAL PROVISIONS 

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

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

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

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

	2. PROVIDER SUBCONTRACTING

Unless otherwise specified in this appendix or OAC rule 5101:3-26-05, all MCPs are required to
enter into fully-executed subcontracts with their providers. These subcontracts must include a
baseline contractual agreement, as well as the appropriate ODJFS-approved Model Medicaid Addendum.
The Model Medicaid Addendum incorporates all applicable Ohio

 

 

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

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

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

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

	3. PROVIDER PANEL REQUIREMENTS 

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

	a. Primary Care Providers (PCPs)	 	

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

 

 

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capacity-by-site requirement must be met for all ODJFS-approved PCPs.

ODJFS reviews the capacity totals for each PCP to determine if they appear excessive. 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). ODJFS may allow up to
an additional 750 member capacity for each nurse practitioner or physician’s assistant that is used
to provide clinical support for a PCP.

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

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

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

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

	b. Non-PCP Provider Network 

In addition to the PCP capacity requirements, each MCP is also required to maintain adequate
capacity in the remainder of its provider network within the following categories: hospitals,

 

 

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cardiovascular, dentists, gastroenterology, nephrology, neurology, oncology, physical medicine,
podiatry, psychiatry, urology, vision care providers, obstetricians/gynecologists (OB/GYNs),
allergists, general surgeons, otolaryngologists, orthopedists, federally qualified health centers
(FQHCs)/rural health centers (RHCs) and qualified family planning providers (QFPPs). CNMs, CNPs,
FQHCs/RHCs and QFPPs are federally-required provider types.

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

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

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

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

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

 

 

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

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

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

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

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

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

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

 

 

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Aged, Blind or Disabled (ABD) population

Page 6

	 	•	 	MCPs must provide expedited reimbursement on a service-specific basis in an
amount no less than the payment made to other providers for the same or similar
service.
	 
	 	•	 	If the MCP has no comparable service-specific rate structure, the MCP must
use the regular Medicaid fee-for-service payment schedule for non-FQHC/RHC providers.
	 
	 	•	 	MCPs must make all efforts to pay FQHCs/RHCs as quickly as possible and not
just attempt to pay these claims within the prompt pay time frames.

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

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

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

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

 

 

Appendix H

Aged, Blind or Disabled (ABD) population

Page 7

under contract with the MCP in the region can be submitted to the PVS, or other system, count
towards MCP minimum panel requirements, and be listed in the MCPs’ provider directory.

	4. PROVIDER PANEL EXCEPTIONS 

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

	 	-	 	the MCP presents sufficient documentation to ODJFS to verify that they have been unable
to meet or maintain certain provider panel requirements in a particular service area
despite all reasonable efforts on their part to secure such a contract(s), and
	 
	 	-	 	if notified by ODJFS, the provider(s) in question fails to provide a reasonable argument
why they would not contract with the MCP, and
	 
	 	-	 	the MCP presents sufficient assurances to ODJFS that their members will have adequate access
to the services in question.

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

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

	5. PROVIDER DIRECTORIES 

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

 

 

Appendix H

Aged, Blind or Disabled (ABD) population

Page 8

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

The directory must also specify:

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

Printed Provider Directory 

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

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

Internet Provider Directory

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

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

 

 

Appendix H

Aged, Blind or Disabled (ABD) population

Page 9

being deleted from the MCP’s panel must be deleted from the internet directory within one week of
notification from the provider to the MCP. These deleted providers must be included in the inserts
to the MCP’s provider directory referenced above.

	6. FEDERAL ACCESS STANDARDS 

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

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

	•	 	The anticipated Medicaid membership.
	 
	•	 	The expected utilization of services, taking into consideration the characteristics and
health care needs of specific Medicaid populations represented in the MCP.
	 
	•	 	The number and types (in terms of training, experience, and specialization) of panel
providers required to deliver the contracted Medicaid services.
	 
	•	 	The geographic location of panel providers and Medicaid members, considering distance, travel
time, the means of transportation ordinarily used by Medicaid members, and whether the
location provides physical access for Medicaid members with disabilities.
	 
	•	 	MCPs must adequately and timely cover services to an out-of-network provider if the MCP’s
contracted provider panel is unable to provide the services covered under the MCP’s provider
agreement. The MCP must cover the out-of-network services for as long as the MCP network is
unable to provide the services. MCPs must coordinate with the out-of-network provider with
respect to payment and ensure that the provider agrees with the applicable requirements.

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

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

 

 

Appendix H

Page 10

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

 

 

APPENDIX J

FINANCIAL PERFORMANCE

ABD ELIGIBLE POPULATION

Molina

	1.	 	SUBMISSION OF FINANCIAL STATEMENTS AND REPORTS
	 
	 	 	MCPs must submit the following financial reports to ODJFS:

	 	a.	 	The National Association of Insurance Commissioners (NAIC) quarterly and annual Health
Statements (hereafter referred to as the “Financial Statements”), as outlined in Ohio
Administrative Code (OAC) rule 5101:3-26-09(B). The Financial Statements must include all
required Health Statement filings, schedules and exhibits as stated in the NAIC Annual
Health Statement Instructions including, but not limited to, the following sections:
Assets, Liabilities, Capital and Surplus Account, Cash Flow, Analysis of Operations by
Lines of Business, Five-Year Historical Data, and the Exhibit of Premiums, Enrollment and
Utilization. The Financial Statements must be submitted to BMHC even if the
Ohio Department of Insurance (ODI) does not require the MCP to submit these
statements to ODI. A signed hard copy and an electronic copy of the reports in the
NAIC-approved format must both be provided to ODJFS;
	 
	 	b.	 	Hard copies of annual financial statements for those entities who have an ownership
interest totaling five percent or more in the MCP or an indirect interest of five percent
or more, or a combination of direct and indirect interest equal to five percent or more in
the MCP;
	 
	 	c.	 	Annual audited Financial Statements prepared by a licensed independent external auditor
as submitted to the ODI, as outlined in OAC rule 5101:3- 26-09(B);
	 
	 	d.	 	Medicaid Managed Care Plan Annual Ohio Department of Job and Family
Services (ODJFS) Cost Report and the auditor’s certification of the cost report, as
outlined in OAC rule 5101:3-26-09(B);
	 
	 	e.	 	Medicaid MCP Annual Restated Cost Report for the prior calendar year. The restated cost
report shall be audited upon BMHC request;
	 
	 	f.	 	Annual physician incentive plan disclosure statements and disclosure of and changes to
the MCP’s physician incentive plans, as outlined in OAC rule 5101:3-26-09(B);
	 
	 	g.	 	Reinsurance agreements, as outlined in OAC rule 5101:3-26-09(C);

 

 

Appendix J

Page 2

	 	h.	 	Prompt Pay Reports, in accordance with OAC rule 5101:3-26-09(B). A hard copy and an electronic
copy of the reports in the ODJFS-specified format must be provided to ODJFS;
	 
	 	i.	 	Notification of requests for information and copies of information released pursuant to a tort
action (i.e., third party recovery), as outlined in OAC rule 5101:3-26-09.1;
	 
	 	j.	 	Financial, utilization, and statistical reports, when ODJFS requests such reports, based on a
concern regarding the MCP’s quality of care, delivery of services, fiscal operations or solvency,
in accordance with OAC rule 5101:3-26-06(D);
	 
	 	k.	 	In accordance with ORC Section 5111.76 and Appendix C, MCP
Responsibilities, MCPs must submit ODJFS-specified franchise fee reports in hard copy
and electronic formats pursuant to ODJFS specifications.

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

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

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

	 
	 	 	 
	 

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

	 
	 	 	 
	 

	 	Standard:
	For the financial report that covers calendar year
2008, a minimum net worth per member of $172.00, as
determined from the annual
Financial Statement submitted to ODI and the ODJFS.

	 
	 	 	 
	 

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

 

 

Appendix J

Page 3

	 	 	 	 	 
	 

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

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

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

	b.	Indicator:
	 	Administrative Expense Ratio
	 
	 	 	 	 
	 

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

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

	c.	Indicator:
	 	Overall Expense Ratio
	 
	 	 	 	 
	 

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

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

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

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

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

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

 

 

Appendix J

Page 4

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

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

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

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

	 	 	 	 	 
	

	d.	Indicator:
	 	Days Cash on Hand
	 
	 	 	 	 
	 

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

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

	e.	Indicator:
	 	Ratio of Cash to Claims Payable
	 
	 	 	 	 
	 

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

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

 

 

Appendix J

Page 5

	3.	 	REINSURANCE REQUIREMENTS
	 
	 	 	Pursuant to the provisions of OAC rule 5101:3-26-09 (C), each MCP must carry reinsurance
coverage from a licensed commercial carrier to protect against inpatient-related medical
expenses incurred by Medicaid members.
	 
	 	 	The annual deductible or retention amount for such insurance must be specified in the
reinsurance agreement and must not exceed $75,000.00, except as provided below. Except for
transplant services, and as provided below, this reinsurance must cover, at a minimum, 80%
of inpatient costs incurred by one member in one year, in excess of $75,000.00.
	 
	 	 	For transplant services, the reinsurance must cover, at a minimum, 50% of inpatient
transplant related costs incurred by one member in one year, in excess of $75,000.00.
	 
	 	 	An MCP may request a higher deductible amount and/or that the reinsurance cover less than
80% of inpatient costs in excess of the deductible amount. If the MCP does not have more
than 75,000 members in Ohio, but does have more than 75,000 members between Ohio and other
states, ODJFS may consider alternate reinsurance arrangements. However, depending on the
corporate structures of the Medicaid MCP, other forms of security may be required in
addition to reinsurance. These other security tools may include parental guarantees,
letters of credit, or performance bonds. In determining whether or not the request will be
approved, the ODJFS may consider any or all of the following:

	 	a.	 	whether the MCP has sufficient reserves available to pay unexpected claims;
	 
	 	b.	 	the MCP’s history in complying with financial indicators 2.a., 2.b., and
2.c., as specified in this Appendix;
	 
	 	c.	 	the number of members covered by the MCP;
	 
	 	d.	 	how long the MCP has been covering Medicaid or other members on a full risk basis;
	 
	 	e.	 	risk based capital ratio of 2.5 or higher calculated from the last annual ODI
financial statement;
	 
	 	f.	 	graph/chart showing the claims history for reinsurance above the previously
approved deductible from the last calendar year.

	 	 	The MCP has been approved to have a reinsurance policy with a deductible amount of $400,000 that
covers 80% of inpatient costs in excess of the deductible amount for non-transplant services.

 

 

Appendix J

Page 6

	 	 	Penalty for noncompliance: If it is determined that an MCP failed to have reinsurance
coverage, that an MCP’s deductible exceeds $75,000.00 without approval from ODJFS, or that
the MCP’s reinsurance for non-transplant services covers less than 80% of inpatient costs
in excess of the deductible incurred by one member for one year without approval from
ODJFS, then the MCP will be required to pay a monetary penalty to ODJFS. The amount of the
penalty will be the difference between the estimated amount, as determined by ODJFS, of
what the MCP would have paid in premiums for the reinsurance policy if it had been in
compliance and what the MCP did actually pay while it was out of compliance plus 5%. For
example, if the MCP paid $3,000,000.00 in premiums during the period of non-compliance and
would have paid $5,000,000.00 if the requirements had been met, then the penalty would be
$2,100,000.00.
	 
	 	 	If it is determined that an MCP’s reinsurance for transplant services covers less than 50%
of inpatient costs incurred by one member for one year, the MCP will be required to develop
a corrective action plan (CAP).
	 
	4.	 	PROMPT PAY REQUIREMENTS
	 
	 	 	In accordance with 42 CFR 447.46, MCPs must pay 90% of all submitted clean claims
within 30 days of the date of receipt and 99% of such claims within 90 days of the date of
receipt, unless the MCP and its contracted provider(s) have established an alternative
payment schedule that is mutually agreed upon and described in their contract. The prompt
pay requirement applies to the processing of both electronic and paper claims for
contracting and non-contracting providers by the MCP and delegated claims processing
entities.
	 
	 	 	The date of receipt is the date the MCP receives the claim, as indicated by its date stamp
on the claim. The date of payment is the date of the check or date of electronic payment
transmission. A claim means a bill from a provider for health care services that is
assigned a unique identifier. A claim does not include an encounter form.
	 
	 	 	A “claim” can include any of the following: (1) a bill for services; (2) a line item of
services; or (3) all services for one recipient within a bill. A “clean claim” is a claim
that can be processed without obtaining additional information from the provider of a
service or from a third party.
	 
	 	 	Clean claims do not include payments made to a provider of service or a third party where
the timing of payment is not directly related to submission of a completed claim by the
provider of service or third party (e.g., capitation). A
clean claim also does not include a claim from a provider who is under investigation for
fraud or abuse, or a claim under review for medical necessity.
	 
	 	 	Penalty for noncompliance: Noncompliance with prompt pay requirements will result in
progressive penalties to be assessed on a quarterly basis, as outlined in Appendix N of the
Provider Agreement.

 

 

Appendix J

Page 7

	5.	 	PHYSICIAN INCENTIVE PLAN DISCLOSURE REQUIREMENTS
	 
	 	 	MCPs must comply with the physician incentive plan requirements stipulated in 42 CFR
438.6(h). If the MCP operates a physician incentive plan, no specific payment can be made
directly or indirectly under this physician incentive plan to a physician or physician
group as an inducement to reduce or limit medically necessary services furnished to an
individual.
	 
	 	 	If the physician incentive plan places a physician or physician group at substantial
financial risk [as determined under paragraph (d) of 42 CFR 422.208] for services that the
physician or physician group does not furnish itself, the MCP must assure that all
physicians and physician groups at substantial financial risk have either aggregate or
per-patient stop-loss protection in accordance with paragraph (f) of 42 CFR 422.208, and
conduct periodic surveys in accordance with paragraph (h) of 42 CFR 422.208.
	 
	 	 	In accordance with 42 CFR 417.479 and 42 CFR 422.210, MCPs must maintain copies of the
following required documentation and submit to ODJFS annually, no later than 30 days after
the close of the state fiscal year and upon any modification of the MCP’s physician
incentive plan:

	 	a.	 	A description of the types of physician incentive
arrangements the MCP has in place which indicates whether they involve a
withhold, bonus, capitation, or other arrangement. If a physician incentive
arrangement involves a withhold or bonus, the percent of the withhold or bonus
must be specified.
	 
	 	b.	 	A description of information/data feedback to a physician/group on their:
1) adherence to evidence-based practice guidelines; and 2) positive and/or
negative care variances from standard clinical pathways that may impact
outcomes or costs. The feedback information may be used by the MCP for
activities such as physician performance improvement projects that include
incentive programs or the development of quality improvement initiatives.
	 
	 	c.	 	A description of the panel size for each physician incentive plan. If patients
are pooled, then the pooling method used to determine if substantial financial risk
exists must also be specified.
	 
	 	d.	 	If more than 25% of the total potential payment of a physician/group is at risk
for referral services, the MCP must maintain a copy of the results of the required
patient satisfaction survey and documentation verifying that the physician or
physician group has adequate stop-loss protection, including the type of coverage
(e.g., per member per year, aggregate), the

 

 

Appendix J

Page 8

	 	 	 	threshold amounts, and any coinsurance required for amounts over the threshold.
	 
	 	 	 	Upon request by a member or a potential member and no later than 14
calendar days after the request, the MCP must provide the following
information to the member: (1) whether the MCP uses a physician incentive
plan that affects the use of referral services; (2) the type of incentive
arrangement; (3) whether stop-loss protection is provided; and (4) a
summary of the survey results if the MCP was required to conduct a survey.
The information provided by the MCP must adequately address the member’s
request.

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

 

 

Appendix K

Aged, Blind or Disabled (ABD) population

Page 1

APPENDIX K

QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM

AND

EXTERNAL QUALITY REVIEW

ABD ELIGIBLE POPULATION

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

a.
PERFORMANCE IMPROVEMENT PROJECTS

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

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

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

b.
UNDER- AND OVER-UTILIZATION

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

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

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

 

 

Appendix K

Aged, Blind or Disabled (ABD) population

Page 2

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 will be required to submit Health
Employer Data Information Set (HEDIS) audited data for measures that will be identified by
ODJFS for the SFY 2009 Provider Agreement.

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

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

e. QAPI PROGRAM SUBMISSION

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

	2.	 	EXTERNAL QUALITY REVIEW

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

a.
EQRO ADMINISTRATIVE REVIEWS

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

 

 

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

b. EXTERNAL QUALITY REVIEW PERFORMANCE

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

 

 

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APPENDIX L

DATA QUALITY

ABD ELIGIBLE POPULATION

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

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

1. ENCOUNTER DATA

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

1.a. Encounter Data Completeness

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

1.a.i. Encounter Data Volume

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

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

 

 

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

	 	 	 	 	 	 	 
	 	 	Data Source:	 	 	 	 
	 	 	Estimated Encounter	 	Quarterly Report	 	 
	Report Period	 	Data File Update	 	Estimated Issue Date	 	Contract Period
	Qtr 1 2007

	 	July 2007
	 	August 2007	 	SFY 2008
	 
	 	 	 	 	 
	Qtr 1, Qtr 2 2007

	 	October 2007
	 	November 2007
	 
	 
	 	 	 	 	 
	Qtr 1 thru Qtr 3 2007

	 	January 2008
	 	February 2008	 
	 
	 	 	 	 	 
	Qtr 1 thru Qtr 4 2007

	 	April 2008
	 	May 2008	 
	 
	 	 	 	 	 	 
	Qtr 1 thru Qtr 4 2007,

 Qtr 1 2008

	 	July 2008
	 	August 2008	 	SFY 2009
	 
	 	 	 	 	 
	Qtr 1 thru Qtr 4 2007, 

Qtr 1, Qtr 2 2008

	 	October 2008
	 	November 2008	 
	 
	 	 	 	 	 
	Qtr 1 thru Qtr 4 2007, 

Qtr 1 thru Qtr 3 2008

	 	January 2009
	 	February 2009
	 
	 
	 	 	 	 	 
	Qtr 1 thru Qtr 4 2007, 

Qtr 1 thru Qtr 4 2008

	 	April 2009
	 	May 2009	 

	 	 	 	 	 	 	 
	Qtr1 = January to March

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

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

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

 

 

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Table 2. Interim Standards — Encounter Data Volume

	 	 	 	 	 	 	 	 	 
	 	 	 	 	Standard for	 	 
	 	 	 	 	Dates of	 	 
	 	 	 	 	Service	 	 
	 	 	Measure per	 	on or after	 	 
	Category	 	1,000/MM	 	1/1/2007	 	Description
	Inpatient
Hospital

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

	 	 	 	 	25.3	 	 	Includes physician and
hospital emergency
department encounters
	 
	 	 	 	 	 	 	 	 
	Dental

	 	 	 	 	25.5	 	 	Non-institutional and
hospital dental visits
	 
	 	 	 	 	 	 	 	 
	Vision

	 	Visits
	 	 	5.3	 	 	Non-institutional and
hospital outpatient
optometry and
ophthalmology visits
	 
	 	 	 	 	 	 	 	 
	Primary and
Specialist Care

	 	 	 	 	116.6	 	 	Physician/practitioner and
hospital outpatient visits
	 
	 	 	 	 	 	 	 	 
	Ancillary
Services

	 	 	 	 	66.8	 	 	Ancillary visits
	 
	 	 	 	 	 	 	 	 
	Behavioral
Health

	 	Service
	 	 	5.2	 	 	Inpatient and outpatient
behavioral encounters
	 
	 	 	 	 	 	 	 	 
	Pharmacy

	 	Prescriptions
	 	 	246.1	 	 	Prescribed drugs

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

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

 

 

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1.a.ii. Incomplete Outpatient Hospital Data

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

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

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

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

	 	 	 	 	 	 	 
	 	 	Data Source:	 	 	 	 
	 	 	Estimated Encounter	 	Quarterly Report	 	 
	      Quarterly Report Periods	 	Data File Update	 	Estimated Issue Date	 	Contract Period
	Qtr 3 & Qtr 4 2004, 2005, 2006
	 	 	 	 	 	SFY 2008
	Qtr 1 2007

	 	July 2007
	 	August 2007	 
	 
	 	 	 	 	 
	Qtr 3 & Qtr 4 2004, 2005, 2006
	 	 	 	 	 
	Qtr 1, Qtr 2 2007

	 	October 2007
	 	November 2007	 
	 
	 	 	 	 	 
	Qtr 4 2004, 2005, 2006
	 	 	 	 	 
	Qtr 1 thru Qtr 3 2007

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

	 	April 2008
	 	May 2008	 
	 
	 	 	 	 	 	 
	Qtr 2 thru Qtr 4 2005,
	 	 	 	 	 	SFY 2009
	Qtr 1 thru Qtr 4: 2006, 2007
	 	July 2008	 	August 2008	 
	Qtr 1 2008

	 	 	 	 	 
	 
	 	 	 	 	 
	Qtr 3, Qtr 4: 2005,
	 	 	 	 	 
	Qtr 1 thru Qtr 4: 2006, 2007

	 	October 2008
	 	November 2008
	 
	Qtr 1, Qtr 2 2008
	 	 	 	 	 
	 
	 	 	 	 	 
	Qtr 4: 2005,
	 	 	 	 	 
	Qtr 1 thru Qtr 4: 2006, 2007

	 	January 2009
	 	February 2009	 
	Qtr 1 thru Qtr 3: 2008
	 	 	 	 	 
	 
	 	 	 	 	 
	Qtr 1 thru Qtr 4: 2006, 2007,
2008

	 	April 2009
	 	May 2009	 

	 	 	 	 	 	 	 
	Qtr1 = January to March

	 	Qtr2 = April to June
	 	Qtr3 = July to September
	 	Qtr4 = October to December

 

 

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

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

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

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

1.a.iii. Rejected Encounters

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

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

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

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

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

 

 

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

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

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

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

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

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

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

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

	 	 	 	 	 
	Third through sixth month with membership:
	 	 	50	%
	 
	Seventh through twelfth month with membership:
	 	 	25	%

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

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

Penalty for Noncompliance with the Data Quality Standard for measure 2: If the MCP is determined
to be noncompliant for either standard, ODJFS will impose a monetary sanction of one

 

 

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

1.a.iv. Acceptance Rate

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

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

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

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

	 	 	 
	     Third through sixth month with
membership:
	 	 
	 

	 	50 encounters per 1,000 MM for NCPDP
	 

	 	65 encounters per 1,000 MM for NSF
	 

	 	20 encounters per 1,000 MM for UB-92
	 
	 	 
	     Seventh through twelfth month of
membership:
	 	 
	 

	 	250 encounters per 1,000 MM for NCPDP
	 

	 	350 encounters per 1,000 MM for NSF
	 

	 	100 encounters per 1,000 MM for UB-92

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

Penalty for Noncompliance: If the MCP is determined to be noncompliant with the standard, ODJFS
will impose a monetary sanction of one percent of the MCP’s current month’s premium payment. The
monetary sanction will be applied for each file type in the ODJFS-specified medium per format that
is determined to be out of compliance. The monetary sanction will be applied only once per file
type per compliance determination period and will not exceed a total of two percent of

 

 

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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. Informational Encounter Data Completeness Measure

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

1.b. Encounter Data Accuracy

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

1.b.i. Encounter Data Accuracy Study

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

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

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

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

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

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

 

 

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1.b.ii. Generic Provider Number Usage

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

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

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

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

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

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

1.c. Timely Submission of Encounter Data

1.c.i. Timeliness

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

 

 

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

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

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

2. CASE MANAGEMENT DATA

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

2.a. Case Management System Data Accuracy

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

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

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

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

Statewide Approach: MCPs will be evaluated using a statewide result specific for the ABD program,
including all regions in which an MCP has ABD membership. An MCP will not be evaluated until the
MCP has at least 3,000 ABD members statewide. As the ABD Medicaid managed care program expands
statewide and regions become active in different months, statewide results will

 

 

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include every region in which an MCP has membership [Example: MCP AAA has: 6,000 members in the
South West region beginning in January 2007; 7,000 members in the West Central region beginning in
February 2007; and 8,000 members in the South East region beginning in March 2007. MCP AAA’s
statewide results for the April-June 2007 report period will include data for the South West, West
Central, and South East regions.]

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

2.b. Timely Submission of Case Management Files

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

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

3. EXTERNAL QUALITY REVIEW DATA

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

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

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

 

 

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3.a. Independent External Quality Review

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

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

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

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

4. MEMBERS’ PCP DATA

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

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

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

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

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

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

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

Data Quality Standard: A minimum rate of 65% of new members with PCP designation by

 

 

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

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

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

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

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

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

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

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

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

 

 

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5. APPEALS AND GRIEVANCES DATA

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

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

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

6. NOTES

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

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

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

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

 

 

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6.b. Combined Remedies

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

6.c. Membership Freezes

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

6.d. Reconsideration

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

6.e. Contract Termination, Nonrenewals, or Denials

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

 

 

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APPENDIX M

PERFORMANCE EVALUATION

ABD ELIGIBLE POPULATION

This appendix establishes minimum performance standards for managed care plans (MCPs) in key
program areas, under the Agreement. Standards are subject to change based on the revision or update
of applicable national standards, methods, benchmarks, or other factors as deemed relevant.
Performance will be evaluated in the categories of Quality of Care, Access, Consumer Satisfaction,
and Administrative Capacity. Each performance measure has an accompanying minimum performance
standard. MCPs with performance levels below the minimum performance standards will be required to
take corrective action. All performance measures, as specified in this appendix, will be calculated
per MCP and include only members in the ABD Medicaid managed care program. Selected measures in
this appendix will be used to determine incentives as specified in Appendix O, Pay for Performance
(P4P).

1. QUALITY OF CARE

1.a. Independent External Quality Review

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

Measure: The independent external quality 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 2008.

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

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

Given the substantial proportion of members with chronic conditions and co-morbidities in the ABD
population, one of the quality of care initiatives of the ABD Medicaid managed care program focuses
on case management. In order to ensure state compliance with the provisions of 42 CFR 438.208, the
Bureau of Managed Health Care established Members with Special Health Care Needs (MSHCN) basic
program requirements as set forth in Appendix G, Coverage and Services of the

 

 

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Agreement, and corresponding minimum performance standards as described below. The purpose of these
measures is to provide appropriate and targeted case management services to MSHCN who have specific
diagnoses and/or who require high-cost or extensive services. Given the expedited schedule for
implementing the ABD Medicaid managed care program, coupled with the challenges facing a new
Medicaid program in the State of Ohio, the minimum performance standards for the case management
requirements for MSHCN are phased in throughout SFY 2007 and SFY 2008. The minimum standards for
these performance measures will be fully phased in by no later than SFY 2009. For detailed
methodologies of each measure, see ODJFS Methods for the ABD Medicaid Managed Care Program’s Case
Management Performance Measures.

1.b.i Case Management of Members

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

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

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

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

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

Penalty for Noncompliance: The first time an MCP is noncompliant with a standard for this measure,
ODJFS will issue a Sanction Advisory informing the MCP that any future noncompliance instances with
the standard for this measure will result in ODJFS imposing a monetary sanction. Upon all
subsequent measurements of performance, if an MCP is again determined to be

 

 

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noncompliant with the standard, ODJFS will impose a monetary sanction (see Section 5) of two
percent of the current month’s premium payment. Monetary sanctions will not be levied for
consecutive quarters that an MCP is determined to be noncompliant. If an MCP is noncompliant for a
subsequent quarter, new member selection freezes or a reduction of assignments will occur as
outlined in Appendix N of the Provider Agreement. Once the MCP is performing at standard levels and
the violations/deficiencies are resolved to the satisfaction of ODJFS, the penalties will be
lifted, if applicable, and monetary sanctions will be returned.

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

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

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

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

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

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

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

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

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

 

 

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

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

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

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

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

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

1.c. Clinical Performance Measures

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

 

 

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

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

An MCP’s second calendar year of ABD managed care program membership (i.e., CY2008) will be the
initial report period of evaluation for performance measures that require one calendar year of
baseline data (i.e., CY2007), and for performance measures that require two calendar years of
baseline data (i.e., CY2006 and CY2007).

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

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

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

Target: TBD

Minimum Performance Standard: The level of improvement must result in at least a TBD% decrease in
the difference between the target and the previous report period’s results. (For example, if last
year’s results were TBD%, then the difference between the target and last year’s results is

 

 

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TBD%. In this example, the standard is an improvement in performance of TBD% of this difference or
TBD%. In this example, results of TBD% or better would be compliant with the standard.)

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

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

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

Target: TBD

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

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

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

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

Target: TBD.

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

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

 

 

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1.c.iv. Coronary Artery Disease (CAD) — Inpatient Hospital Discharge Rate

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

Target: TBD

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

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

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

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

Target: TBD

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

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

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

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

Target: TBD.

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

Action Required for Noncompliance: If the standard is not met and the results are below TBD%, the
MCP is required to complete a Corrective Action Plan to address the area of noncompliance. If

 

 

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the standard is not met and the results are at or above TBD%, ODJFS will issue a Quality
Improvement Directive which will notify the MCP of noncompliance and may outline the steps that the
MCP must take to improve the results.

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

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

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

Target: TBD.

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

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

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

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

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

Target: TBD.

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

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

 

 

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

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

Target: TBD.

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

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

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

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

Target: TBD

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

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

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

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

Target: TBD

 

 

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

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

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

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

Target: TBD

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

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

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

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

Target: TBD

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

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

 

 

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1.c.xiv. Diabetes – Eye Exam

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

Target: TBD.

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

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

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

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

Target: TBD

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

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

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

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

 

 

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Target: TBD

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

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

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

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

Target: TBD

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

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

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

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

Target: TBD

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

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

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

 

 

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

Target: TBD

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

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

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

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

Target: TBD

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

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

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

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

Target: TBD

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

Action Required for Noncompliance: If the standard is not met and the results are below TBD%, the
MCP is required to complete a Corrective Action Plan to address the area of noncompliance. If the
standard is not met and the results are at or above TBD%, ODJFS will issue a Quality

 

 

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Improvement Directive which will notify the MCP of noncompliance and may outline the steps that the
MCP must take to improve the results.

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

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

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

1) 30 Days of discharge, and

2) 7 Days of discharge.

Target: TBD.

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

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

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

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

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

Target: TBD.

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

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

 

 

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

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

Target: TBD

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

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

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

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

Target: TBD

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

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

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

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

Target: TBD.

 

 

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

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

1.c.xxvii. Informational Clinical Performance Measures

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

Table 1. Informational Clinical Performance Measures

	 	 	 
	Condition	 	Informational Performance Measure
	CHF

	 	Discharge rate with age group breakouts
	 
	 	 
	CAD

	 	Discharge rate with age group breakouts
	 
	 	 
	Hypertension

	 	Discharge rate with age group breakouts
	 
	 	 
	Diabetes

	 	Discharge rate with age group breakouts
	 

	 	Comprehensive Diabetes Care (CDC)/HbA1c testing
	 

	 	CDC/kidney disease monitored
	 

	 	CDC/LDL-C screening performed
	 
	 	 
	COPD

	 	Discharge rate with age group breakouts
	 

	 	Use of Spirometry Testing in the Assessment
and Diagnosis of COPD
	 
	 	 
	Asthma

	 	Discharge rate with age group breakouts
	 
	 	 
	Mental Health (SMD)

	 	Discharge rate with age group breakouts
	 

	 	Antidepressant Medication Management
	 
	 	 
	Substance Abuse

	 	Discharge rate with age group breakouts
	 

	 	Initiation and Engagement of Alcohol and Other
Drug Dependence Treatment

2. ACCESS

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

2.a. PCP Turnover

 

 

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

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

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

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

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

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

2.b. Adults’ Access to Designated PCP

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

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

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

Report Period: For the SFY 2008 contract period, performance will be
evaluated using the January —
December 2007 report period (and may be adjusted based on the number of months of

 

 

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ABD managed care membership). For the SFY 2009 contract period, performance will be evaluated using
the January — December 2008 report period. The first reporting period in which MCPs will be held
accountable to the performance standards will be the SFY 2009 contract period.

Minimum Performance Standards: TBD

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

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

This measure indicates whether adult members are accessing health services.

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

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

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

Minimum Performance Standards: TBD

Penalty for Noncompliance: If an MCP is noncompliant with the Minimum Performance

Standard, then the MCP must develop and implement a corrective action plan.

3. CONSUMER SATISFACTION

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

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

 

 

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will be the first contract period in which MCPs will be held accountable to the performance
standards for this measure.

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

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

Minimum
Performance Standard:  TBD.

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

4. ADMINISTRATIVE CAPACITY

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

4.a. Compliance Assessment System

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

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

Performance Standard: A maximum of 15 points

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

4.b. Emergency Department Diversion

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

 

 

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

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

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

Target: TBD

Minimum Performance Standard: TBD

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

5. Notes

Given that unforeseen circumstances (e.g., revision or update of applicable national standards,
methods or benchmarks, or issues related to program implementation) may impact performance

assessment as specified in Sections 1 through 4, ODJFS reserves the right to apply the most
appropriate penalty to the area of deficiency identified with any individual measure,
notwithstanding the penalties specified in this Appendix.

5.a. Monetary Sanctions

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

Refundable monetary sanctions will be based on the capitation payment for the month of the cited
deficiency and will be due within 30 days of notification by ODJFS to the MCP of the amount. Any
monies collected through the imposition of such a sanction would be returned to the MCP (minus any
applicable collection fees owed to the Attorney General’s Office, if the MCP has been

 

 

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delinquent in submitting payment) after they have demonstrated improved performance in accordance
with this

appendix. If an MCP does not comply within two years of the date of notification of noncompliance,
then the monies will not be refunded.

5.b. Combined Remedies

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

5.c. Enrollment Freezes

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

5.d. Reconsideration

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

5.e. Contract Termination, Nonrenewals or Denials

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

 

 

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APPENDIX N

COMPLIANCE ASSESSMENT SYSTEM

ABD ELIGIBLE POPULATION

I. General Provisions of the Compliance Assessment System

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

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

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

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

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

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

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

 

 

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suspend any further new member selections.

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

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

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

II. Types of Sanctions/Remedial Actions

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

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

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

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

 

 

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

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

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

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

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

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

No points will be assigned for any violation where an MCP is able to document that the
precipitating circumstances were completely beyond their control and could not have been
foreseen (e.g., a construction crew severs a phone line, a lightning strike blows a
computer system, etc.).

C.1.
5 Points — Failures to meet program requirements, including but not limited
to, actions which could impair the member’s ability to obtain correct information
regarding services or which could impair a consumer’s or member’s rights, as
determined by ODJFS, will result in the assessment of 5 points.

Examples include, but are not limited to, the following:

	 	•	 	Violations which result in a member’s MCP selection
or termination based on inaccurate provider panel information from the
MCP.
	 
	 	•	 	Failure to provide member materials to new members in
a timely manner.
	 
	 	•	 	Failure to comply with appeal, grievance, or state
hearing requirements, including the failure to notify a member of their
right to a state hearing when the MCP proposes to deny, reduce, suspend or

 

 

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	 	 	 	terminate a Medicaid-covered service.
	 
	 	•	 	Failure to staff 24-hour call-in system with
appropriate trained medical personnel.
	 
	 	•	 	Failure to meet the monthly call-center requirements
for either the member services or the 24-hour call-in system lines.
	 
	 	•	 	Provision of false, inaccurate or materially
misleading information to health care providers, the MCP’s members, or any
eligible individuals.
	 
	 	•	 	Use of unapproved marketing or member materials.
	 
	 	•	 	Failure to appropriately notify ODJFS or members of
provider panel terminations.
	 
	 	•	 	Failure to update website provider directories as
required.

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

	 	•	 	Discrimination among members on the basis of their
health status or need for health care services (this includes any practice
that would reasonably be expected to encourage termination or discourage
selection by individuals whose medical condition indicates probable need
for substantial future medical services).
	 
	 	•	 	Failure to assist a member in accessing needed
services in a timely manner after request from the member.
	 
	 	•	 	Failure to provide medically-necessary Medicaid
covered services to members.
	 
	 	•	 	Failure to process prior authorization requests
within the prescribed time frames.

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

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

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

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

 

 

Appendix N

Aged, Blind or Disabled (ABD) population 

Page 5

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

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

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

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

	 	 	 	 
	 	0 -15 Points

	 	Corrective Action Plan (CAP)
	 	 
	 	 
	 	16-25 Points

	 	CAP + $5,000 fine
	 	 
	 	 
	 	26-50 Points

	 	CAP + $10,000 fine
	 	 
	 	 
	 	51-70 Points

	 	CAP + $20,000 fine
	 	 
	 	 
	 	71-100 Points

	 	CAP + $30,000 fine
	 	 
	 	 
	 	100+ Points

	 	Proposed Contract Termination

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

 

 

Appendix N

Aged, Blind or Disabled (ABD) population

Page 6

as jeopardizing member access to care include:

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

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

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

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

J. Specific Pre-Determined Penalties 

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

 

 

Appendix N

Aged, Blind or Disabled (ABD) population

Page 7

nonrefundable fine for the failure to meet CFC panel requirements; and, (2) a
$1,000 nonrefundable fine for the failure to meet ABD panel requirements).

	 	•	 	practitioner requirements in Franklin county for the CFC population
	 
	 	•	 	practitioner requirements in Franklin county for the ABD population
	 
	 	•	 	hospital requirements in Franklin county for the CFC population
	 
	 	•	 	PCP capacity requirements in Fairfield county for the CFC population

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

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

	 	•	 	GIS requirements in Franklin county for the CFC population
	 
	 	•	 	GIS requirements in Fairfield county for the CFC population
	 
	 	•	 	GIS requirements in Franklin county for the ABD population

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

	 	•	 	Late required submissions

	 	o	 	Annual delegation assessments
	 
	 	o	 	Call center report
	 
	 	o	 	Franchise fee documentation
	 
	 	o	 	Reinsurance information (e.g., prior approval of changes)
	 
	 	o	 	State hearing notifications

	 	•	 	Late required data submissions

	 	o	 	Appeals and grievances, case management, or PCP data

	 	•	 	Late required information requests

	 	o	 	Automatic call distribution reports
	 
	 	o	 	Information/resolution regarding consumer or provider

 

 

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Aged, Blind or Disabled (ABD) population

Page 8

	 	 	 	complaint
	 
	 	o	 	Just cause or other coordination care request from ODJFS
	 
	 	o	 	Provider panel documentation
	 
	 	o	 	Failure to provide ODJFS with a required submission after
ODJFS has notified the MCP that the prescribed deadline for that
submission has passed

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

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

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

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

Subsequent violations will result in an enrollment freeze.

 

 

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Aged, Blind or Disabled (ABD) population

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

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

	 	•	 	A monetary penalty in the amount of $500 for each day any part of the
fee remains unpaid, except the penalty will not exceed an amount
equal to 5 % of the total fee that was due for the calendar quarter for
which the penalty was imposed;
	 
	 	•	 	Withholdings from future ODJFS capitation payments. If an MCP fails to
pay the full amount of its franchise fee when due, or the full amount of the
imposed penalty, ODJFS may withhold an amount equal to the remaining amount
due from any future ODJFS capitation payments. ODJFS will return all
withheld capitation payments when the franchise fee amount has been paid in
full;
	 
	 	•	 	Proposed termination or non-renewal of the MCP’s Medicaid provider
agreement may occur if the MCP:

	 	a.	 	Fails to pay its franchise permit fee or fails to
pay the fee promptly;
	 
	 	b.	 	Fails to pay a penalty imposed under this Appendix
or fails to pay the penalty promptly;
	 
	 	c.	 	Fails to cooperate with an audit conducted in accordance with ORC Section
5111.176.

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

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

J.9. Refusal to Comply with Program Requirements - If ODJFS has instructed
an MCP that they must comply with a specific program requirement and the MCP

 

 

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Aged, Blind or Disabled (ABD) population

Page 10

refuses, such refusal constitutes documentation that the MCP is no longer operating
in the best interests of the MCP’s members or the state of Ohio and ODJFS will move
to terminate or nonrenew the MCP’s provider agreement.

III. Request for Reconsiderations 

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

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

B. All requests for reconsideration must be submitted by either facsimile transmission or
overnight mail to the Chief, Bureau of Managed Health Care, and received by ODJFS by the
tenth business day after receipt of the faxed notification of the imposition of the
remedial action by ODJFS.

C. The MCP will be responsible for verifying timely receipt of all reconsideration
requests. All requests for reconsideration must explain in detail why the specified
remedial action should not be imposed. The MCP’s justification for reconsideration will be
limited to a review of the written material submitted by the MCP. The Bureau Chief will
review all correspondence and materials related to the violation in question in making the
final reconsideration decision.

D. Final decisions or requests for additional information will be made by ODJFS within ten
(10) business days of receipt of the request for reconsideration.

E. If additional information is requested by ODJFS, a final reconsideration decision will
be made within three (3) business days of the due date for the submission. Should ODJFS
require additional time in rendering the final reconsideration decision, the MCP will be
notified of such in writing.

F. If a reconsideration request is decided, in whole or in part, in favor of the MCP, both
the penalty and the points associated with the incident, will be rescinded or reduced, in
the sole discretion of ODJFS. The MCP may still be required to submit a CAP if ODJFS, in
its sole discretion, believes that a CAP is still warranted under the circumstances.

 

 

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Aged, Blind or Disabled (ABD) population

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APPENDIX O

PAY-FOR-PERFORMANCE (P4P)

ABD ELIGIBLE POPULATION

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

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

ODJFS will use the first calendar year of an MCP’s ABD managed care program membership as the
baseline year (i.e., CY2007). The baseline year will be used to determine performance standards
and targets; baseline data may come from a combination of FFS claims data and MCP encounter data.
As many of the performance measures used in the determination of P4P require two calendar years of
baseline data, the additional calendar year (i.e., the calendar year prior to the first calendar
year of ABD managed care program membership, [i.e., CY2006]) data will come from FFS claims.

An MCP’s second calendar year of ABD managed care program membership (i.e., CY2008) will be the
initial report period of evaluation for performance measures that require one calendar year of
baseline data (i.e., CY2007), and for performance measures that require two calendar years of
baseline data (i.e., CY2006 and CY2007). CY2008 will be the initial report period upon which
compliance with the performance standards will be determined. SFY 2009 will become the first year
an MCP’s performance level for P4P can be determined.

1. SFY 2009 P4P

1.a. Qualifying Performance Levels

     To qualify for consideration of the SFY 2009 P4P, an MCP’s performance level must:

	 	1)	 	Meet the minimum performance standards set in Appendix M, Performance Evaluation, for
the measures listed below; and
	 
	 	2)	 	Meet the P4P standards established for the Clinical Performance Measures
below.

 

 

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Aged, Blind or Disabled (ABD)
population 

Page 2

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

Measures for which the minimum performance standard for SFY 2009 established in Appendix M,
Performance Evaluation, must be met to qualify for consideration of incentives are as follows:

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

Report Period: CY 2008

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

Report Period: CY 2008

For each clinical performance measure listed below, the MCP must meet the P4P standard to be
considered for SFY 2009 P4P. The MCP meets the P4P standard if one of two criteria is met. The P4P
standard is a performance level of either:

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

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

	 	 	 	 	 	 	 
	 	 	 	 	 	 	Medicaid
	Clinical Performance Measure	 	Benchmark
	CHF: Inpatient Hospital Discharge Rate	 	TBD
	 
	1.	 	 	 	CAD: Beta-Blocker Treatment after Heart Attack (AMI -related
admission)

	 	TBD
	2.	 	 	 	CAD: Cholesterol Management for Patients with Cardiovascular 

Conditions/LDL-C screening performed

	 	TBD
	3.	 	 	 	Hypertension: Inpatient Hospital Discharge Rate

	 	TBD
	4.	 	 	 	Diabetes: Comprehensive Diabetes Care (CDC)/Eye exam

	 	TBD
	5.	 	 	 	COPD: Inpatient Hospital Discharge Rate

	 	TBD
	6.	 	 	 	Asthma: Use of Appropriate Medications for People with Asthma

	 	TBD
	7.	 	 	 	Mental Health: Follow-up After Hospitalization for Mental Illness

	 	TBD

1.b. Excellent and Superior Performance Levels

For qualifying MCPs as determined by Section 1.a.. herein, performance will be evaluated on the
measures below to determine the status of the at-risk amount or any additional P4P that may be

 

 

Appendix O

Aged, Blind or Disabled (ABD) population

Page 3

awarded. Excellent and Superior standards are set for the three measures described below. The
standards are subject to change based on the revision or update of applicable national standards,
methods or benchmarks.

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

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

Report Period: April – June 2009

Excellent Standard: TBD

Superior Standard: TBD

2. Comprehensive Diabetes Care (CDC)/Eye exam (Appendix M, Section 1.c.xiv.)

Report Period: CY 2008

Excellent Standard: TBD

Superior Standard: TBD

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

Report Period: CY 2008

Excellent Standard: TBD

Superior Standard: TBD

1.c. Determining SFY 2009 P4P

MCPs reaching the minimum performance standards described in Section 1.a. herein, will be
considered for P4P including retention of the at-risk amount and any additional P4P. For each
Excellent standard established in Section 1.b. herein, that an MCP meets, one-third of the at-risk
amount may be retained. For MCPs meeting all of the Excellent and Superior standards established
in Section 1.b. herein, additional P4P may be awarded. For MCPs receiving additional P4P, the amount in the P4P fund (see section 2.) will be divided
equally, up to the maximum additional amount, among all MCPs’ABD and/or CFC programs receiving
additional P4P. The maximum additional amount to be awarded per plan, per program, per contract
year is $250,000. An MCP may receive up to $500,000 should both of the MCP’s ABD and CFC programs
achieve the Superior Performance Levels.

 

 

Appendix O

Aged, Blind or Disabled (ABD) population

Page 4

2. NOTES

2.a. Initiation of the P4P System

For MCPs in their first twenty-four (24) months of Ohio Medicaid ABD Managed Care Program
participation, the status of the at-risk amount will not be determined because compliance with many
of the standards in the ABD program cannot be determined in an MCP’s first two contract years (see
Appendix F., Rate Chart). In addition, MCPs in their first two (2) contract years in the ABD
program are not eligible for the additional P4P amount awarded for superior performance.

Starting with the twenty-fifth (25th) month of participation in the ABD program, the
MCP’s at-risk amount will be included in the P4P system. The determination of the status of this
at-risk amount will occur after two (2) calendar years of ABD membership. Because of this
requirement, the number of months of at-risk dollars to be included in an MCP’s first at-risk
status determination may vary depending on when an MCP starts with the ABD program relative to the
calendar year.

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

For MCPs that have participated in the Ohio Medicaid ABD Managed Care Program long enough to
calculate performance levels for all of the performance measures included in the P4P system,
determination of the status of an MCP’s at-risk amount will occur within six (6) months of the end
of the contract period. Determination of additional P4P payments will be made at the same time the
status of an MCP’s at-risk amount is determined.

2.c. Statewide P4P system

All MCPs will be included in a statewide P4P system for the ABD program. The at-risk amount will be
determined using a statewide result for all regions in which an MCP serves ABD membership.

2.d. Contract Termination, Nonrenewals, or Denials

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

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

2.e. Report Periods

The report period used in determining the MCP’s performance levels varies for each measure
depending on the frequency of the report and the data source. Unless otherwise noted, the most

 

 

Appendix O

Aged, Blind or Disabled (ABD) population

Page 5

recent report or study finalized prior to the end of the contract period will be used in
determining the MCP’s overall performance level for that contract period.exv10w30

 

Exhibit 10.30

	 	 	 
	[SEAL]

	 	STATE OF MISSOURI
	 

	 	OFFICE OF ADMINISTRATION
	 

	 	DIVISION OF PURCHASING AND MATERIALS MANAGEMENT (DPMM)
	 

	 	REQUEST FOR BEST AND FINAL OFFER (BAFO)
	 

	 	FOR REQUEST FOR PROPOSAL (RFP)

	 	 	 
	BAFO REQUEST NO.: 002

	 	REQ NO.: NR 886 25756004320
	RFP NO.: B3Z06118

	 	BUYER: Julie Kleffner
	TITLE: Medicaid Managed Care – Central, Eastern, & Western Regions

	 	PHONE NO.: (573) 751-7656
	ISSUE DATE: 03/28/06

	 	E-MAIL: Julie.Kleffner@oa.mo.gov

RETURN BAFO RESPONSE NO LATER THAN 03/30/06 AT 5:00 PM CENTRAL TIME

	 	 	 
	MAILING INSTRUCTIONS:

	 	Print or type RFP Number and Return Due
Date on the lower left hand corner of the envelope or package.
Sealed BAFOs should be in DPMM office (301 W High Street, Room
630) by the return date and time.

	 	 	 	 	 	 	 
	 

	 	(U.S. Mail)
	 	 	 	(Courier Service)
	RETURN BAFO RESPONSE TO:

	 	DPMM
	 	or
	 	DPMM
	 

	 	PO BOX 809
	 	 	 	301 WEST HIGH STREET, RM 630 
	 

	 	JEFFERSON CITY MO 65102-0809
	 	 	 	JEFFERSON CITY MO 65101

CONTRACT PERIOD: July 1, 2006 through June 30, 2007

               (with two additional one-year renewal periods at the State’s sole option)

DELIVER SUPPLIES/SERVICES FOB (Free on Board) DESTINATION TO THE FOLLOWING ADDRESS:

Department of Social Services

Division of Medical Services

P.O. Box 6500

Jefferson City, MO 65102-6500

The offeror hereby declares understanding, agreement and certification of compliance to provide the
items and/or services, at the prices quoted, in accordance with all terms and conditions,
requirements, and specifications of the original RFP as modified by any previously issued RFP
amendments and by this and any previously issued BAFO requests. The offeror agrees that the
language of the original RFP as modified by any previously issued RFP amendments and by this and
any previously issued BAFO requests shall govern in the event of a conflict with his/his proposal.
The offeror further agrees that upon receipt of an authorized purchase order from the Division of
Purchasing and Materials Management or when a Notice of Award is signed and issued by an authorized
official of the State of Missouri, a binding contract shall exist between the offeror and the State
of Missouri.

SIGNATURE REQUIRED

	 	 	 
	DOING BUSINESS AS (DBA) NAME

	 	LEGAL NAME OF ENTITY/INDIVIDUAL FILED WITH IRS FOR THIS TAX ID NO.
	 
	 	 
	Community CarePlus

	 	Alliance for Community Health
	 
	 	 
	MAILING ADDRESS

	 	IRS FORM 1099 MAILING ADDRESS
	 
	 	 
	10123 Corporate Square Drive

	 	10123 Corporate Square Drive
	 
	 	 
	CITY, STATE, ZIP CODE

	 	CITY, STATE, ZIP CODE
	 
	 	 
	St. Louis, MO 63132

	 	St. Louis, MO 63132
	 
	 	 
	CONTACT PERSON

	 	jlinder@ccphealth.com
	Jerry Linder or Marcia Albridge

	 	malbridge@ccphealth.com
	 
	 	 
	PHONE NUMBER

	 	FAX NUMBER
	 
	 	 
	314-432-9300

	 	314-994-9398

	 	 	 	 	 
	TAXPAYER ID NUMBER (TIN)

	 	TAXPAYER ID (TIN) TYPE (CHECK ONE)
	 	VENDOR NUMBER (IF KNOWN)
	 
	 	 	 	 
	43-1743902

	 	           ___X___ FEIN          ___ SSN
	 	817919905 
	 
	 	 	 	 
	VENDOR TAX FILING TYPE WITH IRS (CHECK ONE)	 	     (NOTE: LLC IS NOT A VALID TAX FILING TYPE.)
	 
	 	 	 	 
	__X_ Corporation           ___ Individual           ___ State/Local Government           ___ Partnership           ___ Sole Proprietor           ___ Other     
        

	 	 	 
	AUTHORIZED SIGNATURE

	 	DATE
	 
	 	 
	 

	 	3/29/06
	 
	 	 
	PRINTED NAME

	 	TITLE
	 
	 	 
	Jerry Linder

	 	CEO

 

 

					
	 	 	 	 	 
	RFP B3Z06118
	 	BAF0#002
	 	Page 2

Medicaid Managed Care – Central, Eastern, & Western Regions

Department of Social Services, Division of Medical Services

Contract Period: July 1, 2006 through June 30, 2007

               (with two additional one-year renewal periods at the State’s sole option)

Offerors are hereby notified that paragraph 2.1.2 a. is hereby revised.

 

 

	 	 	 
	[SEAL]	 	STATE OF MISSOURI
	 	OFFICE OF ADMINISTRATION
	 	DIVISION OF PURCHASING AND MATERIALS MANAGEMENT (DPMM)
	 	REQUEST FOR BEST AND FINAL OFFER (BAFO)
	 	FOR REQUEST FOR PROPOSAL (RFP)

	 	 	 
	BAFO REQUEST NO.: 001

	 	REQ NO.: NR 886 25756004320
	RFP NO.: B3Z06118

	 	BUYER: Julie Kleffner
	TITLE: Medicaid Managed Care — Central, Eastern, & Western Regions

	 	PHONE NO.: (573) 751-7656
	ISSUE DATE: March 10, 2006

	 	E-MAIL: Julie.Kleffner@oa.mo.gov

RETURN BAFO RESPONSE NO LATER THAN March 15, 2006 AT 5:00 PM CENTRAL TIME

	 	 	 
	MAILING INSTRUCTIONS:

	 	Print or type RFP Number and Return Due
Date on the lower left hand corner of the envelope or package.
Sealed BAFOs should be in DPMM office (301 W High Street, Room
630) by the return date and time.

	 	 	 	 	 	 	 
	 

	 	(U.S. Mail)
	 	 	 	(Courier Service)
	RETURN BAFO RESPONSE TO:

	 	DPMM
	 	or
	 	DPMM
	 

	 	PO BOX 809

JEFFERSON CITY MO 65102-0809
	 	 	 	301 WEST HIGH STREET, RM 630

JEFFERSON CITY MO 65101

CONTRACT PERIOD: July 1, 2006 through June 30, 2007

(with two additional one-year renewal periods at the State’s sole option)

DELIVER SUPPLIES/SERVICES FOB (Free on Board) DESTINATION TO THE FOLLOWING ADDRESS:

Department of Social Services

Division of Medical Services

P.O. Box 6500

Jefferson City, MO 65102-6500

The offeror hereby declares understanding, agreement and certification of compliance to provide the
items and/or services, at the prices quoted, in accordance with all terms and conditions,
requirements, and specifications of the original RFP as modified by any previously issued RFP
amendments and by this and any previously issued BAFO requests. The offeror agrees that the
language of the original RFP as modified by any previously issued RFP amendments and by this and
any previously issued BAFO requests shall govern in the event of a conflict with his/his proposal.
The offeror further agrees that upon receipt of an authorized purchase order from the Division of
Purchasing and Materials Management or when a Notice of Award is signed and issued by an authorized
official of the State of Missouri, a binding contract shall exist between the offeror and the State
of Missouri.

SIGNATURE REQUIRED

	 	 	 
	DOING BUSINESS AS (DBA) NAME

	 	LEGAL NAME OF ENTITY/INDIVIDUAL FILED WITH IRS FOR THIS TAX ID NO.
	 
	 	 
	MAILING ADDRESS

	 	IRS FORM 1099 MAILING ADDRESS
	 
	 	 
	CITY, STATE, ZIP CODE

	 	CITY, STATE, ZIP CODE
	 
	 	 
	CONTACT PERSON

	 	EMAIL ADDRESS
	 
	 	 
	PHONE NUMBER

	 	FAX NUMBER

	 	 	 	 	 
	TAXPAYER ID NUMBER (TIN)

	 	TAXPAYER ID (TIN) TYPE (CHECK ONE)
	 	VENDOR NUMBER (IF KNOWN)
	 

	 	___ FEIN      ___ SSN	 	 

	 	 	 
	VENDOR TAX FILING TYPE WITH IRS (CHECK ONE)

	 	(NOTE: LLC IS NOT A VALID TAX FILING TYPE.)
	___ Corporation       ___ Individual     
___ State/Local Government       ___ Partnership       ___ Sole Proprietor     ___ Other ___
	 
	AUTHORIZED SIGNATURE

	 	DATE
	 
	 	 
	PRINTED NAME

	 	TITLE

 

 

					
	RFP B3Z06118
	 	BAFO #001
	 	Page 2

Medicaid Managed Care — Central, Eastern, & Western Regions

Department of Social Services, Division of Medical Services

Contract Period: July 1, 2006 through June 30, 2007

(with two additional one-year renewal periods at the State’s sole option)

Offerors are hereby notified the following paragraphs have been revised:

2.14.4

2.14.4 b. 4)

2.31.1

2.31.3

 

 

	 	 	 
	[SEAL]	 	STATE OF MISSOURI
	 	OFFICE OF ADMINISTRATION
	 	DIVISION OF PURCHASING AND MATERIALS MANAGEMENT (DPMM)
	 	REQUEST FOR PROPOSAL (RFP)

	 	 	 
	AMENDMENT NO.: 002

	 	REQ NO.: NR 886 25756004320
	RFP NO.: B3Z06118

	 	BUYER: Julie Kleffner
	TITLE: Medicaid Managed Care — Central, Eastern, & Western Regions

	 	PHONE NO.: (573) 751-7656
	ISSUE DATE: 02/07/06

	 	E-MAIL: Julie.Kleffner@oa.mo.gov

RETURN PROPOSAL NO LATER THAN: 02/15/06 AT 2:00 PM CENTRAL TIME

	 	 	 
	MAILING INSTRUCTIONS:

	 	Print or type RFP Number and Return Due
Date on the lower left hand corner of the envelope or package.
Delivered Sealed Proposals must be in DPMM office (301 W High Street, Room
630) by the return date and time.

RETURN PROPOSAL AND AMENDMENT(S) TO:

	 	 	 	 	 	 	 
	 

	 	(U.S. Mail)
	 	 	 	(Courier Service)
	 

	 	DPMM
	 	or
	 	DPMM
	 

	 	PO BOX 809

JEFFERSON CITY MO 65102-0809
	 	 	 	301 WEST HIGH STREET, ROOM 630

JEFFERSON CITY MO 65101

CONTRACT PERIOD: July 1, 2006 through June 30, 2007

(with two additional one-year renewal periods at the State’s sole option)

DELIVER SUPPLIES/SERVICES FOB (Free on Board) DESTINATION TO THE FOLLOWING ADDRESS:

Department of Social Services

Division of Medical Services

P.O. Box 6500

Jefferson City, MO 65102-6500

The offeror hereby declares understanding, agreement and certification of compliance to provide the
items and/or services, at the prices quoted, in accordance with all terms and conditions,
requirements, and specifications of the original RFP as modified by
this and any previously issued RFP
amendments. The offeror should, as a matter of clarity and assurance, also sign and return all previously
issued RFP amendment(s) and the original RFP document. The offeror agrees that the
language of the original RFP as modified by this and any previously issued RFP amendments shall govern in the event of a conflict with his/her proposal.
The offeror further agrees that upon receipt of an authorized purchase order from the Division of
Purchasing and Materials Management or when a Notice of Award is signed and issued by an authorized
official of the State of Missouri, a binding contract shall exist between the offeror and the State
of Missouri.

SIGNATURE REQUIRED

	 	 	 
	LEGAL NAME OF ENTITY/INDIVIDUAL
	 
	 	 
	MAILING ADDRESS
	 	 
	 
	 	 
	CITY, STATE, ZIP CODE
	 	 
	 
	 	 
	CONTACT PERSON

	 	EMAIL ADDRESS
	 
	 	 
	PHONE NUMBER

	 	FAX NUMBER

	 	 	 	 	 
	TAXPAYER ID NUMBER (TIN)

	 	TAXPAYER ID (TIN) TYPE (CHECK ONE)
	 	VENDOR NUMBER (IF KNOWN)
	 

	 	___ FEIN      ___ SSN	 	 

	 	 	 
	VENDOR TYPE (CHECK ONE)
	 	 
	___ Corporation       ___ Individual 
     ___ State/Local Government      
___  Partnership      ___ Sole
Proprietor      ___ Other ___
	 
	AUTHORIZED SIGNATURE

	 	DATE
	 
	 	 
	PRINTED NAME

	 	TITLE

 

 

					
	RFP B3Z06118
	 	Amendment #002
	 	Page 2

Medicaid Managed Care — Central, Eastern, and Western Regions

Department of Social Services, Division of Medical Services

CONTRACT PERIOD: July 1, 2006 through June 30, 2007

(with two additional one-year renewal periods at the State’s sole option)

Prospective offerors are hereby advised of the following:

	1.	 	The return by date and time shall be February 15, 2006 at 2:00 PM Central Time in lieu of
February 10, 2006 at 2:00 PM Central Time.
	 
	2.	 	The following have been revised:

1.3.1 b.

2.12.5 d.

2.14.4

Attachment 6 revised to amend Exhibit 1

Attachment 10 revised to clarify the Annual Audit instructions

 

 

	 	 	 
	[SEAL]

	 	STATE OF MISSOURI

OFFICE OF ADMINISTRATION

DIVISION OF PURCHASING AND MATERIALS MANAGEMENT (DPMM)

REQUEST FOR PROPOSAL (RFP)

	 	 	 
	AMENDMENT NO.: 001

	 	REQ NO.: NR 886 25756004320
	RFP NO.: B3Z06118

	 	BUYER: Julie Kleffner
	TITLE: Medicaid Managed Care – Central, Eastern, & Western Regions

	 	PHONE NO.: (573) 751-7656
	ISSUE DATE: 01/31/06

	 	E-MAIL: Julie.Kleffner@oa.mo.gov

Amendment #002 changed the proposal receipt date from February 10, 2006 to February 15, 2006

RETURN PROPOSAL NO LATER THAN: 02/10/06 AT 2:00 PM CENTRAL TIME

			
	MAILING INSTRUCTIONS:	 	Print or type RFP Number and Return Due Date on the lower left hand corner of the
envelope or package. Delivered sealed proposals must be in DPMM office (301 W High Street, Room 630) by the return date and time.

RETURN PROPOSAL AND AMENDMENT(S) TO:

	 	 	 	 	 	 	 
	 

	 	(U.S. Mail)
	 	 	 	(Courier Service)
	 

	 	DPMM
	 	or
	 	DPMM
	 

	 	PO BOX 809
	 	 	 	301 WEST HIGH STREET, ROOM 630
	 

	 	JEFFERSON CITY MO 65102-0809
	 	 	 	JEFFERSON CITY MO 65101

	 	 	 
	CONTRACT PERIOD:

	 	July 1, 2006 through June 30, 2007
	 

	 	     (with two additional one-year renewal periods at the State’s sole option)

DELIVER SUPPLIES/SERVICES FOB (Free on Board) DESTINATION TO THE FOLLOWING ADDRESS:

Department of Social Services

Division of Medical Services

P.O. Box 6500

Jefferson City, MO 65102-6500

The offeror hereby declares understanding, agreement and certification of compliance to provide the
items and/or services, at the prices quoted, in accordance with all terms and conditions,
requirements, and specifications of the original RFP as modified by this and any previously issued
RFP amendments. The offeror should, as a matter of clarity and assurance, also sign and return all
previously issued RFP amendment(s) and the original RFP document. The offeror agrees that the
language of the original RFP as modified by this and any previously issued RFP amendments shall
govern in the event of a conflict with his/her proposal. The offeror further agrees that upon
receipt of an authorized purchase order from the Division of Purchasing and Materials Management or
when a Notice of Award is signed and issued by an authorized official of the State of Missouri, a
binding contract shall exist between the offeror and the State of Missouri.

SIGNATURE REQUIRED

	 	 	 
	LEGAL NAME OF ENTITY/INDIVIDUAL
	 	 
	 
	 	 
	MAILING ADDRESS
	 	 
	 
	 	 
	CITY, STATE, ZIP CODE
	 	 
	 
	 	 
	CONTACT PERSON

	 	EMAIL ADDRESS
	 
	 	 
	PHONE NUMBER

	 	FAX NUMBER

	 	 	 	 	 
	TAXPAYER ID NUMBER (TIN)

	 	TAXPAYER ID (TIN) TYPE (CHECK ONE)
	 	VENDOR NUMBER (IF KNOWN)
	 

	 	___ FEIN       ___ SSN	 	 
	 
	VENDOR TYPE (CHECK ONE)
	 	 	 	 
	___ Corporation       ___ Individual       ___ State/Local
Government       ___ Partnership       ___ Sole Proprietor       ___ Other ___

	 	 	 
	AUTHORIZED SIGNATURE

	 	DATE
	 
	 	 
	PRINTED NAME

	 	TITLE

 

 

					
	 	 	 	 	 
	B3Z06118
	 	Amendment No. 001
	 	Page 2

Medicaid Managed Care – Central, Eastern, and Western Regions

Department of Social Services, Division of Medical Services

	 	 	 
	CONTRACT PERIOD:

	 	July 1, 2006 through June 30, 2007
	 

	 	      (with two additional one-year renewal periods at the State’s sole option)

Prospective offerors are hereby advised of the following:

	1.	 	The following have been revised, inserted, deleted or renumbered:

1.3.1 c.

1.3.1 i.

1.3.1 l.

1.3.1 n.

1.3.1 o.

1.7.2 q.

2.5.5 b.

2.5.5 c.

2.6.2 t. 5)

2.6.2 v.

2.12.10

2.25.5

4.1.1

	Attachment 3 – All references to Attachment 3 shall be deemed to mean revised Attachment 3
	Attachment 6 – All references to Attachment 6 shall be deemed to mean revised Attachment 6

The State of Missouri anticipates that another amendment will be forthcoming at a later date.

 

 

	 	 	 
	[SEAL]

	 	STATE OF MISSOURI

OFFICE OF ADMINISTRATION

DIVISION OF PURCHASING AND MATERIALS MANAGEMENT (DPMM)

REQUEST FOR PROPOSAL (RFP)

	 	 	 
	RFP NO.: B3Z06118

	 	REQ NO.: NR 886 25756004320
	TITLE: Medicaid Managed Care – Central, Eastern, & Western Regions

	 	BUYER: Julie Kleffner
	ISSUE DATE: 01/10/06

	 	PHONE NO.: (573) 751-7656
	 

	 	E-MAIL: Julie.Kleffner@oa.mo.gov

RETURN PROPOSAL NO LATER THAN: 02/10/06 AT 2:00 PM CENTRAL TIME

			
	MAILING INSTRUCTIONS:	 	Print or type RFP Number and Return Due Date on the
lower left hand corner of the envelope or package.
Delivered sealed proposals must be in DPMM office
(301 W High Street, Room 630) by the return date
and time.

	 	 	 	 	 	 	 
	 

	 	(U.S. Mail)
	 	 	 	(Courier Service)
	RETURN PROPOSAL TO:

	 	DPMM
	 	or
	 	DPMM
	 

	 	PO BOX 809
	 	 	 	301 WEST HIGH STREET, RM 630
	 

	 	JEFFERSON CITY MO 65102-0809
	 	 	 	JEFFERSON CITY MO 65101

	 	 	 
	CONTRACT PERIOD:

	 	July 1, 2006 through June 30, 2007
	 

	 	      (with two additional one-year renewal periods at the State’s sole option)

DELIVER SUPPLIES/SERVICES FOB (Free on Board) DESTINATION TO THE FOLLOWING ADDRESS:

Department of Social Services

Division of Medical Services

P.O. Box 6500

Jefferson City, MO 65102-6500

The offeror hereby declares understanding, agreement and certification of compliance to provide the
items and/or services, at the prices quoted, in accordance with all requirements and specifications
contained herein and the Terms and Conditions Request for Proposal (Revised 01/03/06). The offeror
further agrees that the language of this RFP shall govern in the event of a conflict with his/her
proposal. The offeror further agrees that upon receipt of an authorized purchase order from the
Division of Purchasing and Materials Management or when a Notice of Award is signed and issued by
an authorized official of the State of Missouri, a binding contract shall exist between the offeror
and the State of Missouri.

SIGNATURE REQUIRED

	 	 	 
	LEGAL NAME OF ENTITY/INDIVIDUAL
	 	 
	 
	 	 
	MAILING ADDRESS
	 	 
	 
	 	 
	CITY, STATE, ZIP CODE
	 	 
	 
	 	 
	CONTACT PERSON

	 	EMAIL ADDRESS
	 
	 	 
	PHONE NUMBER

	 	FAX NUMBER

	 	 	 	 	 
	TAXPAYER ID NUMBER (TIN)

	 	TAXPAYER ID (TIN) TYPE (CHECK ONE)
	 	VENDOR NUMBER (IF KNOWN)
	 

	 	___ FEIN       ___ SSN	 	 
	 
	VENDOR TYPE (CHECK ONE)
	 	 	 	 
	___ Corporation       ___ Individual
      ___ State/Local Government       ___ Partnership
      ___ Sole Proprietor       ___ Other ___

	 	 	 
	AUTHORIZED SIGNATURE

	 	DATE
	 
	 	 
	PRINTED NAME

	 	TITLE

 

 

			
	 	 	 
	RFP B3Z06118
	 	Page 2

	1.	 	INTRODUCTION AND GENERAL INFORMATION
	 
	1.1	 	Introduction:
	 
	1.1.1	 	This document constitutes a request for competitive, sealed proposals from the health plan
provider community for becoming providers in the Missouri managed care program, hereinafter
referred to as “MC+ managed care” in the following regions of the State of Missouri:

	 	a.	 	Central Region: Audrain, Boone, Callaway, Camden, Chariton, Cole, Cooper,
Gasconade, Howard, Miller, Moniteau, Monroe, Montgomery, Morgan, Osage, Pettis,
Randolph, and Saline counties.
	 
	 	b.	 	Eastern Region: Franklin, Jefferson, Lincoln, St. Charles, St. Francois, Ste.
Genevieve, St. Louis, Warren, and Washington counties and St. Louis City.
	 
	 	c.	 	Western Region: Cass, Clay, Henry, Jackson, Johnson, Lafayette, Platte, Ray,
and St. Clair counties.

	1.1.2	 	Organization — This document, referred to as a Request for Proposal (RFP), is divided into
the following parts:

	 	1)	 	Introduction and General Information
	 
	 	2)	 	Performance Requirements
	 
	 	3)	 	General Contractual Requirements
	 
	 	4)	 	Proposal Submission Information
	 
	 	5)	 	Pricing Pages: The Pricing Pages are a separate link that must be downloaded
from the Division of Purchasing and Materials Management’s Internet web site at:
https://www.moolb.mo.gov. It shall be the sole responsibility of the offeror to obtain
the Pricing Pages. If the pricing page(s) are not downloaded and included with the
response, the response could be determined to be non-responsive and eliminated from
consideration for award.
	 
	 	6)	 	Exhibits A – B
	 
	 	7)	 	Terms and Conditions
	 
	 	8)	 	Attachments 1 – 14: The offeror is advised that attachments exist to this
document which provide additional information and instruction. These attachments are
separate links that must be downloaded from the Division of Purchasing and Materials
Management’s Internet web site at: https://www.moolb.mo.gov. It shall be the sole
responsibility of the offeror to obtain each of the attachments. The offeror shall not
be relieved of any responsibility for performance under the contract due to the failure
of the offeror to obtain a copy of the attachments.

	1.2	 	Pre-Proposal Conference and MC+ Managed Care Quality Assessment and Improvement Advisory
Groups Meeting:
	 
	1.2.1	 	A pre-proposal conference regarding this Request for Proposal will be held on January 24,
2006, at 10:00 a.m. in the Interpretive Center of the James C. Kirkpatrick State Information
Center, 600 West Main Street, Jefferson City, Missouri.
	 
	1.2.2	 	The MC+ Managed Care Quality Assessment and Improvement Advisory Groups quarterly meeting is
scheduled for January 25, 2006 at 10:30 a.m. in room 202 of the Howerton Court Building, 615
Howerton Court, Jefferson City, Missouri. During the meeting, portions of the RFP will be
discussed; specifically section 2.28.2 Adjustments for Performance Based on HEDIS Performance
Ratings and the Quality Strategy, Attachment 6.
	 
	1.2.3	 	All potential offerors are encouraged to attend this conference and the MC+ Managed Care
Quality Assessment and Improvement Advisory Groups quarterly meeting in order to ask questions
and provide comments on the RFP. Attendance is not required in order to submit a response;
however, offerors are encouraged to attend since information relating to this RFP will be
discussed in detail. The offeror should bring a copy of the RFP to the pre-proposal
conference since it will be used as the agenda for the pre-

 

 

			
	 	 	 
	RFP B3Z06118
	 	Page 3

	 	 	proposal conference . The offeror should also bring a copy of the RFP to the MC+ Managed
Care Quality Assessment and Improvement Advisory Groups quarterly meeting.
	 
	1.2.4	 	Offerors may submit questions regarding the RFP prior to the Pre-Proposal Conference to
allow time for the State of Missouri to prepare answers. However, the offeror should restate
each question for verbal response during the Pre-Proposal Conference and/or MC+ Managed Care
Quality Assessment and Improvement Advisory Groups quarterly meeting. Only those
questions/answers which necessitate changes to the RFP will be included in an amendment, if
any.
	 
	1.2.5	 	Offerors are strongly encouraged to advise the Division of Purchasing and Materials
Management within five (5) working days of the scheduled pre-proposal conference and/or MC+
Managed Care Quality Assessment and Improvement Advisory Groups quarterly meeting of any
special accommodations needed for disabled personnel who will be attending the conference
and/or meeting so that these accommodations can be made.
	 
	1.3	 	Available Documentation and Offeror’s Contact:

	1.3.1	 	The offeror may request a copy of any of the following documents by contacting Julie
Kleffner at the Division of Purchasing and Materials Management. Requests for copies may be
sent to Ms. Kleffner via fax at 573-526-9817, or emailed to Julie.Kleffner@oa.mo.gov, or
mailed to the Division of Purchasing and Materials Management, P.O. Box 809, Jefferson City,
MO 65102.

	 	a.	 	Overview — Division of Medical Services. Available via the Internet at the
Division of Medical Services’ website: www.dss.state.mo.us/dms (Look under Missouri
Medicaid Description and Missouri Medicaid History).

Paragraph 1.3.1 b. revised by Amendment #002

	 	b.	 	Quality Improvement System for Managed Care (QISMC)

Paragraph 1.3.1 c. revised by Amendment #001

	 	c.	 	Health Plan Record Layout Manual – available electronically at website
www.emomed.com (Look under Provider, Electronic Billing Layout, System Manuals, Health
Plan Layout Manual)
	 
	 	d.	 	Medicaid Fee-for-Service Pricing File available electronically at the Division
of Medical Service’ website: http://www.dss.mo.gov/dms/providers/pages/cptagree.htm
	 
	 	e.	 	Division of Medical Services MC+ Managed Care Policy Statements
	 
	 	f.	 	Missouri’s 1115 Waiver Amendment
	 
	 	g.	 	EPSDT Screening Codes and Reporting Methodology
	 
	 	h.	 	Historical Enrollment Data

Paragraph 1.3.1 i(MRDD Waiver Services) deleted by Amendment #001 and all other paragraphs
renumbered accordingly

	 	i.	 	Description of Member Satisfaction Survey Data Reporting
	 
	 	j.	 	Hospital Per Diem Rates
	 
	 	k.	 	Federal regulations regarding home health agencies are available via the
Internet at http://www.gpoaccess.gov/cfr/retrieve.html (42 CFR 484, Subpart A, B, C and
42 CFR 441.15).

Paragraph 1.3.1 l. revised by Amendment #001

	 	l.	 	Guidelines for Addressing Fraud and Abuse in managed Care”, is available via
the internet at http://new.cms.hhs.gov/FraudAbuseforProfs/02_MedicaidGuidance.asp
	 
	 	m.	 	Jackson County Consent Decree and Operational Guide

 

 

			
	 	 	 
	RFP B3Z06118
	 	Page 4

Paragraphs 1.3.1 n. and o. inserted by Amendment #001

	 	n.	 	Mercer presentation from the January 24, 2006 Pre-proposal Conference
	 
	 	o.	 	 Criteria for Post-Payment Review of Specialty Pediatric Hospital Discharges.

	1.3.2	 	All possible efforts have been made to ensure that the information provided in these
relevant documents is complete and current. However, the offeror shall not assume that such
information is indeed complete or current.
	 
	1.4	 	Questions:
	 
	1.4.1	 	All questions regarding this Request for Proposal and/or the competitive procurement process
must be directed to Julie Kleffner at the Division of Purchasing and Materials Management.
Questions may be faxed to Julie Kleffner at 573-526-9817, or emailed to
Julie.Kleffner@oa.mo.gov, or mailed to the Division of Purchasing and Materials Management,
P.O. Box 809, Jefferson City, MO 65102. All questions should be submitted three weeks prior
to the proposal receipt date specified on Page 1.
	 
	1.5	 	Description of Missouri MC+ Managed Care Program:
	 
	1.5.1	 	Effective July 1, 2006, the State of Missouri will continue a health care delivery program in
Audrain, Boone, Callaway, Camden, Cass, Chariton, Clay, Cole, Cooper, Franklin, Gasconade,
Henry, Howard, Jackson, Jefferson, Johnson, Lafayette, Lincoln, Miller, Moniteau, Monroe,
Montgomery, Morgan, Osage, Pettis, Platte, Randolph, Ray, Saline, St. Charles, St. Clair, St.
Francois, Ste. Genevieve, St. Louis, Warren, and Washington counties and St. Louis City to
serve MC+ managed care eligibles meeting specified eligibility criteria. The goal is to
improve the accessibility and quality of health care services for Missouri’s MC+ managed care
and State aid eligible populations, while controlling the program’s rate of cost increase.

	 	a.	 	The Missouri Department of Social Services, Division of Medical Services
intends to achieve this goal by enrolling MC+ managed care eligibles in comprehensive,
qualified health plans that contract with the State of Missouri to provide a specified
scope of benefits to each enrolled member in return for a capitated payment made on a
per member, per month basis.

	1.5.2	 	The health care delivery program was designed through a collaborative process that included
feedback from providers, consumers, health plans, communities, the State of Missouri
government agencies, and the Centers for Medicare and Medicaid Services (CMS) (formerly the
Health Care Financing Administration).
	 
	1.5.3	 	The Missouri Department of Social Services, Division of Medical Services has identified
eight (8) guiding principles for Missouri’s Medicaid Program as follows:

	 	1)	 	All recipients must have a medical home.
	 
	 	2)	 	Attention to wellness of the individual (i.e. education).
	 
	 	3)	 	Chronic care management.
	 
	 	4)	 	Care management – (resources focused towards people receiving the services they
need, not necessarily because the service is available).
	 
	 	5)	 	Appropriate setting at the right cost.
	 
	 	6)	 	Emphasis on the individual person.
	 
	 	7)	 	Evidenced based guidelines for improved quality care and use of resources.
	 
	 	8)	 	Encourage responsibility and investment on the part of the recipient to ensure
wellness.

 

 

			
	 	 	 
	RFP B3Z06118
	 	Page 5

	1.6	 	Program Management and Oversight:
	 
	1.6.1	 	In the State of Missouri, the Department of Social Services, Division of Medical Services is
officially designated with administration of the medical assistance and federal Medicaid
(Title XIX and Title XXI) programs. In addition to Division of Medical Services’ oversight,
CMS also monitors MC+ managed care activities through its Regional Office in Kansas City,
Missouri and its Center for Medicaid and State Operations, Division of Integrated Health
Systems in Baltimore, Maryland.
	 
	1.7	 	Missouri MC+ Managed Care Program Eligibility Groups:
	 
	1.7.1	 	For purposes of this Request for Proposal, the MC+ managed care population consists of
different eligibility groups which have been combined for the purpose of rate setting. The
qualifications for the program are based on a combination of factors, including family
composition, income level, insurance status, or pregnancy status depending on the eligibility
group in question. The eligibility groups and their current estimated sizes are described
below and summarized in Attachment 1.

	 	a.	 	Eligibility of Parents/Caretakers, Children, Pregnant Women, and Refugees:
Individuals covered under MC+ managed care within this group are as follows:

	 	1)	 	Parents/Caretakers and Children eligible under Medical Assistance for
Families, and Transitional Medical Assistance.
	 
	 	2)	 	Children eligible under MC+ for Poverty Level Children.
	 
	 	3)	 	Women eligible under Medical Assistance for Pregnant Women and 60
days post-partum.
	 
	 	4)	 	Individuals eligible under Recipients of Refugee Medical Assistance.
	 
	 	5)	 	Individuals eligible under the above groups and are MRDD Waiver
participants.
	 
	 	6)	 	Those that are eligible are defined by their MC+ Medical Eligibility
(ME) Codes as Specified in Attachment 1.

	 	b.	 	Eligibility of Other MC+ Children In the Care and Custody of the State and
Receiving Adoption Subsidy Assistance: All children in the care and custody of the
Department of Social Services; all children placed in a not-for-profit residential
group home by a juvenile court; all children receiving adoption subsidy assistance; and
all children receiving non-medical assistance (i.e., living expenses) that are in the
legal custody of the Department of Social Services shall remain the responsibility of
the Department of Social Services. Those that are eligible are defined by their MC+
Medical Eligibility code as specified in Attachment 1.
	 
	 	c.	 	1115 Demonstration Waiver: Missouri submitted an amendment to its pending 1115
demonstration waiver on August 26, 1997. The amendment is to Missouri’s 1115
demonstration waiver that was submitted on June 30, 1994. The 1115 demonstration
waiver as amended was approved April 28, 1998. The waiver amendment continues
Missouri’s commitment to improving medical care to low income children and supports
families moving from welfare into jobs.

	 	1)	 	Uninsured Children Below 200 Percent Under Title XIX, Coordinated
with Title XXI Funding: Uninsured children with net family income up to 200
percent of the federal poverty level (300 percent gross income) are covered under
an MC+ expansion. The MC+ expansion will occur under a Title XIX 1115 waiver.
Children will include individuals birth through age 18. No new eligibles will be
excluded because of pre-existing illness or condition. “Uninsured Children” are
persons up to nineteen years of age who have not had access to employer-subsidized
health care insurance or other health care coverage for six (6) months prior to

 

 

			
	 	 	 
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	 	 	 	application, are residents of the State of Missouri, and have parents or guardians
who meet the following requirements:

	 	•	 	Furnish to the Department of Social Services the uninsured child’s social
security number or numbers, if the uninsured child has more than one such
number;
	 
	 	•	 	Cooperate with the Department of Social Services in identifying and
providing information to assist the Division of Medical Services in pursuing
any third-party health insurance carrier who may be liable to pay for health
care;
	 
	 	•	 	Cooperate with the Department of Social Services, Family Support Division
in establishing paternity and in obtaining support payments, including medical
support;
	 
	 	•	 	Demonstrate, upon request, their child’s participation in wellness programs
including immunizations and a periodic physical examination. (This shall not
apply to any child whose parent or legal guardian objects in writing to such
wellness programs including immunizations and an annual physical examination
because of religious beliefs or medical contraindications);
	 
	 	•	 	Demonstrate annually that their total net worth does not exceed two hundred
fifty thousand dollars in total value; and
	 
	 	•	 	There will be protections against dropping or foregoing private coverage,
including a six (6) month waiting period and insurance availability screens
through the Division of Medical Services’ Health Insurance Premium Payment
(HIPP) program.

	 	Ø	 	 Any child identified as having special health care needs defined as a
condition which left untreated would result in the death or serious
physical injury of a child, that does not have access to affordable
employer-subsidized health care insurance will be exempt from the
requirement to be without health care coverage for six months in order to
be eligible for services.
	 
	 	Ø	 	A child shall not be subject to the 30-day waiting period as long as
the child meets all other qualifications for eligibility.

	 	d.	 	MC+ managed care eligibles in the above specified eligibility groups may
voluntarily disenroll from the MC+ Managed Care Program or choose not to enroll in the
MC+ Managed Care Program if they:

	 	1)	 	Are eligible for Supplemental Security Income (SSI) under Title XVI
of the Social Security Act;
	 
	 	2)	 	Are described in Section 501(a)(1)(D) of the Social Security Act;
	 
	 	3)	 	Are described in Section 1902(e)(3) of the Social Security Act;
	 
	 	4)	 	Are receiving foster care or adoption assistance under part E of
Title IV of the Social Security Act;
	 
	 	5)	 	Are in foster care or otherwise in out-of-home placement; or
	 
	 	6)	 	Meet the SSI disability definition as determined by the Department of
Social Services.

	1.7.2	 	Not Covered Under the MC+ Managed Care Program: The following individuals are not covered
under the MC+ Managed Care Program and receive their services through the Medicaid/MC+
fee-for-service program:

 

 

			
	 	 	 
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	 	a.	 	Permanently and Totally Disabled individuals eligible under ME Codes 04
(Permanently and Totally Disabled), 13 (Medical Assistance-PTD), 16 (Nursing Care-PTD),
and 11 (Medical Assistance (MA) Spenddown and Non-Spenddown, Old Age Assistance (OAA)).
	 
	 	b.	 	Individuals eligible under ME Code 14 (Nursing Care-OAA) residing in a nursing
home and receiving cash to apply toward their nursing home costs or a vendor payment
directly to a nursing home for their care through the Medicaid program.
	 
	 	c.	 	Individuals eligible under ME Codes 23 and 41 (MA ICF-MR Poverty) residing in a
State Mental Institution or an Intermediate Care Facility for the Mentally Retarded
(ICF/MR).
	 
	 	d.	 	Individuals eligible under ME Codes 28, 49, and 67 (Children placed in foster
homes or residential care by the Department of Mental Health).
	 
	 	e.	 	Pregnant women eligible under ME Code 58 and 59, the Presumptive Eligibility
Program for ambulatory prenatal care only.
	 
	 	f.	 	Individuals eligible under ME Codes 2, 3, 12, and 15 (Aid to the Blind and
Blind Pension).
	 
	 	g.	 	AIDS Waiver participants (individuals twenty-one (21) years of age and over).
	 
	 	h.	 	Any individual eligible and receiving either or both Medicare Part A and Part B
benefits.
	 
	 	i.	 	Individuals eligible under ME Codes 33 and 34 (MO Children with Developmental
Disabilities Waiver).
	 
	 	j.	 	Individuals eligible under ME Code 55 (Qualified Medicare Beneficiary – QMB).
	 
	 	k.	 	Children eligible under ME Code 65, placed in residential care by their
parents, if eligible for MC+/Medicaid on the date of placement.
	 
	 	l.	 	Uninsured women losing their MC+ eligibility 60 days after the birth of their
child would be eligible under ME Code 80 for women’s health services for one year plus
60 days, regardless of income level. This population will obtain their services
through the MC+ fee-for-service program.
	 
	 	m.	 	Individuals with ME code 81 (Temporary Assignment Category).
	 
	 	n.	 	Women eligible under ME codes 83 and 84 (Breast and Cervical Cancer Treatment).
	 
	 	o.	 	 Individuals eligible under ME code 87 (Presumptive Eligibility for Children).
	 
	 	p.	 	Individuals eligible under ME code 88 (Voluntary Placement).

Paragraph 1.7.2 q. inserted by Amendment #001

	 	q.	 	Individuals eligible under ME code 82 (MoRx)

	1.7.3	 	Where economically cost effective, the Division of Medical Services will use the Division of
Medical Services’ HIPP program to obtain available coverage through available commercial
insurance. Those services included in the comprehensive benefit packages described herein,
but not included in the commercial insurance service package, may be obtained through MC+
managed care or fee-for-service as appropriate.

 

 

			
	 	 	 
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	1.8	 	Information:
	 
	1.8.1	 	Although an attempt has been made to provide accurate and up-to-date information, the State
of Missouri does not warrant or represent that the background information provided herein
reflects all relationships or existing conditions related to this Request for Proposal.
	 
	1.8.2	 	The State of Missouri has previously contracted for these services through C302226001
through C302226004 for the Eastern and Central Regions and through C303182001 through
C303182004 for the Western Region. These contracts expire on June 30, 2006. A copy of the
contracts can be viewed and printed from the Division of Purchasing and Materials Management’s
Public Record Search and Retrieval System located on the Internet at:
http://www.oa.mo.gov/purch. In addition, all proposal and evaluation documentation leading to
the award of the expiring contracts may also be viewed and printed from the Division of
Purchasing and Materials Management’s Public Record Search and Retrieval System. Please
reference the Bid number B3Z02226 and B3Z03182 or any of the contract numbers when searching
for these documents. 

 

 

			
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2. CONTRACTUAL REQUIREMENTS

	2.1.1	 	The contractor (hereinafter referred to as the “health plan”) shall provide a managed care
medical service delivery system for the Department of Social Services, Division of Medical
Services (hereinafter referred to as the “state agency”), located in the State of Missouri
pursuant to the requirements contained herein.
	 
	2.1.2	 	Prior to performing services in each of the counties, the health plan shall:

Paragraph 2.1.2 a. revised by BAFO #002

	 	a.	 	Have and maintain a certificate of authority from the Department of Insurance
to establish and operate a health maintenance organization in all the counties
specified herein by no later than April 14, 2006 so the state agency can proceed with
open enrollment with only health plans that are appropriately licensed. In the event
the health plan is awarded a contract and fails to achieve appropriate licensure by
April 14, 2006, the contract shall be cancelled in its entirety;
	 
	 	b.	 	Understand that federal approval is required prior to commitment of the federal
financing share of funds under the contract;
	 
	 	c.	 	Participate in readiness reviews. If the health plan is new to the MC+ managed
care program, the state agency shall conduct on-site readiness reviews of the health
plan in order to document the status of the health plan with respect to meeting the
program requirements outlined herein. If the health plan has an established
relationship with the state agency, the state agency shall conduct off-site reviews of
the health plan in order to document the status of the health plan with respect to
meeting any new program requirements; and
	 
	 	d.	 	Submit to the state agency all policies and procedures that require prior
approval listed in Attachment 12. The health plan must submit all modifications,
additions, or deletions to such policies and procedures to the state agency at least
thirty (30) days prior to implementation. The health plan must operate in accordance
with such policies and procedures. The health plan must incorporate and implement any
revisions identified by the state agency to the health plan’s policies and procedures
within the time frame specified by the state agency. All other policies and procedures
required herein shall be submitted to the state agency on request.

	2.1.3	 	The health plan awarded a contract for the Eastern region shall provide services to individuals
determined eligible by the state agency for the Missouri MC+ Managed Care Program in all of
the following ten areas in the State of Missouri:

	 	a.	 	Franklin County
	 
	 	b.	 	Jefferson County
	 
	 	c.	 	Lincoln County
	 
	 	d.	 	St. Charles County
	 
	 	e.	 	St. Francois County
	 
	 	f.	 	Ste. Genevieve County
	 
	 	g.	 	St. Louis County
	 
	 	h.	 	Warren County
	 
	 	i.	 	Washington County
	 
	 	j.	 	St. Louis City

	2.1.4	 	The health plan awarded a contract for the Central region shall provide services to individuals
determined eligible by the state agency for the Missouri MC+ Managed Care Program in all of
the following eighteen areas in the State of Missouri:

	 	a.	 	Audrain County
	 
	 	b.	 	Boone County
	 
	 	c.	 	Callaway County
	 
	 	d.	 	Camden County

 

 

			
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	 	e.	 	Chariton County
	 
	 	f.	 	Cole County
	 
	 	g.	 	Cooper County
	 
	 	h.	 	Gasconade County
	 
	 	i.	 	Howard County
	 
	 	j.	 	Miller County
	 
	 	k.	 	Moniteau County
	 
	 	l.	 	Monroe County
	 
	 	m.	 	Montgomery County
	 
	 	n.	 	Morgan County
	 
	 	o.	 	Osage County
	 
	 	p.	 	Pettis County
	 
	 	q.	 	Randolph County
	 
	 	r.	 	Saline County

	2.1.5	 	The health plan awarded a contract for the Western region shall provide services to individuals
determined eligible by the state agency for the Missouri MC+ Managed Care Program in all of
the following nine areas in the State of Missouri:

	 	a.	 	Cass County
	 
	 	b.	 	Clay County
	 
	 	c.	 	Henry County
	 
	 	d.	 	Jackson County
	 
	 	e.	 	Johnson County
	 
	 	f.	 	Lafayette County
	 
	 	g.	 	Platte County
	 
	 	h.	 	Ray County
	 
	 	i.	 	St. Clair County

2.2 Health Plan Administration:

	2.2.1	 	The health plan shall have in place sufficient administrative staff and organizational
structure to comply with all requirements described herein. The health plan must be staffed
by qualified persons in numbers appropriate to the health plan’s size of enrollment. At a
minimum, the health plan must provide the following staff to perform the responsibilities
listed. Unless otherwise specified, the health plan may combine or split the listed
responsibilities among the health plan’s staff as long as the health plan demonstrates that
the responsibilities are being met. Similarly, the health plan may contract with a third
party (subcontractor) to perform one or more of these responsibilities.

	 	a.	 	A full time Medicaid Plan Administrator with clear authority over the general
administration and implementation of the requirements set forth herein.
	 
	 	b.	 	Clerical and support staff to ensure appropriate functioning of the health
plan’s operation.
	 
	 	c.	 	A Medical Director who shall be a Missouri-licensed physician. The Medical
Director shall be actively involved in all major clinical and quality program
components of the health plan. The Medical Director shall devote sufficient time to
the health plan to ensure timely medical decisions, including after hours consultation
as needed. The Medical Director shall be responsible for the sufficiency and
supervision of the health plan provider network. The Medical Director shall ensure
compliance with State and local reporting laws on communicable diseases, child abuse,
neglect, etc.
	 
	 	d.	 	A Dental Consultant who shall be a Missouri-licensed dentist. The Dental
Consultant shall devote sufficient time to the health plan to ensure timely dental
decisions and claim review.

 

 

			
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	 	e.	 	A full-time Chief Financial Officer to oversee the budget and accounting
systems implemented by the health plan.
	 
	 	f.	 	A Quality Assessment and Improvement and Utilization Management Coordinator who
shall be a Missouri-licensed registered nurse, nurse practitioner, or physician.
	 
	 	g.	 	A Special Programs Coordinator who shall be a Missouri-licensed social worker,
registered nurse including advanced practice nurse, physician, or physician’s
assistant; or have a Master’s degree in health services, public health, or health care
administration. In addition, the Special Programs Coordinator should be familiar with
the variety of services available through the Missouri human services agencies that
interface with health care. The duties of the Special Programs Coordinator shall
include care coordination with all stakeholders and providers involved in the care of
members. These stakeholders and providers may include, but not be limited to, the
state agency, the Department of Health and Senior Services, local public health
agencies, the Department of Mental Health, the Department of Elementary and Secondary
Education, the Family Support Division, Children’s Division, hospitals, the judicial
system, schools, and Community Mental Health Centers. The Special Programs Coordinator
shall provide timely and comprehensive facilitation of the identification of medically
necessary services and implementation of such when included in a member’s
Individualized Education Program/Individual Family Service Plan. The Special Programs
Coordinator is the point of contact for members, their representatives, providers, the
state agencies, and local public health agencies.
	 
	 	h.	 	A Mental Health Coordinator shall be a qualified mental health professional as
specified herein and possess, at a minimum, a master’s degree.
	 
	 	i.	 	Prior authorization staff shall be available to authorize services twenty-four
(24) hours per day, seven (7) days per week. This staff shall be directly supervised
by a Missouri-licensed registered nurse, physician, or physician’s assistant. Prior
approval functions for mental health services shall be performed by a qualified mental
health professional.
	 
	 	j.	 	Inpatient certification review staff shall conduct inpatient initial,
concurrent, and retrospective reviews. The review staff shall consist of registered
nurses, physicians, physician’s assistants, or licensed practical nurses experienced in
inpatient reviews and under the direct supervision of a registered nurse, physician, or
physician’s assistant.
	 
	 	k.	 	Member services staff shall coordinate communications with members and act as
member advocates. The health plan shall provide sufficient member services staff to
enable members to receive prompt resolution to their problems or inquiries.
	 
	 	l.	 	Provider services staff shall coordinate communications between the health plan
and providers. The health plan shall provide sufficient provider services staff to
enable providers to receive prompt resolution to their problems or inquiries.
	 
	 	m.	 	A Complaint, Grievance, and Appeal Coordinator shall manage and adjudicate
member and provider complaints, grievances, and appeals in a timely manner.
	 
	 	n.	 	Claims Administrator/Management Information System (MIS) Director.
	 
	 	o.	 	Compliance Officer.

	2.2.2	 	The health plan shall inform the state agency in writing within seven (7) calendar days of
staffing changes in the following key positions. The health plan shall fill vacancies in any
of these key positions with permanent qualified replacements within ninety (90) calendar days
of the departure of the former staff member.

 

 

			
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	 	a.	 	Medicaid Plan Administrator
	 
	 	b.	 	Medical Director
	 
	 	c.	 	Quality Assessment and Improvement and Utilization Management Coordinator
	 
	 	d.	 	Special Programs Coordinator
	 
	 	e.	 	Mental Health Coordinator
	 
	 	f.	 	Chief Financial Officer

	2.2.3	 	The health plan shall ensure that all staff have appropriate training, education,
experience, liability coverage, and orientation to fulfill the requirements of the positions
and have met all appropriate licensure requirements.
	 
	2.2.4	 	The health plan may not knowingly employ as a director, officer, partner, or person with
beneficial ownership of more than 5 percent of the health plan’s equity, a person who is
debarred, suspended, or otherwise excluded from participating in procurement activities under
the Federal Acquisition Regulation or from participating in non-procurement activities under
regulations issued pursuant to Executive Order No. 12549 or under guidelines implementing such
order; or is an affiliate (as defined in such Act) of such a person. In addition, the health
plan may not have an employment, consulting, or other agreement with such a person described
above for the provision of items and services that are significant and material to the health
plan’s obligations required herein.
	 
	2.2.5	 	The health plan shall require each physician providing services to members to have a unique
identifier in accordance with the system established under section 1173(b) of the Health
Insurance Portability and Accountability Act of 1996.
	 
	2.2.6	 	Non-Discrimination in Hiring and Provision of Services: The health plan shall ensure that
all federal and state laws, as amended, and policies of non-discrimination in hiring and the
provision of services are strictly enforced. The health plan shall comply with Title VI of
the Civil Rights Act of 1964, as amended; the Rehabilitation Act of 1973, as amended; Title IX
of the Education Amendments of 1972, as amended; the Age Discrimination Act of 1975, as
amended; and the American Disabilities Act of 1990, as amended.

	 	a.	 	The health plan shall incorporate in its policies, administration, and delivery
of services the values of:

	 	1)	 	Honoring member’s beliefs;
	 
	 	2)	 	Being sensitive to cultural diversity; and
	 
	 	3)	 	Fostering in staff and providers attitudes and interpersonal
communication styles which respect the member’s cultural backgrounds.

	 	b.	 	The health plan shall have specific policy statements on minority inclusion and
non-discrimination and procedures to communicate the policy statements and procedures
to subcontractors.
	 
	 	c.	 	The health plan shall not discriminate in regard to the participation,
reimbursement, or indemnification of any provider who is acting within the scope of his
or her license or certification under applicable State law, solely on the basis of that
license or certification. If a health plan declines to include individual or groups of
providers in its network, it must give the affected providers written notice of the
reason for its decision. The health plan’s provider selection policies and procedures
cannot discriminate against particular providers that serve high risk populations or
specialize in conditions that require costly treatment. This section may not be
construed to:

 

 

			
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	 	1)	 	Require the health plan to contract with providers beyond the number
necessary to meet the needs of its members;
	 
	 	2)	 	Preclude the health plan from using different reimbursement amounts
for different specialties or for different practitioners in the same specialty; or
	 
	 	3)	 	Preclude the health plan from establishing measures that are designed
to maintain quality of services, control costs, and are consistent with its
responsibilities to members.

2.3 Health Plan Provider Networks:

	2.3.1	 	The health plan shall establish and maintain health plan provider networks in geographically
accessible locations, in accordance with the travel distance standards specified herein,
comprised of hospitals, physicians, advanced practice nurses, mental health providers,
substance abuse providers, pharmacies, dentists, emergent and non-emergent transportation
services, etc., with sufficient capacity to make available all services in accordance with the
service accessibility standards specified herein. In order to maintain geographically
accessible locations, the health plan should look to providers in contiguous and other
counties for full development of the network.
	 
	2.3.2	 	Primary Care Provider Responsibilities: The health plan shall have written policies and
procedures for linking every member to a primary care provider. The primary care provider
must serve as the member’s initial and most important contact. As such, primary care provider
responsibilities must include at a minimum:

	 	a.	 	Maintaining continuity of each member’s health care.
	 
	 	b.	 	Making referrals for specialty care and other medically necessary services to
both in-network and out-of-network providers.
	 
	 	c.	 	Maintaining a comprehensive current medical record for the member, including
documentation of all services provided to the member by the primary care provider, as
well as any specialty or referral services, diagnostic reports, physical and mental
health screens, etc.
	 
	 	d.	 	Although primary care providers are responsible for the above activities, the
health plan must monitor the primary care providers’ actions for compliance with health
plan and MC+ Managed Care Program policies.
	 
	 	e.	 	Primary care providers may have formalized relationships with other primary
care providers to see their members for after hours care, during certain days, for
certain services, or other reasons to extend their practice. However, the primary care
provider shall be ultimately responsible for the above listed activities.

	2.3.3	 	Eligible Specialties: The health plan shall limit its primary care providers to licensed
residents specializing in family and general practice, pediatrics, obstetrics and gynecology
(OB/GYN), and internal medicine; registered nurses who are advanced practice nurses with
specialties in family practice, pediatric practice, and OB/GYN practice; and licensed
physicians in the following specialties: family and general practitioners, pediatricians,
OB/GYN, and internists.

	 	a.	 	To the maximum extent possible, the health plan should include all of these
specialties in its health plan provider network.

	2.3.4	 	Primary Care Provider Teams and Primary Care Clinics: The responsibilities of a primary
care provider team and a primary care clinic shall be the same as the responsibilities listed
herein for primary care providers.

 

 

			
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	 	a.	 	If the health plan provider network includes institutions with teaching
programs, primary care provider teams, comprised of residents and a supervising faculty
physician, may serve as a primary care provider. In addition, the health plan should
establish primary care provider teams that include advanced practice nurses or
physician assistants as recognized by the Board of Healing Arts who, at the member’s
discretion, may serve as the point of first contact for the member. In both instances,
the health plan shall organize its primary care provider teams so as to ensure
continuity of care to members and identify a “lead physician” within the team for each
member. The “lead physician” must be an attending physician and not a resident.
	 
	 	b.	 	The health plan may also elect to make available clinics to serve as primary
care providers. The primary care clinic must provide the range of services required of
all primary care providers. A centralized medical record shall be maintained on each
member enrolled with the primary care clinic.

	2.3.5	 	The health plan shall offer its members freedom of choice in selecting a primary care
provider. The number of members assigned to a primary care provider shall be decreased by the
health plan if necessary to maintain the appointment availability standards. To the degree
possible, these shifts should occur prospectively (before care has been initiated) and the
health plan should take steps to minimize the need for such shifts.
	 
	2.3.6	 	The health plan shall include a mix of mental health and substance abuse providers with
experience in treating children, adolescents, and adults in the health plan provider network
to ensure a broad range of treatment options are available.

	 	a.	 	To the maximum extent possible, the health plan should include Community Mental
Health Centers (CMHC) in the health plan provider network. A listing of CMHC is
provided in Attachment 5.
	 
	 	b.	 	The mental health provider network may include licensed psychiatrists, licensed
psychologists, licensed psychiatric advance practice nurses, provisional licensed
professional counselors, licensed professional counselors, provisional licensed
clinical social workers, licensed clinical social workers, licensed clinical nurse
specialists, licensed home health, licensed psychiatric nurse, and state certified
mental health or substance abuse program. To be considered adequate, the mental health
provider network must, at a minimum, include Qualified Mental Health Professionals
(QMHP), Qualified Substance Abuse Professionals (QSAP), licensed psychiatrists,
licensed psychologists, licensed psychiatric nurses, licensed professional counselors,
licensed clinical social workers, and licensed clinical nurse specialists.

	 	1)	 	A QMHP shall be one of the following and provide services within
their defined scope of practice:

	 	•	 	A physician, licensed under Missouri state law to practice medicine or
osteopathy who has either specialized training in mental health services or
one (1) year of experience, under supervision, in treating problems related to
mental illness;
	 
	 	•	 	A psychiatrist, a physician licensed under Missouri state law, who has
successfully completed a training program in psychiatry approved by the
American Medical Association, the American Osteopathic Association, or other
training program identified as equivalent by the state agency;
	 
	 	•	 	A psychologist licensed under Missouri state law to practice psychology
with specialized training in mental health services;
	 
	 	•	 	A professional counselor licensed under Missouri state law to practice
counseling who has specialized training in mental health services;

 

 

			
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	 	•	 	A licensed clinical social worker or a clinical social worker with a
Master’s Degree in social work from an accredited program who has specialized
training in mental health services;
	 
	 	•	 	A psychiatric nurse, a registered professional nurse, licensed under
Missouri state law who has at least two (2) years of experience in a
psychiatric setting or a Master’s Degree in psychiatric nursing; or
	 
	 	•	 	An individual possessing a Master’s Degree or Doctorate Degree in
counseling and guidance, rehabilitation counseling, vocational counseling,
psychology, pastoral counseling, family therapy, social work, or a related
field, who has successfully completed a practicum or has one (1) year of
experience under the supervision of a mental health professional.

	 	2)	 	A QSAP shall be one of the following and provide services within
their defined scope of practice:

	 	•	 	A counselor, psychologist, clinical social worker, or physician licensed in
Missouri who has at least one (1) year of full-time experience in the
treatment or rehabilitation of substance abuse;
	 
	 	•	 	A graduate of an accredited college or university with a Master’s Degree in
social work, counseling, psychology, psychiatric nursing, or closely related
field who has at least two (2) years of full-time experience in the treatment
or rehabilitation of substance abuse;
	 
	 	•	 	A graduate of an accredited college or university with a Bachelor’s Degree
in social work, counseling, psychology, or closely related field who has at
least three (3) years of full-time experience in the treatment or
rehabilitation of substance abuse; or
	 
	 	•	 	An alcohol, drug, or substance abuse counselor certified by the Missouri
Substance Abuse Counselors Certification Board, Inc.

	2.3.7	 	Mental Health and Substance Abuse In-Network Self Referrals: The health plan shall have
written policies and procedures that permit members to seek in-network mental health services
and substance abuse services without a referral or authorization from the primary care
provider. The policies and procedures shall permit members to contact an in-network mental
health and substance abuse provider directly and shall provide for the authorization of at
least four (4) visits annually without prior authorization requirements. Health plan mental
health and substance abuse providers shall complete a health status screen, at the initial
point of contact and as part of the re-assessment process for members in treatment. Members
with physical health conditions as indicated by the screen shall be referred to their primary
care provider for evaluation and treatment of the physical health condition.
	 
	2.3.8	 	Physician Specialists: Because of the large number of physician specialties that exist, the
health plan is not required to maintain specific member-to-specialist provider ratios.
However, the health plan must provide adequate access to physician specialists for primary
care provider referrals and employ or contract with physician specialists in sufficient
numbers to ensure specialty services can be made available in a timely manner. The health
plan shall have protocols for coordinating care between primary care providers and specialists
which include the expected response time for consults between primary care providers and
specialists.
	 
	2.3.9	 	Any Willing Pharmacy Provider: Any pharmacy, licensed without restriction under chapter
338, Revised Statutes of the State of Missouri (RSMo), as amended, and participating as an
approved provider in the Missouri Medicaid program, which is qualified under the terms of the
health plan and willing to accept the health plan’s operating terms including, but not limited
to, its schedule of fees, covered expenses, and quality standards, shall be allowed to
participate in the health plan. Nothing shall prevent a

 

 

			
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	 	 	health plan from instituting reasonable credentialing criteria, requiring fee discounts, or establishing any other
reasonable measure designed to maintain quality or control costs.
	 
	2.3.10	 	Federally Qualified Health Centers and Rural Health Clinics: The health plan shall include
Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) in the health plan
provider network, unless the health plan can demonstrate that it has both adequate capacity
and an appropriate range of services to provide care for the expected enrollment in the region
without contracting with FQHCs or RHCs. (A description of FQHC/RHC services is included in
Attachment 2. A listing of FQHCs and RHCs are provided in Attachment 5.) If the health plan
is competing against an FQHC or RHC owned health plan, the health plan shall not be required
to comply with the previous requirement, although the health plan still must provide the
FQHC/RHC services that are within the covered benefits of the MC+ managed care program. The
health plan shall have protocols for coordinating care between the primary care provider and
the FQHC and RHC provider and indicate the expected response time for consults between the
FQHC and RHC and the primary care provider.
	 
	2.3.11	 	Family Planning and Sexually Transmitted Disease (STD) Treatment Providers: The health plan
should include Title X and sexually transmitted disease treatment providers in the health plan
provider network to serve members covered under the comprehensive and extended family
planning, women’s reproductive health, and sexually transmitted diseases benefit packages.
The health plan shall allow for full freedom of choice for the provisions of these services.
A listing of Family Planning and STD treatment providers is provided in Attachment 5.
	 
	2.3.12	 	Local Public Health Agencies: The health plan should include local public health agencies
in the health plan provider network for the public health services described herein or for
other services. (A listing of local public health agencies is provided in Attachment 5.)
However, in order to ensure care coordination of members seeking services at a local public
health agency, the health plan should establish an agreement with local public health agencies
describing, at a minimum, care coordination, medical record management, and billing
procedures. Requirements for reimbursement for certain services are specified in the
Performance Requirements segment regarding public health programs and mandated health plan
reimbursements. Attachment 4 lists a number of conditions for which the health plan shall
report to or cooperate with local public health agencies. In addition, the health plan may
wish to contract with local public health agencies, as defined above, to provide other health
plan covered services.

	 	a.	 	All statutorily mandated disease or condition reporting requirements remain,
regardless of the site of the service. The health plan shall provide a list of their
contracted laboratories to the Missouri Department of Health and Senior Services by
July 1 each year.

	2.3.13	 	Network Changes: The health plan shall notify the state agency within five (5) business days
of first awareness/notification of change to the composition of the health plan provider
network or the health care service subcontractors’ provider network that materially affect the
health plan’s ability to make available all covered services in a timely manner. The health
plan shall have procedures to address changes in the health plan provider network that
negatively affect the ability of members to access services, including access to a culturally
diverse provider network. Material changes in network composition that negatively affect
member access to services may be grounds for contract cancellation or State determined
sanctions.
	 
	2.3.14	 	Mainstreaming: The state agency considers mainstreaming of MC+ managed care members into
the broader health delivery system to be important. The health plan therefore must ensure
that all of the in-network providers accept members for treatment. The health plan also must
accept responsibility for ensuring that in-network providers do not intentionally segregate
members in any way from other persons receiving services.

	 	a.	 	To ensure mainstreaming of members, the health plan shall take affirmative
action so that members are provided covered services without regard to race, color,
creed, sex, religion, age, national origin, ancestry, marital status, sexual
preference, health status, income status, program membership, or

 

 

			
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	 	 	 	physical or mental disability, except where medically indicated. Examples of prohibited practices
include, but are not limited to, the following:

	 	1)	 	Denying or not providing to a member any covered service or
availability of a facility.
	 
	 	2)	 	Providing to a member any covered service which is different, or is
provided in a different manner, or at a different time from that provided to other
members, other public or private patients, or the public at large.
	 
	 	3)	 	Subjecting a member to segregation or separate treatment in any
manner related to the receipt of any covered service.

	 	b.	 	If the health plan knowingly executes a subcontract with a provider with the
intent of allowing or permitting the subcontractor to implement barriers to care (i.e.,
the terms of the subcontract are more restrictive than the contract), the State shall
consider the health plan to have breached the provisions and requirements of the
contract. In addition, if the health plan becomes aware of any of its existing
subcontractors’ failure to comply with this section and does not take action to correct
this within thirty (30) calendar days, the State shall consider the health plan to have
breached the provisions and requirements of the contract.

	2.3.15	 	The health plan shall comply with any applicable federal requirements with respect to home
health agencies, as amended.
	 
	2.3.16	 	School Based Dental Services: The state agency has reimbursed dental providers for the
provision of preventive dental services provided to children in a school setting. These
preventive services have included dental exams, prophylaxis, and sealants. The state agency
is committed to the continuation of such programs for members enrolled with a health plan.
The health plan shall contract and reimburse any licensed dental providers who provide such
services in a school setting. The dental providers must be qualified under the terms of the
health plan and willing to accept the health plan’s operating terms, including but not limited
to, its fee schedule, covered expenses, and quality standards, to be allowed to participate in
the health plan provider network. Nothing shall prevent a health plan from instituting
reasonable credentialing criteria for school-based dental services or establishing other
reasonable measures designed to maintain quality of care or control costs.
	 
	2.3.17	 	Tertiary Care: Tertiary care is defined as health services provided by highly-specialized
providers, such as medical sub-specialists. These services frequently require complex
technological and support facilities. The health plan shall provide tertiary care services
including trauma centers, burn centers, level III (high risk) nurseries, rehabilitation
facilities, and medical sub-specialists available twenty-four (24) hours per day in the
region. If the health plan does not have a full range of tertiary care services, the health
plan must have a process for providing such services including transfer protocols and
arrangements with out-of-network providers.
	 
	2.3.18	 	Specialty Pediatric Hospitals: The health plan shall include specialty pediatric hospitals
as defined in 13 CSR 70-15.010 (2) (P), as amended, in the health plan provider network.
	 
	2.4	 	Payments to Providers:
	 
	 	 	The state agency believes that one of the advantages of a managed care system is that it
permits the health plan and providers to enter into creative payment arrangements intended
to encourage and reward effective utilization management and quality of care. The state
agency therefore shall give the health plan and providers as much freedom as possible to
negotiate mutually acceptable payment rates and payment time frames. All subcontracts shall
contain the time frames for paying in-network providers for covered services. However,
regardless of the specific arrangements the health plan makes with providers, the health
plan shall make timely payments to both in-network and out-of-network providers, subject to
the conditions described below. All disputes between the health plan and in-network and
out-of-network

 

 

			
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	 	 	providers shall be solely between such providers and the health plan. In the
case of any disputes regarding payment for covered services between the health plan and
providers, the member shall not be charged for any of the disputed costs. This agreement
shall only be overcome by written evidence of an agreement between the provider and the
member indicating that the member accepts the status and liabilities of a private pay
patient. The health plan shall make it clear to members that all covered services are
available to the member at no cost subject to any applicable co-pays. The private pay
agreement shall only be for services not included in the comprehensive benefit package.
	 
	2.4.1	 	Retroactive Eligibility Period: Except for newborns, the health plan shall not be
responsible for any payments owed to providers for services rendered prior to a member’s
enrollment even if they fell within the established period of retroactive eligibility.
	 
	2.4.2	 	Claims Processing Requirements: The claim processing requirements are set forth by RSMo
376.383 and RSMo 376.384, as amended.
	 
	2.4.3	 	Clean Claims: Clean claim means a claim that can be processed without obtaining additional
information from the provider of the service or from a third party.
	 
	2.4.4	 	Inappropriate Payment Denials: If the health plan has a pattern of inappropriately denying
or delaying payments for services, the health plan may be subject to suspension of new
enrollments, withholding in full or in part of capitation payments, contract cancellation, or
refusal to contract in a future time period. This applies not only to cases where the state
agency has ordered payment after appeal but to cases where no appeal has been made (i.e., the
state agency is knowledgeable about the documented abuse from other sources).
	 
	2.4.5	 	Copayment Requirements and Member Participation in Pharmacy Professional Dispensing Fee:

	 	a.	 	Copayment requirements do not apply to MC+ Managed Care members.
	 
	 	b.	 	Member Participation in Pharmacy Professional Dispensing Fee

	 	1)	 	Unlike traditional copayment requirements, the current Missouri
Medicaid Recipient Pharmacy fee requirement is considered a portion of the
professional dispensing fee and is not deducted from the reimbursement to
providers. Therefore, the member portion of the pharmacy dispensing fee is
required to be collected, according to current Medicaid policy, for pharmacy
services provided by the health plan. The provider must charge and collect
dispensing fees as specified in accordance with section 208.152 RSMo, as amended.
Providers shall not deny or reduce services to members solely on the basis of the
member’s inability to pay the fee when charged. A member’s inability to pay a
required amount as due and charged when a service is delivered, shall in no way
extinguish the member’s liability to pay the amount due. Fee responsibility and
amounts collectible shall be as follows:

	 	 	 	 	 
	 	 	Member Participation in Pharmacy
	Ingredient Cost for Each Item of Service	 	Professional Dispensing Fee
	$10.00 or Less:
	 	 	$0.50	 
	$10.01 to $25.00:
	 	 	$1.00	 
	$25.01 or More:
	 	 	$2.00	 

	 	2)	 	Under current pharmacy dispensing fee policy, all Missouri eligible
recipients are subject to the fee requirement when provided covered pharmacy
services, with the exception of the following:

	 	•	 	Beneficiaries under age 19.

 

 

			
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	 	•	 	Services related to Early Periodic Screening, Diagnosis and Treatment
(EPSDT): Those drugs which are prescribed and identified as relating to an
EPSDT program screening or referral services must be confirmed as such to the
dispensing provider through one of the following methods:

	 	Ø	 	The prescribing provider identifies on the prescription that it relates
to an EPSDT examination and treatment; or
	 
	 	Ø	 	The prescribing provider verbally states that the prescription relates
to an EPSDT examination and treatment in cases of telephone prescribing.
This verbal assertion must be included in the dispensing provider’s
reduction into writing of the prescription.

	 	•	 	Institutionalized members residing in a skilled nursing facility,
psychiatric hospital, residential care facility, or adult boarding home.
	 
	 	•	 	Foster Care children.
	 
	 	•	 	All Medicare/Medicaid crossover claims as primary coverage as afforded by
the Medicare program.
	 
	 	•	 	Those services specifically identified as related to Family Planning
services.
	 
	 	•	 	Emergency services.
	 
	 	•	 	Services provided to pregnant women which are directly related to the
pregnancy or a complication of the pregnancy.

	 	3)	 	Participation in the health plan provider network shall be limited to
providers who accept, as payment in full, the amounts paid by the health plan plus
any fee amount required of the member and collected by the provider.

	2.4.6	 	Pharmacy Dispensing Fee: The health plan shall pay a pharmacy dispensing fee of $4.09 to
each qualifying pharmacy for the first 1,000 prescriptions filled in any calendar quarter.
The reimbursement of a pharmacy dispensing fee shall be available only to corporations,
partnerships, or individual proprietorships with less than 25 employees who operate pharmacies
or pharmacy franchises and to public health entities owned and operated by a state, county, or
local government agency and where the entity is a hospital which qualifies as a first-tier 10%
add-on disproportionate share hospital in accordance with 13 CSR 70-15.010. The health plan
shall identify its pharmacies that qualify. The health plan shall supply the state agency
with a list of those pharmacies identified to qualify for a pharmacy dispensing fee
reimbursement upon request.
	 
	2.4.7	 	Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs): If the health
plan includes subcontracted FQHCs or RHCs in the health plan provider network, the FQHC or RHC
is entitled to reimbursement of reasonable costs from the state agency and any differential
payment paid by the state agency.

	 	a.	 	The health plan shall reimburse the FQHC/RHC at the same reimbursement level as
other providers for the same services. The state agency shall perform reconciliation
between the health plan reimbursement and the FQHC/RHC’s reasonable costs for the
covered services provided under the contract. The FQHC/RHC must fully comply with the
state agency’s payment and billing systems, and provide the state agency with all cost
reporting information required by the state agency to verify reasonable costs and apply
applicable reasonable cost reimbursement principles. The health plan shall submit a
list of its contracted FQHCs and RHCs to the state agency annually at the start of each
contract period.

 

 

			
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	 	b.	 	If the health plan contracts with FQHCs or RHCs, the health plan shall fulfill
the following:

	 	1)	 	Billing for Services Provided by an FQHC or RHC: The FQHC/RHC must
bill using a valid FQHC/RHC’s Medicaid Provider Number. The health plan shall
include this Medicaid Provider Number on FQHC/RHC claims as follows:

	 	•	 	FQHC Medical and Dental Claims: The health plan shall submit the FQHC’s
Missouri Medicaid Provider Number on the NSF layout, record ‘FAO’, within
field number 23. This field is referenced as the Rendering Provider Number.
	 
	 	•	 	FQHC Home Health Claims: The health plan shall submit the FQHC’s Missouri
Medicaid Provider Number on the UB92 layout, record ‘80’, within field number
11. This field is referenced as the Other Provider.
	 
	 	•	 	FQHC Pharmacy Claims: The health plan shall submit the FQHC’s Missouri
Medicaid Provider Number on the NCPDP 3C layout, field number 411. This field
is referenced as the Prescriber ID.
	 
	 	•	 	RHC Claims: The health plan shall submit the RHC’s Missouri Medicaid
Provider Number on the UB92 layout, record 80’, within field number 11. This
field is referenced as the Other Provider.

	 	2)	 	The FQHC/RHC must bill its usual and customary amount for all payor
classes. The health plan shall include the billed amount when the health plan
submits the encounter claims to the state agency.
	 
	 	3)	 	Reporting Requirements for Services Provided by an FQHC or RHC

	 	•	 	The health plan shall submit Schedule M-1 included with Attachment 7
documenting the accepted charges, denied charges, and payments for each
contracted RHC/FQHC. The health plan shall submit Schedule M-1 thirty (30)
calendar days after the month end for services provided by the contracted
FQHC/RHC. Attachment 7 also provides the instructions for completing Schedule
M-1.
	 
	 	•	 	The health plan shall submit Schedule M-2 included with Attachment 7
documenting the accepted charges, denied charges, and payments for each
contracted RHC/FQHC for the FQHC’s/RHC’s entire fiscal year. The health plan
shall submit Schedule M-2 within 14 business days of request by the state
agency for MC+ managed care services provided by contracted FQHC/RHC during
the reporting period requested. Attachment 7 also provides the instructions
for completing Schedule M-2.
	 
	 	•	 	Health plan records applicable to a FQHC/RHC are subject to audit by the
state agency or its contracted agent.

2.4.8 Payment for Emergency Services and Post-stabilization Care Services:

	 	a.	 	The health plan shall cover and pay for emergency services regardless of
whether the provider that furnishes the services has a contract with the health plan.

	 	1)	 	The state agency encourages the health plan and providers to reach
agreement on payment for services.
	 
	 	2)	 	The health plan shall pay out-of-network providers for emergency
services at the current Missouri Medicaid program rates in effect at the time of
service unless the health plan and provider have negotiated a mutually acceptable
rate.

 

 

			
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	 	b.	 	The health plan may not deny payment for treatment obtained under either of the
following circumstances:

	 	1)	 	A member had an emergency medical condition, including cases in which
the absence of immediate medical attention would not have had the outcomes
specified in the definition of emergency medical condition specified herein.
	 
	 	2)	 	A representative of the health plan instructs the member to seek
emergency services.

	 	c.	 	The health plan shall not limit what constitutes an emergency medical condition
as defined herein on the basis of lists of diagnoses or symptoms.
	 
	 	d.	 	The health plan shall not refuse to cover emergency services based on the
emergency room provider, hospital, or fiscal agent not notifying the member’s primary
care provider or the health plan of the member’s screening and treatment within ten
(10) calendar days of presentation for emergency services.
	 
	 	e.	 	A member who has an emergency medical condition may not be held liable for
payment of subsequent screening and treatment needed to diagnose the specific condition
or stabilize the patient.
	 
	 	f.	 	The attending emergency physician, or the provider actually treating the
member, is responsible for determining when the member is sufficiently stabilized for
transfer or discharge, and that determination is binding on the health plan.
	 
	 	g.	 	The health plan must be financially responsible for post-stabilization care
services obtained within or outside the health plan that are pre-approved by a health
plan provider or other health plan representative.
	 
	 	h.	 	The health plan must be financially responsible for post-stabilization care
services obtained within or outside the health plan that are not pre-approved by a
health plan provider or other health plan organization representative, but administered
to maintain the enrollee’s stabilized condition within thirty (30) minutes of a request
to the health plan for pre-approval of further post-stabilization care services.
	 
	 	i.	 	The health plan must be financially responsible for post-stabilization care
services obtained within or outside the health plan that are not pre-approved by a
health plan provider or other health plan representative, but administered to maintain,
improve, or resolve the enrollee’s stabilized condition if:

	 	1)	 	The health plan does not respond to a request for pre-approval within
thirty (30) minutes;
	 
	 	2)	 	The health plan cannot be contacted; or
	 
	 	3)	 	The health plan representative and the treating physician cannot
reach an agreement concerning the member’s care and a health plan physician is not
available for consultation. In this situation, the health plan must give the
treating physician the opportunity to consult with a health plan physician and the
treating physician may continue with care of the patient until a health plan
physician is reached or one of the criteria in subparagraph l below is met.

	 	j.	 	The health plan must limit charges to members for post-stabilization care
services to an amount no greater than what the health plan would charge the member if
he or she had obtained the services through the health plan.
	 
	 	k.	 	The health plan shall negotiate mutually acceptable payment rates with
out-of-network providers for post-stabilization services for which the health plan has
financial responsibility.

 

 

			
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	 	l.	 	The health plan’s financial responsibility for post-stabilization care services
it has not pre-approved ends when:

	 	1)	 	A health plan physician with privileges at the treating hospital
assumes responsibility for the member’s care;
	 
	 	2)	 	A health plan physician assumes responsibility for the member’s care
through transfer;
	 
	 	3)	 	A health plan representative and the treating physician reach an
agreement concerning the enrollee’s care; or
	 
	 	4)	 	The member is transferred.

	2.4.9	 	The health plan shall maintain the fee schedule for dental services located in Attachment 14
at no lower than the Medicaid fee-for-service fee schedule in effect at the time of service.
	 
	2.4.10  	 	Specialty Pediatric Hospitals. The health plan shall reimburse specialty pediatric
hospitals as defined in 13 CSR 70-15.010 (2) (P) at no lower than the Medicaid fee-for-service
fee schedule in effect at the time of service unless otherwise negotiated with the provider.
	 
	2.4.11	 	A health plan shall pay for services furnished outside their service area to the same extent
that it would pay for services furnished within their service area if the services are
furnished to a member and any of the following conditions are met:

	 	a.	 	Medical services are needed because of a medical emergency;
	 
	 	b.	 	Medical services are needed and the member’s health would be endangered if he
were required to travel to member’s residence:
	 
	 	c.	 	The health plan determines, on the basis of medical advice, that the needed
medical services, or necessary supplementary resources, are more readily available
outside the service area. These services are subject to the health plan’s prior
authorization and concurrent review process.

	2.5	 	Eligibility Determinations:
	 
	 	 	The Missouri Department of Social Services, the Family Support Division performs eligibility
determinations. Trained staff are stationed full-time at field offices located throughout
the State and on a periodic basis at health care provider sites that serve large numbers of
MC+ members.
	 
	2.5.1	 	Health Plan Lock-In: All members will have a twelve (12) month lock-in to provide a solid
continuum of care. Once a member chooses a health plan or is assigned to a health plan, the
member will have ninety (90) calendar days from the effective date of coverage with the health
plan in which to change health plans for any reason. This applies to the member’s initial
enrollment and to any subsequent enrollment periods where the member changed health plans.
All transfers between health plans that members request during the first ninety (90) calendar
days following initial enrollment shall be granted without review by the state agency. Both
the 90-day and the 12-month enrollment period begin on the same day. Children in COA 4 shall
be allowed automatic and unlimited changes in health plan choice as often as circumstances
necessitate.
	 
	2.5.2    	 	Open Enrollment: The state agency may conduct an open enrollment for the contract period.
The state agency may at its sole option adjust enrollment during the transition between
contract periods.

	 	a.	 	Annual Open Enrollment: The state agency shall give members an annual open
enrollment period prior to their 12-month enrollment anniversary date with the health
plan. The state agency shall provide an open enrollment notice to members at least
sixty (60) calendar days before each annual enrollment opportunity.

	2.5.3    	 	Enrollment Counseling: The state agency shall make available helpline operators to all
program MC+ managed care eligibles to provide assistance in selecting and enrolling into a
health plan through the operation of a toll-free telephone line. Helpline operators also
shall be available by telephone to assist

 

 

			
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	 	 	MC+ managed care eligibles who would like to change
health plans (e.g., during open enrollment). MC+ managed care eligibles shall be offered the
assistance of a helpline operator when needed. The helpline operator responsibilities shall
include the following:

	 	a.	 	Educating the family about managed care in general, including the requirement
to enroll in a health plan, the way services typically are accessed under managed care,
the role of the primary care provider, the health plan member’s right to choose a
primary care provider subject to the capacity of the provider, the responsibilities of
the health plan member, and the member’s rights to file grievances and appeals and to
request a State Fair Hearing.
	 
	 	b.	 	Educating the family about benefits available through the health plan, both
in-network and out-of-network.
	 
	 	c.	 	Informing the family of available health plans and outlining criteria that
might be important when making a choice (e.g., presence or absence of the family’s
existing provider in the health plan provider network).
	 
	 	d.	 	Identifying any sources of Third Party Liability that were not identified by
the FSD eligibility technician.
	 
	 	e.	 	Administering a health plan screen when possible, as designated by the state
agency, that collects baseline health status data to be used as part of the health plan
program evaluation. Any baseline health status data shall be made available to the
health plan. (See Attachment 8 for the most current version.)
	 
	 	f.	 	Explaining options for obtaining services outside the health plan network.
	 
	 	g.	 	Providing a listing of the health plan primary care providers generated from
the provider demographic electronic file submitted by the health plan to the state
agency.

	2.5.4	 	Voluntary Selection of Health Plan: Missouri MC+ managed care eligibles shall be given
fifteen (15) calendar days from the time of their eligibility for managed care to select a
health plan. All members of a family shall be encouraged to select the same health plan. If
a family does not select a health plan within the fifteen (15) day window, the state agency
shall automatically assign the family to a health plan.

	2.5.5	 	Automatic Assignment Into Health Plans:

	 	a.	 	The state agency shall employ an algorithm to assign to the health plan, on a
prorated basis, any MC+ managed care eligibles who do not make a voluntary selection of
a health plan during open enrollment. The algorithm shall be based on the following:

	 	1)	 	If the MC+ managed care eligible’s case head is enrolled with a
health plan, the MC+ managed care eligible shall be assigned to that health plan.
If not, the next step in the algorithm shall be followed.
	 
	 	2)	 	If the MC+ managed care eligible is included in a case where another
member is enrolled with a health plan, the MC+ managed care eligible shall be
assigned to that health plan. If not, the MC+ managed care eligible shall be
assigned randomly.

Paragraph 2.5.5 b. revised by Amendment #001

	 	b.	 	Eastern/Western Regions: The random auto assignment shall be based on the total
evaluation determined by the State of Missouri (see Proposal Submission Information
section).

Paragraph 2.5.5 c. inserted by Amendment #001

	 	c.	 	Central Region: The random auto assignment shall be based on the inclusion of
health plan signed contracts with acute care safety net hospitals, as defined in 13 CSR
70-15.010 of the Code of State

 

 

			
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	 	 	 	Regulations, as amended. (A listing of safety net
hospitals is provided in Attachment 5.) The acute care safety net hospital must be
located in the Central region counties.

	 	1)	 	The health plan including such acute care safety net hospitals in its
network shall equally divide seventy percent (70%) of the random auto assignments,
while the remaining health plans shall equally share the remaining thirty percent
(30%) of the algorithm assignments.
	 
	 	2)	 	In the event all health plans have such acute care safety net
hospitals in their networks, all contracted health plans shall equally share one
hundred percent (100%) of the random auto assignments.

	2.5.6	 	Automatic Re-Assignment Following Resumption of Eligibility: Members who are disenrolled
from a health plan due to loss of eligibility, shall automatically be re-enrolled, or
assigned, into the same health plan and to the same primary care provider should they regain
eligibility within sixty (60) calendar days. The member will have ninety (90) calendar days
from the effective date of coverage with the health plan in which to change health plans for
any reason. If more than sixty (60) calendar days have elapsed, the member shall be permitted
to select a health plan and primary care provider through the enrollment process.

	2.6	 	Member Enrollment and Disenrollment:
	 
	2.6.1	 	MC+ Managed Care Marketing Guidelines: The health plan may educate and conduct marketing
campaigns for MC+ managed care members, subject to the restrictions and definitions outlined
herein. Education activities are efforts directed to current members to provide knowledge or
skills. Marketing campaigns are efforts directed to an audience of members and potential
health plan members to retain or increase health plan membership. The health plan and
subcontractors shall not influence member enrollment.

	 	a.	 	Marketing Guidelines: The health plan shall:

	 	1)	 	Submit its proposed marketing plan, all marketing materials, and
member education materials to the state agency for written approval prior to use.
The state agency shall only consider the marketing plan and materials submitted by
the health plan, (not subcontractors). The health plan should submit all
materials in mock camera-ready form. When submitting marketing and education
materials for approval, the health plan shall indicate how and when the material
will be used, the time frames for the use, and the media to be used for
distribution if approved. All written materials must be at a 6th grade
reading level or less. The state agency shall approve, disapprove, or require
modifications of education and marketing materials. The state agency shall review
and respond as soon as possible, but within thirty (30) calendar days of receipt
by the state agency. Marketing and education materials are deemed approved if a
response from the state agency is not returned within thirty (30) calendar days
following receipt of the materials by the state agency. The health plan shall
engage in only those marketing activities which are prior approved in writing.
	 
	 	2)	 	The health plan’s marketing material shall include a listing of their
in-network providers identified by specialty and location, as appropriate for the
document submitted for approval.
	 
	 	3)	 	The health plan’s marketing and education materials shall include the
member’s rights and responsibilities to assistance in obtaining all covered
services.
	 
	 	4)	 	Correct problems and errors with the marketing plan and/or materials
as identified by the state agency. The health plan shall submit to the state
agency a written corrected marketing plan or revised material within ten (10)
business days following receipt date of the written notice from the state agency.

 

 

			
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	 	5)	 	Not display or distribute any marketing materials in any manner at
Family Support Division (FSD) offices, or health plan provider sites, unless the
health plan has received prior written permission to do so from the state agency.
Only approved member handbooks and provider network listing may be distributed to
local FSD offices. The health plan shall supply current materials and remove
their out-dated materials in public areas at the FSD offices.
	 
	 	6)	 	Review all education and marketing materials at least once a year.
The health plan shall provide the state agency with copies of materials and
documentation verifying the health plan reviewed their education and marketing
material.
	 
	 	7)	 	Submit to the state agency, for prior written approval, all materials
used by in-network providers to advise members of the health plans with which they
have contracts. The health plan shall provide the following listing of what
constitutes approved material to in-network providers.

	 	•	 	A list of all health plans with which they have contracts;
	 
	 	•	 	A letter to previous fee-for-service recipients who may be eligible for MC+
managed care, informing them of all health plan(s) with which the
provider has contracted;
	 
	 	•	 	A display of all contracted health plan logos in an equal fashion;
	 
	 	•	 	A listing of all contracted health plan phone numbers;
	 
	 	•	 	Access to all contracted health plan directories and member
handbooks as a member resource but not for distribution; and
	 
	 	•	 	Displaying enrollment helpline phone number.

	 	 	 	The in-network provider shall provide equal representation of all
contracted health plans and shall not favor one health plan over another in
displayed information.
	 
	 	8)	 	Show the date the state agency approved the material in the lower
right-hand corner of all materials.
	 
	 	9)	 	Use mandatory education, marketing, and member notice language
provided by the state agency. The state agency shall provide such language as it
deems necessary. Any publicity given to the MC+ Managed Care Program or the MC+
managed care benefits, including but not limited to: notices, pamphlets, press
releases, research, reports, signs, and public notices prepared by or for the
health plan shall be released only with prior written approval by the state
agency.
	 
	 	10)	 	Not use the state agency’s or the Department of Social Services’
name, logo, or other identifying marks on any of the materials produced or issued
without the prior written approval of the state agency.
	 
	 	11)	 	Not use any report, graph, chart, picture, or other document produced
and included in whole or in part under the MC+ managed care contract which is
subject to copyright or the subject of any application for copyright by or on
behalf of the health plan.
	 
	 	12)	 	Develop MC+ managed care marketing plans and materials that are
accurate and shall not mislead, confuse, defraud, or deceive MC+ managed care
eligibles, or otherwise violate Federal or State consumer protection laws or
regulations. MC+ managed care benefits must be listed according to the current
MC+ managed care contracts. The health plan may not verbally or in writing
identify or portray covered benefits as enhanced, additional, or free.
	 
	 	13)	 	Not practice door-to-door, face-to-face, telephonic, or other “cold
call” marketing. The offerings of cash, prizes, other items for material gain, or
other insurance products as an award for enrollment are prohibited. However, the
health plan may offer additional health benefits to their members. If the health
plan offers additional health benefits, the health plan must notify

 

 

			
	RFP B3Z06118
	 	Page 26

	 	 	 	the state agency of these benefits no later than ten (10) calendar days prior to their
offering and must notify the state agency no less than thirty (30) calendar days
prior to discontinuing such benefits.

	 	•	 	Cold Call Marketing means any unsolicited personal contact by the health
plan with a potential member for the purpose of marketing as defined in this
paragraph.

	 	14)	 	Provide notice to the state agency or have prior written approval
from the state agency in certain situations to sponsor or participate in community
activities, programs, or events.

	 	•	 	Community activities are defined for the purpose of this document as: An
activity where people come together to learn about or question health care
benefits, responsibilities, and procedures. These community activities
require no notice to the state agency, except when held at provider
sites. At community activities, the health plan shall only use materials
approved by the state agency and must adhere to the ban on engaging in
enrollment activities required herein.
	 
	 	•	 	Community activities at provider sites require a seven (7) calendar day
notice to the state agency prior to sponsoring or participating in an
activity. Provider sites may include, but are not limited to pharmacies in
discount or grocery stores if the pharmacies are in an MC+ managed care
network, local public health agency, provider clinics, hospitals etc.
	 
	 	•	 	The health plan may offer the availability of gifts no greater than $10 in
value, and only if such gifts are offered during any community activity (i.e.
health fair). The nominal items must be offered to all individuals attending
the community activity. The gifts must be directly and obviously health
related or limited to printed materials, T-shirts, pens or pencils, caps,
mugs, key chains, etc. All items must have prior written approval by the
state agency and written proof of cost per unit must be provided by the health
plan to the state agency prior to approval. Once an item is approved, it does
not have to be re-approved for additional community activities. Advertising
the availability of such gifts through mailings, TV or radio, posters, and
other promotions or publicity is prohibited.

	 	15)	 	Not offer raffles or conduct lotteries. Door prizes may be offered
within the parameters and limits specified for participation in community
activities, programs, or events.
	 
	 	16)	 	Request state agency prepared mandatory MC+ managed care materials
from the state agency. The health plan and its subcontractors should make the
general public aware of the MC+ program by providing any of the following:

	 	•	 	General MC+ eligibility information; or
	 
	 	•	 	MC+ applications to complete and mail.

	 	17)	 	Not conduct or participate in health plan enrollment, disenrollment,
transfer, or opt out activities. The health plan and the providers shall not
influence a member’s enrollment. Prohibited activities include:

	 	•	 	Requiring or encouraging the member to apply for an assistance category not
included in MC+ managed care;
	 
	 	•	 	Requiring or encouraging the member and/or guardian to use the opt out as
an option in lieu of delivering health plan benefits;
	 
	 	•	 	Mailing or faxing health plan enrollment forms;
	 
	 	•	 	Aiding the member in filling out health plan enrollment forms;

 

 

			
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	 	•	 	Photocopying blank health plan enrollment forms for potential members;
	 
	 	•	 	Distributing blank health plan enrollment forms;
	 
	 	•	 	Participating in three way calls to the MC+ managed care enrollment helpline;
	 
	 	•	 	Suggesting a member transfer to another health plan; or
	 
	 	•	 	Other activities in which the health plan, its representatives, or
in-network providers are engaged in activities to enroll a member in a
particular health plan or in any way assisting a member to enroll in a health
plan (their own or another).

	 	18)	 	Advise the health plan’s subcontractors of these marketing guidelines
and ensure that subcontractors adhere to them. No subcontract shall operate to
relieve the health plan of its obligations. The health plan shall have written
procedures to ensure subcontractor notification and compliance with these
marketing guidelines.
	 
	 	19)	 	Use pre-approved MC+ managed care information and materials for
presentations or interviews with print and electronic media.
	 
	 	20)	 	Not use testimonial materials and/or celebrity endorsements.
	 
	 	21)	 	Insert new language in the educational and marketing materials and
substitute in a timely manner, as outlined by the state agency, any changes in
Federal or State law or regulation, as amended, as the need arises.
	 
	 	22)	 	Make an effort to ensure that presentations shall be available to
maximize consumer access to information, including presentation after normal work
hours, and at sites other than the Family Support Division offices, such as WIC
sites, Head Start centers, health fairs, etc.
	 
	 	23)	 	Make member education available on an ongoing basis to provide
guidance on how to use a health plan, and how to assert certain rights with their
health plan, if necessary.
	 
	 	24)	 	Market to the entire service area
	 
	 	25)	 	All marketing and educational material shall maintain a member’s
right to confidentiality. In particular, post cards must be folded to protect the
confidentiality of the member.
	 
	 	26)	 	Not develop marketing materials that contain any assertion or
statement (whether written or oral) that:

	 	•	 	The recipient must enroll with the health plan in order to obtain benefits
or in order not to lose benefits.
	 
	 	•	 	The health plan is endorsed by CMS, the Federal or State government or
similar entity.

	2.6.2	 	Health Plan Enrollment Procedures:

	 	a.	 	The state agency reserves the right to suspend or limit enrollment into a
health plan. In the event the health plan’s enrollment reaches sixty-five (65) percent
of the total MC+ managed care enrollment in the region, the health plan shall not be
offered as a choice for enrollment nor shall the health plan receive members through
the automatic assignment algorithm. However, the health plan may receive new members
as a result of newborn enrollments, reassignments when a member loses and regains MC+
managed care eligibility within a sixty (60) day period, other family or case members
are members of the health plan, for the member’s continuity of care, or for just cause
determined by

 

 

			
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	 	Page 28

	 	 	 	the state agency. The state agency’s evaluation of a health plan’s enrollment market
share shall take place on a calendar quarter.
	 
	 	b.	 	The state agency shall conduct enrollment activities for MC+ managed care
eligibles. The health plan or its subcontractors shall not conduct or participate in
eligibility or enrollment activities.
	 
	 	c.	 	The health plan shall have written policies and procedures for enrolling these
members within five (5) business days after receiving notification of the member’s
anticipated enrollment date from the state agency (e.g., if the health plan is informed
of a new member on a Wednesday, it must contact the member by the following Tuesday).
	 
	 	d.	 	The health plan shall enroll any MC+ managed care eligible who selects the
health plan or is assigned with the health plan. The only exceptions shall be if:

	 	1)	 	The health plan’s specified enrollment limit has been reached.
	 
	 	2)	 	The member was previously disenrolled from the health plan as the
result of a request for disenrollment by the health plan, as allowed herein.

	 	e.	 	Enrollment of Program Newborns: The health plan shall have written policies
and procedures for enrolling the newborn children of members effective to the date of
birth. Newborns of members enrolled at the time of the child’s birth shall be
automatically enrolled with the mother’s health plan. The health plan shall have a
procedure in place to refer newborns to the Family Support Division to initiate
eligibility determinations. A mother of a newborn may choose a different health plan
for her child; unless a different health plan is requested, the child shall remain with
the mother’s health plan.

	 	1)	 	The mother’s health plan shall be responsible for all medically
necessary services provided under the comprehensive benefit package to the newborn
child of an enrolled mother. The child’s date of birth shall be counted as day
one (1). The health plan shall provide services to the child until the child is
disenrolled from the health plan. When the newborn is assigned a departmental
client number (DCN), the health plan shall receive capitation payment for the
month of birth and for all subsequent months the child remains enrolled with the
health plan.
	 
	 	2)	 	In the case of an administrative lag in enrolling the newborn and
costs are incurred during that period, the health plan shall hold the member
harmless for those costs. The health plan shall be responsible for the cost of
the newborn including medical services provided prior to completion of the State
enrollment process.

	 	f.	 	Changes in Status: The health plan shall encourage its membership to report to
the Family Support Division any changes in the status of families or members, including
changes in family size, income, insurance coverage, and residence.
	 
	 	g.	 	Enrollment and Disenrollment Updates: Every business day, the state agency
shall make available, via electronic media, updates on members newly enrolled into the
health plan, or newly disenrolled. The health plan shall have written policies and
procedures for receiving these updates and incorporating them into the health plan and
health care service subcontractors’ management information system each day.
	 
	 	h.	 	Weekly Reconciliation: On a weekly basis, the state agency shall make
available, via electronic media, a listing of current members. The health plan shall
reconcile this membership list against the health plan internal records within thirty
(30) business days of receipt and shall notify the state agency of any discrepancies.
	 
	 	i.	 	Services for New Members: The health plan shall make available the full scope
of benefits to which a member is entitled immediately upon his or her enrollment.

 

 

			
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	 	j.	 	New Member Orientation: The health plan shall have written policies and
procedures for orienting new members to their benefits; the role of the primary care
provider; how to utilize services; what to do in an emergent or urgent medical
situation; how to file a grievance or appeal; and how to report suspected fraud and
abuse.

	 	1)	 	Member Responsibilities: The health plan shall have written policies
that address the members’ responsibilities for cooperating with providers. These
member responsibility policies must be supplied in writing to all providers and
members. These written policies should address the members’ responsibilities for:

	 	•	 	Providing, to the extent possible, information needed by providers in
caring for the member.
	 
	 	•	 	Contacting their primary care provider as their first point of contact when
needing medical care.
	 
	 	•	 	Following appointment scheduling processes.
	 
	 	•	 	Following instructions and guidelines given by providers.

	 	2)	 	Member Rights: The health plan shall have written policies regarding
member rights as specified below:

	 	•	 	General Rule. Each health plan must comply with any applicable
Federal and State laws that pertain to member rights and ensure that its staff
and affiliated providers take those rights into account when furnishing
services to members.
	 
	 	•	 	Dignity and privacy. Each member is guaranteed the right to be
treated with respect and with due consideration for his or her dignity and
privacy.
	 
	 	•	 	Receive information on available treatment options. Each member is
guaranteed the right to receive information on available treatment options and
alternatives, presented in a manner appropriate to the member’s condition and
ability to understand.
	 
	 	•	 	Participate in decisions. Each member is guaranteed the right to
participate in decisions regarding his or her health care, including the right
to refuse treatment.
	 
	 	•	 	Free from restraint or seclusion. Each member is guaranteed the
right to be free from any form of restraint or seclusion used as a means of
coercion, discipline, convenience, or retaliation.
	 
	 	•	 	Copy of medical records. Each member is guaranteed the right to
request and receive a copy of his or her medical records, and to request that
they be amended or corrected, as specified in 45 CFR part 164.
	 
	 	•	 	Free exercise of rights. Each member is free to exercise his or
her rights, and that the exercise of those rights does not adversely affect
the way the health plan and its providers or the state agency treat the
member.

	 	k.	 	Assignment of Primary Care Providers: The health plan shall have written
policies and procedures for assigning each of the health plan’s members to a primary
care provider. The process must include at least the following features:

 

 

			
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	 	1)	 	The health plan shall contact the member within five (5) business
days from the date of the state agency’s notification to the health plan of the
member’s anticipated enrollment date. To
the extent provider capacity exists, the health plan shall offer freedom of choice
to members in making a primary care provider selection.
	 
	 	 	 	At the time of the state agency’s notification to the health plan, the health plan
may assign a primary care provider taking into consideration factors such as
current provider relationships, language needs, (to the extent they are known), and
area of residence. When contacting the member, the health plan shall provide the
member with the primary care provider’s name, location, and telephone number. When
contacting the member, the health plan shall provide options for selecting a
primary care provider other than the primary care provider assigned to the member.
The health plan shall inform the member he/she has fifteen (15) calendar days to
choose another primary care provider if they do not approve of the primary care
provider assigned to them, and if they have not notified the health plan of their
preferred primary care provider within that time frame, the member will remain with
the primary care provider previously assigned to the member.
	 
	 	2)	 	Prior to becoming effective with the health plan, if a member does
not select a primary care provider or the health plan has not already assigned a
primary care provider to the member at the time of notification from the state
agency of the member’s anticipated enrollment date, the health plan shall make an
automatic assignment, taking into consideration such known factors as current
provider relationships, language needs (to the extent they are known), and area of
residence. The health plan shall then notify the member in writing of his or her
primary care provider’s name, location, and office telephone number. The member
must have a primary care provider assigned by the time the member is effective
with the health plan. If circumstances are such that the member does not have a
primary care provider assigned on the effective date with the health plan, the
health plan shall not deny services or payment of any service. The health plan
shall submit to the state agency the methodology utilized by the health plan to
assign primary care providers to members.
	 
	 	3)	 	Members with disabling conditions or chronic illnesses may request
that their primary care providers be specialists, such as a psychiatrist,
oncologist, obstetrician, gynecologist, or other such specialist. The health plan
must have procedures for ensuring access to needed services for those members or
the request shall be granted. The specialist must accept the member as a primary
care patient and accept the responsibility of a primary care provider as specified
herein. The health plan must communicate its decision to the member within ten
(10) calendar days of request. The adequacy of these policies shall be reviewed
by the state agency.
	 
	 	4)	 	The health plan shall have written policies and procedures for
notifying primary care providers of their assigned member prior to the member’s
effective date with the primary care provider.

	 	l.	 	Changing Primary Care Providers: The health plan shall have written policies
and procedures for allowing members to select or be assigned to a new primary care
provider within the health plan when such a change is mutually agreed to by the health
plan and member. The health plan shall allow members at least two such changes per
year, and shall inform members of the process for initiating these changes. However,
children in COA 4 may change primary care providers at will. Possible reasons for a
member to change primary care providers include, but are not limited to:

	 	1)	 	Accessibility — transportation problems, provider office hours, does
not return phone calls, waiting times.
	 
	 	2)	 	Acceptability — sees too many doctors, uncomfortable with
surroundings or location, provider or staff attitudes, lack of courtesy, following
a member’s initial visit to the primary care provider.

 

 

			
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	 	3)	 	Quality — treatment (medical), referral related, does not explain
treatment plan/diagnosis. If provider problem, may request primary care provider
changes and second opinion.
	 
	 	4)	 	Enrollment — primary care provider with whom the member has an
established patient/provider relationship no longer participates in the health
plan. In cases where the primary care provider no longer participates, the health
plan shall allow members to select another primary care provider or make a
re-assignment within fifteen (15) calendar days of the termination effective date.
	 
	 	5)	 	An act of cultural insensitivity that negatively impacts the member’s
ability to obtain care.
	 
	 	6)	 	A primary care provider change is ordered as part of the resolution
to the grievance and appeal process. A member’s right to request a change in a
primary care provider through the grievance and appeal process or other means
shall not be restricted.

	 	m.	 	Identification Cards: The state agency shall issue a plastic, magnetic strip
identification card to all Missouri MC+ eligibles. This card is not proof of
eligibility, but to be used as a key for accessing the State’s electronic eligibility
verification systems by Medicaid enrolled providers. These systems shall contain the
most current information available to the state agency, including specific information
regarding health plan enrollment. There will be no health plan specific information
printed on the card. In addition to the state agency issued card, the health plan
should issue a membership card that contains information more specific to the health
plan. The health plan issued membership card must be issued to the member prior to the
member’s effective date of coverage with the health plan. Upon selection or assignment
of a health plan, the member’s effective date shall be 15 calendar days in the future,
thereby allowing the health plan to send the appropriate enrollment materials, such as
the identification card, to the member prior to the effective date. Exceptions apply
to this policy for newborns and emergency enrollments. The state agency recognizes
those exceptions and such enrollment materials may be produced as expeditiously as
possible, but no later than 15 calendar days from the notification of the enrollment.
At a minimum, the health plan issued membership card must contain the member’s name,
identification number, primary care provider name and telephone number, instructions
for emergencies, and other relevant toll free lines for access such as mental health,
dental, pharmacy, and nurse advice lines.
	 
	 	n.	 	Member Handbook: The health plan shall mail a member handbook, or other written
materials with information on how to access services, to all members within ten (10)
business days of being notified of their future enrollment with the health plan. When
there are program changes, the health plan shall notify the affected members at least
thirty (30) calendar days before implementation of such change. On an annual basis,
the health plan shall review the member handbook and shall document that such review
occurred.

	 	1)	 	The member handbook must be written at no higher than a sixth grade
level. Suggested reference material to determine whether this requirement is
being met are:

	 	•	 	Fry Readability Index
	 
	 	•	 	PROSE The Readability Analyst (software developed by Education Activities,
Inc.)
	 
	 	•	 	Gunning FOG Index
	 
	 	•	 	McLaughlin SMOG Index
	 
	 	•	 	The Flesch-Kincaid Index or other word processing software approved by the
state agency.

	 	2)	 	At a minimum, the member handbook shall include the information and
items listed below. The health plan may include some of the following information
as inserts to the member

 

 

			
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	 	Page 32

	 	 	 	handbook. The health plan shall include certain passages
and language provided by the state agency in the member handbook. The health plan
shall comply with all changes regarding member handbook content specified by the
state agency in a timely manner as defined by the state agency.

	 	•	 	Table of contents.
	 
	 	•	 	Information about choosing and changing primary care providers, including
notice of how to determine whether a participating provider is accepting new
patients.
	 
	 	•	 	Information about what to do when family size changes.
	 
	 	•	 	Appointment procedures.
	 
	 	•	 	A description of all available health plan services and an explanation of
any service limitations or exclusions from coverage and a notice stating that
the health plan shall be liable only for those services authorized by the
health plan.
	 
	 	•	 	A description of all available services outside the comprehensive benefit
package. Such information shall include information on where and how members
may access benefits not available under the comprehensive benefit package.
	 
	 	•	 	The definition of medical necessity used in determining whether benefits
will be covered.
	 
	 	•	 	A description of all prior authorization or other requirements for
treatments and services.
	 
	 	•	 	A description of utilization review policies and procedures used by the
health plan.
	 
	 	•	 	An explanation of a member’s financial responsibility for payment when
services are provided by an out-of-network provider or by any provider without
required authorization or when a procedure, treatment, or service is not
covered by MC+ managed care.
	 
	 	•	 	Notice that a member may obtain an out-of network provider when the health
plan does not have an in-network provider with appropriate training and
experience to meet the particular health care needs of the member and the
procedure by which the member can obtain such referral.
	 
	 	•	 	Notice that a member with a condition which requires ongoing care from a
specialist may request a standing referral to such a specialist and the
procedure for requesting and obtaining such a standing referral.
	 
	 	•	 	Notice that a member with a life-threatening condition or disease or a
degenerative and disabling condition or disease, either of which requires
specialized medical care over a prolonged period of time, may request a
specialist responsible for providing or coordinating the member’s medical care
and the procedure for requesting and obtaining such a specialist.
	 
	 	•	 	Notice that a member with a life-threatening condition or disease or a
degenerative and disabling condition or disease, either of which requires
specialized medical care over a prolonged period of time, may request access
to a specialty care center and the procedure by which such access may be
obtained.
	 
	 	•	 	A description of the mechanisms by which members may participate in the
development of the policies of the health plan.

 

 

			
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	 	•	 	Notice of all appropriate mailing addresses and telephone numbers to be
utilized by members seeking information or authorization.
	 
	 	•	 	Procedures for disenrollment, including an explanation of the member’s
right to disenroll with and without cause.
	 
	 	•	 	How to contact member services and a description of its function.
	 
	 	•	 	Information on grievance, appeal, and fair hearing procedures and
timeframes. Such information includes:

	 	a)	 	The right to file grievances and appeals.
	 
	 	b)	 	The requirement and timeframes for filing a grievance
or appeal.
	 
	 	c)	 	The availability of assistance in the filing process.
	 
	 	d)	 	The toll-free numbers that the member can use to file
a grievance or an appeal by phone.
	 
	 	e)	 	The procedures for exercising the rights to appeal or
request a State fair hearing.
	 
	 	f)	 	That the member may represent himself or use legal
counsel, a relative, a friend, or other spokesperson.
	 
	 	g)	 	Must explain the specific regulations that support,
or the change in Federal or State law that requires the action.
	 
	 	h)	 	The fact that, when requested by the member -

	 	•	 	Benefits will continue if the member files an appeal or a request
for State fair hearing within the timeframes specified for filing; and
	 
	 	•	 	The member may be required to pay the cost of services furnished
while the appeal is pending, if the final decision is adverse to the
member.

	 	i)	 	The member’s right to request a State fair hearing,
or in cases of an action based on change in law, the circumstances under
which a hearing will be granted.

	 	•	 	A member may request a State fair hearing within 90 calendar days
from the health plan’s notice of action.
	 
	 	•	 	The state agency must reach its decisions within the specified
timeframes:

	 	1)	 	Standard resolution: within 90 calendar
days of the date the member filed the appeal with the health plan if
the member filed initially with the health plan (excluding the days
the enrollee took to subsequently file for a State fair hearing) or
the date the member filed for direct access to a State fair hearing.
	 
	 	2)	 	Expedited resolution (if the appeal was
heard first through the health plan appeal process): within 3
working days from the state agency’s receipt of a hearing request
for a denial of a service that:

	 	•	 	Meets the criteria for an expedited appeal process but was
not resolved using the health plan’s expedited appeal
timeframes, or
	 
	 	•	 	Was resolved wholly or partially adversely to the member
using the health plan’s expedited appeal timeframes.

	 	3)	 	Expedited resolution (if the appeal was
made directly to the State Fair Hearing process without accessing
the health plan appeal process): within 3 working days from the
state agency’s receipt of a hearing request for a denial of a
service that meets the criteria for an expedited appeal process.

	 	j.	 	Any appeal rights that the state chooses to make
available to providers to challenge the failure of the organization to
cover a service.

	 	•	 	How to report suspected fraud and abuse activities.

 

 

			
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	 	•	 	Pharmacy dispensing fee requirements (if applicable): The health plan must
include a statement that care shall not be denied due to lack of payment of
pharmacy dispensing fee requirements.
	 
	 	•	 	Provider network listing including a list of the names, specialty,
telephone numbers, service site address of all providers available for
selection, and in the case of physicians, board
certification. The provider network listing can be a separate document apart
from the member handbook.
	 
	 	•	 	The extent to which, and how, after-hours and emergency coverage are
provided, including the following: (a) What constitutes an emergency medical
condition, emergency services, and post-stabilization services; (b) The fact
that prior authorization is not required for emergency services; (c) The
process and procedures for obtaining emergency services, including use of the
911-telephone system or its local equivalent; (d) The locations of any
emergency settings and other locations at which providers and hospitals
furnish emergency services and post-stabilization services covered herein; (e)
The fact that the member has a right to use any hospital or other setting for
emergency care; and (f) The post-stabilization care services rules specified
herein.
	 
	 	•	 	How to obtain emergency transportation and non-emergency medically
necessary transportation.
	 
	 	•	 	EPSDT services including immunization and lead guidelines designated by the
state agency.
	 
	 	•	 	Maternity, family planning, and sexually transmitted diseases services.
	 
	 	•	 	Mental health and substance abuse services, including information on how to
obtain such services, the rights the member has to request such services, and
how to access services when in crisis, including the toll free number to be
used to access such services.
	 
	 	•	 	How to obtain services when out of the member’s geographic region and for
after-hours coverage.
	 
	 	•	 	Out-of-county and out-of-state moves.
	 
	 	•	 	Statement that the health plan shall protect its members in the event of
insolvency. The health plan shall not hold its members liable for any of the
following:

	 	Ø	 	The debts of the health plan in the case of health plan insolvency;
	 
	 	Ø	 	Services provided to a member in the event the health plan failed to
receive payment from the state agency for such service;
	 
	 	Ø	 	Services provided to a member in the event a health care provider with a
contractual referral or other type arrangement with the health plan fails
to receive payment from the state agency or the health plan for such
services; or
	 
	 	Ø	 	Payments to a provider that furnishes covered services under a
contractual referral or other type arrangement with the health plan in
excess of the amount that would be owed by the member if the health plan
had directly provided the services.

	 	•	 	Inform the member that if he or she has a worker’s compensation claim, or a
pending personal injury or medical malpractice law suit, or has been involved
in an auto accident, to immediately contact the health plan.

 

 

			
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	 	•	 	Inform the member that if he or she has another health insurance policy,
all prepayment requirements must be met as specified by the other health
insurance plan. The member must notify the health plan of any changes to
their other health insurance policy. The member can contact the health plan
with any questions.
	 
	 	•	 	Inform the member of the Health Insurance Premium Payment program which
pays for health insurance for members when it is determined cost effective.
	 
	 	•	 	Contributions the member can make towards his or her own health,
appropriate and inappropriate behavior, and any other information deemed
essential by the health plan or the state agency including the member’s rights
and responsibilities.
	 
	 	•	 	Inform members that multilingual interpreters will be offered when needed
and written information is available in prevalent languages and how to access
those services.
	 
	 	•	 	Inform the member of the procedures that will be utilized to notify members
affected by termination or change in benefits, services, or service delivery
office/site.
	 
	 	•	 	Inform the member that the health plan shall provide information on the
health plan’s physician incentive plan to any member upon request. Enrollment
materials/member handbooks should annually disclose to members their right to
adequate and timely information related to physician incentives.
	 
	 	•	 	With respect to advance directives, inform the member of the following:

	 	a)	 	Their rights under the law of the state.
	 
	 	b)	 	The health plan’s policies respecting the
implementation of those rights, including a statement of any limitation
regarding the implementation of advance directives as a matter of
conscience.
	 
	 	c)	 	The health plan must inform members that complaints
concerning noncompliance with the advance directive requirements may be
filed with the State survey and certification agency.

	 	•	 	Additional information that is available upon request, including the
following:

	 	a)	 	Information on the structure and operation of the MC+
health plan.

	 	•	 	Inform the member how to obtain one free copy of his or her medical records
annually.
	 
	 	•	 	Inform the member how to request and obtain an Explanation of Benefits
(EOB).

	 	o.	 	 The health plan shall submit the member handbook to the state agency for
approval prior to distribution to members. The health plan shall make modifications in
member handbook language if ordered by the state agency so as to comply with the member
handbook requirements.
	 
	 	p.	 	The member must receive written notification of changes in health plan
operations that affect them at least thirty (30) calendar days before the intended
effective date of the change unless otherwise noted. Examples of such changes are as
follows:

	 	1)	 	Network changes such as a new Pharmacy Benefit Manager, mental health
subcontractor, or other major subcontractor. Notification is required to all
members.
	 
	 	2)	 	Primary care provider or other provider seen on a regular basis
leaves the network. The health plan shall provide written notice to the affected
members within 15 calendar days after receipt or issuance of the termination
notice.

 

 

			
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	 	3)	 	Comprehensive Benefit Package changes from what is explained in the
member handbook. Notification is required to all members.
	 
	 	4)	 	Utilization Management Procedure changes from what is explained in
the member handbook. Notification is required to all members.
	 
	 	5)	 	Prior Authorization Procedure changes from what is explained in the
member handbook. Notification is required to all members.
	 
	 	6)	 	Advance directive policy changes as a result of changes in State law.

	 	q.	 	All written member notifications must be prior approved by the state agency and
written at no higher than a sixth grade level. The health plan shall include certain
passages and language provided to the health plan by the state agency in the member
notification. The health plan shall comply with all changes regarding member
notification content specified by the state agency in a timely manner as defined by the
state agency.
	 
	 	r.	 	Transferring Members Between Health Plans: It may be necessary to transfer a
member between health plans for a variety of reasons. The health plan shall have
written policies and procedures for transferring relevant member information, including
medical records and other pertinent materials, to or from another health plan. Upon
request, a copy of the member’s medical records and supporting documentation must
accompany disenrollment and transfer requests from the health plan. The state agency
shall monitor, and approve or disapprove all transfer requests for just cause, within
sixty (60) calendar days subject to medical record review. Possible reasons for a
member to request a transfer include, but are not limited to:

	 	•	 	Member requests health plan transfer during open enrollment.
	 
	 	•	 	Member request health plan transfer during the first 90 days enrolled in
the health plan.
	 
	 	•	 	Transfer is the resolution to a grievance or appeal.
	 
	 	•	 	Enrollment — primary care provider or specialist with whom the member has
an established patient/provider relationship does not participate in the
health plan but does participate in another health plan.
	 
	 	•	 	The member is pregnant and her primary care provider or obstetrician does
not participate in the health plan but does participate in another health
plan.
	 
	 	•	 	The member is a newborn and the primary care provider or pediatrician
selected by the mother does not participate in the health plan but does in
another health plan.
	 
	 	•	 	Transfer to another health plan is necessary to ensure continuity of care.
	 
	 	•	 	An act of cultural insensitivity that negatively impacts the member’s
ability to obtain care and cannot be resolved by health plan.
	 
	 	•	 	Other reasons, including but not limited to, poor quality of care, lack of
access to services covered under the contract, or lack of access to providers
experienced in dealing with the member’s health care needs.

	 	1)	 	Children in COA 4 shall be allowed automatic and unlimited changes in
health plan choice as often as circumstances necessitate. Foster parents will
normally have the decision making responsibility for which health plan shall serve
the foster child residing with them; however, there will be situations where the
Social Service worker or the courts shall select the health plan for a child in
State custody or foster care placement.

	 	s.	 	Member Disenrollment:

 

 

			
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	 	1)	 	The state agency has sole authority for disenrolling members from the
health plan. The health plan may request disenrollment of members from health
plan providers, subject to the conditions described below:

	 	•	 	A persistent refusal of the member to follow prescribed treatments or
comply with health plan requirements that are consistent with federal and
state laws and regulations, as amended.
	 
	 	•	 	Consistently missed appointments without prior notification to the
provider.
	 
	 	•	 	Fraudulent misuse of the MC+ managed care program, or abusive or
threatening conduct.
	 
	 	•	 	Request of a home birth service.

	 	2)	 	The health plan must not initiate disenrollment because of a medical diagnosis
or the health status of a member. The health plan shall not request disenrollment
because of the member’s attempt to exercise his or her rights under the grievance
system. The health plan shall not request disenrollment because of pre-existing
medical conditions or high cost medical bills or an anticipated need for health care.
The health plan shall not request a disenrollment due to behaviors resulting from a
medical or mental illness/disorder.
	 
	 	3)	 	Prior to requesting a disenrollment or transfer of a member, the health plan
shall document at least three interventions over a period of 90 calendar days which
occurred through treatment, case management, and care coordination to resolve any
difficulty leading to the request, unless the member has demonstrated abusive or
threatening behavior in which case only one attempt is required. The health plan shall
cite at least one of the above examples of good cause before requesting that the state
agency disenroll that member. If the health plan intends to proceed with disenrollment
during the ninety (90) calendar day period, the health plan must give a notice citing
the appropriate reason to both the member and the state agency at least 30 calendar
days before the end of the ninety (90) calendar day period. The health plan must
document all notifications regarding requests for disenrollment.

	 	•	 	Members shall have the right to challenge a health plan initiated disenrollment
to both the state agency and the health plan through the appeal process within
ninety (90) calendar days of the health plan’s request to the state agency for
disenrollment of the member. When a member files an appeal, the process must be
completed prior to the health plan and the state agency continuing disenrollment
procedures.
	 
	 	•	 	Within fifteen (15) working days of the final notification (after no appeal or
a final hearing decision), members shall be enrolled in another health plan or
transferred to another provider.
	 
	 	4)	 	If the health plan recommends disenrollment or transfers for reasons
other than those stated above, the State shall consider the health plan to have
breached the provisions and requirements of the contract.

	 	t.	 	Reasons for Disenrollment: The state agency may disenroll members from a
health plan for any of the following reasons:

	 	1)	 	Selection of another health plan during open enrollment, the first 90
calendar days of enrollment, or for just cause.
	 
	 	2)	 	Change of residence that places the member outside of the health
plan’s service area.

 

 

			
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	 	3)	 	To implement the decision of a hearing officer in a grievance
proceeding by the member against the health plan, or by the health plan against
the member.
	 
	 	4)	 	Loss of eligibility for either Medicaid or MC+ managed care.

Paragraph 2.6.2 t. 5. inserted by Amendment #001

	 	5)	 	Member exercises choice to voluntarily disenroll as specified herein
under Missouri MC+ Managed Care Program eligibility groups. This choice can be
referred to as opt out.

	 	u.	 	Disenrollment Effective Dates: Member disenrollments outside of the open
enrollment process shall become effective on the date specified by the state agency.
The health plan shall have written policies and procedures for complying with state
agency disenrollment orders.

Paragraph 2.6.2 v. revised by Amendment #001

	 	v.	 	Hospitalization at the Time of Enrollment or Disenrollment: With the exception
of newborns, the health plan shall not assume financial responsibility for members who
are hospitalized in an acute setting on the effective date of coverage until an
appropriate acute inpatient hospital discharge. If the member is in the Medicaid
fee-for-service program at the time of acute inpatient hospitalization on the effective
date of coverage, the member shall remain in the fee-for-service program until an
appropriate acute inpatient hospital discharge. Members, including newborn members,
who are in another health plan at the time of acute inpatient hospitalization on the
effective date of coverage, shall remain with that health plan until an appropriate
acute inpatient hospital discharge. Members, including newborn members, who are
hospitalized in an acute setting shall not be disenrolled from a health plan until an
appropriate acute inpatient hospital discharge, unless the member is no longer Medicaid
or MC+ managed care eligible or opts out.
	 
	 	 	 	For the purpose of a member moving from one health plan to another health plan, in
addition to acute inpatient hospitalizations, admissions to facilities that provide a
lower level of care in lieu of an acute inpatient admission may be considered as an
acute inpatient hospitalization for purposes of this section. The state agency reserves
the right to determine if such an admission qualifies as an acute inpatient
hospitalization. Only acute inpatient hospitalization shall apply when a new member
moves from the Medicaid fee-for-service program to MC+ managed care. The health plan
shall provide timely notification to the state agency of a member’s acute inpatient
hospitalization on the effective date of coverage to effect a retroactive/prospective
adjustment in the coverage dates for MC+ managed care.

	2.7	 	Comprehensive Benefit Package:
	 
	 	 	Description of Comprehensive Benefit Package: The health plan shall assume the
responsibility for all covered medical conditions of each MC+ managed care member as of the
effective date of coverage. The health plan shall make the comprehensive benefit package
available to members. Services outside the United States, District of Columbia, and the
following territories: Northern Mariana Islands, American Samoa, Guam, Puerto Rico, and the
Virgin Islands are not covered. Services must be provided according to the medical needs of
the member. The health plan may manage specific services as long as the health plan
provides services that are medically appropriate. The health plan shall have a process for
allowing exceptions that is in accordance with 13 CSR 70-2.100. The health plan may develop
criteria by which the health plan shall review future treatment options, set prior
authorization criteria, or exercise other administrative options for the health plan’s
administration of medical care benefits. The health plan may place appropriate limits on a
service on the basis of criteria such as medical necessity; or for utilization control,
provided the services furnished can reasonably be expected to achieve their purpose. The
health plan may not arbitrarily deny or reduce the amount, duration, or scope of a required
service solely because of the diagnosis, type of illness, or condition. Attachment 3
outlines the comprehensive benefit package for all members and the services they will
receive.

	2.7.1	 	The health plan shall include the following services within the comprehensive benefit
package:

	 	a.	 	Inpatient hospital services;

 

 

			
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	 	b.	 	Outpatient hospital services;
	 
	 	c.	 	Emergency room services;
	 
	 	d.	 	Ambulatory surgical center, birthing center;
	 
	 	e.	 	Physician, advanced practice nurse, and certified nurse midwife services;

	 	1)	 	The health plan shall provide certified nurse midwife services that
are medically appropriate either through the health plan provider network or by
other means outside the health plan provider network at the health plan’s expense.
If the member elects a home birth, the member shall be disenrolled from MC+
managed care according to the MC+ managed care home birth policy statement. The
disenrolled member shall then receive services through the MC+ fee-for-service
program.

	 	f.	 	Maternity benefits for inpatient hospital and certified nurse midwife. The
health plan shall provide coverage for a minimum of forty-eight (48) hours of inpatient
hospital services following a vaginal delivery and a minimum of ninety-six (96) hours
of inpatient hospital services following a cesarean section for a mother and her newly
born child in a hospital or any other health care facility licensed to provide
obstetrical care under the provision of Chapter 197, RSMo, as amended.
	 
	 	 	 	The health plan may authorize a shorter length of hospital stay for services related to
maternity and newborn care if a shorter inpatient hospital stay meets with the approval
of the attending physician after consulting with the mother and is in keeping with
federal and state law, as amended. The physician’s approval to discharge shall be made
in accordance with the most current version of the “Guidelines for Perinatal Care”
prepared by the American Academy of Pediatrics and the American College of Obstetricians
and Gynecologists, or similar guidelines prepared by another nationally recognized
medical organization and be documented in the member’s medical record.
	 
	 	 	 	The health plan shall provide coverage for post-discharge care to the mother and her
newborn. The first post-discharge visit shall occur within twenty-four (24) to
forty-eight (48) hours. Post-discharge care shall consist of a minimum of two visits at
least one of which shall be in the home, in accordance with accepted maternal and
neonatal physical assessments, by a registered professional nurse with experience in
maternal and child health nursing or a physician. The location and schedule of the
post-discharge visits shall be determined by the attending physician. Services provided
by the registered professional nurse or physician shall include, but not be limited to,
physical assessment of the newborn and mother, parent education, assistance and training
in breast or bottle feeding, education and services for complete childhood
immunizations, the performance of any necessary and appropriate clinical tests, and
submission of a metabolic specimen satisfactory to the State laboratory. Such services
shall be in accordance with the medical criteria outlined in the most current version of
the “Guidelines for Perinatal Care”, or similar guidelines prepared by another
nationally recognized medical organization. If the health plan intends to use another
nationally recognized medical organization’s guidelines, the state agency must approve
prior to implementation of its use.
	 
	 	g.	 	Family Planning Services — If family planning services are sought
out-of-network by a member, the health plan shall be financially liable for payment of
those services in accordance with federal freedom of choice provisions.
	 
	 	h.	 	Pharmacy benefits excluding protease inhibitors – pharmacy benefits are
included in the comprehensive benefit package if the health plan included pharmacy
benefits in its awarded proposal;

 

 

			
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	 	1)	 	The health plan shall submit the information regarding its pharmacy
program to the state agency for prior approval in accordance with the MC+ Managed
Care Policy Statements, as amended.

	 	i.	 	Dental services related to trauma to the mouth, jaw, teeth or other contiguous
sites as a result of injury. Adults age 21 and over receive treatment of a
disease/medical condition without which the health of the recipient would be adversely
affected through the Fee For Service program.
	 
	 	j.	 	Laboratory, radiology, and other diagnostic services;
	 
	 	k.	 	Prenatal case management;
	 
	 	l.	 	One eye examination every 2 years;
	 
	 	m.	 	Home health services;
	 
	 	n.	 	Adult day health care services;
	 
	 	o.	 	Personal care services;
	 
	 	p.	 	Transportation services;

	 	1)	 	The health plan shall provide emergency transportation (ground and
air) for its members. The health plan shall provide non-emergency medical
transportation to members who do not have the ability to provide their own
transportation (such as their own vehicle, friends, or relatives) to and from
services required herein as well as Medicaid/MC+ Fee-For-Service covered services
not included in the comprehensive benefit package.

	 	q.	 	Hospice services;
	 
	 	r.	 	Durable medical equipment limited to: prosthetic devices (with the exception of
artificial larynx), respiratory equipment and oxygen (with the exception of CPAP,
BiPAP, and nebulizers), wheelchairs, diabetic supplies and equipment, and ostomy
supplies. Members with a Home Health Plan of Care receive all medically necessary
durable medical equipment services during the plan of care coverage period.
	 
	 	s.	 	Podiatry services with the exception of trimming of nondystrophic nails, any
number; debridement of nail(s) by any method(s), one to five; debridement of nail(s) by
any method(s), six or more; excision of nail and nail matrix, partial or complete; and
strapping of ankle and/or foot.
	 
	 	t.	 	Services provided by local public health agencies — The Department of Health
and Senior Services and local public health agencies administer certain public health
programs which are critical to the protection of the public’s health and, therefore,
must be made available to members at local public health agencies whether in-network or
out-of-network. The health plan shall reimburse the local public health agency
according to the most current Medicaid program fee schedule in effect at the time of
service, unless otherwise negotiated. Such services shall include:

	 	1)	 	All sexually transmitted disease (STD) services including screening,
diagnosis, and treatment. In-network providers shall follow current Center for
Disease Control (CDC) Sexually Transmitted Diseases Treatment Guidelines and the
United States Department of Health and Human Services Chlamydia Control Project
Screening Criteria, or their equivalent. The STD guidelines may be found on the
Internet at: http://www.dhss.mo.gov/STDSurveillance/. STD screening, diagnosis,
and treatment services shall include:

	 	•	 	STD screening exam.

 

 

			
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	 	•	 	Screening, diagnosis, and treatment for the following STDs: gonorrhea,
syphilis, chancroid, granuloma inguinale, lymphogranuloma venereum, genital
herpes, genital warts, trichomoniasis, chlamydia (cervicitis), chlamydia
(urethritis), hepatitis B, and others as may be designated by the state
agency.
	 
	 	•	 	Screening, diagnosis, and treatment of vaginal or urethral discharge
including non-gonococcal urethritis and mucopurulent cervicitis.
	 
	 	•	 	Evaluation and initiation of treatment of pelvic inflammatory disease
(PID).
	 
	 	•	 	Diagnosis and preventive treatment of members who are reported as
contacts/sex partners of any person and diagnosed with a STD. The member
shall be given the option of seeing an in-network provider first.
	 
	 	•	 	The local public health agency shall encourage members to follow-up with
their primary care provider; however, if the member chooses follow-up care at
the local public health agency for confidentiality reasons, the health plan
shall reimburse the local public health agency for follow-up office visits
(not to exceed three visits per episode).

	 	2)	 	Human immunodeficiency virus (HIV) services relating to screening and
diagnostic studies. In-network providers shall use current CDC HIV Counseling,
Testing, Referral Standards, and Guidelines or their equivalent. The HIV
guidelines may be found on the internet at: http://www.dhss.mo.gov/HIV_STD_AIDS/.
	 
	 	3)	 	Tuberculosis services including screening, diagnosis, and treatment.
In-network providers shall follow current CDC/American Thoracic Society
Guidelines: Treatment of Tuberculosis and Tuberculosis Infection in Adults and
Children, or their equivalent, including the use of Mantoux PPD skin test to
screen for tuberculosis. The Tuberculosis guidelines may be found on the
Internet at: http://www.dhss.mo.gov/Tuberculosis.

	 	•	 	All members diagnosed with tuberculosis infection or tuberculosis disease
shall be reported to the local public health agency.
	 
	 	•	 	All members receiving treatment for tuberculosis disease shall be referred
to the local public health agency’s tuberculosis contact person for directly
observed therapy (DOT). The health plan shall communicate with the local
public health agency’s tuberculosis contact person to obtain information
regarding the member’s health status. The health plan shall communicate this
information to the in-network provider. The health plan shall be responsible
for care coordination and medically necessary follow-up treatment.
	 
	 	•	 	All laboratory tests for tuberculosis shall meet the standards established
by the CDC/Missouri Department of Health and Senior Services. Sensitivity
tests shall be performed on all initial specimens positive for M.
Tuberculosis. Department of Health and Senior Services encourages all sputum
specimens to be submitted to the Department of Health and Senior Services’
Tuberculosis Reference Laboratory at the Missouri Rehabilitation Center.
Positive cultures for M Tuberculosis isolated at private laboratories must be
sent to the TB Reference Laboratory (Required by Missouri Rule 19 CSR
20-20.080).

	 	4)	 	Childhood Immunizations: In-network providers shall fully immunize
their members following the most recent immunization recommendations designated by
the state agency. The state agency shall provide the health plan’s Medical
Director with copies of the most recent recommendations upon contract award and
upon request and when the recommendations change.

 

 

			
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	 	•	 	The health plan and its in-network providers must enroll and must obtain
vaccines through the Missouri Department of Health and Senior Services
Vaccines for Children (VFC) Program or any such vaccine supply program as
designated by the state agency. Any time a member receives immunizations from
a local public health agency, or at a Special Supplemental Nutrition Program
for Women, Infants, and Children (WIC) site, the health plan shall reimburse
only the cost for administration at the current Medicaid program rates in
effect at the time of the service, unless otherwise negotiated.
	 
	 	•	 	The health plan shall reimburse governmental public health agencies for the
cost of both administration and vaccines not available through the VFC program
or vaccine supply
program as designated by the state agency when the vaccine is deemed medically
necessary.
	 
	 	•	 	The health plan shall collaborate with the state agency and the Missouri
Department of Health and Senior Services to determine the health plan’s
aggregate immunization level. The Missouri Department of Health and Senior
Services, Immunization Program will offer consultation to the health plan to
foster the exchange of immunization information, and to in-network providers
for purposes of assessment, reminder/recall, and reporting.
	 
	 	•	 	The health plan shall establish, as a quality assessment and improvement
measure, a target rate of 90% for the number of two (2) year olds immunized.

	 	5)	 	Childhood lead poisoning prevention services shall include screening,
diagnosis, treatment, and follow-up as indicated. In-network providers shall
follow the Centers for Medicare and Medicaid Services (CMS) (formerly the Health
Care Financing Administration) guidelines in effect for the specific time period
and CDC guidelines: Screening Young Children for Lead Poisoning and Managing
Elevated Blood Lead Levels Among Young Children. The Department of Health and
Senior Services shall provide the health plan’s Medical Director with copies of
current protocols and guidelines upon contract award or at any time upon request.
If there is a discrepancy between guidelines, the state agency requires use of the
HCY/EPSDT Lead Risk Assessment Guide developed in accordance with CMS guidelines.
The HCY/EPSDT Lead Risk Assessment Guide may be used separately or in conjunction
with the HCY Screening form.

	 	u.	 	Emergency Medical/Mental Health Services. Emergency medical/mental health
services means covered inpatient and outpatient services that are furnished by a
provider that is qualified to furnish these services and are needed to evaluate or
stabilize an emergency medical condition.

	 	1)	 	An emergency medical condition means a medical or mental health
condition manifesting itself by acute symptoms of sufficient severity (including
severe pain) that a prudent layperson, who possesses an average knowledge of
health and medicine, could reasonably expect the absence of immediate medical
attention to result in the following:

	 	•	 	Placing the physical or mental health of the individual (or, with respect
to a pregnant woman, the health of the woman or her unborn child) in serious
jeopardy;
	 
	 	•	 	Serious impairment to bodily functions;
	 
	 	•	 	Serious dysfunction of any bodily organ or part;
	 
	 	•	 	Serious harm to self or others due to an alcohol or drug abuse emergency;
	 
	 	•	 	Injury to self or bodily harm to others; or
	 
	 	•	 	With respect to a pregnant woman having contractions: (1) that there is
inadequate time to effect a safe transfer to another hospital before delivery,
or (2) that transfer may pose a threat to the health or safety of the woman or
the unborn.

 

 

			
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	 	2)	 	Post-stabilization care services means covered services, related to
an emergency medical condition that are provided after a member is stabilized in
order to maintain the stabilized conditions or to improve or resolve the member’s
condition.

	 	v.	 	Early Periodic Screening, Diagnosis, and Treatment Services: The Omnibus
Budget Reconciliation Act of 1989 (OBRA-89) mandated that Medicaid cover all medically
necessary services listed in Section 1905 (a) of the Social Security Act to children
from birth through age 20. In Missouri, this program is known as the Healthy Children
and Youth (HCY) Program. In accordance with the health plan’s written policies and
procedures, the health plan shall conduct outreach and education of children eligible
for the HCY/EPSDT program, provide the full HCY/EPSDT services to all eligible children
and young adults under the age of 21, and conduct and document well child visits
(screenings) using the State HCY/EPSDT screening form as amended. (The HCY screening
form may be found on the Internet at: http://manuals.momed.com/ Look under
Missouri Medicaid Provider Manuals, Forms, List of Forms, Healthy Children and Youth
Screening [HCY Screening].) The health plan shall provide the full scope of HCY/EPSDT
services in accordance with the following:

	 	1)	 	The health plan shall conduct HCY/EPSDT well child visits on all
eligible members under age twenty-one (21) to identify health and developmental
problems. The state agency recognizes that the decision to not have a child
screened is the right of the parent or guardian of the child. For those children
that have not had well child visits in accordance with the periodicity schedule
established by the state agency, the health plan shall document its outreach and
educational efforts to the parent or guardian informing them of the importance of
well child visits, that a well child visits is due, that appointment scheduling
assistance is available, and that transportation (except to those children with ME
Codes 71-75) is available. (The current periodicity schedule is contained in
Attachment 3.) The health plan shall follow the MC+ fee-for-service policies for
recognition of completion of all components of a full medical HCY/EPSDT well child
visit service. A full HCY/EPSDT well child visits includes all of the components
listed below. A partial well child visit includes the first six (6) components
listed below. The last three (3) components are individual screens. An
interperiodic screen is defined as any encounter with a health care professional
acting within his or her scope of practice.

	 	•	 	A comprehensive health and developmental history including assessment of
both physical and mental health developments;
	 
	 	•	 	A comprehensive unclothed physical exam;
	 
	 	•	 	Health education (including anticipatory guidance);
	 
	 	•	 	Laboratory tests as indicated (appropriate according to age and health
history unless medically contraindicated);
	 
	 	•	 	Appropriate immunizations according to age;
	 
	 	•	 	Verbal lead assessment beginning at age six (6) months and continuing
through age seventy-two (72) months. Blood level testing is mandatory at
twelve (12) and twenty-four (24) months or annually if residing in a high-risk
area of Missouri as defined by Department of Health and Senior Services
regulation 19 CSR 20-8.030;
	 
	 	•	 	Vision screening;
	 
	 	•	 	Hearing screening;

 

 

			
	 	 	 
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	 	•	 	Dental screening (oral exam by primary care provider as part of
comprehensive exam). Recommended that preventive dental services begin at age
six (6) through twelve (12) months and be repeated every six (6) months.

	 	2)	 	If a suspected problem is detected during a well child visit, the
child must be evaluated as necessary, using the required assessment protocol, for
further diagnosis. This diagnosis is used to determine treatment needs.
	 
	 	3)	 	HCY/EPSDT requires coverage for all follow-up diagnostic and
treatment services deemed medically necessary to ameliorate or correct a problem
discovered during an HCY/EPSDT well child visits. Such medically necessary
diagnosis and treatment services must be provided as long as they are Medicaid
covered services as defined in the Social Security Act.
	 
	 	4)	 	The health plan shall establish a tracking system that provides
information on compliance with HCY/EPSDT service provision requirements in the
following areas:

	 	•	 	Initial visit for newborns. The initial HCY/EPSDT well child visits shall
be the newborn physical exam in the hospital.
	 
	 	•	 	Preventive pediatric visits according to the periodicity schedule inclusive
of a verbal lead assessment and blood lead tests.
	 
	 	•	 	Diagnosis and/or treatment, or other referrals in accordance with HCY/EPSDT
well child visit results.
	 
	 	•	 	The health plan shall ensure that the tracking system generates information
consistent with the requirements regarding encounter data as specified
elsewhere herein.

	 	5)	 	The health plan shall have an established process for reminders,
follow-ups, and outreach to members. This process shall include, but not be
limited to, notifying the parent(s) or guardian(s) of children of the needs and
scheduling of periodic well child visits according to the periodicity schedule.
The health plan shall provide assistance to new members in accessing HCY/EPSDT
well child visit services within ninety (90) calendar days of health plan
enrollment. The health plan shall provide assistance to members in accessing
subsequent HCY/EPSDT well child visits in accordance with the periodicity
schedule. At the time of notification, the health plan shall offer transportation
and scheduling assistance if necessary. For members with ME Codes 71 through 75,
non-emergency medical transportation is not a covered benefit.
	 
	 	6)	 	The health plan should seek innovative, cooperative ways to enhance
care coordination and delivery of HCY/EPSDT. This may include the use of a
standardized data base system among health plans.
	 
	 	7)	 	The health plan shall report HCY/EPSDT well child visits through
encounter data submissions in accordance with the requirements regarding encounter
data as specified elsewhere herein. The state agency shall use such encounter
data submissions and other data sources to determine health plan compliance with
CMS requirements that 80 percent of eligible members under the age of twenty-one
are receiving HCY/EPSDT well child visits in accordance with the periodicity
schedule. The state agency shall use the participant ratio as calculated using
the CMS 416 methodology for measuring the health plan’s performance.

	 	•	 	The health plan shall report HCY/EPSDT well child visits in accordance with
the appropriate well child visits codes established by the state agency.
HCY/EPSDT screening codes are identified in MC+ Managed Care Policy
Statements. Services not reported as

 

 

			
	 	 	 
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	 	Page 45

	 	 	 	HCY/EPSDT well child visits in
accordance with the appropriate codes will not be counted toward the health
plan’s participant ratio.

	 	•	 	In the event the state agency uses other data sources submitted by the
health plan, the health plan shall certify the data provided.

	 	a.	 	The data must be certified by one of the following:

	 	1)	 	The health plan’s Chief Executive Officer.
	 
	 	2)	 	The health plan’s Chief Financial Officer.
	 
	 	3)	 	An individual who has delegated authority to
sign for, and who reports directly to, the health plan’s Chief
Executive Officer or Chief Financial Officer.

	 	b.	 	The certification must attest, based on best
knowledge, information, and belief, as to the accuracy, completeness, and
truthfulness of the data.
	 
	 	c.	 	The health plan must submit the certification
concurrently with the data.

	 	w.	 	Mental health and substance abuse services:

	 	1)	 	For children covered under MC+ managed care within Category of Aid 4,
mental health and substance abuse services, if medically necessary, shall not be
the financial responsibility of the health plan and shall be provided in
accordance with the requirements regarding coordination with services not included
in the comprehensive benefit package as specified elsewhere herein.

	 	•	 	For inpatients with dual diagnoses (physical and mental), the health plan
shall be financially responsible for all inpatient hospital days if the
primary, secondary, or tertiary diagnosis is a combination of physical and
mental health. These admissions are subject to the prior authorization and
concurrent review process identified by the health plan.

	 	2)	 	All other members shall receive all medically necessary mental health
and substance abuse services included in the comprehensive benefit package. The
state agency, in conjunction with the Department of Mental Health, has developed
community-based services with an emphasis on the least restrictive setting. The
health plan shall consider, when appropriate, using such services in lieu of using
an out-of-home placement setting for members.
	 
	 	3)	 	With the member’s or the member’s parent/guardian’s consent, the
health plan shall notify the member’s primary care provider when a member is
admitted for mental health or substance abuse services.
	 
	 	4)	 	The health plan shall have protocols for coordinating the diagnosis,
treatment, and care between primary care providers and mental health and substance
abuse providers which include the expected response time for consults between
primary care providers and mental health and substance abuse providers.
	 
	 	5)	 	Services shall include, but not be limited to:

	 	•	 	Inpatient hospitalization, when provided by acute hospital, private or
state psychiatric hospital.
	 
	 	•	 	Outpatient services when provided by a licensed psychiatrist, licensed
psychologist, licensed clinical social worker, provisional licensed clinical
social worker, licensed
counselor, provisional licensed professional counselor, licensed psychiatric
advanced practice nurse, licensed home health psychiatric nurse, or state
certified mental health or substance abuse program. These services must include
outreach efforts on an as needed

 

 

			
	 	 	 
	RFP B3Z06118
	 	Page 46

	 	 	 	basis that recognize the unique mental health
challenges of some members. These efforts may include phone contacts and home
visits.
	 
	 	•	 	Crisis intervention/access services, which may include the provision of a
24-hour hotline staffed by qualified mental health professionals and qualified
substance abuse counselors providing intake, evaluation and referral services,
including services that are alternatives to out of the home placements and
mobile crisis teams for on-site interventions.
	 
	 	•	 	Alternative services which are reasonable, cost effective, and related to
the member’s treatment plan.

	 	6)	 	The health plan is responsible for payment of mental health and
substance abuse services defined herein that are court ordered, 96 hour
detentions, and for involuntary commitments.
	 
	 	7)	 	Mental Health and Substance Abuse Services: To ensure the continuity
of care and the transition of members who have received mental health and
substance abuse services from an out-of-network provider prior to enrollment with
the health plan, the state agency encourages the out-of network provider to
contact the health plan to make transition arrangements with the health plan.
Upon enrollment, the health plan shall transition the member and provide the
immediate continuation of mental health and substance abuse services. The health
plan shall authorize out-of-network providers to continue ongoing mental health
and substance abuse treatment, services, items, and prescriptions for new members
until such time as the new member has been transferred appropriately to the care
of an in-network provider.

	 	•	 	If the member transferred from an out-of-network provider to an in-network
provider, the health plan shall secure the member’s mental health and
substance abuse medical records from the out-of-network provider. The health
plan shall pay rates comparable to Medicaid, unless otherwise negotiated, to
obtain these records.
	 
	 	•	 	Mental Health Out-of-Network Referrals: If the health plan believes that a
child or youth may require residential services in order to receive
appropriate care and treatment for a serious emotional disorder, the health
plan may apply to the Missouri Division of Comprehensive Psychiatric Services
(CPS) for placement in accordance with the MC+ managed care policy statement
titled, Mental Health and Substance Abuse Fee-For-Service Coordination.
	 
	 	•	 	Services provided by a Community Psychiatric Rehabilitation provider shall
be reimbursed by the state agency on a fee-for-service basis according to the
terms and conditions of the Medicaid program.
	 
	 	•	 	Targeted case management services for mental health services shall be
reimbursed by the state agency on a fee-for-service basis according to the
terms and conditions of the Medicaid program.

	 	x.	 	Transplant Related Services: The health plan shall permit and authorize and
shall be financially responsible for any inpatient, outpatient, physician, and related
support services including presurgery assessment/evaluation prior to the date of the
actual bone marrow/stem cell or solid organ transplant surgery. The bone marrow/stem
cell or solid organ transplant will be prior authorized by the state agency and must be
performed at a state agency’s approved transplant facility in accordance with the MC+
members’ freedom of choice. The health plan shall be responsible for pre-transplant
and post-transplant follow-up care and immuno-suppressive pharmacy products prescribed
after the inpatient transplant discharge. To ensure continuity of care, the health
plan must permit and authorize follow-
up services and the health plan shall be responsible for the reimbursement of such
services. The primary care provider must be allowed to refer a transplant patient to
the performing transplant facility for follow-up transplant care. Reimbursement to
out-of-network providers of transplant

 

 

			
	 	 	 
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	 	Page 47

	 	 	 	support services must be no less than the current
Medicaid program rates in effect at the time of the services.

	2.7.2	 	The health plan shall include all the services specified in the comprehensive benefit
package with the exception of non-emergency medical transportation (NEMT), for uninsured
children in ME Codes 71 through 75 (Refer to Attachment 1, COA 5).
	 
	2.7.3	 	In addition to the services listed in the Comprehensive Benefit Package, herein, the health
plan shall include the following additional services for children under 21 years of age and
pregnant women with ME codes 18, 43, 44, 45, and 61.

	 	a.	 	Dental Services (Dental services for pregnant women age 21 and over with ME
codes 18, 43, 44, 45, and 61 shall be limited to dentures and services
related to trauma to the mouth, jaw, teeth or other contiguous sites as a result of
injury. Services to prepare the mouth for dentures, such as examinations, X-rays, or
extractions will not be covered by the health plan. Ancillary denture services such as
relining, rebasing, and repairs will not be covered by the health plan. All other
Medicaid State Plan dental services for these pregnant women are covered through the
Fee For Service Program);
	 
	 	b.	 	Hearing aids and related services;
	 
	 	c.	 	Optical services (Pregnant women age 21 and over with ME codes 18, 43, 44, 45,
and 61 do not receive eyeglasses except for one pair following cataract surgery. Eye
glasses for these pregnant women are covered through the Fee-For-Service program);
	 
	 	d.	 	Comprehensive Day Rehabilitation (for certain persons with disabling
impairments as the result of a traumatic head injury);
	 
	 	e.	 	Durable medical equipment (including but not limited to: orthotic devices,
artificial larynx, enteral and parenteral nutrition, walkers, wheelchair accessories
and batteries, CPAP, BiPAP, and nebulizers);
	 
	 	f.	 	Diabetes self management training for persons with gestational, Type I or Type
II diabetes;
	 
	 	g.	 	Podiatry services.

	2.7.4	 	Medically Necessary: The health plan shall determine whether or not a service(s) furnished
or proposed to be furnished is (are) reasonable and medically necessary for the prevention,
diagnosis or treatment of a physical or mental illness or injury; to achieve age appropriate
growth and development; to minimize the progression of disability; or to attain, maintain or
regain functional capacity; in accordance with accepted standards of practice in the medical
community of the area in which the physical or mental health services are rendered; and
service(s) could not have been omitted without adversely affecting the member’s condition or
the quality of medical care rendered; and service(s) is (are) furnished in the most
appropriate setting. Services must be sufficient in amount, duration, and scope to reasonably
achieve their purpose and may only be limited by medical necessity.

	 	a.	 	In reference to medically necessary care, mental health services shall be
provided in accordance with a process of mental health assessment that accurately
determines the clinical condition of the member and the acceptable standards of
practice for such clinical conditions. The process of mental health assessment shall
include distinct criteria for children and adolescents.
	 
	 	b.	 	The Omnibus Budget Reconciliation Act of 1989 (OBRA-89) mandated that Medicaid
provide medically necessary services to children from birth through age 20, which are
necessary to treat or ameliorate defects, physical or mental illness, or conditions
identified by an HCY/EPSDT screen.

 

 

			
	 	 	 
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	 	 	 	Services must be sufficient in amount, duration,
and scope to reasonably achieve their purpose and may only be limited by medical
necessity.

	2.8	 	Multilingual Services:
	 
	2.8.1	 	During the enrollment process, members shall be asked if English is their main language. If
English is not the member’s main language, the member shall be asked to identify that
language. The information gathered by the state agency shall be shared with the health plan.
	 
	2.8.2	 	The health plan shall make interpreter services available as necessary to ensure that
members are able to communicate with the health plan and providers and receive covered
benefits. The health plan shall use certified interpreters. The health plan shall inform
members of the availability of interpreter services. If the health plan has more than two
hundred (200) members or five (5) percent of its program membership (whichever is less) who
speak a single language other than English as a primary language, the health plan shall make
available general services and materials, such as the health plan’s member handbook in that
language.
	 
	2.8.3	 	In addition, the health plan shall develop appropriate methods for communicating with visual
and hearing impaired members and accommodating the physically disabled. The health plan shall
offer members standard materials, such as the member handbook and enrollment materials in
alternative formats (i.e., large print, Braille, cassette, and diskette) immediately upon
request from members with sensory impairments.
	 
	2.9	 	Member Services:
	 
	2.9.1	 	Member Services Staff: The health plan shall provide adequately trained member services
staff to operate at least nine (9) consecutive hours during the hours of 7:00 a.m. through
7:00 p.m. (i.e., 8:00 a.m. through 5:00 p.m.), Monday through Friday. The health plan may
observe State designated holidays or the holidays designated in its awarded proposal for its
operation of member services. The health plan’s member services staff shall be responsible
for the following:

	 	a.	 	Explaining the operation of the health plan and assisting members in the
selection of a primary care provider. Educating the family about managed care
including the way services typically are accessed under managed care and the role of
the primary care provider.
	 
	 	b.	 	Specifying member’s rights and responsibilities.
	 
	 	c.	 	Explaining covered benefits.
	 
	 	d.	 	Assisting members to make appointments and obtain services.
	 
	 	e.	 	Arranging medically necessary transportation for members.
	 
	 	f.	 	Handling, recording, and tracking member inquiries promptly and timely.
	 
	 	g.	 	The health plan’s member services staff must have available a complete and
up-to-date list of the in-network providers in the health plan provider network. The
health plan shall have a policy and procedure for regularly updating the provider
listing. Member services staff must provide the following information to members
requesting the names of providers:

	 	1)	 	Whether the provider currently participates in the health plan;
	 
	 	2)	 	Whether the provider is currently accepting new patients; and

 

 

			
	 	 	 
	RFP B3Z06118
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	 	3)	 	Any restrictions on services, including any referral or prior
authorization requirements the member must meet to obtain services from the
provider.

	 	 h.	 	The health plan’s member services staff shall be trained on fraud and abuse
policies and procedures.

	2.9.2	 	Toll-Free Telephone Number: The health plan shall maintain a toll-free member services
telephone number. The toll-free member services telephone or other toll-free voice and
telecommunications device for the deaf members must be staffed twenty-four (24) hours per day
to provide needed authorization of services during evenings and weekends and holidays.
	 
	2.10	 	Provider Services:
	 
	2.10.1	 	Provider Services Staff: The health plan shall provide adequately trained provider services
staff to operate at least nine (9) consecutive hours during the hours of 7:00 a.m. through
7:00 p.m. (i.e., 8:00 a.m. through 5:00 p.m.) Monday through Friday. The health plan may
observe State designated holidays or the holidays designated in its awarded proposal for its
operation of provider services. If the health plan observes holidays different than the
State’s, the health plan must obtain the prior written approval of the state agency.
	 
	2.10.2	 	The health plan’s provider services staff shall be responsible for the following:

	 	a.	 	Establishing a mechanism by which providers may determine in a timely manner
whether a member is covered by the health plan and the member’s primary care provider
assignment;
	 
	 	b.	 	Educating providers on the above mechanism’s use;
	 
	 	c.	 	Educating and assisting providers with the health plan service accessibility
standards including but not limited to prior authorization, denial, and referral
procedures;
	 
	 	d.	 	Educating and assisting providers with claims submission and payment
procedures;
	 
	 	e.	 	Educating providers about conditions under which members may directly access
services including, but not limited to, mental health and substance abuse, family
planning, and public health services;
	 
	 	f.	 	Educating providers about how a member can access emergency care and after-hour
services;
	 
	 	g.	 	Educating providers about pharmacy benefits and formulary guidelines; and
	 
	 	h.	 	Handling provider inquiries and complaints.

	2.10.3	 	The health plan shall develop, distribute, and maintain a provider manual. The health plan
shall obtain and document the approval of the provider manual by the health plan’s Medicaid
Plan Administrator and Medical Director and shall review the provider manual at least annually
and maintain documentation verifying such. The health plan shall issue a copy of the provider
manual to providers at the time of inclusion in the provider network, and shall educate the
provider as to its full content and usage.

	 	a.	 	At a minimum, the provider manual shall contain, sections regarding:

	 	1)	 	Specific covered health services for which the provider shall be
responsible, including any limitations or conditions on services;
	 
	 	2)	 	Claims submission instructions and the procedure for review of denied
claims;
	 
	 	3)	 	Prior authorization procedures, and referral procedures including
exceptions, second, or third opinions;

 

 

			
	 	 	 
	RFP B3Z06118
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	 	4)	 	Primary care provider responsibilities;
	 
	 	5)	 	Specialist/ancillary provider responsibilities;
	 
	 	6)	 	Provider complaint, grievance, and appeal processes;

	 	•	 	Any State-determined provider appeal rights to challenge the failure of the
health plan to cover a service.

	 	7)	 	Member Grievance System;

	 	•	 	The member’s right to file grievances and appeals and their requirements
and timeframes for filing;
	 
	 	•	 	The availability of assistance in filing;
	 
	 	•	 	The toll-free numbers to file oral grievances and appeals;
	 
	 	•	 	The member’s right to request continuation of benefits during an appeal or
State fair hearing filing and, if the health plan’s action is upheld in a
hearing, the member may be liable for the cost of any continued benefits.
	 
	 	•	 	The member’s right to a state fair hearing, how to obtain a hearing, and
representation rules at a hearing;

	 	(a)	 	A member may request a State fair hearing within 90
calendar days from the health plan’s notice of action.
	 
	 	(b)	 	The State must reach its decisions within the specified
timeframes:

	 	1)	 	Standard resolution: within 90 calendar
days of the date the member filed the appeal with the health plan if
the member filed initially with the health plan (excluding the days
the member took to subsequently file for a State fair hearing) or the
date the member filed for direct access to a State fair hearing.
	 
	 	2)	 	Expedited resolution (if the appeal was
heard first through the health plan appeal process): within 3
working days from the state agency’s receipt of a hearing request for
a denial of a service that:

	 	•	 	Meets the criteria for an expedited appeal process but was not
resolved using the health plan’s expedited appeal timeframes, or
	 
	 	•	 	Was resolved wholly or partially adversely to the member using
the health plan’s expedited appeal timeframes.

	 	3)	 	Expedited resolution (if the appeal was
made directly to the State Fair Hearing process without accessing the
health plan appeal process): within 3 working days from the state
agency’s receipt of a hearing request for a denial of a service that
meets the criteria for an expedited appeal process.

	 	8)	 	Procedure for obtaining member eligibility status;
	 
	 	9)	 	Appointment/access standards;
	 
	 	10)	 	Multilingual and TDD availability;
	 
	 	11)	 	Quality Assessment and Improvement;
	 
	 	12)	 	Provider Credentialing;

 

 

			
	 	 	 
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	 	13)	 	Management and retention of medical records;
	 
	 	14)	 	Confidentiality;
	 
	 	15)	 	Advance directives; and
	 
	 	16)	 	Fraud and abuse guidelines.

	2.10.4	 	The health plan shall supply the state agency with the federal tax identification number and
professional license number of each provider performing services for the health plan.
	 
	2.10.5	 	The health plan should specify in writing the following to out-of-network providers at the
time a service is approved to be performed by the out-of-network provider:

	 	a.	 	Claims submission instructions and the procedure for review of denied claims;
	 
	 	b.	 	Prior authorization procedures and referral procedures including exceptions,
second, or third opinions;
	 
	 	c.	 	Provider complaint, grievance, and appeal procedures;

	 	1)	 	Any State-determined provider appeal rights to challenge the failure
of the health plan to cover a service.

	 	d.	 	Member Grievance System;

	 	•	 	The member’s right to file grievances and appeals and their requirements and
timeframes for filing;
	 
	 	•	 	The availability of assistance in filing;
	 
	 	•	 	The toll-free numbers to file oral grievances and appeals;
	 
	 	•	 	The member’s right to request continuation of benefits during an appeal or State
fair hearing filing and, if the health plan’s action is upheld in a hearing, the
member may be liable for the cost of any continued benefits.
	 
	 	•	 	The member’s right to a state fair hearing, how to obtain a hearing, and
representation rules at a hearing;

	 	(a)	 	A member may request a State fair hearing within 90 calendar
days from the health plan’s notice of action.
	 
	 	(b)	 	The State must reach its decisions within the specified
timeframes:

	 	1)	 	Standard resolution: within 90 calendar days of the
date the member filed the appeal with the health plan if the member filed
initially with the health plan (excluding the days the member took to
subsequently file for a State fair hearing) or the date the member filed
for direct access to a State fair hearing.
	 
	 	2)	 	Expedited resolution (if the appeal was heard first
through the health plan appeal process): within 3 working days from the
state agency’s receipt of a hearing request for a denial of a service
that:

	 	•	 	Meets the criteria for an expedited appeal process but was not
resolved using the health plan’s expedited appeal timeframes, or
	 
	 	•	 	Was resolved wholly or partially adversely to the member using the
health plan’s expedited appeal timeframes.

 

 

			
	 	 	 
	RFP B3Z06118
	 	Page 52

	 	3)	 	Expedited resolution (if the appeal was made directly
to the State Fair Hearing process without accessing the health plan appeal
process): within 3 working days from the state agency’s receipt of a
hearing request for a denial of a service that meets the criteria for an
expedited appeal process.

	 	e.	 	Procedure for obtaining member eligibility status;
	 
	 	f.	 	Multilingual and TDD availability; and
	 
	 	g.	 	Confidentiality.

	2.11	 	Release for Ethical Reasons:
	 
	2.11.1	 	As a condition to participating in, or contracting with the health plan, the health plan may
not:

	 	a.	 	Require a provider to perform any treatment or procedure which is contrary to
the provider’s conscience, religious beliefs, or ethical principles or policies; or
	 
	 	b.	 	Prohibit a provider from making a referral to another health care provider
licensed to provide care appropriate to the member’s medical condition.

	2.11.2	 	The health plan shall have a process by which the provider may refer a member to another
health care provider licensed to provide care appropriate to the member’s medical condition or
withdraw from the case and the health plan shall assign the member to another provider
licensed to provide care appropriate to the member’s medical condition.
	 
	2.11.3	 	A health plan that is otherwise required to provide, reimburse for, or provide coverage of,
a counseling or referral service because of the requirement herein may object to the service
on moral or religious grounds. If the health plan objects to service on moral or religious
grounds, the health plan must notify the state agency. Additionally, the health plan shall
notify the state agency whenever the health plan adopts the policy during the term of the
contract. The health plan agrees that such an objection and subsequent release from
providing, reimbursing for, or providing coverage of, a counseling or referral service shall
result in a reduction to the applicable capitation rates paid to the health plan to reflect
such a release as outlined in paragraph 2.28.4.

	 	a.	 	Information to potential members must be provided prior to enrollment regarding
the health plan’s release of provision of such service.
	 
	 	b.	 	The health plan shall be required to notify its members 30 calendar days prior
to any change in its policy regarding coverage of a counseling or referral service.
	 
	 	c.	 	The health plan shall be required to notify its members of how and where to
obtain the service.

	2.12	 	Coordination With Services not Included in the Comprehensive Benefit Package:
	 
	 	 	The health plan is not obligated to provide or pay for any services not included in the
comprehensive benefit package. However, the health plan must perform care coordination of
covered services with services not included within the comprehensive benefit package. These
services include, but are not limited to, the following:
	 
	2.12.1	 	School Based Services:

	 	a.	 	When communities and school boards agree, schools may operate school based
clinics to address unmet medical needs of children. The state agency supports the
efforts of such communities. The health plan shall perform care coordination with
school based clinic services with comprehensive
benefit services that are the responsibility of the health plan. In addition, the
health plan shall have a written process for coordination and collaboration with school
based clinics.

 

 

			
	 	 	 
	RFP B3Z06118
	 	Page 53

	 	b.	 	The health plan shall not be financially liable for physical therapy (PT),
occupational therapy (OT), or speech therapy (ST) included in an Individualized Family
Service Plan (IFSP) developed under the First Steps Program or included in an
Individual Education Plan (IEP) developed by the public school. First Steps is an
early intervention program required by the Individuals with Disabilities Education Act
(IDEA) — Part C (34 CFR 303 Early Intervention Program for Infants and Toddlers with
Disabilities) which also defines the IFSP. IEP services are required by the IDEA Part
B (34 CFR 300 and 301). IFSPs and IEPs will include therapies which are needed due to
developmental and educational needs. The health plan shall be responsible for all
other medically necessary therapy services that are not identified in an IEP or IFSP
including maintenance and developmental therapy. The health plan shall be financially
responsible for all other Medicaid reimbursable services identified in the IFSP or IEP
and are medically necessary. The health plan shall be responsible for medically
necessary equipment and supplies used in connection with PT, OT, and ST services for
all members. Equipment and supplies are covered as a Durable Medical Equipment
benefit. The health plan shall not delay the provision of therapies that are medically
necessary pending completion of the IFSP or IEP.

	 	1)	 	The First Steps program serves children from birth to age three (3)
who are developmentally delayed or have diagnosed conditions associated with
developmental disabilities. Enrollment in the First Steps program is voluntary at
the choice of the child’s parent or guardian. The intent of the program is,
through early detection and intervention, to improve functioning or decrease
deterioration in order to better prepare the child to participate in school. The
Missouri Department of Elementary and Secondary Education (DESE) operates the
First Steps program. Service Coordinators who contract with DESE are responsible
for determining program eligibility. A multi-disciplinary team determines the
child’s service needs including if medical treatment is needed. The team shall
include the child’s physician. With the parent/guardian consent, the health plan
shall refer children who are potentially eligible for First Steps services to the
local First Steps office (System Point of Entry) or call the state-wide toll-free
number, 866-583-2392, to make a referral.
	 
	 	2)	 	The health plan shall have written policies and procedures for
promptly transferring medical and developmental data and for coordinating ongoing
care with special education services.

	 	c.	 	Parents as Teachers (PAT) is a home-school-community partnership which supports
parents in their role as their child’s first and most influential teachers. Every
parent of a child age 5 or under is eligible for PAT, regardless of income. PAT
services include personal visits from certified parent educators, group meetings,
developmental screenings, and connections with other community resources from the time
the child is born until he/she enters kindergarten.

	 	1)	 	PAT programs collaborate with other agencies and programs to meet
families’ needs, including Head Start, First Steps, the Women Infants and Children
Program (nutrition services), local health departments, the Family Support
Division, etc. Independent evaluations of PAT show that children served by this
program are significantly more advanced in language development, problem solving,
and social development at age 3 than comparison children, 99.5% of participating
families are free of abuse or neglect, and early gains are maintained in
elementary school, based on standardized tests.
	 
	 	2)	 	The PAT program is administered at the local level by each public
school district in the state of Missouri. Families interested in PAT may contact
their local district directly. PAT also accepts referrals from other sources
including medical providers. Providers who have contact with families with
children age 5 and under are encouraged to refer those families to PAT.
Additional information about PAT is available at the Department of Elementary and
Secondary
Education’s website at www.dese.state.mo.us. (Look under programs, then Early
Childhood Education, then Parents as Teachers.)

 

 

			
	 	 	 
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	2.12.2	 	Public Health Programs: Services offered by the Department of Health and Senior Services
and local public health agencies and the method of reimbursement shall include:

	 	a.	 	Environmental lead assessments for health plan children with elevated blood
levels shall be reimbursed directly by the state agency on a fee-for-service basis
according to the terms and conditions of the Medicaid program.
	 
	 	b.	 	State Public Health Laboratory Services to Members: In cases where the health
plan is required by law to use the State Public Health Laboratories (e.g., metabolic
testing for newborns) and in cases where the State Public Health Laboratory and
Department of Health and Senior Services designated local public health agency
laboratories perform tests, other than those services listed herein, on members for
public health purposes, the laboratory shall be reimbursed directly by the state agency
on a fee-for-service basis according to the terms and conditions of the Medicaid
program, and such costs shall not be included in the Medicaid State plan capitated
rates.
	 
	 	c.	 	Newborn Screening Collection Kits: According to RSMo 191.331, health care
providers must purchase pre-paid newborn screening collection kits from the Department
of Health and Senior Services. The Department of Health and Senior Services sells the
kit to providers. When the provider submits a specimen to the State Department of
Health and Senior Services Laboratory, the laboratory shall process the test, determine
if the member is MC+ eligible, and bill the state agency for the test.
	 
	 	d.	 	Special Supplemental Nutrition for Women, Infants and Children (WIC) Program -
Sections 1902(a)(11)(C) and 1902(a)(53) of the Social Security Act and Title 42, CFR
431.635 require coordination between the state agency and the WIC program. While WIC
services are not the responsibility of the health plan, the in-network provider shall
document and refer eligible members for WIC services. As part of the initial
assessment of members, and as a part of the initial evaluation of newly pregnant women,
the in-network providers shall provide and document the referral of pregnant,
breast-feeding, or postpartum women, or a parent/guardian of a child under the age of
five, as indicated, to the WIC Program. Upon contract award and upon request, the
Department of Health and Senior Services shall provide the health plan with WIC program
eligibility and referral criteria.

	2.12.3	 	Transplant Services: Solid organ and bone marrow/stem cell transplant services are not
included in the comprehensive benefit package as covered benefits. These services will be
delivered for all populations through separate arrangements. Transplant services are defined
as the hospitalization from the date of transplant procedure until the date of discharge,
including solid organ or bone marrow/stem cell procurement charges, and related physician
services associated with both procurement and the transplant procedure. The health plan shall
be responsible for any services before and after this admission, including the evaluation that
may be related to the condition, even though these services may be delivered out-of-network.

	 	a.	 	According to 42 CFR 431.51, Medicaid must insure freedom of choice of providers
for services provided to Medicaid beneficiaries when those services are paid on a
fee-for-service basis outside the health plan. When in-network providers identify a
member as a potential transplant candidate, the member must be referred to a transplant
facility of their choice without regard to health plan preference.

	2.12.4	 	Comprehensive Substance Treatment Abuse and Rehabilitation (C-STAR) programs are carved out
of the MC+ managed care program. Services provided by a C-STAR Medicaid provider shall be
reimbursed by the state agency on a fee-for-service basis according to the terms and
conditions of the Medicaid program. In order to ensure quality of care, the health plan and
its mental health subcontractors shall maintain open and consistent dialogue with C-STAR
providers. The health plan shall be responsible
for care coordination of services included in the benefit package and C-STAR services in
accordance with the MC+ managed care policy statement titled, Mental Health and Substance
Abuse Fee-For-Service Coordination.

 

 

			
	 	 	 
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	2.12.5	 	Mental Health Services for Category Of Aid 4: For children covered under the health plan
within the COA 4 group, the health plan shall not be financially responsible for the following
medically necessary mental health and substance abuse services:

	 	a.	 	Inpatient Mental Health and Substance Abuse Services shall be any psychiatric
stay in an acute care hospital, or in a private or State psychiatric hospital. The
health plan primary care provider and the child’s caseworker shall coordinate services.
Admissions must be in accordance with established guidelines of the Department of
Social Services in conjunction with the Department of Mental Health. The Department of
Social Services in conjunction with the Department of Mental Health will determine the
appropriateness of inpatient placement, appropriate facility, alternative placement,
and psychiatric diversion. The state agency’s Medical Review Agency must certify
medically necessary inpatient days for mental health and substance abuse services
(billable on an inpatient hospital claim form) beyond the days deemed medically
necessary for physical health.
	 
	 	b.	 	For inpatients with a dual diagnoses (physical and mental) identified at either
admission or during the stay, the health plan shall be financially responsible for all
inpatient hospital days if the primary, secondary, or tertiary diagnosis is a
combination of physical and mental health. These admissions are subject to the health
plan’s prior authorization and concurrent review process.
	 
	 	c.	 	Outpatient Mental Health and Substance Abuse Services are those services not
provided in an inpatient setting. Examples of appropriate settings are outpatient
facility, office, or clinic setting. These services must be provided by a licensed
psychiatrist, licensed psychologist, licensed clinical social worker, provisional
licensed clinical social worker, licensed counselor, provisional licensed professional
counselor, licensed psychiatric advanced practice nurse, licensed home health
psychiatric nurse, or state certified mental health or substance abuse program. The
services will be provided subject to Medicaid program benefits and limitations.

Paragraph 2.12.5 d. revised by Amendment #002

	 	d.	 	Comprehensive Community Support Services: Comprehensive Community Support
Services are provided to children in the custody of the Children’s Division and are
found to have behavioral conditions which require rehabilitative services at a
residential treatment or specialized foster care level of care or who are being
discharged from these two treatment levels, and who require comprehensive community
support services in order to maintain the rehabilitation treatment outcome in a less
restrictive environment. The Children’s Division identifies children in the custody of
the Children’s Division qualifying for these services and authorizes provision of
comprehensive community support. Comprehensive community support services include any
medical or remedial service reasonable and necessary for maximum reduction of a
behavioral disability and restoration of the child to his or her best possible
functional level. Examples include, but are not limited to: Intake, Assessment,
Evaluation and Treatment Planning; Community Support; Specialized Sexual Abuse
Treatment: 24-hour Crisis Intervention and Stabilization; Intensive In-Home Services;
Medication Management and Monitoring; Day Treatment/Psychosocial Rehabilitation;
Therapeutic Counseling or Consultation Services not Covered Separately through the HCY
or Physician’s Services Program, Supported Independent Living and Transitional Living
Services; and School-Based Behavioral Support Services not included in the IEP. The
services will be provided subject to Medicaid program benefits and limitations. The
health plan is not financially liable for comprehensive community support services.

	2.12.6	 	SAFE-CARE Exams: Sexual Assault Forensic Examination and Child Abuse Resource Education
(SAFE-CARE) examinations and related diagnostic studies which ascertain the likelihood of
sexual or physical abuse performed by SAFE-CARE trained providers shall continue to be
reimbursed by the state agency on a fee-for-service basis according to the terms and
conditions of the Medicaid program. The state agency shall define which services will
continue to be reimbursed by the state agency on a fee-for-service basis according to the terms and conditions of the Medicaid program when performed
or requested by a SAFE-CARE trained provider. Other medically necessary services may be
ordered by the SAFE-CARE provider by referring to an in-network provider when possible. The
health plan shall be

 

 

			
	 	 	 
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	 	 	responsible for these services, regardless whether the SAFE-CARE
provider is in or out of the health plan network.

	2.12.7	 	Pharmacy Services: Pharmacy services not included in the health plan’s awarded proposal
shall be reimbursed by the state agency on a fee-for-service basis according to the terms and
conditions of the Medicaid program.
	 
	2.12.8	 	Protease Inhibitors: Protease inhibitors shall be reimbursed by the state agency on a
fee-for-service basis according to the terms and conditions of the Medicaid program.
	 
	2.12.9	 	Abortion Services: Abortion services subject to Medicaid program benefits and limitations
shall continue to be reimbursed by the state agency on a fee-for-service basis according to
the terms and conditions of the Medicaid program.

Paragraph 2.12.10. revised by Amendment #001

	2.12.10	 	Mentally Retarded and Developmental Disabilities (MRDD) Waiver: Home and community based
waiver services for persons in the MRDD waiver are carved out of the MC+ managed care program.
The health plan shall be responsible for MC+ managed care covered services for MRDD waiver
clients enrolled in MC+ managed care, unless specifically excluded. The health plan shall be
responsible for care coordination of services included in the benefit package and the Home and
Community based waiver. The state agency shall identify the MRDD Waiver participants to the
health plan. Information regarding MRDD Waiver Services may be found in Section 19 of the
Missouri Medicaid MRDD Waiver Provider Manual and the Missouri Medicaid Provider Bulletins
located on the internet at www.dss.mo.gov/dms/providers.htm.
	 
	2.12.11	 	Home Birth Services: In accordance with the MC+ managed care home birth policy statement,
if a member elects a home birth the member shall be disenrolled from MC+ managed care. The
disenrolled member shall then receive services through the MC+ fee-for-service program for the
home birth.
	 
	2.12.12	 	Services for Children in the Custody of the Jackson County Office of the Missouri
Children’s Division: Under court order (G.L. v. Stangler, also called the Consent Decree),
children in the custody of the Jackson County office of the Missouri Children’s Division (CD)
and residing in Cass, Clay, Henry, Jackson, Johnson, Lafayette, Platte, Ray, or St. Clair
counties have additional medical care requirements.

	 	a.	 	In addition to the services outlined herein, the health plan shall provide the
following services following the effective date of enrollment with the health plan. If
the child is already enrolled with the health plan and enters custody, the health plan
shall provide the following services from the time the child enters CD custody. The
time frames for these examinations begin with the time and date the child enters CD
custody.

	 	1)	 	A physical examination within 36 hours. The 36 hour exam is due the
next working day following entry into custody. (This shall be paid by Medicaid on
a fee-for-service basis and arranged by CD if the child is not enrolled in a
health plan at the time of entry into CD custody.) A complete physical
examination may be replaced by partial physical examination if the CD caseworker
and the provider agree that a complete physical examination is unnecessary,
repetitive, or would cause undue stress for the child. If agreement is reached
that a partial physical examination is adequate, the provider shall decide the
scope of the partial physical examination. Agreement that a complete physical
examination is not necessary shall be documented in the child’s medical record.
In all cases, if a child is enrolled with the health plan prior to the 36-hour
deadline, the health plan shall be responsible for providing the examination. If
the health plan does not provide the examination, the health plan shall reimburse
the provider that performs the examination in accordance with the current Medicaid
fee schedule. CD, the Medical Case Management Agency, and the health plan shall
work
together to establish a notification process so that the health plan receives
notification of the enrollment of a Consent Decree-covered child in a timely
manner.

 

 

			
	 	 	 
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	 	2)	 	Within 30 calendar days — Follow-up examinations recommended by the
provider during the 36-hour examination; i.e.: hearing and eye exams, dental
screens or a full HCY screen shall be done in accordance with the most recent
periodicity schedule. A partial HCY screening may be administered if the child is
current with his or her HCY screening schedule and the CD caseworker and provider
agree that a full HCY screening is unnecessary, repetitive, or would cause undue
stress for the child. If agreement is reached that a partial HCY screening is
adequate, the provider shall decide the scope of the partial HCY screening.
Agreement that a full HCY screening is not necessary shall be documented in the
child’s medical record.

	 	b.	 	Following the 30 calendar day screening requirements, the HCY schedule shall be
followed for children up to five years of age with annual examinations after age five
unless the child has physical health, mental health, or developmental health problems
identified by the provider that require medically necessary treatment on a more
frequent basis.

	 	c.	 	The health plan shall be responsible for determinations regarding medically
necessary treatments, medically necessary appointments, and medically necessary
services.
	 
	 	d.	 	Consent Decree Medical Case Management: Children in the custody of the Jackson
County office of the Missouri Children’s Division and residing in Jackson County also
receive targeted medical case management services. Medical case management services
are intended to facilitate access to medical services for the targeted children.
Although this medical case management will be provided through a separate contract
between the Department of Social Services and a Medical Case Management agency, the
health plan shall provide the medical care required by the Consent Decree and all
services specified herein for children in State custody. Per the Consent Decree, G.L.
v. Stangler Amended Revised Operational Guide; March 14, 2002, and the contract with
Medical Case Management agencies, children are followed at three different levels:
Category 1, well children; Category 2, children with behavioral or mental health needs;
and Category 3, children with medical needs. Children identified as Category 2 and
Category 3 will remain in targeted medical case management during the entire time they
are in custody. Category 1 children will be enrolled for targeted medical case
management only during the first 30 calendar days of custody. The medical case
management services provided by the Medical Case Management Agency include, but are not
limited to:

	 	1)	 	Promoting the effective and efficient access to comprehensive medical
services for the targeted children,
	 
	 	2)	 	Facilitating the coordination of medical services,

	 
	 	3)	 	
 Maintaining confidential centralized files for each child,
	 
	 	4)	 	Assisting in the education of CD staff, caregivers, and health care
providers regarding the child’s medical care,
	 
	 	5)	 	Providing information regarding the need for specialized health
services,
	 
	 	6)	 	Coordinating and monitoring all primary and specialty care necessary
for the child, and
	 
	 	7)	 	Ensuring that essential medical care received by the child complies
with the Consent Decree, Part III.

	 	e.	 	The health plan and providers shall cooperate with the Medical Case Management
Agency in securing medical histories and providing medical records as required by the
Consent Decree. The health plan shall allow case managers to file an appeal
immediately (or within 12 hours if a concern arises after regular business hours) to
the health plan’s MC+ Medical Director if a Consent Decree case managed child is denied
services or has difficulty accessing services covered in the contract.
	 
	 	f.	 	The health plan shall designate a person within the health plan as a primary
contact for CD staff, caregivers, and health care providers for issues involving these
targeted children. The health plan shall also participate and attend medical oversight
meetings.

 

 

			
	 	 	 
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	2.13	 	Second Opinion: Members have a right to second opinions from qualified health care
professionals, and the health plan shall have policies and procedures for rendering second
opinions both in-network and out-of-network when requested by a member. The health plan’s
policies and procedures shall address whether there is a need for referral by the primary care
provider or self-referral. The adequacy of these policies and procedures shall be examined
during quality assessment reviews. Missouri Revised Statutes Section 208.152 states that
certain elective surgical procedures require a second medical opinion be provided prior to the
surgery. A third surgical opinion, provided by a third provider, shall be allowed if the
second opinion fails to confirm the primary recommendation that there is a medical need for
the specific surgical operation, and if the member desires the third opinion.
	 
	2.14	 	Service Accessibility Standards:
	 
	2.14.1	 	Twenty-Four Hour Coverage: The health plan shall provide coverage to members on a
twenty-four (24) hour per day, seven (7) day per week basis. The health plan shall have
written policies and procedures describing how members and providers can contact the health
plan to receive individual instruction or authorization for treatment of an emergent or urgent
medical, mental health, or substance abuse problem and instruction regarding receiving care
when the member is out of the health plan’s geographic area. The health plan must make the
policies and procedures available in an accessible format upon request. The health plan must
provide for direct contact with qualified clinical staff through a toll-free member or
provider services telephone number and a telecommunication device for the deaf telephone
number. Recorded messages are not acceptable. The health plan shall provide an
accommodation, if needed, to ensure all members equal access to twenty-four hour per day
health care coverage.
	 
	2.14.2	 	Prior Authorization:

	 	a.	 	The health plan shall ensure that prior authorization requirements are not
applied to emergency medical/mental health services as defined herein.
	 
	 	b.	 	The health plan shall specify, in writing, the procedures for prior
authorization of non-emergency services and the time frames in which authorizations
will be processed (approved or denied) and providers and members are notified.
	 
	 	c.	 	If the health plan requires a referral, assessment, or other requirement prior
to the member accessing requested medical or mental health services, such requirements
shall not be an impediment to the timely delivery of the medically necessary service.
The health plan shall assist the member to make any necessary arrangements to fulfill
such requirements (i.e., scheduling appointments, providing comprehensive lists of
available providers, etc.). If such arrangements cannot be made timely, the requested
services shall be approved.
	 
	 	d.	 	The health plan shall ensure that its prior authorization procedures meet the
following minimum requirements:

	 	1)	 	All appeals and denials must be reviewed by a professional with
experience or expertise comparable to the provider requesting the authorization.
	 
	 	2)	 	There is a set of written criteria for review based on sound medical
evidence that is updated regularly and consistently applied and for consultations
with the requesting provider when appropriate.
	 
	 	3)	 	Reasons for decisions are clearly documented and assigned a prior
authorization number which refers to and documents approvals and denials.
	 
	 	4)	 	Documentation shall be maintained on any alternative service(s)
approved in lieu of the original request.

 

 

			
	 	 	 
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	 	5)	 	There is a well-publicized review process for both providers and
members.
	 
	 	6)	 	The review process is completed and communicated to the provider in a
timely manner, as indicated below, or the denials shall be deemed approved. For
the purpose of this section, “necessary information” includes the results of any
face-to-face clinical evaluation or second opinion that may be required.

	 	•	 	Approval or denial of non-emergency services when determined as such by
emergency room staff shall be provided by the health plan within thirty (30)
minutes of request.
	 
	 	•	 	Approval or denial shall be provided within twenty-four (24) hours of
request for services determined to be urgent by the treating provider.
	 
	 	•	 	Approval or denial shall be provided within two (2) business days of
obtaining all necessary information for routine services. The health plan
shall notify the requesting provider within two business days following the
receipt of the request of service regarding any additional information
necessary to make a determination. In no case shall a health plan exceed
fourteen (14) calendar days following the receipt of the request of service to
provide approval or denial.
	 
	 	•	 	Involuntary detentions (96 hour detentions or court ordered detentions) or
commitments shall not be prior authorized.

	 	e.	 	The health plan shall ensure that members are not without necessary medical
supplies, oxygen, nutrition, pharmaceutical products, etc., and must have written
procedures for making an interim supply of an item available.
	 
	 	f.	 	The health plan shall ensure that the member’s treatment regimens are not
interrupted or delayed (i.e. physical, occupational, and speech therapy; psychological
counseling; home health services; personal care, etc.) by the prior authorization
process.
	 
	 	g.	 	If the health plan approves purchase of a custom or power wheelchair,
eyeglasses, hearing aids, dentures (excluding orthodontic services), custom HCY/EPSDT
equipment, augmentative communication devices placed within six months of approval,
etc. which is delivered or placed after enrollment in the health plan ends, the health
plan shall be responsible for payment.
	 
	 	h.	 	If the health plan requires prior authorization for pharmacy products, the
health plan shall provide a response by telephone or other telecommunication device
within 24 hours of a request for prior authorization. Approvals must be granted for
claims meeting established criteria approved by the state. The state will approve
criteria that follows accepted national guidelines for appropriate product use. The
criteria shall be based on medical and clinical information and Missouri-specific data,
consistent with the predetermined standards set by one or more of the following:

	 	•	 	The American Hospital Formulary Service — Drug Information
	 
	 	•	 	The United States Pharmacopoeia Drug Information
	 
	 	•	 	Peer-reviewed medical literature.

	 	 	 	Specific details describing pharmacy prior authorization and step therapy criteria shall
be made available to prescribers upon request. Prescribers shall be informed of the
availability of the criteria
when a prescription is denied. The health plan shall provide for the dispensing of at
least a 72-hour supply or a sufficient supply to the next business day of a drug product
that requires prior authorization in an emergency situation.

 

 

			
	 	 	 
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	 	i.	 	If the health plan prior authorizes health care services, the health plan shall
not subsequently retract its authorization after the services have been provided, or
reduce payment for an item or service unless:

	 	•	 	The authorization is based on material misrepresentation or omission about the
treated person’s health condition or the cause of the health condition; or
	 
	 	•	 	The health plan terminates before the health care services are provided; or
	 
	 	•	 	The covered person’s coverage under the health plan terminates before the
health care services are provided.

	2.14.3	 	Travel Distance: The health plan shall comply with travel distance standards as set forth
by the Department of Insurance in 20 CSR 400-7.095 regarding Provider Network Adequacy
Standards. For those providers not addressed under 20 CSR 400-7.095, the health plan shall
ensure members have access to those providers within a reasonable travel distance. For those
providers addressed under 20 CSR 400-7.095 but not applicable to the MC+ Managed Care Program
(e.g. chiropractors), the health plan shall not be held accountable for the distance standards
for those providers.

Paragraph 2.14.4 revised by Amendment #002 and BAFO #001

	2.14.4	 	Appointment Standards:

	 	a.	 	The average waiting times for primary care appointments shall not exceed one
hour from scheduled appointment time. This includes time spent both in the lobby and
in the examination room prior to being seen by a provider. Providers can be delayed
when they “work in” urgent cases, when a serious problem is found, or when the member
had an unknown need that requires more services or education than was described at the
time the appointment was made.
	 
	 	b.	 	The health plan shall have procedures in place that ensure:

	 	1)	 	Urgent care appointments for illness injuries which require care
immediately but do not constitute emergencies, within 24 hours (e.g. high
temperature, persistent vomiting or diarrhea, symptoms which are of sudden or
severe onset but which do not require emergency room services).
	 
	 	2)	 	Routine care, with symptoms, appointments must be available within
one (1) week or five (5) business days whichever is earlier (e.g. persistent
rash, recurring high grade temperature, nonspecific pain, fever).
	 
	 	3)	 	Routine care, without symptoms, appointments must be available within
thirty (30) calendar days (e.g. well child exams, routine physical exams).

Paragraph 2.14.4 b. 4) revised by BAFO #001

	 	4)	 	For mental health and substance abuse services, aftercare
appointments shall occur within seven (7) calendar days after hospital discharge.

	 	c.	 	For maternity care, the health plan shall be able to provide initial prenatal
care appointments for enrolled pregnant members as follows:

	 	1)	 	First trimester, must be available within seven (7) calendar days of
first request.
	 
	 	2)	 	Second trimester, must be available within seven (7) calendar days of
first request.
	 
	 	3)	 	Third trimester, must be available within three (3) calendar days of
first request.
	 
	 	4)	 	High risk pregnancies, must be available within three (3) calendar
days of identification of high risk to the health plan or maternity care provider,
or immediately if an emergency exists.

 

 

			
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	 	d.	 	Policies and Procedures: The health plan shall disseminate its appointment
standards to the network. The health plan shall monitor the adequacy of its
appointment standards to ensure the reduction of unnecessary use of emergency room
visits.

	 	1)	 	The health plan shall have written policies and procedures concerning
educating the provider network about appointment standards. The health plan shall
monitor compliance with appointment standards and shall have a corrective action
plan when appointment standards are not met.

	2.14.5	 	The health plan shall have established written policies and procedures concerning how a
member may obtain a referral to an out-of-network provider when the health plan does not have
a health care provider with appropriate training or experience in the network to meet the
particular health care needs of the member.
	 
	2.14.6	 	The health plan shall have established written policies and procedures concerning how a
member, with a condition which requires on-going care from a specialist, may request a
standing referral to such a specialist.
	 
	2.14.7	 	The health plan shall have established written policies and procedures concerning how a
member, with a life-threatening condition or disease either of which requires a specialized
medical care over a prolonged period of time, may request and obtain access to a specialty
care center.
	 
	2.14.8	 	In accordance with State law, the health plan must allow members direct access to the
services of the in-network OB/GYN of their choice for the provision of covered services.
	 
	2.14.9	 	In accordance with State law, the health plan must notify the member on an annual basis, in
writing, of cancer screenings covered by the health plan and provide the current American
Cancer Society guidelines for all cancer screenings.
	 
	2.14.10	 	The health plan shall have policies and procedures concerning how it will appropriately
work with an out-of-network provider and/or the previous health plan to effect a transfer of
care to appropriate in-network providers when a newly enrolled member has an existing
relationship with a provider that is not in the health plan’s network. For continuity of
care, there are instances in which care shall continue with the out-of-network provider (e.g.
third trimester pregnancy, in the middle of a course of treatment for cancer, etc.)
	 
	2.14.11	 	Care Management: The health plan shall provide care management to members. Care
management is coordination of care provided to members.

	 	a.	 	The health plan shall coordinate and deliver services designed to achieve the
following outcomes:

	 	1)	 	Improved patient care;
	 
	 	2)	 	Improved health outcomes;
	 
	 	3)	 	Reduction of inappropriate inpatient hospitalization;
	 
	 	4)	 	Reduction of inappropriate utilization of emergent services;
	 
	 	5)	 	Lower total costs; and
	 
	 	6)	 	Better educated providers and patients.

	 	b.	 	The health plan should have the following components in the care management
program:

	 	1)	 	Use of clinical practice guidelines;

2) Provider and patient profiling;
	 
	 	3)	 	Specialized physician and other practitioner care targeted to meet
members special needs;
	 
	 	4)	 	Provider education;
	 
	 	5)	 	Patient education;

 

 

			
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	 	6)	 	Claims analyses; and
	 
	 	7)	 	Quarterly and yearly outcome measurement and reporting. The
reporting requirements specified in Attachment 6 will satisfy this component.
(Definition used with permission of The Center for Case Management, 6 Pleasant
Street, South Natick, MA 01760.)

	 	c.	 	The health plan must have implemented and effective policies and procedures for
case management, care coordination, and disease management:

	 	1)	 	Case management is a clinical system that focuses on the
accountability of an identified individual or group for coordinating a patient’s
care (or group of patients) across an episode or continuum of care; negotiating,
procuring, and coordinating services and resources needed by patients/families
with complex issues; insuring and facilitating the achievement of quality,
clinical, and cost outcomes; intervening at key points for individual patients;
addressing and resolving patterns of issues that have a negative quality cost
impact; and creating opportunities and systems to enhance outcomes. (Definition
used with permission of The Center for Case Management, 6 Pleasant Street, South
Natick, MA 01760.) Case management is understood as including, but not limited
to the development of individualized treatment plans and ongoing communication and
coordination with other systems of care. The treatment plans must be:

	 	•	 	Developed by the member’s primary care provider with member participation,
and in consultation with any specialists caring for the member;
	 
	 	•	 	Approved by the entity in a timely manner, if this approval is required;
and
	 
	 	•	 	In accord with any applicable State quality assurance and utilization
review standards.

	 	2)	 	Care Coordination is a method of coordinating the provision of health
care so as to improve its continuity and quality. (Definition used with
permission of the Center for Health Care Strategies, Inc., Princeton, New Jersey.
“Case Management in Managed Care For People With Developmental Disabilities:
Models, Cost and Outcomes. January, 1999”.)
	 
	 	3)	 	Disease Management is the process of intensively managing a
particular disease or syndrome. Disease management encompasses all settings of
care and places a heavy emphasis on prevention and maintenance. It is similar to
case management, but more focused on a defined set of problems relative to an
illness or syndrome. (Definition used with permission of Center for Health Care
Strategies, Inc., Princeton, New Jersey, “Case Management in Managed Care For
People With Developmental Disabilities: Models, Costs and Outcomes, January,
1999”.)

	2.14.12	 	Certification Review:

	 	a.	 	The health plan shall specify, in writing, the procedures for obtaining
initial, concurrent, and retrospective reviews for inpatient admissions and the time
frames in which authorizations will be processed (approved or denied) and providers and
members are notified. The health plan shall ensure that the procedures meet the
following minimum requirements:

	 	•	 	A professional with experience or expertise comparable to the provider
requesting the authorization must review all appeals and denials.
	 
	 	•	 	There are standard policies and procedures for inpatient hospital admissions,
continued stay reviews, and retrospective reviews and for making determinations on
certifications or extensions of stays based on sound medical evidence that is
updated regularly and consistently applied and for consultations with the
requesting provider when appropriate.

	 	Ø	 	For inpatient hospital admissions, continued stay reviews, and
retrospective reviews to specialty pediatric hospitals, the health plan must
use the same criteria as Medicaid fee-for-service.
	 
	 	Ø	 	For psychiatric inpatient hospital admissions, continued stay reviews, and
retrospective reviews, the health plan must use the same criteria as Medicaid
fee-for-service (LOCUS/CALOCUS).

 

 

			
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	 	•	 	Reasons for decisions are clearly documented and assigned a certification
number, which refers to and documents approvals and denials.
	 
	 	•	 	Documentation shall be maintained on any alternative service approved in lieu
of the original request.
	 
	 	•	 	There are fair and unbiased policies and procedures for reconsideration
requests when the attending physician, the hospital, or the member disagrees with
the health plan’s determination regarding inpatient hospital admission or
continued stays.
	 
	 	•	 	There are written policies and procedures followed to address the failure or
inability of a provider or a member to provide all necessary information for
review. In cases where the provider or a member will not release necessary
information, the health plan may deny certification of an admission.
	 
	 	•	 	There is a well-publicized review process for both provider and members.
	 
	 	•	 	To the extent known, inform inpatient providers of the enrollees recent health
care service history at the time of authorization of a psychiatric inpatient
admission. Such information shall include psychiatric inpatient admissions and
emergency room visits for the prior year, psychiatric outpatient services for the
prior six months, and medications for the prior 90 calendar days. Information
about specific episodes of care shall include date, diagnosis, provider, and
procedure. Services related to substance abuse or HIV disorders are exempt from
this requirement.

	 	b.	 	The review process shall be completed and communicated to the provider and
member in a timely manner, as indicated below, or the denials shall be deemed approved.
For the purpose of this section, “necessary information” includes the results of any
face-to-face clinical evaluation or second opinion that may be required.

	 	•	 	Approval or denial for initial determinations shall be provided by the health
plan within two (2) working days of obtaining all necessary information.
	 
	 	•	 	Approval or denial for concurrent review determinations shall be provided by
the health plan within one (1) working day of obtaining all necessary information.
	 
	 	•	 	Approval or denial for retrospective review determinations shall be provided by
the health plan within thirty (30) working days of receiving all necessary
information.
	 
	 	•	 	The health plan shall notify the requesting provider within two (2) working
days following the receipt of the request of service regarding any additional
information necessary to make a determination.
	 
	 	•	 	In no case shall a health plan exceed fourteen (14) calendar days following the
receipt of the request of service to provide approval or denial for an initial or
concurrent review.

	2.15	 	Member Grievance System: The health plan shall have a system in place for members which
includes a grievance process, an appeal process, and access to the state agency’s fair hearing
system.
	 
	2.15.1	 	For purposes of the health plan’s grievance system, the following definitions shall apply:
	 
	 	 	Action — The denial or limited authorization of a requested service, including the type or
level of service; the reduction, suspension, or termination of a previously authorized
service; the denial, in whole or in part, of payment for a service; the failure of the
health plan to provide services in a timely manner as defined in the appointment standards
described herein; or the failure of the health plan to act within timeframes for the health
plan’s Prior Authorization review process specified herein.
	 
	 	 	Appeal — A request for review of an action, as action is defined in this section.
	 
	 	 	Appeal Process — The health plan’s process for handling of appeals that complies with the
requirements specified herein, including, but not limited to, the procedural steps for a
member to file an appeal, the
process for resolution of an appeal, the right to access the State fair hearing system, and
the timing and manner of required notifications.

 

 

			
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	 	 	Grievance — An expression of dissatisfaction about any matter other than an action, as
action is defined in this section. Possible subjects for grievances include, but are not
limited to, the quality of care or services provided, and aspects of interpersonal
relationships such as rudeness of a provider or employee, or failure to respect the member’s
rights.
	 
	 	 	Grievance Process — The health plan process for handling of grievances that complies with
the requirements specified herein, including, but not limited to, the procedural steps for a
member to file a grievance, the process for disposition of a grievance, and the timing and
manner of required notifications.
	 
	 	 	Grievance System — The overall system in place for members that includes a grievance
process, an appeal process, and access to the State fair hearing system.
	 
	 	 	Inquiry - A request from a member for information that would clarify health plan policy,
benefits, procedures, or any aspect of health plan function but does not express
dissatisfaction.
	 
	2.15.2	 	General Requirements: The health plan shall develop and implement written policies and
procedures that detail the operation of the grievance system and provides simplified
instructions on how to file a grievance or appeal and how to request a state fair hearing.

	 	a.	 	The policies and procedures must be approved by the state agency prior to
implementation.
	 
	 	b.	 	The policies and procedures shall be approved by the health plan’s governing
body and be the direct responsibility of the governing body.
	 
	 	c.	 	The health plan shall distribute an information packet to members upon
enrollment which contains the grievance system policies and procedures, specific
instructions regarding how to contact the health plan’s member services, and identifies
the person from the health plan who receives and processes grievances and appeals. The
health plan shall also distribute the information packet to all in-network providers at
the time they enter into a contract and to out-of-network providers within ten (10)
calendar days of prior approval of a service or the date of receipt of a claim
whichever is earlier.
	 
	 	d.	 	The policies and procedures shall identify specific individuals who have
authority to administer the grievance system policies.
	 
	 	e.	 	The grievance system policies and procedures shall be readily available
verbally and in the member’s primary language. In addition, the health plan shall
demonstrate that they have procedures in place to notify all members in their primary
language of grievance dispositions and appeal resolutions.
	 
	 	f.	 	As part of the grievance system, the health plan shall ensure that health plan
executives with the authority to require corrective action are involved in the
grievance and appeal processes.
	 
	 	g.	 	The health plan shall thoroughly investigate each grievance and appeal using
applicable statutory, regulatory, contractual provisions, and the health plan’s written
policies and procedures. Pertinent facts from all parties must be collected during the
investigation.
	 
	 	h.	 	The health plan shall probe inquiries so as to validate the possibility of any
inquiry actually being a grievance or appeal. The health plan shall identify any
inquiry pattern.
	 
	 	i.	 	The health plan’s grievance system shall not be a substitute for the State fair
hearing process. The state agency shall maintain an independent State fair hearing
process as required by federal law and regulation, as amended. The State fair hearing
process shall provide members an opportunity for a State fair hearing before an
impartial hearing officer. The parties to the State fair hearing include the
health plan as well as the member and his or her representative or the representative of
a deceased member’s estate. The health plan shall comply with decisions reached as a
result of the State fair hearing process. Health plan members shall have the right to
request information regarding:

 

 

			
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	 	•	 	The right to request a State fair hearing.
	 
	 	•	 	The procedures for exercising the rights to appeal or request a State fair
hearing.
	 
	 	•	 	Representing themselves or use legal counsel, a relative, a friend, or other
spokesperson.
	 
	 	•	 	The specific regulations that support or the change in Federal or State law that
requires the action.
	 
	 	•	 	The individual’s right to request a state fair hearing, or in cases of an action
based on change in law, the circumstances under which a hearing will be granted.
	 
	 	•	 	A State fair hearing within 90 calendar days from the health plan’s notice of
action.

	 	j.	 	The State must reach its decisions within the specified timeframes:

	 	1)	 	Standard resolution: within 90 calendar days of the date the member
filed the appeal with the health plan if the member filed initially with the
health plan (excluding the days the enrollee took to subsequently file for a State
fair hearing) or the date the member filed for direct access to a State fair
hearing.
	 
	 	2)	 	Expedited resolution (if the appeal was heard first through the
health plan appeal process): within 3 working days from the state agency’s
receipt of a hearing request for a denial of a service that:

	 	•	 	Meets the criteria for an expedited appeal process but was not resolved
using the health plan’s expedited appeal timeframes, or
	 
	 	•	 	Was resolved wholly or partially adversely to the member using the health
plan’s expedited appeal timeframes.

	 	3)	 	Expedited resolution (if the appeal was made directly to the State
Fair Hearing process without accessing the health plan appeal process): within 3
working days from the state agency’s receipt of a hearing request for a denial of
a service that meets the criteria for an expedited appeal process.

	2.15.3	 	Record Keeping and Reporting Requirements:

	 	a.	 	The health plan shall log and track all inquiries, grievances, and appeals.
	 
	 	b.	 	The health plan shall maintain records of grievances, whether received verbally
or in writing, that include a short, dated summary of the problems, name of the
grievant, date of grievance, date of decision, and the disposition. If the health plan
does not have a separate log for MC+ managed care members, the log shall distinguish
MC+ managed care members from other health plan members.
	 
	 	c.	 	The health plan shall maintain records of appeals, whether received verbally or
in writing, that include a short, dated summary of the issues, name of the appellant,
date of appeal, date of decision, and the resolution. If the health plan does not have
a separate log for MC+ managed care members, the log shall distinguish MC+ managed care
members from other health plan members.
	 
	 	d.	 	The health plan must report grievances and appeals to the state agency in the
format and frequency specified by the state agency. The state agency shall provide the
health plan with no less than ninety (90) days notice of any change in the format or
frequency requested.
	 
	 	e.	 	The state agency may publicly disclose summary information regarding the nature
of grievances and appeals and related dispositions or resolutions in consumer
information materials.

	2.15.4	 	Notice of Action Requirements:

 

 

			
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	 	a.	 	The health plan’s notice must be in writing and must meet the language and
content requirements specified herein to ensure ease of understanding.
	 
	 	b.	 	The health plan’s notice must explain the following:

	 	1)	 	The action the health plan has taken or intends to take.
	 
	 	2)	 	The reasons for the action.
	 
	 	3)	 	The member’s or the provider’s right to file an appeal.
	 
	 	4)	 	The member’s right to request a State fair hearing.
	 
	 	5)	 	The procedures for exercising the rights to appeal or request a State
fair hearing.
	 
	 	6)	 	That the member may represent himself or use legal counsel, a
relative, a friend, or other spokesperson.
	 
	 	7)	 	Must explain the specific regulations that support, or the change in
Federal or State law that requires the action.
	 
	 	8)	 	The member’s right to request a state agency hearing, or in cases of
an action based on change in law, the circumstances under which a hearing will be
granted.
	 
	 	9)	 	The circumstances under which expedited resolution is available and
how to request it.
	 
	 	10)	 	The member’s right to have benefits continue pending resolution of
the appeal, how to request that benefits be continued, and the circumstances under
which the member may be required to pay the costs of these services.

	 	c.	 	The health plan must mail the notice to the member within the following
timeframes:

	 	1)	 	For termination, suspension, or reduction of previously authorized
covered services, at least ten (10) calendar days before the date of action. The
health plan may mail a notice not later than the date of action under the
following circumstances:

	 	•	 	The health plan has factual information confirming the death of a member.
	 
	 	•	 	The health plan receives a clear written statement signed by the member
that he or she no longer wishes services or gives information that requires
termination or reduction of services and indicates that he or she understands
that this must be the result of supplying that information.
	 
	 	•	 	The member’s whereabouts are unknown and the post office returns health
plan mail directed to the member indicating no forwarding address (refer to 42
CFR 431.231 (d) for procedures if the member’s whereabouts become known).
	 
	 	•	 	The member’s physician prescribes a change in the level of medical care.
	 
	 	•	 	The health plan may shorten the period of advance notice to 5 calendar days
before date of action if the health plan has facts indicating that action
should be taken because of probable fraud by the member and the facts have
been verified, if possible, through secondary sources.
	 
	 	•	 	The member’s admission to an institution where he is ineligible for further
services.
	 
	 	•	 	The member has been accepted for Medicaid services by another local
jurisdiction.

	 	2)	 	For denial of payment decisions that result in member liability, at
the time of any action affecting the claim.
	 
	 	3)	 	For service authorization decisions that deny or limit services,
within the timeframes required by the service accessibility standards for prior
authorization specified herein.

	2.15.5	 	Grievance Process:

	 	a.	 	A member may file a grievance either orally or in writing. A member’s
authorized representative including the member’s provider may file a grievance on
behalf of the member.

 

 

			
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	 	b.	 	The health plan shall give members any reasonable assistance in completing
forms and taking other procedural steps. This includes, but is not limited to,
providing interpreter services and toll-free numbers that have adequate TTY/TTD and
interpreter capability.
	 
	 	c.	 	The health plan shall acknowledge receipt of each grievance in writing within
ten (10) business days after receiving a grievance.
	 
	 	d.	 	The health plan shall ensure that the individuals who make decisions on
grievances are individuals who were not involved in any previous level of review or
decision-making; and who, if deciding any of the following, are health care
professionals who have the appropriate clinical expertise, as determined by the state
agency, in treating the member’s condition or disease:

	 	1)	 	A grievance regarding denial of expedited resolution of an appeal.
	 
	 	2)	 	A grievance that involves clinical issues.

	 	e.	 	The health plan shall dispose of each grievance and provide written notice of
the disposition of the grievance, as expeditiously as the member’s health condition
requires but shall not exceed thirty (30) calendar days of the filing date.
	 
	 	f.	 	The health plan may extend the timeframe for disposition of a grievance for up
to fourteen (14) calendar days if the member requests the extension or the health plan
demonstrates (to the satisfaction of the state agency, upon its request) that there is
need for additional information and how the delay is in the member’s interest. If the
health plan extends the timeframe, it must, for any extension not requested by the
member, give the member written notice of the reason for the delay.

	2.15.6	 	Appeal Process:

	 	a.	 	A member may file an appeal and may request a State fair hearing within 90
calendar days from the date on the health plan’s notice of action. A provider, acting
on behalf of the member and with the member’s written consent, may file an appeal.
	 
	 	b.	 	The member or provider may file an appeal either orally or in writing. Unless
he or she requests expedited resolution, must follow an oral filing with a written,
signed appeal.
	 
	 	c.	 	The health plan shall give members any reasonable assistance in completing
forms and taking other procedural steps. This includes, but is not limited to,
providing interpreter services and toll-free numbers that have adequate TTY/TTD and
interpreter capability.
	 
	 	d.	 	Appeals shall be filed directly with the health plan’s governing body, or its
delegated representatives. The governing body may delegate this authority to an appeal
committee, but the delegation must be in writing.
	 
	 	e.	 	The health plan shall acknowledge receipt of each appeal in writing within ten
(10) business days after receiving an appeal.
	 
	 	f.	 	The health plan shall ensure that the individuals who make decisions on appeals
are individuals who were not involved in any previous level of review or
decision-making; and who, if deciding any of the following, are health care
professionals who have the appropriate clinical expertise, as determined by the state
agency, in treating the member’s condition or disease:

	 	1)	 	An appeal of a denial that is based on lack of medical necessity.
	 
	 	2)	 	An appeal that involves clinical issues.

 

 

			
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	 	g.	 	The appeals process must provide that oral inquiries seeking to appeal are
treated as appeals (to establish the earliest possible filing date for the appeal) and
must be confirmed in writing, unless the member or the provider requests expedited
resolution.
	 
	 	h.	 	The appeals process must provide the member a reasonable opportunity to present
evidence, and allegations of fact or law, in person as well as in writing. The health
plan must inform the member of the limited time available for this in the case of
expedited resolution.
	 
	 	i.	 	The appeals process must provide the member and his or her representative
opportunity, before and during the appeals process, to examine the member’s case file,
including medical records, and any other documents and records considered during the
appeals process.
	 
	 	j.	 	The appeals process must include as parties to the appeal the member and his or
her representative or the legal representative of a deceased member’s estate.
	 
	 	k.	 	The health plan shall resolve each appeal and provide written notice of the
appeal resolution, as expeditiously as the member’s health condition requires but shall
not exceed forty-five (45) calendar days from date the health plan receives the appeal.
For expedited resolution of an appeal and notice to affected parties, the health plan
has no longer than three (3) working days after the health plan receives the appeal.
For notice of an expedited resolution, the health plan must also make reasonable
efforts to provide oral notice.
	 
	 	l.	 	The health plan may extend the timeframe for standard or expedited resolution
of the appeal by up to fourteen (14) calendar days if the member requests the extension
or the health plan demonstrates (to the satisfaction of the state agency, upon its
request) that there is need for additional information and how the delay is in the
member’s interest. If the health plan extends the timeframe, it must, for any
extension not requested by the member, give the member written notice of the reason for
the delay.
	 
	 	m.	 	The written notice of the appeal resolution must include the following:

	 	1)	 	The results of the resolution process and the date it was completed.
	 
	 	2)	 	For appeals not resolved wholly in the favor of the members the right
to request a State fair hearing, and how to do so; the right to request to receive
benefits while the hearing is pending, and how to make the request; and that the
member may be held liable for the cost of those benefits if the hearing decision
upholds the health plan’s action.

	 	n.	 	The health plan must establish and maintain an expedited review process for
appeals when the health plan determines (for a request from the member) or the provider
indicates (in making the request on the member’s behalf) that taking the time for a
standard resolution could seriously jeopardize the member’s life or health or ability
to attain, maintain, or regain maximum function. The health plan must ensure that
punitive action is neither taken against a provider who requests an expedited
resolution or supports a member’s appeal.
	 
	 	o.	 	If the health plan denies a member’s request for expedited resolution, it must
transfer the appeal to the timeframe for standard resolution specified herein and must
make reasonable efforts to give the member prompt oral notice of the denial, and follow
up within two (2) calendar days with a written notice.
	 
	 	p.	 	Continuation of benefits while the health plan appeal and State fair hearing
are pending.

	 	1)	 	As used in this section, “timely” filing means filing on or before
the later of the following:

	 	•	 	Within ten (10) calendar days of the health plan mailing the notice of
action.
	 
	 	•	 	The intended effective date of the health plan’s proposed action.

 

 

			
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	 	2)	 	The health plan must continue the member’s benefits if the member or
the provider files the appeal timely; the appeal involves the termination,
suspension, or reduction of a previously authorized course of treatment; the
services were ordered by an authorized provider; the original period covered by
the original authorization has not expired; and the member requests extension of
the benefits.
	 
	 	3)	 	If, at the member’s request, the health plan continues or reinstates
the member’s benefits while the appeal is pending, the benefits must be continued
until one of the following occurs:

	 	•	 	The member withdraws the appeal.
	 
	 	•	 	Ten (10) calendar days pass after the health plan mails the notice,
providing the resolution of the appeal against the member, unless the member,
within the ten (10) calendar day timeframe, has requested a State fair hearing
with continuation of benefits until a State fair hearing decision is reached.
	 
	 	•	 	A State fair hearing officer issues a hearing decision adverse to the
member.
	 
	 	•	 	The time period or service limits of a previously authorized service has
been met.

	 	4)	 	If the final resolution of the appeal is adverse to the member, that
is, upholds the health plans action, the health plan may recover the cost of the
services furnished to the member while the appeal is pending, to the extent that
they were furnished solely because of the requirements of this section.

	 	q.	 	If the health plan or the State fair hearing officer reverses a decision to
deny, limit, or delay services that were not furnished while the appeal was pending,
the health plan must authorize or provide this disputed services promptly, and as
expeditiously as the member’s health condition requires.
	 
	 	r.	 	If the health plan or the State fair hearing officer reverses a decision to
deny authorization of services, and the member received the disputed services while the
appeal was pending, the health plan must pay for those services.

	2.16	 	Provider Inquiries, Complaints, Grievances, and Appeals:
	 
	 	 	The health plan shall establish a complaint, grievance, and appeal process that guarantees
the right for a review to any provider of medical services for a member of the health plan.
	 
	2.16.1	 	For purposes of this document, the following definitions shall apply:
	 
	 	 	Inquiry - A request from a provider regarding information that would clarify health plan
policy benefits, procedures, or any aspect of health plan function that may be in question.
	 
	 	 	Complaint - A verbal or written expression by a provider which indicates dissatisfaction or
dispute with health plan policy, procedure, claims, or any aspect of health plan functions.
All complaints must be logged and tracked whether received by telephone, in person or in
writing.
	 
	 	 	Grievance - A written request for further review of a provider’s complaint that remains
unresolved after completion of the complaint process.
	 
	 	 	Appeal - The formal mechanism which allows a provider the right to appeal a grievance
decision.
	 
	2.16.2	 	The health plan shall develop written policies and procedures which detail the operation of
the provider inquiry, complaint, grievance, and appeal process and provides instructions on
how to file a complaint, grievance, or appeal.

	 	a.	 	The policies and procedures must be approved by the state agency prior to
implementation.

 

 

			
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	 	b.	 	The policies and procedures shall be approved by the health plan governing body
and be the direct responsibility of the governing body.
	 
	 	c.	 	The health plan shall distribute an information packet to providers containing
the complaint, grievance, and appeal policies and procedures, specific instructions
regarding how to contact the health plan’s provider services, and identifies the person
from the health plan who receives and processes complaints, grievances, and appeals.
The health plan shall distribute the policies and procedures to in-network providers at
time of subcontract and to out-of-network providers with the remittance advice of the
processed claim.
	 
	 	d.	 	The process must be addressed in the provider manual.
	 
	 	e.	 	The policies and procedures shall identify specific individuals who have
authority to administer the inquiry, complaint, grievance, and appeal process.

	2.16.3	 	Provider Inquiry, Complaint, Grievance, and Appeal Process:

	 	a.	 	Inquiry: The health plan shall operate a provider services function, which
providers can use to ask questions, file inquiries and complaints, and get problems
resolved. The health plan’s provider services function shall be adequately staffed to
receive telephone calls and meet personally with providers. The health plan shall
identify a person from the health plan specifically designated to receive and process
complaints, grievances, and appeals. The health plan shall probe the inquiries so as
to validate the possibility of any inquiry actually being a complaint. The health plan
shall identify any inquiry patterns.
	 
	 	b.	 	Complaint: A complaint can be filed verbally or in writing within one year of
the incident that resulted in a complaint. Complaints shall be resolved within ten
(10) calendar days of their filing. The provider(s) and health plan should attempt to
resolve complaints before proceeding to a grievance.

	 	1)	 	At the time of the health plan’s decision regarding a complaint, the
health plan shall notify providers in writing of their right to file a grievance
with the health plan. This notification must be prior approved by the state
agency.

	 	c.	 	Grievance: The health plan shall provide a grievance process which providers
can use to file their dissatisfaction with the complaint resolution. If a provider is
dissatisfied with the complaint resolution, the provider may file a grievance in
writing with the health plan within ninety (90) calendar days of the complaint
resolution. The provider must deliver a written, substantiated disagreement with the
complaint resolution to the health plan. The health plan must acknowledge the receipt
of grievances in writing within ten (10) business days after receiving a grievance.
Grievances shall be investigated by the health plan and reviewed by a designated
authority within the health plan. The health plan shall reach decisions on grievances
within thirty (30) calendar days of their filing date.

	 	1)	 	At the time of the health plan’s decision regarding a grievance, the
health plan shall notify the provider in writing of their right to file an appeal
with the health plan. This notification must be prior approved by the state
agency.

	 	d.	 	Appeal: The health plan shall operate an appeals process through which
providers can challenge a negative decision to their grievances. Providers shall have
ninety (90) calendar days following written notification of a grievance decision to
appeal. The appeal must be filed in writing either by the provider or the provider’s
representative, or through the provider’s instruction to the health plan’s
representative that the provider wishes to appeal. The health plan shall acknowledge
receipt of each appeal in writing within ten (10) business days after receiving an
appeal. Appeals shall be filed directly to the health plan’s governing body, or its
delegated representatives (The governing body

 

 

			
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	 	 	 	may delegate this authority to an appeal committee, but the delegation must be in
writing.). The appeal process shall include an opportunity for providers or their
representatives to present their cases in person to the appellate body. The health plan
shall reach a final decision on an appeal and provide written notice of the appeal
resolution within sixty (60) calendar days of receipt of the appeal, with extensions
possible if approved by the state agency.
	 
	 	e.	 	Expedited Review: The health plan shall have a procedure for expedited review of
the complaint or grievance if the standard time frame could seriously jeopardize the
member’s life, physical or mental health, or the member’s ability to regain maximum
function. The expedited review shall be resolved no later than 72 hours or as
expeditiously as the member’s physical or mental health requires.

	2.16.4	 	As a part of the provider complaint, grievance, and appeal process, the health plan shall:

	 	a.	 	Ensure that health plan executives with the authority to require corrective
action are involved in the complaint, grievance, and appeal process.
	 
	 	b.	 	Thoroughly investigate each complaint, grievance, and appeal using applicable
statutory, regulatory, contractual provisions, and the health plan’s written policies
and procedures. Pertinent facts from all parties must be collected during the
investigation.

	2.16.5	 	Records/Reporting:

	 	a.	 	The health plan shall log and track all inquiries.
	 
	 	b.	 	The health plan shall maintain records of complaints that include a short,
dated summary of each of the questions or problems, name of the complainant, date of
complaint, the response, and the resolution. If the health plan does not have a
separate log for in-network providers, the log shall distinguish in-network providers
from other health plan providers.
	 
	 	c.	 	The health plan shall maintain grievance records that include a copy of the
original grievance, the response, and the resolution. This system shall distinguish
in-network providers from other health plan providers and identify the grievant and the
date of filing.
	 
	 	d.	 	The health plan must report provider complaints, grievances, and appeals to the
state agency in the format requested by the state agency.
	 
	 	e.	 	The health plans must maintain records of all provider complaints, grievances,
appeals, and resolutions.

	2.17	 	Quality Assessment and Improvement:
	 
	2.17.1	 	The state agency regulates the quality assessment and improvement functions of the health
plan. The health plan therefore must comply with all the state agency’s quality assessment
and improvement programs as described herein. The health plan shall participate in the
State’s efforts to promote the delivery of services in a culturally competent manner to all
members, including those with limited English proficiency and diverse cultural and ethnic
backgrounds. The health plan shall be held accountable for the ongoing monitoring,
evaluation, and actions as necessary to improve the health of its members and the care
delivery systems for those members. The health plan shall be held accountable for the quality
of care delivered by providers. The state agency’s quality assessment and improvement program
shall consist of internal monitoring by the health plan, oversight by federal and state
governments, and evaluations by an independent, external review organization. The health plan
shall have a quality assessment and improvement program which integrates an internal quality
assessment process that conforms to Quality Improvement System for Managed Care (QISMC) and
additional current standards and guidelines prescribed by CMS. The health plan shall adhere
to the requirements contained within the state agency’s, Quality Management Plan located in
Attachment 6. The health plan shall have a quality assessment and improvement program
composed of:

 

 

			
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	 	a.	 	An internal system of monitoring, analysis, evaluation, and improvement of the
delivery of care that includes care provided by all providers;
	 
	 	b.	 	Designated staff with expertise in quality assessment, utilization management
and continuous quality improvement;
	 
	 	c.	 	Written policies and procedures for quality assessment, utilization management,
and continuous quality improvement that are periodically analyzed and evaluated for
impact and effectiveness;
	 
	 	d.	 	Results, conclusions, team recommendations, and implemented system changes
which are reported to the health plan’s governing body at least quarterly, and
	 
	 	e.	 	Reports that are evaluated, recommendations that are implemented when
indicated, and feedback provided to providers and members.

	2.17.2	 	Internal Staff: The health plan shall designate a Quality Assessment and Improvement and
Utilization Management Coordinator(s). Specifically, the Quality Assessment and Improvement
and Utilization Management Coordinator must:

	 	a.	 	Be a registered nurse, nurse practitioner, or physician. The registered nurse
or nurse practitioner must be licensed in the State of Missouri. The physician must be
Missouri licensed and practice medicine in the United States. He/she must be
board-certified, board-eligible, or have sufficient experience in his or her field or
specialty to be determined competent by the health plan’s Medical Director or the
Credentials Committee.
	 
	 	b.	 	Be responsible for assisting the governing body and their designee in the
process of continually developing, implementing, evaluating, and improving the written
quality assessment and improvement program. The continuous improvement process shall
include care delivery objectives, specific activities implemented from issues
identified as a result of the on-going monitoring process, systems methodologies for
continuous tracking of care delivery, and provider review. The process must include a
focus on health outcomes and action plans for improvement of those outcomes.
	 
	 	c.	 	Be responsible for the health plan’s utilization management and quality
assessment committee, assist the governing board in directing the development and
implementation of the health plan’s internal quality assessment and improvement
program, and monitor the quality of care that members receive.
	 
	 	d.	 	Oversee the development of clinical care standards and practice guidelines and
protocols for the health plan. The health plan must adopt practice guidelines that
meet the following requirements:

	 	1)	 	Are based on valid and reliable clinical evidence or a consensus of
health care professionals in the particular field;
	 
	 	2)	 	Consider the needs of the members;
	 
	 	3)	 	Are adopted in consultation with contracting health care
professionals; and
	 
	 	4)	 	Are reviewed and updated periodically as appropriate.
	 
	 	5)	 	Dissemination of the guidelines to all affected providers and, upon
request, to members and potential members.
	 
	 	6)	 	Ensure that decisions for utilization management, member education,
coverage of services, and other areas to which the guidelines apply should be
consistent with the guidelines.

	 	e.	 	Review all potential quality of care problems, both physical and mental health,
and oversee development and implementation of continuous assessment and improvement of
the quality of care provided to members.
	 
	 	f.	 	Maintain current medical information pertaining to clinical practice and
guidelines.

 

 

			
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	 	g.	 	Ensure that health education resources are available for the provision of
proper medical care to members.
	 
	 	h.	 	Utilize staff in an effective and efficient manner to monitor and assess care
delivery.
	 
	 	i.	 	Specify clinical or health services areas to be monitored.
	 
	 	j.	 	Specify the use of quality indicators that are objective, measurable, and based
on current knowledge and clinical experience for priority areas selected by the state
agency as well as for areas the health plan selects.
	 
	 	k.	 	Monitor and report on the management of the health plan’s EPSDT program.
	 
	 	l.	 	Monitor and report on the health plan’s referral process for specialty and
out-of-network services.
	 
	 	m.	 	Ensure that all denied services are reviewed by a physician, physician
assistant, or advanced nurse practitioner. The reason for the denial must be
documented and logged. Any alternative services authorized must be documented. All
denials must identify appeal rights of the member.
	 
	 	n.	 	Monitor and report on the health plan’s credentialing and recredentialing
activities.
	 
	 	o.	 	Monitor and report on the health plan’s process for prior authorizing and
denying services.
	 
	 	p.	 	Monitor and report on the health plan’s process for ensuring the
confidentiality of medical records and member information.
	 
	 	q.	 	Monitor and report on the health plan’s process for ensuring the
confidentiality of the appointments, treatments, and required state agency reporting of
adolescent STDs.
	 
	 	r.	 	Monitor provider for compliance that reports of disease and conditions are made
to the State Department of Health and Senior Services in accordance with all applicable
State statutes, rules, guidelines, and policies and with all metropolitan ordinances
and policies.
	 
	 	s.	 	Monitor provider for compliance that control measures for tuberculosis, STDs,
and communicable diseases are carried out in accordance with applicable laws and
guidelines and such measures are defined in the provider manual.
	 
	 	t.	 	Serve as a liaison between the health plan and the in-network providers and
communicate at least quarterly with the in-network providers, including oversight of
provider education, in service training, and orientation. Newsletter, web sites, and
other media may be used to meet this criteria.
	 
	 	u.	 	Be available to the health plan’s medical staff for consultation on referrals,
denials, grievances and appeals, and problems.
	 
	 	v.	 	Monitor and report at least annually 24-hour access and after hours
availability of primary care providers.

	2.17.3	 	In addition to internal monitoring of quality of care, the health plan shall submit to the
state agency reports regarding the results of their internal monitoring, evaluation, and
action plan implementation. The reports shall include targeted health indicators monitored by
the state agency and specific quality data periodically requested by the federal government.
The reports may be required on a monthly, quarterly or annual basis or as specified by the
state agency. (Refer to the Quality Management Plan located at Attachment 6 for the current
report format.) The report format shall be periodically reviewed and updated by the state
agency. The state agency shall provide the health plan with no less than ninety (90) calendar

 

 

			
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	 	 	days notice of any changes in the format requested. The health plan shall comply with all
subsequent changes specified by the state agency. The health plan shall provide access to
documentation, medical records, premises, and staff as deemed necessary by the state agency.
	 
	2.17.4	 	The state agency shall contract with independent, external evaluators to examine the quality
of care provided by the health plan. The health plan shall provide access to documentation,
medical records, premises, and staff as deemed necessary by the state agency for the
independent external review.
	 
	2.17.5	 	Internal Procedures: The health plan shall have an internal written quality assessment and
improvement program. The health plan shall include monitoring, assessment, evaluation, and
improvement of the quality of care for all clinical and health service delivery areas.
Emphasis should be placed on, but need not be limited to, clinical areas relating to
maternity, pediatric and adolescent development, EPSDT, family planning, and well woman care,
as well as on key access or other priority issues for members such as reducing the incidence
of STDs, acquired immune deficiency syndrome, and smoking related illnesses. The health plan
must have implemented mechanisms to assess the quality and appropriateness of care furnished
to members with special health care needs. The health plan’s quality review mechanisms shall
address members with special needs as well as COA 1, COA 4, and COA 5 members in the written
monitoring, assessment, evaluation, and improvement plan.

	 	a.	 	Internal policies and procedures must:

	 	1)	 	Ensure that the utilization management and quality assessment
committees have established operating parameters. The committees shall meet at
least quarterly, on a regular schedule. Committee members must be clearly
identified and representative of the health plan’s providers. The committee shall
be accountable to the Medical Director and governing body. The committees must
maintain appropriate documentation of the committees’ activities, findings,
recommendations, actions, and follow up.
	 
	 	2)	 	Provide for regular utilization management and quality assessment
reporting to the health plan management and health plan providers, including
profiling of provider utilization patterns.
	 
	 	3)	 	Be developed and implemented by professionals with adequate and
appropriate experience in quality assessment and improvement: quality assessment,
utilization management, and continuous improvement processes.
	 
	 	4)	 	Provide for systematic data collection, analysis, and evaluation of
performance and member results.
	 
	 	5)	 	Provide for interpretation of this data to practitioners.
	 
	 	6)	 	Provide timelines for correction, and assign a specific staff person
to be responsible for ensuring compliance and follow up.
	 
	 	7)	 	Clearly define the roles, functions, and responsibilities of the
quality assessment committee and the Medical Director.

	 	b.	 	Utilization Management: The health plan shall have written utilization
management policies and procedures that include protocols for denial of services, prior
approval, hospital discharge planning, physician profiling, and concurrent,
prospective, and retrospective review of claims that comply with federal and state laws
and regulations, as amended. The utilization management policies and procedures must
be clearly specified in provider contracts or provider manuals and consistently applied
in accordance with the established utilization management guidelines. As part of the
health plan’s utilization management function, the health plan also must have processes
to identify both over and under utilization problems for inpatient and outpatient
services, undertake corrective action, and follow up. This review must consider the
expected utilization of services regarding the

 

 

			
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	 	 	 	characteristics and health care needs of the member population. In addition, the health
plan shall use an emergency room log, or equivalent method, to track emergency room
services. Compensation to individuals or entities that conduct utilization management
activities shall not be structured so as to provide incentives for the individual or
entity to deny, limit, or discontinue medically necessary services to any member.

	 	c.	 	Provider Credentialing: The health plan shall have written credentialing and
re-credentialing policies and procedures for determining and assuring that all
in-network providers are licensed by the state in which they practice and qualified to
perform their services. The health plan shall have written policies and procedures for
monitoring the in-network providers, reporting the results of the monitoring process,
and disciplining in-network providers found to be out-of-compliance with the health
plan’s medical management standards. The health plan shall use the Missouri
Standardized Credentialing Form (MoSCF), pursuant to RSMo 354.442.1 (15) and 20 CSR
400.7.180, as amended.
	 
	 	d.	 	Performance Improvement Projects: The health plan must conduct performance
improvement projects that are designed to achieve, through ongoing measurements and
intervention, significant improvement, sustained over time, in clinical care and
nonclinical care areas that are expected to have a favorable effect on health outcomes
and member satisfaction. The health plan must report the status and results of each
project to the state agency as requested. The performance improvement projects must
involve the following:

	 	1)	 	Measurement of performance using objective quality indicators.
	 
	 	2)	 	Implementation of system interventions to achieve improvement in
quality.
	 
	 	3)	 	Evaluation of the effectiveness of the interventions.
	 
	 	4)	 	Planning and initiation of activities for increasing or sustaining
improvement.
	 
	 	5)	 	Completion of the performance improvement project in a reasonable
time period so as to generally allow information on the success of performance
improvement projects in the aggregate to produce new information on quality of
care every year.
	 
	 	6)	 	Performance measures and topics for performance improvement projects
specified by CMS in consultation with the state agency and other stakeholders.

	 	e.	 	Member Incentives: The health plan may offer member incentives with a value of
$30.00 or less per eligible member per month. All member incentives must be prior
approved by the state agency. The purpose of the health plan’s member incentives:

	 	•	 	Must be directly related to a health plan quality initiative
	 
	 	•	 	Must be measurable via the quality activity
	 
	 	•	 	Cannot have any relationship to the health plan’s marketing activities
	 
	 	•	 	Cannot be convertible to cash or redemption in any way for alcohol, tobacco
products, firearms or ammunition.

	 	1)	 	The health plan must monitor their member incentives program to ensure that the
program has met the health plan’s quality initiative and to evaluate on an ongoing
basis the effectiveness of the member incentive program.
	 
	 	2)	 	The health plan must report the status and results of member incentives to the
state agency as requested.

	2.18	 	Community Health Assessment:
	 
	2.18.1	 	The health plan shall participate in a community health status assessment and improvement
initiative as approved by the Department of Health and Senior Services. The health status
assessment and improvement initiative shall be developed by a community-based coalition and
include community

 

 

			
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	 	 	benchmarks for measuring access, quality, and health status. The Department of Health and
Senior Services shall provide a list of active community-based health status assessment and
improvement initiatives to the health plan. If there is no approved health status
assessment and improvement initiative in the health plan’s region, the Department of Health
and Senior Services shall provide technical assistance to the health plan to develop the
health status assessment and improvement initiative. Participation in a health status
assessment and improvement initiative shall include:

	 	a.	 	Becoming a member of a community-wide planning coalition. Community means a
geographic entity (a county(ies) for the most part) with broad based representation
from community providers, businesses, local organizations, schools, etc. The
Department of Health and Senior Services would notify the health plan of coalitions
that meet the community standard. Where no such coalition exists, the Department of
Health and Senior Services shall work with the health plan to develop one. The health
plan shall not be required to be the lead agency in establishing a coalition.
	 
	 	b.	 	Assisting with the collection and/or analysis of relevant health data and
information as defined by the coalition.
	 
	 	c.	 	Active involvement in the assessment process including prioritizing community
problems.
	 
	 	d.	 	Active involvement in the development and implementation of the community
strategic plan to implement health improvement programs.
	 
	 	e.	 	Providing feedback on the community strategic plan and its effectiveness.

	2.19	 	State and Federal Reviews:
	 
	2.19.1	 	The health plan shall make available to the state agency or its outside reviewers, on an
annual basis and on an as needed basis, medical and other records for review of quality of
care, access, financial, and other issues. The state agency’s quality assessment and
improvement review may include but is not limited to:

	 	a.	 	On-site visits and inspections of facilities;
	 
	 	b.	 	Staff and member interviews;
	 
	 	c.	 	Review of utilization, denial of services, and other areas that will indicate
quality of care delivered to members;
	 
	 	d.	 	Medical records reviews;
	 
	 	e.	 	Financial records reviews;
	 
	 	f.	 	Review of all quality assessment procedures, reports, committee activities and
recommendations, and corrective actions;
	 
	 	g.	 	Review of staff and provider qualifications;
	 
	 	h.	 	Review of the complaint, grievance, and appeal process and resolutions;
	 
	 	i.	 	Review of requests for transfers between primary care providers within each
health plan;
	 
	 	j.	 	Review of fraud and abuse detection, prevention, and review process,
procedures, cases, and reports; and
	 
	 	k.	 	Evaluation and analysis of coordination and continuity of care.

 

 

			
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	2.19.2	 	External Reviews: The state agency contracts with independent external evaluators to
examine the quality of care provided by the health plan. CMS designates an outside review
agency to conduct an evaluation of the program and its progress toward achieving program
goals. The health plan shall make available to CMS’s outside review agency and the state
agency’s external evaluator medical and other records for review as requested. The health
plan shall provide information for External Quality Reviews in the format specified by the
state agency.
	 
	2.20	 	Financial Reporting:
	 
	2.20.1	 	The health plan shall not hold a member liable for the following:

	 	a.	 	The debts of the health plan, in the event of the health plan’s insolvency;
	 
	 	b.	 	Services provided to the member in the event the health plan fails to receive
payment from the state agency for such services;
	 
	 	c.	 	Services provided to the member in the event a health care provider with a
contractual, referral, or other arrangement with the health plan fails to receive
payment from the state agency or health plan for such services; or
	 
	 	d.	 	Payments to a provider that furnishes covered services under a contractual,
referral, or other arrangement with the health plan in excess of the amount that would
be owed by the member if the health plan had directly provided the services.
	 
	 	e.	 	In the case of insolvency, the health plan shall continue to cover services to
members during insolvency for the duration of period for which payment has been made by
the state agency, as well as for inpatient admissions up until discharge.

	2.20.2	 	Financial Data Reporting: The health plan shall submit unaudited semi-annual reports and an
unaudited and audited annual report for their MC+ managed care book of business to the state
agency. The health plan shall submit the semi-annual and annual reports in the format and
audit guidelines specified by the state agency. The current report format and audit
guidelines can be found in Attachment 10. Changes to the report format must be approved by
the state agency prior to submission.

	 	a.	 	The semi-annual and unaudited and audited annual reports must be certified by
one of the following:

	 	1)	 	The health plan’s Chief Executive Officer.
	 
	 	2)	 	The health plan’s Chief Financial Officer.
	 
	 	3)	 	An individual who has delegated authority to sign for, and who
reports directly to, the health plan’s Chief Executive Officer or Chief Financial
Officer.

	 	b.	 	The certification must attest, based on best knowledge, information, and
belief, as follows:

	 	1)	 	To the accuracy, completeness, and truthfulness of the data.
	 
	 	2)	 	To the accuracy, completeness, and truthfulness of the semi-annual
and annual reports.

	 	c.	 	The health plan must submit the certification concurrently with the semi-annual
and annual reports.

	2.20.3	 	Physician Incentive Plan Requirements: The Department of Health and Human Services
published a federal regulation regarding physician incentive plans in the March 27, 1996,
Federal Register. This regulation is designed to protect beneficiaries enrolled in Medicare
and Medicaid Managed Care Organizations by placing certain limitations on physician incentive
plans that could influence a physician’s care decisions.

 

 

			
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	 	a.	 	In addition, the physician incentive plan regulation applies to all
subcontractors, including any health care services subcontractors. The physician
incentive plan regulation does not apply outside the scope of incentive plans for
physicians providing services to Medicare or MC+ managed care members.
	 
	 	b.	 	The health plan shall not offer financial incentives to induce physicians to
limit or reduce medically necessary services to a specific member. The health plan
shall not offer non-financial incentives to limit or reduce medically necessary
services to a specific member.
	 
	 	c.	 	A physician group is at “substantial” financial risk if more than 25% of its
potential payment is at risk for services it does not provide.

	 	1)	 	If the physician group is at “substantial” financial risk, the health
plan shall provide adequate protection to limit financial losses. The health plan
has the option of: 1) retaining the risk in its direct provider contracts, or 2)
the MCO, intermediate entity, physician or physician group can reinsure the risk
through a reinsurance carrier. Stop-loss protection must cover at least ninety
percent (90%) of the costs of referral amounts that exceed 25% of the total
potential payment on either a per member per year or an aggregate basis.
	 
	 	 	 	For the purposes of the PIP regulation, the term “physician” is defined as: Doctors
of medicine, doctors of osteopathy, doctors of dental surgery or dental medicine,
doctors of podiatric medicine, doctors of optometry, chiropractors, and any limited
practice provider that provides services on State authority to perform such
services.
	 
	 	2)	 	If the physician group is at “substantial risk”, the health plan must
conduct annual member surveys. The health plan shall survey enrolled and
disenrolled members with questions on satisfaction, quality, and access to
services. The result should be submitted to the state agency.

	 	d.	 	In compliance with the federal regulation, the health plan shall disclose to
the members, upon request, whether the health plan used a physician incentive plan,
what type of physician incentive plan it uses, whether stop-loss insurance is provided,
and a summary of any survey results if a survey was required to be conducted.
	 
	 	e.	 	On an annual basis and in compliance with the federal regulation, the health
plan must disclose physician incentive plans to CMS, and the state agency. The
information to be disclosed shall include the following:

	 	1)	 	Effective date of the physician incentive plan;
	 
	 	2)	 	The type of incentive arrangement;
	 
	 	3)	 	The amount and type of stop-loss protection;
	 
	 	4)	 	The patient panel size;
	 
	 	5)	 	If pooled, a description of the method;
	 
	 	6)	 	The computations of significant financial risk;
	 
	 	7)	 	Whether the health plan does not have a physician incentive plan; and
	 
	 	8)	 	Name, address, phone number, and other contact information for a
person from the health plan who may be contacted with questions regarding the
physician incentive plan.

	 	f.	 	The health plan shall notify the state agency within five (5) business days of
any change to the health plan or the subcontractors’ physician incentive plan(s).

	2.20.4	 	The health plan shall provide quarterly reports to the state agency detailing third party
savings in a format prescribed by the state agency. The state agency shall provide the health
plan with no less than ninety (90) calendar days notice of any change in the format requested.
These reports are due on the thirtieth (30) day following the close of the quarter. The
health plan shall maintain records in such a manner as to ensure that all money collected from
third party resources may be identified on behalf of members. The

 

 

			
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	 	 	health plan shall make these records available for audit and review and certify that all
third party collections are identified and used as a source of revenue.

	 	a.	 	The quarterly reports must be certified by one of the following:

	 	1)	 	The health plan’s Chief Executive Officer.
	 
	 	2)	 	The health plan’s Chief Financial Officer.
	 
	 	3)	 	An individual who has delegated authority to sign for, and who
reports directly to, the health plan’s Chief Executive Officer or Chief Financial
Officer.

	 	b.	 	The certification must attest, based on best knowledge, information, and
belief, as follows:

	 	1)	 	To the accuracy, completeness, and truthfulness of the data.
	 
	 	2)	 	To the accuracy, completeness, and truthfulness of the quarterly
reports.

	 	c.	 	The health plan must submit the certification concurrently with the quarterly
reports.

	2.20.5	 	The health plan shall report the categories of all third party liability collections to the
state agency and shall include a complete disclosure demonstrating its efforts to obtain
payment from liable third parties and the amounts and nature of all third party payments
recovered for members including, but not limited to, payments for services and conditions
which are:

	 	a.	 	Employment related injuries or illnesses;
	 
	 	b.	 	Related to motor vehicle accidents, whether injured as pedestrians, drivers,
passengers, or bicyclists; and
	 
	 	c.	 	Contained in diagnosis codes 800 through 999 (ICD 9-M), with the exception of
Code 994.6.

	 	 	The reports must be certified by one of the following:

	 	a.	 	The health plan’s Chief Executive Officer.
	 
	 	b.	 	The health plan’s Chief Financial Officer.
	 
	 	c.	 	An individual who has delegated authority to sign for, and who reports directly
to, the health plan’s Chief Executive Officer or Chief Financial Officer.

	 	 	The certification must attest, based on best knowledge, information, and belief, as follows:

	 	a.	 	To the accuracy, completeness, and truthfulness of the data.
	 
	 	b.	 	To the accuracy, completeness, and truthfulness of the reports.

	 	 	The health plan must submit the certification concurrently with the reports.

	2.21	 	Operational Data Reporting:
	 
	2.21.1	 	To measure the MC+ managed care program’s actual accomplishments in the areas of access to
care, utilization, medical outcomes, health status, and satisfaction, the health plan shall
provide the state agency with information concerning uniform utilization, quality assessment
and improvement, member satisfaction, complaint, grievance, and appeal, and fraud and abuse
detection data on a regular basis. On a periodic basis, the health plan shall make available
clinical outcome data in areas of concern to the state agency. The health plan shall
cooperate with the state agency in carrying out data validation steps.
	 
	2.21.2	 	The state agency shall provide report formats and variable definitions for the health plan
to use in reporting operational data. Data elements and reporting requirements are outlined
in the Performance Requirements segment. Final formats will be made available as finalized.

 

 

			
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	2.21.3	 	Quarterly Complaint, Grievance, and Appeal Report: On a quarterly basis, the health plan
shall submit to the state agency a Quarterly Complaint, Grievance, and Appeal Report, in
accordance with the State Management Plan included as Attachment 6.
	 
	2.21.4	 	Quality Assessment and Improvement Evaluation and Reports: The health plan shall submit an
annual Quality Assessment and Improvement Evaluation and Report. The format will be
periodically reviewed and updated by the state agency. The health plan shall comply with all
changes as specified by the state agency. The state agency shall provide the health plan with
no less than ninety (90) calendar days notice of any change in the format requested.
	 
	2.21.5	 	Member Satisfaction Report: The Department of Health and Senior Services has authority
under RSMo 192.068, as amended, to collect the member satisfaction survey data from the health
plan. To reduce duplication and ensure consistent survey methodology, the state agency shall
rely upon the member satisfaction survey data from this process. The health plan shall submit
member satisfaction data to the Department of Health and Senior Services in accordance with 19
CSR 10-5.010, as amended. The health plan shall use the survey instrument specified by the
Department of Health and Senior Services and must fund the cost of the survey.
	 
	2.21.6	 	Presentation of Findings: The health plan shall obtain the state agency’s approval prior to
publishing or making formal public presentations of statistical or analytical material based
on the health plan’s MC+ managed care membership.
	 
	2.22	 	Third Party Liability: Third Party Liability is defined as any individual, entity, or
program that is or may be liable to pay all or part of the health care expenses of a Medicaid
beneficiary. Under Section 1902(a) (25) of the Social Security Act, the State is required to
take all reasonable measures to identify legally liable third parties and treat third party
liability as a resource of the Medicaid beneficiary.
	 
	2.22.1	 	Coordination of Benefits: By law, Medicaid is the payer of last resort. Therefore, the
health plan shall be used as a source of payment for covered services only after all other
sources of payment have been exhausted. The two methods used in the coordination of benefits
are cost avoidance and post-payment recovery (i.e., “pay and chase “). The health plan shall
act as an agent of the state agency for the purpose of coordination of benefits.

	 	a.	 	If health plan has established the probable existence of liability of a third
party health insurance carrier at the time a claim is filed, the health plan shall
reject the claim and return it to the provider for a determination of the amount of
liability except in certain defined situations referenced below. This rejection is
called cost avoidance. If a service is medically necessary, the health plan shall
ensure that its cost avoidance efforts do not prevent a member from receiving such
service and that the member is not required to pay any cost-sharing for use of the
other insurer’s providers.
	 
	 	b.	 	The establishment of liability takes place when the health plan receives
confirmation from the provider or the third party health insurance carrier indicating
the extent of liability taking into account any agreement between the provider and
third party health insurance carrier regarding acceptance of the carrier’s payment as
payment in full with the exception of any patient cost-sharing. If the probable
existence of a liable third party cannot be established or third party benefits are not
available to pay the member’s medical expenses at the time the claim is filed, the
health plan shall pay the full amount allowed under the health plan’s payment schedule.
When the amount of liability is determined, the health plan shall pay the claim to the
extent that payment allowed under the health plan’s payment schedule exceeds the amount
of the third party health insurance carrier’s payment taking into account any agreement
between the provider and the third party health insurance carrier regarding acceptance
of the carrier’s payment as payment in full with the exception of any patient
cost-sharing. If a third party health insurance carrier (other than Medicare) requires
the member to pay any cost-sharing (such as copayment, coinsurance, or deductible) the
health plan shall pay the cost-sharing amounts, even if services were provided by an
out-of-network provider. The health plan may require prior authorization of
out-of-network services. The health plan’s liability for such cost-

 

 

			
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	 	 	 	sharing amounts shall not exceed the amount the health plan would have paid under the
health plan’s payment schedule for the service. The out-of-network provider must agree
in writing to accept the amount of the health plan’s payment as payment in full prior to
the service being provided. If the out-of-network provider does not agree to accept the
health plan’s payment as payment in full, the health plan shall inform the member
verbally and in writing that due to lack of such agreement, the member will be liable
for the cost sharing amounts to the out-of-network provider or the member may seek
services without charge from an in-network provider.

	 	1)	 	For additional clarity on establishment of the health plan’s
liability, the following examples are provided:

	 	•	 	A provider submits a charge for $100 to the health plan for which the
health plan’s allowable is $80. The provider received $75 from the third
party insurance carrier. There is no agreement between the provider and third
party insurance carrier that the amount paid by the carrier is payment in
full. The provider normally bills all patients with this carrier the
remaining balance of $25. The provider would submit a claim to the health
plan indicating the remaining balance of $25 is owed after receiving $75 from
the third party carrier. The amount the health plan pays the provider is the
difference between the health plan’s allowable ($80) and the carrier’s payment
($75) or $5.
	 
	 	•	 	A provider has a charge of $100.00. The third party carrier and provider
have agreed that the amount paid by the carrier is payment in full except for
any cost-sharing. The carrier has an allowable of $50 with the remaining $25
to be a contractual write-off. The member has a co-payment of $25.00. The
provider bills all patients with this carrier only the co-payment amount. The
provider bills the health plan the $25 co-payment. The health plan’s
liability is not $30 ($80-$50) in this situation as there exists an agreement
between the provider and third party carrier that there is no liability by the
patient other than cost-sharing. The health plan’s pays the provider $25 as
the co-payment does not exceed its allowable of $80.

	 	c.	 	The requirement of cost avoidance applies to all covered services except claims
for labor and delivery and postpartum care (costs associated with the inpatient
hospital stay for labor and delivery and postpartum care must be cost avoided);
prenatal care for pregnant women; preventive pediatric services; or if the claim is for
a service that is provided to a member on whose behalf child support enforcement is
being carried out by the Missouri Department of Social Services, Family Support
Division. For these services, the health plan shall provide such service and then
recover payment from the third party health insurance carrier (“pay and chase”).
	 
	 	d.	 	The health plan may retain up to 100 percent of its third party collections if
all of the following conditions exist:

	 	1)	 	Total collections received do not exceed the total amount of the
health plan’s financial liability for the member.
	 
	 	2)	 	There are no payments made by the state agency related to
fee-for-service.
	 
	 	3)	 	Such recovery is not prohibited by Federal or State law.

	 	e.	 	The state agency shall provide the health plan with a daily file of third party
health insurance carrier information (other than Medicare) for the purpose of updating
the health plan’s files. The state agency shall continue to perform verification of
the health insurance information. The state agency does not warrant that the
information is complete or accurate. The file is to be considered a “lead” file to
assist the health plan in identifying legally liable third parties. The health plan
shall timely notify the state agency of any known changes, additions, or deletions of
coverage in a format prescribed by the state agency.

 

 

			
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	 	f.	 	The state agency shall annually perform a data match with the United States
Department of Defense to identify members covered by TRICARE. The state agency shall
provide the health plan with the results of the data match annually and in a format
specified by the state agency. The health plan shall perform post-payment recovery and
cost avoidance activities as appropriate based on the information supplied by the data
match.

	2.22.2	 	Casualty/Tort: The health plan shall act as an agent of the state agency for purposes of
third party reimbursement pursuant to RSMo 208.215, as amended. In addition to coordination
of benefits, the health plan shall pursue reimbursement in the following circumstances:
Workers’ Compensation, Tortfeasors, Motorist Insurance, and Liability/Casualty Insurance.

	 	a.	 	The health plan shall take action to identify those paid claims for members
that contain diagnosis codes 800 through 999 (ICD 9-CM), with the exception of 994.6,
for the purpose of determining the legal liability of third parties so that the health
plan may process claims under the third party liability payment procedures specified in
42 CFR 433.139 (b) through (f), as amended.
	 
	 	b.	 	The state agency shall perform a data match with the Department of Labor,
Division of Workers’ Compensation to identify members that the Division of Workers’
Compensation has a record of a work-related injury claim. The state agency shall
provide the health plan with the results of the data match monthly and in a format
specified by the state agency. The health plan shall perform post payment recovery and
cost avoidance activities as appropriate based on the information supplied by the data
match. If the probable existence of third party liability cannot be established or
third party benefits are not available to pay the member’s medical expenses at the time
the claim is filed, the health plan shall pay the full amount allowed under the health
plan’s payment schedule.
	 
	 	c.	 	The state agency shall perform a data match with the State Traffic Accident
Reporting System (STARS) of the Missouri Highway Patrol to identify members that the
STARS system has a record of a member involved in a motor vehicle accident. The state
agency shall provide the health plan with the results of the match monthly and in a
format specified by the state agency. The health plan shall perform further validation
activities when using information supplied by the data match to ensure the member is in
fact the person referenced in the match. If the probable existence of third party
liability cannot be established or third party benefits are not available to pay the
member’s medical expenses at the time the claim is filed, the health plan shall pay the
full amount allowed under the health plan’s payment schedule.
	 
	 	d.	 	The health plan shall perform all research, investigations, and payment of
lien-related costs, including but not limited to, attorney fees and costs related to
such cases.
	 
	 	e.	 	If a member initiates a legal action as a result of an injury that occurred
during the health plan contract period, the health plan may file a lien for
reimbursement for medical services provided to treat the injury that occurred during
the contract period even after the contract period has ended.
	 
	 	f.	 	If the health plan initiates a lien during the contract period but the case
remains unsettled at the end of the contract period, the health plan may continue
pursuit of the action for the medical services related to the injury that were provided
during the contract period.
	 
	 	g.	 	If the member enrolls with a new health plan while legal action is pending,
each health plan may file separate liens to recover reimbursement for medical services
related to the injury that were provided during the respective contract periods.

	2.23	 	Reinsurance: The state agency will not administer a reinsurance program funded from
capitation payment withholdings.
	 
	2.24	 	Reserving: As part of its accounting and budgeting function, the health plan shall establish
an actuarially sound process for estimating and tracking incurred but not reported costs. The
health plan should reserve

 

 

			
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	 	 	funds by major categories of service (e.g., hospital inpatient;
hospital outpatient) to cover both incurred
but not reported, and reported but unpaid claims. As part of its reserving methodology, the
health plan should conduct annual reviews to assess its reserving methodology and make
adjustments as necessary.

	2.25	 	Claims Processing and Management Information System:
	 
	2.25.1	 	The health plan shall have a Claims Processing and Management Information System (MIS)
capable of meeting the MC+ managed care program requirements and maintaining satisfactory
performance throughout the life of the contract. The health plan shall have the capability to
transmit and receive data, support provider payments, and data reporting requirements as
specified herein. The health plan shall have the capability to process claims, retrieve and
integrate enrollment data, assign primary care providers, maintain provider network data, and
submit encounter data. The Claims Processing and MIS should be of sufficient capacity to
expand as needed due to member enrollment or program changes.
	 
	2.25.2	 	The health plan shall transmit encounter data and all required files in accordance with the
Health Plan Record Layout Manual, as amended. The health plan shall maintain an encounter
overall acceptance rate of at least 95 % as measured by the state agency.

	 	a.	 	The health plan shall submit encounter data for all services provided including
those services that are reimbursed by the health plan through a capitated arrangement
or other subcontracted arrangement.

	 	1)	 	The encounter data must be certified by one of the following:

	 	•	 	The health plan’s Chief Executive Officer.
	 
	 	•	 	The health plan’s Chief Financial Officer
	 
	 	•	 	An individual who has delegated authority to sign for, and who reports
directly to, the health plan’s Chief Executive Officer or Chief Financial
Officer.

	 	2)	 	The certification must attest, based on best knowledge, information,
and belief, as to the accuracy, completeness, and truthfulness of the encounter
data.
	 
	 	3)	 	The health plan must submit the certification concurrently with the
encounter data.

	 	b.	 	The health plan shall transmit primary care provider assignments and changes or
additions to the provider demographic file.

	2.25.3	 	The health plan shall accept claims electronically from all providers. The health plan
shall make every effort to encourage providers to submit claims electronically using HIPAA
compliant formats.
	 
	2.25.4	 	The health plan shall employ or have available, the resources necessary to make
modifications to claims processing edits or expansion of MIS capabilities as a result of
changes in MC+ managed care policies and/or procedures. The state agency shall make every
effort to give the health plan 60 calendar days notice of changes in the MC+ managed care
program that may require the health plan to make system changes in order to comply.

Paragraph 2.25.5 inserted by Amendment #001

	2.25.5	 	Timeliness of Claim Adjudication Report: On a quarterly basis, the health plan shall submit
to the state agency a “Timeliness of Claims Adjudication Report” in accordance with the
quarterly reporting schedule outlined in Attachment 6 in a format specified by the state
agency.
	 
	2.26	 	Records Retention:
	 
	2.26.1	 	The health plan shall maintain books and records relating to MC+ managed care services and
expenditures, including reports to the state agency and source information used in preparation
of these reports. The books and records shall include, but are not limited to, financial
statements, records relating to quality of care, medical records, and prescription files.

 

 

			
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	2.26.2	 	The health plan shall also comply with all standards for record keeping specified by the
state agency.
	 
	2.26.3	 	The health plan shall maintain and retain all financial and programmatic records, supporting
documents, statistical records, and other records of members for five (5) years. If any
litigation, claim, negotiation, audit or other action involving the records has been started
before the expiration of the five (5) year period, the health plan shall retain the records
until completion of the action and resolution of all issues which arise from it or until the
end of the regular five (5) year period, whichever is later.
	 
	2.26.4	 	The health plan shall retain the source records for the health plan’s data reports for a
minimum of five (5) years and must have written policies and procedures for storing this
information.
	 
	2.26.5	 	Medical Records: The health plan shall have written policies and procedures for the
maintenance of medical records so that the records are documented accurately and in a timely
manner, are readily accessible, and permit prompt and systematic retrieval of information.
Complete medical records shall include but are not limited to medical charts, health status
screens, prescription files, hospital records, physician specialists, consultant and other
health care professionals’ findings, and other documentation sufficient to disclose the
quantity, quality, appropriateness, and timeliness of services provided. The health plan
shall make such medical records available to duly authorized representatives of the state
agency and the United States Department of Health and Human Services to evaluate, through
inspections or other means, the quality, appropriateness, and timeliness of services
performed. The health plan must have procedures to provide for prompt transfer of member
records upon request to other in-network or out-of-network providers for the medical
management of the member.

	 	a.	 	In accordance with Senate Bill No. 1024, enacted by the General Assembly of the
State of Missouri, Section A., Chapter 334, RSMo, amended to be known as Section
334.097, physicians shall maintain an adequate and complete patient record for each
patient and may maintain electronic records provided the record keeping format is
capable of being printed for review. An adequate and complete patient record shall
include documentation of the following information:

	 	•	 	Identification of the patient, including name, birthdate, address and telephone
number;
	 
	 	•	 	The date or dates the patient was seen;
	 
	 	•	 	The current status of the patient, including the reason for the visit;
	 
	 	•	 	Observation of pertinent physical findings;
	 
	 	•	 	Assessment and clinical impression of diagnosis;
	 
	 	•	 	Plan for care and treatment, or additional consultations or diagnostic testing,
if necessary. If treatment includes medication, the physician shall include in
the patient record the medication and dosage of any medication prescribed,
dispensed or administered; and
	 
	 	•	 	Any informed consent for office procedures.
	 
	 	1)	 	Patient records remaining under the care, custody, and control of the
physician shall be maintained by the physician, or the physician’s designee, for a
minimum of seven (7) years from the date of when the last professional service was
provided.
	 
	 	2)	 	Any correction, addition, or change in any patient record made more
than forty-eight hours after the final entry is entered in the record and signed
by the physician shall be clearly marked and identified as such, and the date,
time, and name of the person making the correction, addition, or change shall be
included, as well as the reason for the correction, addition, or change.
	 
	 	3)	 	A consultative report shall be considered an adequate medical record
for a radiologist, pathologist, or a consulting physician.

	 	b.	 	The member’s medical record is the property of the provider who generates the
record. Upon the written request of a member, guardian, or legally authorized
representative of a member the health

 

 

			
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	 	 	 	plan shall furnish a copy of the medical records
of the member’s health history and treatment rendered. Such medical records shall be
furnished within a reasonable time of the receipt of the written request. Each member
is entitled to one free copy of his or her medical records annually.
The fee for additional copies shall not exceed the actual cost of time and materials
used to compile, copy, and furnish such records.
	 
	 	c.	 	The health plan shall provide the state agency with access to all members’
medical records, whether electronic or paper, within thirty (30) calendar days of
receipt of written request at no charge. The health plan shall provide the state
agency with access to a single or small volume of medical records within five (5)
calendar days of receipt of written request at no charge. The health plan shall
provide the state with immediate access for on-site review of medical records. For
on-site review of medical records, the state agency may provide the health plan with an
advance notice of a partial list of medical records. The health plan shall fax or send
by overnight mail to the state agency all medical records involving an emergency or
urgent care issue when requested by the state agency at no charge. Access to record
requirements applies to the health plan and all providers.
	 
	 	d.	 	The health plan shall have written standards for documentation on the medical
record for legibility, accuracy, and plan of care.
	 
	 	e.	 	The health plan shall require its providers to maintain medical records in a
detailed and comprehensive manner which conforms to good professional medical practice,
permits effective professional medical review and medical audit processes, and
facilitates an adequate system for follow-up treatment. Medical records must be
legible, signed and dated.
	 
	 	f.	 	When a member changes primary care providers, upon request, his or her medical
records or copies of medical records must be forwarded to the new primary care provider
within ten (10) business days from receipt of request or prior to the next scheduled
appointment to the new primary care provider whichever is earlier.
	 
	 	g.	 	The state agency is not required to obtain written approval from a member
before requesting the member’s record from the provider.
	 
	 	h.	 	If the state agency requests, the health plan shall gather all medical records
from their providers.

	2.27	 	Health Plan Disputes With Other Providers: All disputes between the health plan and any
affiliated or unaffiliated provider, or between the health plan and any other subcontractors,
shall be solely between such provider or subcontractors and the health plan. The health plan
shall indemnify, defend, save and hold harmless the State of Missouri, the Department of
Social Services and its officers, employees and agents and enrolled MC+ managed care members
from any and all actions, claims, demands, damages, liabilities, or suits of any nature
whatsoever arising out of the contract because of any breach of the contract by the health
plan, its subcontractors, agents, providers or employees, including but not limited to any
negligent or wrongful acts, occurrence of omission of commission or negligence of the health
plan, its subcontractors, agents, providers or employees.
	 
	2.28	 	Rate Adjustments for Performance Based on HCY/EPSDT Participant Ratio and Remedies for
Violation, Breach, or Non-Compliance of Contract Requirements:
	 
	2.28.1	 	Rate Adjustments for Performance Based on HCY/EPSDT Participant Ratio: In accordance with
CMS guidelines, the state agency requires 80 percent of eligible members to have HCY/EPSDT
well child visits and, accordingly, has included an 80 percent participant ratio in the rates
paid to the health plan. In accordance with CMS 416 reporting methodology, the state agency
shall measure the health plan’s performance regarding the percentage of eligible members
having HCY/EPSDT well child visits (participant ratio). The state agency applies state
specific criteria to the CMS methodology to reflect the MC+ managed care program. The state
specific criteria reflects performance by Category of Aid and rate cell, the measurement
schedule in Attachment 11, and recognition of a month to be greater than 27 days.

 

 

			
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	 	 	The
participant ratio is defined as the number of total eligibles receiving at least one initial
or periodic well child visit divided by the number of total eligibles who should receive at
least one initial or periodic well child visit. The current HCY/EPSDT Measurement Schedule is
reflected in Attachment 11. The
state agency reserves the right to amend the HCY/EPSDT Measurement Schedule and shall give
the health plan prior written notice of such amendment.

	 	a.	 	In the event that the HCY/EPSDT participant ratio is not equal to 80 percent of
eligible members having an HCY/EPSDT well child visit as calculated using the HCFA 416
reporting methodology, the state agency shall with five (5) calendar days prior notice
make a pro rata adjustment to the monthly capitation payment to the health plan for
each percentage point above or below 80 percent, but not to exceed 100 percent. This
pro rata adjustment shall be based on the portion of the monthly capitation payment
related to HCY/EPSDT well child visits and shall be applied to each rate cell in which
well child visits are required. Refer to Attachment 13. The state agency shall
continue making such adjusted monthly capitation payments until the next scheduled
measurement.
	 
	 	b.	 	If the health plan is new to a MC+ managed care region, the health plan shall
agree that its capitation rate shall reflect the average participant ratio of the MC+
managed care health plans that are not new to the region by rate cell and category of
assistance for the applicable measurement period reflected in Attachment 11. Beginning
January 2007, the new health plan shall agree that their future capitation rates shall
be adjusted by the health plan’s actual 12-month HCY/EPSDT participant ratio.

	2.28.2	 	Adjustments for Performance Based on HEDIS Performance Ratings: The health plan’s results
of HEDIS performance measures as identified in Attachment 6 shall annually be rated by the
state agency as high (HI), average (AV), low (LO), Not Applicable (NA), or Not Reported (NR).
This rating shall be determined by computing the statewide average of all health plans in all
regions and determining whether a health plan’s individual results, from a statistical level
of confidence, vary from the statewide average and to what degree the results are precise and
accurate. Those HEDIS performance measures that are rated as high shall be assigned a numeric
value of three (3). Those HEDIS performance measures that are rated as average shall be
assigned a numeric value of two (2). Those HEDIS performance measures that are rated as low
shall be assigned a numeric value of one (1). Any performance measure that according to HEDIS
specifications should not be reported shall be rated as Not Applicable and shall be assigned a
value of zero (0). Any performance measure not reported due to the health plan’s failure
shall be rated as Not Reported and assigned a value of negative one (-1). The state agency
shall then total the numeric value of each HEDIS measure. The HEDIS measures relating to the
CAHPS member satisfaction shall not be included in the total. The state agency shall use only
combined measures, where applicable, when computing the total. The totals are then averaged
ignoring values of zero (0) and rounded to the nearest whole number. The health plan shall
maintain a minimum performance standard of an overall score of average with a value of two
(2).

	 	a.	 	The first annual rating shall occur upon receipt of the HEDIS measures due June
30, 2007.
	 
	 	b.	 	The second annual rating shall occur upon receipt of the HEDIS measured due June
30, 2008.
	 
	 	c.	 	The third annual rating shall occur upon receipt of the HEDIS measured due June
30, 2009.
	 
	 	d.	 	The first time a health plan achieves an average of low with a value of one (1),
the health plan shall develop and implement a corrective action to improve the
substandard performance.

	 	1)	 	The state agency shall inform enrollees in enrollment materials that
the health plan failed to achieve the minimum performance standard.
	 
	 	2)	 	The state agency shall reduce the random auto assignment percentage
assigned to the health plan by one half (1/2). The random auto assignment
percentage that was removed from the low performing health plan shall be
distributed to the highest rated health plan(s) within the same MC+ Managed Care
region.

 

 

			
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	 	e.	 	The first time a health plan achieves an average of high with a value of three
(3), the state agency shall inform enrollees in enrollment materials that the health
plan(s) achieved above the minimum performance standard.
	 
	 	f.	 	The second time a health plan achieves an average of low with a value of one
(1), the health plan shall develop and implement a corrective action to improve the
substandard performance.

	 	1)	 	The state agency shall inform enrollees in enrollment materials that
the health plan failed to achieve the minimum performance standard.
	 
	 	2)	 	The state agency shall reduce the random auto assignment percentage
assigned to the health plan by one half (1/2). The random auto assignment
percentage that was removed from the low performing health plan shall be
distributed to the highest rated health plan(s) within the same MC+ Managed Care
region.

	 	g.	 	The second time a health plan achieves an average of high with a value of
three, the state agency shall inform enrollees in enrollment materials that the health
plan or health plans achieved above the minimum performance standard.
	 
	 	h.	 	The third time a health plan achieves an average of low with a value of one
(1), the state agency shall with five (5) calendar days prior notice make a .25 percent
reduction to the total amount paid the health plan in monthly capitation payments.

	 	1)	 	The state agency shall inform enrollees in enrollment materials that
the health plan failed to achieve the minimum performance standard.
	 
	 	2)	 	The reduction of total monthly capitation payments from any low
performing health plan shall be distributed equally to the health plan(s) rated
high within the same MC+ Managed Care region.

	 	i.	 	The third time a health plan achieves an average of high with a value of three
(3), the state agency shall inform enrollees in enrollment materials that the health
plan achieved above the minimum performance standard.

	2.28.3	 	Federal Sanctions: Section 1903(m)(5)(A) and (B) of the Social Security Act vests the
Secretary of the Department of Health and Human Services with the authority to deny Medicaid
payments to a health plan for members who enroll after the date on which the health plan has
been found to have committed one or more of the violations identified below. Therefore,
whenever, and for so long as, federal payments are denied, the state agency shall deduct the
total amount of federal payments denied from the next monthly capitation payment made to the
health plan.

	 	a.	 	Substantial failure to provide required medically necessary items or services
when the failure had adversely affected (or has substantial likelihood of adversely
affecting) a member,
	 
	 	b.	 	Discrimination among members with respect to enrollment, re-enrollment, or
disenrollment on the basis of the member’s health status or requirements for health
care services,
	 
	 	c.	 	Misrepresentation or falsification of certain information, or
	 
	 	d.	 	Failure to comply with the requirements for physician incentive plans as
specified herein.

	2.28.4	 	Liquidated Damages for Failure to Provide Covered Services: In the event the state agency
determines the health plan failed to provide one or more of the covered services, the state
agency shall direct the health plan to provide such service. If the health plan continues to
refuse to provide the covered

 

 

			
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	 	 	service(s), the state agency shall authorize the member to
obtain the covered service from another source and shall notify the health plan in writing
that the health plan shall be charged the actual amount of the cost of such service. In such
event, the charges to the health plan shall be obtained by the state agency in the form of
deductions of that amount from the next monthly capitation payment made to the health plan.
With such deductions, the state agency shall provide a list of the members from whom payments
were
deducted, the nature of the service(s) denied, and payments the state agency made or will
make to provide the medically necessary covered services.
	 
	2.28.5	 	Remedies for Failure to Perform Administrative Services: Whenever the state agency
determines that the health plan has failed to perform an administrative function required per
the requirements of the contract, the state agency shall notify the health plan of the health
plan’s failure to perform required administrative services pursuant to the requirements of the
contract and shall give the health plan five (5) working days to develop an acceptable action
plan for correcting the administrative services failure. For the purposes these provisions,
“administrative services” are defined as any contract requirements other than the actual
provision of covered services.

	 	a.	 	If the health plan submits an action plan for correcting the failure and if the
plan is acceptable to the state agency, no action shall be taken at that time, provided
that the health plan implements the corrective action as approved by the state agency.
	 
	 	b.	 	If the health plan fails to submit an action plan within the five working days
or if the health plan does not implement the corrective action plan within the time
frame stated in the action plan, the state agency shall withhold payment from the next
capitation payment due the health plan as stated below:

	 	1)	 	The amount withheld shall be up to three percent (3%) of the total
amount of the next capitation payment due the health plan.
	 
	 	2)	 	The state agency shall continue to withhold up to three percent (3%)
until successful correction of the administrative services failure by the health
plan.
	 
	 	3)	 	After successful correction of the administrative services failure,
the state agency shall pay the health plan the total amount of all payments
withheld.

	 	c.	 	If the health plan implements the corrective action according to the approved
plan but does not successfully correct the administrative services failure within the
time frame approved in the action plan, the state agency shall withhold payment from
the next capitation payment due the health plan according to the same provisions as
stated above.

	2.28.6	 	Remedies for Failure to Comply with Marketing Requirements: In the event the state agency
determines that the health plan has failed to comply with any of the marketing requirements of
the contract, one or more of the remedial actions listed below shall apply. The state agency
shall notify the health plan in writing of the determination of the non-compliance, of the
action(s) that must be taken, and of any other conditions related thereto such as the length
of time the remedial actions shall continue and of the corrective actions that the health plan
must perform.

	 	a.	 	The state agency shall require the health plan to recall the previously
authorized marketing materials.
	 
	 	b.	 	The state agency shall suspend enrollment of new members to the health plan.
	 
	 	c.	 	The state agency shall deduct the amount of capitation payment for members
enrolled as a result of non-compliant marketing practices from the next monthly
capitation payment made to the health plan and shall continue to deduct such payment
until correction of the failure.
	 
	 	d.	 	The state agency shall require the health plan to contact each member who
enrolled during the period while the health plan was out of compliance, in order to
explain the nature of the non-compliance and inform the member of his or her right to
transfer to another health plan.

 

 

			
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	 	e.	 	The state agency shall prohibit future marketing activities by the health plan
for an amount of time specified by the state agency.

	2.28.7	 	Attorney Fees: In the event the state agency should prevail in any legal action arising out
of the performance or non-performance of the contract, the health plan shall pay, in addition
to any damages, all
expenses of such action including reasonable attorney’s fees and costs. The term “legal
action” shall be deemed to include administrative proceedings of all kinds, as well as all
actions at law or equity.
	 
	2.28.8	 	Remedial Actions: The state agency may pursue all remedial actions with the health plan
that are taken with fee-for-service providers. The state agency will work with the health
plan and the health plan providers to change and correct problems and will recoup funds only
if the health plan fails to correct a problem within a timely manner.
	 
	2.28.9	 	In addition to above referenced described rate adjustments and remedies, if the state agency
determines that the health plan is not taking proper action to correct the identified
failures, the state agency shall have the right to implement any other legal processes deemed
necessary including cancellation of the contract, recovery of damages, suspension of
enrollment to the health plan, etc.
	 
	2.28.10	 	Intermediate Sanctions. The state agency may establish and specify intermediate sanctions
that may be imposed when a health plan acts or fails to act as specified below. The state
agency may require a corrective action plan, as referenced in section 2.28.5, to be developed
and approved by the state agency in situations where intermediate sanctions may be imposed.
The state agency shall approve and monitor implementation of such a plan and set appropriate
timelines to bring activities of the health plan into compliance with state and federal
regulations. The state agency may monitor via required reporting on a specified basis and/or
through on-site evaluations, the effectiveness of the plan. Before imposing intermediate
sanctions, the state agency shall give the health plan timely written notice that explains the
basis and nature of the sanction and any other due process protections that the state agency
elects to provide.

	 	a.	 	Fails substantially to provide medically necessary services that the health
plan is required to provide, under law or under the contract, to a member covered under
the contract.
	 
	 	b.	 	Imposes on members premiums or charges that are in excess of the premiums or
charges permitted under the Medicaid program.
	 
	 	c.	 	Acts to discriminate among members on the basis of their health status or need
for health care services.
	 
	 	d.	 	Misrepresents or falsifies information that it furnishes to CMS or to the state
agency.
	 
	 	e.	 	Misrepresents or falsifies information that it furnishes to a member, potential
member, or a health care provider.
	 
	 	f.	 	Fails to comply with the requirements for physician incentive plans, as set
forth (for Medicare) in 42 CFR 422.208 and 422.210.
	 
	 	g.	 	Distributes directly, or indirectly through any agent or independent
contractor, marketing materials that have not been approved by the state agency or that
contain false or materially misleading information.
	 
	 	h.	 	Violates any of the other applicable requirements of sections 1903(m) or 1932
of the Act and any implementing regulations.

 

 

			
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	 	i.	 	Violates any of the other applicable requirements of sections 1932 or
1905(t)(3) of the Act and any implementing regulations.

	2.28.11	 	Intermediate Sanctions: Types. The types of intermediate sanctions that the state agency
may impose upon the health plan include:

	 	a.	 	Civil monetary penalties in the following specified amounts:

	 	1)	 	A maximum of $25,000 for each determination of failure to provide
services; misrepresentation or falsification of statements to members, potential
members or health care providers; failure to comply with physician incentive plan
requirements; or marketing violations.
	 
	 	2)	 	A maximum of $100,000 for each determination of discrimination among
members on the basis of their health status or need for services; or
misrepresentation or falsification to CMS or the state agency.
	 
	 	3)	 	A maximum of $15,000 for each member the state agency determines was
discriminated against based on the member’s health status or need for services
(subject to the $100,000 limit above).
	 
	 	4)	 	A maximum of $25,000 or double the amount of the excess charges
(whichever is greater), for charging premiums or charges in excess of the amounts
permitted under the Medicaid program. The state agency shall return the amount of
overcharge to the affected member(s).

	 	b.	 	Appointment of temporary management for a health plan as provided in 42 CFR
438.706.
	 
	 	c.	 	Granting members the right to terminate enrollment without cause and notifying
the affected members of their right to disenroll.
	 
	 	d.	 	Suspension of all new enrollment, including default enrollment, after the
effective date of the sanction.
	 
	 	e.	 	Suspension of payment for members enrolled after the effective date of the
sanction and until CMS or the state agency is satisfied that the reason for imposition
of the sanction no longer exists and is not likely to recur.
	 
	 	f.	 	Additional sanctions allowed under state statutes or regulations that address
areas of noncompliance described above.

	2.28.12	 	Sanction by Centers for Medicare and Medicaid Services: Special Rules for MCOs and Denial
of Payment. Payments provided for under the contract for new members when, and for so long as
payment for those members is denied by CMS in accordance with the requirements in 42 CFR
438.730.
	 
	2.28.13	 	Special Rules for Temporary Management. The state agency shall specify the circumstances
under which the sanction of temporary management will be imposed upon the health plan.

	 	a.	 	Optional: Temporary management may be imposed by the state agency only if it
finds that:

	 	1)	 	There is continued egregious behavior by the health plan,
including, but not limited to behavior that is described in 42 CFR 438.700, or
that is contrary to any requirements of sections 1903(m) and 1932 of the Act;
or
	 
	 	2)	 	There is substantial risk to members’ health; or
	 
	 	3)	 	The sanction is necessary to ensure the health of the health
plan’s members while improvements are made to remedy violations under 42 CFR
438.700 or until there is an orderly termination or reorganization of the
health plan.

 

 

			
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	 	b.	 	Required: The state agency shall impose temporary management if it finds that
the health plan has repeatedly failed to meet substantive requirements in section
1903(m) or section 1932 of the Act. The state agency shall also grant members the right
to terminate enrollment without cause and shall notify the affected members of their
right to terminate enrollment.
	 
	 	c.	 	The state agency’s election to appoint temporary management shall not act as an
implied waiver of the state agency’s right to terminate the contract, suspend
enrollment, or to pursue any other remedy available to the state agency under the
contract.

	2.28.14	 	Termination of a Health Plan Contract:

	 	a.	 	Nothing in this section shall limit the state agency’s right to terminate the
contract or to pursue any other legal or equitable remedies. Pursuant to 42 CFR
438.708, the state agency may terminate the contract as a sanction and enroll that
health plan’s members in other health plans or provide their benefits through other
options included in the state plan if the state agency, at its sole discretion,
determines that the health plan has failed to:

	 	1)	 	Carry out the substantive terms of the contract.
	 
	 	2)	 	Meet applicable requirements in sections 1932, 1903(m) and 1905(t) of
the Act.

	 	b.	 	After a state agency notifies the health plan that it intends to terminate the
contract, the state agency may do the following:

	 	1)	 	Give the health plan’s members written notice of the state agency’s
intent to terminate the contract.
	 
	 	2)	 	Allow members to disenroll immediately without cause.

	 	c.	 	Before terminating a health plan’s contract under 42 CFR 438.708, the state
agency shall provide the health plan a pre-termination hearing. The state agency
shall:

	 	1)	 	Give the health plan written notice of its intent to terminate, the
reason for termination, and the time and place of hearing;
	 
	 	2)	 	Give the health plan (after the hearing) written notice of the
decision affirming or reversing the proposed termination of the contract, and for
an affirming decision, the effective date of termination; and
	 
	 	3)	 	For an affirming decision, give members of the health plan notice of
the termination and information, consistent with 42 CFR 438.10, on their options
for receiving Medicaid services following the effective date of termination.

	2.29	 	Access to Premises: During normal business hours (defined as 8:00 a.m. through 5:00 p.m.,
Monday through Friday, except State designated holidays), the health plan shall allow duly
authorized agents or representatives of the Federal or State government access to the health
plan’s premises or the health plan’s subcontractor’s premises to inspect, audit, monitor, or
otherwise evaluate the performance of the health plan or its subcontractors.
	 
	2.30	 	Advance Directives:
	 
	2.30.1	 	The health plan shall maintain written policies and procedures related to advance
directives. At the time of enrollment, the health plan shall provide written information to
all adult members regarding the member’s rights under the Missouri law to make decisions
concerning medical care.
	 
	2.30.2	 	As part of recredentialing, the health plan shall audit records of primary care provider,
hospitals, home health agencies, personal care providers, and hospices to determine whether
the provider is following the policies and procedures related to advance directives.

 

 

			
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	2.30.3	 	The health plan shall provide education to the health plan’s staff and members on issues
concerning advance directives.
	 
	2.30.4	 	The above provisions shall not be construed to prohibit the application of any Missouri law
which allows for an objection on the basis of conscience for any provider or agent of such
provider.
	 
	2.31	 	Fraud and Abuse:

Paragraph 2.31.1 revised by BAFO #001

	2.31.1	 	The following definitions are taken from “Guidelines for Addressing Fraud and Abuse in
Medicaid Managed Care”, A Product of the National Medicaid Fraud and Abuse Initiative, Health
Care Financing Administration National Initiative, October 2000. These definitions are
provided to assist the health plan in preventing, coordinating, detecting, investigating,
enforcing, and reporting fraud and abuse:
	 
	 	 	Medicaid Managed Care Fraud: Any type of intentional deception or misrepresentation made by
an entity or person in a capitated MCO, PCCM program, or other managed care setting with the
knowledge that the deception could result in some unauthorized benefit to the entity,
himself, or some other person.
	 
	 	 	Medicaid Managed Care Abuse: Practices in a capitated MCO, PCCM program, or other managed
care setting that are inconsistent with sound fiscal, business, or medical practices, and
result in an unnecessary cost to the Medicaid program, or in reimbursement for services that
are not medically necessary or that fail to meet professionally recognized standards or
contractual obligations for health care. The abuse can be committed by an MCO, contractor,
subcontractor, provider, State employee, Medicaid beneficiary, or Medicaid managed care
enrollee, among others. It also includes beneficiary practices in a capitated MCO, PCCM
program, or other managed care setting that result in unnecessary cost to the Medicaid
program or MCO, contractor, subcontractor, or provider. It should be noted that Medicaid
funds paid to an MCO, then passing to subcontractors, are still Medicaid funds from a fraud
and abuse perspective
	 
	2.31.2	 	The health plan shall implement internal controls, policies, and procedures designed to
prevent, detect, review, report to the state agency, and assist in the prosecution of fraud
and abuse activities by providers, subcontractors, and members. The policies and procedures
shall articulate the health plan’s commitment to comply with all applicable Federal and State
standards. In order to implement the above, the health plan must submit a written fraud and
abuse plan to the state agency for approval prior to implementation. Any changes to the
approved fraud and abuse plan must have state agency approval prior to implementation.

	 	a.	 	The health plan’s fraud and abuse plan must include, but is not limited to the
following components:

	 	1)	 	The designation of a compliance officer and a compliance committee that
are responsible for the health plan’s fraud and abuse program and activities. The
compliance officer is supervised by and reports to the Chief Executive Officer
(CEO), health plan administrator, or the governing body;
	 
	 	2)	 	Provision for a data system, resources and staff to perform the
fraud, abuse, and other compliance responsibilities;
	 
	 	3)	 	Procedures for internal prevention, detection, reporting, review, and
corrective action;
	 
	 	4)	 	Procedures for prompt response to detected offenses;
	 
	 	5)	 	Procedures for reporting to the state agency, including timelines and
use of state approved forms;
	 
	 	6)	 	Written standards for organizational conduct;

 

 

			
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	 	7)	 	A compliance committee that periodically meets and documents review of
compliance issues. These issues include fraud, abuse, and regulatory and
contractual compliance.
	 
	 	8)	 	Effective training and education for the compliance officer and the
organization’s employees, management, board members, and subcontractors;
	 
	 	9)	 	Inclusion of information about fraud and abuse identification and
reporting in provider and member materials; and
	 
	 	10)	 	Enforcement of standards through well-publicized disciplinary
guidelines.

	 	b.	 	The health plan’s fraud and abuse activities should include, but not be limited
to the following:

	 	1)	 	Conducting regular reviews and audits of operations to guard against
fraud and abuse;
	 
	 	2)	 	Assessing and strengthening internal controls to ensure claims are
submitted and payments are made properly;
	 
	 	3)	 	Educating employees, network providers, and beneficiaries about fraud
and abuse and how to report it;
	 
	 	4)	 	Effective organizational resources to respond to complaints of fraud
and abuse;
	 
	 	5)	 	Establishing procedures to process fraud and abuse complaints;
	 
	 	6)	 	Establishing procedures for reporting information to the state
agency; and
	 
	 	7)	 	Developing procedures to monitor utilization/service patterns of
providers, subcontractors, and beneficiaries.

Paragraph 2.31.3 revised by BAFO #001

	2.31.3	 	The health plan must quarterly report suspected fraud or abuse cases to the state agency.
The health plan must initiate an immediate investigation to gather facts regarding the
suspected fraud or abuse. In addition, the health plan shall provide reports of its
investigative, corrective, and legal activities to the state agency in accordance with
contractual and regulatory requirements.
	 
	2.31.4	 	The health plan and its subcontractors shall cooperate fully in any state reviews or
investigations and in any subsequent legal action. The health plan must implement corrective
actions in instances of fraud and abuse detected by the state agency, or other authorized
agencies or entities.
	 
	2.31.5	 	The health plan must also provide a quarterly report of fraud and abuse activities to the
state agency. The report must be submitted in accordance with state agency guidelines
contained within the fraud and abuse policy statement. An annual evaluation of the
effectiveness of the fraud and abuse program must be provided to the state agency. This
evaluation must be a component of the annual evaluation of the effectiveness of the quality
assessment and improvement program.
	 
	2.31.6	 	Identification of Debarred Individuals or Excluded Providers in Health Plans: The health
plan shall exclude providers from the health plan network that have been identified as having
Office of Inspector General (OIG) sanctions, having failed to renew license or certification
registration, having a revoked professional license or certification, or have been terminated
by the state agency. The health plan can access debarred and OIG sanction information on the
Internet. The health plan should also access information from the Professional Registration
Boards Internet site to identify State initiated terminations. The state agency or its
authorized agent shall conduct a periodic review to determine if appropriate exclusions and
corrective action have occurred.

 

 

			
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	2.31.7	 	Health Plan Pharmacy Lock-In: The health plan must submit its lock-in policies and
procedures to the state agency for approval prior to implementation. The policies and
procedures must include the member and provider communication documents that shall be utilized
for the lock-in process. The lock-in policy must comply with the requirements located in 13
CSR 70-4.070, Title XIX Recipient Lock-In Program.
	 
	 	 	The health plan must provide services in accordance with the requirements located in
Attachment 3, Managed Care Policies Governing MC+ Services. If the health plan determines
inappropriate utilization of pharmacy services by a member, the health plan may restrict the
member to obtaining pharmacy services from one pharmacy provider. The health plan must
initiate an investigation to identify the extent of the fraud or abuse. When a member is
suspected of fraud or abuse (i.e., presenting an altered prescription), the health plan
should notify the state agency within ten (10) calendar days of identification of the
suspected activity in accordance with 2.31.2 and 2.31.3.
	 
	2.31.8	 	Member Explanation of Benefits (EOB): The health plan must provide an EOB to members upon
request. The EOB will consist of a list of services that were billed to the health plan. The
list shall contain paid and unpaid claims; for any unpaid claims, the list shall provide the
reason the claim was not paid.
	 
	2.32	 	Other Requirements:
	 
	2.32.1	 	Unless otherwise specified herein, the health plan shall furnish all materials, labor,
facilities, equipment, and supplies necessary to perform the service required herein.
	 
	2.32.2	 	Within five (5) business days after issuance of the Notice of Award by the Division of
Purchasing and Materials Management, the health plan shall submit a written identification and
notification to the state agency of the name, title, address, and telephone number of one (1)
individual within its organization as a duly authorized representative to whom all
correspondence, official notices, and requests related to the health plan’s performance under
the contract shall be addressed. The health plan shall have the right to change or substitute
the name of the individual described above as deemed necessary provided that the state agency
is notified immediately.
	 
	2.32.3	 	The health plan shall understand and agree that the contract, in part, shall implement the
MC+ managed care program. Therefore, the health plan shall conform to such requirements or
regulations as the United States Department of Health and Human Services issues.
	 
	2.32.4	 	If the state agency receives written notice from the United States Department of Health and
Human Services that the health plan does not meet the definition of a Health Maintenance
Organization as set forth in the Medicaid State Plan and 42 CFR 434 or receives written notice
from the Department of Insurance that the health plan does not have a certificate of authority
to establish or operate a HMO, the Division of Purchasing and Materials Management may cancel
the contract with the health plan pursuant to contract cancellation provisions contained
herein.
	 
	2.32.5	 	In the event that changes in federal or state law require the Division of Purchasing and
Materials Management to modify the contract, a written amendment shall be issued to the health
plan pursuant to provisions for contract amendment stated herein.

	 	a.	 	The terms of the contract and any amendment thereto must receive the approval
of the United States Department of Health and Human Services. The United States
Department of Health and Human Services failure to approve a provision of the contract
shall render the provision null and void. The contract is contingent on the health
plan meeting the definition of a Health Maintenance Organization as set forth in the
Medicaid State Plan and 42 CFR 434.

	2.32.6	 	The health plan shall guarantee and certify that no State of Missouri legislator or State of
Missouri employee holds a controlling interest in the health plan.

 

 

			
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	2.32.7	 	The health plan shall guarantee and certify that no funds paid to the health plan by the
state agency shall be used for the purpose of influencing or attempting to influence an
officer or employee of any Federal or State agency, a member of the United States Congress, or
State Legislature. The health plan shall disclose if any funds other than those paid to the
health plan by the state agency have been used or will be used to influence the persons or
entities indicated above and will assist the state agency in making such disclosures to CMS.
	 
	2.32.8	 	Termination or cancellation of the contract does not eliminate the health plan’s
responsibility to the state agency for overpayments made to the health plan. If the contract
is terminated or canceled, the health plan shall return to the state agency any payments
advanced to the health plan for coverage of members for periods after the date of contract
termination or cancellation. The health plan shall return such payments to the state agency
within ninety (90) calendar days of contract termination/cancellation.

	 	a.	 	If the contract is terminated, the health plan shall promptly supply all
information necessary for the reimbursement of any outstanding claims.

	2.32.9	 	In the event the contract is canceled, the state agency shall notify all members of the date
of cancellation and process by which the members will continue to receive contract services
and the health plan shall be responsible for all expenses related to said notification under
these circumstances. In the event the contract is terminated by mutual consent, the state
agency shall notify all members of the date of termination and process by which the members
will continue to receive contract services; and the state agency shall be responsible for all
expenses relating to said notification.
	 
	2.32.10	 	The health plan shall have a written policy regarding the illegality of sexual harassment.
At a minimum, the policy shall include:

	 	a.	 	The definition of sexual harassment under federal and state law, as amended;
	 
	 	b.	 	The health plan’s internal complaint process including penalties;
	 
	 	c.	 	The legal recourse, investigative, and complaint process available for members
through the state agency and for employees through the Missouri Commission on Human
Rights; and
	 
	 	d.	 	Instructions on how to contact the state agency and the Missouri Commission on
Human Rights.

	2.32.11	 	The health plan shall understand and agree that the State of Missouri (its departments and
employees) does not maintain commercial liability insurance.
	 
	2.32.12	 	If the performance of any part of the contract is prevented, hindered or delayed by fire,
flood or an act of God, then the health plan or the state agency shall be excused from such
performance during the continuance of such events. This clause shall not become operative
until the party whose performance is hindered notifies the other party of the occurrence and
the reasons for the delay.
	 
	2.32.13	 	Members are the intended beneficiaries of the contracts and as such are entitled to the
remedies accorded to third party beneficiaries under the law.
	 
	2.32.14	 	The health plan is prohibited from using MC+ managed care funds for services provided in
the following circumstances:

	 	a.	 	Non-emergency services provided by or under the direction of an excluded
individual,
	 
	 	b.	 	Any funds not used under the Assisted Suicide Funding Restriction Act of 1997,

	 
	 	c.	 	Any amount expended for roads, bridges, stadiums, or any other item.

 

 

			
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	2.32.15	 	The Missouri Department of Insurance regulates the health plans licensed in Missouri
including their financial stability. Therefore, the health plan must comply with all
Department of Insurance applicable standards.
	 
	2.33	 	Invoicing and Payment Requirements: On a monthly basis, as near as practical to the fifth
day of the calendar month following the month for which services have been performed and for
which payment is being made, the state agency shall make payments to the health plan via
electronic funds transfer in accordance with the following:
	 
	2.33.1	 	For each member enrolled on the first of the month, the state agency shall pay the health
plan the firm fixed per member, per month net capitation amount specified on the specific
region’s Pricing Page for the Category of Aid Rate Subgroup for the member. The per member,
per month net capitation amount shall reflect any reduction or increase pursuant to the health
plan’s performance in screening 80 percent of eligible members as measured in accordance with
the CMS 416 reporting methodology.

	 	a.	 	The state agency shall pro-rate the net capitation amount when the member’s
birth date necessitates a change to a different Category of Aid or Rate Subgroup in a
given month.
	 
	 	b.	 	For members enrolled at any time after the beginning of the month’s payment
cycle, the state agency shall pro-rate the net capitation amount for the first partial
month.
	 
	 	c.	 	For members whose enrollment lapses for any period of a month in which a
capitation payment was made due to loss of eligibility, death, or other circumstance,
the state agency shall adjust its next monthly capitation payment to recoup the portion
of the capitation payment to which it is due a refund.
	 
	 	d.	 	Any payment pro-rations shall be on a daily basis.

	2.33.2	 	The health plan shall accept capitation payments as specified herein and must have written
policies and procedures for receiving and processing the capitation payments.
	 
	2.33.3	 	The health plan shall agree and understand that the capitation payments specified herein
shall be the only payments made to the health plan for all services required herein and that
no other payment or reimbursement for any reason whatsoever shall be made to the health plan.
In exchange for the capitation payments, the health plan shall be liable or “at risk” for the
costs of all covered services.
	 
	2.33.4	 	In the event that the Missouri General Assembly appropriates funds expressly for the
services required herein, the State of Missouri shall amend the contract. In such event, the
health plan shall pass fee increases to its providers commensurate with the Missouri General
Assembly’s intent. It must clearly be the intent of the Missouri General Assembly that
increases be added during an ongoing contract period for any such amendment to take place
	 
	2.34	 	Business Associate Provisions:
	 
	2.34.1	 	Health Insurance Portability and Accountability Act of 1996 (HIPAA) — The state agency is
subject to and must comply with provisions of the Health Insurance Portability and
Accountability Act of 1996 (HIPAA) and all regulations promulgated pursuant to authority
granted therein. The health plan constitutes a “Business Associate” of the state agency as
such term is defined in the Code of Federal Regulations (CFR) at 45 CFR 160.103. Therefore,
the term, “health plan” as used in this section shall mean “Business Associate.”

	 	a.	 	The health plan shall agree and understand that for purposes of the Business
Associate Provisions contained herein, terms used but not otherwise defined shall have
the same meaning as those terms defined in 45 CFR parts 160 and 164, including, but not
limited to the following:

 

 

			
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	 	1)	 	“Privacy Rule” shall mean the Standards for Privacy of Individually
Identifiable Health Information at 45 CFR part 160 and part 164, subparts A and E.
	 
	 	2)	 	“Security Rule” shall mean the Security Standards for the Protection
of Electronic Protected Health Information at 45 CFR part 164, subpart C.
	 
	 	3)	 	“Individual” shall have the same meaning as the term “individual” in
45 CFR 164.501 and shall include a person who qualifies as a personal
representative in accordance with 45 CFR 164.502 (g).
	 
	 	4)	 	“Protected Health Information” shall mean individually identifiable
health information:

- (1) Except as provided in paragraph (2) of this definition, that is: (i)
Transmitted by electronic media; or (ii) Maintained in electronic media; or
(iii) Transmitted or maintained in any other form or medium.

- (2) Protected Health Information excludes individually identifiable health
information in (i) Education records covered by the Family Educational Rights
and Privacy Act, as amended, 20 U.S.C. 1232g; (ii) Records described at 20
U.S.C. 1232g(a)(4)(B)(iv); and (iii) Employment records held by a covered entity
[state agency] in its role as employer.

	 	5)	 	“Electronic Protected Health Information” shall mean information that
comes within paragraphs (1)(i) or (1)(ii) of the definition of protected health
information as specified above.

	 	b.	 	The health plan shall agree and understand that wherever in this document the
term Protected Health Information is used, it shall also be deemed to include
Electronic Protected Health Information.
	 
	 	c.	 	The health plan shall agree the state agency must comply with 45 CFR 160 and 45
CFR 164, as currently in effect and as may be amended at some later date, and that to
achieve such compliance, the health plan must appropriately safeguard Protected Health
Information (as that term is defined in 45 CFR 164.501), which the health plan receives
from or creates or receives on behalf of the state agency. To provide reasonable
assurance of appropriate safeguards, the health plan shall comply with the business
associate provisions stated herein.
	 
	 	d.	 	The state agency and the health plan agree to amend the contract as is
necessary for the state agency to comply with the requirements of the Privacy Rule and
HIPAA requirements.

	2.34.2	 	Permitted uses and disclosures of Protected Health Information:

	 	a.	 	The health plan may use or disclose Protected Health Information to perform
functions, activities, or services for, or on behalf of, the state agency as specified
in the contract, provided that such use or disclosure would not violate the Privacy
Rule as the Privacy Rule applies to the state agency.
	 
	 	b.	 	The health plan may use Protected Health Information to report violations of
law to appropriate Federal and State authorities, consistent with 45 CFR 164.502(j)(1)
and shall notify the state agency by no later than ten (10) calendar days after the
health plan becomes aware of the disclosure of the Protected Health Information.
	 
	 	c.	 	If required to properly perform the contract and subject to the terms of the
contract, the health plan may use or disclose Protected Health Information if necessary
for the proper management and administration of the health plan’s business.
	 
	 	d.	 	If the disclosure is required by law, the health plan may disclose Protected
Health Information to carry out the legal responsibilities of the health plan.
	 
	 	e.	 	The health plan may use Protected Health Information to provide Data
Aggregation services to the state agency as permitted by 45 CFR 164.504(e)(2)(i)(B).

	2.34.3	 	Obligations of the Health plan:

 

 

			
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	 	a.	 	The health plan shall not use or disclose Protected Health Information other
than as permitted or required by the contract or as otherwise required by law.
	 
	 	b.	 	The health plan shall use appropriate safeguards to prevent use or disclosure
of the Protected Health Information other than as provided for by the contract. Such
safeguards may include, but shall not be limited to:

	 	1)	 	Workforce training on the appropriate uses and disclosures of
Protected Health Information pursuant to the terms of the contract.
	 
	 	2)	 	Policies and procedures implemented by the health plan to prevent
inappropriate uses and disclosures of Protected Health Information by its
workforce.
	 
	 	3)	 	Any other safeguards necessary to prevent the inappropriate use or
disclosure of Protected Health Information.

	 	c.	 	With respect to Electronic Protected Health Information, the health plan shall
implement administrative, physical and technical safeguards that reasonably and
appropriately protect the
confidentiality, integrity and availability of the Electronic Protected Health
Information that health plan creates, receives, maintains or transmits on behalf of the
state agency.
	 
	 	d.	 	The health plan shall require that any agent or subcontractor to whom the
health plan provides any Protected Health Information received from, created by, or
received by the health plan pursuant to the contract, also agrees to the same
restrictions and conditions stated herein that apply to the health plan with respect to
such information.
	 
	 	e.	 	By no later than ten (10) calendar days of receipt of a written request from
the state agency, or as otherwise required by state or federal law or regulation, or by
another time as may be agreed upon in writing by the state agency, the health plan
shall make the health plan’s internal practices, books, and records, including policies
and procedures and Protected Health Information, relating to the use and disclosure of
Protected Health Information received from, created by, or received by the health plan
on behalf of the state agency available to the state agency and/or to the Secretary of
the Department of Health and Human Services or designee for purposes of determining
compliance with the Privacy Rule.
	 
	 	f.	 	The health plan shall document any disclosures and information related to such
disclosures of Protected Health Information as would be required for the state agency
to respond to a request by an individual for an accounting of disclosures of Protected
Health Information in accordance with 45 CFR 164.528. By no later than five (5)
calendar days of receipt of a written request from the state agency, or as otherwise
required by state or federal law or regulation, or by another time as may be agreed
upon in writing by the state agency, the health plan shall provide an accounting of
disclosures of Protected Health Information regarding an individual to the state
agency.
	 
	 	g.	 	In order to meet the requirements under 45 CFR 164.524, the health plan shall,
within five (5) calendar days following a state agency request, or as otherwise
required by state or federal law or regulation, or by another time as may be agreed
upon in writing by the state agency, provide the state agency access to the Protected
Health Information in an individual’s Designated Record Set. However, if requested by
the state agency, the health plan shall provide access to the Protected Health
Information in a Designated Record Set directly to the individual for whom such
information relates.
	 
	 	h.	 	At the direction of the state agency, the health plan shall promptly make any
amendment(s) to Protected Health Information in a Designated Record Set pursuant to 45
CFR 164.526.
	 
	 	i.	 	The health plan shall report to the state agency’s Security Officer any
security incidents no later than five (5) calendar days of becoming aware of such
incident. For purposes of this paragraph, security

 

 

			
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	 	 	 	incident shall mean the
unauthorized access, use, modification or destruction of information or interference
with systems operations in an information system.
	 
	 	j.	 	By no later than five (5) calendar days after the health plan becomes aware of
any use or disclosure of the Protected Health Information not permitted or required as
stated herein, the health plan shall notify the state agency’s Privacy Officer, in
writing, of the unauthorized use or disclosure and shall take immediate action to stop
the unauthorized use or disclosure. The health plan shall include a description of any
remedial action taken to mitigate any harmful effect of such disclosure. The health
plan shall also provide the state agency’s Privacy Officer with a proposed written plan
of action for approval that describes plans for preventing any such future unauthorized
uses or disclosures.

	2.34.4	 	Obligations of the State Agency:

	 	a.	 	The state agency shall notify the health plan of limitation(s) that may affect
the health plan’s use or disclosure of Protected Health Information, by providing the
health plan with the state agency’s notice of privacy practices in accordance with 45
CFR 164.520.
	 
	 	b.	 	The state agency shall notify the health plan of any changes in, or revocation
of, authorization by an Individual to use or disclose Protected Health Information.
	 
	 	c.	 	The state agency shall notify the health plan of any restriction to the use or
disclosure of Protected Health Information that the state agency has agreed to in
accordance with 45 CFR 164.522.
	 
	 	d.	 	The state agency shall not request the health plan to use or disclose Protected
Health Information in any manner that would not be permissible under the Privacy Rule
as the Privacy Rule applies to the state agency.

	2.34.5	 	Expiration/Termination/Cancellation — Except as provided in the subparagraph below, upon the
expiration, termination, or cancellation of the contract for any reason, the health plan shall
return to the state agency or shall destroy all Protected Health Information received by the
health plan from the state agency, or created or received by the health plan on behalf of the
state agency, and shall not retain any copies of such Protected Health Information. This
provision shall also apply to Protected Health Information that is in the possession of
subcontractors or agents of the health plan.

	 	a.	 	In the event the health plan determines and the state agency agrees that
returning or destroying the Protected Health Information is not feasible, the health
plan shall extend the protections of the contract to the Protected Health Information
for as long as the health plan maintains the Protected Health Information and shall
limit the use and disclosure of the Protected Health Information to those purposes that
made return or destruction of the information infeasible. If at any time it becomes
feasible to return or destroy any such Protected Health Information maintained pursuant
to this paragraph, the health plan must notify the state agency and obtain instructions
from the state agency for either the return or destruction of the Protected Health
Information.

	2.34.6	 	Breach of Contract – In the event the health plan is in breach of contract with regard to
the business associate provisions included herein, the health plan shall agree and understand
that in addition to the requirements of the contract related to cancellation of contract, if
the state agency determines that cancellation of the contract is not feasible, the State of
Missouri may elect not to cancel the contract, but the state agency shall report the
contractual breach to the Secretary of the Department of Health and Human Services.

 

 

			
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	3.	 	GENERAL CONTRACTUAL REQUIREMENTS:
	 
	3.1	 	Contract : A binding contract shall consist of: (1) the RFP, amendments thereto, and any
Best and Final Offer (BAFO) request(s) with RFP changes/additions, (2) the health plan’s
proposal including any BAFOs and (3) the Division of Purchasing and Materials Management’s
acceptance of the proposal by “notice of award” or by “purchase order”. All Exhibits and
Attachments included in the RFP shall be incorporated into the contract by reference.
	 
	3.1.1	 	The notice of award does not constitute a directive to proceed. Before providing equipment,
supplies and/or services, the health plan must receive a properly authorized purchase order
unless the purchase is equal to or less than $3,000. Purchases equal to or less than $3,000
may be processed with a purchase order at the discretion of the state agency.
	 
	3.1.2	 	The contract expresses the complete agreement of the parties and performance shall be
governed solely by the specifications and requirements contained therein.
	 
	3.1.3	 	Any change to the contract, whether by modification and/or supplementation, must be
accomplished by a formal contract amendment signed and approved by and between the duly
authorized representative of the health plan and the Division of Purchasing and Materials
Management or by a modified purchase order prior to the effective date of such modification.
The health plan expressly and explicitly understands and agrees that no other method and/or no
other document, including correspondence from the state agency, acts, and oral communications
by or from any person, shall be used or construed as an amendment or modification to the
contract.
	 
	3.2	 	Contract Period: The original contract period shall be as stated on page 1 of the Request
for Proposal (RFP). The contract shall not bind, nor purport to bind, the state for any
contractual commitment in excess of the original contract period. The Division of Purchasing
and Materials Management shall have the right, at its sole option, to renew the contract for
two (2) additional one-year periods, or any portion thereof. In the event the Division of
Purchasing and Materials Management exercises such right, all terms and conditions,
requirements and specifications of the contract shall remain the same and apply during the
renewal period, pursuant to the following:
	 
	3.2.1	 	The state agency will include in each year’s budget request to the Office of Administration,
Division of Budget and Planning, a rate change based on the state agency’s review of recent
health plan financial experience, medical trends from other state Medicaid programs and
national trend indices (CPI/DRI), and pharmacy market trends including specific drug
introductions and expiring patents. The rate changes will be reflective of anticipated
programmatic changes.
	 
	3.2.2	 	If the State of Missouri elects to renew the contract for the first renewal option, the
health plan shall accept the amount appropriated by the Governor and the Missouri General
Assembly.
	 
	3.2.3	 	If the State of Missouri elects to renew the contract for the second renewal option and if
the health plan intends to renew the contract for the second renewal option, the State of
Missouri and the health plan shall negotiate the firm, fixed rates applicable to the second
renewal period. The State of Missouri shall commence such negotiation process approximately
six months prior to the expiration of the first renewal period. Individual negotiations shall
be conducted with each health plan in accordance with the negotiation provisions provided
elsewhere herein.

	 	a.	 	The health plan must submit information which establishes and supports the
actuarial soundness of the proposed rates and a certification of said soundness from an
Associate of the Society of Actuaries (ASA), a Fellow of Society of Actuaries (FSA), or
a Member of the American Academy of Actuaries (MAAA).
	 
	 	b.	 	If the State of Missouri and the health plan are unable to agree upon the firm,
fixed rates for the second renewal period, the pending contract renewal shall be
canceled. In the event of such, the

 

 

			
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State of Missouri reserves its right to extend the contract at the current firm, fixed
rates for no more than 180 days from the date such determination is made.

	 	c.	 	If the health plan does not intend to renew the contract for the second renewal
option and does not desire to enter into the negotiation process, the health plan shall
provide written notification to the State of Missouri of such within at least 180
calendar days prior to the expiration of the contract period.

	3.2.4	 	During the second and final renewal option, the State of Missouri may issue a public notice
of the pending contract expiration and the upcoming opportunity to contract with the State of
Missouri for MC+ managed care services. If no health plans, other than the health plans the
State of Missouri currently contracts with, indicate interest in contracting with the State of
Missouri for such, the State of Missouri may elect to renew the contract with the health plan
for the continuation of the MC+ managed care services. In the event of such, the State of
Missouri and the health plan shall negotiate the firm, fixed rates applicable to the renewal
period. The State of Missouri shall have the option of issuing such notification on an annual
basis.
	 
	3.3	 	Price: All prices shall be as indicated on the specific region’s Pricing Page. The state
shall not pay nor be liable for any other additional costs including but not limited to taxes,
shipping charges, insurance, interest, penalties, termination payments, attorney fees,
liquidated damages, etc.
	 
	3.4	 	Termination: The Division of Purchasing and Materials Management reserves the right to
terminate the contract at any time, for the convenience of the State of Missouri, without
penalty or recourse, by giving written notice to the health plan at least thirty (30) calendar
days prior to the effective date of such termination. In the event of termination pursuant to
this paragraph, all documents, data, reports, supplies, equipment, and accomplishments
prepared, furnished or completed by the health plan pursuant to the terms of the contract
shall, at the option of the Division of Purchasing and Materials Management, become the
property of the State of Missouri. The health plan shall be entitled to receive just and
equitable compensation for services and/or supplies delivered to and accepted by the State of
Missouri pursuant to the contract prior to the effective date of termination.
	 
	3.5	 	Transition:
	 
	3.5.1	 	Upon expiration, termination, or cancellation of the contract, the health plan shall assist
the state agency to insure an orderly transfer of responsibility and/or the continuity of
those services required under the terms of the contract to an organization designated by the
state agency, if requested in writing. At a minimum, the health plan shall perform the
following related to transition:

	 	a.	 	For a period not to exceed ninety (90) calendar days after the expiration,
termination, or cancellation of the contract, the health plan shall continue providing
any part or all of the services in accordance with the terms and conditions,
requirements, and specifications of the contract for a price not to exceed those prices
set forth in the contract.
	 
	 	b.	 	In addition, for 365 calendar days after expiration, termination, or
cancellation of the contract, the health plan shall provide those administration
functions that cannot be completed prior to the expiration, termination, or
cancellation of the contract due to the nature of the function. Such administrative
functions, shall include, but are not limited to, payment of claims for service dates
prior to expiration, termination, or cancellation of the contract; operation of the
member grievance system and provider complaints, grievances, and appeals; operational
data reporting, financial reporting, and communication links with the state agency.
	 
	 	c.	 	The health plan shall deliver, FOB destination, all records, documentation,
reports, data, recommendations, master, or printing elements, etc., which were required
to be produced under the terms of the contract to the state agency and/or to the state
agency’s designee within thirty (30) days after receipt of the written request.

 

 

			
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	 	d.	 	The state agency, at its sole option, may discontinue enrolling new membership
to the health plan, on a date specified by the state agency, prior to expiration,
cancellation, or termination of the contract.

	3.6	 	Health Plan Liability: The health plan shall be responsible for any and all personal injury
(including death) or property damage as a result of the health plan’s negligence involving any
equipment or service provided under the terms and conditions, requirements and specifications
of the contract. In addition, the health plan assumes the obligation to save the State of
Missouri, including its agencies, employees, and assignees, from every expense, liability, or
payment arising out of such negligent act.

	 	a.	 	The health plan also agrees to hold the State of Missouri, including its
agencies, employees, and assignees, harmless for any negligent act or omission
committed by any subcontractor or other person employed by or under the supervision of
the health plan under the terms of the contract.
	 
	 	b.	 	The health plan shall not be responsible for any injury or damage occurring as
a result of any negligent act or omission committed by the State of Missouri, including
its agencies, employees, and assignees.
	 
	 	c.	 	Under no circumstances shall the health plan be liable for any of the
following: (1) third party claims against the state for losses or damages (other than
those listed above); (2) loss of, or damage to, the state’s records or data; or (3)
economic consequential damages (including lost profits or savings) or incidental
damages, even if the health plan is informed of their possibility.

	3.7	 	Insurance: The health plan shall understand and agree that the State of Missouri cannot save
and hold harmless and/or indemnify the health plan or employees against any liability incurred
or arising as a result of any activity of the health plan or any activity of the health plan’s
employees related to the health plan’s performance under the contract. Therefore, the health
plan shall maintain adequate liability insurance in the form(s) and amount(s) sufficient to
protect the State of Missouri, its agencies, its employees, its clients, and the general
public against any loss, damage, and/or expense related to his/her performance under the
contract.

	 	a.	 	The insurance coverage shall include, but shall not necessarily be limited to,
general liability, professional liability, etc. In addition, automobile liability
coverage for the operation of any motor vehicle must be maintained if the terms of the
contract require any form of transportation services.
	 
	 	b.	 	The limits of liability for all types of coverage shall not be less than
$2,000,000 per occurrence.
	 
	 	c.	 	The health plan shall provide written evidence of the insurance to the state
agency. Such evidence shall include, but shall not necessarily be limited to:
effective dates of coverage, limits of liability, insurer’s name, policy number,
endorsement by representatives of the insurance company, etc. Evidence of
self-insurance coverage or of another alternate risk financing mechanism may be
utilized provided that such coverage is verifiable and irrevocably reliable. The
evidence of insurance coverage must be submitted before or upon award of the contract.
The contract number must be identified on the evidence of insurance coverage.
	 
	 	d.	 	In the event the insurance coverage is canceled, the state agency must be
notified immediately.

	3.8	 	Subcontractors: Any subcontracts for the products/services described herein must include
appropriate provisions and contractual obligations to ensure the successful fulfillment of all
contractual obligations agreed to by the health plan and the State of Missouri and to ensure
that the State of Missouri is indemnified, saved, and held harmless from and against any and
all claims of damage, loss, and cost (including attorney fees) of any kind related to a
subcontract in those matters described in the contract between the State of Missouri and the
health plan.

 

 

			
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	3.8.1	 	The health plan shall expressly understand and agree that he/she shall assume and be solely
responsible for all legal and financial responsibilities related to the execution of a
subcontract.
	 
	3.8.2	 	The health plan shall agree and understand that utilization of a subcontractor to provide
any of the products/services in the contract shall in no way relieve the health plan of the
responsibility for providing the products/services as described and set forth herein. The
health plan must obtain acknowledgement from the State of Missouri prior to establishing any
new subcontracting arrangements and before changing any subcontractors.
	 
	3.8.3	 	All subcontracts for health care services must be in writing and shall comply with all
provisions of the contract and shall include at least the items listed below. In addition,
all subcontractors shall comply with the applicable provisions of federal and state laws and
regulations, as amended, and policies. Before any delegation of any functions and
responsibilities to any subcontractor, the health plan shall evaluate the prospective
subcontractor’s ability to perform the activities to be delegated. The health plan shall have
policies and procedures to monitor the performance of health care service subcontractors to
ensure that such subcontractors comply with the provisions of the RFP. The health plan shall
prepare and issue an annual report to the state agency regarding the results of its monitoring
activities in previous calendar year for each health care service subcontractor and any
corrective actions implemented as a result of its monitoring activities. The annual report
shall be due by November 30 of each year. In addition, the health plan shall fully
investigate and timely respond to issues involving subcontractors upon request of the state
agency.

	 	a.	 	A description of services to be provided or other activities performed. This
description shall be in such form as to permit the state agency to ascertain
definitively which contractual obligations have been subcontracted.
	 
	 	b.	 	Provision(s) for release to the health plan of any information necessary for
the health plan to perform any of its obligations under the contract including but not
limited to compliance with all reporting requirements (for example encounter data
reporting requirements), timely payment requirements, and quality assessment
requirements.
	 
	 	c.	 	The provision available to a health care provider to challenge or appeal the
failure of the health plan to cover a service.
	 
	 	d.	 	Provision(s) that (1) the subcontractor’s facilities and records shall be open
to inspection by the health plan and appropriate federal and state agencies and, (2)
the medical records, or copies thereof, shall be provided to the health plan, upon
request, for transfer to subsequent subcontractors for review by the state agency.
	 
	 	e.	 	Provisions that require each health care provider to maintain comprehensive
medical records for a minimum of five years.
	 
	 	f.	 	A provision that when no member co-payment is required, the subcontractor shall
look solely to the health plan for compensation for services provided to member.
	 
	 	g.	 	Provision(s) that prohibit any financial incentive arrangement to induce
subcontractors to limit medically necessary services. A description of all financial
incentive arrangements shall be included in the subcontract. In the event of a change
to these financial incentive arrangements, the subcontractor shall immediately notify
the health plan of such change so the health plan can meet its requirement to notify
the state agency.
	 
	 	h.	 	Provisions that the health plan may not prohibit, or otherwise restrict, a
health care professional acting within the lawful scope of practice, from advising or
advocating on behalf of a member who is his or her patient:

 

 

			
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	 	1)	 	For the member’s health status, medical care, or treatment options,
including any alternative treatment that may be self-administered.
	 
	 	2)	 	For any information the member needs in order to decide among all
relevant treatment options.
	 
	 	3)	 	For the risks, benefits, and consequences of treatment or
non-treatment.
	 
	 	4)	 	For the member’s right to participate in decisions regarding his or
her health care, including the right to refuse treatment, and to express
preferences about future treatment decisions.

	 	i.	 	Provisions that subcontractors shall not conduct or participate in health plan
enrollment, disenrollment, transfer, or opt out activities. The subcontractors shall
not influence a member’s enrollment. Prohibited activities include:

	 	1)	 	Requiring or encouraging the member to apply for an assistance
category not included in MC+ managed care;
	 
	 	2)	 	Requiring or encouraging the member and/or guardian to use the opt
out provision as an option in lieu of delivering health plan benefits;
	 
	 	3)	 	Mailing or faxing health plan enrollment forms;
	 
	 	4)	 	Aiding the member in filling out health plan enrollment forms;
	 
	 	5)	 	Photocopying blank health plan enrollment forms for potential
members;
	 
	 	6)	 	Distributing blank health plan enrollment forms;
	 
	 	7)	 	Participating in three way calls to the MC+ managed care enrollment
helpline;
	 
	 	8)	 	Suggesting a member transfer to another health plan; or
	 
	 	9)	 	Other activities in which subcontractors are engaged in to enroll a
member in a particular health plan or in any way assisting a member to enroll in a
health plan.

	 	j.	 	If a subcontract is with a federally qualified health center (FQHC) or rural
health clinic (RHC) to provide services to members under a prepayment arrangement, a
provision that the state agency shall reimburse the FQHC or RHC 100% of its reasonable
cost for covered services.
	 
	 	k.	 	All hospital subcontracts must require that the hospital subcontractor notify
the health plan of births where the mother is a member. The subcontracts must specify
which entity is responsible for notifying the Family Support Division of the birth.
	 
	 	l.	 	For contracted services, the subcontractor shall follow the claim processing
requirements set forth by RSMo 376.383 and 376.384, as amended.
	 
	 	m.	 	Provisions in accordance with federal and state laws and regulations, as
amended, and policy regarding termination of the subcontract between the health plan
and the subcontractor.
	 
	 	n.	 	Provisions that in the event of the subcontractor’s insolvency or other
cessation of operations, covered services to members shall continue through the period
for which a capitation payment has been made to the health plan or until the member’s
discharge from an inpatient facility, whichever time is greater.
	 
	 	o.	 	The health plan and its subcontractors shall establish reasonable timely filing
requirements for claims to be filed by a provider for reimbursement. The subcontractor
shall inform its provider network of the timely filing requirements.

 

 

			
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	 	1)	 	In the case of capitated arrangements with providers, the
subcontractor shall establish reasonable reporting of encounters to the health
plan in sufficient detail to meet the health plan’s encounter data reporting
requirements.
	 
	 	2)	 	In the case of services provided by out-of-network providers, the
health plan shall comply with state law regarding timely filing requirements.

	 	p.	 	Provision for revoking the subcontract agreement or imposing other sanctions if
the subcontractor’s performance is inadequate.
	 
	 	q.	 	The health plan shall agree and understand that consumer protection shall be
integral to the MC+ managed care program. All contracts between the health plan and
providers shall ensure that the provider complies with the consumer protection
provisions outlined in the marketing guidelines.
	 
	 	r.	 	Provision(s) that entitle each member to one free copy of his or her medical
records annually. The fee for additional copies shall not exceed the actual cost of
time and materials used to compile, copy, and furnish such records.

	3.9	 	Assignment:
	 
	3.9.1	 	The health plan shall not transfer any interest in the contract, whether by assignment or
otherwise, without the prior written consent of the Division of Purchasing and Materials
Management.
	 
	3.9.2	 	The health plan shall agree and understand that, in the event the Division of Purchasing and
Materials Management consents to a financial assignment of the contract in whole or in part to
a third party, any payments made by the State of Missouri pursuant to the contract, including
all of those payments assigned to the third party, shall be contingent upon the performance of
the prime health plan in accordance with all terms and conditions, requirements and
specifications of the contract.
	 
	3.10	 	Substitution of Personnel: The health plan agrees and understands that the State of
Missouri’s agreement to the contract is predicated in part on the utilization of the specific
individual(s) and/or personnel qualifications identified in the proposal. The health plan
further agrees that any substitution made pursuant to this paragraph must be equal or better
than originally proposed.
	 
	3.11	 	Health Plan Status: The health plan represents himself or herself to be an independent
health plan offering such services to the general public and shall not represent
himself/herself or his/her employees to be an employee of the State of Missouri. Therefore,
the health plan shall assume all legal and financial responsibility for taxes, FICA, employee
fringe benefits, workers compensation, employee insurance, minimum wage requirements,
overtime, etc., and agrees to indemnify, save, and hold the State of Missouri, its officers,
agents, and employees, harmless from and against, any and all loss; cost (including attorney
fees); and damage of any kind related to such matters.
	 
	3.12	 	Coordination: The health plan shall fully coordinate all contract activities with those
activities of the state agency. As the work of the health plan progresses, advice and
information on matters covered by the contract shall be made available by the health plan to
the state agency or the Division of Purchasing and Materials Management throughout the
effective period of the contract.
	 
	3.13	 	Property of State:
	 
	3.13.1	 	All reports, documentation, and material developed or acquired by the health plan as a
direct requirement specified in the contract shall become the property of the State of
Missouri.
	 
	3.13.2	 	The health plan shall agree and understand that all discussions with the health plan and all
information gained by the health plan as a result of the health plan’s performance under the
contract, including member information, medical records, data, and data elements established,
collected, maintained, or used

 

 

			
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in the administration of the contract shall be confidential and
that no reports, documentation, or material prepared as required by the contract shall be
released to the public without the prior written consent of the state agency.

	 	a.	 	The health plan shall provide safeguards that restrict the use or disclosure of
information concerning members to purposes directly connected with the administration
of the contract.
	 
	 	b.	 	The health plan shall not disclose the contents of member information or
records to anyone other than the state agency, the member or the member’s legal
guardian, or other parties with the member’s written consent.
	 
	 	c.	 	In complying with the requirements of this section, the health plan and the
state agency shall follow the requirements of 42 Code of Federal Regulations Part 431,
Subpart F, as amended, regarding confidentiality of information concerning applicants
and members of public assistance and 42 Code of Federal Regulations Part 2, as amended,
regarding confidentiality of alcohol and drug abuse patient records.
	 
	 	d.	 	The health plan shall have written policies and procedures for maintaining the
confidentiality of data, including medical records, member information, and appointment
records for adult and adolescent STDs and adolescent family planning services.

	3.14	 	Performance Security Deposit: The health plan must furnish a performance security deposit in
the form of an original bond issued by a surety company authorized to do business in the State
of Missouri (no copy or facsimile is acceptable), check, cash, bank draft, or irrevocable
letter of credit to the Office of Administration, Division of Purchasing and Materials
Management within thirty (30) days after award of the contract and prior to performance of
service under the contract.

	 	a.	 	The performance security deposit must be made payable to the State of Missouri
in an amount equal to the in the amount of $1,000,000. In the event the health plan is
awarded a contract for more than one region, the health plan shall provide a separate
performance security deposit in the amount of $1,000,000.00 for each region.
	 
	 	b.	 	The contract number and contract period must be specified on the performance
security deposit.
	 
	 	c.	 	In the event the Division of Purchasing and Materials Management exercises an
option to renew the contract for an additional period, the health plan shall maintain
the validity and enforcement of the security deposit for the said period, pursuant to
the provisions of this paragraph, in an amount stipulated at the time of contract
renewal
	 
	 	d.	 	Additionally, during the 365 day transition period, the health plan shall
maintain the validity and enforcement of the performance security deposit for
performance of the administrative functions pursuant to the provisions of this
paragraph, in an amount stipulated via written notification by DPMM.

	3.15	 	Federal Funds Requirements — The health plan shall understand and agree that the contract may
involve the use of federal funds.
	 
	3.15.1	 	Steven’s Amendment — In accordance with the Departments of Labor, Health and Human
Services, and Education and Related Agencies Appropriations Act, Public Law 101-166, Section
511, “Steven’s Amendment”, the health plan shall not issue any statements, press releases, and
other documents describing projects or programs funded in whole or in part with Federal money
unless the prior approval of the state agency is obtained and unless they clearly state the
following as provided by the state agency:

	 	a.	 	The percentage of the total costs of the program or project which will be
financed with Federal money;

 

 

			
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	 	b.	 	The dollar amount of Federal funds for the project or program; and
	 
	 	c.	 	The percentage and dollar amount of the total costs of the project or program
that will be financed by nongovernmental sources.

	3.16	 	Terminology
	 
	3.16.1	 	All references to the term “contractor” as used in the Terms and Conditions attached hereto
shall mean “health plan”.

 

 

			
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	4.	 	PROPOSAL SUBMISSION INFORMATION
	 
	4.1	 	Submission of Proposals:
	 
	4.1.1	 	ELECTRONIC SUBMISSION OF PROPOSALS THROUGH THE ON-LINE BIDDING WEB SITE IS NOT
AVAILABLE FOR THIS RFP.
	 
	4.1.2	 	Proposal Security Deposit Required: The offeror must furnish a proposal security deposit in
the form of an original bond (copies or facsimiles shall not be acceptable), check, cash, bank
draft, or irrevocable letter of credit to the Office of Administration, Division of Purchasing
and Materials Management by the proposal opening date and time. The Request for Proposal
number must be specified on the proposal security deposit.

	 	a.	 	The proposal security deposit must be made payable to the State of Missouri in
the amount of $500,000 for each proposed region.
	 
	 	b.	 	Any proposal security deposit submitted shall remain in force until such time
as the health plan submits a performance security deposit pursuant to the contract
requirements specified elsewhere herein. Failure to submit a performance security
deposit in the time specified or failure to accept award of the contract shall be
deemed sufficient cause to forfeit the proposal security deposit.
	 
	 	c.	 	If the proposal security deposit is submitted in the form of cash or a check,
it will be deposited. However, the Division of Purchasing and Materials Management
shall issue a check in the same amount as the offeror’s proposal security deposit to
the offeror either once the performance security deposit is received if the offeror is
awarded the contract, or at the time of award of the contract if the offeror is not
awarded a contract.

	4.1.3	 	When submitting a proposal, the offeror should include nine (9) additional copies along with
their original proposal. The front cover of the original proposal should be labeled “original”
and the front cover of all copies should be labeled “copy”.

	 	a.	 	In addition the offeror should provide one (1) copy of their entire proposal,
including all attachments, in Microsoft compatible format on diskette(s) or CD(s).
	 
	 	b.	 	Both the original and the copies should be printed on recycled paper and double
sided.
	 
	 	c.	 	Imaging Ready — In addition, all proposals are scanned into the Division of
Purchasing and Materials Management imaging system after a contract is executed, or all
proposals are rejected.

	 	1)	 	The scanned information will be able to be viewed through the
Internet from the Public Record Search system. Therefore, the offeror is advised
not to include personal identifying information such as social security numbers in
the proposal.
	 
	 	2)	 	In preparing a proposal, the offeror should be mindful of document
preparation efforts for imaging purposes and storage capacity that will be
required to image the proposals. Glue bound materials should not be used.

	4.1.4	 	To facilitate the evaluation process, the offeror is encouraged to organize their proposal
into distinctive sections that correspond with the individual evaluation categories described
herein. The offeror is cautioned that it is the offeror’s sole responsibility to submit
information related to the evaluation categories and that the State of Missouri is under no
obligation to solicit such information if it is not included with the proposal. The offeror’s
failure to submit such information may cause an adverse impact on the evaluation of the
proposal.

	 	a.	 	Each distinctive section should be titled with each individual evaluation
category and all material related to that category should be included therein.
	 
	 	b.	 	The proposal should be page numbered.

 

 

			
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	 	c.	 	The signed page one from the original RFP and all signed amendments should be
placed at the beginning of the proposal.

	4.1.5	 	The offeror should complete and submit Exhibit A, Miscellaneous Information.
	 
	4.1.6	 	Offeror’s Contacts:

	 	a.	 	Offerors and their agents (including subcontractors, employees, consultants, or
anyone else acting on their behalf) must direct all of their questions or comments
regarding the RFP, the evaluation, etc. to the buyer of record indicated on the first
page of this RFP. The buyer may be contacted via e-mail or phone as shown on the first
page, or via facsimile to 573-526-9817.
	 
	 	b.	 	Offerors and their agents may not contact any other state employee regarding
any of these matters during the solicitation and evaluation process. Inappropriate
contacts are grounds for suspension and/or exclusion from specific procurements.
Offerors and their agents who have questions regarding this matter should contact the
buyer of record.
	 
	 	c.	 	Offerors are advised that any questions received less than three weeks prior to
the RFP opening date may not be answered.

	4.2	 	Competitive Negotiation of Proposals — The offeror is advised that under the provisions of
this Request for Proposal, the Division of Purchasing and Materials Management reserves the
right to conduct negotiations of the proposals received or to award a contract without
negotiations. If such negotiations are conducted, the following conditions shall apply:
	 
	4.2.1	 	Negotiations may be conducted in person, in writing, or by telephone.
	 
	4.2.2	 	Negotiations will only be conducted with potentially acceptable proposals. The Division of
Purchasing and Materials Management reserves the right to limit negotiations to those
proposals which received the highest rankings during the initial evaluation phase. All
offerors involved in the negotiation process will be invited to submit a best and final offer.
	 
	4.2.3	 	Terms, conditions, prices, methodology, or other features of the offeror’s proposal may be
subject to negotiation and subsequent revision. As part of the negotiations, the offeror may
be required to submit supporting financial, pricing and other data in order to allow a
detailed evaluation of the feasibility, reasonableness, and acceptability of the proposal.

	 	a.	 	The offeror must submit information which establishes and supports the
actuarial soundness of the proposed rates and a certification of said soundness from an
Associate of the Society of Actuaries (ASA), a Fellow of Society of Actuaries (FSA), or
a Member of the American Academy of Actuaries (MAAA).
	 
	 	b.	 	The offeror shall understand that the decision of the State of Missouri
regarding whether or not a rate is within actuarially sound rate ranges and does not
exceed the cost to the state agency of providing those same services on a
fee-for-service basis shall be final and without recourse.

	4.2.4	 	The mandatory requirements of the Request for Proposal shall not be negotiable and
shall remain unchanged unless the Division of Purchasing and Materials Management determines
that a change in such requirements is in the best interest of the State of Missouri.

 

 

			
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	4.3	 	Evaluation and Award Process:
	 
	4.3.1	 	After determining that a proposal was submitted by a responsible and reliable offeror and
after confirming that the offeror is responsive to the mandatory requirements stated in the
Request for Proposal, a subjective evaluation and an objective analysis of the proposals shall
be conducted in accordance with the evaluation criteria stated below and further described
elsewhere herein. .

	 	a.	 	Objective Criteria:

	 		
	1) Cost Evaluation
	 	20 points
	2) Blind/Sheltered Workshops
	 	5 points

	 	b.	 	Subjective Criteria:

	 		
	1) Organizational Experience
	 	45 points
	2) Proposed Method of Performance
	 	30 points

	4.3.2	 	After an initial screening process, a question and answer conference, interview, and/or
negotiation discussion may be conducted with the offeror, if deemed necessary by the Division
of Purchasing and Materials Management. In addition, the offeror may be asked to make an oral
presentation of their proposal during the conference. Attendance cost at the conference shall
be at the offeror’s expense. All arrangements and scheduling shall be coordinated by the
Division of Purchasing and Materials Management.
	 
	4.3.3	 	Separate evaluations shall be conducted by each area (East, Central, and West). One
subjective evaluation shall be conducted as identified in the Subjective Criteria section of
the RFP and points assigned accordingly. Two separate cost evaluations shall be conducted as
identified in the Objective Criteria, Evaluation of Cost. The first evaluation of cost shall
be for those offerors proposing to include pharmacy services from the MC+ managed care benefit
package benefits and points assigned accordingly. The second evaluation of cost shall be for
those offerors proposing to exclude the pharmacy services from the MC+ managed care benefit
package and points assigned accordingly. For auto assign purposes, the sum of the subjective
points and cost points for all offerors in an area will be grouped together.

Paragraph 4.1.1 renumbered correctly by Amendment #001

	4.3.4	 	The State of Missouri shall award multiple contracts.
	 
	4.4	 	Offeror’s Organization (Responsible and Reliable):
	 
	4.4.1	 	If the offeror is not Federally qualified, the offeror must disclose the following
information on certain types of business transactions the offeror has with a “party in
interest” as defined in the Public Health Services Act.

	 	a.	 	Any sale, exchange, or lease of any property between the offeror and a “party
in interest”;
	 
	 	b.	 	Any lending of money or other extension of credit between the offeror and a
“party in interest”; and
	 
	 	c.	 	Any furnishing for consideration of goods, services (including management
services), or facilities between the offeror and a “party in interest”. This does not
include salaries paid to employees for services provided in the normal course of their
employment.
	 
	 	d.	 	If the offeror has operated previously in the commercial or Medicare markets,
the offeror must disclose the information listed below regarding business transactions
for the previous year. The offeror must report all of the offeror’s business
transactions, not just the transactions relating to serving the Medicaid enrollment.

	 	1)	 	The name of the “party in interest” for each business transaction;

 

 

			
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	 	2)	 	A description of each business transaction and the quantity or units
involved;
	 
	 	3)	 	The accrued dollar value of each business transaction during the
fiscal year; and
	 
	 	4)	 	Justification of the reasonableness of each business transaction.

	 	e.	 	For purposes of the above information, a “party in interest” shall be defined
as:

	 	1)	 	Any director, officer, partner, or employee responsible for
management or administration of an HMO; any person who is directly or indirectly
the beneficial owner of more than 5% of the equity of the HMO; any person who is
the beneficial owner of a mortgage, deed of trust, note, or other interest secured
by, and valuing more than 5% of the HMO; or, in the case of an HMO organized as a
nonprofit corporation, an incorporator or member of such corporation under
applicable State corporation law;
	 
	 	2)	 	Any organization in which a person as described above is director,
officer, or partner; has directly or indirectly a beneficial interest of more than
5% of the equity of the HMO; or has a mortgage, deed of trust, note, or other
interest valuing more than 5% of the assets of the HMO.
	 
	 	3)	 	Any person directly or indirectly controlling, controlled by, or
under common control with a HMO; or
	 
	 	4)	 	Any spouse, child, or parent of a person as described in above.

	4.4.2	 	The offeror must provide full and complete information by disclosing the following related
to the identity of each “person or corporation with an ownership or control interest” in the
offeror, or any health service subcontractor in which the offeror has a 5% or more ownership
interest for the prior 12-month period. The offeror may satisfy this requirement by providing
a completed Form CMS-855 (Medicare and Other Federal Health Care Programs Provider/Supplier
Enrollment Application).

	 	a.	 	The name and address of each person with an ownership or controlling interest
of 5% or more in the offeror or in any subcontractor in which the offeror has direct or
indirect ownership of 5% or more;
	 
	 	b.	 	A statement as to whether any such person with ownership or control interest is
related to any other of the persons named with ownership or control interest; as
spouse, parent, child, or sibling, and
	 
	 	c.	 	The name of any other organization in which the person also has ownership or
control interest. This is required to the extent that the offeror can obtain this
information by requesting it in writing. The offeror must keep copies of all of these
requests and responses to them, make them available upon request, and advise the State
of Missouri when there is no response to a request.
	 
	 	d.	 	For purposes of providing the above information, the offeror shall understand
that a “person with an ownership or control interest” shall mean a person or
corporation that (1) owns directly or indirectly, 5% or more of the offeror’s capital
or stock or received 5% or more of its profits; or (2) has an interest in any mortgage,
deed of trust, note, or other obligation secured in whole or in part by the offeror or
by its property or assets, and that interest is equal to or exceeds 5% of the total
property and assets of the offeror, or (3) is an officer or director of the offeror (if
it is organized as a corporation) or is a partner in the offeror (if it is organized as
a partnership).

	 	1)	 	The percentage of direct ownership or control is calculated by
multiplying the percent of interest which a person owns by the percent of the
offeror’s assets used to secure the obligation (e.g., if a person owns 10 percent
of a note secured by 60 percent of the offeror’s assets, the person owns 6% of the
offeror).
	 
	 	2)	 	The percentage of indirect ownership or control is calculated by
multiplying the percentages of ownership in each organization (e.g., if a person
owns 10 percent of the stock in a corporation which owns 80 percent of the stock
of the offeror, the person owns 8% of the offeror).

	 	e.	 	Financial statements for all owners with 5% or more shall be submitted.

 

 

			
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	4.4.3	 	The offeror must provide the following financial information pertaining to the offeror’s
organization (the legal entity that is submitting the proposal and that will be the party
responsible for any contract awarded).

	 	a.	 	Audited financial statements and balance sheets for the previous three (3)
years, or as many years up to three (3) years that the entity has been in operation.
If the offeror has not been in operation for at least one year, the offeror must submit
unaudited financial statements and balance sheets. If the offeror is an existing
Health Maintenance Organization, a financial statement must be submitted on the form as
prescribed by the National Association of Insurance (NAIC) and must include an
actuarial certification.
	 
	 	b.	 	Financial plan for the offeror’s current fiscal year.
	 
	 	c.	 	Information about the offeror’s financial forecasts for the contract period and
possible contract renewal periods. These forecasts shall include at least income
statements and enrollment forecasts.
	 
	 	d.	 	Names and addresses of independent auditors.
	 
	 	e.	 	Documentation of insurance coverage such as a list of the insurers used
(including contact person and address) and the type and amounts of each policy held.
	 
	 	f.	 	Proof of reinsurance.
	 
	 	g.	 	Documentation of any outstanding litigation and malpractice settlements since
January 1, 1998.

	4.4.4	 	Debarment Certification — The offeror certifies by signing the signature page of this
original document and any amendment signature page(s) that the offeror is not presently
debarred, suspended, proposed for debarment, declared ineligible, voluntarily excluded from
participation, or otherwise excluded from or ineligible for participation under federal
assistance programs. The offeror should complete and return the attached certification
regarding debarment, etc., Exhibit B with the proposal. This document must be satisfactorily
completed prior to award of the contract.
	 
	4.4.5	 	Business Compliance — The offeror must be in compliance with the laws regarding conducting
business in the State of Missouri. The offeror certifies by signing the signature page of
this original document and any amendment signature page(s) that the offeror and any proposed
subcontractors are presently in compliance with such laws. The offeror shall provide
documentation of compliance upon request by the Division of Purchasing and Materials
Management. The compliance to conduct business in the state shall include, but not
necessarily be limited to:

	 	a.	 	Registration of business name (if applicable)
	 
	 	b.	 	Certificate of authority to transact business/certificate of good standing (if
applicable)
	 
	 	c.	 	Taxes (e.g., city/county/state/federal)
	 
	 	d.	 	State and local certifications (e.g., professions/occupations/activities)
	 
	 	e.	 	Licenses and permits (e.g., city/county license, sales permits)
	 
	 	f.	 	Insurance (e.g., worker’s compensation/unemployment compensation)

	4.5	 	Confirmation of Compliance with Requirements:

The offeror must submit all of the following information in order to determine if the
offeror satisfies the mandatory requirements of the Request for Proposal. The State of
Missouri reserves the right to reject any offeror’s proposal which does not include the
required information.

In addition, the offeror should address the requirements contained in the Performance
Requirements section of the RFP. Specifically, the offeror should address the individual
requirements in the

 

 

			
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Performance Requirements section of the RFP and provide a description of
how, when, by whom, with what, to what degree, why, where, etc., the requirement will be
satisfied.

The offeror should not provide a separate response to both the Performance Requirements
section and this section. Rather, the offeror’s response to the following items should be
included within the offeror’s response to the Performance Requirements.

To the extent possible, the specific paragraph number of the applicable section of the
Performance Requirements is provided with the following items and is denoted in parenthesis.
The State does not guarantee that all references have been provided.

	4.5.1	 	The offeror shall submit proof that the offeror has a Certificate of Authority from the
Missouri Department of Insurance to operate a Health Maintenance Organization in each county
specified herein. (2.1.2.a)

	 	a.	 	If the offeror does not currently have a certificate for a certain county, the
offeror shall provide documentation that the offeror has or will submit an application
to the Department of Insurance for such certification.

	4.5.2	 	Physician Incentive Plans: The offeror must provide a minimum of the following information
regarding each of the offeror’s physician incentive plans (PIP) and each of the offeror’s
subcontractor’s PIPs with their downstream providers, if the PIPs place the providers at
significant financial risk (SFR). (2.20.3)

	 	a.	 	Effective date of the physician incentive plan,
	 
	 	b.	 	The type of incentive arrangement,
	 
	 	c.	 	The amount and type of stop-loss protection,
	 
	 	d.	 	The patient panel size,
	 
	 	e.	 	If the patient panel is pooled, provide a description of the method,
	 
	 	f.	 	The computations of significant financial risk, and
	 
	 	g.	 	The name, address, telephone number, and other contact information for a person
from the offeror’s organization who may be contacted with questions regarding the
physician incentive plan.

If the offeror does not have any PIPs with the health care service providers, the offeror
must confirm in the proposal that no such arrangements exist. If the offeror’s
subcontractors do not have any PIPs with their downstream providers, the offeror must
confirm in the proposal that no such arrangements exist and maintain documentation that
demonstrates that no such arrangements exist.

	4.5.3	 	Networks

	 	a.	 	The offeror shall submit documentation demonstrating that the offeror’s
networks comply with travel distance access standards as set forth by the Department of
Insurance in 20 CSR 400-7.095 regarding Provider Network Adequacy Standards. For any
demonstrated access that differs from these standards, the offeror must submit proof of
approval of the differences by the Department of Insurance. (2.14.3)
	 
	 	b.	 	The offeror shall provide documentation verifying that the offeror’s network
has adequate capacity. Such documentation shall include, but it is not limited to,
appointment availability, 24 hour/7 days a week access, sufficient experienced
providers to serve special needs populations, waiting times, open panels, and PCP to
member rations. (2.3.1)
	 
	 	c.	 	The offeror shall describe how it will provide tertiary care providers
including trauma centers, burn centers, level III (high risk) nurseries, rehabilitation
facilities, and medical sub-specialists available twenty-four (24) hours per day in the
region. If the offeror does not have a full range of tertiary care providers, the
offeror shall describe how the services will be provided including transfer protocols
and arrangements with out of network facilities. (2.3.17)

 

 

			
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	4.5.4	 	The offeror shall list each proposed health care service subcontractor to whom the offeror
proposes to delegate contract requirements. Examples include, but are not limited to, mental
health services, vision, dental, or pharmacy. The offeror shall describe the services and activities that will be
provided by such health service subcontractor. (3.8.3)
	 
	4.5.5	 	Personnel/Staffing: The offeror shall submit information related to the qualifications of
the proposed personnel concerning their experience in serving the Medicaid population
including education, training, and previous work assignments. In particular, the offeror must
submit the following:

	 	a.	 	Resumes, job descriptions, and full time equivalent status for the offeror’s
Medicaid Plan Administrator, medical director, quality assessment and improvement and
utilization management coordinator, special programs coordinator, mental health
coordinator, and chief financial officer. (2.2.2)
	 
	 	b.	 	Information for other personnel, including dental consultant, grievance and
appeal coordinator, MIS director, and compliance officer. (2.2.1)
	 
	 	c.	 	Information on staffing levels, job descriptions, and qualifications for prior
authorization staff, concurrent review staff, member services staff, and providers
service staff. (2.2.1)

	4.5.6	 	Claims Payment Processes — The offeror must submit the following information regarding the
offeror’s claims payment processes: (2.25)

	 	a.	 	Information describing the offeror’s claim adjudication processes — The offeror
shall provide a flow chart or written description that details the flow of claims from
receipt until payment. Information shall be provided documenting the offeror’s audit
trail of all claims that enter the system and any review processes that are in place.
	 
	 	b.	 	The offeror shall document the offeror’s past and current performance with
regard to the timely payment to in-network and out-of-network providers.
	 
	 	c.	 	A description of the offeror’s claims processing and management information
system functions, including, but not limited to information about the offeror’s
liability management practices regarding its “Incurred But Not Reported Claims” and
“Received But Unadjudicated Claims”.

	4.5.7	 	Additional Benefits — The offeror must provide a listing, description, and conditions under
which it will offer additional benefits to its members. Examples of such services are nurse
advice lines; non-emergency transportation (NEMT) for those members who do not have NEMT as
part of their benefit package; sponsorship in youth programs such as Boy Scouts or YMCA; or
smoking cessation programs. This is not an exhaustive list of such services but only provides
examples of the types of services that may qualify as an additional benefit. (2.6.1.a. 13))

	 	a.	 	Member Services and Provider Services — The offeror shall describe the hours
of operation, holiday schedule, member and provider communication and education plans,
and staff training plans for member services and provider services. (2.9 and 2.10)
	 
	 	b.	 	Member Grievance System — The offeror shall describe the offeror’s member
grievance system being sure to address the grievance process, the appeal process,
expedited resolution process, and process for ensuring that members receive proper
notice of action. (2.15)
	 
	 	c.	 	Release for Ethical Reasons — The offeror must state if reimbursement for, or
provider coverage, of a counseling or referral service will be objected to based on
moral or religious grounds. (2.11.3)

 

 

			
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	4.6	 	Objective Criteria:
	 
	4.6.1	 	Preference for Organizations for the Blind and Sheltered Workshops — Pursuant to 34.165
RSMo, a five (5) bonus point preference shall be granted to offerors including products and/or
services manufactured, produced or assembled by a qualified nonprofit organization for the
blind established pursuant to 41 U.S.C. sections 46 to 48c or a sheltered workshop holding a
certificate of approval from the Department of Elementary and Secondary Education pursuant to
section 178.920 RSMo. Five bonus points will be added to the total evaluation points for
offerors qualifying for the preference.

	 	a.	 	If the offeror is an organization for the blind or sheltered workshop, the
offeror should provide evidence of qualifications (i.e., copy of certificate or
certificate number).
	 
	 	b.	 	If the offeror is utilizing an organization for the blind or a sheltered
workshop as a subcontractor, the offeror should submit: (1) a letter of intent signed
by the organization for the blind or sheltered workshop describing the
products/services they will provide and indicating their commitment to aid the
contractor’s performance under the prospective state contract and (2) evidence that the
subcontractor qualifies as an organization for the blind or sheltered workshop.
	 
	 	c.	 	A list of Missouri sheltered workshops can be found at the following internet
address:

http://www.dese.mo.gov/divspeced/shelteredworkshops/index.html.

	4.6.2	 	Evaluation of Cost:

	 	a.	 	The objective evaluation of cost shall be computed by using the firm, fixed Per
Member Per Month (PMPM) Net Capitation Rates for each Category of Aid Rate Subgroup as
quoted by the offeror on the Pricing Pages multiplied by the corresponding projected
member months stated in UPL/Rate Development Process (see Attachment 9). The State
shall not consider awarding a contract to any offeror with a rate for any Category of
Aid rate subgroup which exceeds the State’s Maximum Net Capitation Rate listed in
Column 1 on the Pricing Page.
	 
	 	b.	 	Requirements promulgated by the federal government stipulate that the State of
Missouri can only contract for services at rates that are within actuarially sound rate
ranges. The actuarial soundness of rates differing from those of the state shall be
reviewed by the State of Missouri during the formal evaluation of proposals.
	 
	 	c.	 	The offeror must submit information which establishes and supports the
actuarial soundness of the proposed rates and a certification of said soundness from an
Associate of the Society of Actuaries (ASA), a Fellow of Society of Actuaries (FSA), or
a Member of the American Academy of Actuaries (MAAA).
	 
	 	d.	 	The offeror shall understand that the decision of the State of Missouri
regarding whether or not a rate is within actuarially sound rate ranges shall be final
and without recourse.
	 
	 	e.	 	Cost points shall be calculated based on the sum from the above calculation
using the following formula:

	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	Lowest Responsive Offeror’s Price
 

Compared Offeror’s Price

	 	X
	 	 	20	 	 	=
	 	Cost evaluation points
	 	 

 

 

			
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	4.7	 	Subjective Criteria:
	 
	4.7.1	 	Organizational Experience: The offeror’s organization and the offeror’s health care service
subcontractor’s organizations shall be subjectively judged. Therefore, the offeror should
submit sufficient information to document successful and reliable experience in past/current
performances of the offeror and the offeror’s health care service subcontractor’s. The
offeror should document experience with a Missouri Medicaid population, or if not available,
document experience with another State’s Medicaid population.

	 	a.	 	The offeror should document its experience in positively impacting the
healthcare status of Missouri Medicaid population, or if not available, another State’s
Medicaid population. Examples of areas of interest include, but are not limited to the
following:

	 	1)	 	EPSDT
	 
	 	2)	 	Lead
	 
	 	3)	 	Children with special health care needs
	 
	 	4)	 	Asthma
	 
	 	5)	 	Reduction of inappropriate utilization of emergent services
	 
	 	6)	 	Case management
	 
	 	7)	 	Pre-natal care
	 
	 	8)	 	Dental
	 
	 	9)	 	Mental health
	 
	 	10)	 	Partnering with stakeholders (e.g. community based service providers,
local public health agencies, schools, state agencies, FQHCs, consumer groups,
etc.) for delivery of care
	 
	 	11)	 	Reduction of racial and ethnic health care disparities to improve
health status
	 
	 	12)	 	Complaints, Grievances, and Appeals
	 
	 	13)	 	Denials
	 
	 	14)	 	Access

	 	b.	 	The offeror should provide a description of focus studies performed, quality
improvement projects, and any improvements the offeror has implemented and their
outcomes. Such outcomes should include cost savings realized, process efficiencies,
and improvements to member health status. Such descriptions should address such
activities since 1998. The offeror should address how issues and root causes were
identified, and what was changed.

	4.7.2	 	Proposed Method of Performance —

	 	a.	 	The offeror’s proposed Quality Improvement Programs shall be subjectively
evaluated. Therefore, the offeror should address the Quality Improvement Programs
proposed to be implemented during the term of the contract. The offeror should address
how the proposed Quality Improvement Programs will expand the quality improvement
services beyond what the offeror is currently providing (as addressed in response to
item 4.7.1 a. and b.) and the difference between the offeror’s current programs and the
proposed programs. The offeror should also indicate how the proposed Quality
Improvement Program will improve the health care status of the Missouri Medicaid
population. The offeror should address the rationale for selecting the particular
programs including the identification of particular health care problems and issues
within the Missouri Medicaid population that each program will address and the
underlying cause(s) of such problems and issues. The proposed Quality Improvement
programs may include, but is not necessarily, limited to the following:

	 	1)	 	New innovative programs and processes.
	 
	 	2)	 	New contracts and/or partnerships being established to enhance the
delivery of health care such as contracts/partnerships with school districts.
	 
	 	3)	 	The continuation, expansion, and/or increase of the current quality
improvement programs as listed in response to 4.7.1 a. and b.

 

 

			
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	 	b.	 	Economic Impact to Missouri:

	 	1)	 	The offeror should provide a description of the proposed services
that will be performed and/or the proposed products that will be provided by
Missourians and/or Missouri products.
	 
	 	2)	 	The offeror should provide a description of the economic impact
returned to the State of Missouri through tax revenue obligations.
	 
	 	3)	 	The offeror should provide a description of the company’s economic
presence within the State of Missouri, including employee status.

 

 

			
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5. PRICING PAGES

	5.1	 	Instructions for Completing Pricing Page: The offeror shall provide firm, fixed prices for
providing all required services for all specified counties within a region pursuant to the
requirements of this Request for Proposal. The offeror must choose to include Pharmacy
services as a MC+ managed care benefit or choose to exclude Pharmacy services from the MC+
managed care benefit package. The offeror shall provide either a firm, fixed Per Member Per
Month (PMPM) Net Capitated Rate for each Category of Aid rate subgroup with Pharmacy services
included in the MC+ managed care benefit package or a firm, fixed PMPM Net Capitated Rate for
each Category of Aid rate subgroup with Pharmacy services excluded from the MC+ managed care
benefit package. All costs associated with providing the required services shall be included
in the offeror’s quoted rates.
	 
	 	 	If the offeror is proposing to provide services for the Western region, the offeror must
complete Pricing Page 5.2.
	 
	 	 	If the offeror is proposing to provide services for the Eastern region, the offeror must
complete Pricing Page 5.3.
	 
	 	 	If the offeror is proposing to provide services for the Central region, the offeror must
complete Pricing Page 5.4.
	 
	5.1.1	 	Requirements promulgated by the federal government stipulate that the State of Missouri can
only contract for services at rates that are actuarially sound. Column 1A on the Pricing
Pages lists the State’s Maximum Net Capitation Rate for each Category of Aid rate subgroup
with Pharmacy service costs included in the MC+ managed care benefit package. Each rate
listed in Column 1A is actuarially sound, compliant with federal regulations, and is the
maximum amount that the State will allow. Column 2A on the Pricing Pages lists the State’s
maximum Net Capitation Rate for each Category of Aid rate subgroup with Pharmacy service costs
excluded from the MC+ managed care benefit package. Each rate listed in the Column 2A is
actuarially sound, compliant with federal regulations, and is the maximum amount that the
State will allow.
	 
	5.1.2	 	To assist the offeror in completion of the Pricing Page, the offeror should use the
information provided in Attachment 9. However, the offeror is advised that this information
should not be used as the only source of information in making pricing decisions. The offeror
is solely responsible for research, preparation, and documentation of the offeror’s proposal
including the offeror’s rates as quoted on the Pricing Page.
	 
	5.1.3	 	The offeror must complete either Column 1B or 2B on the Pricing Page by providing a firm,
fixed PMPM rate for each Category of Aid rate subgroup.

	 	a.	 	The offeror’s firm, fixed rates must not include:

	 	1)	 	Estimates for services which are not the offeror’s responsibility.
	 
	 	2)	 	Cost of marketing as an administrative expense.
	 
	 	3)	 	Cost for Pharmacy services, if the offeror chooses to exclude
Pharmacy services from the MC+ managed care benefit package.

	 	b.	 	The offeror’s firm, fixed rates shall be net of Third Party Liability
recoveries.
	 
	 	c.	 	The offeror should calculate medical expenses by specific Category of Aid rate
subgroup and make adjustments for administrative, profit, and contingency and risk
charges to obtain the proposed Firm Fixed Net Capitation rates.
	 
	 	d.	 	The offeror’s firm, fixed PMPM Net Capitated Rate for each Category of Aid rate
subgroup must not exceed the State’s Maximum Net Capitation Rate listed in Column 1A or
2A. The State shall

 

 

			
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	 	 	 	not consider awarding a contract to an offeror with any quoted rate which exceeds the
State’s Maximum Net Capitation Rate list in Column 1A or 2A.

******The Pricing Pages are a separate link in Excel Format that must be downloaded separately from
the Division of Purchasing and Materials Management’s Internet web site at:
https://www.moolb.mo.gov. There is separate tab in the excel spreadsheet for each region. ******

 

 

			
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EXHIBIT A

MISCELLANEOUS INFORMATION

Organizations for the Blind or Sheltered Workshop

If the offeror qualifies as either a nonprofit organization for the blind or a sheltered workshop,
or if the offeror is proposing to include products and/or services manufactured, produced, or
assembled by such an organization, the offeror should identify the name of the organization in the
space below and should attach all supporting documentation, as referenced elsewhere herein.

	 	 	 
	Name & Address of Organization for Blind/Sheltered
	 	 
	 

	 	 
	Workshop:
	 	 
	 

	 	 

Outside United States

If any products and/or services offered under this RFP are being manufactured or performed at sites
outside the continental United States, the offeror MUST disclose such fact and provide details in
the space below or on an attached page.

	 	 	 	 	 	 	 	 	 
	Are products and/or services
being manufactured or performed
at sites outside the
continental United States?
	 	Yes  __	 	No  __
	 
	 	 	 	 	 	 	 	 
	Describe and provide details:
	 	 	 	 	 	 	 	 

Employee Bidding/Conflict of Interest

Offerors who are employees of the State of Missouri, a member of the General Assembly or a
statewide elected official must comply with Sections 105.450 to 105.458 RSMo regarding conflict of
interest. If the offeror and/or any of the owners of the offeror’s organization are currently an
employee of the State of Missouri, a member of the General Assembly or a statewide elected
official, please provide the following information.

	 	 	 	 	 	 	 	 	 
	Name of State Employee, General Assembly Member, or
Statewide Elected Official:
	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 
	In what office/agency are they
employed?
	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 
	Employment Title:
	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 
	Percentage of ownership interest in offeror’s
organization:
	 	 	____________	%	 	 	 	 

 

 

			
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EXHIBIT B

Certification Regarding

Debarment, Suspension, Ineligibility and Voluntary Exclusion

Lower Tier Covered Transactions

This certification is required by the regulations implementing Executive Order 12549, Debarment and
Suspension, 29 CFR Part 98 Section 98.510, Participants’ responsibilities. The regulations were
published as Part VII of the May 26, 1988, Federal Register (pages 19160-19211).

(BEFORE COMPLETING CERTIFICATION, READ INSTRUCTIONS FOR CERTIFICATION)

	(1)	 	The prospective recipient of Federal assistance funds certifies, by submission of this
proposal, that neither it nor its principals are presently debarred, suspended, proposed for
debarment, declared ineligible, or voluntarily excluded from participation in this transaction
by any Federal department or agency.
	 
	(2)	 	Where the prospective recipient of Federal assistance funds is unable to certify to any of
the statements in this certification, such prospective participant shall attach an explanation
to this proposal.

 

Name and Title of Authorized Representative

	 	 	 
	 

	 	 
	Signature

	 	Date

Instructions for Certification

	1.	 	By signing and submitting this proposal, the prospective recipient of Federal assistance
funds is providing the certification as set out below.
	 
	2.	 	The certification in this clause is a material representation of fact upon which reliance was
placed when this transaction was entered into. If it is later determined that the prospective
recipient of Federal assistance funds knowingly rendered an erroneous certification, in
addition to other remedies available to the Federal Government, the Department of Labor (DOL)
may pursue available remedies, including suspension and/or debarment.
	 
	3.	 	The prospective recipient of Federal assistance funds shall provide immediate written notice
to the person to which this proposal is submitted if at any time the prospective recipient of
Federal assistance funds learns that its certification was erroneous when submitted or has
become erroneous by reason of changed circumstances.
	 
	4.	 	The terms “covered transaction,” “debarred,” “suspended,” “ineligible,” “lower tier covered
transaction,” “participant,” “person,” “primary covered transaction,” “principal,” “proposal,”
and “voluntarily excluded,” as used in this clause, have the meanings set out in the
Definitions and Coverage sections of rules implementing Executive Order 12549. You may
contact the person to which this proposal is submitted for assistance in obtaining a copy of
those regulations.
	 
	5.	 	The prospective recipient of Federal assistance funds agrees by submitting this proposal
that, should the proposed covered transaction be entered into, it shall not knowingly enter
into any lower tier covered transaction with a person who is debarred, suspended, declared
ineligible, or voluntarily excluded from participation in this covered transaction, unless
authorized by the DOL.
	 
	6.	 	The prospective recipient of Federal assistance funds further agrees by submitting this
proposal that it will include the clause titled “Certification Regarding Debarment,
Suspension, Ineligibility and Voluntary Exclusion — Lower Tier Covered Transactions,” without
modification, in all lower tier covered transactions and in all solicitations for lower tier
covered transactions.
	 
	7.	 	A participant in a covered transaction may rely upon a certification of a prospective
participant in a lower tier covered transaction that it is not debarred, suspended,
ineligible, or voluntarily excluded from the covered transaction, unless it knows that the
certification is erroneous. A participant may decide the method and frequency by which it
determines the eligibility of its principals. Each participant may but is not required to
check the List of Parties Excluded from Procurement or Nonprocurement Programs.
	 
	8.	 	Nothing contained in the foregoing shall be construed to require establishment of a system of
records in order to render in good faith the certification required by this clause. The
knowledge and information of a participant is not required to exceed that which is normally
possessed by a prudent person in the ordinary course of business dealings.
	 
	9.	 	Except for transactions authorized under paragraph 5 of these instructions, if a participant
in a covered transaction knowingly enters into a lower tier covered transaction with a person
who is suspended, debarred, ineligible, or voluntary excluded from participation in this
transaction, in addition to other remedies available to the Federal Government, the DOL may
pursue available remedies, including suspension and/or debarment.

 

 

			
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STATE OF MISSOURI

DIVISION OF PURCHASING AND MATERIALS MANAGEMENT

TERMS AND CONDITIONS — REQUEST FOR PROPOSAL

1. TERMINOLOGY/DEFINITIONS

	 	 	Whenever the following words and expressions appear in a Request for Proposal (RFP) document or
any amendment thereto, the definition or meaning described below shall apply.
	 
	a.	 	Agency and/or State Agency means the statutory unit of state government in the State
of Missouri for which the equipment, supplies, and/or services are being purchased by the
Division of Purchasing and Materials Management (DPMM). The agency is also responsible for
payment.
	 
	b.	 	Amendment means a written, official modification to an RFP or to a contract.
	 
	c.	 	Attachment applies to all forms which are included with an RFP to incorporate any
informational data or requirements related to the performance requirements and/or
specifications.
	 
	d.	 	Proposal Opening Date and Time and similar expressions mean the exact deadline
required by the RFP for the receipt of sealed proposals.
	 
	e.	 	Offeror means the person or organization that responds to an RFP by submitting a
proposal with prices to provide the equipment, supplies, and/or services as required in the
RFP document.
	 
	f.	 	Buyer means the procurement staff member of the DPMM. The Contact Person as
referenced herein is usually the Buyer.
	 
	g.	 	Contract means a legal and binding agreement between two or more competent parties,
for a consideration for the procurement of equipment, supplies, and/or services.
	 
	h.	 	Contractor means a person or organization who is a successful offeror as a result of
an RFP and who enters into a contract.
	 
	i.	 	Exhibit applies to forms which are included with an RFP for the offeror to complete
and submit with the sealed proposal prior to the specified opening date and time.
	 
	j.	 	Request for Proposal (RFP) means the solicitation document issued by the DPMM to
potential offerors for the purchase of equipment, supplies, and/or services as described in
the document. The definition includes these Terms and Conditions as well as all Pricing
Pages, Exhibits, Attachments, and Amendments thereto.
	 
	k.	 	May means that a certain feature, component, or action is permissible, but not
required.
	 
	l.	 	Must means that a certain feature, component, or action is a mandatory condition.
	 
	m.	 	Pricing Page(s) applies to the form(s) on which the offeror must state the price(s)
applicable for the equipment, supplies, and/or services required in the RFP. The pricing
pages must be completed and submitted by the offeror with the sealed proposal prior to the
specified proposal opening date and time.
	 
	n.	 	RSMo (Revised Statutes of Missouri) refers to the body of laws enacted by the
Legislature which govern the operations of all agencies of the State of Missouri. Chapter 34
of the statutes is the primary chapter governing the operations of DPMM.
	 
	o.	 	Shall has the same meaning as the word must.
	 
	p.	 	Should means that a certain feature, component and/or action is desirable but not
mandatory.

2. APPLICABLE LAWS AND REGULATIONS

	a.	 	The contract shall be construed according to the laws of the State of Missouri. The
contractor shall comply with all local, state, and federal laws and regulations related to the
performance of the contract to the extent that the same may be applicable.
	 
	b.	 	To the extent that a provision of the contract is contrary to the Constitution or laws of the
State of Missouri or of the United States, the provisions shall be void and unenforceable.
However, the balance of the contract shall remain in force between the parties unless
terminated by consent of both the contractor and the DPMM.
	 
	c.	 	The contractor must be registered and maintain good standing with the Secretary of State of
the State of Missouri and other regulatory agencies, as may be required by law or regulations.
	 
	d.	 	The contractor must timely file and pay all Missouri sales, withholding, corporate and any
other required Missouri tax returns and taxes, including interest and additions to tax.
	 
	e.	 	The exclusive venue for any legal proceeding relating to or arising out of the RFP or
resulting contract shall be in the Circuit Court of Cole County, Missouri.

3. OPEN COMPETITION/REQUEST FOR PROPOSAL DOCUMENT

	a.	 	It shall be the offeror’s responsibility to ask questions, request changes or clarification,
or otherwise advise the DPMM if any language, specifications or requirements of an RFP appear
to be ambiguous, contradictory, and/or arbitrary, or appear to inadvertently restrict or limit
the requirements stated in the RFP to a single source. Any and all communication from
offerors regarding specifications, requirements, competitive proposal process, etc., must be
directed to the buyer from the DPMM, unless the RFP specifically refers the offeror to another
contact. Such communication should be received at least ten calendar days prior to the
official proposal opening date.
	 
	b.	 	Every attempt shall be made to ensure that the offeror receives an adequate and prompt
response. However, in order to maintain a fair and equitable procurement process, all
offerors will be advised, via the issuance of an amendment to the RFP, of any relevant or
pertinent information related to the procurement. Therefore, offerors are advised that unless
specified elsewhere in the RFP, any questions received less than ten calendar days prior to
the RFP opening date may not be answered.
	 
	c.	 	Offerors are cautioned that the only official position of the State of Missouri is that which
is issued by the DPMM in the RFP or an amendment thereto. No other means of communication,
whether oral or written, shall be construed as a formal or official response or statement.
	 
	d.	 	The DPMM monitors all procurement activities to detect any possibility of deliberate
restraint of competition, collusion among offerors, price-fixing by offerors, or any other
anticompetitive conduct by offerors which appears to violate state and federal antitrust laws.
Any suspected violation shall be referred to the Missouri Attorney General’s Office for
appropriate action.
	 
	e.	 	The RFP is available for viewing and downloading on the state’s On-Line Bidding/Vendor
Registration System website. Premium registered offerors are electronically notified of the
proposal opportunity based on the information maintained in the State of Missouri’s vendor
database. If a Premium registered offeror’s e-mail address is incorrect, the offeror must
update the e-mail address themselves on the state’s On-Line Bidding/Vendor Registration System
website.
	 
	f.	 	The DPMM reserves the right to officially amend or cancel an RFP after issuance. Premium
registered offerors who received e-mail notification of the proposal opportunity when the RFP
was established and Premium registered offerors who have responded to the RFP on-line prior to
an amendment being issued will receive e-mail notification of the amendment(s). Premium
registered offerors who received e-mail notification of the proposal opportunity when the RFP
was established and Premium registered offerors who have responded to the proposal on-line
prior to a cancellation being issued will receive e-mail notification of a cancellation issued
prior to the exact closing time and date specified in the RFP.

4. PREPARATION OF PROPOSALS

	a.	 	Offerors must examine the entire RFP carefully. Failure to do so shall be at offeror’s risk.
	 
	b.	 	Unless otherwise specifically stated in the RFP, all specifications and requirements
constitute minimum requirements. All proposals must meet or exceed the stated specifications
and requirements.
	 
	c.	 	Unless otherwise specifically stated in the RFP, any manufacturer names, trade names, brand
names, information and/or catalog numbers listed in a specification and/or requirement are for
informational purposes only and are not intended to limit competition. The offeror may offer
any brand which meets or exceeds the specification for any item, but must state the
manufacturer’s name and model number for any such brands in the proposal. In addition, the
offeror shall explain, in

 

 

			
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	 	 	detail, (1) the reasons why the proposed equivalent meets or exceeds the specifications and/or
requirements and (2) why the proposed equivalent should not be considered an exception thereto.
Proposals which do not comply with the requirements and specifications are subject to rejection
without clarification.
	 
	d.	 	Proposals lacking any indication of intent to offer an alternate brand or to take an
exception shall be received and considered in complete compliance with the specifications and
requirements as listed in the RFP.
	 
	e.	 	In the event that the offeror is an agency of state government or other such political
subdivision which is prohibited by law or court decision from complying with certain
provisions of an RFP, such a offeror may submit a proposal which contains a list of statutory
limitations and identification of those prohibitive clauses which will be modified via a
clarification conference between the DPMM and the offeror, if such offeror is selected for
contract award. The clarification conference will be conducted in order to agree to language
that reflects the intent and compliance of such law and/or court order and the RFP. Any such
offeror needs to include in the proposal, a complete list of statutory references and
citations for each provision of the RFP which is affected by this paragraph.
	 
	f.	 	All equipment and supplies offered in a proposal must be new, of current production, and
available for marketing by the manufacturer unless the RFP clearly specifies that used,
reconditioned, or remanufactured equipment and supplies may be offered.
	 
	g.	 	Prices shall include all packing, handling and shipping charges FOB destination, freight
prepaid and allowed unless otherwise specified in the RFP.
	 
	h.	 	Prices offered shall remain valid for 90 days from proposal opening unless otherwise
indicated. If the proposal is accepted, prices shall be firm for the specified contract
period.
	 
	i.	 	Any foreign offeror not having an Employer Identification Number assigned by the United
States Internal Revenue Service (IRS) must submit a completed IRS Form W-8 prior to or with
the submission of their proposal in order to be considered for award.

5. SUBMISSION OF PROPOSALS

	a.	 	Proposals may be submitted by delivery of a hard copy to the DPMM office. Electronic
submission of proposals by Premium registered offerors through the State of Missouri’s On-Line
Bidding/Vendor Registration System website is not available unless stipulated in the RFP.
Delivered proposals must be sealed in an envelope or container, and received in the DPMM
office located at 301 West High St, Rm 630 in Jefferson City, MO no later than the exact
opening time and date specified in the RFP. All proposals must (1) be submitted by a duly
authorized representative of the offeror’s organization, (2) contain all information required
by the RFP, and (3) be priced as required. Hard copy proposals may be mailed to the DPMM post
office box address. However, it shall be the responsibility of the offeror to ensure their
proposal is in the DPMM office (address listed above) no later than the exact opening time and
date specified in the RFP.
	 
	b.	 	The sealed envelope or container containing a proposal should be clearly marked on the
outside with (1) the official RFP number and (2) the official opening date and time.
Different proposals should not be placed in the same envelope, although copies of the same
proposal may be placed in the same envelope.
	 
	c.	 	A proposal submitted electronically by a Premium registered offeror may be modified on-line
prior to the official opening date and time. A proposal which has been delivered to the DPMM
office, may be modified by signed, written notice which has been received by the DPMM prior to
the official opening date and time specified. A proposal may also be modified in person by
the offeror or its authorized representative, provided proper identification is presented
before the official opening date and time. Telephone or telegraphic requests to modify a
proposal shall not be honored.
	 
	d.	 	A proposal submitted electronically by a Premium registered offeror may be canceled on-line
prior to the official opening date and time. A proposal which has been delivered to the DPMM
office, may only be withdrawn by a signed, written notice or facsimile which has been received
by the DPMM prior to the official opening date and time specified. A proposal may also be
withdrawn in person by the offeror or its authorized representative, provided proper
identification is presented before the official opening date and time. Telephone, e-mail, or
telegraphic requests to withdraw a proposal shall not be honored.
	 
	e.	 	When submitting a proposal electronically, the Premium registered offeror indicates
acceptance of all RFP terms and conditions by clicking on the “Submit” button on the
Electronic Bid Response Entry form. Offerors delivering a hard copy proposal to DPMM must
sign and return the RFP cover page or, if applicable, the cover page of the last amendment
thereto in order to constitute acceptance by the offeror of all RFP terms and conditions.
Failure to do so may result in rejection of the proposal unless the offeror’s full compliance
with those documents is indicated elsewhere within the offeror’s response.

6. PROPOSAL OPENING

	a.	 	Proposal openings are public on the opening date and at the opening time specified on the RFP
document. Only the names of the respondents shall be read at the proposal opening. Premium
registered vendors may view the same proposal response information on the state’s On-Line
Bidding/Vendor Registration System website. The contents of the responses shall not be
disclosed at this time.
	 
	b.	 	Proposals which are not received in the DPMM office prior to the official opening date and
time shall be considered late, regardless of the degree of lateness, and normally will not be
opened. Late proposals may only be opened under extraordinary circumstances in accordance
with 1 CSR 40-1.050.

7. PREFERENCES

	a.	 	In the evaluation of proposals, preferences shall be applied in accordance with Chapter 34
RSMo. Contractors should apply the same preferences in selecting subcontractors.
	 
	b.	 	By virtue of statutory authority, a preference will be given to materials, products,
supplies, provisions and all other articles produced, manufactured, made or grown within the
State of Missouri and to all firms, corporations or individuals doing business as Missouri
firms, corporations or individuals. Such preference shall be given when quality is equal or
better and delivered price is the same or less.
	 
	c.	 	In accordance with Executive Order 05-30, contractors are encouraged to utilize certified
minority and women-owned businesses in selecting subcontractors.

8. EVALUATION/AWARD

	a.	 	Any clerical error, apparent on its face, may be corrected by the buyer before contract
award. Upon discovering an apparent clerical error, the buyer shall contact the offeror and
request clarification of the intended proposal. The correction shall be incorporated in the
notice of award. Examples of apparent clerical errors are: 1) misplacement of a decimal
point; and 2) obvious mistake in designation of unit.
	 
	b.	 	Any pricing information submitted by an offeror shall be subject to evaluation if deemed by
the DPMM to be in the best interest of the State of Missouri.
	 
	c.	 	The offeror is encouraged to propose price discounts for prompt payment or propose other
price discounts that would benefit the State of Missouri. However, unless otherwise specified
in the RFP, pricing shall be evaluated at the maximum potential financial liability to the
State of Missouri.
	 
	d.	 	Awards shall be made to the offeror whose proposal (1) complies with all mandatory
specifications and requirements of the RFP and (2) is the lowest and best proposal,
considering price, responsibility of the offeror, and all other evaluation criteria specified
in the RFP and any subsequent negotiations and (3) complies with Sections 34.010 and 34.070
RSMo and Executive Order 04-09.
	 
	e.	 	In the event all offerors fail to meet the same mandatory requirement in an RFP, DPMM
reserves the right, at its sole discretion, to waive that requirement for all offerors and to
proceed with the evaluation. In addition, the DPMM reserves the right to waive any minor
irregularity or technicality found in any individual proposal.
	 
	f.	 	The DPMM reserves the right to reject any and all proposals.
	 
	g.	 	When evaluating a proposal, the State of Missouri reserves the right to consider relevant
information and fact, whether gained from a proposal, from a offeror, from offeror’s
references, or from any other source.
	 
	h.	 	Any information submitted with the proposal, regardless of the format or placement of such
information, may be considered in making decisions related to the responsiveness and merit of
a proposal and the award of a contract.
	 
	i.	 	Negotiations may be conducted with those offerors who submit potentially acceptable
proposals. Proposal revisions may be permitted for the purpose of obtaining best and final
offers. In conducting negotiations, there shall be no disclosure of any information submitted
by competing offerors.

 

 

			
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	j.	 	Any award of a contract shall be made by notification from the DPMM to the successful
offeror. The DPMM reserves the right to make awards by item, group of items, or an all or none
basis. The grouping of items awarded shall be determined by DPMM based upon factors such as
item similarity, location, administrative efficiency, or other considerations in the best
interest of the State of Missouri.
	 
	k.	 	Pursuant to Section 610.021 RSMo, proposals and related documents shall not be available for
public review until after a contract is executed or all proposals are rejected.
	 
	l.	 	The DPMM posts all proposal results on the On-line Bidding/Vendor Registration System website
for Premium registered offerors to view for a reasonable period after proposal award and
maintains images of all proposal file material for review. Offerors who include an e-mail
address with their proposal will be notified of the award results via e-mail.
	 
	m.	 	The DPMM reserves the right to request clarification of any portion of the offeror’s response
in order to verify the intent of the offeror. The offeror is cautioned, however, that its
response may be subject to acceptance or rejection without further clarification.
	 
	n.	 	Any proposal award protest must be received within ten (10) calendar days after the date of
award in accordance with the requirements of 1 CSR 40-1.050 (10).
	 
	o.	 	The final determination of contract(s) award shall be made by DPMM.

9. CONTRACT/PURCHASE ORDER

	a.	 	By submitting a proposal, the offeror agrees to furnish any and all equipment, supplies
and/or services specified in the RFP, at the prices quoted, pursuant to all requirements and
specifications contained therein.
	 
	b.	 	A binding contract shall consist of: (1) the RFP, amendments thereto, and/or Best and Final
Offer (BAFO) request(s) with RFP changes/additions, (2) the contractor’s proposal including
the contractor’s BAFO, and (3) DPMM’s acceptance of the proposal by “notice of award” or by
“purchase order.”
	 
	c.	 	A notice of award issued by the State of Missouri does not constitute an authorization for
shipment of equipment or supplies or a directive to proceed with services. Before providing
equipment, supplies and/or services for the State of Missouri, the contractor must receive a
properly authorized purchase order unless the purchase is equal to or less than $3,000. State
purchases equal to or less than $3,000 may be processed with a purchase order or other form of
authorization given to the contractor at the discretion of the state agency.
	 
	d.	 	The contract expresses the complete agreement of the parties and performance shall be
governed solely by the specifications and requirements contained therein. Any change, whether
by modification and/or supplementation, must be accomplished by a formal contract amendment
signed and approved by and between the duly authorized representative of the contractor and
the DPMM or by a modified purchase order prior to the effective date of such modification.
The contractor expressly and explicitly understands and agrees that no other method and/or no
other document, including correspondence, acts, and oral communications by or from any person,
shall be used or construed as an amendment or modification.

10. INVOICING AND PAYMENT

	a.	 	The State of Missouri does not pay state or federal taxes unless otherwise required under law
or regulation.
	 
	b.	 	The statewide financial management system has been designed to capture certain receipt and
payment information. For each purchase order received, an invoice must be submitted that
references the purchase order number and must be itemized in accordance with items listed on
the purchase order. Failure to comply with this requirement may delay processing of invoices
for payment.
	 
	c.	 	The contractor shall not transfer any interest in the contract, whether by assignment or
otherwise, without the prior written consent of the DPMM.
	 
	d.	 	Payment for all equipment, supplies, and/or services required herein shall be made in arrears
unless otherwise indicated in the RFP.
	 
	e.	 	The State of Missouri assumes no obligation for equipment, supplies, and/or services shipped
or provided in excess of the quantity ordered. Any unauthorized quantity is subject to the
state’s rejection and shall be returned at the contractor’s expense.
	 
	f.	 	All invoices for equipment, supplies, and/or services purchased by the State of Missouri
shall be subject to late payment charges as provided in Section 34.055 RSMo.
	 
	g.	 	The State of Missouri reserves the right to purchase goods and services using the state
purchasing card.

11. DELIVERY

	 	 	Time is of the essence. Deliveries of equipment, supplies, and/or services must be made no
later than the time stated in the contract or within a reasonable period of time, if a
specific time is not stated.

12. INSPECTION AND ACCEPTANCE

	a.	 	No equipment, supplies, and/or services received by an agency of the state pursuant to a
contract shall be deemed accepted until the agency has had reasonable opportunity to inspect
said equipment, supplies, and/or services.
	 
	b.	 	All equipment, supplies, and/or services which do not comply with the specifications and/or
requirements or which are otherwise unacceptable or defective may be rejected. In addition,
all equipment, supplies, and/or services which are discovered to be defective or which do not
conform to any warranty of the contractor upon inspection (or at any later time if the defects
contained were not reasonably ascertainable upon the initial inspection) may be rejected.
	 
	c.	 	The State of Missouri reserves the right to return any such rejected shipment at the
contractor’s expense for full credit or replacement and to specify a reasonable date by which
replacements must be received.
	 
	d.	 	The State of Missouri’s right to reject any unacceptable equipment, supplies, and/or services
shall not exclude any other legal, equitable or contractual remedies the state may have.

13. WARRANTY

	a.	 	The contractor expressly warrants that all equipment, supplies, and/or services provided
shall: (1) conform to each and every specification, drawing, sample or other description
which was furnished to or adopted by the DPMM, (2) be fit and sufficient for the purpose
expressed in the RFP, (3) be merchantable, (4) be of good materials and workmanship, and (5)
be free from defect.
	 
	b.	 	Such warranty shall survive delivery and shall not be deemed waived either by reason of the
state’s acceptance of or payment for said equipment, supplies, and/or services.

14. CONFLICT OF INTEREST

	a.	 	Officials and employees of the state agency, its governing body, or any other public
officials of the State of Missouri must comply with Sections 105.452 and 105.454 RSMo
regarding conflict of interest.
	 
	b.	 	The contractor hereby covenants that at the time of the submission of the proposal the
contractor has no other contractual relationships which would create any actual or perceived
conflict of interest. The contractor further agrees that during the term of the contract
neither the contractor nor any of its employees shall acquire any other contractual
relationships which create such a conflict.

15. REMEDIES AND RIGHTS

 

 

			
	B3Z06118
	 	Page 125

	a.	 	No provision in the contract shall be construed, expressly or implied, as a waiver by the
State of Missouri of any existing or future right and/or remedy available by law in the event
of any claim by the State of Missouri of the contractor’s default or breach of contract.
	 
	b.	 	The contractor agrees and understands that the contract shall constitute an assignment by the
contractor to the State of Missouri of all rights, title and interest in and to all causes of
action that the contractor may have under the antitrust laws of the United States or the State
of Missouri for which causes of action have accrued or will accrue as the result of or in
relation to the particular equipment, supplies, and/or services purchased or procured by the
contractor in the fulfillment of the contract with the State of Missouri.

16. CANCELLATION OF CONTRACT

	a.	 	In the event of material breach of the contractual obligations by the contractor, the DPMM
may cancel the contract. At its sole discretion, the DPMM may give the contractor an
opportunity to cure the breach or to explain how the breach will be cured. The actual cure
must be completed within no more than 10 working days from notification, or at a minimum the
contractor must provide DPMM within 10 working days from notification a written plan detailing
how the contractor intends to cure the breach.
	 
	b.	 	If the contractor fails to cure the breach or if circumstances demand immediate action, the
DPMM will issue a notice of cancellation terminating the contract immediately.
	 
	c.	 	If the DPMM cancels the contract for breach, the DPMM reserves the right to obtain the
equipment, supplies, and/or services to be provided pursuant to the contract from other
sources and upon such terms and in such manner as the DPMM deems appropriate and charge the
contractor for any additional costs incurred thereby.
	 
	d.	 	The contractor understands and agrees that funds required to fund the contract must be
appropriated by the General Assembly of the State of Missouri for each fiscal year included
within the contract period. The contract shall not be binding upon the state for any period
in which funds have not been appropriated, and the state shall not be liable for any costs
associated with termination caused by lack of appropriations.

17. COMMUNICATIONS AND NOTICES

	 	 	Any notice to the contractor shall be deemed sufficient when deposited in the United States
mail postage prepaid, transmitted by facsimile, transmitted by e-mail or hand-carried and
presented to an authorized employee of the contractor.

18. BANKRUPTCY OR INSOLVENCY

	a.	 	Upon filing for any bankruptcy or insolvency proceeding by or against the contractor, whether
voluntary or involuntary, or upon the appointment of a receiver, trustee, or assignee for the
benefit of creditors, the contractor must notify the DPMM immediately.
	 
	b.	 	Upon learning of any such actions, the DPMM reserves the right, at its sole discretion, to
either cancel the contract or affirm the contract and hold the contractor responsible for
damages.

19. INVENTIONS, PATENTS AND COPYRIGHTS

	 	 	The contractor shall defend, protect, and hold harmless the State of Missouri, its officers,
agents, and employees against all suits of law or in equity resulting from patent and
copyright infringement concerning the contractor’s performance or products produced under
the terms of the contract.

20. NON-DISCRIMINATION AND AFFIRMATIVE ACTION

	 	 	In connection with the furnishing of equipment, supplies, and/or services under the
contract, the contractor and all subcontractors shall agree not to discriminate against
recipients of services or employees or applicants for employment on the basis of race,
color, religion, national origin, sex, age, disability, or veteran status. If the
contractor or subcontractor employs at least 50 persons, they shall have and maintain an
affirmative action program which shall include:

	a.	 	A written policy statement committing the organization to affirmative action and assigning
management responsibilities and procedures for evaluation and dissemination;
	 
	b.	 	The identification of a person designated to handle affirmative action;
	 
	c.	 	The establishment of non-discriminatory selection standards, objective measures to analyze
recruitment, an upward mobility system, a wage and salary structure, and standards applicable
to layoff, recall, discharge, demotion, and discipline;
	 
	d.	 	The exclusion of discrimination from all collective bargaining agreements; and
	 
	e.	 	Performance of an internal audit of the reporting system to monitor execution and to provide
for future planning.
	 
	 	 	If discrimination by a contractor is found to exist, the DPMM shall take appropriate
enforcement action which may include, but not necessarily be limited to, cancellation of the
contract, suspension, or debarment by the DPMM until corrective action by the contractor is
made and ensured, and referral to the Attorney General’s Office, whichever enforcement
action may be deemed most appropriate.

21. AMERICANS WITH DISABILITIES ACT

	 	 	In connection with the furnishing of equipment, supplies, and/or services under the
contract, the contractor and all subcontractors shall comply with all applicable
requirements and provisions of the Americans with Disabilities Act (ADA).

22. FILING AND PAYMENT OF TAXES

	 	 	The commissioner of administration and other agencies to which the state purchasing law applies
shall not contract for goods or services with a vendor if the vendor or an affiliate of the
vendor makes sales at retail of tangible personal property or for the purpose of storage, use, or
consumption in this state but fails to collect and properly pay the tax as provided in chapter
144, RSMo. For the purposes of this section, “affiliate of the vendor” shall mean any person or
entity that is controlled by or is under common control with the vendor, whether through stock
ownership or otherwise. Therefore offeror’s failure to maintain compliance with chapter 144,
RSMo may eliminate their proposal from consideration for award.

23. TITLES

	 	 	Titles of paragraphs used herein are for the purpose of facilitating reference only and shall not
be construed to infer a contractual construction of language.

Revised 01/03/06

 

 

					
	 
	 	
	 	

NOTICE OF AWARD

State Of Missouri

Office Of Administration

Division Of Purchasing And Materials Management

PO Box 809

Jefferson City, MO 65102

http://www.oa.mo.gov/purch

	 	 	 
	CONTRACT NUMBER
	 	CONTRACT TITLE
	 
	 	 
	C306118003
	 	Medicaid Managed Care – Central, Eastern, and
	 
	 	Western Regions
	 
	 	 
	AMENDMENT NUMBER
	 	CONTRACT PERIOD
	 
	 	 
	Amendment #001
	 	July 1, 2006 through June 30, 2007
	 
	 	 
	REQUISITION NUMBER
	 	VENDOR NUMBER
	 
	 	 
	NR 886 25757001820
	 	4317439020 2
	 
	 	 
	CONTRACTOR NAME AND ADDRESS
	 	STATE AGENCY’S NAME AND ADDRESS
	 
	 	 
	Mercy CarePlus
	 	Department of Social Services
	10123 Corporate Square Drive
	 	Division of Medical Services
	St. Louis MO 63132
	 	PO Box 6500
	 
	 	Jefferson City MO 65102-6500
	 
	 	 
	ACCEPTED BY THE STATE OF MISSOURI AS FOLLOWS:
	 
	 	 
	Contract C306118003 is hereby amended pursuant to the attached Amendment #001 dated 07/31/06.
	 
	 	 
	BUYER
	 	BUYER CONTACT INFORMATION
	 
	 	E-Mail: laura.ortmeyer@oa.mo.gov
	Laura Ortmeyer
	 	Phone: (573) 751-4579    Fax: (573) 526-9817
	 
	 	 
	SIGNATURE OF BUYER
	 	DATE
	 
	 	 
	/s/ Laura Ortmeyer
	 	8/10/06
	 
	 	 
	DIRECTOR OF PURCHASING AND MATERIALS MANAGEMENT
	 	 
	/s/ James Miluski
	 	 

 

 

	 	 	 
	

	 	STATE OF MISSOURI
OFFICE OF ADMINISTRATION
DIVISION OF
PURCHASING AND MATERIALS MANAGEMENT (DPMM)
CONTRACT AMENDMENT
	 

	 	

	 	 	 
	AMENDMENT NO.: 001

	 	REQ NO.: NR 886 25757001820
	CONTRACT NO.: C306118003

	 	BUYER: Laura Ortmeyer
	TITLE: Medicaid Managed Care — Central, Eastern, & Western Regions

	 	PHONE NO.: (573) 751-4579
	ISSUE DATE: 07/24/06

	 	E-MAIL: Laura.Ortmeyer@oa.mo.gov

TO: Alliance for Community Health

RETURN AMENDMENT NO LATER THAN: August 4, 2006 AT 5:00 PM CENTRAL TIME

RETURN AMENDMENT TO:

	 	 	 	 	 	 	 
	(U.S. Mail)	 	 	 	(Courier Service)
	Div of Purchasing & Matls Mgt (DPMM)
	 	OR
	 	Div of Purchasing & Matls Mgt (DPMM)
	 

	 	 	 	 	 	 
	PO BOX 809
	 	 	 	301 WEST HIGH STREET, ROOM 630
	JEFFERSON CITY MO 65102-0809
	 	 	 	JEFFERSON CITY MO 65101

OR FAX TO: (573) 526-9817 (either mail or fax, not both)

DELIVER SUPPLIES/SERVICES FOB (Free On Board) DESTINATION TO THE FOLLOWING ADDRESS:

	 	 	 	 	 
	 

	 	Department of Social Service	 	 
	 

	 	Division of Medical Services	 	 
	 

	 	P.O. Box 6500	 	 
	 

	 	Jefferson City, MO 65102-6500
	 	RCVD AUG 1’06 AM 9:44 OA-DPMM
	 
	 	 	 	 
	 

	 	SIGNATURE REQUIRED	 	 

	 	 	 
	DOING BUSINESS AS (DBA) NAME

	 	LEGAL NAME OF
ENTITY/INDIVIDUAL FILED
WITH IRS FOR THIS TAX ID NO.
	 
	 	 
	Mercy CarePlus

	 	Alliance for Community Health
	 
	 	 
	MAILING ADDRESS

	 	IRS FORM 1099 MAILING ADDRESS
	 
	 	 
	10123 Corporate Square DR.

	 	10123 Corporate Square DR.
	 
	 	 
	CITY, STATE, ZIP CODE

	 	CITY, STATE, ZIP CODE
	 
	 	 
	St. Louis, MO 63132

	 	St. Louis, MO 63132

	 	 	 
	CONTACT PERSON

	 	EMAIL ADDRESS
	 
	 	 
	Jerry Linder/Marcia Albridge

	 	Malbridge@mercycareplus.com

jlinder@mercycareplus.com
	 
	 	 
	PHONE NUMBER

	 	FAX NUMBER
	 
	 	 
	314- 432-9300

	 	314-994-9398

	 	 	 	 	 
	TAXPAYER ID NUMBER (TIN)

	 	TAXPAYER ID (TIN) TYPE (CHECK ONE)
	 	VENDOR NUMBER (IF KNOWN)
	 
	 	 
	43-1743902

	 	þ FEIN       o SSN
	 	43-17439020 2

	 	 	 	 	 	 	 	 	 	 	 
	VENDOR TAX FILING TYPE WITH IBS (CHECK ONE)	 	(NOTE: LLC IS NOT A
VALID TAX FILING TYPE.)

	 
	þ Corporation

	 	o Individual
	 	o State/Local Government
	 	o Partnership
	 	o Sole Proprietor
	 	o Other                    
	 

	 	 	 
	AUTHORIZED SIGNATURE

	 	DATE
	 
	/s/ Jerry Linder

	 	7/31/06
	 
	 	 
	PRINTED NAME

	 	TITLE
	 
	Jerry Linder

	 	CEO

 

 

			
	Contract C306118003
	 	Page 2

AMENDMENT #001 TO CONTRACT C306118003

	 	 	 
	CONTRACT TITLE:

	 	Medicaid Managed Care — Central, Eastern, & Western
Regions
	 
	CONTRACT PERIOD:

	 	July 1, 2006 through June 30, 2007

In accordance with the attached Agreement and Consent document and effective July 1, 2006, the
State of Missouri hereby assigns the above-referenced contract from Alliance for Community Health
LLC d/b/a Community CarePlus (4317439020 1) to Mercy CarePlus. All references to Community CarePlus
or CCP shall be replaced with Mercy CarePlus.

As a result of such assignment, the response to section 4.4.2 a. is replaced with the following:

The name and address of each person with an ownership or controlling interest of 5% or more in
Mercy CarePlus is as follows:

	 	•	 	CCP Acquisition Limited, a MO Corporation (“CAL”) has a 40.050 %
direct ownership interest. CCP Acquisition Limited is located at 101
S. Hanley, Suite 1250, Clayton, MO 63105
	 
	 	•	 	Mercy Health Plans, Inc. (MHP), a Delaware corporation, has a 50%
direct ownership interest. MHP is located at 14528 South Outer 40
Drive, Chesterfield MO 63017.

The above documents those entities with ownership of 5% or greater.

Missouri Physicians Associates, a MO Domestic Insurance Company (“MPA”) owns all of the capital
stock of CAL; therefore, for purposes of this response, MPA is deemed to own an indirect
interest of ownership or control in Mercy CarePlus. The address for MPA is 101 S. Hanley, Suite
1250, Clayton, MO 63105.

Also, the attached documentation from the Missouri Department of Insurance dated June 23, 2006 is
included as an addition to Attachment 1 (reference the response to 4.5.1).

Additionally, the response to section 4.4.2 e and the originally submitted Attachment 10 is
replaced with the Revised Attachment 10 attached hereto.

All other terms, conditions and provisions of the contract, including all prices, shall remain the
same and apply hereto.

The contractor shall sign and return this document, on or before the date indicated, signifying
acceptance of the amendment.

 

 

			
	Contract C306118003
	 	Page 3

AGREEMENT AND CONSENT

TO ASSIGNMENT OF CONTRACT

	 	 	 	 	 
	ALLIANCE FOR COMMUNITY HEALTH

	 	Alliance for community Health	 	 
	dba COMMUNITY CAREPLUS

	 	dba : Mercy CarePlus	 	 
	10123 CORPORATE SQUARE DRIVE
	 	 	 	 
	ST LOUIS, MO 63132

	 	 

	 	     
	 

	 	 	 	 
	(Assignor)

	 	(Assignee)	 	 

RE:       Contract C306118003

The Assignor, as named above, assigns the contract in its entirety to the Assignee, as named
above.

The Assignee shall honor and comply with all terms and conditions, requirements and
specifications of the contract, and hereby entitles the State of Missouri to performance by
Assignee of all obligations under the contract. This assignment does not entitle the
Assignee to receive payment in any amount above that which the Assignor would otherwise
receive. In addition, the Assignee releases the State of Missouri from all responsibilities
for payment made previously to the Assignor pursuant to the contract.

The Assignee agrees that any payments made by the State of Missouri pursuant to the
contract, including all payments assigned to the Assignee, shall be contingent upon the
performance of the Assignee in accordance with all terms and conditions, requirements and
specifications of the contract, and the approval and acceptance of such performance by the
State of Missouri.

This Agreement and Consent shall not be final until it is incorporated into the subject
contract by formal amendment subject to approval and acceptance by the State of Missouri,
Division of Purchasing and Materials Management.

IN WITNESS THEREOF, the parties hereto have executed this Agreement and Consent on the date
as stated below.

	 	 	 	 	 	 	 	 	 	 	 
	(ASSIGNOR)	 	 	 	(ASSIGNEE)	 	 
	 	 	 	 	 	 	 	 	 	 	 
	BY:

	 	 	 	 	 	BY:
	 	/s/ Jerry Linder	 	 
	NAME:

	 	 

	 	 
	 	NAME:
	 	 

Jerry Linder
	 	 
	 

	 	 	 	 	 	 	 	 	 	 
	TITLE:

	 	 	 	 	 	TITLE:
	 	CEO	 	 
	 

	 	 	 	 	 	 	 	 	 	 
	DATE:

	 	 	 	 	 	DATE:
	 	7/31/06	 	 
	 

	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	FEIN:
	 	43-1743902	 	 

 

 

	 	 	 	 	 
	

	 	STATE OF MISSOURI

OFFICE OF ADMINISTRATION

DIVISION OF PURCHASING AND MATERIALS MANAGEMENT (DPMM)

CONTRACT AMENDMENT

	 	

	 	 	 
	AMENDMENT
NO.: 002

	 	REQ NO.: NR 886 25757002046
	CONTRACT
NO.: C306118003

	 	BUYER: Laura Ortmeyer
	TITLE: Medicaid
Managed Care — Central, Eastern, and Western Regions 	 	PHONE NO.:
(573)751-4579
	ISSUE
DATE: 07/27/06

	 	E-MAIL: Laura.Ortmeyer@oa.mo.gov

TO:
MERCY CARE PLUS

RETURN
AMENDMENT NO LATER THAN: August 14, 2006 AT 5:00 PM CENTRAL
TIME

RETURN
AMENDMENT TO:

	 	 	 	 	 
	(U.S. Mail)	 	 	 	(Courier Service)
	
Div of Purchasing & Matls Mgt (DPMM)

	 	OR
	 	Div of Purchasing & Matls
Mgt (DPMM)
	PO
BOX 809

	 	 	 	301 WEST HIGH STREET, ROOM
630
	JEFFERSON
CITY MO 65102-0809

	 	 	 	JEFFERSON CITY MO 65101

OR FAX
TO: (573) 526-9817 (either mail or fax, not both)

DELIVER SUPPLIES/SERVICES FOB (Free On Board) DESTINATION TO THE FOLLOWING ADDRESS:

Department of Social Service

Division of Medical Services

P.O. Box 6500

Jefferson City, MO 65102-6500

SIGNATURE REQUIRED

	 	 	 
	DOING BUSINESS AS (DBA) NAME

	 	LEGAL NAME OF ENTITY/INDIVIDUAL
FILED WITH IRS FOR THIS TAX ID NO.
	 
	 	 
	MAILING ADDRESS

	 	IRS FORM 1099 MAILING ADDRESS
	 
	 	 
	CITY, STATE, ZIP CODE

	 	CITY, STATE, ZIP CODE

	 	 	 
	CONTACT PERSON

	 	EMAIL ADDRESS
	 
	 	 
	PHONE NUMBER

	 	FAX NUMBER

	 	 	 	 	 
	TAXPAYER ID NUMBER (TIN)

	 	TAXPAYER ID
(TIN) TYPE (CHECK ONE)
	 	VENDOR NUMBER (IF KNOWN)
	 

	 	o
 FEIN      o SSN	 	 

			
	(VENDOR TAX FILING TYPE WITH IRS (CHECK ONE)
	 	(NOTE: LLC IS NOT A VALID TAX FILING TYPE.)

o
Corporation     o
Individual     o
State/Local Government     o
Partnership     o
Sole
Proprietor     
o
Other                    

	 	 	 
	AUTHORIZED SIGNATURE

	 	DATE
	 
	 	 
	PRINTED NAME

	 	TITLE

 

 

		
	Contract C306118003	Page 2

AMENDMENT
#002 TO CONTRACT C306118003

	 	      	 
	CONTRACT TITLE:

	 	Medicaid Managed Care — Central, Eastern, and Western Regions
	 
	 	 
	CONTRACT PERIOD:

	 	July 1, 2006 through June 30, 2007

The State of Missouri hereby desires to amend the above-referenced contract, as follows, effective
July 1,2006:

	 	1.	 	Paragraph 2.4.9 is hereby amended as follows:

	 	 	2.4.9	 	The health plan shall maintain the fee schedule for office visit services
and dental services located in Attachment 14 at no lower than the Medicaid
fee-for-service fee schedule in effect at the time
of service.

	 	2.	 	Paragraph 2.7.l 1. is hereby amended as follows:

	 	 	2.7.1 l.	 	Optical services include one comprehensive or one limited eye examination
every two years for refractive error, services related to trauma or treatment of
disease/medical condition (including eye prosthetics), and one pair eyeglasses
following cataract surgery.

	 	3.	 	Paragraphs 2.7.1 r. is hereby amended as follows:

	 	 	2.7.1 r.	 	Durable medical equipment limited to: prosthetic devices (with the
exception of artificial larynx), respiratory equipment and oxygen (with the exception
of CPAP, BiPAP, and nebulizers), wheelchairs (including accessories and batteries),
diabetic supplies and equipment, and ostomy supplies. Members with
Home Health Plan
of Care receive all medically necessary durable medical equipment services
during the plan of care coverage period.

	 	4.	 	Paragraph 2.7.2 is hereby amended as follows:

	 	 	2.7.2	 	The health plan shall include all the services specified in the comprehensive
benefit package with the exception of non-emergency medical transportation (NEMT) for
uninsured children in ME Codes 71-75 (Refer to Attachment 1, COA 5) and children in
state custody with the following ME Codes 08, 52, 57, and 64 (Refer to Attachment 1,
COA 4).

	 	5.	 	Paragraph 2.7.3 c is hereby amended as follows:

	 	 	2.7.3 c.	 	 Optical services for children under age 21 include one comprehensive or one
limited eye examination per year for refractive error, eyeglasses, and HCY/EPSDT optical
screens and services. Optical services for pregnant women age 21 and over with ME codes
18, 43, 44, 45, or 61 include one comprehensive or one limited eye examination per year
for refractive error. Eyeglasses (except the one pair following cataract surgery covered
by the health plan) for these pregnant women are covered through the Fee for Service
program.

	 	6.	 	Paragraph 2.7.3 e. is hereby amended as follows

	 	 	2.7.3 e.	 	 Durable medical equipment (including but not limited to: orthotic devices,
artificial larynx, enteral and parenteral nutrition, walkers, CPAP, BiPAP, and
nebulizers);

	 	7.	 	Paragraph 2.12.7 is hereby amended as follows:

 

 

			
	Contract C306118003
	 	Page 3

	 	 	2.12.7	 	Pharmacy Services: Pharmacy services (including physician injections) not included
in the health plan’s awarded proposal shall be reimbursed by the state agency on a
fee-for-service basis according to the terms and conditions of the Medicaid program.

	 	8.	 	Attachment 3 is hereby revised.
	 
	 	9.	 	Attachment 6 is hereby revised.
	 
	 	10.	 	Attachment 12 is hereby revised.
	 
	 	11.	 	Attachment 14 is hereby revised.

The contractor shall indicate in Column 2 on the attached Pricing page, any changes to the firm
fixed prices of the contract for performing the required services in accordance with the terms,
conditions, and provisions of the contract, including the above stated changes. The contractor’s
firm, fixed PMPM Net Capitation Rate for Each Category of Aid (COA) Rate subgroup must not exceed
the State’s Maximum Net Capitation Rate Listed in Column 1.

All other terms, conditions and provisions of the contract shall remain the same and apply hereto.

The contractor shall sign and return this document, on or before the date indicated, signifying
acceptance of the amendment.

 

 

REVISED ATTACHMENT 3

MANAGED CARE POLICIES GOVERNING MC+ SERVICES

The following are brief descriptions of the services included in the standard benefit package
and the various programs and policies governing the delivery of services for the MC+ Managed
Care Program, These policies follow the amount, duration, and scope of services covered under
the Missouri Medicaid State Plan. For those services included in the MC+ Managed Care benefit
package, the MC+ Managed Care health plan must offer, at a minimum, the amount, duration, and
scope of that service included in the Medicaid State Plan. The state agency produces and up
dates MC+ Managed Care policy statements governing the delivery of services under MC+
managed care. The MC+ Managed Care health plan shall comply with such policies governing the
delivery of services and as amended by the state agency. Detailed information regarding MC+
fee-for-service services is contained in the fee-for-service provider manuals and bulletins, and
the deluxe pricing file.

ADULT DAY HEALTH CARE

Adult Day Health Care is a covered benefit for members.

Adult Day Health Care is a program of organized therapeutic, medical, rehabilitative, and social
activities provided outside of the home. MC-t+ fee-for-service eligible persons are assessed to
be eligible for the program by the Missouri Department of Health and Senior Services (DHSS). They
must have functional impairments requiring nursing home level of cafe, but with the provision of
this service and perhaps other supports, they may safely remain in their home. Adult Day Health
Care must be provided in a DHSS licensed facility or be exempt from licensure by way of
regulation.

AMBULATORY SURGICAL CENTERS (INCLUDING BIRTHING CENTERS)

Ambulatory Surgical Center services are a covered benefit. MC+ Managed Care health plans may
utilize Ambulatory Surgical Centers as an alternative to outpatient hospital services. The
Ambulatory Surgical Center provides a place for operative procedures to be accomplished that can
be safely performed in an outpatient setting and be able to be completed within 90 minutes. This
is the maximum length of time that a person may be placed under anesthetic in an Ambulatory
Surgical Center.

Birthing Centers are also licensed as Ambulatory Surgical Centers and are appropriate settings
for the delivery of services provided by a physician, advanced practice nurse, or certified
nurse midwife. MC+ Managed Care health plans are responsible for Birthing Center services.

ANESTHESIA SERVICES

Anesthesia services are a covered benefit. Anesthesia services are covered when performed by an
Anesthesiologist or Certified Registered Nurse Anesthetist (CRNA). Medical direction of
anesthetists by an anesthesiologist is also a covered service.

CASE MANAGEMENT

Case management is a clinical system that focuses on the accountability of an identified
individual or group for coordinating a patient’s care (or group of patients) across an episode or
continuum of care; negotiating, procuring, and coordinating services and resources needed by
patients/families with complex issues; insuring and facilitating the achievement of quality,
clinical, and cost outcomes; intervening at key points for individual patients; addressing and
resolving patterns of issues that have a negative quality cost impact; and creating opportunities
and systems to enhance outcomes. (Definition used with permission of The Center for Case
Management, 6 Pleasant Street, South Natick, MA 01760.) Case management is understood as
including, but not limited to the
development of individualized treatment plans and ongoing communication and coordination with
other systems
of care. The treatment plans must be:

	 	•	 	Developed by the member’s primary care provider with member participation, and in
consultation with
any specialists caring for the member;
	 
	 	•	 	Approved by the MC+ Managed Care health plan in a timely manner, if this approval is
required; and
	 
	 	•	 	In accord with any applicable State quality assurance and utilization review standards.

 

 

MC+ Managed Care health plans shall provide case management to members with special health care
needs and maintain a detailed case management record on each member. Members with special health
care needs are those members who have ongoing special conditions that require a course of
treatment or regular care monitoring. The Case Management MC+ Managed Care Policy Statement shall
include a list of diagnoses for children and adults that, at a minimum, the MC+ Managed Care
health plan shall use for identification of members with special health care needs requiring case
management and criteria for maintaining a detailed case management record. The following groups of
individuals are at high risk of having a special health care need:

	 	•	 	Individuals eligible for Supplemental Security Income (SSI);
	 
	 	•	 	Individuals in foster care or other out-of-home placement;
	 
	 	•	 	Individuals receiving foster care or adoption subsidy; and
	 
	 	•	 	Individuals receiving services through a family-centered community-based coordinated
care system that
receives grant funds under Section 501(a)(l)(D) of Title V, as defined by the state agency
in terms of
either program participant or special health care needs.

At the time of enrollment, the MC+ Managed Care health plan shall perform an initial health
assessment of members with special health care needs and members who are at high risk of having a
special health care need and implement appropriate case management based upon that assessment
appropriate to the member’s needs.

The MC+ Managed Care health plan shall be responsible for providing members with special health
care needs all services covered under the contract beginning with the effective date of
enrollment. All services authorized prior to enrollment in an MC+ Managed Care health plan shall
be terminated only after a case-specific, clinical decision has been
made by an MC- Managed Care
health plan provider. The MC+ Managed Care health plan shall have a mechanism in place to allow
members direct access to a specialist as appropriate for the member’s condition and identified
needs.

HCY CASE MANAGEMENT: MC+ Managed Care health plans are required to provide medically
necessary HCY case management services for members under the age of 21. Healthy Children and Youth
(HCY) Case Management is an activity under which responsibility for locating, coordinating, and
monitoring necessary and appropriate services for members under age 21, rests with an MC+ Managed
Care Health Plan or an organization or individual that the MC+ Managed Care Health Plan has
contracted with. HCY Case Management is the process of collecting information on the health needs
of the child, making (and following up on) referrals as needed, maintaining a health history,
activating the Early Periodic Screening and Diagnostic Treatment (EPSDT) program and ensuring
collaboration between providers.

LEAD CASE MANAGEMENT: The MC+ Managed Care health plan is responsible for the provision of
lead case management for those children with elevated blood lead levels. The MC+ Managed Care
health plan must screen children for elevated blood lead levels as part of the requirement for the
EPSDT/HCY program. When a child is identified with an elevated blood
lead level, the MC+
Managed Care health plan is responsible for providing medically necessary services including
case management for the child.

CASE MANAGEMENT — PREGNANT WOMEN

MC+ Managed Care health plans are required to provide prenatal case management services for at
risk pregnant women enrolled in their MC+ Managed Care health plan. Based on the prenatal risk
assessment, the case manager will formulate an individualized plan of management designed to
accomplish the intended objectives.

CHILDREN WITH SPECIAL HEALTH CARE NEEDS

Children with special health care needs are likely to require the services of the MC+ Managed Care
health plan’s special programs coordinator. These children may
also be served by the Departments
of Health and Senior Services, Mental Health, or Elementary and Secondary Education in early
intervention programs (Individuals with Disabilities Education Act — Part C), school-based
services, etc.

Without services such as private duty nursing, personal care, home health, durable medical
equipment/supplies, and case management these children may require hospitalization or
institutionalization. Nursing homes are not usually an option for children due to their intense
needs as well as their age. Some examples of children with

 

 

special health care needs include: children with special needs due to physical and/or mental
illnesses, foster care children, homeless children, children with serious and persistent mental
illness and/or substance abuse, and children who are disabled or chronically ill with developmental
or physical disabilities. The following information identifies some of the special health care
needs of this population.

	 	X	 	Requires vital functions to be sustained through unusual support such as oxygen, respirator
support, total
parenteral nutrition, inhalation therapy, and postural drainage.
	 
	 	X	 	Requires continuous nursing attention as the result of a surgical or medical
procedure such as
tracheostomy, ileostomy, colostomy, gastrostomy, nephrotomy, cast, or shunt.
	 
	 	X	 	Requires continuous maintenance because of gavage feedings, frequent oral suctioning,
elimination care,
and positioning needs.
	 
	 	X	 	Requires therapy such as physical, occupational, and/or speech therapy to reach their
greatest potential
and to minimize progression of disability as in children with cerebral palsy, rheumatoid
arthritis, and spinabifida.
	 
	 	X	 	Require continuous medical monitoring of underlying disease and its therapy.
	 
	 	X	 	Requires monitoring of indicators of vital functions such as heart rate, respiration, blood
sugar, oxygen
levels, blood pressure, and urine output.
	 
	 	X	 	Requires assistance in bathing, toileting, eating, or other activities of daily living
because of a medical
condition.

COMPREHENSIVE DAY REHABILITATION

Comprehensive Day Rehabilitation services are a covered benefit for children under the age of 21
and pregnant women with ME codes 18, 43, 44, 45, and 61. Coverage for comprehensive day
rehabilitation services is required for certain persons with disabling impairments as the result
of a traumatic head injury. Comprehensive day rehabilitation services are services beginning early
post trauma as part of a coordinated system of care. Rehabilitation services must be based on an
individualized, goal-oriented, comprehensive and coordinated treatment plan. The treatment plan
must be developed, implemented, and monitored through an interdisciplinary assessment designed to
restore an individual to optimal level of physical, cognitive, and behavioral function (See RSMo
208.152). MC+ Managed Care health plans are responsible for providing rehabilitation services to
survivors of a Traumatic Brain Injury (TBI).

DENTAL

All MC+ Managed Care members receive dental care related to trauma to the mouth, jaw, teeth or
other contiguous sites as a result of injury. Adults age 21 and over receive treatment of a
disease/medical condition without which the health of the recipient would be adversely affected
through the fee for service program. Medically necessary covered dental services provided by a
dentist, doctor of medicine, osteopathy or dentistry are the responsibility of the MC+ Managed
Care health plan. Medications prescribed by a dentist for MC+ Managed Care health plan members are
the responsibility of the MC+ Managed Care health plan. The MC+ Managed Care health plan is not
responsible for dental services which are exclusively for cosmetic reasons.

DENTAL — CHILDREN UNDER AGE 21

Dental screens, dental services, and orthodontic services are covered for members under age 21.

It is recommended that preventive dental services and oral treatment for children begin at age
6-12 months and be repeated every six months or as medically indicated.

DENTAL — PREGNANT WOMEN AGE 21 AND OVER WITH ME CODES 18, 43, 44, 45, AND 61: Dental
services for pregnant women age 21 and over with ME codes 18, 43, 44, 45, and 61 shall be limited
to dentures and services related to trauma to the mouth, jaw, teeth or other contiguous sites as a
result of injury. Services to prepare the mouth for dentures, such as examinations, X-rays, or
extractions will not be covered by the health plan. Ancillary denture services such as relining,
rebasing, and repairs will not be covered by the health plan. All other Medicaid State Plan dental
services for this population is covered through the fee for service program and is not the
responsibility of the MC+ Managed Care health plan.

 

 

DIABETES SELF-MANAGEMENT TRAINING

Coverage of self management training must be provided to all children under age 21 and pregnant
women in ME Codes 18, 43, 44, 45, and 61 used in the management and treatment of gestational, Type
I, and Type II diabetes as prescribed by a health care provider licensed by law to prescribe such
services.

DURABLE MEDICAL EQUIPMENT (DME)

MC+ Managed Care health plans are required to provide medically necessary DME items to children
under the age of 21, pregnant women with ME codes 18,43, 44, 45, and 61, and members with a Home
Health Plan of Care. MC+ Managed Care health plans are required to provide limited medically
necessary DME items to all other MC+ Managed Care members.

CHILDREN UNDER THE AGE OF 21 AND PREGNANT WOMEN WITH ME CODES 18, 43, 44, 45, AND 61 AND THOSE
WITH A HOME HEALTH PLAN OF CARE REGARDLESS OF AGE: Medically necessary equipment such as
hospital beds, walkers, commodes, decubitus care equipment, hoyer lifts, augmentative communication
devices when prior authorized by the MC+ Managed Care health plan, trapeze equipment, canes, and
crutches, etc. will be provided to children under the age of 21 and pregnant women with ME codes
18, 43, 44, 45, and 61 and those with a home health plan of care regardless of age. The recipient
must be MC+ eligible on the date the equipment is delivered or dispensed. Equipment that is
purchased becomes the property of the recipient. Those with a home health plan of care receive
covered DME items during the plan of care coverage period.

In addition to the above-mentioned DME items, the MC+ Managed Care health plans are required to
provide the following:

	 	X	 	HCY DME items and services to members under the age of 21. This includes medically
necessary
items such as diapers, medical supplies, enteral nutrition, PKU nutrition, and
positioning equipment. MC+ Managed Care health plans must arrange for continuation of
coverage of HCY equipment and supplies presently being reimbursed under the HCY
program.
	 
	 	X	 	All medically necessary Total Parenteral Nutrition (TPN) items and services. This includes
TPN pumps, nutritional solutions, and supplies.
	 
	 	X	 	All medically necessary non-sterile ostomy supplies.
	 
	 	X	 	All medically necessary orthotic and prosthetic devices.
	 
	 	X	 	All medically necessary diabetic supplies and equipment.
	 
	 	X	 	All medically necessary oxygen and respiratory equipment. This includes oxygen and oxygen
delivery systems, ventilators, nebulizers, Apnea monitors, suction pumps, etc. A
summary of oxygen and respiratory equipment benefits and limitations may be found
in the MC+ Durable Medical Equipment Policy Statement.
	 
	 	X	 	Augmentative communication evaluations, devices, and training. Medically necessary
communication devices prescribed as a result of the augmentative evaluation are
covered as a Durable Medical Equipment (DME) benefit when the augmentative
communication device is prior authorized by the MC+ Managed Care health plan.

LIMITED DURABLE MEDICAL EQUIPMENT FOR MC+ MANAGED CARE ELIGIBLE INDIVIDUALS WHO ARE NOT
CHILDREN UNDER THE AGE OF 21. PREGNANT WOMEN WITH ME CODES 18, 43, 44, 45, AND 61, OR THOSE WITH A
HOME HEALTH PLAN OF CARE INCLUDES:

	 	•	 	Diabetic supplies and equipment (insulin and needles are considered Pharmaceuticals),
	 
	 	•	 	Manual and power wheelchairs including wheelchair accessories and batteries,
	 
	 	•	 	Prosthetic devices (artificial larynx is not covered),
	 
	 	•	 	Respiratory equipment and oxygen. (Nebulizers, CPAP and BiPAP are not covered services unless
medical
necessity is determined through the MC+ Managed Care health plan’s exception process. If
services are currently authorized, the MC+ Managed Care health plan may only discontinue or
reduce these services after a determination of medical necessity is made through the MC+
Managed Care health plan’s exception process.)
	 
	 	•	 	Ostomy supplies.

 

 

EPSDT/HCY

The Omnibus Budget Reconciliation Act of 1989 (OBRA-89) mandated that MC+ fee-for-service provide
medically necessary services to children from birth through age 20 which are necessary to treat or
ameliorate detects, physical or mental illness, or conditions identified by an Early Periodic
Screening, Diagnosis, and Treatment (EPSDT) well child visit (screen) regardless of whether or not
the services are covered under the MC+ fee-for-service state plan. This program is referred to
nationally as the EPSDT Program. In Missouri this program is referred to as the Healthy Children
and Youth (HCY) Program. Services must be sufficient in amount, duration, and scope to
reasonably achieve their purpose and may only be limited by medical necessity. The MG+ Managed Care
health plans are responsible for providing EPSDT/HCY services for all members. If a problem is
detected during a well child visit (screening examination), the child must be evaluated as
necessary for further diagnosis and treatment services. The MC+ Managed Care health plan is
responsible for the treatment services.

EPSDT/HCY WELL CHILD (SCREENING) SERVICES: MC+ Managed Care health plans are responsible
for ensuring that HCY well child visits (screens) are performed on all members under the age of
21. Missouri has adopted the American Academy of Pediatrics’ (AAP) Schedule for Preventive
Pediatric Health Care as a minimum standard for frequency of providing full HCY well child visits.
Immunizations are recommended in accordance with the Advisory Committee on Immunization Practices
(ACIP) guidelines. MC+ Managed Care health plans are required to keep immunizations and well child
visits current according to schedules as specified by the state agency. The current schedules are
as follows:

Children should receive HCY/EPSDT well child visits regularly, at the ages listed below.

	 	 	 	 	 
	o Newborn

	 	o 15-17 months
	 	o 8-9 years
	o By age one month

	 	o 18-23 months
	 	o 10-11 years
	o 2-3 months

	 	o 24 months
	 	o 12-13 years
	o 4-5 months

	 	o 3 years
	 	o 14-15 years
	o 6-8 months

	 	o 4 years
	 	o 16-17 years
	o 9-11 months

	 	o 5 years
	 	o 18-19 years
	o 12- 14 months

	 	o 6-7 years
	 	o 20 years

EPSDT/HCY LEAD SCREENING SERVICES: All children from 6 to 72 months of age are considered
at risk and must be assessed for lead poisoning. A verbal risk assessment must be completed at
each HCY visit and if at high risk, the child must have a blood lead test. A blood lead test is
required at 12 and 24 months, regardless of risk or annually if residing in a high-risk area of
Missouri as defined by Department of Health and Senior Services regulation 19 CSR 20-8.030. The
Division of Medical Services requires the use of the Lead Screening Guide (MO 886-2998) when
providing services to MC+ eligible children.

Childhood Immunization Schedule: Children should receive childhood immunizations regularly,
at the ages listed on the Recommended Childhood Immunization Schedule, as a mended. The current
schedule appears in the Missouri Medicaid Provider Manuals that may be found on the Internet at the
Division of Medical Services website, http://www.medicaid.state.irio.us/indexl.html (Look
under Missouri Medicaid Provider Manuals, List of Forms, Recommended Childhood Immunization
Schedule.)

FAMILY PLANNING/STERILIZATIONS

Family planning services are a covered benefit. MC+ Managed Care health plans are required to
provide freedom of choice for family planning and reproductive health services which may be
accessed out-of-network. Examples of reproductive health services are: contraception management,
insertion of Norplant, intrauterine devices, Depo-Provera injections, pap test, pelvic exams,
sexually transmitted disease testing, and family planning counseling/education on various methods
of birth control. For family planning purposes, sterilizations shall only be those elective
sterilization procedures performed for the purpose of rendering an individual permanently incapable
of reproducing and must always be reported as family planning services in accordance with mandated
federal regulations 42 CFR 441.250-441.259.

 

 

HEARING AID - Limited to Children under the age of 21 and Pregnant Women with ME codes 18, 43,
44, 45, and 61

MC+ Managed Care health plans are required to provide medically necessary hearing aids and related
services. This includes medically necessary audiometric and hearing aid services for all MC+
Managed Care members under the age of 21 including but not limited to hearing aid batteries, FM
system, diagnostic testing, post cochlear implant training, aural habilitation, auditory trainers,
etc.

HOME HEALTH

MC+ Managed Care health plans are responsible for covering medically necessary, physician ordered
home health benefits. M C+ Managed C are health plans shall not terminate such services without a
case-specific, clinical decision made by a provider. Home health services provide primarily
medically oriented treatment or supervision to members with an acute illness, or an exacerbation
of a chronic or long term illness which can be therapeutically managed at home. The delivered care
should follow a written plan of treatment established and periodically reviewed by a physician.

The home health program is divided into two distinct segments based on the age of the member.
Members who are 21 years of age and older are defined as adults within the home health program.
Members 20 and under are classified as children and are eligible to receive expanded home health
services as part of the EPSDT federal mandate. Services include skilled nursing, aide visits,
psychiatric nursing, physical, occupational, and speech therapy and supplies.

HOSPICE

MC+ Managed Care health plans are required to provide hospice services when a terminally ill
member elects those services. The hospice benefit is designed to meet the needs of members with
life-limiting illnesses and to help their families cope with related problems and feelings. To be
eligible to elect hospice care, members must be certified by a physician as being terminally ill
with a life expectancy of six months or less. Hospice care cannot be prescribed or ordered by a
physician. The member must elect hospice care and agree to seek only palliative care for the
duration of the hospice election.

HYSTERECTOMY SERVICES

In order to be in compliance with 42 CFR 441.256, the MC+ Managed Care health plan must require a
completed copy of the “Acknowledgement of Receipt of Hysterectomy Information” form from the
performing provider. The MC+ Managed Care health plan must assure that the “Acknowledgement of
Receipt of Hysterectomy Information” form meets all of the criteria required by HCFA in 42 CFR
441.250 through 441.259.

INPATIENT/OUTPATIENT HOSPITAL including MENTAL HEALTH

Inpatient hospitalization and outpatient services for physical health needs are the responsibility
of the MC+ Managed Care health plan for all members, based on medical necessity. This includes
charges for the pretransplant and post discharge follow-up for transplant recipients (see
Transplants).

MATERNITY PRE-NATAL CARE AND DELIVERY

MC+ Managed Care health plans are required to cover maternity pre-natal care and delivery.

MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES

MC+ Managed Care health plans are responsible for all medically necessary mental health and
substance abuse services available in the fee-for-service program for members. Mental health and
substance abuse services shall
include court ordered, 96 hour detentions and involuntary commitments. Mental health and substance
abuse services may be provided by an acute care hospital (for a psychiatric stay), private or state
psychiatric hospital, community mental health or substance abuse treatment program certified or
licensed by the joint commission, Commission for Accreditation of Rehabilitation Facilities (CARF),
or the Missouri Department of Mental Health including qualified mental health professionals,
licensed and provisionally licensed psychologists, licensed and provisionally licensed clinical
social workers, licensed and provisionally licensed professional counselors, psychiatrist,
psychiatric advance practice nurse or home health psychiatric nurse.

Mental health and substance abuse services (including inpatient and outpatient) for children in
Category of Aid 4 (primarily children in state custody) are not the financial
responsibility of the MC+ Managed Care health plan and

 

 

will be reimbursed to MC+ fee-for-service enrolled providers on a fee-for-service basis. For
inpatients with dual diagnoses (physical and mental) identified at admission or during the stay,
the MC+ Managed Care health plans will be financially responsible for all inpatient hospital days
if the primary, secondary, or tertiary diagnosis is a combination of physical and mental health.

OPTICAL

MC+ Managed Care health plans are required to provide medically necessary optical services for
members as described herein.

Optical services include one comprehensive or one limited eye examination every two years for
refractive error, services related to trauma or treatment of disease/medical condition (including
eye prosthetics), and one pair eyeglasses following cataract surgery. Additionally:

	§	 	Children under age 21 services include one comprehensive or one limited eye
examination per year for
refractive error, eyeglasses, HCY/EPSDT optical screens and services.
	 
	§	 	Pregnant women age 21 and over with ME codes 18, 43, 44, 45, and 61 services include one
comprehensive
or one limited eye examination per year for refractive error. Eyeglasses (except the one pair
following
cataract surgery covered by the health plan) for these pregnant women are covered through the
Fee for
Service program.

When it is medically necessary for an optical procedure to be performed in an inpatient or
outpatient hospital facility, emergency room, or ambulatory surgical center, the facility charges
and ancillary services associated with the optical procedure are the responsibility of the MC+
Managed Care health plan.

If the MC+ Managed Care health plan approves optical items which are delivered or placed after
enrollment in the MC+ Managed Care health plan ends, the MC+ Managed Care health plan that approves
the optical item(s) is responsible for payment.

PERSONAL CARE

Personal care services are covered benefits for all members. Personal care services are medically
oriented tasks that may be reviewed by a physician. Personal care services are not physician
driven. Personal care services are tasks which assist an individual in activities of daily living
due to a stable, chronic condition. Personal care services are provided as a cost effective
alternative to nursing home placement.

Basic personal care services are services related to an MC+ enrollee’s physical
requirements, such as assistance with eating, bathing, dressing, personal hygiene, and activities
of daily living. They also include services essential to the health and welfare of the MC+
enrollee, such as housekeeping chores like preparing meals, bedmaking, dusting, and vacuuming.

Advanced personal care tasks are maintenance services provided to assist MC+ enrollees
with stable, chronic conditions when such assistance requires devices and procedures related to
altered body functions.

Nurse visits provided by an RN or LPN in the personal care program are authorized to
provide increased supervision of the aid, assessment of the MC+ enrollee’s health and the
suitability of the care plan to meet the patient’s needs as well as referral and/or follow-up
action. In addition, nurse visits may be authorized for skilled tasks that must be performed by a
nurse, such as filling insulin syringes, setting up oral medications, monitoring skin conditions,
providing nail care for diabetic patients, etc.

If personal care services have been authorized prior to a member enrolling in an MC+ Managed Care
health plan, the MC+ Managed Care health plan may only discontinue or reduce these services
based on an assessment performed by the Department of Health and Senior Services.

PERSONAL CARE (HCY): Children, ages 0 through 20, are determined to be in need of
personal care by medical necessity. Personal care needs (including advanced personal care needs)
for children are demonstrated by

 

 

their need for extra assistance in bathing, toileting, eating, or other activities of daily living
because of a medical condition. The fact that a child has a caretaker does not make him or her
ineligible for personal care services. The primary caretaker may not be present to deliver the
required services or may lack the time or ability to deliver the essential care. A family member
may not be reimbursed for the delivery of personal care services.

PHARMACY

MC+ Managed Care health plans are required to provide pharmacy services if the health plan
included pharmacy benefits in its proposal. Under the current Missouri MC+ Fee-For-Service
Pharmacy Program, nearly all products of manufacturers participating in the national rebate
program are reimbursable, including many over-the-counter preparations. Insulin syringes are also
reimbursable under this program.

Some products have been excluded from coverage under the current Missouri MC+ Fee-For-Service
Pharmacy Program. MC+ Managed Care health plans may elect to exclude these, but may not exclude
from coverage any product not excluded from the current Fee-For-Service Pharmacy Program (see the
MC+ Pharmacy Policy Statement for a list of products excluded from coverage). Protease inhibitors
will be reimbursed by the state agency on a fee-for-service basis.

It is not essential that MC+ Managed Care health plans cover pharmaceutical products without
restriction to the same extent that current fee-for-service policy dictates. However, any product
that is reimbursable by the current Fee-For-Service Pharmacy Program must be made available to
members, regardless of whether or not the prescriber is in the MC+ Managed Care health plan’s
network. MC+ Managed Care health plans may elect to have a restricted formulary; however,
products not included on that formulary that are covered or allowed through prior authorization by
the current Fee-For-Service Pharmacy Program must be made available to members when medically
necessary. MC+ Managed Care health plans may also require that prior authorization be obtained for
prescriptions generated by an out-of-network prescriber. MC+ Managed Care health plans may have a
more extensive list of products requiring prior authorization, but MC+ Managed Care health plans
may not exclude from coverage any products not excluded under the current Fee-For-Service Pharmacy
Program.

It is acceptable for MC+ Managed Care health plans to implement a drug authorization program in
order to provide this access. Any drug prior authorization program implemented by an MC+ Managed
Care health plan must meet the following criteria:

	 	X	 	MC+ Managed Care health plans must provide response by telephone or other telecommunication
device
within 24 hours of a request for prior authorization.
	 
	 	X	 	MC+ Managed Care health plans must provide for the dispensing of at least a 72-hour
supply of a drug
product that requires prior authorization in an emergency situation.
	 
	 	X	 	Approvals must be granted for any medically accepted use. Medically accepted use is
defined as any use for an FDA approved drug product which appears in peer-reviewed literature or
which is accepted by one
or more of the following compendia: the American Hospital Formulary Service — Drug
Information and
the United States Pharmacopeia — Drug Information and DRUGDEX.

In addition, MC+ Managed Care health plans must have a mechanism whereby drugs can be
prior-authorized if a member is out of the MC+ Managed Care health plans’ service area and during
the time lag between the date of a members’ effective enrollment and that members’ assignment to a
primary care provider.

PHARMACY DISPENSING FEES: The recipient portion of the pharmacy dispensing fee is to be
collected according to current fee-for-service policy. Unlike traditional copayment requirements,
the current Fee-For-Service Pharmacy fee requirement is considered a portion of the professional
dispensing fee and is not deducted from reimbursement to providers. Therefore, the recipient
portion of the dispensing fees is required to be collected for pharmacy services provided by MC+
Managed Care health plans. Providers of service may not deny or reduce services to MC+ members
solely on the basis of the member’s inability to pay the fee when
charged, A member’s inability to pay a required amount as due and charged when a service is
delivered, shall in no way extinguish the member’s liability to pay the amount due. Fee
responsibility and amounts collectible shall be as follows:

 

 

	 	 	 
	MC+ Fee-For-Service Maximum Allowable	 	Beneficiary Participation in Professional
	Ingredient Cost for Each Prescription	 	Dispensing Fee
	$10.00 or less
	 	$0.50
	$10.01 to $25.00
	 	$1.00
	$25.01 or greater
	 	$2.00

Under the current pharmacy dispensing fee policy all Missouri eligible beneficiaries are subject
to the fee requirement when provided covered pharmacy services, with the exception of the
following which are excluded:

	 	X	 	Beneficiaries under age 19;
	 
	 	X	 	Services related to Early Periodic Screening, Diagnosis and Treatment (EPSDT);
	 
	 	X	 	Institutionalized beneficiaries who are residing in a skilled nursing facility, a psychiatric
hospital, a
residential care facility, or an adult boarding
home;
	 
	 	X	 	Foster Care children up to 21 years of age;
	 
	 	X	 	All Medicare/MC+ Fee-For-Service crossover claims as primary coverage is afforded by the
Medicare Program;
	 
	 	X	 	Those services specifically identified as relating to Family Planning services;
	 
	 	X	 	Emergency services; and
	 
	 	X	 	Services provided to pregnant women which are directly related to the pregnancy or a
complication
of the pregnancy.

Participation in each MC+ Managed Care health plan’s pharmacy network shall be limited to
providers who accept, as payment in full, the amounts paid by the MC+ Managed Care health plan
plus any fee amount required of the member and collected by the provider.

PHARMACY — GENERIC DRUG REIMBURSEMENT OVERRIDE POLICY: The current MC+ Fee-For-Service
Pharmacy Program reimbursement methodology limits payment at a generic level for many drugs that
are available generically from multiple sources. The majority of these reimbursement limitations
are established as federal upper limits by the Centers for Medicare and Medicaid Services (CMS).
Other such limitations have been established by the state agency (Missouri Maximum Allowable Cost
or MAC).

Both CMS and the Missouri Division of Medical Services recognize that there are situations in
which trade name products are necessary for patient’s treatment. There is currently a generic
reimbursement override procedure. If the MC+ Managed Care health plan intends to implement similar
generic reimbursement limitations on multiple source products, a mechanism must exist so that
trade name reimbursement is available when it is medically necessary. This mechanism may not be
more restrictive than current fee-for-service policy.

PHYSICIAN INJECTIONS: Under the current Fee-For-Service Pharmacy Program, all FDA approved
injectable products are reimbursable when billed by National Drug Code (NDC) on a pharmacy claim
form by a private physician for administration in his/her office. MC+ Managed Care health plans
are required to provide pharmacy services (including physician injections) if the health plan
included pharmacy benefits in it’s proposal. In addition, certain non-injectable products are also
reimbursable when billed by a private physician. These products include Norplant and irrigation
solutions. Every product that is reimbursable by the current Fee-For-Service Pharmacy Program
either without restriction or through prior authorization, must be covered by the MC+ Managed Care
health plans either without restriction or through prior authorization except for protease
inhibitors which are excluded from MC+ Managed Care. However, it is not essential that health
plans cover injectable pharmaceutical products without restriction to the same extent that current
policy dictates. Coverage must be granted for any medically accepted use.

PHYSICAL, OCCUPATIONAL AND SPEECH THERAPY FOR ADULT PREGNANT WOMEN WITH ME CODES 18, 43,44, 45,
AND 61

MC+ Managed Care health plans are required to provide physical therapy (PT), occupational therapy
(OT), and speech therapy (ST) services for adult pregnant women with ME codes 18, 43, 44, 45, and
61 as follows.

 

 

Medically necessary physical therapy (PT) benefits are covered in the outpatient hospital setting
and as part of home health when the patient is medically homebound. PT is covered in a
rehabilitation center if the services are for adaptive training for a prosthetic or orthotic
device.

Occupational therapy (OT) is covered in a rehabilitation center for adaptive training for a
prosthetic or orthotic device. Medically necessary OT is covered as part of home health if the
patient is medically homebound.

Speech therapy (ST) is covered in a rehabilitation center for adaptive training for an artificial
larynx. Medically necessary ST is covered in as part of home health if the patient is medically
homebound.

PHYSICAL, OCCUPATIONAL AND SPEECH THERAPY (HCY)

MC+ Managed Care health plans are required to provide medically necessary physical (PT),
occupational (OT), and speech (ST) therapy and supplies used for casting and splinting to children
age 20 and under. Physical, occupational, and speech therapy services identified in a child’s
Individual Education Plan (IEP) or Individualized Family Service Plan (IFSP) will not be the
responsibility of the MC+ Managed Care health plan. These services will be paid fee-for-service by
the state agency. Medically necessary PT, OT, and ST services beyond the scope identified in a
child’s IEP or IFSP are the responsibility of the MC+ Managed Care health plan. This includes
developmental as well as maintenance therapy.

Medically necessary equipment and supplies used in connection with PT, OT, and ST services are the
responsibility of the MC+ Managed Care health plan.

PHYSICIAN/ADVANCED PRACTICE NURSE SERVICES

MC+ Managed Care health plans are required to provide medically necessary physician/advanced
practice nurse services within their scope of practice.

FEDERALLY QUALIFIED HEALTH CENTER (PQHC): Federally Qualified Health Center (FQHC)
services are the responsibility of the MC+ Managed Care health plans. FQHC core services that must
be performed in an FQHC setting are listed in Attachment 2. To receive FQHC provider status, a
health center must be certified by the Public Health Services, be certified for participation in
MC+ Fee-For-Service and enrolled with Missouri MC+ Fee-For-Service as an FQHC. FQHCs are entitled
to cost-based reimbursement from the state agency for FQHC services provided to MC+ enrollees.
The cost settlement will be performed by the state agency through an FQHC MC+ Fee-For-Service cost
report.

PODIATRY SERVICES

MC+ Managed Care health plans are required to provide medically necessary podiatry services that
are within the scope of practice of the podiatrist for children under the age of 21 or pregnant
women with ME codes 18, 43, 44, 45, and 61. All other MC+ Managed Care enrollees are eligible
for podiatry services with the exception of trimming of nondystrophic nails, any number;
debridement of nail(s) by any method(s), one to five; debridement of nail(s) by any method(s), six
or more; excision of nail and nail matrix, partial or complete; and strapping of ankle and/or
foot.

PRIVATE DUTY NURSING (HCY)

Private Duty Nursing services are covered under the Healthy Children and Youth (HCY) program. The
HCY program serves children age 20 and under. Private duty nursing is shift care delivered either
by an R.N. or an L.P.N acting within the scope of the Missouri Nurse Practice Act according to an
individualized plan of care approved by a physician. The duration of care can extend up to
twenty-four (24) hours per day. The duration and frequency of care is dependent upon the child’s
need and physician orders. Children receiving private duty nursing care are high risk children that
are medically fragile. The MC+ Managed Care health plans shall only terminate such services after a
case-specific, clinical decision has been reached by a provider.

RADIOLOGY AND LABORATORY SERVICES

MC+ Managed Care health plans are required to provide medically necessary radiology and laboratory
services. The MC+ Managed Care health plan must assure that the criteria required by CMS defined
under the CLIA Act of 1988 as defined in 42 CFR 493.2 and Section 2303 of the Deficit Reduction Act
of 1984 (P.L. 98-369) for Clinical Diagnostic Laboratory Procedures are met.

 

 

TRANSPLANTS

MC+ Managed Care health plans are responsible for the pre-surgery assessment/evaluation, care
(excluding the solid organ procurement or bone marrow/stem cell harvest), post-transplant
discharge follow-up care, and immuno-suppressive pharmacy products prescribed after the inpatient
transplant discharge.

The transplant must be prior authorized by the Division of Medical Services (DMS) and must be
performed at a DMS approved transplant facility. DMS will continue to cover the solid organ/stem
cell/bone marrow procurement costs, the inpatient stay for the transplant from the date of the
transplant through the date of discharge and the transplant surgeon’s fee, all physician, lab etc.
charges incurred during the transplant stay (date of transplant through the date of discharge).

TRANSPORTATION

The MC+ Managed Care health plan must provide emergency (ground or air) medical transportation.

The MC+ Managed Care health plan must provide necessary non-emergency medical transportation
(NEMT) for members accessing health care services included in the comprehensive benefit package as
well as health care services that are carved out of the MC+ Managed Care contract. The MC+ Managed
Care health plan must arrange the least expensive and most appropriate mode of transportation
based on the MC+ Managed Care member’s medical needs.

MC+ Managed Care health plans are not required to provide transportation to MC+ Managed Care
members with access to free transportation at no cost to them, however, such members may be
eligible for ancillary services. Also, MC+ Managed Care health plans are not required to provide
NEMT services to Durable Medical Equipment providers that provide free delivery or mail order
services nor to a pharmacy.

An offer of transportation assistance must be made to all children prior to periodic screenings
required under EPSDT/HCY. Parents/guardians must be informed of this transportation benefit.

NEMT services are not covered for those MC+ enrollees with ME Codes 71 through 75.

VACCINE FOR CHILDREN (VFC)

VFC services are a covered benefit. Under the provision of the Omnibus Budget Reconciliation Act
(OBRA) of 1993, vaccines are available free to providers who enroll with the VFC Program. MC+
Managed Care health plans and their subcontractors must enroll in the VFC Program administered by
the Missouri Department of Health and Senior Services and must use the free vaccines when
administering vaccines to members. A separate administration fee will not be paid to the MC+
Managed Care health plans as the reimbursement is included in the capitation payment. If a vaccine
is medically necessary and not covered through the VFC program, the MC+ Managed Care health plan is
responsible for the vaccine and the administration costs.

 

 

Revised Attachment 6

The following is the state agency’s Quality Improvement (QI) Strategy. The state agency produces
and updates the MC+ Managed Care Quality Improvement (QI) Strategy, MC+ Managed Care contract
and the MC+ Managed Care policy statements. The MC+ Managed Care health plan shall comply with
the Quality Improvement (QI) Strategy, MC+ Managed Care policy statements and the MC+ Managed
Care contract.

MISSOURI DEPARTMENT OF SOCIAL SERVICES

DIVISION OF MEDICAL SERVICES

QUALITY IMPROVEMENT 

(Q I) STRATEGY

1. DEPARTMENT OF SOCIAL SERVICES MISSION STATEMENT

To maintain or improve the quality of life for people in the state of Missouri by providing the
best possible services to the public, with respect, responsiveness and accountability which
will enable individuals and families to better fulfill their potential.

Purpose

The Department of Social Services (DSS), Division of Medical Services (DMS) seeks to assure access
and availability of quality health care services for MC+ Managed Care members through a Managed
Care delivery system, standards setting and enforcement, and education of providers and members.
This QI strategy supports the following DMS objectives:

	 	o	 	Assessment of the quality and appropriateness of care and services furnished to
members,including those with special health care needs, centered on evidenced based practice;
	 
	 	o	 	Use of care management with emphasis on the individual member to ensure that
members have a
medical home which focuses attention on the wellness of the member and includes personal
responsibility and investment on the part of the member;
	 
	 	o	 	Use of data regarding the race, ethnicity, and primary language spoken of
each member to
improve care delivery;
	 
	 	o	 	Use of national performance measures and levels when identified and developed
by CMS in
consultation with states and other relevant stakeholders;
	 
	 	o	 	An effective information system that supports initial and ongoing operation and
review of the
quality strategy;
	 
	 	o	 	A process for public input that provides for the integration of various
perspectives and priorities
and will facilitate improvements in member health status;
	 
	 	o	 	Appropriate use of sanctions, including intermediate sanctions, to assure
appropriate delivery of care to members; and
	 
	 	o	 	Compliance with regulatory and contractual
requirements.

 

 

Goal

The goal is to ensure that:

	 	o	 	Quality health care services are provided to MO Managed Care members;
	 
	 	o	 	MC+ Managed Care health plans are in compliance with Federal, State, and contract
requirements; and
	 
	 	o	 	A collaborative process is maintained to collegially work with the MC+ Managed
Care health
plans to improve care.

Overview

This strategy will be annually evaluated for effectiveness. This process includes obtaining
input from stakeholders, the State Quality Assessment & Improvement Advisory Group, Consumer
Advisory Committee, and approval from CMS prior to implementation. In the instance there is
significant change in outcome or indicator status that is not self-limiting and impacts on
more than one area of the population’s health status, modifications will be made to the
strategy reporting process. These modifications may include changes to the monthly, quarterly
and annual MC+ Managed Care health plan reports, on-site review topics, and MC+ Managed Care
performance measures.

Each MC+ Managed Care health plan must meet program standards for monitoring and evaluation of
systems as outlined in the MC+Managed Care contract to meet Federal and State regulations.
Each MC+ Managed Care health plan must implement a QI strategy that addresses the standards as noted
but is not
limited to the requirements within the MC+ Managed Care Quality Improvement (QI) Strategy or
the MC+ Managed Care contract. The MC+ Managed Care health plan’s strategy shall include
components to monitor, evaluate, and implement the contract standards and processes to
improve:

	 	o	 	Quality management;
	 
	 	o	 	Utilization management;
	 
	 	o	 	Records management;
	 
	 	o	 	Information management;
	 
	 	o	 	Care management;
	 
	 	o	 	Member services;
	 
	 	o	 	Provider services;
	 
	 	o	 	Organizational structure;
	 
	 	o	 	Credentialing;
	 
	 	o	 	Network Performance;
	 
	 	o	 	Fraud and abuse detection and prevention;
	 
	 	o	 	Access and availability; and
	 
	 	o	 	Data collection, analysis and reporting.

1.1 Program Components

I. MC+ Managed Care Health Plans Reports of Quality Assessment and Improvement

The MC+ Managed Care health plans will provide the DMS with regular reports of utilization
and quality assessment. These reports will be provided in accordance with the:

	 	o	 	MC+ Managed Care Policy Statements;
	 
	 	o	 	MC+ Managed Care contract;
	 
	 	o	 	MC+ Managed Care Performance Measures (Exhibit 1); and
	 
	 	o	 	MC+ Managed Care QA & I Program, Reporting Period Schedule, (Exhibit 2).

The frequency and types of reports include:

 

 

	 	A.	 	Monthly Reports: Monthly reports regarding special needs and lead poisoning
prevention will be submitted to DMS in a format specified by the state agency.
Monthly
reports will be due the last working day of each month.
	 
	 	B.	 	Quarterly Reports: Quarterly reports of member grievances and
appeals, provider
complaints, grievances, and appeals, and fraud and abuse detection will be
submitted to
DMS in a format specified by the state agency.
	 
	 	C.	 	Annual Evaluation: An annual evaluation of the MC+ Managed Care health plan’s
quality assessment and improvement program specific to the Missouri MC+ Managed Care
Program is to be submitted in the format specified by the state agency (Exhibit 4). The
evaluation shall contain information concerning the effectiveness and impact of the
health plan’s MC+ Managed Care quality assessment and improvement strategy. The annual
evaluation report must provide information that indicates that data is collected,
analyzed and reported, and health operations are in compliance with State, federal and
MC+ Managed Care contractual requirements. The annual evaluation of the health plan’s QA
&I program must incorporate multiple year outcomes and trends. The evaluation must show
the health plan’s QA & I program is ongoing, continuous and based upon evaluation of
past outcomes. The evaluation will, at a minimum, contain information from
subcontractors and internal processes including:

	 	a.	 	An analysis and evaluation of member grievances and appeals and provider complaints,
grievances and appeals;
	 
	 	b.	 	An analysis and evaluation of how the health plan incorporates race,
ethnicity, and primary
language into the health plan’s quality strategy. The DSS asks each potential
enrollee their
race, ethnicity and primary language at the time of application in accordance with
Medicaid eligibility rules. DSS uses the federally recognized categories for race,
ethnicity
and language. The state agency shall electronically provide race, ethnicity and
language to
the health plan upon member enrollment.
	 
	 	c.	 	An analysis and evaluation of utilization and clinical performance data
that supports use of
evidenced based practice;
	 
	 	d.	 	An analysis and evaluation of 24 access/after hours availability,
appointment availability
and open/closed panels;
	 
	 	e.	 	An analysis and evaluation of the MC+ Managed Care health plan’s
provider network
including provider/enrollee ratios;
	 
	 	f.	 	An analysis and evaluation of all MC+ Managed Care quality indicators:

	 	1.	 	Trends in Missouri Medicaid Quality Indicators provided by
the Department of
Health and Senior Services (DHSS) (Exhibit 3);
	 
	 	2.	 	HEDIS Indicators by Missouri MC+ Managed Care Health Plans
Within Regions,
Live Births provided by the Department of Health and Senior Services (DHSS)
(Exhibit 3); and
	 
	 	3.	 	MC+ Managed Care Performance Measures (Exhibit 1).

	 	h.	 	An analysis and evaluation of quality is sues and actions identified through
the quality
strategy and how these efforts were used to improve systems of care and health outcomes;
	 
	 	i.	 	An analysis and evaluation of action items documented in the meeting minutes of
the MC+ Managed Care health plan’s quality and compliance committee(s) including:

	 	1.	 	Trends identified for focused study; results of focused studies; corrective action
taken;
evaluation of the effectiveness of the actions and outcomes.

	 	j.	 	An analysis and evaluation of Performance Improvement Projects
(PIP) that addresses clinical and non-clinical PIPs and the requirement for
on-going interventions and improvement;
	 
	 	k.	 	An analysis and evaluation of subcontractor relationships that addresses
integration with the health plan’s QA&I program. This analysis and evaluation is not a
replication of the Subcontractor Oversight Annual Evaluation report;
	 
	 	l.	 	An analysis and evaluation of the health plan’s fraud and abuse program;

 

 

	 	m.	 	An analysis and evaluation of care management that includes case
management, disease management and care coordination for both medical and
mental health services; and
	 
	 	n.	 	An analysis and evaluation of the health plan’s claims
processing and Management Information System.

	 	D.	 	Periodic Reports of Quality and Utilization: The MC+ Managed Care health plan will provide
periodic
reports regarding case management, quality initiatives, and other quality analysis reports
per DMS
request.
	 
	 	E.	 	An annual report regarding multilingual services for members who speak a language other
than English
and the MC+ Managed Care health plan’s methods for communicating with members with visual
and hearing impairments and accommodating for the physically disabled. The health plan’s
report shall include but not be limited to the following:

	 	1.	 	A count by language of how many members declared a language other than English as
their
primary language.
	 
	 	2.	 	A summary by language of translation services provided to members (oral and
in-person).
	 
	 	3.	 	A count of members identified as needing communication accommodations due to visual
or
hearing impairments or a physical .disability.
	 
	 	4.	 	A summary of services provided to members with visual or hearing impairments or
members
who are physically disabled (Braille, large print, cassette, sign interpreters-, etc.).
	 
	 	5.	 	An inventory by language of member material translated.
	 
	 	6.	 	An inventory of member materials available in alternative formats.
	 
	 	7.	 	A summarization of grievances regarding multilingual issues and dispositions.

	 	F.	 	Annual subcontractor oversight reports that reflect the health plan’s monitoring activities
in the
previous year for each health care service subcontractor and any corrective actions
implemented as a result of its monitoring activities. The annual subcontractor oversight
reports shall be submitted in the format specified by the state agency (Exhibit 5).

II. DMS Analysis and Evaluation

DMS will analyze and evaluate data from a variety of sources including the state agency’s
Medicaid Management Information System (MMIS) to assess the quality and appropriateness of care
delivery to the MC+ Managed Care population. The DMS will analyze and evaluate the following:

	 	•	 	Monthly reports, quarterly reports, periodic reports, annual reports,
and the annual evaluations
submitted by MC+ Managed Care health plans.
	 
	 	•	 	Encounter data.
	 
	 	•	 	Performance measures.
	 
	 	•	 	Performance improvement projects.
	 
	 	•	 	Compliance with the MC+ Managed Care contract.
	 
	 	•	 	Enrollment, transfer and disenrollment activity.

Results from the analysis and evaluation activities will be compiled and presented through
regularly scheduled meetings of the State Quality Assessment & Improvement Advisory Group. The
QA & I Advisory Group will review these results to identify opportunities for improvement.

 

 

III. External Quality Review

An external quality review of the MC+ Managed Care health plans will be conducted annually
in accordance with the “Medicaid Program; External Quality Review of Medicaid Managed Care
Organizations; Final Rule, 42 CFR Part 438, Subpart E”. External quality review means the
analysis and evaluation by an External Quality Review Organization (EQRO) of aggregated
information on quality, timeliness, and access to health care services. The EQRO will
provide an annual evaluation report to the QA & I Advisory Group regarding, but not limited
to, the following:

	 	1.	 	Validation of two (2) performance improvement projects
that were underway during the
preceding 12 months for each MC+ Managed Care health plan.
	 
	 	2.	 	Validation of three (3) performance measures reported during the preceding 12
months.
	 
	 	3.	 	A review every three years to determine the MC+ Managed Care health plan’s
compliance with
standards as listed within the MC+ Managed Care contract.
	 
	 	4.	 	Validation of encounter data.

IV. Compliance

	 	A.	 	Intermediate Sanctions. The DMS may establish and specify intermediate sanctions that
may be
imposed when a MC+ Managed Care health plan acts or fails to act as specified below. The DMS
 may require a corrective action plan, as referenced in section 2.28.5, to be developed and
approved by
the DMS in situations where intermediate sanctions may be imposed. The DMS shall
approve and monitor implementation of such a plan and set appropriate timelines to
bring activities of the MC+ Managed Care health plan into compliance with state and
federal regulations. The DMS may monitor via required reporting on a specified
basis and/or through on-site evaluations, the effectiveness of the plan. Before
imposing intermediate sanctions, the DMS shall give the MC+ Managed Care health
plan timely written notice that explains the basis and nature of the sanction and
any other due process protections that the DMS elects to provide.

	 	1.	 	Fails substantially to provide medically necessary services that the
MC+ Managed Care health
plan is required to provide, under law or under this contract, to a member covered
under the
contract.
	 
	 	2.	 	Imposes on members premiums or charges that are in excess of the
premiums or charges permitted
under the Medicaid program.
	 
	 	3.	 	Acts to discriminate among members on the basis of their health
status or need for health care
services.
	 
	 	4.	 	Misrepresents or falsifies information that it furnishes to CMS or to the DMS.
	 
	 	5.	 	Misrepresents or falsifies information that it furnishes to a member,
potential member, or a health
care provider.
	 
	 	6.	 	Fails to comply with the requirements for physician incentive plans,
as set forth (for Medicare) in
42 CFR 422.208 and 422.210.
	 
	 	7.	 	Distributes directly, or indirectly through any agent or independent
contractor, marketing materials
that have not been approved by the DMS or that contain false or materially
misleading
information.
	 
	 	8.	 	Violates any of the other applicable requirements of sections 1903(m)
or 1932 of the Act and any
implementing regulations.
	 
	 	9.	 	Violates any of the other applicable requirements of sections 1932 or
1905(t)(3) of the Act and any
implementing regulations.

	 	B.	 	Intermediate Sanctions: Types. The types of intermediate sanctions that
the DMS may impose
include:

 

 

	 	1.	 	Civil monetary penalties in the following specified amounts:

	 	a.	 	A maximum of $25,000 for each determination of failure
to provide services;
misrepresentation or falsification of statements to members, potential members or
health care
providers; failure to comply with physician incentive plan requirements; or
marketing
violations.
	 
	 	b.	 	A maximum of $100,000 for each determination of discrimination among
members on the
basis of their health status or need for services; or misrepresentation or
falsification to CMS
or the DMS.
	 
	 	c.	 	A maximum of $15,000 for each member the DMS determines was discriminated
against
based on the member’s health status or need for services (subject to the $100,000
limit
above).
	 
	 	d.	 	A maximum of $25,000 or double the amount of the excess charges
(whichever is greater),
for charging premiums or charges in excess of the amounts permitted under the
Medicaid
program. The DMS shall return the amount of overcharge to the affected member(s).

	 	2.	 	Appointment of temporary management for a health plan as provided in 42 CFR 438.706.
	 
	 	3.	 	Granting members the right to terminate enrollment without cause and notifying
the affected
members of their right to disenroll.
	 
	 	4.	 	Suspension of all new enrollment, including default enrollment, after the effective date
of the
sanction.
	 
	 	5.	 	Suspension of payment for members enrolled after the effective date of the sanction
and until
CMS or the DMS is satisfied that the reason for imposition of the sanction no longer
exists and is not likely to recur.
	 
	 	6.	 	Additional sanctions allowed under state statutes or
regulations that address areas of noncompliance described above.

 

 

Exhibit 1

MC+
MANAGED CARE PERFORMANCE MEASURES

a.    EFFECTIVENESS OF CARE

	1.	 	(H) Childhood Immunization Status (CIS)*
	 
	2.	 	(H) Adolescent Immunization Status (AIS)*
	 
	3.	 	(H) Cervical Cancer Screening (CCS)*
	 
	4.	 	(H) Chlamydia Screening in Women (CHL)*
	 
	5.	 	(H) Follow-up After Hospitalization For Mental Health Disorders (FUH)
	 
	6.	 	(H) Use of Appropriate Medications for People with Asthma (ASM)*

1) ACCESS/AVAILABILITY OF CARE

	7.	 	(H) Prenatal and Postpartum Care (PPC)
	 
	8.	 	(H) Annual dental visit (ADV)*

2) SATISFACTION WITH THE EXPERIENCE OF CARE

	9.	 	(H) CAHPS 3.OH Child/Adult Survey*

3) USE OF SERVICES

	10.	 	(H) Well child Visits in the First 15 Months of Life (W15)
	 
	11.	 	(H) Well Child Visits in the Third, Fourth, Fifth, and Sixth Year of Life (W34)
	 
	12.	 	(H) Adolescent Well-Care Visits (AWC)*
	 
	13.	 	(H) Ambulatory Care (AMB)

	14.	 	(H) Mental Health Utilization — Percentage of Members Receiving Inpatient,
Intermediate Care and
Ambulatory Services (MPT)

	15.	 	(H) Identification of Alcohol and Other Drug Services (IAD)

(H) = HEDIS Measure

 

* DHSS required measure. Follow the instructions provided within 19 CSR 10-5.010.

Note: The measures shall be collected and reported in accordance with HEDIS specifications. In the
event that NCQA retires a DMS required measure, the Division will inform the health plan whether
the DMS will require the health plan to collect and report using HEDIS specifications in effect
prior to the measurement’s retirement or whether the Division will follow NCQA’a retirement of the
measure. NCQA rotates certain measures every year. As approved by DMS, rotated measures shall be
reported in accordance with current HEDIS technical specifications for reporting rotated measures.
DMS shall not approve rotation of CAHPS. DHSS measures shall be reported according to DHSS
specifications as provided in 19 CSR 100-5.010. MC+ Managed Care health plans contracted for more
than one region shall submit region specific data. All MC+ Managed Care health plans shall submit
the measures in an electronic format utilizing tables provided by the DMS and DHSS.

 

 

Exhibit 2

MC+ Managed Care Quality Assessment and Improvement

Reporting Periods

The following reporting periods have been defined for reporting of monthly, quarterly and
annual reports by MC+ Managed Care health plans participating in the MC+ Managed Care
Program.

MONTHLY REPORTING

	 	 	 
	Time Period	 	Due Date
	Calendar month

	 	Last working day of the month

QUARTERLY REPORTING

	 	 	 
	Time Period	 	Due Date
	1st Quarter (July thru September)

	 	December 1st of each year
	2nd Quarter (October thru December)

	 	March 1st of each year
	3rd Quarter (January thru March)

	 	June 1st of each year
	4th Quarter (April thru June)

	 	September 1st of each year

ANNUAL REPORTS — ANNUAL EVALUATION, MULTILINGUAL SERVICES,

SUBCONTRACTOR OVERSIGHT

	 	 	 
	Time Period	 	Due Date
	July 1 thru June 30

	 	November 30, 2007 and on November 30 of
each subsequent year

PERFORMANCE MEASURES

	 	 	 
	Time Period	 	Due Date
	January 1 thru December 31
	 	June 30 of each year

 

 

Exhibit 3

Trends in Missouri Medicaid Quality Indicators

(Secondary-Source Reporting)

	1.	 	Trimester Prenatal Care Began:

	 	a.	 	First
	 
	 	b.	 	Second
	 
	 	c.	 	Third
	 
	 	d.	 	None
	 
	 	e.	 	Total

	2.	 	Inadequate Prenatal Care
	 
	3.	 	Birth weight (grams) — total number of births by weight category For each live birth.

	 	a.	 	<500Gms.
	 
	 	b.	 	500-1499 Gms.
	 
	 	c.	 	1500-1999 Gms.
	 
	 	d.	 	2000-2499 Gms.
	 
	 	e.	 	.2500 Gms.
	 
	 	f.	 	Stillborn fetuses

	4.	 	Low Birth Weight (<2500 grams)
	 
	5.	 	Method of Delivery

	 	a.	 	C-Section
	 
	 	b.	 	VBAC
	 
	 	c.	 	Repeat C-Section

	6.	 	Smoking During Pregnancy
	 
	7.	 	Spacing <18 months since last birth
	 
	8.	 	Births to mothers <18 years of age
	 
	9.	 	Repeat teen births
	 
	10.	 	Fetal Deaths (20+weeks)*
	 
	11.	 	Total live birth or stillbirth fetuses 500 grams or more**
	 
	12.	 	Percent of pregnant women on Women’s Infants and Children Program (WIC)
	 
	13.	 	Percent of prenatals on WIC
	 
	14.	 	VLBW not delivered in level 111 hospitals
	 
	15.	 	Average maternal length of stay (days), Inpatient admissions
	 
	16.	 	Average behavioral health length of stay (days), Inpatient admissions
	 
	17.	 	Asthma inpatient admissions ages 4-17**
	 
	18.	 	Asthma emergency room visits ages 4-17**
	 
	19.	 	Asthma admissions under age 16, Inpatient admissions**
	 
	20.	 	Asthma admissions ages 18 — 64, Inpatient admissions**
	 
	21.	 	Emergency room visits under age 18**
	 
	22.	 	Emergency room visits ages 18 — 64**
	 
	23.	 	Hysterectomies**
	 
	24.	 	Vaginal hysterectomies
	 
	25.	 	Preventable hospitalization under age 18**

 

			
	*	 	Rate per 1000 live births
	 
	**	 	Rate per 1000 population

 

 

Exhibit 3

HEDIS Indicators by Missouri MC+ Managed Care Health Plans Within Regions, Live Births

(Secondary-Source Reporting)

	1.	 	C-Sections
	 
	2.	 	VBACs
	 
	3.	 	Adequacy of Prenatal Care
	 
	4.	 	Early Prenatal Care
	 
	5.	 	Low Birth Weight
	 
	6.	 	Low Birth Weight Delivered in Level II/III Hospitals
	 
	7.	 	Very Low Birth Weight Delivered in Level II/III Hospitals
	 
	8.	 	Smoking During Pregnancy
	 
	9.	 	Spacing Less Than 18 Months
	 
	10.	 	Births to Mothers Less Than 18
	 
	11.	 	Repeat Births to Teen Mothers
	 
	12.	 	Prenatal WIC Participants

 

 

Exhibit 4

MC+ MANAGED CARE ANNUAL EVALUATION REPORT FORMAT

TABLE OF CONTENTS

EXECUTIVE SUMMARY

     Overview of the Quality Improvement Program

     Overview of the Effectiveness of the Quality Improvement Program

DEVELOPMENT, APPROVAL AND MONITORING OF THE QI PROGRAM

     Quality and Compliance Committee

     Analysis of Quality Improvement Process

     Overall Effectiveness of the Quality Improvement Program

          Strengths and Accomplishments

          Opportunities for Improvement

POPULATION CHARACTERISTICS

     Race/Ethnicity

     Special Needs

     Languages Identified

     Opt Outs

QUALITY INDICATORS

     Performance Measures

     Trends in Missouri Medicaid Quality Indicators

     HEDIS Indicators by Missouri MC+ Managed Care Health Plans Within Regions, Live Births

ACCESSIBILITY OF SERVICES

     Average Speed of Answer

     Call Abandonment Rate

     Non-Routine Needs Appointments

     Routine Needs Appointments

     Access to Emergent and Urgent Care

     Network Adequacy — Provider/Enrollee Ratios

     24 Hour Access/After Hours Availability

     Open/Closed Panels

     Cultural Competency

     Requests to Change Practitioners

FRAUD AND ABUSE

     Prevention, Detection, Investigation

     Training and Education

INFORMATION MANAGEMENT

     Claims Processing — Timeliness of Claims Payment

     Membership

     Providers

QUALITY MANAGEMENT

     Provider Satisfaction

     Care Coordination

     Case Management

     Disease Management Program

     Mental Health Care Management including Case Management

     Clinical Practice Guidelines

     Credentialing and Re-Credentialing

     Medical Record Review

     Subcontractor Monitoring

RIGHTS AND RESPONSIBILITIES

 

 

     Provider Complaint, Grievance and Appeal Management

     Member Grievance and Appeal Management

     Confidentiality

UTILIZATION MANAGEMENT

     Utilization Improvement Program Scope

     Discharges Per Year*

     Inpatient Visits*

     Average Length of Stay

     Re-Admissions*

     Emergency Department Utilization*

     Outpatient Visits* .

     Over/Under Utilization

     Inter-Rater Reliability

     Timeliness of Care Delivery

     Timeliness of Prior Authorization/Certification Decision Making

*Per 1000 members

PERFORMANCE IMPROVEMENT PROJECTS (PIP)

     Clinical

     Non- Clinical

     On-going Interventions and Improvements

     Effect on Health Outcomes and Member Satisfaction

WORKPLAN FOR NEXT YEAR

APPENDICES

 

 

Exhibit 5

SUBCONTRACTOR OVERSIGHT ANNUAL EVALUATION REPORT TEMPLATE

(Complete for each subcontractor- 2-5pages)

Subcontractor Name

	A.	 	Overview of subcontractor including contract effective dates
	 
	B.	 	Description of delegated services/products/activities
	 
	C.	 	Description of MC+ Managed Care health plan’s oversight process (must include, but
shall not be limited to, the following:)

	 	1)	 	Review of subcontractor contract documents compliance with requirements
included in the MC+ Managed Care contract with state (Refer to Section 3.8.3 of
MC+ Managed Care contract)
	 
	 	2)	 	Subcontractor policies and procedures comply with subcontractor/MC+
Managed Care health plan’s/state contract requirements
	 
	 	3)	 	Implementation of policies/procedures/contract requirements

	D.	 	Oversight outcomes/findings (must include, but shall not be limited to, the following:)

	 	1)	 	Access/availability
	 
	 	2)	 	Fraud and abuse
	 
	 	3)	 	Grievances and appeals
	 
	 	4)	 	Performance projects and measures
	 
	 	5)	 	Encounter data
	 
	 	6)	 	Prior authorization denials
	 
	 	7)	 	Timely payment

	E.	 	Work plan for next year

 

 

Revised Attachment 14

Page 1 of 5

OFFICE VISIT SERVICES

	 	 	 	 	 
	 	 	 	 	Allowable Fee for
	 	 	 	 	Dates of Service
	 	 	 	 	July 1, 2006 and
	Procedure Code	 	Program Type	 	after
	99201
	 	Medical Services	 	$21.52
	99201 GE
	 	Medical Services	 	$21.52
	99201 GT
	 	Medical Services	 	$21.52
	99201
	 	Nurse Midwife	 	$21.52
	99201
	 	Podiatry	 	$21.52
	99201 GE
	 	Podiatry	 	$21.52
	99201 W2
	 	Podiatry	 	$21.52
	99201
	 	Other Medical	 	$21.52
	99201 GE
	 	Other Medical	 	$21.52
	99202
	 	Medical Services	 	$38.23
	99202 EP
	 	Medical Services	 	$38.23
	99202 GT
	 	Medical Services	 	$38.23
	99202 GT EP
	 	Medical Services	 	$38.23
	99202 GE
	 	Medical Services	 	$38.23
	99202 GE EP
	 	Medical Services	 	$38.23
	99202
	 	Nurse Midwife	 	$38.23
	99202 EP
	 	Nurse Midwife	 	$38.23
	99202
	 	Podiatry	 	$38.23
	99202 W2
	 	Podiatry	 	$38.23
	99202 GE
	 	Podiatry	 	$38.23
	99202
	 	Other Medical	 	$38.23
	99202 EP
	 	Other Medical	 	$38.23
	99202 GE
	 	Other Medical	 	$38.23
	99202 GE EP
	 	Other Medical	 	$38.23
	99203
	 	Medical Services	 	$56.93
	99203 EP
	 	Medical Services	 	$56.93
	99203 GE
	 	Medical Services	 	$56.93
	99203 GE EP
	 	Medical Services	 	$56.93
	99203 GT
	 	Medical Services	 	$56.93
	99203 GT EP
	 	Medical Services	 	$56.93
	99203
	 	Nurse Midwife	 	$56.93
	99203 EP
	 	Medical Services	 	$56.93
	99203
	 	Podiatry	 	$56.93
	99203 W2
	 	Podiatry	 	$56.93
	99203
	 	Other Medical	 	$56.93
	99203 EP
	 	Other Medical	 	$56.93
	99203 GE
	 	Other Medical	 	$56.93

 

 

Revised Attachment 14

Page 2 of 5

OFFICE VISIT SERVICES

	 	 	 	 	 	 	 	 	 
	 	 	 	 	Allowable Fee for	 	 	 	 
	 	 	 	 	Dates of Service	 	 	 	 
	 	 	 	 	July 1, 2006 and	 	 	 	 
	Procedure Code	 	Program Type	 	after	 	 	 	 
	99203 GE EP
	 	Other Medical	 	$56.93	 	 	 	 
	99204
	 	Medical Services	 	$80.62	 	 	 	 
	99204 EP
	 	Medical Services	 	$80.62	 	 	 	 
	99204 GT
	 	Medical Services	 	$80.62	 	 	 	 
	99204 GT EP
	 	Medical Services	 	$80.62	 	 	 	 
	99204
	 	Nurse Midwife	 	$80.62	 	 	 	 
	99204 EP
	 	Nurse Midwife	 	$80.62	 	 	 	 
	99204
	 	Podiatry	 	$80.62	 	 	 	 
	99204 W2
	 	Podiatry	 	$80.62	 	 	 	 
	99204
	 	Other Medical	 	$80.62	 	 	 	 
	99204 EP
	 	Other Medical	 	$80.62	 	 	 	 
	99205
	 	Medical Services	 	$102.58	 	 	 	 
	99205 EP
	 	Medical Services	 	$102.58	 	 	 	 
	99205 GT
	 	Medical Services	 	$102.58	 	 	 	 
	99205 GT EP
	 	Medical Services	 	$102.58	 	 	 	 
	99205
	 	Nurse Midwife	 	$102.58	 	 	 	 
	99205 EP
	 	Nurse Midwife	 	$102.58	 	 	 	 
	99205
	 	Podiatry	 	$102.58	 	 	 	 
	99205 W2
	 	Podiatry	 	$102.58	 	 	 	 
	99205
	 	Other Medical	 	$102.58	 	 	 	 
	99205 EP
	 	Other Medical	 	$102.58	 	 	 	 
	99211
	 	Medical Services	 	$12.55	 	 	 	 
	99211 GE
	 	Medical Services	 	$12.55	 	 	 	 
	99211 GT
	 	Medical Services	 	$12.55	 	 	 	 
	99211
	 	Nurse Midwife	 	$12.55	 	 	 	 
	99211
	 	Podiatry	 	$12.55	 	 	 	 
	99211 W2
	 	Podiatry	 	$12.55	 	 	 	 
	99211 GE
	 	Podiatry	 	$12.55	 	 	 	 
	99211
	 	Other Medical	 	$12.55	 	 	 	 
	99211 GE
	 	Other Medical	 	$12.55	 	 	 	 
	99212
	 	Medical Services	 	$22.60	 	 	 	 
	99212 GT
	 	Medical Services	 	$22.60	 	 	 	 
	99212 GE
	 	Medical Services	 	$22.60	 	 	 	 
	99212
	 	Nurse Midwife	 	$22.60	 	 	 	 
	99212
	 	Podiatry	 	$22.60	 	 	 	 
	99212 W2
	 	Podiatry	 	$22.60	 	 	•	 
	99212 GE
	 	Podiatry	 	$22.60	 	 	 	 

 

 

Revised Attachment 14

Page 3 of 5

OFFICE VISIT SERVICES

	 	 	 	 	 
	 	 	 	 	Allowable Fee for
	 	 	 	 	Dates of Service
	 	 	 	 	July 1, 2006 and
	Procedure Code	 	Program Type	 	after
	99212
	 	Other Medical	 	$22.60
	99212 GE
	 	Other Medical	 	$22.60
	99213
	 	Medical Services	 	$30.86
	99213 GE
	 	Medical Services	 	$30.86
	99213 GT
	 	Medical Services	 	$30.86
	99213
	 	Nurse Midwife	 	$30.86
	99213
	 	Podiatry	 	$30.86
	99213 W2
	 	Podiatry	 	$30.86
	99213 GE
	 	Podiatry	 	$30.86
	99213
	 	Other Medical    .	 	$30.86
	99213 GE
	 	Other Medical	 	$30.86
	99214
	 	Medical Services	 	$48.45
	99214 EP
	 	Medical Services	 	$48.45
	99214 GT
	 	Medical Services	 	$48.45
	99214 GT EP
	 	Medical Services	 	$48.45
	99214
	 	Nurse Midwife	 	$48.45
	99214 EP
	 	Nurse Midwife	 	$48.45
	99214
	 	Podiatry	 	$48.45
	99214 W2
	 	Podiatry	 	$48.45
	99214
	 	Other Medical	 	$48.45
	99214 EP
	 	Other Medical	 	$48.45
	99215
	 	Medical Services	 	$70.63
	99215 EP
	 	Medical Services	 	$70.63
	99215 GT
	 	Medical Services	 	$70.63
	99215 GT EP
	 	Medical Services	 	$70.63
	99215
	 	Nurse Midwife	 	$70.63
	99215 EP
	 	Nurse Midwife	 	$70.63
	99215
	 	Podiatry	 	$70.63
	99215 W2
	 	Podiatry	 	$70.63
	99215
	 	Other Medical	 	$70.63
	99215 EP
	 	Other Medical	 	$70.63

 

 

Revised Attachment 14

Page 4 of5

DENTAL SERVICES

	 	 	 
	Procedure Code	 	Age
	D0210
	 	0-125
	D0270
	 	0-125
	D0272
	 	0-125
	D0330
	 	0-125
	D0340
	 	0-20
	D0350
	 	0-20
	D1110
	 	13-125
	D1203
	 	0-20
	D1204
	 	21-125
	D1351
	 	0-20
	D2140
	 	0-125
	D2150
	 	0-125
	D2160
	 	0-125
	D2161
	 	0-125
	D2330
	 	0-125
	D2331
	 	0-125
	D2332
	 	0-125
	D2335
	 	0-125
	D2910
	 	0-125
	D2920
	 	0-125
	D2930
	 	0-125
	D2931
	 	0-125
	D2932
	 	0-125
	D2940
	 	0-125
	D3220
	 	0-125
	D3310
	 	0-125
	D3320
	 	0-125
	D3330
	 	0-125
	D3346
	 	0-125
	D3347
	 	0-125
	D3348
	 	0-125
	D3410
	 	0-125
	D3421
	 	0-125
	D3425
	 	0-125
	D4210
	 	0-125
	D5510
	 	0-125
	D5520
	 	0-125
	D5610
	 	0-125
	D5630
	 	0-125
	D5640
	 	0-125

 

 

Revised Attachment 14

Page 5 of 5

DENTAL SERVICES

	 	 	 
	Procedure Code	 	Age
	D5650
	 	0-125
	D5660
	 	0-125
	D5710
	 	0-125
	D5711
	 	0-125
	D5721
	 	0-125
	D5730
	 	0-125
	D5731
	 	0-125
	D5740
	 	0-125
	D5741
	 	0-125
	D5750
	 	0-125
	D5751
	 	0-125
	D5760
	 	0-125
	D5761
	 	0-125
	D5820
	 	0-125
	D5821
	 	0-125
	D6930
	 	0-125
	D7220
	 	0-125
	D7230
	 	0-125
	D7240
	 	0-125
	D7241
	 	0-125
	D7960
	 	0-125
	D7970
	 	0-125
	D9110
	 	0-125
	D9241
	 	0-125
	D9910
	 	0-125
	D9951
	 	0-125

NOTE: The health plan shall review provider bulletins posted on the DMS website for future code
changes due to HCPCS and HIPAA.

 

 

5.2 West Region — Firm Fixed Net Capitation Pricing Page

	 	 	 	 	 	 	 	 	 
	Category	 	 	 	 	 	State’s Maximum Net	 	Firm Fixed Net
	of	 	 	 	 	 	Capitation Rate	 	Capitation Rate
	Aid	 	Age	 	Sex	 	(Per Member Per Month)	 	(Per Member Per Month)
	1
	 	Newborn < 01	 	Male and Female	 	$677.81	 	$
	 
	 	 	 	 	 	 	 	 
	1
	 	01 - 06	 	Male and Female	 	$125.63	 	$
	 
	 	 	 	 	 	 	 	 
	1
	 	07 - 13	 	Male and Female	 	$107.39	 	$
	 
	 	 	 	 	 	 	 	 
	1
	 	14 - 20	 	Female	 	$265.58	 	$
	 
	 	 	 	 	 	 	 	 
	1
	 	14 - 20	 	Male	 	$121.43	 	$
	 
	 	 	 	 	 	 	 	 
	1
	 	21 - 44	 	Female	 	$353.42	 	$
	 
	 	 	 	 	 	 	 	 
	1
	 	21 - 44	 	Male	 	$196.90	 	$
	 
	 	 	 	 	 	 	 	 
	1
	 	45 - 99	 	Male and Female	 	$402.91	 	$
	 
	 	 	 	 	 	 	 	 
	4
	 	00 - 20 JC	 	Male and Female	 	$206.11	 	$
	 
	 	 	 	 	 	 	 	 
	4
	 	00 - 20 OSJC	 	Male and Female	 	$249.74	 	$
	 
	 	 	 	 	 	 	 	 
	5
	 	00 - 06	 	Male and Female	 	$159.62	 	$
	 
	 	 	 	 	 	 	 	 
	5
	 	07 - 13	 	Male and Female	 	$128.99	 	$
	 
	 	 	 	 	 	 	 	 
	5
	 	14 - 18	 	Male and Female	 	$172.28	 	$
	 
	 	 	 	 	 	 	 	 

 

 

5.3 East Region — Firm Fixed Net Capitation Pricing Page

	 	 	 	 	 	 	 	 	 
	Category	 	 	 	 	 	State’s Maximum Net	 	Firm Fixed Net 
	of	 	 	 	 	 	Capitation Rate	 	Capitation Rate
	Aid	 	Age	 	Sex	 	(Per Member Per Month)	 	(Per Member Per Month)
	1
	 	Newborn < 01	 	Male and Female	 	$777.07	 	$
	 
	 	 	 	 	 	 	 	 
	1
	 	01 - 06	 	Male and Female	 	$113.59	 	$
	 
	 	 	 	 	 	 	 	 
	1
	 	07 - 13	 	Male and Female	 	$90.07	 	$
	 
	 	 	 	 	 	 	 	 
	1
	 	14 - 20	 	Female	 	$240.17	 	$
	 
	 	 	 	 	 	 	 	 
	1
	 	14 - 20	 	Male	 	$114.66	 	$
	 
	 	 	 	 	 	 	 	 
	1
	 	21 - 44	 	Female	 	$333.06	 	$
	 
	 	 	 	 	 	 	 	 
	1
	 	21 - 44	 	Male	 	$172.85	 	$
	 
	 	 	 	 	 	 	 	 
	1
	 	45 - 99	 	Male and Female	 	$399.40	 	$
	 
	 	 	 	 	 	 	 	 
	4
	 	00 - 20	 	Male and Female	 	$207.76	 	$
	 
	 	 	 	 	 	 	 	 
	5
	 	00 - 06	 	Male and Female	 	$  140.03	 	$
	 
	 	 	 	 	 	 	 	 
	5
	 	07 - 13	 	Male and Female	 	$ 108.12	 	$
	 
	 	 	 	 	 	 	 	 
	5
	 	14 - 18	 	Male and Female	 	$158.18	 	$
	 
	 	 	 	 	 	 	 	 

 

 

5.4 Central Region — Firm Fixed Net Capitation Pricing Page

	 	 	 	 	 	 	 	 	 
	Category	 	 	 	 	 	State’s Maximum Net	 	Firm Fixed Net
	of	 	 	 	 	 	Capitation Rate	 	Capitation Rate
	Aid	 	Age	 	Sex	 	(Per Member Per Month)	 	(Per Member Per Month)
	1
	 	Newborn < 01	 	Male and Female	 	$581.95	 	$
	 
	 	 	 	 	 	 	 	 
	1
	 	01 - 06	 	Male and Female	 	$126.99	 	$
	 
	 	 	 	 	 	 	 	 
	1
	 	07 - 13	 	Male and Female	 	$103.08	 	$
	 
	 	 	 	 	 	 	 	 
	1
	 	14 - 20	 	Female	 	$301.80	 	$
	 
	 	 	 	 	 	 	 	 
	1
	 	14 - 20	 	Male	 	$123.65	 	$
	 
	 	 	 	 	 	 	 	 
	1
	 	21 - 44	 	Female	 	$405.35	 	$
	 
	 	 	 	 	 	 	 	 
	1
	 	21 - 44	 	Male	 	$ 194.98	 	$
	 
	 	 	 	 	 	 	 	 
	1
	 	45 - 99	 	Male and Female	 	$416.76	 	$
	 
	 	 	 	 	 	 	 	 
	4
	 	00 - 20	 	Male and Female	 	$207.15	 	$
	 
	 	 	 	 	 	 	 	 
	5
	 	00 - 06	 	Male and Female	 	$162.54	 	$
	 
	 	 	 	 	 	 	 	 
	5
	 	07 - 13	 	Male and Female	 	$124.27	 	$
	 
	 	 	 	 	 	 	 	 
	5
	 	14 - 18	 	Male and Female	 	$178.45	 	$
	 
	 	 	 	 	 	 	 	 

  

 

REVISED ATTACHMENT 12

	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Policies and Procedures Requiring Prior Approval
	 	 	 	Contract	 	 	 	 	Contract	 	 	 	 	Contract
	Required Policy	 	 	Reference	 	Required Policy	 	 	Reference	 	Required Policy	 	 	Reference
	Non-Discrimination in Hiring
and Provisions of Services

	 	 	2.2.6	 	 	24-Hour Coverage
	 	 	2.14.1	 	 	Provider C, G & A
	 	 	2.16	 
	Linking Members to PCPs

	 	 	2.3.2	 	 	Prior Authorization
	 	 	2.14.2	 	 	QA&I
	 	 	2.17.1	 
	Marketing Guidelines

	 	 	2.6.1 a.18)	 	 	Appointment Standards Edu.
	 	 	2.14.4 d.1)	 	 	Utilization Management
	 	 	2.17.5 b	 
	Member Rights

	 	 	2.6.2 j.2)	 	 	Referral to non-network provider
	 	 	2.14.5	 	 	Provider Credentialing
	 	 	2. 17.5 c	 
	Assignment of PCP

	 	 	2.6.2 k.	 	 	Standing Referral to Specialist
	 	 	2.14.6	 	 	Monitoring Providers
	 	 	2.17.5 c.	 
	Assignment of PCP

	 	 	2.6.2 k.4)	 	 	Referral to Specialty Care Cntr.
	 	 	2.14.7	 	 	Records Retention
	 	 	2.26.4	 
	Transfers Between Health Plans

	 	 	2.6.2 r.	 	 	Transitioning of Care
	 	 	2.14.10	 	 	Medical Records
	 	 	2.26.5	 
	Disenrollment Effective Dates

	 	 	2.6.2 u.	 	 	Care Management
	 	 	2.14.11 c.	 	 	Fraud & Abuse
	 	 	2.31	 
	Provider Listing Updates

	 	 	2.9.1 g.	 	 	Certification Review
	 	 	2.14.12	 	 	Subcontractor Oversight
	 	 	3.8.3	 
	Second Opinion

	 	 	2.13	 	 	Member Grievance System
	 	 	2.15	 	 	 	 	 	 	 

 

 

	 	 	 
	

	 	STATE OF MISSOURI

OFFICE OF ADMINISTRATION

DIVISION OF PURCHASING AND MATERIALS MANAGEMENT (DPMM)

CONTRACT AMENDMENT

	 	 	 
	AMENDMENT NO.: 003

	 	REQ NO.: NR 886 25757007159
	CONTRACT NO.: C306118003

	 	BUYER: Laura Ortmeyer
	TITLE: Medicaid Managed Care — Central, Eastern, and Western Regions 	 	PHONE NO.: (573) 751-4579
	ISSUE DATE: 02/23/07

	 	E-MAIL: laura.ortmeyer@oa.mo.gov

			
	TO:	 	MERCY CAREPLUS

10123 CORPORATE SQUARE DR

ST LOUIS, MO 63132

RETURN AMENDMENT NO LATER THAN: March 7, 2007 AT 5:00 PM CENTRAL TIME

RETURN AMENDMENT TO:

	 	 	 	 	 
	(U.S. Mail)	 	 	 	(Courier Service)
	Div of Purchasing & Matls Mgt (DPMM)

	 	OR
	 	Div of Purchasing & Matls Mgt (DPMM)
	 

	 	 	 	 
	PO BOX 809

	 	 	 	301 WEST HIGH STREET, ROOM 630
	JEFFERSON CITY MO 65102-0809

	 	 	 	JEFFERSON CITY MO 65101

OR FAX
TO: (573) 526-9817 (either mail or fax, not both)

DELIVER SUPPLIES/SERVICES FOB (Free On Board) DESTINATION TO THE FOLLOWING ADDRESS:

Missouri Department of Social Service

Division of Medical Services

P.O. Box 6500

Jefferson City, MO 65102-6500

SIGNATURE REQUIRED

	 	 	 
	DOING
BUSINESS AS (DBA) NAME

	 	LEGAL NAME OF ENTITY/INDIVIDUAL
FILED WITH IRS FOR THIS TAX ID NO.
	 
	 	 
	Mercy CarePlus

	 	Alliance for Community Health, LLC
	MAILING
ADDRESS

	 	IRS FORM 1099 MAILING ADDRESS
	 
	 	 
	10123 Corporate Square Drive

	 	10123 Corporate Square Drive
	CITY,
STATE, ZIP CODE

	 	CITY, STATE, ZIP CODE
	 
	 	 
	St. Louis, MO 63132

	 	St. Louis, MO 63132

	 	 	 
	CONTACT
PERSON

	 	EMAIL ADDRESS
	 
	 	 
	Jerry Linder

	 	jlinder@mercycareplus.com
	PHONE
NUMBER

	 	FAX NUMBER
	 
	 	 
	(314) 432-9300 Ext. 202

	 	(314) 432-9203 or (314) 994-9398

					
	 	 	 	 	 
	TAXPAYER ID NUMBER (TIN)
	 	TAXPAYER ID (TIN) TYPE (CHECK ONE)
	 	VENDOR NUMBER (IF KNOWN)
	 	 	 	 	 
	43-1743902
	 	þ FEIN     

o SSN
	 	4317439020 2

			
	 	 	 
	VENDOR TAX FILING TYPE WITH IRS
(CHECK ONE)
	 	(NOTE: LLC IS NOT A VALID TAX
FILING TYPE.)

											
	 	 	 	 	 	 	 	 	 	 	 
	þ Corporation
	 	
o
Individual
	 	
o
State/Local Government
	 	o
Partnership
	 	o
Sole Proprietor
	 	o
Other
                 

	 	 	 
	AUTHORIZED
SIGNATURE

	 	DATE
	 
	 	 
	/s/ Jerry Linder

	 	February 27, 2007 
	PRINTED
NAME

	 	Chief Executive Officer - President
	 
	 	 
	Jerry Linder
	 	 

 

 

			
	Contract C306118003
	 	Page 2

AMENDMENT #003 TO CONTRACT C306118003

	 	 	 
	CONTRACT TITLE:

	 	Medicaid Managed Care - Central, Eastern, and Western Regions
	 
	 	 
	CONTRACT PERIOD:

	 	July 1, 2006 through June 30, 2007

The State of Missouri hereby desires to amend the above-referenced contract, as follows, effective
July 1, 2006:

In order to determine the impact of the eligibility changes implemented effective with fiscal year
2007 on the overall birth rate, the state agency’s actuary consultant conducted an analysis
specific to the female child bearing rate cells in order to ensure the actuarially soundness of the
rates. The attached Pricing Page reflects the actuarially sound rates determined as a result of the
analysis.

The contractor shall indicate in Column 2 on the attached Pricing Page, any changes to the firm
fixed prices of the contract for performing the required services in accordance with the terms,
conditions, and provisions of the contract. The contractor’s firm, fixed PMPM Net Capitation Rate
for Each Category of Aid (COA) Rate subgroup must not exceed the State’s Maximum Net Capitation
Rate Listed in Column 1.

All other terms, conditions and provisions of the contract, including all prices, shall remain the
same and apply hereto.

The
contractor shall sign and return this document, on or before the date indicated, signifying
acceptance of the amendment.

 

 

5.2 West Region — Firm Fixed Net Capitation Pricing Page

	 	 	 	               	 	 	 	 	 	 	 	 	 	 	 	 	 
	Category	 	 	 	 	 	 	 	State’s Maximum
Net	 	Firm Fixed Net
	of	 	 	 	 	 	 	 	Capitation Rate	 	Capitation Rate
	Aid	 	Age	 	Sex	 	(Per Member Per Month)	 	(Per Member Per Month)
	 	1	 	 	Newborn < 01
	 	Male and Female	 	$	677.81	 	 	$	677.81	 
	 	1	 	 	01 - 06
	 	Male and Female	 	$	125.63	 	 	$	125.63	 
	 	1	 	 	07 - 13
	 	Male and Female	 	$	107.39	 	 	$	107.39	 
	 	1	 	 	14 - 20
	 	Female	 	$	270.37	 	 	$	270.37	 
	 	1	 	 	14 - 20
	 	Male	 	$	121.43	 	 	$	121.43	 
	 	1	 	 	21 - 44
	 	Female	 	$	368.58	 	 	$	368.58	 
	 	1	 	 	21 - 44
	 	Male	 	$	196.90	 	 	$	196.90	 
	 	1	 	 	45 - 99
	 	Male and Female	 	$	402.91	 	 	$	402.91	 
	 	4	 	 	00 - 20 JC
	 	Male and Female	 	$	249.74	 	 	$	249.74	 
	 	4	 	 	00 - 20 OSJC
	 	Male and Female	 	$	206.11	 	 	$	206.11	 
	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	 	5	 	 	00 - 06
	 	Male and Female	 	$	159.62	 	 	$	159.62	 
	 	5	 	 	07 - 13
	 	Male and Female	 	$	128.99	 	 	$	128.99	 
	 	5	 	 	14 - 18
	 	Male and Female	 	$	172.28	 	 	$	172.28	 

 

 

5.3 East Region — Firm Fixed Net Capitation Pricing Page

	 	 	 	               	 	 	 	 	 	 	 	 	 	 	 	 	 
	Category	 	 	 	 	 	 	 	State’s Maximum
Net	 	Firm Fixed Net
	of	 	 	 	 	 	 	 	Capitation Rate	 	Capitation Rate
	Aid	 	Age	 	Sex	 	(Per Member Per Month)	 	(Per Member Per Month)
	 	1	 	 	Newborn < 01
	 	Male and Female	 	$	777.07	 	 	$	777.07	 
	 	1	 	 	01 - 06
	 	Male and Female	 	$	113.59	 	 	$	113.59	 
	 	1	 	 	07 - 13
	 	Male and Female	 	$	90.07	 	 	$	90.07	 
	 	1	 	 	14 - 20
	 	Female	 	$	269.72	 	 	$	269.72	 
	 	1	 	 	14 - 20
	 	Male	 	$	114.66	 	 	$	114.66	 
	 	1	 	 	21 - 44
	 	Female	 	$	368.27	 	 	$	368.27	 
	 	1	 	 	21 - 44
	 	Male	 	$	172.85	 	 	$	172.85	 
	 	1	 	 	45 - 99
	 	Male and Female	 	$	399.40	 	 	$	399.40	 
	 	4	 	 	00 - 20
	 	Male and Female	 	$	207.76	 	 	$	207.76	 
	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	 	5	 	 	00 - 06
	 	Male and Female	 	$	140.03	 	 	$	140.03	 
	 	5	 	 	07 - 13
	 	Male and Female	 	$	108.12	 	 	$	108.12	 
	 	5	 	 	14 - 18
	 	Male and Female	 	$	158.18	 	 	$	158.18	 

 

 

5.4 Central Region — Firm Fixed Net Capitation Pricing Page

	 	 	 	                 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Category	 	 	 	 	 	 	 	State’s Maximum
Net	 	Firm Fixed Net
	of	 	 	 	 	 	 	 	Capitation Rate	 	Capitation Rate
	Aid	 	Age	 	Sex	 	(Per Member Per Month)	 	(Per Member Per Month)
	 	1	 	 	Newborn < 01
	 	Male and Female	 	$	581.95	 	 	$	581.95	 
	 	1	 	 	01 - 06
	 	Male and Female	 	$	126.99	 	 	$	126.99	 
	 	1	 	 	07 - 13
	 	Male and Female	 	$	103.08	 	 	$	103.08	 
	 	1	 	 	14 - 20
	 	Female	 	$	314.36	 	 	$	314.36	 
	 	1	 	 	14 - 20
	 	Male	 	$	123.65	 	 	$	123.65	 
	 	1	 	 	21 - 44
	 	Female	 	$	427.42	 	 	$	427.42	 
	 	1	 	 	21 - 44
	 	Male	 	$	194.98	 	 	$	194.98	 
	 	1	 	 	45 - 99
	 	Male and Female	 	$	416.76	 	 	$	416.76	 
	 	4	 	 	00 - 20
	 	Male and Female	 	$	207.15	 	 	$	207.15	 
	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	 	5	 	 	00 - 06
	 	Male and Female	 	$	162.54	 	 	$	162.54	 
	 	5	 	 	07 - 13
	 	Male and Female	 	$	124.27	 	 	$	124.27	 
	 	5	 	 	14 - 18
	 	Male and Female	 	$	178.45	 	 	$	178.45	 

 

 

	 	 	 
	

	 	STATE OF MISSOURI

OFFICE OF ADMINISTRATION

DIVISION OF PURCHASING AND MATERIALS MANAGEMENT (DPMM)

CONTRACT AMENDMENT

	 	 	 
	AMENDMENT NO.: 004

	 	REQ NO.: NR 886 25757006928
	CONTRACT NO.: C306118003

	 	BUYER: Laura Ortmeyer
	TITLE: Medicaid
Managed Care — Central, Eastern, and Western Regions	 	PHONE NO.: (573) 751-4579
	ISSUE DATE: 02/23/07

	 	E-MAIL: laura.ortmeyer@oa.mo.gov

	TO:	 	MERCY CAREPLUS

10123 CORPORATE SQUARE DR 

ST LOUIS, MO 63132

RETURN AMENDMENT NO LATER THAN: March 7, 2007 AT 5:00 PM CENTRAL TIME

RETURN AMENDMENT TO:

	 	 	 	 	 
	(U.S. Mail)	 	 	 	(Courier Service)
	Div of Purchasing & Matls Mgt (DPMM)

	 	OR
	 	Div of Purchasing & Matls Mgt (DPMM)
	PO BOX 809

	 	 	 	301 WEST HIGH STREET, ROOM 630
	JEFFERSON CITY MO 65102-0809

	 	 	 	JEFFERSON CITY MO 65101

OR FAX TO: (573) 526-9817 (either mail or fax, not both)

DELIVER SUPPLIES/SERVICES FOB (Free On Board) DESTINATION TO THE FOLLOWING ADDRESS:

Missouri Department of Social Service

Division of Medical Services

P.O. Box 6500

Jefferson City, MO 65102-6500

SIGNATURE REQUIRED

	 	 	 
	DOING BUSINESS AS (DBA) NAME

	 	LEGAL NAME OF ENTITY/INDIVIDUAL FILED WITH IRS FOR THIS TAX ID NO.
	 
	 	 
	Mercy CarePlus

MAILING ADDRESS

	 	Alliance for Community Health, LLC

IRS FORM 1099 MAILING ADDRESS
	 
	 	 
	10123 Corporate Square Drive

CITY, STATE, ZIP CODE

	 	10123 Corporate Square Drive

CITY, STATE, ZIP CODE
	 
	 	 
	St. Louis, MO 63132

	 	St. Louis, MO 63132

	 	 	 
	CONTACT PERSON

	 	EMAIL ADDRESS
	 
	 	 
	Jerry Linder

PHONE NUMBER

	 	jlinder@mercycareplus.com

FAX NUMBER
	 
	 	 
	(314) 432-9300 Ext. 202

	 	(314)432-9203 or (314) 994-9398

	 	 	 	 	 
	TAXPAYER ID NUMBER (TIN)

	 	TAXPAYER ID (TIN) TYPE (CHECK ONE)
	 	VENDOR NUMBER(IF- KNOWN)
	 
	 	 	 	 
	43-1743902

	 	þ
FEIN    o SSN
	 	4317439020 2

			
	VENDOR TAX FILING TYPE WITH IRS (CHECK ONE)
	 	(NOTE: LLC IS NOT A VALID TAX FILING TYPE.)

þ
Corporation           
o
Individual          
o State/Local Government          

o Partnership          
o Sole
Proprietor          
o Other          

	 	 	 
	AUTHORIZED SIGNATURE

	 	DATE
	 
	 	 
	/s/
Jerry Linder

PRINTED NAME

	 	February 27, 2007

TITLE
	 
	 	 
	Jerry Linder

	 	Chief Executive Officer — President

 

 

			
	Contract C306118003
	 	Page 2

AMENDMENT #004 TO CONTRACT C306118003

	 	 	 
	CONTRACT TITLE:

	 	Medicaid Managed Care — Central, Eastern, and Western Regions
	 
	 	 
	CONTRACT PERIOD:

	 	July 1, 2006 through June 30, 2007

The State of Missouri hereby desires to amend the above-referenced contract in accordance with the
following:

	1.	 	Paragraph 2.4.8 a. 2) is hereby amended effective January 1, 2007:

	 	2)	 	The health plan shall pay out-of-network providers for emergency
services at the current Missouri Medicaid program rates in effect at the time of
service.

	2.	 	Paragraph 2.28.1 b. is hereby amended effective July 1, 2006:

	 	b.	 	If the health plan is new to a MC+ managed care region, the health plan
shall agree that its capitation rate shall reflect the average participant ratio of
the MC+ managed care health plans that are not new to the region by rate cell and
category of assistance for the applicable measurement period reflected in
Attachment 11. Beginning January 2008, the new health plan shall agree that their
future capitation rates shall be adjusted by the health plan’s actual 12-month
HCY/EPSDT participant ratio.

All other terms, conditions and provisions of the contract, including all prices, shall remain the
same and apply hereto.

The contractor shall sign and return this document, on or before the date indicated, signifying
acceptance of the amendment.

 

 

(SEAL)

NOTICE OF AWARD

State Of Missouri

Office Of Administration

Division Of Purchasing And Materials Management

PO Box 809

Jefferson City, MO 65102

http://www.oa.mo.gov/purch

	 	 	 
	CONTRACT NUMBER

	 	CONTRACT TITLE
	 
	 	 
	C306118003

	 	Medicaid Managed Care-Central, Eastern, and Western Regions
	 
	 	 
	AMENDMENT NUMBER

	 	CONTRACT PERIOD
	 
	 	 
	005

	 	July 1, 2007 through June 30, 2008
	 
	 	 
	REQUISITION NUMBER

	 	VENDOR NUMBER
	 
	 	 
	MR 886 25757008216

	 	4317439020 2
	 
	 	 
	CONTRACTOR NAME AND ADDRESS

	 	STATE AGENCY’S NAME AND ADDRESS
	 
	 	 
	Mercy Careplus

	 	Department of Social Services
	10123 Corporate Square Dr

	 	Division of Medical Services
	St. Louis, MO 63132

	 	Jefferson City, MO 65102-6500 PO Box 6500
	 
	 	 
	ACCEPTED BY THE STATE OF MISSOURI AS FOLLOWS:
	 
	 	 
	Contract C306118003 is hereby amended pursuant to the attached Amendment #005 dated April 16, 1007.
	 
	 	 
	 
	 	 
	BUYER

	 	BUYER CONTACT INFORMATION
	 
	 	 
	Laura Ortmeyer

	 	Email: laura.ortmeyer@oa.mo.gov
	 

	 	Phone: (573) 751-4579
	 

	 	Fax: (573)526-9817
	SIGNATURE OF BUYER

	 	DATE
	 
	 	 
	/s/ Laura Ortmeyer

	 	April 24, 2007
	 
	 	 
	DIRECTOR
OF PURCHASING AND MATERIALS MANAGEMENT

	 
	 	 
	/s/
James Milvsk
	 	 

 

 

	 	 	 
	(SEAL)

	 	STATE OF MISSOURI
	 

	 	OFFICE OF ADMINISTRATION
	 

	 	DIVISION OF PURCHASING AND MATERIALS MANAGEMENT (DPMM)

	 

	 	CONTRACT RENEWAL

	 	 	 
	AMENDMENT NO.: 005

	 	REQ NO.: NR 886 25757008216
	CONTRACT NO.: C306118003

	 	BUYER: Laura Ortmeyer
	TITLE: Medicaid Managed Care — Central, Eastern, and Western Regions  

	 	PHONE NO.: (573) 751-4579
	ISSUE DATE: 04/10/07

	 	E-MAIL: laura.ortmeyer@oa.mo.gov

	 	 	 
	TO:

	 	MERCY CAREPLUS
	 

	 	10123 CORPORATE SQUARE DR
	 

	 	ST LOUIS MO 63132

RETURN AMENDMENT NO LATER THAN: 04/24/07 AT 5:00 PM CENTRAL TIME

RETURN AMENDMENT TO:

	 	 	 	 	 
	(U.S. Mail)	 	 	 	(Courier Service)
	Div of Purchasing & Matls Mgt (DPMM)

	 	OR
	 	Div of Purchasing & Matls Mgt (DPMM)
	PO BOX 809

	 	 	 	301 WEST HIGH STREET, ROOM 630
	JEFFERSON CITY MO 65102-0809

	 	 	 	JEFFERSON CITY MO 65101

OR FAX
TO: (573) 526-9817 (either mail or fax, not both)

DELIVER SUPPLIES/SERVICES FOR (Free On Board) DESTINATION TO THE FOLLOWING ADDRESS:

Department of Social Services

Division of Medical Services

PO Box 6500

Jefferson City MO 65102-6500

SIGNATURE REQUIRED

	 	 	 
	DOING BUSINESS AS (DBA) NAME

	 	LEGAL NAME OF ENTITY/INDIVIDUAL FILED WITH IRS FOR THIS TAX ID NO.
	 
	Mercy CarePlus

	 	Alliance for Community Health, LLC dba Mercy CarePlus
	 
	MAILING ADDRESS

	 	IRS FORM 1099 MAILING ADDRESS
	 
	10123 Corporate Square Drive

	 	10123 Corporate Square Drive
	CITY, STATE, ZIP CODE

	 	CITY, STATE, ZIP CODE
	 
	St. Louis, MO 63132

	 	St. Louis, MO 63132
	CONTACT PERSON

	 	EMAIL ADDRESS
	 
	Jerry Linder

	 	jlinder@mercycareplus. com
	PHONE NUMBER

	 	FAX NUMBER
	 
	(314) 432-9300 ext. 202

	 	(314) 994-9389

	 	 	 	 	 
	TAXPAYER ID NUMBER (TIN)

	 	TAXPAYER ID (TIN) TYPE (CHECK ONE)
	 	VENDOR NUMBER (IF KNOWN)
	 
	43-1743902

	 	þ FEIN       o SSN
	 	4317439020 2

	 	 	 	 	 	 	 	 	 	 	 
	VENDOR TAX FILING TYPE WITH IRS (CHECK ONE)	 	 	 	(NOTE: LLC IS NOT A VALID TAX FILING TYPE.)
	 
	 	 	 	 	 	 	 	 	 	 
	þ  Corporation

	 	o  Individual
	 	o  State/Local Government
	 	o  Partnership
	 	o   Sole Proprietor   o  Other               

	 	 	 
	AUTHORIZED SIGNATURE

	 	DATE
	 
	/s/ Jerry Linder

	 	4-16-07
	PRINTED NAME

	 	TITLE
	 
	Jerry Linder

	 	CEO

 

 

			
	 

Contract C306118003 
	 	Page 2

AMENDMENT #005 TO CONTRACT C306118003

	 	 	 
	CONTRACT TITLE:

	 	Medicaid Managed Care — Central, Eastern, and Western Regions
	 
	CONTRACT PERIOD:

	 	July 1, 2007 through June 30, 2008

The State of Missouri hereby exercises its option to renew the above-referenced contract.

The contractor shall indicate in Column 2 on the attached Pricing page, any changes to the firm,
fixed prices of the contract for performing the required services in accordance with the terms,
conditions, and provisions of the contract. The contractor’s firm, fixed PMPM Net Capitation Rate
for Each Category of Aid (COA) Rate subgroup must not exceed the State’s Maximum Net Capitation
Rate listed in Column 1.

The contractor must furnish a performance security deposit in accordance with the terms and
conditions stated in the original contract in the amount of $1,000,000.00 for each region. The
performance security deposit must specify the contract number and contract period.

All other terms, conditions and provisions of the previous contract period shall remain and apply
hereto. The contractor shall sign and return this document, along with completed pricing and the
applicable bond, on or before the date indicated.

	NOTE:	 	The contractor’s failure to complete and return this document shall not stop the action
specified herein. If the contractor fails to complete and return this document prior to the
return date specified or the effective date of the contract period stated above,
whichever is later, the state may renew the contract at the same price(s) as the
previous contract period or at the price(s) allowed by the contract, whichever is
lower.

 

 

C306118003

5.3 East Region — Firm Fixed Net Capitation Pricing Page

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	Column 1	 	Column 2
	Category	 	 	 	 	 	State’s Maximum Net	 	Firm Fixed Net
	of	 	 	 	 	 	Capitation Rate	 	Capitation Rate
	Aid	 	Age	 	Sex	 	(Per Member Per Month)	 	(Per Member Per Month)
	1

	 	Newborn < 01
	 	Male and Female
	 	$	863.53	 	 	$	863.53	 
	1

	 	01 - 06
	 	Male and Female
	 	$	125.55	 	 	$	125.55	 
	1

	 	07 - 13
	 	Male and Female
	 	$	98.44	 	 	$	98.44	 
	1

	 	14 - 20
	 	Female
	 	$	306.93	 	 	$	306.93	 
	1

	 	14 - 20
	 	Male
	 	$	126.73	 	 	$	126.73	 
	1

	 	21 - 44
	 	Female
	 	$	418.80	 	 	$	418.80	 
	1

	 	21 -  44
	 	Male
	 	$	191.64	 	 	$	191.64	 
	1

	 	45 - 99
	 	Male and Female
	 	$	436.77	 	 	$	436.77	 
	4

	 	00 - 20
	 	Male and Female
	 	$	233.97	 	 	$	233.97	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	5

	 	00 - 06
	 	Male and Female
	 	$	152.68	 	 	$	152.68	 
	5

	 	07 - 13
	 	Male and Female
	 	$	117.88	 	 	$	117.88	 
	5

	 	14 - 18
	 	Male and Female
	 	$	175.38	 	 	$	175.38	 

 

 

C306118003

5.2 West Region — Firm Fixed Net Capitation Pricing Page

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	Column 1	 	Column 2
	Category	 	 	 	 	 	State’s Maximum Net	 	Firm Fixed Net
	of	 	 	 	 	 	Capitation Rate	 	Capitation Rate
	Aid	 	Age	 	Sex	 	(Per Member Per Month)	 	(Per Member Per Month)
	1

	 	Newborn < 01
	 	Male and Female
	 	$	758.67	 	 	$	758.67	 
	1

	 	01 - 06
	 	Male and Female
	 	$	147.55	 	 	$	147.55	 
	1

	 	07 - 13
	 	Male and Female
	 	$	119.08	 	 	$	119.08	 
	1

	 	14 - 20
	 	Female
	 	$	312.64	 	 	$	312.64	 
	1

	 	14 - 20
	 	Male
	 	$	149.02	 	 	$	149.02	 
	1

	 	21 - 44
	 	Female
	 	$	469.35	 	 	$	469.35	 
	1

	 	21 - 44
	 	Male
	 	$	229.66	 	 	$	229.66	 
	1

	 	45 - 99
	 	Male and Female
	 	$	447.06	 	 	$	447.06	 
	4

	 	00 - 20 JC
	 	 
	 	$	284.16	 	 	$	284.16	 
	4

	 	00 - 20 OSJC
	 	Male and Female
	 	$	230.99	 	 	$	230.99	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	5

	 	00 - 06
	 	Male and Female
	 	$	177.17	 	 	$	177.17	 
	5

	 	07 - 13
	 	Male and Female
	 	$	142.71	 	 	$	142.71	 
	5

	 	14 - 18
	 	Male and Female
	 	$	191.75	 	 	$	191.75	 

 

 

C306118003

5.4 Central Region — Firm Fixed Net Capitation Pricing Page

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	Column 1	 	Column 2
	Category	 	 	 	 	 	State’s Maximum Net	 	Firm Fixed Net
	of	 	 	 	 	 	Capitation Rate	 	Capitation Rate
	Aid	 	Age	 	Sex	 	(Per Member Per Month)	 	(Per Member Per Month)
	1

	 	Newborn < 01
	 	Male and Female
	 	$	687.17	 	 	$	687.17	 
	1

	 	01 - 06
	 	Male and Female
	 	$	143.61	 	 	$	143.61	 
	1

	 	07 - 13
	 	Male and Female
	 	$	116.00	 	 	$	116.00	 
	1

	 	14 - 20
	 	Female
	 	$	340.24	 	 	$	340.24	 
	1

	 	14 - 20
	 	Male
	 	$	144.98	 	 	$	144.98	 
	1

	 	21 - 44
	 	Female
	 	$	483.82	 	 	$	483.82	 
	1

	 	21 - 44
	 	Male
	 	$	230.15	 	 	$	230.15	 
	1

	 	45 - 99
	 	Male and Female
	 	$	470.57	 	 	$	470.57	 
	4

	 	00 - 20
	 	Male and Female
	 	$	227.94	 	 	$	227.94	 
	 
	 	 	 	 	 	 	 	 	 	 	 	 
	5

	 	00 - 06
	 	Male and Female
	 	$	175.25	 	 	$	175.25	 
	5

	 	07 - 13
	 	Male and Female
	 	$	134.72	 	 	$	134.72	 
	5

	 	14 - 18
	 	Male and Female
	 	$	193.45	 	 	$	193.45

Source: [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00138-of-00352.parquet"}, [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00138-of-00352.parquet"}]]