Document:

Exhibit 10.16

    
      
        

      

    

    Back
      to Form 10-Q

     

    Exhibit
      10.16

     

     

    Contract
      with Eligible Medicare Advantage Organization Pursuant to 

    Sections
      1851 through 1859 of the Social Security Act for the Operation 

     

    of
      a
      Medicare Advantage Private Fee-For-Service Plan(s)

     

    

     

    CONTRACT
      (#4577)

     

    Between

     

    Centers
      for Medicare & Medicaid Services (hereinafter referred to as
      CMS)

     

    And

    

    Home
      Owners / WellCare PFFS Insurance, Inc.

    (hereinafter
      referred to as the MA Organization)

     

    CMS
      and
      the MA Organization, an entity which has been determined to be an eligible
      Medicare Advantage Organization by the Administrator of the Centers for Medicare
      & Medicaid Services under 42 CFR 422.503, agree to the following for the
      purposes of sections 1851 through 1859 of the Social Security Act (hereinafter
      referred to as the Act):

     

    (NOTE:
      Citations indicated in brackets are placed in the text of this contract to
      note
      the regulatory authority for certain contract provisions. All references to
      Part
      422 are to 42 CFR Part 422.)

     

    

      You
        must check off AND initial each required Addendum type to reflect the coverage
        offered under the H (or R) number associated with this
        contract

       

    

    
      	
              Addendum
                Type

            	
              Initials

            
	
              ü 

            	
              Part
                D Addendum

            	
              TF   
                

            
	
              ü

            	
              Employer-Only
                MA-PD Addendum (800 Series)

            	
              TF    

            
	
              __

            	
              Employer-Only
                MA Only Addendum (800 Series)

            	
              ____

            
	
              __

            	
              Variances/Waivers
                (Provided directly to Demonstration Organizations by CMS)

            	
              ____

            

    

     

    
 

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    

       

      Article
        I

       

      Term
        of
        Contract

       

      The
        term
        of this contract shall be from the date of signature by CMS' authorized
        representative through December 31, 2007, after which this contract may be
        renewed for successive one-year periods in accordance with 42 CFR 422.505(c).
        [422.505]

      This
        contract governs the respective rights and obligations of the parties as
        of the
        effective date set forth above, and supersedes any prior agreements between
        the
        MA Organization and CMS as of such date. MA organizations offering Part D
        benefits also must execute an Addendum to the Medicare Managed Care Contract
        Pursuant to Sections 1860D-1 through 1860D-42 of the Social Security Act
        for the
        Operation of a Voluntary Medicare Prescription Drug Plan (hereafter the "Part
        D
        Addendum"). For MA Organizations offering MA-PD plans, the Part D Addendum
        governs the rights and obligations of the parties relating to the provision
        of
        Part D benefits, in accordance with its terms, as of its effective
        date.

      

      Article
        II

      

      Private
        Fee-For-Service Plan

       

      A.
        The MA
        Organization agrees to operate one or more private fee-for-service plans
        (as
        defined in
        42 CFR
        422.4(a)(3)), as described in its final Plan Benefit Package (PBP) bid
        submission (benefit
        and price bid) proposal as approved by CMS and as attested to in the Medicare
        Advantage
        Attestation of Benefit Plan and Price, and in compliance with the requirements
        of this contract
        and applicable Federal statutes, regulations, and policies.

       

      B.
        Except
        as provided in paragraph (C) of this Article, this contract is deemed to
        incorporate any changes
        that are required by statute to be implemented during the term of the contract
        and any regulations
        or policies implementing or interpreting such statutory provisions.

       

      C.
        CMS
        will not implement, other than at the beginning of a calendar year, requirements
        under 42 CFR
        Part
        422 that impose a new significant cost or burden on MA organizations or plans,
        unless a
        different effective date is required by statute.
        [422.521]

      

      Article
        III

      

      Functions
        To Be
        Performed By Medicare Advantage Organization

       

      A.
        PROVISION OF BENEFITS

      1.
        The MA
        Organization agrees to provide enrollees in each of its MA plans the basic
        benefits as
        required under §422.101 and, to the extent applicable, supplemental benefits
        under §422.102 and as established in the MA Organization's final benefit and
        price bid proposal as approved by CMS and listed in The MA Organization
        Attestation of Benefit Plan and Price, which is attached to this contract.
        The
        MA Organization agrees to provide access to
        such
        benefits as required under
        subpart C in a manner consistent with professionally recognized standards
        of
        health care and according to the access standards stated in §422.114. The MA
        Organization agrees to

       

      2

      provide
        post-hospital extended care services, should an MA enrollee elect such coverage,
        through
        a
        skilled nursing facility according to the requirements of section 1852(1)
        of the
        Act and §422.133 . A home skilled nursing facility is a facility in which an MA
        enrollee resided at the time of admission to the hospital, a facility that
        provides services through a continuing care retirement community, or a facility
        in which the spouse of the enrollee is residing at the time of the enrollee's
        discharge from the hospital, or hospital, or wherever the enrollee resides
        immediately before admission for extended care services. [422.133;
        422.504(a)(3)]

      2.
        The MA
        Organization shall authorize benefits according to the local medical review
        policies (LMRPs) for services provided in geographic areas where the LMRPs
        represent an expansion of Medicare coverage policies as compared to national
        Medicare coverage policies.
        [422.101(b)(2)]

       

      B.
        ENROLLMENT REQUIREMENTS

      1.
        The MA
        Organization agrees to accept new enrollments, make enrollments effective,
        process voluntary disenrollments, and limit involuntary disenrollments, as
        provided in subpart B of part 422.

      2.
        The MA
        Organization shall comply with the provisions of §422.110 concerning
        prohibitions against discrimination in beneficiary enrollment. [422.504(a)(2)]

       

      C.
        BENEFICIARY PROTECTIONS

      1.
        The MA
        Organization agrees to comply with all requirements in subpart M of part
        422
        governing coverage determinations, grievances, and appeals. [422.504(a)(7)]

      2.
        The MA
        Organization agrees to comply with the confidentiality and enrollee record
        accuracy requirements in §422.118.

      3.
        Beneficiary
        Financial Protection.
        The MA
        Organization agrees to comply with the following requirements:

      (a)
        Each
        MA Organization must adopt and maintain arrangements satisfactory to CMS
        to
        protect its enrollees from incurring liability for payment of any fees that
        are
        the legal obligation of the MA Organization. To meet this requirement the
        MA
        Organization must—

      (i)
        Ensure that all contractual (including deemed contracts under §422.216) or other
        written arrangements with providers prohibit the Organization's providers
        from
        holding any beneficiary enrollee liable for payment of any fees that are
        the
        legal obligation of the MA Organization; and

      (ii)
        Indemnify the beneficiary enrollee for payment of any fees that are the legal
        obligation of the MA Organization for services furnished by providers that
        do
        not contract, or that have not otherwise entered into an agreement with the
        MA
        Organization, to provide services to the organization's beneficiary enrollees.
        This provision does not apply to providers operating under deemed contracts
        under §422.216.
        [422.504(g)(l)]

      (iii)
        Ensure that in the MA Organization's terms and conditions of payment to
        hospitals, if balance billing is imposed, the hospitals are obligated to
        provide
        notice to enrollees of their potential liability for services where balance
        billing could amount to not less than $500. This notice shall be provided
        according to the requirements of §422.216(d)(2).

      (b)
        The
        MA Organization must provide for continuation of enrollee health care
        benefits-

      (i)
        For
        all enrollees, for the duration of the contract period for which CMS payments
        have been made" and

      (ii)
        For
        enrollees who are hospitalized on the date its contract with CMS terminates,
        or,
        in the event of the MA Organization's insolvency, through the date of discharge.
        [422.504(g)(2)]

      (c)
        In
        meeting the requirements of this section (C), other than the provider contract
        requirements specified in paragraph (C)(3)(a) of this Article, the MA
        Organization may use—

      (i)
        Contractual arrangements;

      (ii)
        Insurance acceptable to CMS;

      (iii)
        Financial reserves acceptable to CMS; or

      (iv)
        Any
        other arrangement acceptable to CMS.
        [422.504(g)(3)

       

      3

       

      D.
        PROVIDER PROTECTIONS

      1.
        The MA
        Organization agrees to comply with all applicable provider requirements in
        42
        CFR Part 422 Subpart E, including provider certification requirements,
        anti-discrimination requirements, provider participation and consultation
        requirements, the prohibition on interference with provider advice, limits
        on
        provider indemnification, rules governing payments to providers, and limits
        on
        physician incentive plans.
        [422.504(a)(6)]

      2.
        Prompt
        Payment.

      (a)
        The
        MA Organization must pay 95 percent of "clean claims" within 30 days of receipt
        if they are submitted by, or on behalf of, an enrollee of a MA PFFS plan
        or are
        for claims for services that are not furnished under a written agreement
        between
        the organization and the provider.

      (i)
        The
        MA Organization must pay interest on clean claims that are not paid within
        30
        days in accordance with sections 1816(c)(2) and 1842(c)(2) of the
        Act.

      (ii)
        All
        other claims from non-contracted providers must be paid or denied within
        60
        calendar days from the date of the request. [422.520(a)]

      (b)
        Contracts, deemed contracts, or other written agreements between the MA
        Organization and its providers must contain a prompt payment provision, the
        terms of which are developed and agreed to by both the MA Organization and
        the
        relevant provider.
        [422.520(b)]

      (c)
        If
        CMS determines, after giving notice and opportunity for hearing, that the
        MA
        Organization has failed to make payments in accordance with subparagraph
        (2)(a)
        of this section, CMS may provide—

      (i)
        For
        direct payment of the sums owed to providers; and

      (ii)
        For
        appropriate reduction in the amounts that would otherwise be paid to the
        MA
        Organization, to reflect the amounts of the direct payments and the cost
        of
        making those payments.
        [422.520(c)]

       

      3.
        Payment
        Rates:

      (a)
        The
        MA Organization shall make payments to providers according to the requirements
        of §422.114.

      (b)
        CMS
        and the MA Organization shall reach agreement, on or before the effective
        date
        of this contract, on provider payment methodologies, which shall include
        provider payment proxies, also described as estimated Original Medicare payment
        amounts.

      (c)
        The
        MA Organization agrees to implement revised provider payment schedules on
        the
        same date that such changes are required of contractors administering the
        Original Medicare benefit.

       

      4

       

      

      (d)
        The
        MA Organization agrees that it shall revise its provider payment schedule
        to
        reflect the requirements of legislative or regulatory changes made during
        the
        term of this contract. Also, the MA Organization agrees that CMS may require
        the
        MA Organization to revise its provider payment schedule if CMS determines
        that
        the existing schedule does not comply with the provisions
        of§422.114(a)(2).
        [422.114]

      (e)
        The
        MA Organization agrees that it shall establish and maintain a payment appeal
        system under which MA plan providers may have their payment claims reviewed
        in
        the event that the provider believes he was paid less than he would have
        been
        paid under Original Medicare. Under such a system, if a provider reasonably
        demonstrates that they have not received proper payment, the MA Organization
        shall pay the provider the difference between what the provider had received
        and
        what he would have received under Original Medicare.

      (f)
        The
        MA Organization agrees to make its provider payment schedule available to
        the
        public in such a manner as to allow providers a reasonable opportunity to
        be
        informed about payment methodologies under the MA plan. This includes posting
        the schedule on a Web site maintained by the Organization.

      

      E.
        QUALITY REQUIREMENTS 

      The
        MA
        Organization agrees to comply with quality requirements as described in
§422.152(f).

       

      F.
        COMPLIANCE PLAN

      The
        MA
        Organization agrees to implement a compliance plan in accordance with the
        requirements
        of§422.503(b)(4)(vi). [422.503(b)(4)(vi)]

       

      G.
        COMPLIANCE DEEMED ON THE BASIS OF ACCREDITATION: CMS may deem the MA
        Organization to have met the quality improvement requirements of§1852(e) of the
        Act and §422.152, the confidentiality and accuracy ofenrollee records
        requirements of§1852(h) of the Act and §422.118, the anti-discrimination
        requirements of§1852(b) of the Act and §422.110, the access to services
        requirements of§1852(d) of the Act and §422.112, the advance directives
        requirements of§1852(i) of the Act and §422,128, the provider participation
        requirements of §1852(j) of the Act and 42 CFR Part 422, Subpart F, and the
        applicable requirements described in §423.165, if the MA Organization is fully
        accredited (and periodically reaccredited) by a private, national accreditation
        organization approved by CMS and the accreditation organization used the
        standards approved by CMS for the purposes of assessing the MA Organization's
        compliance with Medicare requirements. The provisions of §422.156 shall govern
        the MA Organization's use of deemed status to meet MA program
        requirements.

       

      H.
        PROGRAM INTEGRITY

      1.
        The MA
        Organization agrees to provide notice based on best knowledge, information,
        and
        belief to CMS of any integrity items related to payments from governmental
        entities, both federal and state, for healthcare or prescription drug services.
        These items include any investigations, legal actions or matters subject
        to
        arbitration brought involving the MA Organization (or MA Organization's firm
        if
        applicable) and its subcontractors (excluding contracted network providers),
        including any key management or executive staff, or any major shareholders
        (5%
        or more), by a government agency (state or federal) on matters relating to
        payments from governmental entities, both federal and state, for healthcare
        and/or prescription drug services. 

      

      

      5

      

      

      

      In
        providing the notice, the sponsor shall keep the government informed of when
        the
        integrity item is initiated and when it is closed. Notice should be provided
        of
        the details concerning any resolution and monetary payments as well as any
        settlement agreements or corporate integrity agreements.

       

      2.
        The MA
        Organization agrees to provide notice based on best knowledge, information,
        and
        belief to CMS in the event the; MA Organization or any of its subcontractors
        is
        criminally convicted or has a civil judgment entered against it for fraudulent
        activities or is sanctioned under any Federal program involving the provision
        of
        health care or prescription drug services.

       

      I.
        MARKETING

      1.
        The MA
        Organization may not distribute any marketing materials, as defined in 42
        CFR
        422.80(b) and in the Marketing Materials Guidelines for Medicare
        Advantage-Prescription Drug Plans and Prescription Drug Plans (Medicare
        Marketing Guidelines), unless they have been filed with and not disapproved
        by
        CMS in accordance with §422.80. The file and use process set out at
§422.80(a)(2) must be used, unless the MA organization notifies CMS that it
        will
        not use this process.

      2.
        CMS
        and the MA Organization shall agree upon language setting forth the benefits,
        exclusions and other language of the Plan. The MA Organization bears full
        responsibility for the accuracy of its marketing materials. CMS, in its sole
        discretion, may order the MA Organization to print and distribute the agreed
        upon marketing materials, in a format approved by CMS. The MA Organization
        must
        disclose the information to each enrollee electing a plan as outlined in
        42 CFR
        422. 111.

      3.
        The MA
        Organization agrees that any advertising material, including that labeled
        promotional material, marketing materials, or supplemental literature, shall
        be
        truthful and not misleading. All marketing materials must include the Contract
        number. All membership identification cards must include the Contract number
        on
        the front of the card.

      4.
        The MA
        Organization must comply with the Medicare Marketing Guidelines, as well
        as all
        applicable statutes and regulations, including and without limitation Section
        1851(h) of the Act and 42 CFR §§422.80, 422.111 and 423.50. Failure to comply
        may result in sanctions as provided in 42 CFR Part 422 Subpart 0.

      

      Article
        IV 

      

      CMS
        Payment to MA Organization

       

      A.
        The MA
        Organization agrees to develop its annual benefit and price bid proposal
        and
        submit to CMS all required information on premiums, benefits, and cost sharing,
        as required under 42 CFR Part 422 Subpart F.
        [422.504(a)(10)]

       

      B.
        Methodology.
        CMS
        agrees to pay the MA Organization under this contract in accordance with
        the
        provisions of section 1853 of the Act and 42 CFR Part 422 Subpart G.
        [422.504(a)(9)]

       

      

       

      

       

      6

       

      C.
        Attestation
        of
        payment data (Attachments A, B. and C).
        

      As
        a
        condition for receiving a monthly payment under paragraph B of this article,
        and
        42 CFR Part 422 Subpart G, the MA Organization agrees that its chief executive
        officer (CEO), or chief financial officer (CFO), or an individual delegated
        with
        the authority to sign on behalf of one of these officers, and who reports
        directly to such officer, must request payment under the contract on the
        forms
        attached as Attachment A (enrollment attestation) and Attachment B (risk
        adjustment data) hereto which attest to (based
        on best knowledge, information and belief, as of the date specified on the
        attestation form)
        the
        accuracy, completeness, and truthfulness of the data identified on these
        attachments. The Medicare Advantage Plan Attestation of Benefit Plan and
        Price
        must be signed and attached to the executed version of this
        contract.

      1.
        Attachment A requires that the CEO, or CFO, or an individual delegated with
        the
        authority to sign on behalf of one of these officers, and who reports directly
        to such officer, must attest based on best knowledge, information, and belief
        that each enrollee-for whom the MA Organization is requesting payment is
        validly
        enrolled, or was validly enrolled during the period for which payment is
        requested, in an MA plan offered by the MA Organization. The MA Organization
        shall submit completed enrollment attestation forms to CMS, or its contractor,
        on a monthly basis. (NOTE: The forms included as attachments to this contract
        are for reference only. CMS will provide instructions for the completion
        and
        submission of the forms in separate documents. MA Organizations should not
        take
        any action on the forms until appropriate CMS instructions become
        available.)

      2.
        Attachment B requires that: the CEO, or CFO, or an individual delegated with
        the
        authority to sign on behalf of one of these officers, and who reports directly
        to such officer, must attest
        to (based on best knowledge, information and belief, as of the date specified
        on
        the attestation form)
        that the
        risk adjustment data it submits to CMS under §422.310 are accurate, complete,
        and truthful. The MA Organization shall make annual attestations to this
        effect
        for risk adjustment data on Attachment B and according to a schedule to be
        published by CMS. If such risk adjustment data are generated by a related
        entity, contractor, or subcontractor of an MA Organization, such entity,
        contractor, or subcontractor must similarly attest
        to (based on best knowledge, information, and belief, as of the date specified
        on the attestation form)
        the
        accuracy, completeness, and truthfulness of the data. [422.504(1)]

      3.
        The
        Medicare Advantage Plan Attestation of Benefit Plan and Price (which is attached
        hereto) requires that the CEO, CFO, or an individual delegated with the
        authority to sign on behalf of one of these officers, and who reports directly
        to such officer, must attest (based
        on best knowledge, information and belief, as of the date specified on the
        attestation form)
        that the
        information and documentation comprising the bid submission proposal is
        accurate, complete, and truthful and fully conforms to the Bid Form and Plan
        Benefit Package requirements; and that the benefits described in the
        CMS-approved proposal bid submission agree with the benefit package the MA
        Organization will offer during the period covered by the proposal bid
        submission. This document is being sent separately to the MA Organization
        and
        must be signed and attached to the executed version of this contract, and
        is
        incorporated herein by reference. [422.502(1)]

       

       

      7

      

      

      

      Article
        V

      

      MA
        Organization Relationship with Related Entities, Contractors, and
        Subcontractors

       

      A.
        All
        references to "contracts" and "contractors" in this Article shall include
        deemed
        contracts (where applicable) and deemed contract providers (where applicable)
        as
        defined in §422.216(f).

       

      B.
        Notwithstanding any relationship(s) that the MA Organization may have with
        related entities, contractors, or subcontractors, the MA Organization maintains
        full responsibility for adhering to and otherwise fully complying with all
        terms
        and conditions of its contract with CMS.
        [422.504(i)(l)]

       

      C.
        The MA
        Organization agrees to require all related entities, contractors, or
        subcontractors to agree that—

      1.
        HHS,
        the Comptroller General, or their designees have the right to inspect, evaluate,
        and audit any pertinent contracts, books, documents, papers, and records
        of the
        related entity(s), contractors), or subcontractor(s) involving transactions
        related to this contract; and

      2.
        HHS,
        the Comptroller General, or their designees have the right to inspect, evaluate,
        and audit any pertinent information for any particular contract period for
        10
        years from the final date of the contract period or from the date of completion
        of any audit, whichever is later.
        [422.504(i)(2)]

       

      D.
        The MA
        Organization agrees that all contracts or written arrangements into which
        the MA
        Organization enters with providers, related entities, contractors, or
        subcontractors (first tier and downstream entities) shall contain the following
        elements:

      1.
        Enrollee protection provisions that provide—

      (a)
        Consistent with Article III(C), arrangements that prohibit providers from
        holding an enrollee liable for payment of any fees that are the legal obligation
        of the MA Organization; and

      (b)
        Consistent with Article III(C), provision for the continuation of
        benefits.

      2.
        Accountability provisions that indicate that—

      (a)
        The
        MA Organization oversees and is accountable to CMS for any functions or
        responsibilities that are described in these standards; and

      (b)
        The
        MA Organization may only delegate activities or functions to a provider,
        related
        entity, contractor, or subcontractor in a manner consistent with requirements
        set forth at paragraph D of this article.

      3.
        A
        provision requiring that any services or other activity performed by a related
        entity, contractor or subcontractor in accordance with a contract or written
        agreement between the related entity, contractor, or subcontractor and the
        MA
        Organization will be consistent and comply with the MA Organization's
        contractual obligations to CMS. [422.504(i)(3)]

       

      E.
        If any
        of the MA Organization's activities or responsibilities under this contract
        with
        CMS is delegated to other parties, the following requirements apply to any
        related entity, contractor, subcontractor, or provider:

       

      1.
        Written arrangements must specify delegated activities and reporting
        responsibilities.

       

       

      8

       

       

      2.
        Written arrangements must either provide for revocation of the delegation
        activities and reporting requirements or specify other remedies in instances
        where CMS or the MA Organization determine that such parties have not performed
        satisfactorily.

      3.
        Written arrangements must specify that the performance of the parties is
        monitored by the MA Organization on an ongoing basis.

      4.
        Written arrangements must specify that either—

      (a)
        The
        credentials of medical professionals affiliated with the party or parties
        will
        be either reviewed by the MA Organization; or

      (b)
        The
        provider verification process will be reviewed and approved by the MA
        Organization and the MA Organization must audit the provider verification
        process on an ongoing basis. The provider verification process will consist,
        at
        a minimum, of ensuring that providers have a state license to operate and
        be
        eligible for payment by Medicare.

      5.
        All
        contracts or written arrangements must specify that the related entity,
        contractor, or subcontractor must comply with all applicable Medicare laws,
        regulations, and CMS instructions.
        [422.504(i)(4)]

       

      F.
        If the
        MA Organization delegates selection of the providers, contractors, or
        subcontractors to another organization, the MA Organization's written
        arrangements with that organization must state that the MA Organization retains
        the right to approve, suspend, or terminate any such arrangement. [422.504(i)(5)]

      

       

      Article
        VI 

       

      Records
        Requirements

       

      A.
        MAINTENANCE OF RECORDS

      1.
        The MA
        Organization agrees to maintain for 10 years books, records, documents, and
        other

      evidence
        of accounting procedures and practices that—

      (a)
        Are
        sufficient to do the following:

      (i)
        Accommodate periodic auditing of the financial records (including data related
        to Medicare utilization, costs, and computation of the benefit and price
        bid) of
        the MA Organization.

      (ii)
        Enable CMS to inspect or otherwise evaluate the quality, appropriateness
        and
        timeliness of services performed under the contract, and the facilities of
        the
        MA Organization.

      (iii)
        Enable CMS to audit and inspect any books and records of the MA Organization
        that pertain to the ability of the organization to bear the risk of potential
        financial losses, or to services performed or determinations of amounts payable
        under the contract.

      (iv)
        Properly reflect all direct and indirect costs claimed to have been incurred
        and
        used in the preparation of the benefit and price bid proposal.

      (v)
        Establish component rates of the benefit and price bid for determining
        additional and supplementary benefits.

      (vi)
        Determine the rates utilized in setting premiums for State insurance agency
        purposes and for other government and private purchasers; and

      (b)
        Include at least records of the following:

      

       

      9

      

      (i)
        Ownership and operation of the MA Organization's financial, medical, and
        other
        record keeping systems.

      (ii)
        Financial statements for the current contract period and ten prior
        periods.

      (iii)
        Federal income tax or informational returns for the current contract period
        and
        ten prior periods.

      (iv)
        Asset acquisition, lease, sale, or other action.

      (v)
        Agreements, contracts (including, but not limited to with related or unrelated
        prescription drug benefit managers) and subcontracts.

      (vi)
        Franchise, marketing, and management agreements.

      (vii)
        Schedules of charges for the MA Organization's fee-for-service
        patients.

      (viii)
        Matters pertaining to costs of operations.

      (ix)
        Amounts of income received, by source and payment.

      (x)
        Cash
        flow statements.

      (xi)
        Any
        financial reports filed with other Federal programs or State authorities.
        [422.504(d)]
        

      2.
        Access
        to facilities and records.
        The MA
        Organization agrees to the following:

      (a)
        The
        Department of Health and Human Services (HHS), the Comptroller General, or
        their
        designee may evaluate, through inspection or other means—

      (i)
        The
        quality, appropriateness, and timeliness of services furnished to Medicare
        enrollees under the contract;

      (ii)
        The
        facilities of the MA Organization; and

      (iii)
        The
        enrollment and disenrollment records for the current contract period and
        ten
        prior periods.

      (b)
        HHS,
        the Comptroller General, or their designees may audit, evaluate, or inspect
        any
        books, contracts, medical records, documents, papers, patient care
        documentation, and other records of the MA Organization, related entity,
        contractor (including deemed contract providers as defined in §422.216(f)),
        subcontractor, or its transferee that pertain to any aspect of services
        performed, reconciliation of benefit liabilities, and determination of amounts
        payable under the contract, or as the Secretary may deem necessary to enforce
        the contract.

      (c)
        The
        MA Organization agrees to make available, for the purposes specified in section
        (A) of this article, its premises, physical facilities and equipment, records
        relating to its Medicare enrollees, and any additional relevant information
        that
        CMS may require, in a manner that meets CMS record maintenance
        requirements.

      (d)
        HHS,
        the Comptroller General, or their designee's right to inspect, evaluate,
        and
        audit extends through 10 years from the final date of the contract period
        or
        completion of audit, whichever is later unless-

      (i)
        CMS
        determines there is a special need to retain a particular record or group
        of
        records for a longer period and notifies the MA Organization at least 30
        days
        before the normal disposition date;

      (ii)
        There has been a termination, dispute, or fraud or similar fault by the MA
        Organization, in which case the retention may be extended to 10 years from
        the
        date of any resulting final resolution of the termination, dispute, or fraud
        or
        similar fault; or

      (iii)
        HHS, the Comptroller General, or their designee determines that there is
        a
        reasonable possibility of fraud, in which case they may inspect, evaluate,
        and
        audit the MA Organization at any time.
        [422.504(e)]

       

      10

       

      

      B.
        REPORTING REQUIREMENTS

      1.
        The MA
        Organization shall have an effective procedure to develop, compile, evaluate,
        and report to CMS, to its enrollees, and to the general public, at the times
        and
        in the manner that CMS requires, and while safeguarding the confidentiality
        of
        the doctor-patient relationship, statistics and other information as described
        in the remainder of this section (B).
        [422.516(a)]

       

      2.
        The MA
        Organization agrees to submit to CMS certified financial information that
        must
        include the following:

      (a)
        Such
        information as CMS may require demonstrating that the organization has a
        fiscally sound operation, including:

      (i)
        The
        cost of its operations;

      (ii)
        A
        description, submitted to CMS annually and within 120 days of the end of
        the
        fiscal year, of significant business transactions (as defined in §422.500)
        between the MA Organization and a party in interest showing that the costs
        of
        the transactions listed in paragraph (2)(a)(v) of this section do not exceed
        the
        costs that would be incurred if these transactions were with someone who
        is not
        a party in interest; or

      (iii)
        If
        they do exceed, a justification that the higher costs are consistent with
        prudent management and fiscal soundness requirements.

      (iv)
        A
        combined financial statement for the MA Organization and a party in interest
        if
        either of the following conditions is met:

      (aa)
        Thirty-five percent or more of the costs of operation of the MA Organization
        go
        to a party in interest.

      (bb)
        Thirty-five percent or more of the revenue of a party in interest is from
        the MA
        Organization.
        [422.516(b)]

      (v)Requirements
        for combined financial statements.

      (aa)
        The
        combined financial statements required by paragraph (2)(a)(iv) must display
        in
        separate columns the financial information for the MA Organization and each
        of
        the parties in interest.

      (bb)
        Inter-entity transactions must be eliminated in the consolidated
        column.

      (cc)
        The
        statements must have been examined by an independent auditor in accordance
        with
        generally accepted accounting principles and must include appropriate opinions
        and notes.

      (dd)
        Upon
        written request from the MA Organization showing good cause, CMS may waive
        the
        requirement that the organization's combined financial statement include
        the
        financial information required in paragraph (2)(a)(v) with respect to a
        particular entity.
        [422.516(c)]

      (vi)
        A
        description of any loans or other special financial arrangements the MA
        Organization makes with contractors, subcontractors, and related
        entities.

      (b)
        Such
        information as CMS may require pertaining to the disclosure of ownership
        and
        control of the MA Organization. [422.504(f)(l)(ii)]

      (c)
        Patterns of utilization of the MA Organization's services.

      3.
        The MA
        Organization agrees to participate in surveys required by CMS and to submit
        to
        CMS all information that is necessary for CMS to administer and evaluate
        the
        program and to simultaneously establish and facilitate a process for current
        and
        prospective beneficiaries to exercise choice in obtaining Medicare services.
        This information includes, but is not limited to:

      (a)
        The
        benefits covered under the MA plan;

      (b)
        The
        MA monthly basic beneficiary premium and MA monthly supplemental beneficiary
        premium, if any, for the plan.

       

      11

       

      

      (c)
        The
        service area and continuation area,' if any, of each plan and the enrollment
        capacity of each plan;

      (d)
        Plan
        performance indicators for the benefits under the plan including — (i)
        Disenrollment rates for Medicare enrollees electing to receive benefits through
        the plan
        for
        the previous 2 years;

      (ii)
        Information on Medicare enrollee satisfaction;

      (iii)
        The
        patterns of utilization of plan services;

      (iv)
        The
        availability, accessibility, and acceptability of the plan's
        services;

      (v)
        Information on health outcomes and other performance measures required by
        CMS;

      (vi)
        The
        recent record regarding compliance of the plan with requirements of this
        part,
        as determined
        by CMS; and

      (vii)
        Other information determined by CMS to be necessary to assist beneficiaries
        in
making
        an
        informed choice among MA plans and traditional Medicare;

      (e)
        Information about beneficiary appeals and their disposition;

      (f)
        Information regarding all formal actions, reviews, findings, or other similar
        actions by States, other regulatory bodies, or any other certifying or
        accrediting organization;

      (g)
        Any
        other information deemed necessary by CMS for the administration or evaluation
        of the Medicare program.
        [422.504(f)(2)]

       

      4.
        The MA
        Organization agrees to provide to its enrollees and upon request, to any
        individual eligible to elect an MA plan, all informational requirements under
        §422.64 and, upon an enrollee's, request, the financial disclosure information
        required under §422.516.
        (422.504(f)(3)]

      5.
        Reporting
        and disclosure under ERISA.

      (a)
        For
        any employees' health benefits plan that includes an MA Organization in its
        offerings, the MA Organization must furnish, upon request, the information
        the
        plan needs to fulfill its reporting and disclosure obligations (with respect
        to
        the MA Organization) under the Employee Retirement Income Security Act of
        1974
        (ERISA).

      (b)
        The
        MA Organization must furnish the information to the employer or the employer's
        designee, or to the plan administrator, as the term "administrator" is defined
        in ERISA. [422.516(d)]

      6.
        Electronic
        communication.
        The MA
        Organization must have the capacity to communicate with CMS
        electronically.
        [422.504(b)j

      7.
        Risk
        Adjustment data. The MA Organization agrees to comply with the requirements
        in
§422.310 for submitting risk adjustment data to CMS.
        [422.504(a)(8)]

       

      

      Article
        VII 

       

      Renewal
        of the MA Contract

       

      A.
        Renewal
        of contract:
        In
        accordance with §422.505, following the initial contract period, this contract
        is renewable annually only if-

       

      (1)
        The
        MA Organization has not provided CMS with a notice of intention not to renew;
        [422.506(a)]

       

      12

       

      

      (2)
        CMS
        and the MA Organization reach-agreement on the bid under 42 CFR Part 422
        Subpart
        F; and
        [422.505(d)]

      (3)
        CMS
        informs the MA Organization that it authorizes a renewal.

       

      B.
        Nonrenewal of contract

      (1)
        Nonrenewal
        by the Organization.

      (a)
        In
        accordance with §422.506, the MA Organization may elect not to renew its
        contract with CMS as of the end of the term of the contract for any reason,
        provided it meets the time frames for doing so set forth in subparagraphs
        (b)
        and (c) of this paragraph.

      (b)
        If
        the MA Organization does not intend to renew its contract, it must
        notify—

      (i)
        CMS,
        in writing, by the first Monday in June of the year in which the contract
        would
        end, pursuant to §422.506;

      (ii)
        Each
        Medicare enrollee, at least 90 days before the date on which the nonrenewal
        is
        effective. This notice must include a written description of all alternatives
        available for obtaining Medicare services within the service area including
        alternative MA plans, Medigap options, and original Medicare and prescription
        drug plans and must receive CMS approval prior to issuance.

      (iii)
        The
        general public, at least 90 days before the end of the current calendar year,
        by
        publishing a CMS-approved notice in one or more newspapers of general
        circulation in each community located in the MA Organization's service
        area.

      (c)
        CMS
        may accept a nonrenewal notice submitted after the applicable annual non-renewal
        notice deadline if —

      (i)
        The
        MA Organization notifies its Medicare enrollees and the public in accordance
        with subparagraph (l)(b)(ii) and (l)(b)(iii) of this section; and

      (ii)
        Acceptance is not inconsistent with the effective and efficient administration
        of the Medicare program.

      (d)
        If
        the MA Organization does not renew a contract under subparagraph (1), CMS
        will
        not enter into an MA contract with the Organization for 2 years from the
        date of
        contract separation unless there are special circumstances that warrant special
        consideration, as determined by CMS. [422.506(a)]

      (2)
        CMS
        decision not to renew.

      (a)
        CMS
        may elect not to authorize renewal of a contract for any of the following
        reasons:

      (i)
        The
        MA Organization's level of enrollment, growth in enrollment, or insufficient
        number of contracted providers is determined by CMS to threaten the viability
        of
        the organization under the MA program and or be an indicator of beneficiary
        dissatisfaction with the MA plan(s) offered by the organization.

      (ii)
        For
        any of the reasons listed in §422.510(a) [Article VIII, section (B)(l)(a) of
        this contract], which would also permit CMS to terminate the
        contract.

      (iii)
        The
        MA Organization has committed any of the acts in §422.752(a) that would support
        the imposition of intermediate sanctions or civil money penalties under 42
        CFR
        Part 422 Subpart 0.

      (iv)
        The
        MA Organization did not submit a benefit and price bid or the benefit and
        price
        bid was not acceptable.

       

      13

       

      

      (b)
        Notice.
        CMS
        shall provide notice of its decision whether to authorize renewal of the
        contract as follows:

      (i)
        To
        the MA Organization by May 1 of the contract year, except in the event of
        (2)(a)(iv) above, for which notice will be sent by September 1.

      (ii)
        To
        the MA Organization's Medicare enrollees by mail at least 90 days before
        the end
        of the current calendar year.

      (iii)
        To
        the general public at least 90 days before the end of the current calendar
        year,
        by publishing a notice in one or more newspapers of general circulation in
        each
        community or county located in the MA Organization's service area.

      (c)
        Notice
        of appeal rights.
        CMS
        shall give the MA Organization written notice of its right to reconsideration
        of
        the decision not to renew in accordance with §422.644. [422.506(b)]

      

       

      Article
        VIII 

       

      Modification
        or Termination of the Contract

       

      A.
        Modification or Termination of Contract by Mutual Consent

      1.
        This
        contract may be modified or terminated at any time by written mutual
        consent.

      (a)
        If
        the contract is modified by written mutual consent, the MA Organization must
        notify its Medicare enrollees of any changes that CMS determines are appropriate
        for notification within time frames specified by CMS. [422.508(a)(2)]

      (b)
        If
        the contract is terminated by written mutual consent, except as provided
        in
        section (A)(2) of this Article, the MA Organization must provide notice to
        its
        Medicare enrollees and the general public as provided in section B(2)(b)(ii)
        and
        B(2)(b)(iii) of this Article.
        [422.508(a)(l)]

      2.
        If
        this contract is terminated by written mutual consent and replaced the day
        following such termination by a new MA contract, the MA Organization is not
        required to provide the notice specified in section B of this article.
[422.508(b)]

       

      B.
        Termination of the Contract by CMS or the MA Organization 1. Termination
        by CMS.

      (a)
        CMS
        may terminate a contract for any of the following reasons:

      (i)
        The
        MA Organization has failed substantially to carry out the terms of its contract
        with CMS.

      (ii)
        The
        MA Organization is carrying out its contract with CMS in a manner that is
        inconsistent with the effective and efficient implementation of 42 CFR Part
        422.

      (iii)
        CMS
        determines that the MA Organization no longer meets the requirements of 42
        CFR
        Part 422 for being a contracting organization.

      (iv)
        There is credible evidence that the MA Organization committed or participated
        in
        false, fraudulent or abusive activities affecting the Medicare program,
        including submission of false or fraudulent data.

      (v)
        The
        MA Organization experiences financial difficulties so severe that its ability
        to
        make necessary health services available is impaired to the point of posing
        an
        imminent and serious risk to the health of its enrollees, or otherwise fails
        to
        make services available to the extent that such a risk to health
        exists.

       

      14

       

      

      (vi)
        The
        MA Organization substantially fails to comply with the requirements in 42
        CFR
        Part 422 Subpart M relating to grievances and appeals.

      (vii)
        The
        MA Organization fails to provide CMS with valid risk adjustment data as required
        under §422.310 and 423.329(b)(3).

      (viii)
        The MA Organization substantially fails to comply with the prompt payment
        requirements in §422.520.

      (ix)
        The
        MA Organization substantially fails to comply with the service access
        requirements in §422.114.

      (x)
        The
        MA Organization fails to comply with the requirements of §422.208 regarding
        physician incentive plans.

      (xi)
        The
        MA Organization substantially fails to comply with the marketing requirements
        in
§422.80.

      (b)
        Notice.
        If CMS
        decides to terminate a contract for reasons other than the grounds specified
        in
        section (B)(l)(a) above, it will give notice of the termination as
        follows:

      (i)
        CMS
        will notify the MA Organization in writing 90 days before the intended date
        of
        the termination.

      (ii)
        The
        MA Organization will notify its Medicare enrollees of the termination by
        mail at
        least 30 days before the effective date of the termination.

      (iii)
        The
        MA Organization will notify the general public of the termination at least
        30
        days before the effective date of the termination by publishing a notice
        in one
        or more newspapers of general circulation in each community or county located
        in
        the MA Organization's service area.

      (c)
        Immediate
        termination of contract by CMS.

      (i)
        For
        terminations based on violations prescribed in paragraph (B)(l)(a)(v) of
        this
        article, CMS will notify the MA Organization in writing that its contract
        has
        been terminated effective the date of the termination decision by CMS. If
        termination is effective in the middle of a month, CMS has the right to recover
        the prorated share of the capitation payments made to the MA Organization
        covering the period of the month following the contract
        termination.

      (ii)
        CMS
        will notify the MA Organization's Medicare enrollees in writing of CMS' decision
        to terminate the MA Organization's contract. This notice will occur no later
        than 30 days after CMS notifies the plan of its decision to terminate this
        contract. CMS will simultaneously inform the Medicare enrollees of alternative
        options for obtaining Medicare services, including alternative MA Organizations
        in a similar geographic area and original Medicare.

      (iii)
        CMS
        will notify the general public of the termination no later than 30 days after
        notifying the MA Organization of CMS' decision to terminate this contract.
        This
        notice will be published in one or more newspapers of general circulation
        in
        each community or county located in the MA Organization's service
        area.

      (d)
        Corrective
        action plan

      (i)
        General.
        Before
        terminating a contract for reasons other than the grounds specified in section
        (B)(l)(a)(v) of this article, CMS will provide the MA Organization with
        reasonable opportunity, not to exceed time frames specified at 42 CFR Part
        422
        Subpart N, to develop and receive CMS approval of a corrective action plan
        to
        correct the deficiencies that are the basis of the proposed
        termination.

       

      15

       

      

      (ii)
        Exception.
        If a
        contract is terminated under section (B)(l)(a)(v) of this article, the MA
        Organization will not have the opportunity to submit a corrective action
        plan.

      (e)
        Appeal
        rights.
        IfCMS
        decides to terminate this contract, it will send written notice to the MA
        Organization informing it of its termination appeal rights in accordance
        with 42
        CFR Part 422 Subpart N.
        [422.510] 2.
        Termination by the MA Organization

      (a)
        Cause
        for termination.
        The MA
        Organization may terminate this contract ifCMS fails to substantially carry
        out
        the terms of the contract.

       

      (b)
        Notice.
        The MA
        Organization must give advance notice as follows:

      (i)
        To
        CMS, at least 90 days before the intended date of termination. This notice
        must
        specify the reasons why the MA Organization is requesting contract
        termination.

      (ii)
        To
        its Medicare enrollees, at least 60 days before the termination effective
        date.
        This notice must include a written description of alternatives available
        for
        obtaining Medicare services within the service area, including alternative
        MA
        and MA-PD plans, PDP plans, Medigap options, and original Medicare and must
        receive CMS approval.

      (iii)
        To
        the general public at least 60 days before the termination effective date
        by
        publishing a CMS-approved notice in one or more newspapers of general
        circulation in each community or county located in the MA Organization's
        geographic area.

      c)
        Effective
        date of termination.
        The
        effective date of the termination will be determined by CMS and will be at
        least
        90 days after the date CMS receives the MA Organization's notice of intent
        to
        terminate.

      (d)
        CMS'
        liability.
        CMS'
        liability for payment to the MA Organization ends as of the first day of
        the
        month after the last month for which the contract is in effect, but CMS shall
        make payments for amounts owed prior to termination but not yet
        paid.

      (e)
        Effect
        of termination by the organization.
        CMS will
        not enter into an agreement with the MA Organization for a period of two
        years
        from the date the Organization has terminated this contract, unless there
        are
        circumstances that warrant special consideration, as determined by CMS.
[422.512]

      

       

      Article
        IX 

       

      Restrictions
        on Use of Data

       

      The
        MA
        Organization agrees that its use of the data it is authorized to collect
        to
        carry out the terms of this contract shall be used exclusively for the purpose
        of operating its MA private fee-for-service plan. The MA Organization may
        not
        use data collected under this contract in the operation of any other line
        of
        business offered by the MA Organization or its related entities, contractors,
        or
        subcontractors.

       

      16

       

      

      Article
        X

       

      Requirements
        of Other Laws and Regulations

       

      A.
        The MA
        Organization agrees to comply with—

      (1)
        Federal laws and regulations designed to prevent or ameliorate fraud, waste,
        and
        abuse, including, but not limited to, applicable provisions of Federal criminal
        law, the False Claims Act (31 USC 3729 et seq.), and the anti-kickback statute
        (section 1128B(b) of the Act):

      and

      (2)
        HIPAA
        administrative simplification rules at 45 CFR Parts 160, 162, and 164.
[422.504(h)]

       

      B.
        The MA
        Organization maintains ultimate responsibility for adhering to and otherwise
        fully complying with all terms and conditions of its contract with CMS,
        notwithstanding any relationship(s) that the MA organization may have with
        related entities, contractors, or subcontractors.
        [422.504(i)]

       

      C.
        In the
        event that any provision of this contract conflicts with the provisions of
        any
        statute or regulation applicable to an MA Organization, the provisions of
        the
        statute or regulation shall have full force and effect.

      

      Article
        XI Severability

       

      The
        MA
        Organization agrees that, upon CMS' request, this contract will be amended
        to
        exclude any MA plan or State-licensed entity specified by CMS, and a separate
        contract for any such excluded plan or entity will be deemed to be in place
        when
        such a request is made.
        [422.504(k)]

      

      Article
        XI

       

      Miscellaneous

       

      A.
        Definitions. Terms not otherwise defined in this contract shall have the
        meaning
        given to such terms in 42 CFR Part 422.

      B.
        Alteration to Original Contract Terms. The MA Organization agrees that it
        has
        not altered in any way the terms of this contract presented for signature
        by
        CMS. The MA Organization agrees that any alterations to the original text
        the MA
        Organization may make to this contract shall not be binding on the
        parties.

      C.
        Approval to Begin Marketing and Enrollment. The MA Organization agrees that
        it
        must complete CMS operational requirements prior to receiving CMS approval
        to
        begin Part C marketing and enrollment activities. Such activities include,
        but
        are not limited to, establishing and successfully testing connectivity with
        CMS
        systems to process enrollment applications (or contracting with an entity
        qualified to perform such functions on the MA Organization's Sponsor's behalf)
        and successfully demonstrating capability to submit accurate and timely
        price

       

      17

       

      

      comparison
        data. To establish and successfully test connectivity, the MA Organization
        must,

       1)
        establish and test physical connectivity to the CMS data center, 2) acquire
        user
        identifications and
        passwords, 3) receive, store, and maintain data necessary to perform enrollments
        and send and
        receive transactions to and from CMS, and 4) check and receive transaction
        status information.

      D.
        Incorporation of Applicable Addenda. All addenda checked off and initialed
        on
        the cover sheet
        of
        this contract by the MA Organization are hereby incorporated by
        reference.

       

      18

     

    

    In
      witness whereof, the parties hereby execute this contract. 

    FOR
      THE
      MA ORGANIZATION

     

    
      	
              Todd
                S. Farha 

              Printed
                Name

            	
              President
                and CEO

              Title

               

            
	
                
                /s/ Todd S. Farha    

              Signature

            	
              9/14/06

              Date

               

            
	
              Homeowner’s/WellCare
                PFFS Insurance, Inc.

              Organization

            	
              8735
                Henderson Rd Tampa, FL 33634

              Address

            
	 	 
	
              FOR
                THE CENTERS FOR MEDICARE & MEDICAID SERVICES

            
	
               

              /s/  
                David Lewis 

              David
                A. Lewis

              Acting
                Director

              Medicare
                Advantage Group

              Center
                for Beneficiary Choices

            	
               

              9/25/06

              Date

            

    

     

     

    19

    

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    

      ATTACHMENT
        A

       

      ATTESTATION
        OF ENROLLMENT INFORMATION RELATING TO CMS PAYMENT TO A MEDICARE ADVANTAGE
        ORGANIZATION

       

      Pursuant
        to the contract(s) between the Centers for Medicare & Medicaid Services
        (CMS) and (INSERT
        NAME OF MA ORGANIZATION),
        hereafter referred to as the MA Organization, governing the operation of
        the
        following Medicare Advantage plans (INSERT
        PLAN IDENTIFICATION NUMBERS HERE),
        the MA
        Organization hereby requests payment under the contract, and in doing so,
        makes
        the following attestation concerning CMS payments to the MA Organization.
        The MA
        Organization acknowledges that the information described below directly affects
        the calculation of CMS payments to the MA Organization and that
        misrepresentations to CMS about the accuracy of such information may result
        in
        Federal civil action and/or criminal prosecution. This attestation shall
        not be
        considered a waiver of the MA Organization's right to seek payment adjustments
        from CMS based on information or data which does not become available until
        after the date the MA Organization submits this attestation.

       

      1.
        The MA
        Organization has reported to CMS for the month of (INDICATE MONTH AND
        YEAR)
        all new
        enrollments, disenrollments, and changes in enrollees' institutional status
        with
        respect to the above-stated MA plans. Based on best knowledge, information,
        and
        belief, all information submitted to CMS in this report is accurate, complete,
        and truthful.

       

      2.
        The MA
        Organization has reviewed the CMS monthly membership report and reply listing
        for the month of (INDICATE MONTH AND YEAR) for the above-stated MA plans
        and has
        reported to CMS any discrepancies between the report and the MA Organization's
        records. For those portions of the monthly membership report and the reply
        listing to which the MA Organization raises no objection, the MA Organization,
        through the certifying CEO/CFO, will be deemed to have attested, based on
        best
        knowledge, information, and belief, as of the date indicated below, to their
        accuracy, completeness, and truthfulness.

      

      

      

      To
        be
        signed monthly by CFO

      (INDICATE
        TITLE [CEO or CFO, or person delegated to sign for either officer])

       

      (INDICATE
        MA ORGANIZATION)

       

      20

       

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      ATTACHMENT
        B

       

      ATTESTATION
        OF RISK ADJUSTMENT DATA INFORMATION RELATING TO CMS PAYMENT TO A MEDICARE
        ADVANTAGE ORGANIZATION

       

      Pursuant
        to the contract(s) between the Centers for Medicare & Medicaid Services
        (CMS) and (INSERT
        NAME OF MA ORGANIZATION),
        hereafter referred to as the MA Organization, governing the operation of
        the
        following Medicare Advantage plans (INSERT
        PLAN IDENTIFICATION NUMBERS HERE),
        the MA
        Organization hereby requests payment under the contract, and in doing so,
        makes
        the following attestation concerning CMS payments to the MA Organization.
        The MA
        Organization acknowledge-s that the information described below directly
        affects
        the calculation of CMS payments to the MA Organization or additional benefit
        obligations of the MA Organization and that misrepresentation to CMS about
        the
        accuracy of such information may result in Federal civil action and/or criminal
        prosecution.

       

      The
        MA
        Organization has reported to CMS for the period of (INDICATE DATES) all
        (INDICATE TYPE OF D AT'A
        -INPATIENT HOSPITAL, OUTPATIENT HOSPITAL. OR PHYSICIAN)
        risk
        adjustment data available to the MA Organization with respect to the
        above-stated MA plans. Based on best knowledge, information, and belief that,
        as
        of the date indicated below, all information submitted to CMS in this report
        is
        accurate, complete, and truthful.

      

      

      

      To
        be
        signed by CFO 

      (INDICATE
        TITLE [CEOor
        CFO,
        or person delegated to sign for either officer]) 

       

      (INDICATE
        MA ORGANIZATION)

       

      21

    

    

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    
 

    [SAMPLE
      - DO NOT USE
      - THIS DOCUMENT WILL BE
      SENT
      DIRECTLY TO THE MAO THROUGH HPMS] ATTACHMENT
      C
      -
      Medicare Advantage Plan Attestation of Benefit Plan and Price

    

    <Legal
      Entity Name>

    <Contract
      #>

    

    Date:
      <XX/XX/XXXX>

     

    I
      attest
      that the following plan numbers as established in the final Plan Benefit Package
      (PBP) will be operated by the above-stated organization and made available
      to
      eligible Medicare beneficiaries in the approved service area during program
      year
      2007.

     

    
      	
              Plan
                ID

            	
              Segment
                ID

            	
              Version

            	
              Plan
                Name

            	
              Plan
                Type

            	
              Transaction
                Type

            	
              MA
                Premium

            	
              Part
                D Premium

            	
              CMS
                Approval
                Date

            	
              Effective
                Date

            
	
               

              <xxx>

            	
               

              <x>

            	
               

              <x>

            	
               

              <Plan
                Name>

            	
               

              <Plan
                Type>

            	
               

              <Transaction
                Type>

            	
               

              $<Plan
                Premium>

            	
               

              $<Part
                D Premium>

            	
               

              <xx/xx/xx>

            	
               

              <xx/xx/xx>

            
	
               

              <xxx>

            	
               

              <x>

            	
               

              <x>

            	
               

              <Plan
                Name>

            	
               

              <Plan
                Type>

            	
               

              <Transaction
                Type>

            	
               

              $<Plan
                Premium>

            	
               

              $<Part
                D Premium>

            	
               

              <xx/xx/xx>

            	
               

              <xx/xx/xx>

            
	
               

              <xxx>

            	
               

              <x>

            	
               

              <x>

            	
               

              <Plan
                Name>

            	
               

              <Plan
                Type>

            	
               

              <Transaction
                Type>

            	
               

              $<Plan
                Premium>

            	
               

              $<Part
                D Premium>

            	
               

              <xx/xx/xx>

            	
               

              <xx/xx/xx>

            

    

    

    

    

    
      	
              CEO

            	 	
              CFO

            	 
	 	 	 	 
	
              <Name
                of CEO>

            	
              Date

            	
              <Name
                of CEO>

            	
              Date

            
	
              <Title>

            	 	
              <Title>

            	 
	
              <Address
                1>

            	 	
              <Address
                1>

            	 
	
              <Address
                2>

            	 	
              <Address
                2>

            	 
	
              <City,
                State Zip>

            	 	
              <City,
                State Zip>

            	 
	
              <Phone
                #>

            	 	
              <Phone
                #>

            	 

    

     

    22

     

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    ADDENDUM
      TO MEDICARE MANAGED CARE CONTRACT PURSUANT 

    TO
      SECTIONS 1860D-1 THROUGH 1860D-42 OF THE SOCIAL SECURITY ACT

    FOR
      THE OPERATION OF A VOLUNTARY MEDICARE PRESCRIPTION DRUG
      PLAN

     

    The
      Centers for Medicare & Medicaid Services (hereinafter referred to as "CMS")
      and HomeOwner’s
      WellCare PFFS Ins. Inc. ,
      a
      Medicare managed care organization (hereinafter referred to as the MA-PD
      Sponsor) agree to amend the contract (INSERT
      "H.OR "R" NUMBER)
      governing the MA-PD Sponsor's operation of a Part C plan described in Section
      1851(a)(2)(A) of the Social Security Act (hereinafter referred to as "the Act")
      or a Medicare cost plan to include this addendum under which the MA-PD Sponsor
      shall operate a Voluntary Medicare Prescription Drug Plan pursuant to sections
      1860D-1 through 1860D-42 (with the exception of section 1860D-22 and 1860D-31)
      of the Act.

     

    This
      addendum is made pursuant to Subpart L of 42 CFR Part 417 (in the case of cost
      plan sponsors offering a Part D benefit) and Subpart K- of 42 CFR Part 422
      (in
      the case of an MA-PD Sponsor offering a Part C plan).

     

    NOTE:
      For
      purposes of this addendum, unless otherwise noted, reference to an "MA-PD
      Sponsor" or "MA-PD Plan" is deemed to include a cost plan sponsor or a MA
      private fee-for-service contractor offering a Part D benefit.

     

    

    Article
      I 

    Medicare
      Voluntary Prescription Drug Benefit

     

    A.
      The
      MA-PD Sponsor agrees to operate one or more Medicare Voluntary Prescription
      Drug
      Plans as described in its application and related materials, including but
      not
      limited to all the attestations contained therein and all supplemental guidance,
      for Medicare approval and in compliance with the provisions of this addendum,
      which incorporates in its entirety the Solicitation
      For Applications for New Medicare Advantage Prescription Drug Plan (MA-PD)
      Sponsors, released on January 24, 2006 [applicable
      to Medicare Part C contractors] or the Solicitation
      for Applications for New
      Cost
      Plan Sponsors, released on January 24. 2006 [applicable to Medicare cost plan
      contractors] (hereinafter collectively referred to as "the addendum"). The
      MA-PD
      Sponsor also agrees to operate in accordance witlrthe regulations at 42 CFR
      §423.1 through 42 CFR §423.910 (with the exception ofSubparts Q, R, and S),
      sections 1860D-1 through 1860D-42 (with the exception of sections 1860D-22(a)
      and 1860D-31) of the Social Security Act, and the applicable solicitation
      identified above, as well as all other applicable Federal statutes, regulations,
      and policies. This addendum is deemed to incorporate any changes that are
      required by statute to be implemented during the term of this addendum and
      any
      regulations or policies implementing or interpreting such statutory
      provisions.

     

    B.
      CMS
      agrees to perform its obligations to the MA-PD Sponsor consistent with the
      regulations at 42 CFR §423.1 through 42 CFR §423.910 (with the exception of
      Subparts Q, R, and S), sections 1860D-1 through 1860D-42 (with the exception
      of
      sections 1860D-22(a) and 1860D-31) of the Social Security Act, and the
      applicable solicitation, as well as all other applicable Federal statutes,
      regulations, and policies.

     

    C.
      CMS
      agrees that it will not implement, other than at the beginning of a calendar
      year, regulations under 42 CFR Part 423 that impose new, significant regulatory
      requirements on the MA-PD Sponsor. This provision does not apply to new
      requirements mandated by statute.

     

    D.
      This
      addendum is in no way intended to supersede or modify 42 CFR, Parts 417, 422
      or
      423. Failure to reference a regulatory requirement in this addendum does not
      affect the applicability of such requirements to the MA-PD Sponsor and
      CMS.

     

    

    Article
      II 

    Functions
      to be Performed by the MA-PD Sponsor

     

    A.
      ENROLLMENT

     

    1.
      MA-PD
      Sponsor agrees to enroll in its MA-PD plan only Part D-eligible

    beneficiaries
      as they are defined in 42 CFR §423.30(a) and who have elected to enroll in MA-PD
      Sponsor's Part C or Section 1876 benefit.

    

    2

    

     

    2.
      If the
      MA-PD Sponsor is a cost plan sponsor, the MA-PD Sponsor acknowledges that its
      Section 1876 plan enrollees are not required to elect enrollment in its Part
      D
      plan.

     

    B.
      PRESCRIPTION DRUG BENEFIT

     

    1.
      MA-PD
      Sponsor agrees to provide the required prescription drug coverage as defined
      under 42 CFR §423.100 and, to the extent applicable, supplemental benefits as
      defined in 42 CFR §423.100 and in accordance with Subpart C of 42 CFR Part 423.
      MA-PD Sponsor also agrees to provide Part D benefits as described in the MA-PD
      Sponsor's Part D bid(s) approved each year by CMS (and in the Attestation of
      Benefit Plan and Price, attached hereto).

    2.
      MA-PD
      Sponsor agrees to calculate and collect beneficiary Part D premiums in
      accordance with 42 CFR §§423.286 and 423.293.

    3.
      If the
      MA-PD Sponsors is a cost plans sponsor, it acknowledge that its Part D benefit
      is offered as an optional supplemental service in accordance with 42 CFR
§417.440(b)(2)(n).

     

    C.
      DISSEMINATION OF PLAN INFORMATION

     

    1.
      MA-PD
      Sponsor agrees to provide the information required in 42 CFR
§423.48.

     

    2.
      MA-PD
      Sponsor agrees to disclose information related to Part D benefits to
      beneficiaries in the manner and the form specified by CMS under 42 CFR §§423.128
      and 423.50 and in the "Marketing Materials Guidelines for Medicare
      Advantage-Prescription Drug Plans (MA-PDs) and Prescription Drug Plans
      (PDPs)."

     

    3.
      MA-PD
      Sponsor certifies that all materials it submits to CMS under the File and Use
      Certification authority described in the Marketing Materials Guidelines are
      accurate, truthful, not misleading, and consistent with CMS marketing
      guidelines.

     

    D.
      QUALITY ASSURANCE/UTILIZATION MANAGEMENT

     

    MA-PD
      Sponsor agrees to operate quality assurance, cost, and utilization management,
      medication therapy management programs, and support electronic prescribing
      in
      accordance with Subpart D of 42 CFR Part 423.

     

    E.
      APPEALS AND GRIEVANCES

     

    MA-PD
      Sponsor agrees to comply with all requirements in Subpart M of 42 CFR Part
      423
      governing coverage determinations, grievances and appeals, and formulary
      exceptions. MA-PD Sponsor acknowledges that these requirements are separate
      and
      distinct from the appeals and grievances requirements applicable to the MA-PD
      Sponsor through the operation of its Part C or cost plan benefits.

     

     

    3

     

    F.
      PAYMENT TO MA-PD SPONSOR

     

    1.
      MA-PD
      Sponsor and CMS agree that payment paid for Part D services under the addendum
      will be governed by the rules in Subpart G of 42 CFR Part 423.

     

    2.
      If the
      MA-PD Sponsor is participating in the Part D Reinsurance Payment

    Demonstration,
      described in 70 FR 9360 (Feb. 25, 2005), it affirms that it will not seek
      payment under the demonstration for services provided to employer group
      enrollees.

     

    G.
      BID
      SUBMISSION AND REVIEW

     

    If
      the
      MA-PD Sponsor intends to participate in the Part D program for the future year,
      MA-PD Sponsor agrees to submit a future year's Part D bid, including all
      required information on premiums, benefits, and cost-sharing, by the applicable
      due date, as provided in Subpart F of 42 CFR Part 423 so that CMS and the MA-PD
      Sponsor may conduct negotiations regarding the terms and conditions of the
      proposed bid and benefit plan renewal. MA-PD Sponsor acknowledges that failure
      to submit a timely bid under this section may affect the sponsor's ability
      to
      offer a Part C plan, pursuant to the provisions of 42 CFR
§422.4(c).

     

    H.
      COORDINATION WITH OTHER PRESCRIPTION DRUG COVERAGE

     

    1.
      MA-PD
      Sponsor agrees to comply with the coordination requirements with State Pharmacy
      Assistance Programs (SPAPs) and plans that provide other prescription drug
      coverage as described in Subpart J of 42 CFR Part 423.

     

    2.
      MA-PD
      Sponsor agrees to comply with Medicare Secondary Payer procedures as stated
      in
      42 CFR §423.462.

     

    I.
      SERVICE AREA AND PHARMACY ACCESS

     

    1.
      The
      MA-PD Sponsor agrees to provide Part D benefits in the service area for which
      it
      has been approved by CMS to offer Part C or cost plan benefits utilizing a
      pharmacy network and formulary approved by CMS that meet the requirements of
      42
      CFR §423.120.

     

    2.
      The
      MA-PD Sponsor agrees to ensure adequate access to Part D-covered drugs at
      out-of-network pharmacies according to 42 CFR §423.124.

     

    3.
      MA-PD
      Sponsor agrees to provide benefits by means ofpoint-of-service systems to
      adjudicate prescription drug claims in a timely and efficient manner in
      compliance with CMS standards, except when necessary to provide access in
      underserved areas, I/T/U pharmacies (as defined in 42 CFR §423.100), and
      long-term care pharmacies (as defined in 42 CFR §423.100).

     

    4

     

    4.
      MA-PD
      Sponsor agrees to contract with any pharmacy that meets the MA-PD Sponsor's
      reasonable and relevant standard terms and conditions. If MA-PD Sponsor has
      demonstrated that it historically fills 98% or more of its enrollees'
      prescriptions at pharmacies owned and operated by the MA-PD Sponsor (or presents
      compelling circumstances that prevent the sponsor from meeting the 98% standard
      or demonstrates that its Part D plan design will enable the sponsor to meet
      the
      98% standard during the contract year), this provision does not apply to MA-PD
      Sponsor's plan.

     

    5.
      The
      provisions of 42 CFR §423.120(a) concerning the TRICARE retail pharmacy access
      standard do not apply to MA-PD Sponsor if the Sponsor has demonstrated to CMS
      that it historically fills more than 50% of its enrollees' prescriptions at
      pharmacies owned and operated by the MA-PD Sponsor. MA-PD Sponsors excused
      from
      meeting the TRICARE standard are required to demonstrate retail pharmacy access
      that meets the requirements of 42 CFR §422.112 for a Part C contractor and 42
      CFR §417.416(e) for a cost plan contractor.

     

    J.
      COMPLIANCE PLAN/PROGRAM INTEGRITY

     

    MA-PD
      Sponsor agrees that it will develop and implement a compliance plan that applies
      to its Part D-related operations, consistent with 42 CFR
§423.504(b)(4)(vi).

     

    K.
      LOW-INCOME SUBSIDY

     

    MA-PD
      Sponsor agrees that it will participate in the administration of subsidies
      for
      low-income individuals according to Subpart P of 42 CFR Part 423.

     

    L.
      BENEFICIARY FINANCIAL PROTECTIONS

     

    The
      MA-PD
      Sponsor agrees to afford its enrollees protection from liability for payment
      of
      fees that are the obligation of the MA-PD Sponsor in accordance with 42 CFR
      §423.505(g).

     

    M.
      RELATIONSHIP WITH RELATED ENTITIES, CONTRACTORS, AND SUBCONTRACTORS

     

    1.
      The
      MA-PD Sponsor agrees that it maintains ultimate responsibility for adhering
      to
      and otherwise fully complying with all terms and conditions of this
      addendum.

     

    2.
      The
      MA-PD Sponsor shall ensure that any contracts or agreements with

    subcontractors
      or agents performing functions on the MA-PD Sponsor's behalf related to the
      operation of the Part D benefit are in compliance with 42 CFR
§423.505(1).

    

     

    

    5

     

    N.
      CERTIFICATION OF DATA THAT DETERMINE PAYMENT MA-PD
      Sponsor must provide certifications in accordance with 42 CFR
§423.505(k).

     

    Article
      III

    Record
      Retention and Reporting Requirements

     

    A.
      MAINTENANCE OF RECORDS

     

    MA-PD
      Sponsor agrees to maintain records and provide access in accordance with 42
      CFR
§§423.504(d) and 505(d) and (e).

     

    B.
      GENERAL REPORTING REQUIREMENTS

     

    The
      MA-PD
      Sponsor agrees to submit to information to CMS according to 42 CFR §§423.505(1),
      423.514, and the "Final Medicare Part D Reporting Requirements," a document
      issued by CMS and subject to modification each program year.

     

    C.
      CMS
      LICENSE FOR USE OF PLAN FORMULARY

     

    PDP
      Sponsor agrees to submit to CMS each plan's formulary information, including
      any
      changes to its formularies, and hereby grants to the Government[ and any person
      or entity who might receive the formulary from the Government,] a non-exclusive
      license to use all or any portion of the formulary for any purpose related
      to
      the administration of the Part D program, including without limitation publicly
      distributing, displaying, publishing or reconfiguration of the information
      in
      any medium, including www.medicare.gov, and by any electronic, print or other
      means of distribution.

     

    

    Article
      IV HIPAA Transactions/Privacy/Security

     

    A.
      MA-PD
      Sponsor agrees to comply with the confidentiality and enrollee record accuracy
      requirements specified in 42 CFR §423.136.

     

    B.
      MA-PD
      Sponsor agrees to enter into a business associate agreement with the entity
      with
      which CMS has contracted to track Medicare beneficiaries' true out-of-pocket
      costs.

    
 

     

    6

     

    

    Article
      V 

    Addendum
      Term and Renewal

     

    A.
      TERM
      OF ADDENDUM

     

    This
      addendum is effective from the date ofCMS' authorized representative's signature
      through December 31, 2007. This addendum shall be renewable for successive
      one-year periods thereafter according to 42 CFR §423.506. MA-PD Sponsor shall
      not conduct Part D-related marketing activities prior to October 1, 2006 and
      shall not process enrollment applications prior to November 15, 2006. MA-PD
      Sponsor shall begin delivering Part D benefit services on January 1,
      2007.

     

    B.
      QUALIFICATION TO RENEW ADDENDUM

     

    1.
      In
      accordance with 42 CFR §423.507, the MA-PD Sponsor will be determined qualified
      to renew this addendum annually only if—

    (a)
      CMS
      informs the MA-PD Sponsor that it is qualified to renew its addendum;
      and

    (b)
      The
      MA-PD Sponsor has not provided CMS with a notice of intention not to renew
      in
      accordance with Article VII of this addendum.

     

    2.
      Although MA-PD Sponsor may be determined qualified to renew its addendum under
      this Article, if the MA-PD Sponsor and CMS cannot reach agreement on the Part
      D
      bid under Subpart F of 42 CFR Part 423, no renewal takes place, and the failure
      to reach agreement is not subject to the appeals provisions in Subpart N of
      42
      CFR Parts 422 or 423. (Refer to Article XI for consequences of non-renewal
      on
      the Part C contract and the ability to enter into a Part C
      contract.)

    

    Article
      VI 

    Nonrenewal
      of Addendum

     

    A.
      NONRENEWAL BY
      THE
      MA-PD SPONSOR

     

    1.
      MA-PD
      Sponsor may non-renew this addendum in accordance with 42
      CFR423.507(a).

    2.
      If the
      MA-PD Sponsor non-renews this addendum under this Article, CMS cannot enter
      into
      a Part D addendum with the organization for 2 years unless there are special
      circumstances that warrant special consideration, as determined by
      CMS.

     

    B.
      NONRENEWAL BY CMS

     

    CMS
      may
      non-renew this addendum under the rules of 42 CFR 423.507(b). (Refer to Article
      X for consequences of non-renewal on the Part C contract and the ability to
      enter into a Part C contract.)

     

    

     

    7

    

    Article
      VII 

    Modification
      or Termination of Addendum by Mutual Consent

    

     

    This
      addendum may be modified or terminated at any time by written mutual consent
      in
      accordance with 42 CFR 423.508. (Refer to Article X for consequences of
      non-renewal on the Part C contract and the ability to enter into a Part C
      contract.)

     

    

    Article
      VIII 

    Termination
      of Addendum by CMS

    

     

    CMS
      may
      terminate this addendum in accordance with 42 CFR 423.509. (Refer to Article
      X
      for consequences of non-renewal on the Part C contract and the ability to enter
      into a Part C contract.)

    Article
      IX 

    Termination
      of Addendum by the MA-PD Sponsor

    

     

    A.
      The
      MA-PD Sponsor may terminate this addendum only in accordance with 42 CFR
      423.510.

     

    B.
      CMS
      will not enter into a Part D addendum with an organization that has terminated
      its addendum within the preceding 2 years unless there are circumstances that
      warrant special consideration, as determined by CMS.

     

    C.
      If the
      addendum is terminated under section A of this Article, the MA-PD Sponsor must
      ensure the timely transfer of any data or files. (Refer to Article X for
      consequences of non-renewal on the Part C contract and the ability to enter
      into
      a Part C contract.)

     

    

    Article
      X 

    Relationship
      Between Addendum and Part C Contract or 1876 Cost Contract

    

     

    A.
      MA-PD
      Sponsor acknowledges that, if it is a Medicare Part C contractor, the
      termination or nonrenewal of this addendum by either party may require CMS
      to
      terminate or non-renew the Sponsor's Part C contract in the event that such
      non-renewal or termination prevents the MA-PD Sponsor from meeting the
      requirements of 42 CFR §422.4(c), in which case the Sponsor must provide the
      notices specified in this contract, as well as the notices specified under
      Subpart K of 42 CFR Part 422. MA-PD Sponsor also acknowledges that Article
      X.B.
      of this addendum may prevent the sponsor from entering into a Part C contract
      for two years following an addendum termination or non-renewal where such
      non-renewal or termination prevents the MA-PD Sponsor from meeting the
      requirements of 42 CFR §422.4(c).

    

     

    8

     

    

     

    

    B.
      The
      termination of this addendum by either party shall not, by itself, relieve
      the
      parties from their obligations under the Part C or cost plan contracts to which
      this document is an addendum.

     

    C.
      In the
      event that the MA-PD Sponsor's Part C or cost plan contract (as applicable)
      is
      terminated or nonrenewed by either party, the provisions of this addendum shall
      also terminate. In such an event, the MA-PD Sponsor and CMS shall provide notice
      to enrollees and the public as described in this contract as well as 42 CFR
      Part
      422, Subpart K or 42 CFR Part 417, Subpart K, as applicable.

     

    

    Article
      XI 

    Intermediate
      Sanctions

     

    The
      MA-PD
      Sponsor shall be subject to sanctions and civil monetary penalties, consistent
      with Subpart 0 of 42 CFR Part 423.

     

    

    Article
      XII 

    Severability

     

    Severability
      of the addendum shall be in accordance with 42 CFR §423.504(e).

     

    Article
      XIII 

    Miscellaneous

     

    A.
      DEFINITIONS: Terms not otherwise defined in this addendum shall have the meaning
      given such terms at 42 CFR Part 423 or, as applicable, 42 CFR Part 422 or Part
      417.

     

    B.
      ALTERATION TO ORIGINAL ADDENDUM TERMS: The MA-PD Sponsor

    agrees
      that it has not altered in any way the terms of the MA-PD addendum presented
      for
      signature by CMS. MA-PD Sponsor agrees that any alterations to the original
      text
      the MA-PD Sponsor may make to this addendum shall not be binding on the
      parties.

     

    C.
      ADDITIONAL CONTRACT TERMS: The MA-PD Sponsor agree to include in this addendum
      other terms and conditions in accordance with 42 CFR §423.505(j).

     

    D.
      CMS
      APPROVAL TO BEGIN MARKETING AND ENROLLMENT ACTIVITIES:

    The
      MA-PD
      Sponsor agrees that it must complete CMS operational requirements related to
      its
      Part D benefit prior to receiving CMS approval to begin MA-PD plan marketing
      activities relating to its Part D benefit. Such activities include, but are
      not
      limited to, establishing and successfully testing connectivity with CMS systems
      to process enrollment applications (or contracting with an entity qualified
      to
      perform

     

    

    

    9

    

     

    such
      functions on MA-PD Sponsor's behalf) and successfully demonstrating the
      capability to submit accurate and timely price comparison data. To establish
      and
      successfully test connectivity, the PDP Sponsor must, 1) establish and test
      physical connectivity to the CMS data center, 2) acquire user identifications
      and passwords, 3) receive, store, and maintain data necessary to perform
      enrollments and send and receive transactions to and from CMS, and 4) check
      and
      receive transaction status information.

     

    10

     

     

    

    

    MA-PD
      PART D CONTRACT ADDENDUM

     

    In
      witness whereof, the parties hereby execute this Addendum.

     

    FOR
      THE
      MA ORGANIZATION

    

    

    
      	
              Todd
                Farha

            	 	
              President
                and CEO

            
	
              Printed
                Name

               

            	 	
              Title

            
	
                 
                /s/ Todd Farha       

            	 	
              9-14-06

            
	
              Signature

               

            	 	
              Date

            
	
              Home
                Owners /WellCare PFFS Insurance,  Inc.

            	 	
              8735
                Henderson Road-Ren 2 Tampa FL 33634

            
	
              Organization

            	 	
              Address

            
	 	 	 
	 FOR THE CENTERS
              FOR MEDICARE & MEDICAID SERVICES	 	 
	 	 	 
	   /s/  
              Brenda Tranchida        
              Brenda
                J. Tranchida

              Deputy
                Director

              Employer
                Policy & Operations Group

              Center
                for Beneficiary Choices

            	 	 

    

    

     

    Page 1
      of  1

     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    

    PART
      C/D BENEFIT PLAN(S) DESCRIPTION

    TO
      BE ATTACHED TO MA CONTRACT

     

    SECTION
      1876/PART D OPTIONAL SUPPLEMENTAL BENEFIT PLAN DESCRIPTION TO BE ATTACHED TO
      SECTION 1876 CONTRACT

    

     

    

    

    11

     

    

    MA-PD
      EMPLOYER/UNION-ONLY GROUP CONTRACT ADDENDUM

     

    EMPLOYER/UNION-ONLY
      GROUP ADDENDUM TO CONTRACT WITH APPROVED ENTITY PURSUANT TO SECTIONS 1851
      THROUGH 1859 AND

    1860D-1
      THROUGH 1860D-42 OF THE SOCIAL SECURITY ACT FOR THE OPERATION OF A MEDICARE
      ADVANTAGE PRESCRIPTION DRUG PLAN

     

    The
      Centers for Medicare & Medicaid Services (hereinafter referred to as "CMS")
      and HomeOwner’s/WellCare
      PFFS Ins. Inc. a
      Medicare Advantage Organization (hereinafter referred to as the "MA
      Organization") agree to amend the contract H4577
      (INSERT
      "H" OR "R" NUMBER)
      governing the MA Organization's operation of a Medicare Advantage plan described
      in section 1851(a)(2)(A) or section 1851(a)(2)(C) of the Social Security Act
      (hereinafter referred to as "the Act"), including all attachments, addenda,
      and
      amendments thereto, to include the provisions contained in this Addendum
      (collectively hereinafter referred to as the "contract"), under which the MA
      Organization shall offer Employer/Union-Only Group MA-PD Plans (hereinafter
      referred to as "employer/union-only group MA-PDs") in accordance with the
      waivers granted by CMS under section 1857(i) of the Act. The terms of this
      Addendum shall only apply to MA-PD plans offered exclusively to
      employers/unions.

     

    This
      Addendum is made pursuant to Subparts K of 42 CFR Parts 422 and
      423.

     

    Page
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      10

     

    

    MA-PD
      EMPLOYER/UNION-ONLY GROUP CONTRACT ADDENDUM

     

    ARTICLE
      I

    EMPLOYER/UNION-ONLY
      GROUP MEDICARE ADVANTAGE PRESCRIPTION DRUG PLANS

     

    A.
      MA
      Organization agrees to operate one or more employer/union-only group MA-PDs
      in
      accordance with the terms of the Medicare Advantage contract, this Addendum,
      which incorporates in its entirety: either the 2006 Solicitation For
      Applications From Prescription Drug Plans released on January 21, 2005 (as
      revised on March 9, 2005) or the 2007 Solicitation For Applications For New
      Medicare Advantage Prescription Drug (MA-PD) Sponsors released on January 27,
      2006 (as revised on February 2, 2006), as modified by the 2007 Application
      For
      Medicare Advantage Organizations To Offer New Employer/Union-Only Group Waiver
      Plans (EGWPs) (released on January 27, 2006) (except for requirements contained
      therein that are expressly waived or modified by this Addendum), all provisions
      of Federal statutes, regulations, and policies applicable to MA Organizations
      and MA plans (except to the extent any such provisions are expressly waived
      or
      modified by this Addendum); and any employer/union-only group waiver guidance.
      MA Organization also agrees to operate one or more employer/union-only group
      MA-PDs in accordance with the regulations at 42 CFR Parts 422 and 423 (with
      the
      exception of Subparts Q, R, and S), sections 1851 through 1859 and 1860D-1
      through 1860D-42 of the Act (with the exception of 1860D-22(a) and 1860D-31),
      and the applicable solicitations/applications, as well as all other applicable
      Federal statutes, regulations, and policies, including any employer/union-only
      group waiver guidance.

     

    B.
      This
      Addendum is deemed to incorporate any changes that are required by statute
      to be
      implemented during the term of the contract, and any regulations and policies
      implementing or interpreting such statutory provisions.

     

    C.
      In the
      event of any conflict between the employer/union-only group waiver guidance
      issued prior to the execution of the contract and this Addendum, the provisions
      of this Addendum shall control. In the event of any conflict between the
      employer/union-only group waiver guidance issued after the execution of the
      contract and this Addendum, the provisions of the employer/union-only group
      guidance shall control.

     

    D.
      This
      Addendum is in no way intended to supersede or modify 42 CFR Parts 422 and
      423
      or sections 1851 through 1859 and 1860D-1 through D-42 of the Act, except as
      specifically provided in applicable employer/union-only group waiver guidance
      and/or in this Addendum. Failure to reference a statutory or regulatory
      requirement in this Addendum does not affect the applicability of such
      requirement to the MA Organization and CMS.

     

    E.
      The
      provisions of this Addendum apply to all employer/union-only group MA-PDs
      offered by MA Organization under this contract number. In the event of any
      conflict between the provisions of this Addendum and any other provision of
      the
      contract, the terms of this Addendum shall control.

     

    Page
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      10

     

    

    MA-PD
      EMPLOYERAJNION-ONLY GROUP CONTRACT ADDENDUM

     

    ARTICLE
      II

    FUNCTIONS
      TO BE PERFORMED BY THE MEDICARE ADVANTAGE ORGANIZATION

     

    A.
      PROVISION OF MA BENEFITS

     

    1.
      MA
      Organization agrees to provide enrollees in each of its employer/union-only
      group MA-PDs the basic benefits (hereinafter referred to as "basic benefits")
      as
      required under 42 CFR §422.101 and, to the extent applicable, supplemental
      benefits under 42 CFR §422.102 and as established in the MA Organization's final
      benefit and price bid proposal as approved by CMS.

     

    2.
      The
      requirements in section 1852 of the Act and 42 CFR §422.100(c)(l) pertaining to
      the offering of benefits covered under Medicare Part A and in section 1851
      of
      the Act and 42 CFR §422.50(a)(l) pertaining to who may enroll in an MA-PD are
      waived for employer/union-only group MA-PD enrollees who are not entitled to
      Medicare Part A.

     

    3.
      For
      employer/union-only group MA-PDs offering non-calendar year coverage, MA
      Organization may determine basic and supplemental benefits (including
      deductibles, out-of-pocket limits, etc.) on a non-calendar year basis subject
      to
      the following requirements:

     

    (a)
      Applications, bids, and other submissions to CMS must be submitted on a calendar
      year basis; and

     

    (b)
      CMS
      payments will be determined on a calendar year basis.

     

    4.
      For
      employer/union-only group MA-PDs that have a monthly beneficiary rebate
      described in 42 CFR §422.266:

     

    (a)
      MA
      Organization may vary the form of rebate for a particular plan benefit package
      so that the total monthly rebate amount may be credited differently for each
      employer/union group to whom MA Organization offers the plan benefit package,
      with the exception of a rebate credited toward the reduction of the Part B
      premium as stated in II.A.4(b); and

     

    (b)
      MA
      Organization must:

     

    (i)
      ensure Part B premium reductions are the same for all enrollees in a plan
      benefit package;

     

    (ii)
      ensure that the total monthly rebate amount per enrollee is uniform across
      all
      employer/union groups within the plan benefit package;

     

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      10

     

    

    MA-PD
      EMPLOYER/UNION-ONLY GROUP CONTRACT ADDENDUM

     

    (iii)
      ensure that all rebates are accounted for and used only for the purposes
      provided in the Act; and

     

    (iv)
      retain documentation that supports the use of all of the rebates on a detailed
      basis for each employer/union group within the plan benefit package and must
      provide access to this documentation in accordance with the requirements of
      42
      CFR §422.501.

     

    B.
      PROVISION OF PRESCRIPTION DRUG BENEFITS

     

    1.
      (a)
      Except as provided in II.B. 1 (b), MA Organization agrees to provide basic
      prescription drug coverage, as defined under 42 CFR §423.100, under any
      employer/union-only group MA-PD, in accordance with Subpart C of 42 CFR Part
      423. MA Organization also agrees to provide Part D benefits under any
      employer/union-only group MA-PD as described in MA Organization's bid approved
      each year by CMS.

     

    (b)
      CMS
      agrees that MA Organization will not be subject to the actuarial equivalence
      requirement set forth in 42 CFR §423.104(e)(5) with respect to any
      employer/union-only group MA-PD and may provide less than the defined standard
      coverage between the deductible and initial coverage limit. MA Organization
      agrees that its basic prescription drug coverage under any employer/union-only
      group MA-PD will satisfy all of the other actuarial equivalence standards set
      forth in 42 CFR §423.104, including but not limited to the requirement set forth
      in 42 CFR §423.104(e)(3) that the plan has a total or gross value that is at
      least equal to the total or gross value of defined standard
      coverage.

     

    (c)
      CMS
      agrees that nothing in this Addendum prevents MA Organization from offering
      benefits in addition to basic prescription drug coverage to employers/unions.
      Such additional benefits offered pursuant to private agreements between MA
      Organization and employers/unions will be considered non-Medicare Part D
      benefits. MA Organization agrees that such additional benefits may not reduce
      the value of basic prescription drug coverage (e.g., additional benefits cannot
      impose a cap that would preclude enrollees from realizing the full value of
      such
      basic prescription drug coverage).

     

    (d)
      MA
      Organization agrees that enrollees of employer/union-only group MA-PDs shall
      not
      be charged more than the sum of his or her monthly beneficiary premium
      attributable to basic prescription drug coverage and 100% of the monthly
      beneficiary premium attributable to his or her supplemental prescription drug
      coverage (if any). MA Organization must pass through the direct subsidy payments
      received from CMS to reduce the amount that the beneficiary pays.

     

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      10

     

    

    MA-PD
      EMPLOYER/UNION-ONLY GROUP CONTRACT ADDENDUM

     

    (e)
      MA
      Organization agrees that any additional non-Medicare Part D benefits offered
      to
      an employer/union will always pay primary to the subsidies provided by CMS
      to
      low-income individuals under Subpart P of 42 CFR Part 423 (the "Low-Income
      Subsidy").

     

    2.
      MA
      Organization agrees enrollees of employer/union-only group MA-PDs will not
      be
      permitted to make payment of premiums under 42 CFR §423.293(a) through
      withholding from the enrollee's Social Security, Railroad Retirement Board,
      or
      Office of Personnel Management benefit payment.

     

    3.
      MA
      Organization agrees it shall obtain written agreements from each

    employer/union
      that provide that the employer/union may determine how much of an enrollee's
      Part D monthly beneficiary premium it will subsidize, subject to the
      restrictions set forth in II.B.3(a) through (e). MA Organization agrees to
      retain these written agreements with employers/unions and provide access to
      these written agreements to CMS in accordance with 42
      CFR§§423.504(d)
      and 423.505(d)and(e).

     

    (a)
      The
      employer/union can subsidize different amounts for different classes of
      enrollees in the employer/union-only group MA-PD provided such classes are
      reasonable and based on objective business criteria, such as years of service,
      date of retirement, business location, job category, and nature of compensation
      (e.g., salaried v. hourly). Different classes cannot be based on eligibility
      for
      the Low Income Subsidy.

     

    (b)
      The
      employer/union cannot vary the premium subsidy for individuals within a given
      class of enrollees.

     

    (c)
      The
      employer/union cannot charge an enrollee for prescription drug coverage provided
      under the plan more than the sum of his or her monthly beneficiary premium
      attributable to basic prescription drug coverage and 100% of the monthly
      beneficiary premium attributable to his or her supplemental prescription drug
      coverage (if any). The employer/union must pass through direct subsidy payments
      received from CMS to reduce the amount that the beneficiary pays.

     

    (d)
      For
      all enrollees eligible for the Low Income Subsidy, the low income premium
      subsidy amount will first be used to reduce the portion of the monthly
      beneficiary premium attributable to basic prescription drug coverage paid by
      the
      enrollee, with any remaining portion of the premium subsidy amount then applied
      toward the portion of the monthly beneficiary premium attributable to basic
      prescription drug coverage paid by the employer/union.

     

    (e)
      If
      the low income premium subsidy amount for which an enrollee is eligible is
      less
      than the portion of the monthly beneficiary premium paid by the enrollee, then
      the employer/union should communicate to the enrollee the financial consequences
      for the beneficiary
      of
      enrolling in the employer/union-only group

     

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      10

     

    

    MA-PD
      EMPLOYER/UNION-ONLY GROUP CONTRACT ADDENDUM

     

    MA-PD
      as
      compared to enrolling in another Part D plan with a monthly beneficiary premium
      equal to or below the low income premium subsidy amount.

     

    4.
      For
      non-calendar year employer/union-only group MA-PDs, MA Organization may
      determine benefits (including deductibles, out-of-pocket limits, etc.) on a
      non-calendar year basis subject to the following requirements:

     

    (a)
      Applications, formularies, bids and other submissions to CMS must be submitted
      on a calendar year basis;

     

    (b)
      The
      employer/union-only group MA-PD must be actuarially equivalent to defined
      standard coverage for the portion of its plan year that falls in a given
      calendar year. An employer/union-only group MA-PD will meet this standard if
      it
      is actuarially equivalent for the calendar year in which the plan year starts
      and no design change is made for the remainder of the plan year. In no event
      can
      MA Organization increase during the plan year the annual out-of-pocket
      threshold;

     

    (c)
      After
      an enrollee's incurred costs exceed the annual out-of-pocket threshold, the
      employer/union-only group MA-PD must provide coverage that is at least
      actuarially equivalent to that provided under standard prescription drug
      coverage;

    eligibility
      for such coverage can be determined on a plan year basis.

     

    C.
      ENROLLMENT REQUIREMENTS

     

    1.
      MA
      Organization agrees to restrict enrollment in an employer/union-only group
      MA-PD
      to those individuals eligible for the employer's/union's employment-based group
      coverage.

     

    2.
      MA
      Organization will not be subject to the requirement to offer the

    employer/union-only
      group MA-PD to all Medicare eligible beneficiaries residing in its service
      area
      as set forth in 42 CFR §422.50.

     

    3.
      If an
      employer/union elects to enroll individuals eligible for its employer/union-only
      group MA-PD through a group enrollment process, MA Organization will not be
      subject to the individual enrollment requirements set forth in 42 CFR §422.60
      and §423.32(b). MA Organization agrees that all individuals eligible for its
      employer/union-only group MA-PD will be advised that the employer/union
      contracting with MA Organization to offer an employer/union-only group MA-PD
      (hereinafter referred to as "employer/union") intends to enroll them into the
      plan through a group enrollment process unless the individual affirmatively
      opts
      out of such enrollment. MA Organization agrees that all such individuals will
      be
      provided this information at least 30 days prior to the effective date of the
      individual's enrollment in the employer/union-only group MA-PD. MA Organization
      agrees the information must include a summary of benefits offered under the
      employer/union-only group MA-PD, an explanation of how to get more information
      on such plan, and an explanation of how to contact Medicare for

     

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      6 of
      10

     

    

    MA-PD
      EMPLOYER/UNION-ONLY GROUP CONTRACT ADDENDUM

     

    information
      on other MA-PD plans that' might be available to the individual. In addition,
      MA
      Organization agrees that all information necessary to effectuate enrollment
      must
      be submitted electronically to CMS, consistent with CMS
      instructions.

     

    D.
      BENEFICIARY PROTECTIONS

     

    1.
      Except
      as provided in II.D.2., CMS agrees that, with respect to any

    employer/union-only
      group MA-PDs, MA Organization will not be subject to the information
      requirements set forth in 42 CFR §423.48 and the prior review and approval of
      marketing materials and election forms requirements set forth in 42 CFR §422.80
      and §423.50. MA Organization will be subject to all other disclosure and
      dissemination requirements contained in 42 CFR §422.111, §423.128 and in CMS
      guidance, including those requirements contained in the "Medicare Marketing
      Materials Guidelines for Medicare Advantage Plans (MAs), Medicare Advantage
      Prescription Drug Plans (MA-PDs), Prescription Drug Plans (PDPs) and 1876 Cost
      Plans."

     

    2.
      CMS
      agrees that the disclosure and dissemination requirements set forth in 42 CFR
      §422.111 and §423.128 will not apply with respect to any employer/union-only
      group MA-PD when the employer/union is subject to alternative disclosure
      requirements (e.g., the Employee Retirement Income Security Act of 1974
      ("ERISA")) and fully complies with such alternative requirements. MA
      Organization agrees to comply with the requirements for this waiver contained
      in
      employer/union-only group waiver guidance, including those requirements
      contained in Chapter 13 of the "Medicare Marketing Guidelines for Medicare
      Advantage Plans (MAs), Medicare Advantage Prescription Drug Plans (MA-PDs),
      Prescription Drug Plans (PDPs) and 1876 Cost Plans."

     

    E.
      SERVICE AREA, FORMULARIES AND PHARMACY ACCESS

     

    1.
      CMS
      agrees that employer/union-only group Local MA-PDs that provide coverage to
      individuals in any part of a State can offer coverage to retirees eligible
      for
      the employer/union-only group MA-PD throughout that State. CMS also agrees
      that
      employer/union-only group Regional MA-PDs that provide coverage to individuals
      in any part of a Region can offer coverage to retirees eligible for the
      employer/union-only group MA-PD throughout that Region.

     

    2.
      CMS
      agrees that non-network Private Fee-for-Service employer/union-only group MA-PDs
      may extend coverage beyond their designated service areas to all enrollees
      of a
      particular employer/union-only group plan, regardless of where they reside
      in
      the nation, when the most substantial portion of the employer's employees (or
      in
      the case of a union, the union's participants) reside in the service area where
      the MA Organization, either itself or through subcontractors or other partners,
      is a provider of non-group MA-PD coverage. The MA Organization agrees to conduct
      an actual review of where the substantial portion of the

     

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    MA-PD
      EMPLOYER/UNION-ONLY GROUP CONTRACT ADDENDUM

     

    employer's/union's
      employees/participants resideand
      to
      maintain adequate supporting documentation of such review (including the date
      of
      such review, by whom the review was conducted, and any other relevant
      documentation to substantiate the review), and to permit CMS to audit and review
      such documentation. Such expanded service areas must have convenient Part D
      pharmacy access sufficient to meet the needs of enrollees wherever they
      reside.

     

    3.
      MA
      Organization agrees to utilize, as the formulary for any employer/union-only
      group MA-PD, a base formulary that has received approval from CMS, in accordance
      with CMS formulary guidance, for use in a non-group MA-PD offered by MA
      Organization. Except as set forth in 42 CFR §423.120(b) and sub-regulatory
      guidance, MA Organization may not modify the approved base formulary used for
      any employer/union-only group MA-PD by removing drugs, adding additional
      utilization management restrictions, or increasing the cost-sharing status
      of a
      drug from the base formulary. Enhancements that are permitted to the base
      formulary include adding additional drugs, removing utilization management
      restrictions, and improving the cost-sharing status of drugs.

     

    4.
      For
      any employer/union-only group MA-PD, MA Organization agrees to provide Part
      D
      benefits in the plan's service area utilizing a pharmacy network and formulary
      that meets the requirements of 42 CFR §423.120, with the following exception:
      CMS agrees that the retail pharmacy access requirements set forth in 42 CFR
      §423.120(a)(l) ("Tricare" standards) will not apply when the employer/union-only
      group MA-PD's pharmacy network is sufficient to meet the needs of its enrollees
      throughout the employer/union-only group MA-PD's service area, as determined
      by
      CMS. CMS may periodically review the adequacy of the employer/union-only group
      MA-PD's pharmacy network and require the employer/union-only group MA-PD to
      expand access if CMS determines that such expansion is necessary in order to
      ensure that the employer/union-only group MA-PD's network is sufficient to
      meet
      the needs of its enrollees.

     

    F.
      PAYMENT TO MA ORGANIZATION

     

    Except
      as
      provided in II.F.I through 4, payment under this Addendum will be governed
      by
      the rules of Subparts G and J of 42 CFR Part 423.

     

    1.
      MA
      Organization acknowledges that the risk sharing, plan entry and retention bonus
      provisions of section 1858 of the Act and 42 CFR §422.458 shall not apply to any
      employer/union-only group Regional MA-PDs.

     

    2.
      MA
      Organization acknowledges that the risk-sharing payment adjustment described
      in
      42 CFR §423.336 is not applicable for any employer/union-only group MA-PD
      enrollee.

     

    3.
      MA
      Organization will receive a monthly direct subsidy under 42 CFR Subpart
      G

     

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      10

     

    

    MA-PD
      EMPLOYER/UNION-ONLY GROUP CONTRACT ADDENDUM

     

    for
      each
      employer/union-only group MA-PD enrollee equal to the amount of the national
      average monthly bid amount (not its approved standardized bid), adjusted for
      health status (as determined under 42 CFR §423.329(b)(l)) and reduced by the
      base beneficiary premium for the employer/union-only group MA-PD, as adjusted
      under 42 CFR §423.286(d)(3), if applicable. The further adjustments to the base
      beneficiary premium contained in 42 CFR §423.286(d)(l) and (2) will not
      apply.

     

    4.
      MA
      Organization will not receive monthly reinsurance payment amounts in the manner
      set forth in 42 CFR §423.329(c)(2)(i) for any employer/union-only group MA-PD
      enrollee, but instead will receive the full reinsurance payment following the
      end of year reconciliation as described in 42 CFR
§423.329(c)(2)(ii).

     

    5.
      For
      non-calendar year plans:

     

    (a)
      CMS
      payments will be determined on a calendar year basis;

     

    (b)
      Low
      income subsidy payments and reconciliations will be determined based on the
      calendar year for which the payments are made; and

     

    (c)
      MA
      Organization acknowledges that it will not receive reinsurance payments under
      42
      CFR §423.329(c).

     

     

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    MA-PD
      EMPLOYER/UNION-ONLY GROUP CONTRACT ADDENDUM

     

    In
      witness whereof, the parties hereby execute this Addendum.

     

    FOR
      THE
      MA ORGANIZATION

     

    

    
      	
              Todd
                Farha

            	 	
              President
                and CEO

            
	
              Printed
                Name

               

            	 	
              Title

            
	
              /s/
                Todd Farha         
                

            	 	
              9-14-06

            
	
              Signature

               

            	 	
              Date

            
	
              Home
                Owners/WellCare PFFS Ins. Inc

            	 	
              8735
                Henderson Road-Ren 2 Tampa FL 33634

            
	
              Organization

            	 	
              Address

            
	 	 	 
	
               FOR THE CENTERS FOR MEDICARE & MEDICAID
                SERVICES

               

              
                 
                  /s/  Brenda
                  Tranchida                 
                    

                Brenda
                  J. Tranchida

                Deputy
                  Director

                Employer
                  Policy & Operations Group

                Center
                  for Beneficiary Choices

              

            	 	
               

              9/28/06

              
                Date

              

            

    

     

     

     

    
 

    
    

    Page
      10
      of 10

     

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    Medicare
      Advantage Attestation of Benefit Plan and Price 

    HOME
      OWNERS/WELLCARE PFFS INSURANCE INC. 

    H4577
      

    Date:
      09/12/2006 

     

    
      	
              I
                attest that the following plan numbers as established in the final
                Plan
                Benefit Package (PBP) will be operated by the above-stated organization
                and made available to eligible beneficiaries in the approved service
                area
                during program year 2007. I further attest that the organization
                will
                comply with all applicable program guidance that CMS has issued to
                date
                and will issue during the remainder of 2006 and 2007 pursuant to
                Medicare
                program authorizing statutes and regulations, including but not limited
                to, the 2007 Call Letters, the 2007 Solicitations for New Contract
                Applicants, and
                the CMS memoranda issued through the Health Plan Management System
                (HPMS).

               

            
	
              Plan
                ID

            	
              Segment
                ID

            	
              Version

            	
              Plan
                Name

            	
              Plan
                Type

            	
              Transaction
                Type

            	
              MA
                Premium

            	
              Part
                D Premium

            	
              CMS
                Approval Date

            	
              Effective
                Date

            
	
              001

            	
              0

            	
              3

            	
              Duet

            	
              PFFS

            	
              Initial

            	
              0.00

            	
              N/A

            	
              9/12/2006

            	
              01/01/2007

            
	
              002

            	
              0

            	
              3

            	
              Duet

            	
              PFFS

            	
              Initial

            	
              0.00

            	
              N/A

            	
              9/12/2006

            	
              01/01/2007

            
	
              003

            	
              0

            	
              3

            	
              Duet

            	
              PFFS

            	
              Initial

            	
              0.00

            	
              N/A

            	
              9/12/2006

            	
              01/01/2007

            
	
              004

            	
              0

            	
              3

            	
              Duet

            	
              PFFS

            	
              Initial

            	
              0.00

            	
              N/A

            	
              9/12/2006

            	
              01/01/2007

            
	
              005

            	
              0

            	
              3

            	
              Summit

            	
              PFFS

            	
              Initial

            	
              91.00

            	
              0.00

            	
              9/12/2006

            	
              01/01/2007

            
	
              006

            	
              0

            	
              3

            	
              Summit

            	
              PFFS

            	
              Initial

            	
              121.00

            	
              0.00

            	
              9/12/2006

            	
              01/01/2007

            
	
              007

            	
              0

            	
              5

            	
              Summit

            	
              PFFS

            	
              Initial

            	
              126.50

            	
              14.40

            	
              9/12/2006

            	
              01/01/2007

            
	
              008

            	
              0

            	
              3

            	
              Summit

            	
              PFFS

            	
              Initial

            	
              129.70

            	
              31.30

            	
              9/12/2006

            	
              01/01/2007

            
	
              009

            	
              0

            	
              4

            	
              Summit

            	
              PFFS

            	
              Initial

            	
              137.90

            	
              43.10

            	
              9/12/2006

            	
              01/01/2007

            
	
              010

            	
              0

            	
              3

            	
              Summit

            	
              PFFS

            	
              Initial

            	
              160.90

            	
              50.10

            	
              9/12/2006

            	
              01/01/2007

            
	
              011

            	
              0

            	
              3

            	
              Freedom

            	
              PFFS

            	
              Initial

            	
              0.00

            	
              0.00

            	
              9/12/2006

            	
              01/01/2007

            
	
              012

            	
              0

            	
              3

            	
              Concert

            	
              PFFS

            	
              Initial

            	
              0.00

            	
              0.00

            	
              9/12/2006

            	
              01/01/2007

            
	
              013

            	
              0

            	
              3

            	
              Concert

            	
              PFFS

            	
              Initial

            	
              39.10

            	
              1.90

            	
              9/12/2006

            	
              01/01/2007

            
	
              014

            	
              0

            	
              3

            	
              Concert

            	
              PFFS

            	
              Initial

            	
              42.80

            	
              38.20

            	
              9/12/2006

            	
              01/01/2007

            
	
              015

            	
              0

            	
              3

            	
              Concert

            	
              PFFS

            	
              Initial

            	
              60.30

            	
              48.70

            	
              9/12/2006

            	
              01/01/2007

            
	
              801

            	
              0

            	
              5

            	
              Employer
                Plan 3

            	
              PFFS

            	
              Initial

            	
              0.00

            	
              28.50

            	
              9/12/2006

            	
              01/01/2007

            
	
              802

            	
              0

            	
              5

            	
              Employer
                Plan 4

            	
              PFFS

            	
              Initial

            	
              0.00

            	
              28.50

            	
              9/12/2006

            	
              01/01/2007

            

    

     

    Page 1
      of 3 - HOME OWNERS/WELLCARE PFFS INSURANCE INC. - H4577 -
      09/12/2006

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

    *
      For all
      800-series Plan IDs, plans have the flexibility to vary the premium amounts
      that
      they charge. Therefore, the amount listed in the "MA Premium" and "Part D
      Premium" columns may not coincide with the amount actually charged. For CY2007,
      the direct subsidy payment will be based on the national average monthly bid
      amount rather than on the bid submitted by the plan. Also, the base beneficiary
      premium will be used rather than the plan's premium as derived from their
      standardized bid in determining the low-income premium subsidy.

    

    

    
      	
              /s/
                Todd Farha         
                

            	 	
              9-14-06

            
	
              CEO:

            	 	
              Date:

            
	
              Todd
                Farha

            	 	 
	
              CEO/President

            	 	 
	
              8735
                Henderson Rd Ren 2

            	 	 
	 	 	 
	
              Tampa,
                FL 33634

            	 	 
	
              813-290-6200

            	 	 
	 	 	 
	
              CFO:

            	 	 
	
              Paul
                Behrens

            	 	
              Date:

            
	
              CFO

            	 	 
	
              8735
                Henderson Rd Ren 2

            	 	 
	 	 	 
	 	 	 
	
              Tampa,
                FL 33634

            	 	 
	
              813-290-6200

            	 	 

    

     

    Page
      3 of
      3 - HOME OWNERS/WELLCARE PFFS INSURANCE INC. - H4577 - 09/12/2006Exhibit 10.17

    
      
        

      

    

    Back to Form 10-Q

     

    Exhibit
      10.17

     

    

    OHIO
      DEPARTMENT OF JOB AND FAMILY SERVICES

     

    OHIO
      MEDICAL ASSISTANCE PROVIDER AGREEMENT FOR MANAGED CARE
      PLAN

     

    This
      provider agreement is entered into this first day of November, 2006, at
      Columbus, Franklin County, Ohio, between the State of Ohio, Department of Job
      and Family Services, (hereinafter referred to as ODJFS) whose principal offices
      are located in the City of Columbus, County of Franklin, State of Ohio, and
      WellCare of Ohio, Inc. Managed Care Plan (hereinafter referred to as MCP),
      an
      Ohio tor-profit corporation, whose principal office is located in the city
      ofBeechwood, County ofCuyahoga, State of Ohio.

     

    MCP
      is
      licensed as a Health Insuring Corporation by the State of Ohio, Department
      of
      Insurance (hereinafter referred to as OD1), pursuant to Chapter 1751. of the
      Ohio Revised Code and is organized and agrees to operate as prescribed by
      Chapter 5101:3-26 of the Ohio Administrative Code (hereinafter referred to
      as
      OAC), and other applicable portions of the OAC as amended from time to
      time.

     

    MCP
      is an
      entity eligible to enter into a provider agreement in accordance with 42 CFR
      438.6 and is engaged in the business of providing prepaid comprehensive health
      care services as defined in 42 CFR 438.2 through the managed care program for
      the Covered Families and Children (CFC) eligible population described in OAC
      rule 5101:3-26-02 (B).

     

    ODJFS,
      as
      the single state agency designated to administer the Medicaid program under
      Section 5111.02 of the Ohio Revised Code and Title XIX of the Social Security
      Act, desires to obtain MCP services for the benefit of certain Medicaid
      recipients. In so doing, MCP has provided and will continue to provide proof
      of
      MCP's capability to provide quality services, efficiently, effectively and
      economically during the term of this agreement.

     

    

    

    Page
      2 of
      10

     

    This
      provider agreement is a contract between the ODJFS and the undersigned Managed
      Care Plan (MCP), provider of medical assistance, pursuant to the federal
      contracting provisions of 42 CFR 434.6 and 438.6 in which the MCP agrees to
      provide comprehensive medical services through the managed care program as
      provided in Chapter 5101:3-26 of the Ohio Administrative Code, assuming the
      risk
      of loss, and complying with applicable state statutes, Ohio Administrative
      Code,
      and Federal statutes, rules, regulations and other requirements, including
      but
      not limited to title VI of the Civil Rights Act of 1964: title IX of the
      Education Amendments of 1972 (regarding education programs and activities);
      the
      Age Discrimination Act of 1975; the Rehabilitation Act of 1973; and the
      Americans with Disabilities Act.

     

    ARTICLE
      I
      - GENERAL

     

    A.
      MCP
      agrees to report to the Chief of Bureau of Managed Health Care (hereinafter
      referred to as BMHC) or their designee as necessary to assure understanding
      of
      the responsibilities and satisfactory compliance with this provider
      agreement.

     

    B.
      MCP
      agrees to furnish its support staff and services as necessary for the
      satisfactory performance of the services as enumerated in this provider
      agreement.

     

    C.
      ODJFS
      may, from time to time as it deems appropriate, communicate specific
      instructions and requests to MCP concerning the performance of the services
      described in this provider agreement. Upon such notice and within the designated
      time frame after receipt of instructions, MCP shall comply with such
      instructions and fulfill such requests to the satisfaction of the department.
      It
      is expressly understood by the parties that these instructions and requests
      are
      for the sole purpose of performing the specific tasks requested to ensure
      satisfactory completion of the services described in this provider agreement,
      and are not intended to amend or alter this provider agreement or any part
      thereof.

     

    If
      the
      MCP previously had a provider agreement with the ODJFS and the provider
      agreement terminated more than two years prior to the effective date of any
      new
      provider agreement, such MCP will be considered a new plan in its first year
      of
      operation with the Ohio Medicaid comprehensive managed care
      program.

     

    ARTICLE
      II - TIME OF PERFORMANCE

     

    A.
      Upon
      approval by the Director of ODJFS this provider agreement shall be in effect
      from the date entered through June 30, 2007, unless this provider agreement
      is
      suspended or terminated pursuant to Article VIII prior to the termination date,
      or otherwise amended pursuant to Article IX.

     

    ARTICLE
      III - REIMBURSEMENT

     

    A.
      ODJFS
      will reimburse MCP in accordance with rule 5101:3-26-09 of the Ohio
      Administrative Code and the appropriate appendices of this provider
      agreement.

     

    

    

    Page
      3 of
      10

     

    ARTICLE
      IV - MCP INDEPENDENCE

     

    A.
      MCP
      agrees that no agency, employment, joint venture or partnership has been or
      will
      be created between the parties hereto pursuant to the terms and conditions
      of
      this agreement. MCP also agrees that, as an independent contractor, MCP assumes
      all responsibility for any federal, state, municipal or other tax liabilities,
      along with workers compensation and unemployment compensation, and insurance
      premiums which may accrue as a result of compensation received for services
      or
      deliverables rendered hereunder. MCP certifies that all approvals, licenses
      or
      other qualifications necessary to conduct business in Ohio have been obtained
      and are operative. If at any time during the period of this provider agreement
      MCP becomes disqualified from conducting business in Ohio, for whatever reason,
      MCP shall immediately notify ODJFS of the disqualification and MCP shall
      immediately cease performance of its obligation hereunder in accordance with
      OAC
      Chapter 5101:3-26.

     

    ARTICLE
      V
      - CONFLICT OF INTEREST; ETHICS LAWS

     

    A.
      In
      accordance with the safeguards specified in section 27 of the Office of Federal
      Procurement Policy Act (41 U.S.C. 423) and other applicable federal
      requirements, no officer, member or employee of MCP. the Chief of BMHC, or
      other
      ODJFS employee who exercises any functions or responsibilities in connection
      with the review or approval of this provider agreement or provision of services
      under this provider agreement shall, prior to the completion of such services
      or
      reimbursement, acquire any interest, personal or otherwise, direct or indirect,
      w'hich is incompatible or in conflict with, or would compromise in any manner
      or
      degree the discharge and fulfillment of his or her functions and
      responsibilities with respect to the carrying out of such services. For purposes
      of this article, "members" does not include individuals whose sole connection
      with MCP is the receipt of services through a health care program offered by
      MCP.

     

    B.
      MCP
      hereby covenants that MCP, its officers, members and employees of the MCP have
      no interest, personal or otherwise, direct or indirect, which is incompatible
      or
      in conflict with or would compromise in any manner of degree the discharge
      and
      fulfillment of his or her functions and responsibilities under this provider
      agreement. MCP shall periodically inquire of its officers, members and employees
      concerning such interests.

     

    C.
      Any
      person who acquires an incompatible, compromising or conflicting personal or
      business interest shall immediately disclose his or her interest to ODJFS in
      writing. Thereafter, he or she shall not participate in any action affecting
      the
      services under this provider agreement, unless ODJFS shall determine that.
      in
      the light of the personal interest disclosed, his or her participation in any
      such action would not be contrary to the public interest. The written disclosure
      of such interest shall be made to: Chief, Bureau of Managed Health Care,
      ODJFS.

     

    

    

    Page
      4 of
      10

     

    D.
      No
      officer, member or employee ofMCP shall promise or give to any ODJFS employee
      anything of value that is of such a character as to manifest a substantial
      and
      improper influence upon the employee with respect to his or her duties. No
      officer, member or employee ofMCP shall solicit an ODJFS employee to violate
      any
      ODJFS rule or policy relating to the conduct of the parties to this agreement
      or
      to violate sections 102.03, 102.04, 2921.42 or 2921.43 of the Ohio Revised
      Code.

     

    E.
      MCP
      hereby covenants that MCP. its officers, members and employees are in compliance
      with section 102.04 of the Revised Code and that if MCP is required to file
      a
      statement pursuant to 102.04(D)(2) of the Revised Code, such statement has
      been
      filed with the ODJFS in addition to any other required filings.

     

    ARTICLE
      VI - EQUAL EMPLOYMENT OPPORTUNITY

     

    A.
      MCP
      agrees that in the performance of this provider agreement or in the hiring
      of
      any employees for the performance of services under this provider agreement,
      MCP
      shall not by reason of race, color, religion, sex, sexual orientation, age,
      disability, national origin, veteran's status, health status, or ancestry,
      discriminate against any citizen of this state in the employment of a person
      qualified and available to perform the services to which the provider agreement
      relates.

     

    B.
      MCP
      agrees that it shall not, in any manner, discriminate against, intimidate,
      or
      retaliate against any employee hired for the performance or services under
      the
      provider agreement on account of race, color, religion, sex, sexual orientation,
      age, disability, national origin, veteran's status, health status, or
      ancestry.

     

    C.
      In
      addition to requirements imposed upon subcontractors in accordance with OAC
      Chapter 5101:3-26, MCP agrees to hold all subcontractors and persons acting
      on
      behalf of MCP in the performance of services under this provider agreement
      responsible for adhering to the requirements of paragraphs (A) and (B) above
      and
      shall include the requirements of paragraphs (A) and (B) above in all
      subcontracts for services performed under this provider agreement, in accordance
      with rule 5101:3-26-05 of the Ohio Administrative Code.

     

    ARTICLE
      VII - RECORDS, DOCUMENTS AND INFORMATION

     

    A.
      MCP
      agrees that all records, documents, writings or other information produced
      by
      MCP under this provider agreement and all records, documents, writings or other
      information used by MCP in the performance of this provider agreement shall
      be
      treated in accordance with rule 5101:3-26-06 of the Ohio Administrative Code.
      MCP must maintain an appropriate record system for services provided to members.
      MCP must retain all records in accordance with 45 CFR 74.

     

    B.
      All
      information provided by MCP to ODJFS that is proprietary shall be held to be
      strictly confidential by ODJFS. Proprietary information is information which,
      if
      made public, would put MCP at a disadvantage in the market place and trade
      of
      which MCP is a part

     

    

    

    Page
      5 of
      10

     

    [see
      Ohio
      Revised Code Section 1333.61 (D)]. MCP is responsible for notifying ODJFS of
      the
      nature of the information prior to its release to ODJFS. ODJFS reserves the
      right to require reasonable evidence of MCP's assertion of the proprietary
      nature of any information to be provided and ODJFS will make the final
      determination of whether this assertion is supported. The provisions of this
      Article are not self-executing.

     

    C.
      MCP
      shall not use any information, systems, or records made available to it for
      any
      purpose other than to fulfill the duties specified in this provider agreement.
      MCP agrees to be bound by the same standards of confidentiality that apply
      to
      the employees of the ODJFS and the State of Ohio. The terms of this section
      shall be included in any subcontracts executed by MCP for services under this
      provider agreement. MCP must implement procedures to ensure that in the process
      of coordinating care, each enrollee's privacy is protected consistent with
      the
      confidentiality requirements in 45 CFR parts 160 and 164.

     

    ARTICLE
      VIII - SUSPENSION AND TERMINATION

     

    A.
      This
      provider agreement may be canceled by the department or MCP upon written notice
      in accordance with the applicable rule(s) of the Ohio Administrative Code,
      with
      termination to occur at the end of the last day of a month.

     

    B.
      MCP,
      upon receipt of notice of suspension or termination, shall cease provision
      of
      services on the suspended or terminated activities under this provider
      agreement; suspend, or terminate all subcontracts relating to such suspended
      or
      terminated activities, take all necessary or appropriate steps to limit
      disbursements and minimize costs, and furnish a report, as of the date of
      receipt of notice of suspension or termination describing the status of all
      services under this provider agreement.

     

    C.
      In the
      event of suspension or termination under this Article, MCP shall be entitled
      to
      reconciliation of reimbursements through the end of the month for which services
      were provided under this provider agreement, in accordance with the
      reimbursement provisions of this provider agreement.

     

    D.
      ODJFS
      may, in its judgment, suspend, terminate or fail to renew this provider
      agreement if the MCP or MCP's subcontractors violate or fail to comply with
      the
      provisions of this agreement or other provisions of law or regulation governing
      the Medicaid program. Where ODJFS proposes to suspend, terminate or refuse
      to
      enter into a provider agreement, the provisions of applicable sections of the
      Ohio Administrative Code with respect to ODJFS' suspension, termination or
      refusal to enter into a provider agreement shall apply, including the MCP's
      right to request a public hearing under Chapter 119. of the Revised
      Code.

     

    

    

    Page
      6 of
      10

     

    E.
      When
      initiated by MCP, termination of or failure to renew the provider agreement
      requires written notice to be received by ODJFS at least 75 days in advance
      of
      the termination or renewal date, provided, however, that termination or
      non-renewal must be effective at the end of the last day of a calendar month.
      In
      the event of non-renewal of the provider agreement with ODJFS, if MCP is unable
      to provide notice to ODJFS 75 days prior to the date when the provider agreement
      expires, and if, as a result of said lack of notice, ODJFS is unable to
      disenroll Medicaid enrollees prior to the expiration date, then the provider
      agreement shall be deemed extended for up to two calendar months beyond the
      expiration date and both parties shall, for that time, continue to fulfill
      their
      duties and obligations as set forth herein. If an MCP wishes to terminate or
      not
      renew their provider agreement for a specific region(s), ODJFS reserves the
      right to initiate a procurement process to select additional MCPs to serve
      Medicaid consumers in that region(s).

     

    ARTICLE
      IX - AMENDMENT AND RENEWAL

     

    A.
      This
      writing constitutes the entire agreement between the parties with respect to
      all
      matters herein. This provider agreement may be amended only by a writing signed
      by both parties. Any written amendments to this provider agreement shall be
      prospective in nature.

     

    B.
      This
      provider agreement may be renewed one or more times by a writing signed by
      both
      parties for a period of not more than twelve months for each
      renewal.

     

    C.
      In the
      event that changes in State or Federal law. regulations, an applicable waiver,
      or the terms and conditions of any applicable federal waiver, require ODJFS
      to
      modify this agreement, ODJFS shall notify MCP regarding such changes and this
      agreement shall be automatically amended to conform to such changes without
      the
      necessity for executing written amendments pursuant to this Article of this
      provider agreement.

     

    ARTICLE
      X
      - LIMITATION OF LIABILITY

     

    A.
      MCP
      agrees to indemnify the State of Ohio for any liability resulting from the
      actions or omissions of MCP or its subcontractors in the fulfillment of this
      provider agreement.

     

    B.
      MCP
      hereby agrees to be liable for any loss of federal funds suffered by ODJFS
      for
      enrollees resulting from specific, negligent acts or omissions of the MCP or
      its
      subcontractors during the term of this agreement, including but not limited
      to
      the nonperformance of the duties and obligations to which MCP has agreed under
      this agreement.

     

    C.
      In the
      event that, due to circumstances not reasonably within the control of MCP or
      ODJFS, a major disaster, epidemic, complete or substantial destruction of
      facilities, war, riot or civil insurrection occurs, neither ODJFS nor MCP will
      have any liability or obligation on account of reasonable delay in the provision
      or the arrangement of covered services; provided that so long as MCP's
      certificate of authority remains in full force and

     

    

    

    Page
      7 of
      10

     

    effect,
      MCP shall be liable for the covered services required to be provided or arranged
      for in accordance with this agreement.

     

    ARTICLE
      XI - ASSIGNMENT

     

    A.
      ODJFS
      will not allow the transfer of Medicaid members by one MCP to another MCP unless
      this membership has been obtained as a result of an MCP selling their entire
      Ohio corporation to another health plan. MCP shall not assign any interest
      in
      this provider agreement and shall not transfer any interest in the same (whether
      by assignment or novation) without the prior written approval of ODJFS and
      subject to such conditions and provisions as ODJFS may deem necessary. Any
      such
      assignments shall be submitted for ODJFS' review 120 days prior to the desired
      effective date. No such approval by ODJFS of any assignment shall be deemed
      in
      any event or in any manner to provide for the incurrence of any obligation
      by
      ODJFS in addition to the total agreed-upon reimbursement in accordance with
      this
      agreement.

     

    B.
      MCP
      shall not assign any interest in subcontracts of this provider agreement and
      shall not transfer any interest in the same (whether by assignment or novation)
      without the prior written approval of ODJFS and subject to such conditions
      and
      provisions as ODJFS may deem necessary. Any such assignments of subcontracts
      shall be submitted for ODJFS' review 30 days prior to the desired effective
      date. No such approval by ODJFS of any assignment shall be deemed in any event
      or in any manner to provide for the incurrence of any obligation by ODJFS in
      addition to the total agreed-upon reimbursement in accordance with this
      agreement.

     

    ARTICLE
      XII - CERTIFICATION MADE BY MCP

     

    A.
      This
      agreement is conditioned upon the full disclosure by MCP to ODJFS of all
      information required for compliance with federal regulations as requested by
      ODJFS.

     

    B.
      By
      executing this agreement. MCP certifies that no federal funds paid to MCP
      through this or any other agreement with ODJFS shall be or have been used to
      lobby Congress or any federal agency in connection with a particular contract,
      grant, cooperative agreement or loan. MCP further certifies compliance with
      the
      lobbying restrictions contained in Section 1352, Title 31 of the U.S. Code.
      Section 319 of Public Law 101-121 and federal regulations issued pursuant
      thereto and contained in 45 CFR Part 93, Federal Register, Vol. 55, No. 38,
      February 26, 1990, pages 6735-6756. If this provider agreement exceeds $100,000,
      MCP has executed the Disclosure of Lobbying Activities, Standard Form LLL,
      if
      required by federal regulations. This certification is material representation
      of fact upon which reliance was placed when this provider agreement was entered
      into.

     

    C.
      By
      executing this agreement, MCP certifies that neither MCP nor any principals
      of
      MCP (i.e., a director, officer, partner, or person with beneficial ownership
      of
      more than 5% of the MCP's equity) is presently debarred, suspended, proposed
      for
      debarment, declared ineligible, or otherwise excluded from participation in
      transactions by any Federal agency. The MCP also certifies that the MCP has
      no
      employment, consulting or any other arrangement with any such debarred or
      suspended person for the provision of items or services or services that are
      significant and material to the MCP's contractual

     

    

    

    Page
      8 of
      10

     

    obligation
      with ODJFS. This certification is a material representation of fact upon which
      reliance was placed when this provider agreement was entered into. If it is
      ever
      determined that MCP knowingly executed this certification erroneously, then
      in
      addition to any other remedies, this provider agreement shall be terminated
      pursuant to Article VII, and ODJFS must advise the Secretary of the appropriate
      Federal agency of the knowingly erroneous certification.

     

    D.
      By
      executing this agreement, MCP certifies compliance with Article V as well as
      agreeing to future compliance with Article V. This certification is a material
      representation of fact upon which reliance was placed when this contract was
      entered into.

     

    E.
      By
      executing this agreement, MCP certifies compliance with the executive agency
      lobbying requirements of sections 121.60 to 121.69 of the Ohio Revised Code.
      This certification is a material representation of fact upon which reliance
      was
      placed when this provider agreement was entered into.

     

    F.
      By
      executing this agreement, MCP certifies that MCP is not on the most recent
      list
      established by the Secretary of State, pursuant to section 121.23 of the Ohio
      Revised Code, which identifies MCP as having more than one unfair labor practice
      contempt of court finding. This certification is a material representation
      of
      fact upon which reliance was placed when this provider agreement was entered
      into.

     

    G.
      By
      executing this agreement MCP agrees not to discriminate against individuals
      who
      have or are participating in any work program administered by a county
      Department of Job and Family Services under Chapters 5101 or 5107 of the Revised
      Code.

     

    H.
      By
      executing this agreement. MCP certifies and affirms that. as applicable to
      MCP,
      no party listed in Division (1) or (J) of Section 3517.13 of the Ohio Revised
      Code or spouse of such party has made, as an individual, within the two previous
      calendar years, one or more contributions in excess of $1.000.00 to the Governor
      or to his campaign committees. This certification is a material representation
      of fact upon which reliance was placed when this provider agreement was entered
      into. If it is ever determined that MCP's certification of this requirement
      is
      false or misleading, and not withstanding any criminal or civil liabilities
      imposed by law. MCP shall return to ODJFS all monies paid to MCP under this
      provider agreement. The provisions of this section shall survive the expiration
      or termination of this provider agreement.

     

    I.
      By
      executing this agreement, MCP certifies and affirms that HHS, US Comptroller
      General or representatives will have access to books, documents, etc. of
      MCP.

     

    J.
      By
      executing this agreement, MCP agrees to comply with the false claims recovery
      requirements of section 1902(a)(68) of the Social Security Act.

     

    ARTICLE
      XIII - CONSTRUCTION

     

    A.
      This
      provider agreement shall be governed, construed and enforced in accordance
      with
      the laws and regulations of the State of Ohio and appropriate federal statutes
      and

     

    

    

    Page
      9 of
      10

     

    regulations.
      If any portion of this provider agreement is found unenforceable by operation
      of
      statute or by administrative or judicial decision, the operation of the balance
      of this provider agreement shall not be affected thereby; provided, however,
      the
      absence of the illegal provision does not render the performance of the
      remainder of the provider agreement impossible.

     

    ARTICLE
      XIV - INCORPORATION BY REFERENCE

     

    A.
      Ohio
      Administrative Code Chapter 5101:3-26 (Appendix A) is hereby incorporated by
      reference as part of this provider agreement having the full force and effect
      as
      if specifically restated herein.

     

    B.
      Appendices B through P and any additional appendices are hereby incorporated
      by
      reference as part of this provider agreement having the full force and effect
      as
      if specifically restated herein.

     

    C.
      In the
      event ofinconsistence or ambiguity between the provisions ofOAC 5101:3-26 and
      this provider agreement, the provision of OAC 5101:3-26 shall be determinative
      of the obligations of the parties unless such inconsistency or ambiguity is
      the
      result of changes in federal or state law, as provided in Article IX of this
      provider agreement, in which case such federal or state law shall be
      determinative of the obligations of the parties. In the event OAC 5101:3-26
      is
      silent with respect to any ambiguity or inconsistency, the provider agreement
      (including Appendices B through P and any additional appendices), shall be
      determinative of the obligations of the parties. In the event that a dispute
      arises which is not addressed in any of the aforementioned documents, the
      parties agree to make every reasonable effort to resolve the dispute, in keeping
      with the objectives of the provider agreement and the budgetary and statutory
      constraints ot'ODJFS.

     

    

    

    Page
      10
      of 10

     

    The
      parties have executed this agreement the date first written above. The agreement
      is hereby accepted and considered binding in accordance with the terms and
      conditions set forth in the preceding statements.

     

    

    WELLCARE
      OF OHIO, INC.:

    

    

    

    
      	
              WELLCARE
                OF OHIO, INC.

               

              BY:
                /s/
                Todd S. Farha

              Todd
                S. Farha

            	
               

               

              DATE:
                10/23/06

            
	
              DEPARTMENT
                OF JOB AND FAMILY SERVICES:

               

              BY:
                /s/
                Barbara
                Riley          

                
BARBARA
                E. RILEY, DIRECTOR

            	
               

               

               

              DATE:
                10/27/06

            

    

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

     

    

    
      	
              PROVIDER
                AGREEMENT INDEX 

              JULY
                1, 2006

            
	
              APPENDIX

            	
              TITLE

            
	
              APPENDIX
                A

            	
              OAC
                RULES 101:3-26

            
	
              APPENDIX
                B

            	
              SERVICE
                AREA SPECIFICATIONS 

            
	
              APPENDIX
                C

            	
              MCP
                RESPONSIBILITIES 

            
	
              APPENDIX
                D

            	
              ODJFS
                RESPONSIBILITIES

            
	
              APPENDIX
                E

            	
              RATE
                METHODOLOGY 

            
	
              APPENDIX
                F

            	
              COUNTY
                AND REGIONAL RATES

            
	
              APPENDIX
                G

            	
              COVERAGE
                AND SERVICES 

            
	
              APPENDIX
                H

            	
              PROVIDER
                PANEL SPECIFICATIONS

            
	
              APPENDIX
                I

            	
              PROGRAM
                INTEGRITY 

            
	
              APPENDIX
                J

            	
              FINANCIAL
                PERFORMANCE

            
	
              APPENDIX
                K

            	
              QUALITY
                ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM

            
	
              APPENDIX
                L 

            	
              DATA
                QUALITY

            
	
              APPENDIX
                M

            	
              PERFORMANCE
                EVALUATION 

            
	
              APPENDIX
                N

            	
              COMPLIANCE
                ASSESSMENT SYSTEM

            
	
              APPENDIX
                0

            	
              PERFORMANCE
                INCENTIVES

            
	
              APPENDIX
                P

            	
              MCP
                TERM1NATIONS/NONRENEWALS/
                AMENDMENTS

            

    

    

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    

    

    APPENDIX
      A 

    OAC
      RULES 5101:3-26

     

    The
      managed care program rules can be accessed electronically through the BMHC
      page
      of the ODJFS website.

     

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

    APPENDIX
      B

     

    SERVICE
      AREA SPECIFICATIONS

     

    MCP
      : WellCare of Ohio, Inc.

     

    The
      MCP agrees to provide services to Covered Families and Children (CFC) members
      residing in the following service area(s):

     

    Service
      Area: Northeast Region
      -
      Ashtabula, Cuyahoga, Erie, Geauga, Huron, Lake, Lorain, and Medina
      counties.

     

    

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    APPENDIX
      C

    MCP
      RESPONSIBILITIES

     

    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.

     

    General
      Provisions

     

    1.
      The
      MCP agrees to implement program modifications 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).

     

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

     

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

     

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

     

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

     

    

    8.
      The
      MCP must assure that all new employees are trained on applicable program
      requirements

    

    Appendix
      C 

    Page
      2

     

    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 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.

     

    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.
      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.

     

    14.
      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.
      If
      an MCP elects to provide additional services, the MCP must ensure 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 that
      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.

    

    

    Appendix
      C

    Page
      3

    

    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 90 days prior notice when decreasing or ceasing
      any
      additional benefit(s). When it is beyond the control of the MCP, ODJFS must
      be
      notified within 1 working day.

     

    15.
      MCPs
      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 w'hen furnishing services to members.

     

    16.
      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.

     

    17.
      Upon
      request, the MCP will provide members and potential members with a copy of
      their
      practice guidelines.

     

    18.
      The
      MCP is responsible for promoting the delivery of services in a culturally
      competent manner to all members, including those with limited English
      proficiency (LEP) and diverse cultural and ethnic backgrounds.

     

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

     

    a.
      When
      10% or more of the 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, 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 members in the MCP's service area have

     

    

    

    Appendix
      C

    Page
      4

    

    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. 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.

     

    19.
      The
      MCP must utilize a centralized database which records the special 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 needs information for MCP
      members, as indicated above, when identified by a 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 special needs information with
      their providers [e.g.. PCPs, Pharmacy Benefit Managers (PBMs). and Third Party
      Administrators (TPAs)], as applicable. MCPs must submit to ODJFS, upon request,
      detailed information regarding the MCP's members with special needs, which
      could
      include individual member names, their specific special 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.UA), 5101:3-26-08, and 5101-3-26-08.2.

     

    20.
      The
      MCP is responsible for ensuring that all member materials use easily understood
      language and format.

     

    21.
      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. 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.

     

    

    

    Appendix
      C 

    Page
      5

     

    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 ODJFsT.

     

    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.

     

    22.
      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 1 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;

     

    

    

    Appendix
      C 

    Page
      6

    

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

     

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

     

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

     

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

     

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

     

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

     

    23.
      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 OD.IFS 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 its receipt prior to the member's effective date of coverage.
      No other materials may be included with this mailing.

     

    (c)
      The
      member handbook, provider directory and advance directives information must
      be
      mailed 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 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 5 days.

     

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

     

    

    

    Appendix
      C 

    Page
      7

     

    24.
      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 a.m to 7:00 p.m 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 30 days in advance of the
      closure.

     

    The
      MCP
      must also provide access to medical advice and direction through a centralized
      twenty-four-hour toll-free call-in system pursuant to OAC rule
      5101:3-26-03.1(A)(6). The twenty-four 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-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

     

    

    

    Appendix
      C 

    Page
      8

    

    requirement
      may not be met through the execution of a Medicaid Delegation Subcontract
      Addendum or Medicaid Combined Services Subcontract Addendum.

     

    25.
      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 counties must notify
      their new members that MCP membership is optional for certain populations.
      Specifically. MCPs must include information in their new member letter that
      the
      following CFC populations are not required to select an MCP in order to receive
      their Medicaid healthcare benefit and what steps they need to take if they
      do
      not wish to be a member of an MCP:

    -
      Indians
      who are members of federally-recognized tribes. 

    -
      Children under 19 years of age who are:

     

    o
      Eligible for Supplemental Security Income under title XVI;

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

    o
      Receiving foster care of adoption assistance;

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

     

    26.
      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
      ofPHI.

     

    c.
      MCPs
      shall report to ODJFS any unauthorized use or disclosure of PHI of which it
      becomes aware.

     

    

    

    Appendix
      C 

    Page
      9

    

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

     

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

     

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

     

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

     

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

     

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

     

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

     

    27.
      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.

     

    28.
      MCP
      Membership acceptance, documentation and reconciliation

     

    a.
      Selection
      Services Contractor:
      The MCP
      shall provide to the selection services contractor (SSC) 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 SSC-produced consumer contact
      record (CCR) with the ODJFS-produced monthly member roster (MMR) and report
      to
      the ODJFS any difficulties in interpreting or reconciling information received.
      Membership reconciliation questions must be identified and reported to the
      ODJFS
      prior to the first of the month to assure that no member is left without
      coverage. The MCP shall reconcile membership with premium payments and delivery
      payments as reported on the monthly remittance advice (RA).

     

    

    

    Appendix
      C 

    Page
      10

     

    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 30 days of receipt of
      theRA.

     

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

     

    d.
      Hospital
      Deferment Requests:
      When the
      MCP learns of a new member's hospitalization that is eligible for deferment
      prior to that member's discharge, the MCP shall notify the hospital and treating
      providers of the potential that the MCP may not be the payer. The MCP shall
      work
      with hospitals, 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 months following the member's
      effective date, when the MCP learns of a deferment-eligible hospitalization.
      the
      MCP shall make every effort to notify the ODJFS and request the deferment as
      soon as possible. When the MCP is notified by ODJFS of a potential hospital
      deferment, the MCP must make every effort to respond to ODJFS within 10 business
      days of the receipt of the deferment information.

     

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

     

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

     

    g.
      Eligible
      Individuals:
      If an
      eligible individual contacts the MCP, the MCP must provide any MCP-specific
      managed care program information requested. The MCP must not attempt to assess
      the eligible individual's health care needs. However, if the eligible individual
      inquires about continuing/transition ing health care services, MCPs must 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.

     

    

    

    Appendix
      C 

    Page
      11

    

     

    h.
      Pending
      Member

     

    If
      a
      pending member (i.e., an eligible individual subsequent to plan selection 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, 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.

     

    i.
      Transition
      ofFee-For-Service Members

     

    (i)
      MCPs
      must allow their new members that are transitioning from medicaid
      fee-for-service to receive services from out-of-panel providers if the members
      contact the MCP to discuss the scheduled health services in advance of the
      service date and the services relate to one of the following:

     

    (a)
      The
      member has been approved to receive an organ, bone marrow, or hematapoietic
      stem
      cell transplant pursuant to OAC rule 5101:3-2-07.1.

     

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

     

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

     

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

     

    (e)
      The
      member is receiving ongoing chemotherapy or radiation treatment.

     

    (ii)
      MCPs
      must reimburse these out-of-panel providers at 100% of the current Medicaid
      fee-for-service provider rate for the service(s).

     

    

    

    Appendix
      C 

    Page
      12

     

    (a)
      As
      expeditiously as the situations warrant, MCPs must contact the providers'
      offices via telephone to confirm that the services meet the above
      criteria.

     

    (b)
      For
      services that meet the above criteria, MCPs must inform the providers that
      they
      are sending a form for signature to document that they accept/do not accept
      the
      terms for the provision of the services and copy members on the
      forms.

     

    (c)
      If
      the providers agree to the terms, MCPs must notify the members and providers
      of
      the authorization and ensure that the claims processing system will not deny
      the
      claim payment because the providers are out-of-panel.

     

    (d)
      If
      the providers do not agree to the terms. MCPs must notify the members and assist
      the embers with locating a provider as expeditiously as the members' conditions
      warrant.

     

    (e)
      MCPs
      must use the ODJFS-specified model language for the provider and member
      notices.

     

    (f)
      MCPs
      must maintain documentation of all member and/or provider contacts relating
      to
      such out-of-panel services, including but not limited to telephone calls and
      letters.

     

    29.
      Health
      Information System Requirements

    

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

     

    a.
      Health
      Information System

     

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

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

     

    

    

    Appendix
      C 

    Page
      13

     

    (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 prepare!" 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 flies in the ODJFS-specified formats. Once an acceptable
      test file is submitted to 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 w'ill have
      up
      to 90 days to submit an acceptable test file and an acceptable production
      file.

     

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

     

    b.
      Electronic Data Interchange and Claims Adjudication Requirements

     

    Claims
      Adjudication

     

    

    

    Appendix
      C 

    Page
      14

     

    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 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)] w ithin 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; and Standard code sets.

     

    Each
      EDI
      transaction processed by the MCP shall be implemented in conformance with the
      appropriate version of the transaction implementation guide, as specified by
      federal 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
      XI 2
      820 - Payroll Deducted and Other Group Premium Payment for Insurance Products;
      and

     

    ASC
      XI 2
      834 - Benefit Enrollment and Maintenance.

     

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

     

    Documentation
      of Compliance with Mandated EDI Standards

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

    

    

    Appendix
      C 

    Page
      15

     

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

    MCPs
      shall submit written verification for transaction standards and code sets
      specified in 45 CFR Part 162 - Health Insurance Reform: Standards for Electronic
      Transactions (HIPAA regulations), that the MCP has established the capability
      of
      sending and receiving applicable transactions in compliance with the HIPAA
      regulations. The written verification shall specify the date that the MCP has:
      1) achieved capability for sending and/or receiving the following transactions,
      2) entered into the appropriate trading partner agreements, and 3) 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).

     

    1.
      Trading Partner Agreements

    2.
      Code
      Sets

    3.
      Transactions

     

    a.
      Health
      Care Claims or Equivalent Encounter Information (ASCX12N837&NCPDP5.1)

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

    c.
      Referral Certification and Authorization (ASC X12N 278) 

    d.
      Health
      Care Claim Status (ASC X 12N 276/277) 

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

    f.
      Health
      Care Payment and Remittance Advice (ASC X 12N 835) 

    g.
      Health
      Plan Premium Payments (ASC X12N 820) 

    h.
      Coordination of Benefits

     

    Trading
      Partner Agreement with OD.1FS

    MCPs
      must
      complete and submit an ED1 trading partner agreement in a format specified
      by
      the ODJFS. Submission of the copy of the trading partner agreement prior to
      entering into the provider agreement may be waived at the discretion of ODJFS;
      if submission prior to entering into the provider agreement is waived, the
      trading partner agreement must be submitted at a subsequent date determined
      by
      ODJFS.

     

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

     

    c.
      Encounter
      Data Submission Requirements

     

    General
      Requirements

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

    

    

    Appendix
      C

    Page
      16

     

    •
      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 and performance measures and standards
      are
      described in the MCP Provider 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 betw een 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. How'ever, 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 POP examines
      the member and has laboratory procedures done within the office, then this
      is
      one encounter between the member and their PCP.

     

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

     

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

     

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

     

    

    

    Appendix
      C 

    Page
      17

     

    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.

     

    No
      more
      than two production files in the ODJFS-specified medium per format (e.g., NSF)
      should be submitted each month. If it is necessary for an MCP to submit more
      than two production files in the ODJFS-specified medium for a particular format
      in a month, they must request permission to do so through their Contract
      Administrator.

     

    Timing
      of Encounter Data Submissions

    ODJFS
      recommends that MCPs submit encounters no more than thirty-five 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

     

    Every
      two
      years, and before ODJFS enters into a provider agreement with a new MCP, ODJFS
      or designee may review the information system capabilities of each MCP. Each
      MCP
      must participate in the review, except as specified below. The review will
      assess the extent to which MCPs are capable of maintaining a health information
      system including producing valid encounter data, performance measures, and
      other
      data necessary to support quality assessment and improvement, as well as
      managing the care delivered to its members. The following activities will be
      carried out during the review. ODJFS or its desianee will:

     

    

    

    Appendix
      C 

    Page
      18

    

    (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.

     

    As
      noted
      above, the information system review may be performed every two years. However,
      if ODJFS or its designee identifies significant information system problems.
      then ODJFS or its designee may conduct, and the MCP must participate in, a
      review the following year.

     

    If
      an MCP
      had an assessment performed of its information system through a private sector
      accreditation body or other independent entity within the two years preceding
      when the ODJFS or its designee will be conducting its review, and has not made
      significant changes to its information system since that time, and the
      information gathered is the same as or consistent w ith the ODJFS or its
      designee's proposed review, as determined by the ODJFS. then the MCP will not
      required to undergo the IS review. The MCP must provide ODJFS or its designee
      with a copy of the review that was performed so that ODJFS can determine whether
      or not the MCP will be required to participate in the IS review. MCPs w'ho
      are
      determined to be exempt from the IS review must participate in subsequent
      information system reviews.

     

    

    

    Appendix
      C 

    Page
      19

     

    30.
      Delivery
      Payments

     

    MCPs
      will
      be reimbursed for paid deliveries that are identified in the
      submitted

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

     

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

     

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

     

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

     

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

     

    Rejections

    If
      a
      delivery encounter is not submitted according to ODJFS specifications, it will
      be

    rejected
      and MCPs will receive this information on the exception report (or error
      report)

    that
      accompanies every file in the ODJFS-specified format. Tracking, correcting
      and

    resubmitting
      all rejected encounters is the responsibility of the MCP and is required
      by

    ODJFS.

     

    Timing
      of Delivery Payments

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

    

     

    Appendix
      C 

    Page
      20

     

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

     

    Updating
      and Deleting Delivery Encounters

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

     

    The
      process for deleting delivery encounters can be found on page 35 of the LJB-92
      technical specifications (record/field 20-7) and page 111-47 of the NSF
      technical specifications (record/field CAO-31.0a).

     

    Auditing
      of Delivery Payments

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

     

    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 approval from ODJFS that verifies that the proper safeguards, firewalls,
      etc.. are in place to protect member data.

     

    32.
      MCPs
      must receive prior 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 is prohibited from holding a member
      liable for services provided to the member in the event that the ODJFS fails
      to
      make payment to the MCP.

     

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

     

    

    

    Appendix
      C 

    Page
      21

     

    35.
      Franchise
      Fee Assessment Requirements

     

    a.
      Each
      MCP is required to pay a franchise permit fee to ODJFS for each calendar quarter
      in compliance with ORC Section 5111.176. The fee to be paid is an amount equal
      to 4!/z percent of the managed care premiums, minus Medicare premiums that
      the
      MCP received from any payer in the quarter to \\hich 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
      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.
      Provider
      Directory
      - MCPs
      must have an internet-based provider directory available in the same format
      as
      their ODJFS-approved provider directory, that allow's members to electronically
      search for the MCP panel providers based on name. provider type, and geographic
      proximity (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.
      Member
      Websitc - MCPs must have a secure internet-based website which is updated to
      include the most current ODJFS approved materials. The website at a minimum
      must
      include: (1) a list of the counties that are covered in their service area;
      (2)
      the ODJFS-approved MCP member handbook, recent newsletters/announcements, MCP
      contact information including member services hours and closures: (3) the MCP
      provider directory as referenced in section 36(a) of this appendix; (4) the
      MCP's current preferred drug list (PDL), including an explanation of the list,
      which drugs require prior authorization (PA), and the PA process; (5) the MCP's
      current list of drugs covered only with PA, the PA process, and the MCP's policy
      for covering generic for brand-name drugs; and (6) the ability for members
      to
      submit questions/comments/grievances/appeals/etc, and receive a response
      (members must be given the option of a return e-mail or phone call) within
      one
      working day of receipt.

     

    

    

    Appendix
      C 

    Page
      22

     

    c.
      Provider
      Website -
      MCPs
      must have a secure internet-based website for 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 36(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; and (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.

     

    37.
      MCPs
      must provide members w'ith a printed version of their PDL and PA lists, upon
      request.

     

    38.
      MCPs
      must not use, or propose to use , any offshore programming or call center
      services in fulfilling the program requirements.

     

    

    

    APPENDIX
      D 

    ODJFS
      RESPONSIBILITIES

     

    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 (G1S) software, if ODJFS determines that significant changes
      have occurred in the availability of specific provider!} pes and the number
      and
      composition ofthe 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.

     

    

    

    Appendix
      D 

    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, w'tiich includes
      their Medicaid Provider Number, as well as all providers who have been assigned
      a provider reporting number for 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 ofTLS 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 will 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.
      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' 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.

     

    13.
      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 will provide MCP eligible individuals, including current MCP
      members, with a Consumer Guide. The Consumer Guide will describe the managed
      care program and include information on the MCP options in the service area
      and
      other information regarding the managed care program as specified in 42 CFR
      438.10.

     

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

     

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

     

     

    Appendix
      D

    Page
      3

     

    14. Membership
      Selection and Premium Payment

     

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

     

    The
      SSC
      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-Assigment
      Limitations -
      In order
      to ensure market and program stability, ODJFS will limit an MCP's
      auto-assignments if they meet any of the following enrollment
      thresholds;

     

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

     

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

     

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

     

    Once
      an
      MCP meets one of these enrollment thresholds, the MCP will only be permitted
      to
      receive the additional new membership (in the region or statewide, as
      applicable) through: (1) consumer-initiated enrollment; and (2) auto-assignments
      which are based on previous enrollment in that MCP or an historical provider
      relationship w ith a provider w ho is not on the panel of any other MCP in
      that
      region. In the event that all MCPs in a region meet one or more of these
      enrollment thresholds, ODJFS reserves the right to not impose the
      auto-assignment limitation and to 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 ccr.s
      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 SSC-initiated MCP assignment
      processed through the SSC. 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 and Delivery Payments:
      ODJFS
      will remit payment to the MCPs via an electronic funds transfer (EFT), or at
      the
      discretion of ODJFS, by paper warrant.

     

    

    

    Appendix
      D 

    Page
      4

     

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

     

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

     

    15.
      ODJFS
      will make available a website which includes current program
      information.

     

    16.
      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.

     

    17.
      ODJFS
      will periodically review a random sample of online and printed directories
      to
      ensure that MCP information is both accessible and updated.

     

    18.
      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
      Contract Administrator (CA) has been assigned to each MCP. Unless specifically
      directed otherwise. MCPs are to 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 w ithin the
      Contract Administration Section.

     

    b.
      ODJFS
      contracting-entities:
      ODJFS-contracting entities should never be contacted by the MCPs unless the
      MCPs
      have been specifically informed to contact the ODJFS contracting entity
      directly. Ensuring that MCP staff know to contact their CA will help ensure
      that
      the MCP does not receive conflicting, inaccurate, or incomplete information
      as a
      result of conversing with ODJFS staff (and ODJFS-contracting entities) w'ho
      do
      not have the full context and/or understanding of the managed care program.
      Because MCPs are ultimately responsible for meeting program requirements, the
      BMHC will not discuss MCP issues with the

     

    

    

    Appendix
      D

    Page
      5

     

     

    MCPs'
      delegated entities unless the applicable MCP is also participating in the
      discussion.

     

    
 

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

    
      	
               

              MERCER

            	 
	
              Government
                Human Services Consulting

            	
              333
                South 7th Street, Suite 1600 

              Minneapolis.
                MN 55402

              www.mercerHR.com

            

    

     

    October
      12, 2006

     

    Mr.
      Jon
      Barley

     

    Bureau
      of
      Managed Health Care

    Ohio
      Department of Job and Family Services

    255
      East
      Main Street. 2nd Floor

     

    Columbus,
      OH 43215-5222

     

    Subject:

    Supplemental
      Certification for Contract Period 2006 Regional Rates - Final &
Confidential

     

    Dear
      Jon:

     

    Mercer
      Government Human Services Consulting (Mercer) provided the Ohio Department
      of
      Job and Family Services (ODJFS) with a rate certification letter dated June
      14.
      2006. The letter described the analysis and methodology used by Mercer in
      developing regional capitation rates for the Healthy Families and Healthy Start
      managed care populations.

     

    At
      that
      time, the contract period and effective date were known for only one of the
      eight regions, East-Central. The contract period for the East-Central region
      w
      'as July 1, 2006 - December 31, 2006. Effective August 1, 2006, ODJFS expanded
      managed care for these populations into two more regions, Southwest and
      West-Central. Mercer provided ODJFS with a supplemental certification for these
      regions dated July 12, 2006. Mercer also provided ODJFS with supplemental
      certifications dated August 11, 2006 and September 12, 2006 for rates developed
      for the Southeast and Northwest regions, respectively, with an effective period
      of October 1. 2006 - December 31, 2006.

     

    ODJFS
      is
      now set to expand managed care for the Healthy Families and Health Start
      populations into the sixth region (Northeast) starting November 1. 2006. This
      supplemental certification presents the rates developed for the Northeast region
      with an effective period of November 1, 2006 - December 31, 2006.

     

    The
      June
      14, 2006 certification is still applicable and valid, as the overall rating
      methodology has not changed. Mercer made two modifications to the rating
      methodology due to the change in the effective date and ramp-up schedule. The
      first change was the inclusion of two additional months of trend to reflect
      the
      November 1, 2006 start date. instead of July 1, 2006. The second and only other
      change made was an update to the voluntary selection factors based on the new
      effective date and the current

     

    

    

    MERCER

    Government
      Human Services Consulting

     

    Page
      2

    October
      12,2006

    Mr.
      Jon
      Barley

    Bureau
      of
      Managed Health Care

     

    penetration
      level within the Northeast region. The voluntary selection factors for this
      region are displayed in the following table.

     

    
      	
               

              Region

            	
               

              Projected
                Penetration

            	
              Voluntary
                Selection Adjustment

            
	
              FFS

            	
              Encounter

            	
              Cost
                Report

            
	
              Northeast

            	
              76%

            	
              -9.2%

            	
              0.9%

            	
              0.9%

            

    

     

    All
      other
      steps in the rate development process are consistent with the methodology
      presented in the June 14 letter. A summary of the Northeast rates for November
      1, 2006 - December 31, 2006 is presented in Appendix A.

     

    Mercer
      certifies the attached rates were developed in accordance with generally
      accepted actuarial practices and principles by actuaries meeting the
      qualification standards of the American Academy of Actuaries for the populations
      and services covered under the managed care contract. Mercer has developed
      these
      rates on behalf of ODJFS to demonstrate compliance with the Centers for Medicare
      and Medicaid Services (CMS) requirements under 42 CFR 438.6(c) and to
      demonstrate that the rates are in accordance with applicable law and
      regulations.

     

    MCPs
      are
      advised that the use of these rates may not be appropriate for their particular
      circumstance and Mercer disclaims any responsibility for the use of these rates
      by MCPs for any purpose. Mercer recommends any MCP considering contracting
      with
      ODJFS should analyze its own projected medical expense, administrative expense,
      and any other premium needs for comparison to these rates before deciding
      whether to contract with ODJFS. Use of these rates for purposes beyond that
      stated may not be appropriate.

     

    If
      you
      have any questions, please contact Angie WasDyke at 612 642 8892 or Wendy Radunz
      at 612 6428868.

     

    Sincerely,

     

    

    
      	
              /s/
                Angela WasDyke

            	
              /s/
                Wendy Radunz

            
	
              Angela
                WasDyke, ASA, MAAA

            	
              Wendy
                Radunz, FSA, MAAA

            

    

     

     

     

    Copy:

    Mitali
      Ghatak, Chuck Betley - ODJFS Katie Olecik, Jon Rasmussen - Mercer

     

     

    
 

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

    State
      of
      Ohio

    Final
      & Confidential

    

    Appendix
      A 

    November
      1, 2006 - December 31, 2006 Regional Rates

    

    

    

    
      	
              Region

            	
              Rate
                Cohort

            	
              Annualized
                April 2006 Managed Care

              MM/Delv

            	
              %
                of Member

              Months

            	
              November
                1, 2006 - December 31, 2006

              Guaranteed
                Rate

            	
              November
                1, 2006

              December
                31, 2006 Rate At Risk

            	
              November
                1, 2006 - 

              December
                31, 2006

              Rate
                w/ Admin and 2006
                

              Franchise
                Fee

            
	
               

              Northeast

            	
               

              HF/HST,
                Age 0, M & F

            	
               

              123,246

            	
               

              5.2%

            	
               

              $
                577.16

            	
               

              $
                5.57

            	
               

              $
                582.73

            
	
               

              Northeast

            	
               

              HF/HST,
                Age 1, M &F

            	
               

              107,766

            	
               

              4.5%

            	
               

              $
                147.25

            	
               

              $
                1.42

            	
               

              $
                148.67

            
	
               

              Northeast

            	
               

              HF/HST,
                Age 2-13, M &F

            	
               

              1,112,861

            	
               

              46.7%

            	
               

              $
                92.71

            	
               

              $
                0.89

            	
               

              $
                93.60

            
	
               

              Northeast

            	
               

              HF/HST,
                Age 14-18, M

            	
               

              179,728

            	
               

              7.5%

            	
               

              $
                99.79

            	
               

              $
                0.96

            	
               

              $
                100.75

            
	
               

              Northeast

            	
               

              HF/HST,
                Age 14-18, F

            	
               

              190,200

            	
               

              8.0%

            	
               

              $
                158.21

            	
               

              $
                1.53

            	
               

              $
                159.73

            
	
               

              Northeast

            	
               

              HF,Age
                19-44, M

            	
               

              110,384

            	
               

              4.6%

            	
               

              $
                175.50

            	
               

              $
                1.69

            	
               

              $
                177.19

            
	
               

              Northeast

            	
               

              HF,Age
                19-44, F

            	
               

              463,912

            	
               

              19.5%

            	
               

              $
                265.95

            	
               

              $
                2.56

            	
               

              $
                268.51

            
	
               

              Northeast

            	
               

              HF,Age45+,
                M&F

            	
               

              60,998

            	
               

              2.6%

            	
               

              $
                401.44

            	
               

              $
                3.87

            	
               

              $
                405.31

            
	
               

              Northeast

            	
               

              HST.Age
                19-64, F

            	
               

              33,295

            	
               

              1.4%

            	
               

              $
                351.88

            	
               

              $
                3.39

            	
               

              $
                355.27

            
	
               

              Northeast

            	
               

              Subtotal

            	
               

              2,382,389

            	
               

              100.0%

            	
               

              $
                175.10

            	
               

              $
                1.69

            	
               

              $
                176.78

            
	
               

              Northeast

            	
               

              Delivery
                Payment

            	
               

              7,377

            	
               

              0.3%

            	
               

              $
                5,168.45

            	
               

              $
                49.83

            	
               

              $
                5,218.29

            
	
               

              Northeast

            	
               

              Total

            	
               

              2,382,389

            	
               

              100.0%

            	
               

              $
                191.10

            	
               

              $
                1.84

            	
               

               $192.94

            

    

     

    

    Mercer
      Government Human Services Consulting 

    A-1

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

    

    APPENDIX
      F

    REGIONAL
      RATES

     

    1.
      PREMIUM RATES WITHOUT THE AT-RISK PAYMENT AMOUNTS FOR 11/01/06, THROUGH
      12/31/06, SHALL BE AS FOLLOWS;

    An
      at-risk amount of 1% is applied to the MCP rates. The status of the at-risk
      amount is determined in accordance with Appendix 0, performance
      incentives.

    

     

    MCP:
      WellCare of Ohio, lnc.

     

    
      	
              SERVICE
                ENROLLMENT AREA

            	
              VOLUNTARY/
                MANDATORY**

            	
              HF/HST
                

              Age
                < 1

            	
              HF/HST
                

              Age
                1

            	
              HF/HST
                

              Age
                2-13

            	
              HF/HST
                

              Age
                14-18 Male

            	
              HF/HST
                

              Age
                14-18 Female

            	
              HF
                

              Age
                19-44 Male

            	
              HF
                

              Age
                19-44 Female

            	
              HF
                

              Age
                45 and over

            	
              HST
                

              Age
                19-64 Female

            	
               

              Delivery
                Payment

            
	
              Northeast

            	
              Mandatory

            	
              S589.42

            	
              $150.38

            	
              $94.68

            	
              $101.91

            	
              $161.57

            	
              $179.22

            	
              $271.60

            	
              $409.97

            	
              $359.36

            	
              $5,278.27

            
	
               

            	
               

            	
               

            	
               

            	
               

            	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 

    

     

    List
      of Eligible Assistance Groups (AGs)

    

    
      	
              Healthy
                Families:

            	
              -
                MA-C Categorically eligible due to ADC cash

              -
                MA-T Children under 21

              -
                MA-Y Transitional Medicaid

            
	
               

              Healthy
                Start:

            	
               

              -
                MA-P Pregnant Women and Children

            

    

     

    Note:
      An
      MCP's county membership for this program must not exceed their Primary Care
      Physician (PCP) capacity for that county as verified by the ODJFS provider
      database.

    For
      the
      SPY 2007 contract period. MCPs will be put al-risk for a portion of the premiums
      received for members in counties they served as of January 1, 2006, provided
      the
      MCP has participated in the program for more than twenty-four
      months.

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

     

    Page
      1 of
      3

    

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    APPENDIX
      F

    REGIONAL RATES

     

    2.
      AT-R1SK AMOUNTS FOR 11/01/06, THROUGH 12/31/06, SHALL BE AS
      FOLLOWS:

    An
      at-risk amount of 1% is applied to the MCP rates. The status of the at-risk
      amount is determined in accordance with Appendix 0, performance
      incentives.

     

    MCP:
      WellCare of Ohio, Inc.

    AT-RISK
      AMOUNTS*

    
      	
               

              SERVICE
                ENROLLMENT AREA

            	
               

              VOLUNTARY/
                MANDATORY**

            	
               

              HF/HST
                

              Age<
                1

            	
               

              HF/HST
                

              Age
                1

            	
               

              HF/HST
                

              Age
                2-13

            	
              HF/HST
                

              Age
                14-18 Male

            	
              HF/HST
                

              Age
                14-18 Female

            	
              HF
                

              Age
                19-44 Male

            	
              HF
                

              Age
                19-44 Female

            	
              HF
                

              Age
                45 and over

            	
              HST
                

              Age
                19-64 Female

            	
               

              Delivery
                

              Payment

            
	
              Northeast

            	
              Mandatory

            	
              $0.00

            	
              $0.00

            	
              $0.00

            	
              $0.00

            	
              $0.00

            	
              $0.00

            	
              $0.00

            	
              $0.00

            	
              $0.00

            	
              $0.00

            
	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 

    

     

    

    
      	
               

              List
                of Eligible Assistance Groups (AGs)

            
	
              Healthy
                Families:

            	
              -
                MA-C Categorically eligible due to ADC cash

              -
                MA-T Children under 21

              -
                MA-Y Transitional Medicaid

            
	
              Healthy
                Start:

            	
              -
                MA-P Pregnant Women and Children

            

    

     

     

    Note:
      An
      MCP's county membership for this program must not exceed their Primary Care
      Physician (PCP) capacity for that county as verified by the ODJFS provider
      database.

     

    

    For
      the
      SFY 2007 contract period, MCPs will be put at-risk for a portion of the premiums
      received for members in counties they served as of January 1, 2006, provided
      the
      MCP has participated in the program for more than twenty-four
      months.

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

    Page
      2 of
      3

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

    APPENDIX
      F

    REGIONAL
      RATES

     

    3.
      PREMIUM RATES* FOR 11/01/06, THROUGH 12/31/06, SHALL BE AS FOLLOWS:

    An
      at-risk amount of 1% is applied to the MCP rates. The status of the at-risk
      amount is determined in accordance with Appendix 0, performance
      incentives.

    

    

     

    MCP:
      WellCareofOhio.lnc.

     

    
      	
              SERVICE
                ENROLLMENT AREA

            	
              VOLUNTARY/
                MANDATORY**

            	
              HF/HST

               Age<
                1

            	
              HF/HST
                

              Age
                1

            	
              HF/HST
                

              Age
                2-13

            	
              HF/HST
                

              Age
                14-18 Male

            	
              HF/HST
                

              Age
                14-18 Female

            	
              HF
                

              Age
                19-44 Male

            	
              HF
                

              Age
                19-44 

              Female

            	
              HF
                

              Age
                45 and over

            	
              HST
                

              Age
                19-64 Female

            	
               

              Delivery
                Payment

            
	
               

              Northeast

            	
               

              Mandatory

            	
               

              $589.42

            	
               

              $150.38

            	
               

              $94.68

            	
               

              $101.91

            	
               

              $161.57

            	
               

              $179.22

            	
               

              $271.60

            	
               

              $409.97

            	
               

              $359.36

            	
               

              $5,278.27

            
	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 

    

     

    List
      of Eligible Assistance Groups (AGs)

    

    
      	
              Healthy
                Families:

            	
              -
                MA-C Categorically eligible due to ADC cash

              -
                MA-T Children under 21

              -
                MA-Y Transitional Medicaid

            
	
              Healthy
                Start:

            	
              -
                MA-P Pregnant Women and Children

            

    

     

    Note:
      An
      MCP's county membership for this program must not exceed their Primary Care
      Physician (PCP) capacity for that county as verified by the ODJFS provider
      database.

    For
      the
      SFY 2007 contract period, MCPs will be put at-risk for a portion of the premiums
      received for members in counties they served as of January 1, 2006, provided
      the
      MCP has participated in the program for more than twenty-four
      months.

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

     

    Page
      3 of
      3

     

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

    APPENDIX
      G

     

    COVERAGE
      AND SERVICES

     

    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 BMHC page
      of
      the ODJFS website. The following is a general list of the benefits covered
      by
      the Ohio Medicaid fee-for-service program:

     

    •
      Inpatient hospital services

     

    •
      Outpatient hospital services

     

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

     

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

     

    •
      Laboratory and x-ray services

     

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

     

    •
Family
      planning services and supplies

     

    •
Home
      health services

     

    •
      Podiatry

     

    •
      Chiropractic services [not covered for adults age twenty-one (21) and
      older]

     

    •
      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

    Page
      2

     

    •
      Short-term rehabilitative stays in a nursing facility

     

    •
Hospice
      care

     

    •
      Behavioral health services (see section G.2.b.iii of this appendix). Note:
      Independent psychologist services not covered for adults age twenty-one (21)
      and
      older.

     

    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 BMHC page of 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

     

    •
Sex
      change surgery and related services

     

    •
Sexual
      or marriage counseling

     

    

    

    Appendix
      G

    Page
      3

    

    

    •
Court
      ordered testing

     

    •
      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(0) 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 ofw'hen 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 "Annual Opportunity"
      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

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

     

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

     

    

    

    Appendix
      G 

    Page
      5

    

    Where
      an
      MCP is responsible for providing MH services for their members, the MCP is
      responsible for ensuring access to counseling and psychotherapy,
      physician/psychologist/psychiatrist services, outpatient clinic services,
      general hospital outpatient psychiatric services, pre-hospitalization screening,
      diagnostic assessment (clinical evaluation), crisis intervention, psychiatric
      hospital ization 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 free-standing
      psychiatric hospital.

     

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

     

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

     

    Financial
      Responsibility: MCPs are responsible for the payment .of Medicaid-covered
      prescription drugs prescribed by a CMHC or ODADAS-certified provider when
      obtained through an MCP's panel pharmacy. MCPs are also responsible for the
      payment of Medicaid-covered services provided by an MCP's panel laboratory
      when
      referred by a CMHC or ODADAS-certified provider. Additionally, MCPs are
      responsible for the payment of all other behavioral health services obtained
      through providers other than those who are CMHC or ODADAS-certified providers
      when arranged/authorized by the MCP. MCPs are not responsible for paying for
      behavioral health services provided through CMHCs and ODADAS-certified Medicaid
      providers. MCPs are also not required to cover the payment of partial
      hospitalization (mental health), inpatient psychiatric care in a free-standing
      inpatient psychiatric hospital, outpatient detoxification, or methadone
      maintenance.

     

    iv.
      Pharmacy
      Benefit:
      In
      providing the Medicaid pharmacy benefit to their members. MCPs must use the
      same
      fundamental drug formulary as the Ohio Medicaid fee-for-service
      program.

     

    

    

    Appendix
      G 

    Page
      6

     

    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 §5111.72. ODJFS may approve MCP-specific pharmacy program
      utilization management strategies (see appendix G.3.a).

     

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

     

    3. Care
      Coordination

     

    a.
      Utilization
      Management (Modification) Programs

     

    General
      Provisions - Pursuant to OAC rule 5101:3-26-03.1(A)(7). MCPs must implement
      the
      ODJFS-required emergency department diversion (EDD) utilization management
      program to maximize the effectiveness of the care provided to members and may
      develop other utilization management programs, subject to prior approval by
      ODJFS. For the purposes of tills requirement, the specific utilization
      management programs which require ODJFS prior-approval are those programs
      designed by the MCP with the purpose of redirecting or restricting access to
      a
      particular service or service location. These programs are referred to as
      utilization modification programs. MCP care coordination and disease management
      activities which are designed to enhance the services provided to members with
      specific health care needs would not be considered utilization management
      programs nor would the designation of specific services requiring prior approval
      by the MCP or the member's PCP. MCPs must also implement the ODJFS-required
      emergency department diversion (EDD) program for frequent users. In that
      ODJFS

     

    

    

    Appendix
      G

    Page
      7

    

    has
      developed the parameters for an MCP's EDD program, it therefore does not require
      ODJFS approval.

     

    Pharmacy
      Programs
      -
      Pursuant to ORC Sec. 5111.172 and OAC rule 5101:3-26-03(A) and (B), MCPs subject
      to ODJFS prior-approval, may implement strategies, including prior authorization
      and limitations on the type of provider and locations where certain medications
      may be administered, for the management of pharmacy utilization.

     

    Prior
      Authorizations:
      MCPs
      must receive prior approval from ODJFS on the types of medication that they
      wish
      to cover through prior authorizations. MCPs must establish their prior
      authorization system so that it does not unnecessarily impede member access
      to
      medically-necessary medicaid-covered services.

     

    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.

     

    MCPs
      may
      also, w ith ODJFS prior approval, implement pharmacy utilization modification
      programs designed to address members demonstrating high or inappropriate
      utilization of specific prescription

    drugs.

     

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

     

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

     

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

     

    

    

    Appendix
      G 

    Page
      8

    

    these
      providers as so indicated.

     

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

     

    b.
      Case
      Management

     

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

     

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

     

    ii..
      The
      MCP's case management system must include, at a minimum, the follow'ing
      components:

     

    a.
      specification of the criteria used by the MCP to identify those potentially
      eligible for case management services, including diagnosis. cost threshold
      and/or amount of service utilization, and the methodology or process (e.g.
      administrative data, provider referrals, self-referrals) used to identify the
      members who meet the criteria for case management;

     

    b.
      a
      process for comprehensive assessment of the member's health condition to confirm
      the results of a positive identification, and determine the need for case
      management, including information regarding the credentials of the staff
      performing the assessments of CSHCN;

     

    c.
       a
      process
      to inform members and their PCPs in writing that they have been identified
      as
      meeting the criteria for case management^ including their enrollment into case
      management services;

     

    d.
       the
      procedure by which the MCP will assure the timely development of a care
      treatment plan for any member receiving case management services; offer both
      the
      member and the member's PCP/specialist the opportunity to participate in the
      care treatment plan's development based on the

     

    

    

    Appendix
      G

    Page
      9

    health
      needs assessment; and provide for the periodic review of the member's need
      for
      case management and updating of the care treatment plan;

     

    e.
       a
      process
      to facilitate, maintain, and coordinate communication between service providers,
      and member/family, including an accountable point of contact to help obtain
      medically necessary care. and assist with health-related services and coordinate
      care needs.

     

    iii.
      MCPs
      must submit a monthly electronic report to the Case Management System (CAMS)
      for
      all members who are case managed by the MCP as outlined in the ODJFS
"Case
      Management File and Submission Specifications."
      The CAMS
      tiles are due the 1011
      business
      day of each month.

     

    iv.
      MCPs
      must have an ODJFS-approved case management system which includes the items
      in
      Section G.3.b.i. and Section G.3.b.ii. of this Appendix. Each MCP must implement
      an evaluation process to review, revise and/or update the case management
      program. The MCP must annually submit its case management program for review
      and
      approval by ODJFS. Any subsequent changes to an approved case management system
      description must be submitted to ODJFS in writing for review and approval prior
      to implementation.

     

    c.
      Children
      with Special Health Care Needs

     

    Children
      with special health care needs (CSHCN) are a particularly vulnerable population
      which often have chronic and complex medical health care conditions. In order
      to
      ensure state compliance with the provisions of 42 CFR 438.208. ODJFS has
      implemented program requirements for the identification, assessment, and case
      management of CSHCN.

     

    Each
      MCP
      must establish a CSHCN program with the goal of conducting timely identification
      and screening, assuring a thorough and comprehensive assessment, and providing
      appropriate and targeted case management services for any CSHCN.

     

    

    

    Appendix
      G

    Page
      10

    

    i.
      Definition of CSHCN

     

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

     

    
      	·  	
              Asthma

            

    

    
      	·  	
              HIV/AIDS

            

    

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

            

    

    
      	·  	
              Supplemental
                security income (SS1) for a health-related
                condition

            

    

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

            

    

     

    ii.
      Identification of CSHCN

     

    All
      MCPs
      must implement mechanisms to identify CSHCN.

     

    MCPs
      are
      expected to use a variety of mechanisms to identify children that meet the
      definition of CSHCN and are in need of a follow-up assessment including: MCP
      administrative review; information as reported by the SSC during membership
      selection; PCP referrals; outreach; and contacting newly-enrolled children.
      The
      MCP must annually submit the process used to identify and assess CSHCN for
      review and approval by OD.IFS as part of their CSHCN program.

     

    iii.
      Assessment of CSHCN

     

    All
      MCPs
      must implement mechanisms to assess children with a positive identification
      as a
      CSHCN. A positive assessment confirms the results of the positive identification
      and should assist the MCP in determining the need for case
      management.

     

    This
      assessment mechanism must include, at a minimum:

     

    •
The
      use
      of the ODJFS
      CSHCN Standard Assessment Tool
      to
      assess all children with a positive identification using the methods described
      in Section 2.c., Children with Special Health Care Needs, of this appendix
      as
      having a

     

    

    

    Appendix
      G

    Page
      11

    condition
      that may warrant case management. See ODJFS CSHCN Program Requirements for
      a
      description of the ODJFS
      CSHCN Standard Assessment Tool.

     

    •
      Completion of the assessment by a physician, physician assistant, RN, LPN,
      licensed social worker, or a graduate of a two or four year allied health
      program.

     

    •
The
      oversight and monitoring by either a registered nurse or a physician, if the
      assessment is completed by another medical professional.

     

    iv.
      Case
      Management of CSHCN

     

    All
      MCPs
      must implement mechanisms to provide case management services for all CSHCN
      with
      a positive assessment, including those children with an ODJFS mandated
      condition. The ODJFS mandated conditions for case management are HIV/A1DS,
      asthma, and pregnant teens as specified by the ODJFS methods outlined in
      Appendix M Case Management System Performance Measures. This case management
      mechanism must include, at a minimum:

     

    •
The
      components required in Section 3. b., Case Management, of this
      Appendix.

     

    •
Case
      management of CSHCN must include at a minimum, the elements listed in the
Minimum
      Case Management Components
      document. See ODJFS
      CSHCN Program Requirements
      for a
      description of the Minimum
      Case ^Management Components.

     

    v.
      Access
      to Specialists for CSHCN

     

    All
      MCPs
      must implement mechanisms to notify all CSHCN with a positive assessment and
      determined to need case management 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.

     

    

    

    Appendix
      G 

    Page
      12

    vi.
      Submission of Data on CSHCN

     

    MCPs
      must
      submit to ODJFS all case management records as specified by the ODJFS
      Case Management File and Submission Specifications.

     

    vii.
      MCPs
      must have an ODJFS-approved CSHCN system which includes the items specified
      in
      Section G.3.c.ii-vi of this Appendix. Each MCP should implement an evaluation
      process to review, revise and/or update the CSHCN program. The MCP must annually
      submit its CSHCN program for review and approval by ODJFS. Any subsequent
      changes to an approved CSHCN system description must be submitted to ODJFS
      in
      writing for review and approval prior to implementation.

     

    d.
      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 Health Centers. ODADAS-certified Medicaid
      providers. FQHCs/RHCs. QFPPs. CNMs. CNPs [if applicable]. and hospitals) a
      quick
      reference information packet which includes the following:

     

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

     

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

     

    •
Claims
      submission information including the MCP's Medicaid provider number for each
      region;

     

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

     

    •
A
      picture of the MCP's member identification card (front and back);

     

    •
Contact
      numbers and/or website location for obtaining information for eligibility
      verification, claims

     

    

    

    Appendix
      G 

    Page
      13

     

    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).

     

    The
      MCP
      must notify ODJFS when this requirement has been fulfilled.

     

    

    

    APPENDIX
      H

    PROVIDER
      PANEL SPECIFICATIONS 

    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 minimum pediatrician
      requirement but a member is unable to obtain a timely appointment from a
      pediatrician on the MCP's provider panel in that, the MCP will be required
      to
      secure an appointment from a panel pediatrician or arrange for an out-of-panel
      referral to a pediatrician.

     

    MCPs
      are required
      to make
      transportation available to any member that 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 these minimum provider panel requirements. ODJFS considered, on
      a
      county-by-county basis, the population size and utilization patterns of the
      Covered Families and Children (CFC) consumers, as well a.s the potential
      availability of the designated provider types. ODJFS has tried to integrate
      existing utilization patterns into the minimum provider network requirements
      to
      avoid disruption of care. Most provider panel requirements, therefore, 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.

     

    Although
      ODJFS does offer some latitude in where the minimum required provider panel
      members may be located, MCPs are strongly urged to consider the importance
      of
      geographic accessibility and existing utilization patterns in developing their
      entire provider panel.
      Available and accessible providers have been found to be the essential element
      in attracting and retaining members.

     

    2.
      PROVIDER SUBCONTRACTING

     

    Unless
      otherwise specified in this appendix or OAC rule 5101:3-26-05, all MCPs will
      be
      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

     

    

    

    Appendix
      H 

    Page
      2

     

    Medicaid
      Addendum. The Model Medicaid Addendums incorporate all applicable Ohio
      Administrative Code rule requirements specific to provider subcontracting and
      therefore cannot be modified except to add personalizing information such as
      the
      MCP's name.

     

    ODJFS
      must prior approve all MCP providers in the ODJFS- required provider type
      categories before they can begin to provide services to that MCP's members.
      MCPs
      may not employ or contract with providers excluded from participation in Federal
      health care programs under either section 1128 or section 1128A of the Social
      Security Act. As part of the prior approval process, MCPs must submit
      documentation verifying that all necessary contract documents have been
      appropriately completed. ODJFS will verify the approvability of the submission
      and process this information using the ODJFS Provider Verification System (PVS).
      The PVS is a 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
      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
      initiated 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. If an MCP determines
      that
      an ODJFS-approved provider does not meet credentialing requirements they must
      notify ODJFS within one working day of this determination.

     

    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 Physicians (PCPs)

     

    Primary
      Care Physicians (PCPs) may be individuals or group practices/clinics [Primary
      Care Clinics (PCCs)]. Acceptable specialty types for PCPs are family/general
      practice, internal medicine, pediatrics and obstetrics/gynecology(OB/GYMs).
      As
      part of their subcontract w'ith 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. and to be included in the MCP's
      total PCP capacity calculation. The capacity-by-site requirement must be met
      for
      all ODJFS-approved PCPs.

     

    

    

    Appendix
      H 

    Page
      3

     

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

     

    ODJFS
      reviews the capacity totals for each PCP to determine if they appear excessive.
      ODJFS reserves the right to request clarification from an MCP for any PCP whose
      total stated capacity for all MCP networks added together exceeds 2000 Medicaid
      members (i.e., 1 FTE). ODJFS may also compare a PCP's capacity against the
      number of members assigned to that PCP. and/or the number of patient encounters
      attributed to that PCP to determine if the reported capacity number reasonably
      reflects a PCP's expected caseload for a specific MCP. Where indicated, ODJFS
      may set a cap on the maximum amount of capacity that we will recognize for
      a
      specific PCP. ODJFS will 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 minimum 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. 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
      and therefore may not appear as PCPs in the MCP's provider directory. Also,
      no
      PCP capacity will be counted for these providers. These PCPs will, however,
      need
      to execute a subcontract with the MCP which includes the appropriate Model
      Medicaid Addendum.

     

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

    

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

     

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

     

    b.
      Non-PCP
      Minimum Provider Network

     

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

     

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

     

    Although
      there are currently no FTE capacity requirements for any of the non-PCP required
      provider types, MCPs are required to ensure that adequate access is available
      to
      members for all required provider types. Additionally, for certain non-PCP
      required provider types, MCPs must ensure that these providers maintain a
      full-time practice at a site(s) located in the specified county/region (i.e.,
      the ODJFS-specified county within the region or anywhere within the region
      if no
      particular county is specified). A full-time practice is defined as one where
      the provider is available to patients at their practice site(s) in the specified
      county/region for at least 25 hours a week. ODJFS will monitor access to
      services through a variety of data sources, including:

    consumer
      satisfaction surveys; member appeals/grievances/complaints and state hearing
      notifications/requests; clinical quality studies; encounter data volume;
      provider complaints, and clinical performance measures.

    

    

    Appendix
      H 

    Page
      5

     

    Hospitals
      -
      MCPs
      must contract with the number and type of hospitals specified by ODJFS for
      each
      county/region. In developing these minimum hospital requirements, ODJFS
      considered, on a county-by-county basis, the population size and utilization
      patterns of the Covered Families and Children (CFC) consumers and integrated
      the
      existing utilization patterns into the minimum hospital network requirements
      to
      avoid disruption of care. For this reason, ODJFS may require that MCPs contract
      w ith 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, then the MCP
      must ensure that these hospital services are available to its members through
      another MCP-contracted hospital
      in the
      specified county/region.

     

    OB/GYNs
      -
      MCPs
      must contract with the specified number of OB/GYNs for each county/region,
      all
      of whom must maintain a full-time obstetrical practice at a site(s) located
      in
      the specified county/region. All MCP-contracting OB/GYNs must have current
      hospital delivery privileges at a hospital under contract with the MCP in the
      region.

     

    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. For this provider panel requirement, 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.

     

    Contracting
      CNMs must have hospital delivery privileges at a hospital under contract to
      the
      MCP in the region. 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 w'ill be expected
      to
      contract with an adequate number of opthalmologists as part of their overall
      provider panel, but only opthalmologists who regularly perform routine eye
      exams
      can be used to meet the minimum 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

    

    

    Appendix
      H 

    Page
      6

     

    contract
      with an adequate number of optical dispensers located in the
      region.

     

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

     

    Federally
      Qualified Health Centers/Rural Health Clinics (FQHCs/RHCs) -
      MCPs are
      required to ensure member access to any federally qualified health center or
      rural health clinic (FQHCs/RHCs). regardless of contracting status. Contracting
      FQHC/RHC providers must be submitted for ODJFS approval via the PVS process.
      (ODJFS maintains a list of FQHCs/RHCs on our website). 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 assure FQHC/RHC access to members, MCPs may require that their members
      request a referral from their PCP in order to access FQHC/RHC providers;
      however, such referral requests must be approved.

     

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

     

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

     

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

     

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

     

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

     

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

     

    

    

    Appendix
      H

    Page
      7

     

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

     

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

     

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

     

    4.
      PROVIDER
      PANEL EXCEPTIONS

     

    ODJFS
      may
      specify minimum 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
        1:0 meet or maintain certain minimum provider panel requirements in a particular
        service area despite all reasonable efforts on their part to secure such
        a
        contract(s), and

    

    ·    
      when
      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 minimum provider panel criteria, the MCP may request an
      exception to these criteria by submitting a provider panel exception request
      as
      specified by ODJFS. ODJFS w'ill review the exception request and determine
      w
      hether 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.
      MCPs are
      strongly

     

    

    

    Appendix
      H 

    Page
      8

     

    cautioned
      against ceasing their recruitment efforts and submitting a provider panel
      exception request unless they are confident that they can document that they
      have truly exhausted all reasonable efforts to contract with the needed
      provider(s). ODJFS' approval of a provider panel exception request does not
      preclude the MCP from continuing to obtain contracts with providers of the
      type(s) in question.

     

    ODJFS
      will aggressively monitor access to any services provided pursuant 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 ODJFS 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 with the data currently on file in the ODJFS PVS.

     

    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.

    

    

    Appendix
      H

    Page
      9

     

    Printed
      Provider Directory

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

     

    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 ofODJFS-approval of the provider
      via
      the Provider Verification process. Providers being deleted from the MCP's panel
      must be posted to the internet directory within one week of notification from
      the provider to the MCP of the deletion. These deleted providers must be
      included in the inserts to the MCP's provider directory referenced
      above.

     

    Note:
      MCPs
      currently functioning under a county specific Provider Agreement may choose
      to
      develop either regional or county based Provider Directory(ies) for their
      existing counties.

     

    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 furnish 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

    

    

    Appendix
      H

    Page
      10

    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 w ith the applicable requirements.

     

    Contracting
      panel 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
      w'ith these timely access requirements. MCPs are required to regularly monitor
      their provider panels to determine compliance and if necessary 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 OD.IFS. that demonstrates it offers an appropriate range of
      preventive, primary care and specialty services adequate for the anticipated
      number of members in the service area, while maintaining a provider panel that
      is sufficient in number, mix. and geographic distribution to meet the needs
      of
      the number of members in the service area.

     

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

     

    MCPs
      are to follow the procedures specified in the current MCP
      PVS Instructional Manual
      in
      order to comply with these federal access requirements.

     

    

    

    North
      East Region
      -
Hospitals

     

    
      	
              Minimum
                Provider Panel Requirements

            	
              Preferred
                Providers 1

            
	 	
              Total
                Required Hospitals

            	
              Ashtabula

            	
              Cuyahoga

            	
              Erie

            	
              Geauga

            	
              Huron

            	
              Lake

            	
              Lorain

            	
              Medina

            	
              Additional
                Required Hospitals: Out-of-Region

            	
              Preferred
                Hospitals: In-Region2

            	
              Preferred
                Hospitals: Out-of Region

            
	
               

              General
                Hospital3

            	
               

              84

            	
               

              1

            	
               

              14

            	
               

              1

            	
               

              1

            	
               

              1

            	
               

              1

            	
               

              1

            	
               

              1

            	
               

            	
               

              +3

            	
               

              Childrens
                Hospital of Akron

            
	
               

              Hospital
                System

            	
               

              1

            	
               

            	
               

              1

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

              +1

            	
               

            

    

     

    

    
      	
              1

            	
              Preferred
                Providers are the additional provider contracts that must be secured
                in
                order for the MCP to receive bonus points.

            
	
              2

            	
              These
                hospitals cannot be included under any subcontract used to meet the
                minimum required provider panel requirements.

            
	
              3

            	
              These
                hospitals must provide obstetrical services if such a hospital is
                available in the county/region. 

            
	
              4

            	
              The
                Cuyahoga hospital requirement may be met by either contracting with
                (1) a
                single hospital that includes fifty (50) pediatric beds and five
                (5)
                pediatric intensive care unit (PICU) beds OR
                (2) a single general hospital that includes fifty (50) pediatric
                beds and
                five (5) pediatric intensive care unit (PICU) beds and a hospital
                system.

            

    

     

    

    

    

    NORTHEAST
      REGION

     

    
      	 	
              Minimum
                PCP Capacity Requirements

            	 
	
               

              PC
                Ps

            	
               

              Total
                Required

            	
               

              Ashtabula

            	
               

              Cuyahoga

            	
               

              Erie

            	
               

              Geauga

            	
               

              Huron

            	
               

              Lake

            	
               

              Lorain

            	
               

              Medina

            	
               

              Additional
                Required:
                In-Region *

            	
               

              Additional
                Preferred:

              In-Region

            
	
               

              Capacity
                1

            	
               

              146,000

            	
               

              6,560

            	
               

              111,520

            	
               

              3,680

            	
               

              2,080

            	
               

              3,960

            	
               

              3,680

            	
               

              11,320

            	
               

              3,200

            	
               

            	
               

              +36,500

            
	
               

              FTEs

            	
               

              73.00

            	
               

              3.28

            	
               

              55.76

            	
               

              1.84

            	
               

              1.04

            	
               

              1.98

            	
               

              1.84

            	
               

              5.66

            	
               

              1.60

            	
               

            	
               

              +
                18,25

            

    

     

    1
      Based
      on
      an FTE of 2000 members

     

    *
      Must be
      located within the region.

     

    

    

    NORTHEAST
      REGION

     

    

     

    
      	
              Minimum
                Provider Panel Requirements

            	
              Preferred
                Providers (In Region)

            
	
               

              Provider
                Types

            	
               

              Total
                Required Providers1

            	
               

              Ashtabula

            	
               

              Cuyahoga

            	
               

              Erie

            	
               

              Geauga

            	
               

              Huron

            	
               

              Lake

            	
               

              Lorain

            	
               

              Medina

            	
               

              Additional
                Require Providers2

            	
               

              Total
                Preferred

              Providers3

            
	
               

              Pediatricians4

            	
              90

            	
              1

            	
              66

            	
              2

            	 	 	
              3

            	
              8

            	
              3

            	
              7

            	
              +23

            
	
               

              OB/GYNs

            	
              25

            	
              1

            	
              16

            	
              1

            	 	
              1

            	
              1

            	
              2

            	
              1

            	
              2

            	
              +7

            
	
               

              Vision

            	
              33

            	
              1

            	
              25

            	
              1

            	 	 	
              1

            	
              2

            	
              1

            	
              2

            	
              +9

            
	
               

              General
                Surgeons

            	
              20

            	 	
              12

            	
              1

            	 	
              1

            	
              1

            	
              2

            	
              1

            	
              2

            	
              +5

            
	
               

              Otolaryngologist

            	
              6

            	 	
              2

            	 	 	 	 	
              1

            	 	
              3

            	
              +2

            
	
               

              Allergists

            	
              5

            	 	
              2

            	 	 	 	 	
              1

            	 	
              2

            	
              +1

            
	
               

              Orthopedists

            	
              16

            	 	
              8

            	
              1

            	 	 	
              1

            	
              2

            	
              1

            	
              3

            	
              +4

            
	
               

              Dentists5

            	
              90

            	
              3

            	
              65

            	
              1

            	
              1

            	
              1

            	
              5

            	
              10

            	
              3

            	
              1

            	
              +
                23

            

    

    

    
      	
              1

            	
              All
                required providers must be located within the region.

            
	
              2

            	
              Additional
                required providers may be located anywhere within the
                region.

            
	
              3

            	
              Preferred
                Providers are the additional provider contracts that must be secured
                in
                order for the MCP to receive bonus points.

            
	
              4

            	
              Half
                of this number must be certified by the American Board of
                Pediatrics.

            
	
              5

            	
              No
                more than two-thirds of this number can be pediatric
                dentists.

            

    

    

    

     

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

    APPENDIX
      I 

    PROGRAM
      INTEGRITY

     

    MCPs
      must
      comply with all applicable program integrity requirements, including those
      specified in 42 CFR 455 and Subpart H.

     

    1.
      Fraud
      and Abuse Program:

    In
      order
      to comply with OAC rule 5101:3-26-06, MCPs must have a program that includes
      administrative and management arrangements or procedures, including a mandatory
      compliance plan, to guard against fraud and abuse. The MCP's compliance plan
      must designate staff responsibility for administering the plan and include
      clear
      goals, milestones or objectives, measurements, key dates for achieving
      identified outcomes, and explain how the MCP will determine the compliance
      plan's effectiveness.

     

    a.
      Monitoring
      for fraud and abuse:
      In
      addition to the requirements in OAC rule 5101:3-26-06. the MCP's program which
      safeguards against fraud and abuse must specifically address the MCP's
      prevention, detection, investigation, and reporting strategies in at least
      the
      following areas:

     

    i.
      Embezzlement and theft - MCPs must monitor activities on an ongoing basis to
      prevent and detect activities involving embezzlement and theft (e.g., by staff,
      providers, contractors, etc.) and respond promptly to such
      violations.

     

    ii.
      Underutilization of services - MCPs must monitor for the potential
      underutilization of services by their members in order to assure that all
      Medicaid-covered services are being provided, as required. If any underutilized
      services are identified, the MCP must immediately investigate and. if indicated,
      correct the problem(s) which resulted in such underutilization of
      services.

     

    The
      MCP's
      monitoring efforts must, at a minimum, include the following activities: a)
      an
      annual review of their prior authorization procedures to determine that they
      do
      not unreasonably limit a member's access to Medicaid-covered services; b) an
      annual review of the procedures providers are to follow in appealing the MCP's
      denial of a prior authorization request to determine that the process does
      not
      unreasonably limit a member's access to Medicaid-covered services: and c)
      ongoing monitoring of MCP service denials and utilization in order to identify
      services which may be underutilized.

     

    

    

    Appendix
      I 

    Page
      2

     

    

     

    iii.
      Claims submission and billing - On an ongoing basis, MCPs must identify and
      correct claims submission and billing activities which are potentially
      fraudulent including, at a minimum, double-billing and improper coding, such
      as
      upcoding and bundling.

     

    b.
      Reporting
      MCP fraud and abuse activities:
      Pursuant
      to OAC rule 5101:3-26-06, MCPs are required to submit annually to ODJFS a report
      which summarizes the MCP's fraud and abuse activities for the previous year
      in
      each of the areas specified above. The MCP's report must also identify any
      proposed changes to the MCP's compliance plan for the coming year.

     

    c.
      Reporting
      fraud and abuse:
      MCPs are
      required to promptly report all instances of provider fraud and abuse to ODJFS
      and member fraud to the CD.IFS. The MCP must report the following information
      on
      cases w'here the MCP's investigation has revealed that an incident of fraud
      and/or abuse has occurred:

     

    i.
      provider's name and Medicaid provider number or provider reporting number
      (PRN):

     

    ii.
      source of complaint:

     

    iii.
      type
      of provider;

     

    iv.
      nature of complaint:

     

    v.
      approximate range of dollars involved, if applicable;

     

    vi.
      results of MCP's investigation and actions taken;

     

    vii.
      name(s) of other agencies/entities (e.g., medical board, law enforcement)
      notified by MCP: and

     

    viii.
      legal and administrative disposition of case, including actions taken by law
      enforcement officials to whom the case has been referred.

     

    2.
      Data
      Certification:

    Pursuant
      to 42 CFR. 438.604 and 42 CFR 438.606, MCPs are required to provide
      certification as to the accuracy, completeness, and truthfulness of data and
      documents submitted to ODJFS which may affect MCP payment.

     

    a.
      MCP
      Submissions:
      MCPs
      must submit the appropriate ODJFS-developed certification concurrently with
      the
      submission of the following data or documents:

     

    i.
      Encounter Data [as specified in the Data Quality Appendix (Apendix
      L)]

     

    

    

    Appendix
      I 

    Page
      3

     

    ii.
      Prompt Pay Reports [as specified in the Fiscal Performance Appendix (Appendix
      J)]

     

    iii.
      Cost
      Reports [as specified in the Fiscal Performance Appendix (Appendix
•I)]

     

    b.
      Source
      of Certification:
      The
      above MCP data submissions must be certified by one of the
      following:

     

    i.
      The
      MCP's Chief Executive Officer;

     

    ii.
      The
      MCP's Chief Financial Officer, or

     

    iii.
      An
      individual who has delegated authority to sign for, or who reports directly
      to,
      theCP's Chief Executive Officer or Chief Financial Officer.

     

    ODJFS
      may
      also require MCPs to certify as to the accuracy, completeness, and truthfulness
      of additional submissions.

     

    3.
      Prohibited
      Affiliations:

    Pursuant
      to 42 CFR 438.610. MCPs must not knowingly have a relationship with individuals
      debarred by Federal Agencies, as specified in Article XII of the Baseline
      Provider Agreement.

     

     

    
 

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

    APPENDIX
      J

    FINANCIAL
      PERFORMANCE

    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(8). 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(8);

     

    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.
      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);

     

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

     

    g.
      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;

     

    

    

    Appendix
      J 

    Page
      2

     

    
      	 	
              h.
                

            	
              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;

            

    

     

    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(0);

     

    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 OD1 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 2006, a minimum net worth per member
      of $156.00, as determined from the annual Financial Statement submitted to
      OD1
      and the OD.IFS.

     

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

     

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

     

    0.90
      if
      the MCP had a total membership of less than 100.000 for that calendar
      year

     

    

    

    Appendix
      J 

    Page
      3

     

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

     

    b.
      Indicator: Administrative Expense Ratio

     

    Definition:
      Administrative Expense Ratio = Administrative Expenses divided by Total
      Revenue

     

    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 divided by Total Revenue

     

    Medical
      Expense Ratio = Medical Expenses divided by Total Revenue

     

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

     

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

     

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

     

    

    

    Appendix
      J 

    Page
      4

     

    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
      OD1
      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
      DJFS.

     

    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.

     

    

    

    Appendix
      J

    Page
      5

     

    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 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.

     

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

     

    Penally/or
      noncompliatice:
      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 betw'een 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.

     

    

    

    Appendix
      J 

    Page
      6

     

    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 pi-ovider(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.

     

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

     

    5.
      PHYSICIAN INCENTIVE PLAN DISCLOSURE REQUIREMENTS

     

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

     

    If
      the
      physician incentive plan places a physician or physician group at substantial
      financial risk [as determined under paragraph (d) of 42 CFR 422.208] for
      services that the physician or physician group does not furnish itself, the
      MCP
      must assure that all physicians and physician groups at substantial financial
      risk have either aggregate or per-

     

    

    

    Appendix
      J 

    Page
      7

     

    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 make this information available to
      OD.IFS upon request:

     

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

     

    b.
      A
      description of 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.

     

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

     

    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

     

    QUALITY
      ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM AND EXTERNAL QUALITY
      REVIEW

     

    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 (EQR.O) process, the EQRO will assist MCPs with
      conducting PIPs by providing technical assistance and will annually validate
      the
      PIPs. In addition, the MCP must annually submit to ODJFS the status and results
      of each PIP.

     

    MCPs
      must
      initiate the following PIPs:

    

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

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

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

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

     

    In
      addition, as noted in Appendix M, if an MCP fails to meet the Minimum
      Performance Standard for selected Clinical Performance Measures, the MCP will
      be
      required to complete a PIP.

     

    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.

     

    

    

    Appendix
      K 

    Page
      2

     

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

     

    In
      addition, beginning in SFY 2005, the MCP must conduct an ongoing review of
      service denials and must monitor utilization on an ongoing basis in order to
      identify services which may be under-utilized.

     

    c.
      SPECIAL
      HEALTH CARE NEEDS

     

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

     

    d.
      SUBMISSION
      OF PERFORMANCE MEASUREMENT DATA

     

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

     

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

     

    i.
      Comprehensive Diabetes Care

    ii.
      Child
      Immunization Status

    iii.
      Adolescent Immunization Status

     

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

     

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

     

    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.

    

    

    Appendix
      K 

    Page
      3

     

    a.
      EORO
      ADMINISTRATIVE REVIEW AND NON-DUPLICATION OF MAMDATORY
      ACTIVITIES

     

    The
      EQRO
      will conduct administrative compliance assessments for each MCP every three
      (3)
      years. The review will include- but not be limited to, the following domains
      as
      specified by ODJFS: member rights and services, QAPI program, access standards,
      provider network, grievance system, case management, coordination and continuity
      of care, and utilization management. 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
      07.

     

    b.
      ANNUAL
      REVIEW OF QAPI AND CASE MANAGEMENT PROGRAM

     

    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.

     

    The
      annual QAPI and case management/CSHCN (refer to Appendix G) program submissions
      are subject to an administrative review by the EQRO. If the EQRO identifies
      deficiencies during its review, the MCP must develop and implement Corrective
      Action Plan(s) that are prior approved by ODJFS. Serious deficiencies may result
      in immediate termination or non-renewal of the provider agreement.

     

    c.
      EXTERNAL
      QUALITY REVIEW PERFORMANCE

     

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

     

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

    APPENDIX
      L 

    DATA
      QUALITY

     

    A
      high
      level of performance on the data quality measures established in this appendix
      is crucial in order for the Ohio Department of Job and Family Services (ODJFS)
      to determine the value of the Medicaid Managed Health Care Program and to
      evaluate Medicaid consumers' access to and quality of services. Data collected
      from MCPs are used in key performance assessments such as the external quality
      review, clinical performance measures, utilization review, care coordination
      and
      case management, and in determining incentives. The data will also be used
      in
      conjunction with the cost reports in setting the premium payment
      rates.

     

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

     

    1.
      ENCOUNTER DATA

     

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

     

    l.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.

     

    l.a.i.
      Encounter Data Volume

     

    Measure:
      The
      volume measure for each service category, as listed in Table 1 below, is the
      rate of utilization (e.g., discharges, visits) per 1.000 member months
      (MM).

     

    Report
      Period:
      The
      report periods for the SFY 2007 and SFY 2008 contract periods are listed in
      the
      table below.

     

    

    

    Appendix
      L

    Page
      2

     

    Table
      1. Report Periods for the SFY 2007 and 2008 Contract
      Periods

     

    
      	
               

              Quarterly
                Report Periods

            	
               

              Data
                Source: Estimated Encounter Data File Update

            	
               

              Quarterly
                Report Estimated Issue Date

            	
               

              Contract
                Period

            
	
               

              Qtr
                3& Qtr4 2003, 2004, 2005 
                Qtrl
                2006

            	
               

              July
                2006

            	
               

              August
                2006

            	
               

              SFY
                7007

            
	
               

              Qtr
                3 & Qtr 4 2003, 2004, 2005 Qtrl, Qtr 2 2006

            	
               

              October
                2006

            	
               

              November
                2006

            
	
               

              Qtr
                3 & Qtr 4 2003, 2004, 2005 Qtr 1 thru Qtr 3 2006

            	
               

              January
                2007

            	
               

              February
                2007

            
	
               

              Qtr
                3 & Qtr 4 2003, 2004, 2005 Qtr 1 thru Qtr 4 2006

            	
               

              April
                2007

            	
               

              May
                2007

            
	
               

              Qtr
                3 & Qtr 4 2003, 2004,2005,2006 Qtrl 2007

            	
               

              July
                2007

            	
               

              August
                2007

            	
               

              SFY
                2008

            
	
               

              Qtr
                3 & Qtr 4 2003, 2004,2005.2006 Qtr 1, Qtr 2 2007

            	
               

              October
                2007

            	
               

              November
                2007

            
	
               

              Qtr
                3 & Qtr 4 2003. 2004,2005,2006 Qtr 1 ihru Qtr 3 2007

            	
               

              January
                2008

            	
               

              February
                2008

            
	
               

              Qtr
                3 & Qtr 4 2003, 2004,2005,2006 Qtr 1 thru Qtr 4 2007

            	
               

              April
                2008

            	
               

              May
                2008

            

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

    

    

    Appendix
      L 

    Page
      3

     

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

     

    
      	
               

              Category

            	
               

              Measure
                per 1,000/MM

            	
               

              Standard
                for Dates of Service 7/1/2003 thru 6/30/2004

            	
               

              Standard
                for Dates of Service 7/1/2004 thru 6/30/2006

            	
               

              Standard
                for Dates of Service on or after 7/1/2006

            	
               

              Description

            
	
               

              Inpatient
                Hospital

            	
               

              Discharges

            	
               

              5.4

            	
               

              5.0

            	
               

              5.4

            	
               

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

            
	
               

              Emergency
                Department

            	
               

              Visits

            	
               

              51.6

            	
               

              51.4

            	
               

              50.7

            	
               

              Includes
                physician and hospital emergency department encounters

            
	
               

              Dental

            	
               

              38.2

            	
               

              41.7

            	
               

              50.9

            	
               

              Non-institutional
                and hospital dental visits

            
	
               

              Vision

            	
               

              11.6

            	
               

              11.6

            	
               

              10.6

            	
               

              Non-institutional
                and hospital outpatient optometry and ophthalmology
                visits

            
	
               

              Primary
                and Specialist Care

            	
               

              220.1

            	
               

              225.7

            	
               

              233.2

            	
               

              Physician/practitioner
                and hospital outpatient visits

            
	
               

              Ancillary
                Services

            	
               

              144.7

            	
               

              123.0

            	
               

              133.6

            	
               

              Ancillary
                visits

            
	
               

              Behavioral
                Health

            	
               

              Service

            	
               

              7.6

            	
               

              8.6

            	
               

              10.5

            	
               

              Inpatient
                and outpatient behavioral encounters

            
	
               

              Pharmacy

            	
               

              Prescriptions

            	
               

              388.5

            	
               

              457.6

            	
               

              492.2

            	
               

              Prescribed
                drugs

            

    

     

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

     

    Da/a
      Quality Standard. County-Based Approach:
      The
      standards in Table 2 apply to the MCP's county-based results (see County-Based
      Approach
      above).
      The utilization rate for all service

     

    

    

    Appendix
      L

    Page
      4

     

    

     

    categories
      listed in Table 2 must be equal to or greater than the standard established
      in
      Table 2 below.

     

    Interim
      Regional-Based Approach:

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

     

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

     

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

     

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

     

    
      	
               

              Category

            	
               

              Measure
                per 1,000/MM

            	
              Standard
                for Dates of Service on or after

              7/1/2006

            	
               

              Description

            
	
               

              Inpatient
                Hospital

            	
               

              Discharges

            	
               

              2.7

            	
               

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

            
	
               

              Emergency
                Department

            	
               

              Visits

            	
               

              25.3

            	
               

              Includes
                physician and hospital emergency

               

              department
                encounters

            
	
               

              Dental

            	
               

              25.5

            	
               

              Non-institutional
                and hospital dental visits

            
	
               

              Vision

            	
               

              5.3

            	
               

              Non-institutional
                and hospital outpatient optometry and ophthalmology
                visits

            
	
               

              Primary
                and Specialist Care

            	
               

              116.6

            	
               

              Physician/practitioner
                and hospital outpatient visits

            
	
               

              Ancillary
                Services

            	
               

              66.8

            	
               

              Ancillary
                visits

            
	
               

              Behavioral
                Health

            	
               

              Service

            	
               

              5.2

            	
               

              Inpatient
                and outpatient behavioral encounters

            
	
               

              Pharmacy

            	
               

              Prescriptions

            	
               

              246.1

            	
               

              Prescribed
                drugs

            

    

    

    

    Appendix
      L

    Page
      5

     

    Determination
      of Compliance:
      Performance is monitored once every quarter for the entire report

     

    period.
      If the standard is not met for every service category in all quarters of the
      report period in

    either
      the county-based or interim regional-based approach, or both, then the MCP
      will
      be

     

    determined
      to be noncompliant for the report period.

    Penalty/or
      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 

    

     

    Appendix
      L

    Page
      6

     

    determined
      to be compliant with the standard and the violations/deficiencies are resolved
      to the satisfaction of ODJFS, the penalties will be lifted, if applicable,
      and
      monetary sanctions will be returned.

     

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

     

    l.a.ii.
      Encounter Data Omissions

     

    Omission
      studies will evaluate the completeness of the encounter data.

     

    Measure:
      This
      study will compare the medical records of members during the time of membership
      to the encounters submitted. Omission rates will be calculated per MCP (i.e.,
      to
      include all counties serviced by the MCP).

     

    The
      encounters documented in the medical record that do not appear in the encounter
      data 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.

     

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

     

    

    

    Appendix
      L

    Page
      6

     

    

    Data
      Quality Standard:
      The data
      quality standard is a maximum omission rate of 15% for studies

     

    with
      time
      periods ending in the CY 2007 contract 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 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.

     

    l.a.iii.
      Incomplete Outpatient Hospital Data

     

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

     

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

     

    Report
      Period:
      For the
      SPY 2007 contract period, performance will be evaluated using the following
      report periods: January - March 2006; April - June 2006; July-September 2006;
      October -December 2006. For the SFY 2008 contract period, performance will
      be
      evaluated using the following report periods: January- March 2007; April-June
      2007; July-September 2007; October-December 2007.

     

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

     

    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.

     

    

    

    Appendix
      L 

    Page7

     

    l.a.iv.
      Incomplete Data For Last Menstrual Period

     

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

     

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

     

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

     

    Measure:
      The
      percentage of recipients with a live birth during the report period where a
      ''valid" LMP date was given on one or more of the recipient's perinatal claims.
      If the LMP date is before the date of birth and there is a difference of between
      119 and 315 days between the date the recipient gave birth and the LMP date.
      then the LMP date will be considered a valid date. The measure will be
      calculated per MCP (i.e.. to include all counties serviced by the
      MCP).

     

    Report
      Period:
      For the
      SFY 2007 contract period, performance will be evaluated using the January -
      December 2006 report period. For the SFY 2008 contract period, performance
      will
      be evaluated using the January - December 2007 report period.

     

    Data
      Quality Standard:
      The data
      quality standard is 80%.

     

    Penalty/or
      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.

     

    l.a.v.
      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 (i.e., to include all counties serviced by the
      MCP).

     

    

    

    Appendix
      L 

    Page
      8

     

    Report
      Period'.
      For the
      SFY 2007 contract period, performance will be evaluated using the following
      report periods: April - June 2006; July - September 2006; October - December
      2006 and January - March 2007. For the SFY 2008 contract period, performance
      will be evaluated using the following report periods: April - June 2007; July
      -
      September 2007; October - December 2007 and January - March 2008.

     

    Data
      Quality Standard I:
      Data
      Quality Standard 1 is a maximum encounter data rejection rate of 10% for each
      file in the ODJFS-specified medium per format for encounters submitted in SFY
      2004 and thereafter. The measure will be calculated per MCP (i.e., to include
      all counties serviced by the MCP).

     

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

     

    Penalty
      for noncompliance with Data Quality Standard 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 w'ill 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 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 (i.e., to include all counties serviced by the
      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 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 months with membership: 50% Seventh through twelfth month with
      membership: 25%

     

    

    

    Appendix
      L 

    Page
      9

    

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

     

    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 Data Quality Standard 2:
      If the
      MCP is determined to be noncompliant for either standard. ODJFS will impose
      a
      monetary sanction of one percent of the MCP's current month's premium payment.
      The monetary sanction will be applied only once per measure 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.vi.Acceptance
      Rate

     

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

     

    Measure:
      The rate
      of encounters (encounters per 1.000 member months (MM)) submitted to ODJFS.
      The
      measure will be calculated per MCP (i.e.. to include all counties serviced
      by
      the 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

     

    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.

     

    Penally
      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 only once per measure per compliance
      determination period and will not exceed a total of two percent of the MCP's
      current month's

     

    

    

    Appendix
      L

    Page
      10

     

    

     

    premium
      payment. Once the MCP is performing at standard levels and
      violations/deficiencies are resolved
      to the satisfaction of ODJFS- the monev will be refunded.

     

    l.a.vii.
      Incomplete Birth Weight Data

     

    Measure:
      The
      percentage of newborn delivery inpatient encounters during the report period
      which contained a birth weight. If a value of "88" through "96" is found on
      any
      of the five condition code fields on the UB-92 inpatient claim format, then
      the
      encounter will be considered to have a birth weight. The condition code fields
      are described in Items 24-30 of the "Inpatient Hospital. UB-92 Claim Form
      Instructions." The measure will be calculated per MCP (i.e., to include all
      counties serviced by the MCP).

     

    Report
      Period:
      For the
      SFY 2007 contract period, performance will be evaluated using the January
      -December 2006 report period. For the SFY 2008 contract period, performance
      will
      be evaluated using the January - December 2007 report period.

     

    Data
      Quality Standard:
      The data
      quality standard is 90%.

     

    Penalty/or
      noncompliance:
      If an
      MCP is 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 flB resolved to the satisfaction of ODJFS. the
      money
      will be refunded.

     

    l.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.

     

    l.b.i.
      Encounter Data Accuracy Studies

     

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

     

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

     

    Medical
      records retrieval from the provider and submittal to ODJFS or its designee
      is an
      integral component of the validation process. ODJFS has optimized the sampling
      to minimize the number of

     

    

    

    Appendix
      L

    Page
      11

     

    

    records
      required. This methodology requires a high record submittal rate. To aid MCPs
      in
achieving

     

    a
      high
      submittal rate, ODJFS will give at least an 8 week period to retrieve and submit
      medical records as a part of the validation process. A record submittal rate
      will be calculated as a percentage of all records requested for the
      study.

     

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

     

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

     

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

     

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

     

    Measure
      2:
      This
      accuracy study will compare the accuracy and completeness of payment data stored
      in MCPs' claims systems during the study period to payment data submitted to
      and
      accepted by ODJFS. The measure will be calculated per MCP (i.e.. to include
      all
      counties serviced by the MCP).

     

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

     

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

     

    Data
      Quality Standard for Measure 2:
      TBD for
      SFY 2008 based on study conducted in SFY 2007

     

    Penalty/or
      Noncompliance:
      Does not
      apply for SFY 2006 or SFY 2007. The first time an MCP is noncompliant with
      a
      standard for this measure. ODJFS will issue a Sanction Advisory informing the
      MCP that any future noncompliance instances with the standard for this measure
      will result in ODJFS imposing a monetary sanction.

     

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

     

    

    

    Appendix
      L 

    Page
      12

     

    l.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 OD.IFS with the generic provider number 9111115. The
      measure will be calculated per MCP (i.e., to include all counties serviced
      by
      the 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 2007 contract period, performance will be evaluated using the following
      periods: January - March 2006; April - June 2006; July - September 2006: October
      -December 2006. For the SFY 2008 contract period, performance will be evaluated
      using the following periods: January - March 2007; April - June 2007; July
      -
      September 2007; October -December 2007.

     

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

     

    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.

    

    I.c.
      Timely Submission of Encounter Data 

    l.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 l.a.i.) and the rejected
      encounter (Section l.a.v.) standards are based on encounters being submitted
      within this time frame.

     

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

     

    MCP
      submissions of encounter data files in the ODJFS-specified medium per format
      to
      ODJFS are limited to two per format per month. Should an MCP wish to send
      additional files in the ODJFS-specified medium per format, permission to do
      so
      must be obtained by contacting BMHC.

     

    

    

    Appendix
      L

    Page
      13

     

    

     

    Information
      concerning the proper submission of encounter data may be obtained from the
      ODJFS

     

    Encounter
      Data File and Submission Specifications
      document. The MCP must submit a letter of

     

    certification,
      using the form required by ODJFS, with each encounter data file in the
      OD.IFS-

    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.
      CASEMANAGEMENT
      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 w'ill be assessed for completeness and
      accuracy. The MCP is responsible for submitting a a case management file every
      month. Failure to do so jeopardizes the MCP's ability to demonstrate compliance
      w ith CSF1CN requirements. For detailed descriptions of the case management
      measures below, see ODJFS
      Methods/or Case Management Data Quality Measures.

    2.a.
      Case Management System Data Accuracy 2.a.i. Open Case Management Spans for
      Disenrolled Members

     

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

     

    Report
      Period:
      For the
      SFY 2007 contract period, performance will be evaluated using the January -June
      2006 and July - December 2006 report periods. For the SFY 2007 contract period,
      July -September 2006. October - December 2006. January - March 2007, and 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.

     

    Da/a
      Quality Standard:
      A rate
      of open case management spans for disenrolled members of no more than
      L0%.

     

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

     

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

     

    

    

    Appendix
      L

    Page
      14

     

    

     

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

    in
      the
      region.

     

    Penally
      for nonconipliance:
      [fan 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/or
      nonconipliance:
      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. TheOAC 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 the clinical
      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.

     

    If
      an MCP
      does not complete a study because either their encounter data is of insufficient
      quality or too few medical records are submitted, accurate evaluation of
      clinical quality in the study area cannot be determined for the individual
      MCP
      and the assurance of adequate clinical quality for the program as a whole is
      jeopardized.

     

    3.a.
      Independent External Quality Review

     

    

    

    Appendix
      L

    Page
      15

     

    

     

    Measure:
      The
      independent external quality review covers both administrative and clinical
      focus

     

    areas
      of
      study.

     

    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 1:
      Sufficient encounter data quality in each study area to draw a sample as
      determined by the external quality review organization

     

    Penalty
      for noncompliance with Data Quality Standard 1:
      For each
      study that is completed during this contract period, if an MCP is noncompliant
      with the standard, OD.IFS will impose a non-refundable $10,000 monetary
      sanction.

     

    Data
      Quality Standard 2:
      A
      minimum record submiltal rate of 85% for each clinical measure.

     

    Penalty
      for noncompliance for Data Quality Standard 2:
      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

     

    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
      Members' PCP Data File and Submission Specifications.

     

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

     

    5.
      APPEALS AND GRIEVANCES DATA

     

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

     

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

     

    Penalty
      for noncompliance:
      MCPs who
      fail to submit their monthly electronic data files to the ODJFS by the specified
      due date or who fail to resubmit, by no later than the end of that month,
      a

     

    

    

    Appendix
      L

    Page
      16

     

    

     

    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 l.a.i. and l.a.v., no monetary sanctions described in this appendix
      will be imposed if the MCP is in its first contract year of Medicaid program
      participation. Notwithstanding the penalties specified in this Appendix, ODJFS
      reserves the right to apply the most appropriate penalty to the area of
      deficiency identified

     

    when
      an
      MCP is determined to be noncompliant with a standard. Monetary penalties for
      noncompliance with any individual measure, as determined in this appendix,
      shall
      not exceed $300,000 during each evaluation period.

     

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

     

    Any
      monies collected through the imposition of such a sanction will be returned
      to
      the MCP (minus any applicable collection P;es 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 w ithin two years of the date of notification of noncompliance.
      then the monies will not be refunded.

     

    6.b.
      Combined Remedies

     

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

     

    6.c.
      Membership Freezes

     

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

     

    6.d.
      Reconsideration

     

    Requests
      for reconsideration of monetary sanctions and enrollment freezes may be
      submitted as

    provided
      in Appendix N, Compliance
      Assessment System.

    

    

    Appendix
      L 

    Page
      17

     

    6.e.
      Contract Termination, Nonrenewals, or Denials

     

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

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

    

    APPENDIX
      M 

    PERFORMANCE
      EVALUATION

     

    This
      appendix establishes minimum performance standards for managed care plans (MCPs)
      in key program areas. The intent is to maintain accountability for contract
      requirements. Standards are subject to change based on the revision or update
      of
      applicable national standards, methods or benchmarks. Performance will be
      evaluated in the categories of Quality of Care, Access, Consumer Satisfaction,
      and Administrative Capacity. Each performance measure has an accompanying
      minimum performance standard. MCPs with performance levels below the minimum
      performance standards will be required to take corrective action. The Ohio
      Medicaid managed care program will transition to a regional-based system as
      managed care expands statewide, beginning in SPY 2007. Evaluation of performance
      will transition to a regional-based approach after completion of the statewide
      expansion. Due to differences in data and reporting requirements, transition
      to
      the regional-based approach will vary by performance measure. Unless otherwise
      noted, performance measures and standards (see Sections 1. 2, 3 and 4) will
      be
      applicable for all counties in which the MCP has membership as of January 1.
      2006, until the regional-based approach is developed.

     

    Selected
      measures in this appendix will be used to determine incentives as specified
      in
      Appendix
      0, Performance
      Incentives.

     

    1.
      QUALITY OF CARE

     

    l.a.i
      Independent External Quality Review [Only use in SFY2006 Incentive System;
      only
      applicable for MCPs with membership as ofJanuary I,
      2006}

    In
      accordance with federal law. and regulations state Medicaid agencies must
      annually provide for an external 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
      w'ith program requirements and facilitates the collection of accurate and
      reliable information concerning, MCP performance.

     

    Measure:
      The
      independent external quality review covers both an administrative component
      and
      clinical focus areas of study. The overall score is weighted to emphasize
      clinical performance.

     

    Report
      Period:
      For the
      SFY 2006 contract period, performance will be evaluated using the reviews that
      are finalized during SFY 2006.

     

    Minimum
      Performance Standard 1:
      A
      minimum score of 75% for each clinical study and the administrative
      component.

     

    Action
      Required for Noncompliance with the Minimum Performance Standard
      1:
      For all
      studies that are finalized during this contract period, if an MCP is
      noncompliant with the standard, then the MCP is required to complete a
      Performance Improvement Project, as described in Appendix K, Quality
      Assessment and Performance Improvement Program,
      to
      address the area(s) of noncompliance.

     

    

    

    Appendix
      M

    Page
      3

     

    Minimum
      Performance Standard:
      For
      results that are below the performance target the performance standard is an
      improvement level that results in a 20% decrease between the target and the
      previous reporting period's results. For MCPs that reach or surpass the
      performance target, then the standard is to keep the results at or above the
      performance target.

     

    Penalty
      for Noncompliance:
      The
      first time an MCP is noncompliant with the standard for this measure, ODJFS
      will
      issue a Sanction Advisory informing the MCP that any future noncompliance
      instances with the standard for this measure w'ill result in ODJFS imposing
      a
      monetary sanction. Upon all subsequent semi-annual measurements of performance,
      if an MCP is again determined to be noncompliant with the standard for this
      measure. ODJFS will impose a monetary sanction (see Section 5) of one half
      of
      one percent of the current month's premium payment. Once the MCP is performing
      at standard levels and the violations/deficiencies are resolved to the
      satisfaction of ODJFS, the money will be refunded.

     

    l.b.ii.
      Case Management of Children

     

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

     

    Report
      Period:
      For the
      SFY 2007 contract period. July - September 2006. October - December 2006,
      January - March 2007. and April - June 2007 report periods. For the SFY 2008
      contract period, July-September 2007. October-December 2007.
      January-March2008.andApril-.Iune 2008 report periods.

     

    County-Based
      Approach:
      MCPs
      with managed care membership as of January 1. 2006 will be evaluated using
      their
      county-based statewide result until regional evaluation is implemented for
      the
      county's applicable region. The county-based statew ide result will include
      data
      for all counties with membership as of January 1. 2006 that are not included
      in
      any regional-based result. Regional-based results will not be used for
      evaluation until all selected MCPs in a active region have at least 10.000
      members during each month of the entire report period. Upon implementation
      of
      regional-based evaluation for a particular county's region, the county will
      be
      included in the MCP's regional-based result and will no longer be included
      in
      the MCP's county-based statew ide result. [Example: The county-based statewide
      result for MCP AAA. which has contracts in the Central and West Central regions,
      will include Franklin. Pickaway. Montgomery. Greene and dark counties (i.e.,
      counties with managed care membership as of January 1, 2006). When
      regional-based evaluation is implemented for the Central region. Franklin and
      Pickaway counties, along with all other counties in the region, will then be
      included in the Central region results for MCP AAA; Montgomery, Greene, and
      dark
      counties will remain in the county-based statewide result for evaluation of
      MCP
      AAA until the West Central regional-based approach is implemented.]

     

    Regional-Based
      Approach:
      MCPs
      will be evaluated by region, using results for all counties included in the
      region. Performance will begin to be evaluated using regional-based results
      for
      any active region in which all selected MCPs had at least 10.000 members during
      each month of the entire report period.

     

     

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    Minimum
      Performance Standard:
      For the
      first and second quarters of SPY 2007, a case management rate of 4.5%. For
      the
      third and fourth quarters ofSFY 2007, a case management rate of 5.0%. For SFY
      2008, a case management rate of 6.0%.

    

    Penally
      for Noncompliance:
      The
      first time an MCP is noncompliant with the 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 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 new member selection
      freeze/reduction of assignments will be lifted.

    

    l.b.iii.
      Case Management oFChiIdren with an ODJFS-Mandated Condition
(only
      applicable for MCPs with membership as of January 1,
      2006)

    

    Measure
      1:
      The
      percent of children 6 months and over and under 21 years of age with a positive
      identification through an ODJFS administrative review of data for the
      ODJFS-mandated case management condition of asthma that are case
      managed.

    

    Report
      Period:
      For the
      SFY 2006 contract period, performance will be evaluated using the July
      -September 2005 and January - March 2006 report periods. Measure
      2:
      The
      percent of children age 17 and under with a positive identification through
      an
      ODJFS administrative review of data for the ODJFS-mandated case management
      condition of teenage
      pregnancy
      that are
      case managed.

    

    Report
      Period:
      For the
      SFY 2006 contract period, performance will be evaluated using the -January
      -
      June 2005 and July - December 2005 report periods. For the SFY 2007 contract
      period, performance will be evaluated using the January - June 2006 report
      period.

    

    Measure
      3:
      The
      percent of children 6 months and over and under 21 years of age with a positive
      identification through an ODJFS administrative review of data for the
      ODJFS-mandated case management condition of HIV/A1DS that are case
      managed.

    

    Report
      Period:
      For the
      SFY 2006 contract period, performance will be evaluated using the July
      -September 2005 and January - March 2006 report periods.

    Performance
      Target for Measures I, 2, and 3:
      A
      minimum case management rate of 80%.

    

    Minimum
      Performance Standard for Measures
      7,
2,
      and 3:
      For
      results that are below the performance target the performance standard is an
      improvement level that results in a 20% decrease between the target and the
      previous reporting period's results. For MCPs that reach or surpass the
      performance target, then the standard is to keep the results at or above the
      performance target.

    

    Penalty
      for Noncompliance for Measures 1 and 2:
      The
      first time an MCP is noncompliant with the 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 semi-annual measurements of performance,
      if an MCP is

    

    

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    again
      determined to be noncompliant with the standard (see Section 5) for measures
      1
      or 2, 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 the violations/deficiencies are resolved to the satisfaction of ODJFS,
      the
      money will be refunded. Note: For SFY 2006, measure 3 is a reporting-only
      measure.

    

    l.b.iv.
      Case Management of Children with an ODJFS-Mandated
      Condition

    

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

    

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

    Measure
      3:
      The
      percent of children under 21 years of age with a positive identification through
      an ODJFS administrative review of data for the ODJFS-mandated case management
      condition of H1V/A1DS
      that are
      case managed.

    

    Report
      Periods/or Measures 1, 2, and 3:
      For the
      SFY 2007 contract period. July - September 2006, October-December 2006, January
      -March 2007. and 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.

    

    County-Based
      Approach:
      MCPs
      with managed care membership as of January 1, 2006 will be evaluated using
      their
      county-based statewide result until regional evaluation is implemented forthe
      county's applicable region. The county-based statewide result will include
      data
      for all counties with membership as of January 1, 2006 that are not included
      in
      any regional-based result. Regional-based results will not be used for
      evaluation until all selected MCPs in an active region have at least 10,000
      members during each month of the entire report period. Upon implementation
      of
      regional-based evaluation fora particular county's region, the county will
      be
      included in the MCP's regional-based result and will no longer be included
      in
      the MCP's county-based statewide result. [Example:

    The
      county-based statewide result for MCP AAA, which has contracts in the Central
      and West Central regions, will include Franklin, Pickaway, Montgomery, Greene
      and dark counties (i.e., counties with managed care membership as of January
      1.2006). When regional-based evaluation is implemented forthe Central region.
      Franklin and Pickaway counties, along with all other counties in the region,
      will then be included in the Central region results for MCP AAA; Montgomery,
      Greene, and dark counties will remain in the county-based statewide result
      for
      evaluation of MCP AAA until the West Central regional-based approach is
      implemented.]

    

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

    

    

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    Minimum
      Performance Standard for Measures 1 and 3:
      For the
      first and second quarters of SPY 2007, a case management rate of 65%. For the
      third and fourth quarters of SFY 2007. a case management rate of 70%. For SFY
      2008. a case management rate of 80%.

    

    Minimum
      Performance Standard for .Measure 2:
      For the
      first and second quarters of SFY 2007, a case management rate of 55%. For the
      third and fourth quarters of SFY 2007. a case management rate of 60%. For SFY
      2008. a case management rate of 70%.

    

    Penalty
      for Noncompliance for Measures 1 and 2:
      The
      first time an MCP is noncompliant with the 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 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 new member
      selection freeze/reduction of assignments will be lifted. Note: For the first
      reporting period during w hich regional results are used to evaluate
      performance, measures 1, 2. and 3 are reporting-only measures. For both SFY
      2007
      and 2008, measure 3 is a reporting-only measure.

    

    1.c.
      Clinical Performance Measures

    

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

    

    The
      clinical performance measures described below closely follow the National
      Committee for Quality Assurance's Health Plan Employer Data and Information
      Set(HEDIS). Minor adjustments to HEDIS measures were required to account for
      the
      differences between the commercial population and the Medicaid population such
      as shorter and interrupted enrollment periods. NCQA may annually change its
      method for calculating a measure. These changes can make it difficult to
      evaluate whether improvement occurred from a prior year. For this reason, ODJFS
      will use the same methods to calculate the baseline results and the results
      for
      the period in which the MCP is being held accountable. For example, the same
      methods were being used to calculate calendar year 2003 results (the baseline
      period) and calendar year 2004 results. The methods will be updated and a new
      baseline will be created during 2005 for calendar year 2004 results. These
      results will then serve as the baseline to evaluate whether improvement occurred
      from calendar year 2004 to calendar year 2005. 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.
      Performance standards are subject to change based on the revision or update
      of
      NCQA methods or other national standards, methods or benchmarks.

    

    For
      an MCP which had membership as of January 1, 2006:
      Prior to
      the transition to the regional-based approach. MCP performance will be evaluated
      using an MCP's statewide result for the counties in which the MCP had membership
      as of January 1.2006. For reporting periods CY 2007

    

    

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    and
      CY
      2008, targets and performance standards for Clinical
      Performance Measures in this Appendix (l.c.i - l.c.vii)
      will be
      applicable to all counties in which MCPs had membership as of January 1, 2006.
      The final reporting year for the counties in which an MCP had membership as
      of
      January 1, 2006, will be CY 2008. ^

    

    For
      any MCP which did not have membership as of January 3. 2006:
      Performance will be evaluated using a regional-based approach for any active
      region in which the MCP had membership.

    Regional-Based
      Approach:
      MCPs
      will be evaluated by region, using results for all counties included in the
      region. CY 2008 will be the first reporting year that MCPs will be held
      accountable to the performance standards for an active region, and penalties
      will be applied for noncompliance. CY 2007 will be the first baseline reporting
      year for an active region.

    

    ODJFS
      will use a sufficient amount of data needed per performance measure from all
      MCPs serving an active region to determine performance standards and targets
      for
      that region. For example, should a measure call for one calendar year of
      baseline data. the first full calendaryearofdata will be used. CY 2008 will
      be
      the first reporting year for measures that call for one year of baseline data.
      Should a measure call for two calendar years of baseline data, the first two
      full calendar years of data will be used. CY 2009 will be the first reporting
      year for measures that call for two years of baseline data.

    

    Report
      Period:
      For the
      SPY 2006 contract period, performance will be evaluated using the January
      -December 2005 report period. For the SFY 2007 contract period, performance
      will
      be evaluated using the January - December 2006 report period. For the SFY 2008
      contract period, performance will be evaluated using the January - December
      2007
      report period.

    

    l.c.i.
      Perinatal Care- Frequency of Ongoing Prenatal Care

    

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

    

    Target:
      80% of
      the eligible population must receive 81% or more of the expected number of
      prenatal visits.

    

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

    

    Action
      Required for Noncompliance:
      If the
      standard is not met and the results are below 42%, then the MCP is required
      to
      complete a Performance Improvement Project, as described in Appendix K,
Quality
      Assessment and Performance Improvement Program,
      to
      address the area of noncompliance.

    

    

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    If
      the
      standard is not met and the results are at or above 42%, then OD.IFS will issue
      a Quality Improvement Directive which will notify the MCP ofnoncompliance and
      may outline the steps that the MCP must take to improve the
      results.

    

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

    

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

    

    Target:
      90% of
      the eligible population initiate prenatal care within the specified
      time.

    

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

    

    Action
      Required for Noncompliance:
      If the
      standard is not met and the results are below 71 %, then the MCP is required
      to
      complete a Performance Improvement Project, as described in Appendix K,
Quality
      Assessment and Performance Improvement Program,
      to
      address the area ofnoncompliance. If the standard is not met and the results
      are
      at or above 71%, then ODJFS will issue a Quality Improvement Directive which
      will notify the MCP ofnoncompliance and may outline the steps that the MCP
      must
      take to improve the results.

    

    l.c.iii.
      Perinatal Care - Postpartum Care

    

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

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

    

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

    Action
      Required for Noncompliance:
      If the
      standard is not met and the results are below 48%, then the MCP is required
      to
      complete a Performance Improvement Project, as described in Appendix K,
Quality/Assessment
      and Performance Improvement Program,
      to
      address the area of noncompliance. If the standard is not met and the results
      are at or above 48%, then 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.

    

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

    

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

    

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

    

    

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

    

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

    

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

    

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

    

    Action
      Required for Noncompliance (15 month old age group):
      If the
      standard is not met and the results are below 34%, then the MCP is required
      to
      complete a Performance Improvement Project, as described in Appendix K.
Quality
      Assessment and Performance Improvement Program,
      to
      address the area of noncompliance. If the standard is not met and the results
      are at or above 34%. then ODJFS will issue a Quality Improvement Directive
      which
      will notify the MCP of noncompliance and may outline the steps that the MCP
      must
      take to improve the results.

    

    Action
      Required for Noncompliance (3-6 year old age group):
      If the
      standard is not met and the results are below 50%. then the MCP is required
      to
      complete a Performance Improvement Project, as described in Appendix K,
Quality
      Assessment and Performance Improvement Program,
      to
      address the area of noncompliance. If the standard is not met and the results
      are at or above 50%. then ODJFS will issue a Quality Improvement Directive
      which
      will notify the MCP of noncompliance and may outline the steps that the MCP
      must
      take to improve the results.

    

    Action
      Required for Noncompliance (12-21 year old age group):
      If the
      standard is not met and the results are below 30%. then the MCP is required
      to
      complete a Performance Improvement Project, as described in Appendix K.
Quality
      Assessment and Performance Improvement Program,
      to
      address the area of noncompliance. If the standard is not met and the results
      are at or above 30%, then 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.

    

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

    

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

    

    Target:
      95% of
      the eligible population must receive the recommended medications.

    

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

    

    Action
      Required for Noncompliance:
      If the
      standard is not met and the results are below 83%, then the MCP is required
      to
      complete a Performance Improvement Project, as described in Appendix K.
Quality
      Assessment and Performance Improvement Program,
      to
      address the area of noncompliance. If the standard is not met and the results
      are at or above 83%, then ODJFS will

    

    

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    issue
      a
      Quality Improvement Directive which will notify the MCP ofnoncompliance and
      may
      outline the steps that the MCP must take to improve the results.

    

    l.c.vi.
      Annual Dental Visits

    

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

    

    Target:
      At least
      60% of the eligible population receive a dental visit.

    

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

    

    Action
      Required for Noncompliance:
      If the
      standard is not met and the results are below 40%, then the MCP is required
      to
      complete a Performance Improvement Project, as described in Appendix K,
Quality
      Assessment and 

    Performance
      Improvement Program,
      to
      address the area ofnoncompliance. If the standard is not met and the results
      are
      at or above 40%. then ODJFS will issue a Quality Improvement Directive which
      will notify the MCP ofnoncompliance and may outline the steps that the MCP
      must
      take to improve the results.

    

    l.c.vii.
      Lead Screening

    

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

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

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

    

    Action
      Required for Noncompliance (I year olds):
      If the
      standard is not met and the results are below 45% then 

    the
      MCP
      is required to complete a Performance Improvement Project, as described in
      Appendix K. Quality
      Assessment and Performance Improvement Program,
      to
      address the area of noncompliance. If the standard is not met and the results
      are at or above 45%, then OD.IFS will issue a Quality Improvement Directive
      which will notify the MCP ofnoncompliance and may outline the steps that the
      MCP
      must take to improve the results.

    

    Action
      Required for Noncompliance (2 year olds):
      If the
      standard is not met and the results are below 28% then the MCP is required
      to
      complete a Performance Improvement Project, as described in Appendix K,
Quality
      Assessment and Performance Improvement Program,
      to
      address the area of noncompliance.

    

    If
      the
      standard is not met and the results are at or above 28%, then ODJFS will issue
      a
      Quality Improvement Directive which will notify the MCP ofnoncompliance and
      may
      outline the steps that the MCP must take to improve the results.

    

    

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    2.
      ACCESS

    

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

    

    2.a.
      PCP Turnover

    

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

    

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

    

    For
      an MCP which had membership as of January J, 2006:
      Prior to
      the transition to the regional-based approach, MCP performance will be evaluated
      using an MCP's statewide result for the counties in which the MCP had membership
      as of January 1. 2006. The minimum performance standard in the Appendix
      (2.a)
      will be
      applicable to the MCP's statewide result for the counties in which the MCP
      had
      membership as of January 1. 2006. The last reporting year using the MCP's
      statewide result for the counties in which the MCP had membership as of January
      1, 2006 for performance
      evaluation
      is
      CY2007: the last reporting year using the MCP's statew'ide result for the
      counties in which the MCP had membership as of January 1. 2006 for performance
      incentives {Appendix
      0)
      is
      CY2008.

    

    For
      any MCP which did not have membership as of January 1. 2006:
      Performance w i 11 be evaluated using a regional-based approach for any active
      region in which the MCP had membership.

    

    Regional-Based
      Approach:
      MCPs
      will be evaluated by region, using results for all counties included in the
      region. ODJFS will use the first full calendar year of data (i.e.. CY2007)
      from
      all MCPs serving an active region to determine a minimum performance standard
      for that region. CY 2008 will be the first reporting year that MCPs will be
      held
      accountable to the performance standards for an active region, and penalties
      will be applied for noncompliance.

    

    Report
      Period:
      For the
      SFY 2006 contract period, performance will be evaluated using the January
      -December 2005 report period. For the SFY 2007 contract period, performance
      will
      be evaluated using the January - December 2006 report period. For the SFY 2008
      contract period, performance will be evaluated using the January - December
      2007
      report period.

    

    Minimum
      Performance Standard:
      A
      maximum PCP Turnover rate of 18%.

    

    Action
      Required/or 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

    

    

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    care.
      If
      access has been reduced or coordination of care affected, then the MCP must
      develop and implement an action plan to address the findings.

    

    2.b.
      Children's Access to Primary Care

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

    

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

    

    For
      an MCP which had membership as of January 1, 2006:
      Prior to
      the transition to the regional-based approach. MCP performance will be evaluated
      using an MCP's statewide result for the counties in which the MCP had membership
      as of January 1, 2006. The minimum performance standard in the Appendix
      (2.b)
      will be
      applicable to the MCP's statewide result for the counties in which the MCP
      had
      membership as of January 1, 2006. The last reporting year using the MCP's
      statewide result for the counties in which the MCP had membership as of January
      1, 2006 is CY2008.

    

    For
      any MCP which did not have membership as of January 1. 2006:
      Performance will be evaluated using a regional-based approach for any active
      region in which the MCP had membership.

    

    Regional-Based
      Approach:
      MCPs
      will be evaluated by region, using results for all counties included in the
      region. ODJFS will use the first two full calendar years of data (i.e., CY2007
      and CY2008) from all MCPs serving an active region to determine a minimum
      performance standard for that region. CY 2009 will be the first reporting year
      that MCPs will be held accountable to the performance standards for an active
      region, and penalties will be applied for noncompliance. Performance measure
      results for that region will be calculated after a sufficient amount of time
      has
      passed after the end of the report period in order to allow for claims
      runout.

    

    Report
      Period:
      For the
      SFY 2006 contract period, performance will be evaluated using the January -
      December 2005 report period. For the SFY 2007 contract period, performance
      will
      be evaluated using the January - December 2006 report period. For the SFY 2008
      contract period, performance will be evaluated using the January - December
      2007
      report period.

    

    Minimum
      Performance Standards:

    

    CY
      2005
      report period - 70% of the children must receive a visit. CY 2006 report period
      - 70% of the children must receive a visit. CY 2007 report period - 71% of
      the
      children must receive a visit.

    

    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

    

    

    Appendix
      M 

    Page
      13

    

    This
      measure indicates whether adult members are accessing health
      services.

    

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

    

    For
      an MCP which had membership as of January 1, 2006:
      Prior to
      the transition to the regional-based approach, MCP performance will be evaluated
      using an MCP's statewide result for the counties in which the MCP had membership
      as of January 1. 2006. The minimum performance standard in the Appendix
      (2.c)
      will be
      applicable to the MCP's statewide result for the counties in which the MCP
      had
      membership as of January 1, 2006. The last reporting year using the MCP's
      statewide result for the counties in which the MCP had membership as of January
      1, 2006 for performance evaluation is CY2007: the last reporting year using
      the
      MCP's statewide result for the counties in which the MCP had membership as
      of
      January 1. 2006 for performance
      incentives (Appendix
      0)
      is
      CY2008.

    

    For
      any MCP which did not have membership as of January 1. 2006:
      Performance will be evaluated using a regional-based approach for any active
      region in which the MCP had membership.

    

    Regional-Based
      Approach:
      MCPs
      will be evaluated by region, using results for all counties included in the
      region. OD.IFS will use the first full calendar year of data (i.e., CY2007)
      from
      all MCPs serving an active region to determine a minimum performance standard
      for that region. CY 2008 will be the first reporting year that MCPs will be
      held
      accountable to the performance standards for an active region, and penalties
      will be applied for noncompliance. Performance measure results for that region
      will be calculated after a sufficient amount of time has passed after the end
      of
      the report period in order to allow for claims runout.

    

    Report
      Period:
      For the
      SFY 2006 contract period, performance will be evaluated using the January -
      December 2005 report period. For the SFY 2007 contract period, performance
      will
      be evaluated using the January - December 2006 report period. For the SFY 2008
      contract period, performance will be evaluated using the January - December
      2007
      report period.

    

    Minimum
      Performance Standards:
      63% of
      the adults must receive a visit.

    

    Penally
      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

    

    The
      regional approach for this measure is to be determined for SFY 2008. The
      county-based approach remains effective in SFY 2007; the county-based approach
      is only applicable for MCPs with membership as of January 1, 2006 and for the
      counties in which the MCPs had membership as of January 1,2006.

    

    

    Appendix
      M 

    Page
      14

    

    In
      accordance with federal requirements and in the interest of assessing enrollee
      satisfaction with MCP performance, ODJFS periodically 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. Performance in this category will be determined by the
      overall satisfaction score. For a comprehensive description of the Consumer
      Satisfaction performance measure below, see ODJFS
      Methods for Consumer Satisfaction Performance Measures.

    

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

    

    Report
      Period:
      For the
      SFY 2006 contract period, performance will be evaluated using the results from
      the most recent consumer satisfaction survey completed prior to the end of
      the
      SFY 2006. For the SFY 2007 contract period, performance will be evaluated using
      the results from the most recent consumer satisfaction survey completed prior
      to
      the end of the SFY 2007. For the SFY 2008 contract period, the measure is under
      review and the report period has not been determined.

    

    Minimum
      Performance Standard:
      An
      average score of no less than 7.0.

    

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

    

    4.
      ADMINISTRATIVE CAPACITY

    

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

    

    4.a.
      Compliance Assessment System

    Measure:
      The
      number of points accumulated for one contract year (one state fiscal year)
      through the Compliance Assessment System.

    Report
      Period:
      For the
      SFY 2005 contract period, performance will be evaluated using the July 2004
      -
      June 2005 report period. For the SFY 2006 contract period, performance will
      be
      evaluated using the July 2005 - June 2006 report period.

    

    Minimum
      Performance Standard:
      No more
      than 25 points

    

    

    Appendix
      M 

    Page
      15

    

    Penalty/or
      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 ED services and implement action plans
      designed to minimize inappropriate ED utilization.

    

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

    

    For
      an MCP which had membership as of January 1, 2006:
      Prior to
      the transition to the regional-based approach, MCP performance w'ill be
      evaluated using an MCP's statewide result for the counties in which the MCP
      had
      membership as of January 1. 2006. The minimum performance standard and the
      target in the Appendix
      (4.b)
      will be
      applicable to the MCP's statewide result for the counties in which the MCP
      had
      membership as of January 1, 2006. The last reporting period using the MCP's
      statewide result for the counties in which the MCP had membership as of January
      1, 2006 for performance evaluation is July-December 2007; the last reporting
      period using the MCP's statewide result for the counties in which the MCP had
      membership as of January 1, 2006 for performance
      incentives {Appendix
      0)
      is
      July-December 2008.

    

    For
      any MCP which did not Have membership as of January 1, 2006:
      Performance wi 11 be evaluated using a regional-based approach for any active
      region in which the MCP had membership.

    

    Regional-Based
      Approach:
      MCPs
      w'ill be evaluated by region, using results for all counties included in the
      region. The reporting period will be a full calendar year. ODJFS will use the
      first full calendar year of data (i.e.. CY2007) as a baseline from all MCPs
      serving an active region to determine a minimum performance standard and a
      target for that region. CY 2008 will be the first reporting year that MCPs
      will
      be held accountable to the performance standards for an active region, and
      penalties will be applied for noncompliance. Performance measure results for
      that region will be calculated after a sufficient amount of time has passed
      after the end of the report period in order to allow for claims
      runout.

    

    Report
      Period:
      For the
      SFY 2006 contract period, a baseline level of performance will be set using
      the
      January - June 2005 report period. Results will be calculated for the reporting
      period of July-December 2005 and compared to the baseline results to determine
      if the minimum performance standard is met. For the SFY 2007 contract period,
      a
      baseline level of performance will be set using the January - June 2006 report
      period. Results will be calculated for the reporting period of July -December
      2006 and compared to the baseline results to determine if the minimum
      performance standard is met. For the SFY 2008 contract period, a baseline level
      of performance will be set using the January - June 2007 report period. Results
      will be calculated for the reporting period of July -December 2007 and compared
      to the baseline results to determine if the minimum performance standard is
      met.
      SFY2008 is also the first year for regional based reporting, using January
      -December 2007 as a baseline.

    

    

    Appendix
      M 

    Page
      16

    

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

    

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

    

    Penalty
      for Noncompliance:
      If the
      standard is not met and the results are above 1.1 %. then the MCP must

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

    

    5.
      NOTES

    

    5.a.
      Report Periods

    

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

    

    5.b.
      Monetary Sanctions

    

    Penalties
      for noncompliance with individual standards in this appendix will be imposed
      as
      the results are finalized. Penalties for noncompliance with individual standards
      for each period compliance is determined in this appendix will not exceed
      $250.000.

    

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

    

    5.c.
      Combined Remedies

    

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

    

    5.d.
      Enrollment Freezes

    

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

    

    5.e.
      Reconsideration

    

    

    Appendix
      M 

    Page
      17

    

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

    

    S.f.
      Contract Termination, Nonrenewals or Denials

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

    

    

    APPENDIX
      N

    

    COMPLIANCE
      ASSESSMENT SYSTEM (CAS)

    

    The
      compliance assessment system (CAS) is designed to improve the quality of each
      MCP's performance through a progressive series of actions taken by ODJFS to
      address identified failures to meet certain program requirements. The CAS
      assesses progressive remedies with specified values (occurrences or points)
      assigned for certain documented failures to satisfy the deliverables required
      by
      the provider agreement. Remedies are progressive based upon the severity of
      the
      violation, or a repeated pattern of violations. Progressive measures that
      recognize and monitor continuous quality improvement efforts enable both ODJFS
      and the MCPs to determine performance consistently across MCPs over
      time.

    

    The
      CAS
      focuses on noncompliance with clearly identifiable deliverables and
      occurrences/points are only assessed in documented and verified instances of
      noncompliance. 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 Ohio Administrative Code (OAC) rule 5101:3-26-10, including the
      proposed termination, amendment, or nonrenewal of the MCP's provider agreement
      in certain circumstances.

    

    The
      CAS
      does not include categories which require subjective assessments or which are
      not under the MCP's control. Documented violations in the categories specified
      in this appendix will ^^ result in the assessment of occurrences and points,
      with point values proportional to the severity alat
      of the
      violation. This approach allows the accumulated point total to reflect both
      patterns of less serious violations as well as less frequent, more serious
      violations.

    

    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.

    

    Corrective
      Action Plans (CAPs)
      - MCPs
      may be required to develop CAPs for any instance of noncompliance, and CAPs
      are
      not limited to actions taken under the CAS. All CAPs requiring ongoing activity
      on the part of an MCP to ensure their compliance with a program requirement
      remain in effect for the next provider agreement period. 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 an ODJFS-approvable CAP, ODJFS may
      require the MCP to comply with an ODJFS-developed or "directed"
      CAP.

    

    

    Appendix
      N 

    Page
      2

    

    Occurrences
      and Points
      -
      Occurrences and points are defined and applied as follows:

    

    Occurrences
      — Failures to meet program requirements, including but not limited to,
      noncompliance with administrative requirements.

    

    Examples:
      

    -
      Use
      ofunapproved/unapprovable marketing materials.

    -
      Failure
      to attend a required meeting.

    -
      Second
      failure to meet a call center standard.

    

    5
      Points
— Failures to meet program requirements, including but not limited to, actions
      which could impair the member's ability to access information regarding services
      in a timely manner or which could impair a member's rights.

    

    Examples:
      

    -
      24-hour
      call-in system is not staffed by medical personnel.

    -
      Failure
      to notify a member of their right to a state hearing when the MCP proposes
      to
      deny, reduce, suspend or terminate a Medicaid-covered service.

    -
      Failure
      to appropriately notify ODJFS of provider panel terminations.

    

    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 member to access
      covered services.

    Examples:
      

    -
      Failure
      to comply with the minimum provider panel requirements specified in Appendix
      H.

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

    -
      Failure
      to meet the electronic claims adjudication requirements.

    

    Failure
      to submit or comply with CAPs will be assessed occurrences or points based
      on
      the nature of the violation under correction.

    

    In
      order
      to reflect appropriately the impact of repeated violations, the following also
      applies:

    

     

    Appendix
      N 

    Page
      3

    

    After
      accumulating a total of three occurrences within the accumulation period, all
      subsequent occurrences during the period will be assessed as 5-point violations,
      regardless of the number of 5-point violations which have been accrued by the
      MCP.

    

    After
      accumulating a total of three 5-point violations within the accumulation period,
      all subsequent 5-point violations during the period will be assessed as 8-point
      violations, except as specified above.

    

    After
      accumulating a total of two 10-point violations within the accumulation period,
      all subsequent 10-point violations during the period will be assessed as
      15-point violations.

    

    Occurrences
      and points will accumulate over the duration of the provider agreement. With
      the
      beginning of a new provider agreement, the MCP will begin the new accumulation
      period with a score of zero unless the MCP has accrued a total of 55 points
      or
      more during the prior provider agreement period. Those MCPs who have accrued
      a
      total of 55 points or more during the provider agreement will carry these points
      over for the first three months of their next provider agreement. If the MCP
      does not accrue any additional points during this three-month period the MCP
      will then have their point total reduced to zero and continue on in the new
      accumulation period. If the MCP does accrue additional points during this
      three-month period, the MCP will continue to carry the points accrued from
      the
      prior provider agreement plus any additional points accrued during the new
      provider agreement accumulation period.

    

    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
      provider agreement period will be subject to remedial action under CAS at the
      time that ODJFS first becomes aware of this noncompliance.

    

    In
      cases
      where an MCP subcontracting provider is found to have violated a program
      requirement (e.g., failing to provide adequate contract termination notice,
      marketing to potential members, unapprovable billing of members, etc.). ODJFS
      will not assess occurrences or 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. Repeated incidents will be reviewed to determine if the MCP has a
      systemic problem in this area, and if so, occurrences or points may be
      assessed.

    

    ODJFS
      expects all required submissions to be received by their specified deadline.
      Unless otherwise specified, late submissions will initially be addressed through
      CAPs, with repeated instances of untimely submissions resulting in escalating
      penalties.

     

    

    Appendix
      N 

    Page
      4

    

    If
      an MCP
      determines that they will be unable to meet a program deadline, the MCP must
      verbally inform the designated ODJFS contact person (or their supervisor) of
      such and submit a written request (by facsimile transmission) for an extension
      of the deadline by no later than 3 PM on the date of the deadline in question.
      Extension requests should only be submitted in situations where unforeseeable
      circumstances have arisen which make it impossible for the MCP to meet an
      ODJFS-stipulated deadline. Only written approval by ODjFS of a deadline
      extension will preclude the assessment of a CAP. occurrence or points for
      untimely submissions.

    No
      points
      or occurrences 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.).

    

    REMEDIES

    Progressive
      remedies will be based on the number of points accumulated at the time of the
      most recent incident. Unless otherwise indicated in this appendix, all fines
      issued under the CAS are nonrefundable.

    

    1-9
      Points Corrective Action Plan (CAP)

    10-19
      Points CAP + $5.000 fine

    20-29
      Points CAP + $ 10,000 fine

    30-39
      Points CAP + $20.000 fine

    40-69
      Points CAP + $30.000 fine

    70+
      Points Proposed Contract Termination

    

    

    Appendix
      N 

    Page
      5

    

    New
      Member Selection Freezes:

    ODJFS
      may
      prohibit an MCP from receiving new membership through consumer initiated
      selection or the assignment process (selection freeze) in one or more counties
      if: (1) the MCP has accumulated a total of 20 or more points during the accrual
      period; (2) the MCP fails to fully implement a CAP within the designated time
      frame; or (3) circumstances exist which potentially jeopardize the MCP's
      members' access to care. Examples of circumstances that ODJFS may consider
      as
      jeopardizing member access to care include:

    

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

            

    

    
      	§  	
              the
                MCP has been found by ODJFS to be out of compliance with the provider
                panel requirements specified in Appendix
                H;

            

    

    
      	§  	
              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 this provider agreement will be denied for new enrollees,
      when and for so long as, payments for those enrollees is denied by CMS in
      accordance with the requirements in 42 CFR 438.730.

    

    Reduction
      of Assignments

    ODJFS
      may
      reduce the number of assignments an MCP receives if ODJFS determines that the
      MCP lacks sufficient administrative capacity to meet the needs of the increased
      volume in membership. Examples of circumstances which ODJFS may determine
      demonstrate a lack of sufficient administrative capacity include, but are not
      limited to an MCP's failing to: 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, designated PCP and SACMS data
      files.

    

    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, ODJFS will assess the MCP with a 10-point
      penalty and a monetary sanction of $20,000 per day for the period
      ofnoncompliance. ODJFS may assess additional penalty points based on the length
      ofnoncompliance.

    

    

    Appendix
      N 

    Page
      6

    

    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 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 ofnoncompliance.

    

    Noncompliance
      with Prompt Payment:

    

    Noncompliance
      with the prompt pay requirements as specified in Appendix J will result in
      progressive penalties. The first violation during the contract term will result
      in the assessment of 5 points, quarterly prompt pay reporting, and submission
      of
      monthly status reports to ODJFS until the next quarterly report is due. The
      second and any subsequent violation during the contract term will result in
      the
      submission of monthly status reports, assessment of 10 points 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 consecutive quarters.

    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 a
      selection freeze of not less than three months duration.

    

    Noncompliance
      with Franchise Fee Assessment Requirements

    

    In
      accordance with ORC Section 5111.176. 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.

    •
       A
      10
      point penalty assessment for the period of noncompliance.

    •
       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;

    

    

    Appendix
      N 

    Page
      7

    

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

    

    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 documented violation.

    

    Noncompliance
      with Encounter Data Submissions:

    

    Submission
      of unpaid encounters (except for immunization services as specified in Appendix
      L) will result in the assessment of a nonrefundable $1.000 fine for each
      documented violation.

    

    Noncompliance
      with Abortion and Sterilization Payment

    

    Noncompliance
      with abortion and sterilization requirements as specified by ODJFS will result
      in the assessment of a nonrefundable $1.000 fine for each documented violation.
      Additionally, MCPs must take all appropriate action to correct each such
      ODJFS-documented violation.

    

    Refusal
      to Comply w'ith Program Requirements

    

    If
      ODJFS
      has instructed an MCP that they must comply with a specific program requirement
      and the MCP refuses, ODJFS v»'ill consider this to mean that the MCP is no
      longer operating in the best interests of the MCP's members or the state of
      Ohio
      and will move to terminate or nonrenew the MCP's provider agreement pursuant
      to
      OAC rule 5101:3-26-10(G).

    

    General
      Provisions:

    

    All
      notifications of the imposition of a fine or freeze will be made via certified
      or overnight mail to the identified MCP Medicaid Coordinator.

    

    Pursuant
      to procedures specified by ODJFS, refundable and nonrefundable monetary
      sanctions/assurances must be remitted to ODJFS within thirty days of receipt
      of
      the invoice by the MCP. In addition, per Ohio Revised Code Section 131.02,
      payments not received within forty-five 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.

    

    Refundable
      monetary sanctions/assurances applied by ODJFS will be based on the premium
      payment for the month in which the MCP was cited for the deficiency. Any monies
      collected through the imposition of such a tine would be returned to the MCP
      (minus any applicable collection fees owed to the Attorney General's Office
      if
      the MCP has been delinquent in submitting payment) after they have demonstrated
      full compliance with the particular program requirement.

    

    

    Appendix
      M 

    Page
      8

    

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

    

    ODJFS
      may
      impose a combined remedy which will address all areas of noncompliance
      ifODJFS

    determines
      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.

    

    Again,
      ODJFS can at any time move to terminate, amend or deny renewal of a provider
      agreement pursuant to the provisions ofOAC rule 5101:3-26-10.

    

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

    

    In
      addition to the remedies imposed under the CAS, remedies related to areas of
      data quality and financial performance may also be imposed pursuant to
      Appendices J, L, and M respectively.

    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, the ODJFS may, pursuant to the provisions of OAC rule 5101:3-26-10(A):
      (1) notify the MCP's members that they may terminate from the MCP without cause;
      and/or (2) suspend any further new member selections.

    

    RECONSIDERATIONS

    Requests
      for reconsiderations of remedial action taken under the CAS may be submitted
      as
      follows:

    •
MCPs
      notified of ODJFS' imposition of remedial action taken under the CAS (i.e.,
      occurrences, points, tines, assignment reductions and selection freezes), will
      have five working days from the date of receipt to request reconsideration,
      although ODJFS will impose selection freezes based on an access to care concern
      concurrent with initiating notification to the MCP. (All notifications of the
      imposition of a fine or a freeze will be made via certified or overnight mail
      to
      the identified MCP Contact.) Any information that the MCP would like reviewed
      as
      part of the reconsideration must be submitted with the reconsideration request,
      unless ODJFS extends the time frame in writing.

    •
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
      the fifth working day after receipt of notification of the imposition of the
      remedial action by ODJFS.

    

    

    Appendix
      N 

    Page
      9

    

    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 w. ill review all correspondence and materials related
      to the violation in question in making the final reconsideration
      decision.

    •
Final
      decisions or requests for additional information will be made by ODJFS within
      five working days of receipt of the request for reconsideration.

    If
      additional information is requested by ODJFS, a final reconsideration decision
      will be made within three working 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.

    •
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. The MCP may still be required to submit a CAP if the Bureau Chief
      believes that a CAP is still warranted.

    

    

    Appendix
      N 

    Page
      10

    

    

    POINT
      COMPLIANCE SYSTEM - POINT VALUES

    

    OCCURRENCES:
      Failures
      to meet program requirements, including but not limited to, noncompliance with
      administrative requirements. Examples are:

    

    •
      Unapproved use of marketing/member materials.

    •
Failure
      to attend ODJFS-required meetings or training sessions. Failure to maintain
      ODJFS-required documentation.

    •
Use
      ofunapprovcd subcontracting providers where prior approval is required by
      ODJFS.

    •
Use
      of
      unapprovable subcontractors (e.g., not in good standing with Medicaid and/or
      Medicare programs, provider listed in directory but no current contract, etc.)
      where prior-approval is not required by OD.IFS.

    •
Failure
      to provide timely notification to members, as required by ODJFS (e.g., notice
      of
      PCP or hospital termination from provider panel).

    •
      Participation in a prohibited or unapproved marketing activity.

    •
Second
      failure to meet the monthly call-center requirements for either the member
      services or 24-hour call-in system lines.

    •
Failure
      to submit and/or comply with a Corrective Action Plan (CAP) requested by ODJFS
      as the result of an occurrence, or when no occurrence was designated for the
      precipitating violation of the OAC rules or provider agreement

    •
Failure
      to comply with the physician incentive plan requirements, except for
      noncompliance where member rights are violated (i.e. failure to complete
      required patient satisfaction surveys or to provide members with requested
      physican incentive information) or where false, misleading or inaccurate
      information is provided to ODJFS.

    

    

    Appendix
      N 

    Page
      11

    

    5
      POINTS:
      Failures
      to meet program requirements, including but not limited to, actions which could
      impair the member's ability to access information regarding services in a timely
      manner or which could impair a consumer's or member's rights. Examples
      are:

    

    •
      Violations which result in selection or termination counter to the recipient's
      preference (e.g., a recipient makes a selection decision based on inaccurate
      provider panel information from the MCP).

    •
Any
      violation of an member's rights.

    •
Failure
      to provide member materials to new members in a timely manner.

    •
Failure
      to comply with appeal, grievance, or state hearing requirements, including
      timely submission to ODJFS.

    •
Failure
      to staff 24-hour call-in system with appropriate trained medical
      personnel.

    •
Third
      failure to meet the monthly call-center requirements for either the member
      services or the 24-hour call-in system lines.

    •
Failure
      to submit and/or comply with a CAP as a result of a 5-point
      violation.

    •
Failure
      to meet the prompt payment requirements (first violation).

    •
      Provision of false, inaccurate or materially misleading information to health
      care providers, the MCP's members, or any eligible individuals.

    •
Failure
      to submit a required monthly SACMS file (as specified in Appendix L) by the
      end
      of the month the submission was required.

    •
Failure
      to submit a required monthly Members' Designated PCP file (as specified in
      Appendix L) by the end of the month the submission was required.

    

    

    Appendix
      N 

    Page
      12

     

    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. Examples are:

    

    •
Failure
      to meet any of the provider panel requirements as specified in Appendix
      H.

    •
      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 process prior authorization requests w ithin prescribed time
      frame.

    •
Failure
      to remit any ODJFS-required payments within the specified time
      frame.

    •
Failure
      to meet the electronic claims adjudication requirements.

    •
Failure
      to submit and/or comply with a CAP as a result of a 10-point
      violation.

    •
Failure
      to meet the prompt payment requirements (second and subsequent
      violations).

    •
Fourth
      and any subsequent failure to meet the monthly call-center requirements for
      either the member services or the 24-hour call-in system lines.

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

    •
Failure
      to submit a required monthly appeal or grievance file (as specified in Appendix
      L) by the end of the month the submission was required.

    •
      Misrepresentation or falsification of information that the MCP furnishes to
      the
      ODJFS or to the Centers for Medicare and Medicaid Services.

    

    

    PROPOSED
      CHANGES FOR 2007

    The
      Compliance Assessment System (CAS) w as designed to monitor and to improve
      the
      quality of each MCP's performance in limited counties utilizing the
      zero-tolerance approach to program requirements with progressive remedies in
      the
      form of occurences/points and fines based on the severity of the violation
      or
      repeated patterns. Due to the expansion of Ohio's Medicaid Managed Care Program
      to all eighty-eight counties, the Ohio Department of Job and Family Services
      (ODJFS) will be reassessing the current CAS based upon MCP compliance data
      collected during state fiscal year 2007. ODJFS anticipates that the CAS will
      be
      redesigned and driven by a comprehensive approach to enhancing the quality
      of
      each MCP's performance by rewarding the MCPs that have continuously demonstrated
      excellent compliance and performance and focusing attention on improving the
      performance of MCPs for which deficiencies have been identified.

    

    

    APPENDIX
      0 

    PERFORMANCE
      INCENTIVES

    

    This
      Appendix establishes incentives for managed care plans (MCPs) to improve
      performance in specific areas important to the Medicaid MCP members. Incentives
      include the at-risk amount included with the monthly premium payments (see
      Appendix F, Rate
      Chart),
      and
      possible additional monetary rewards up to $250.000.

    

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

    

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

    

    1.
      SFY 2006 Incentives l.a. Qualifying Performance Levels

    

    To
      qualify for consideration of the SFY 2006 incentives, 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 incentive standards established for the Emergency Department Diversion
      and
      Clinical Performance Measures below.

    

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

    

    Measures
      for which the minimum performance standard for SFY 2006 established in Appendix
      M, Performance
      Evaluation,
      must be
      met to qualify for consideration of incentives are as follows:

    1.
      Independent External Quality Review (Appendix M, Section l.a.i. - Minimum
      Performance Standard 2)

    

    

    Appendix
      0 

    Page
      2

    

    Report
      Period:
      The most
      recent Independent External Quality Review completed prior to the end of the
      SFY
      2006 contract period.

    

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

    Report
      Period:
      CY
      2005

    

    3.
      Children's Access to Primary Care (Appendix M, Section 2.b.) Report
      Period:
      CY
      2005

    

    4.
      Adults' Access to Preventive/Ambulatory Health Services (Appendix M, Section
      2.c.) Report
      Period:
      CY
      2005

    

    5.
      Overall Satisfaction with MCP (Appendix M. Section 3.)

    Report
      Period:
      The most
      recent consumer satisfaction survey completed prior to the end of the SFY 2006
      contract period.

    

    For
      the
      EDD performance measure, the MCP must meet the incentive standard for the report
      period of July - December. 2005 to be considered for SFY 2006 incentives. The
      MCP meets the incentive standard if one of two criteria are met. The incentive
      standard is a performance level of either:

    

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

    

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

    

    For
      each
      clinical performance measure listed below, the MCP must meet the incentive
      standard to be considered for SFY 2006 incentives. The MCP meets the incentive
      standard if one of two criteria are met. The incentive standard is a performance
      level of either:

    

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

    

    2)
      The
      Medicaid benchmarks for seven of the nine clinical performance measures listed
      below.

    

    
      	
              Clinical
                Performance Measure

            	
              Medicaid
                Benchmark

            
	
              1.
                Perinatal Care- Frequency of Ongoing Prenatal Care

            	
              42%

            
	
              2.
                Perinatal Care- Initiation of Prenatal Care

            	
              71%

            
	
              3.
                Perinatal Care- Postpartum Care

            	
              48%

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

            	
              34%

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

            	
              50%

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

            	
              30%

            
	
              7.
                Use of Appropriate Medications for People with Asthma

            	
              59%

            
	
              8.
                Annual Dental Visits

            	
              40%

            
	
              9.
                Blood Lead - 1 year olds

            	
              45%

            

    

    

    

    Appendix
      0 

    Page
      3

     

     

     

    l.b.
      Excellent and Superior Performance Levels

    

    For
      qualifying MCPs as determined by Section 2.a.. performance will be evaluated
      on
      the measures below to determine the status of the at-risk amount or any
      additional incentives that may be awarded. Excellent and Superior standards
      are
      set for the three measures described below.

    

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

    

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

    Report
      Period:
      July -
      December 2005

    Excellent
      Standard:
      2.5%
Superior
      Standard:
      3.8%

    

    2.
      Use of
      Appropriate Medications for People with Asthma (Appendix M, Section 1 .c.vi.)
      Report
      Period:
      CY 2005
Excellent
      Standard:
      59%
Superior
      Standard:
      68%

    

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

    Report
      Period:
      CY
      2005

    Excellent
      Standard:
      76%

    Superior
      Standard:
      83%

    

    1.c.
      Determining SFY 2006
      Incentives

    

    MCP's
      reaching the minimum performance standards described in Section 2.a. will be
      considered for incentives including retention of the at-risk amount and any
      additional incentives. For each Excellent standard established in Section 2.b.
      that an MCP meets, one-third of the at-risk amount may be retained. For MCPs
      meeting all of the Excellent and Superior standards established in Section
      2.b.,
      additional incentives may be awarded. For MCPs receiving

    

    

    Appendix
      0 

    Page
      4

    

    

    additional
      incentives, the amount in the incentive fund (see section 3.) will be divided
      equally, up to the maximum amount, among all MCPs receiving additional
      incentives. The maximum amount to be awarded to a single plan in incentives
      additional to the at-risk amount is $250,000 per contract year.

    

    2.
      SFY 2007 Incentives 

    

    2.a.
      Qualifying Performance Levels

    

    To
      qualify for consideration of the SFY 2007 incentives, 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 incentive standards established for the Emergency Department
      Diversion

    and
      Clinical Performance Measures below.

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

    

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

    

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

    Report
      Period:
      CY
      2006

    

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

    Report
      Period:
      CY
      2006

    

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

    Report
      Period:
      CY
      2006

    

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

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

    

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

    

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

    

    

    Appendix
      0 

    Page
      5

    

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

    

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

    

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

    

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

    

    
      	
              Clinical
                Performance Measure

            	
              Medicaid
                Benchmark

            
	
              1.
                Perinatal Care - Frequency of Ongoing Prenatal Care

            	
              42%

            
	
              2.
                Perinatal Care - Initiation of Prenatal Care

            	
              71%

            
	
              3.
                Perinatal Care - Postpartum Care

            	
              48%

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

            	
              34%

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

            	
              50%

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

            	
              30%

            
	
              7.
                Use of Appropriate Medications for People with Asthma

            	
              83%

            
	
              8.
                Annual Dental Visits

            	
              40%

            
	
              9.
                Blood Lead - 1 year olds 

            	
              45%

            

    

     

    2.b.
      Excellent and Superior Performance Levels

    

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

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

    

    1.
      Case
      Management of Children (Appendix M, Section l.b.ii.) Report
      Period:
      April -
      June 2007

    Excellent
      Standard:
      5.5%

    Superior
      Standard:
      6.5%

    

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

    

    

    Appendix
      0 

    Page
      6

    

    Report
      Period:
      CY 2006

    Excellent
      Standard:
      86%

    Superior
      Standard:
      88%

    

    3.
      Adults' Access to Preventive/Ambulatory Health Services (Appendix M, Section
      2.c.) Report
      Period:
      CY 2006
Excellent
      Standard:
      76%
Superior
      Standard:
      83%

    

    2.c.
      Determining SFY 2007 Incentives

    

    MCP's
      reaching the minimum performance standards described in Section 2.a. will be
      considered for incentives including retention of the at-risk amount and any
      additional incentives. For each Excellent standard established in Section 2.b.
      that an MCP meets, one-third of the at-risk amount may be retained. For MCPs
      meeting all of the Excellent and Superior standards established in Section
      2.b..
      additional incentives may be awarded. For MCPs receiving additional incentives,
      the amount in the incentive fund (see section 3.) will be divided equally,
      up to
      the maximum amount, among all MCPs receiving additional incentives. The maximum
      amount to be awarded to a single plan in incentives additional to the at-risk
      amount is $250,000 per contract year.

    

    3.
      NOTES

    

    3.a.
      Initiation of the Performance Incentive System

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

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

    

    

    Appendix
      0 

    Page
      7

    

    3-b.
      Determination ofat-risk amounts and additional incentive
      payments

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

    

    3.c.
      Transition from a county-based to a regional-based performance incentive
      system.

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

    

    3.c.i.
      County-based performance incentive system

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

    

    3.c.ii.
      Regional-based performance incentive system

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

    The
      status of the at-risk amount for counties not included in the county-based
      performance incentive system will not be determined for the first twenty-four
      months of regional membership. Starting with the twenty-fifth month of regional
      membership, the MCP's at-risk amount will be included in the incentive system.
      The determination of the status of this at-risk amount will be after at least
      three full calendar years of regional membership as many of the performance
      standards require three full calendar years to determine an MCP's performance
      level. Because of this requirement, more than 12 months ofat-risk dollars may
      be
      included in an MCP's first regional at-risk status determination depending
      on
      when regional membership starts relative to the calendar year.

    

    3.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 OD.IFS in
      accordance with Appendix P., Termmations/Nonrenewals/AmendmenIs,
      of the
      provider agreement.

    

    

    Appendix
      0 

    Page
      8

    

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

    

    3.e.
      Report Periods

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

    

    

    APPENDIX
      P 

    MCPTERMINATIONS/NONRENEWAES/AMENDMENTS

    

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

    

    MCP-FN1T1ATEDTERMINATIONS/NONRENEWAES

    

    If
      an MCP
      provides notice of the termination/nonrenewal of their provider agreement to
      ODJFS, pursuant to Article VIII of the agreement- the MCP will be required
      to
      submit a refundable monetary assurance. This monetary assurance will be held
      by
      ODJFS until such time that the MCP has submitted all outstanding monies owed
      and
      reports, including, but not limited to, grievance, appeal, encounter and cost
      report data related to time periods through the final date of service under
      the
      MCP's provider agreement. The monetary assurance must be in an amount of either
      $50,000 or 5 % of the capitation amount paid by ODJFS in the month the
      termination/nonrenewal notice is issued, whichever is greater.

    

    The
      MCP
      must also return to ODJFS the at-risk amount paid to the MCP under the current
      provider agreement. The amount to be returned will be based on actual MCP
      membership for preceding months and estimated MCP membership through the end
      date of the contract. MCP membership for each month betw een the month the
      termination/nonrenewal is issued and the end date of the provider agreement
      will
      be estimated as the MCP membership for the month the termination/nonrenewal
      is
      issued. Any over payment will be determined by comparing actual to estimated
      MCP
      membership and will be returned to the MCP following the end date of the
      provider agreement.

    

    The
      MCP
      must remit the monetary assurance and the at-risk amount in the specified
      amounts via separate electronic fund transfers (EFT) payable to Treasurer
      of State. Stale of Ohio (ODJFS).
      The MCP
      should contact their Contract Administrator to verify the correct amounts
      required for the monetary assurance and the at-risk amount and obtain an invoice
      number prior to submitting the monetary assurance and the at-risk amount.
      Information from the invoices must be included with each EFT to ensure monies
      are deposited in the appropriate ODJFS Fund account. In addition, the MCP must
      send copies of the EFT bank confirmations and copies of the invoices to their
      Contract Administrator.

    

    If
      the
      monetary assurance and the at-risk amount are not received as specified above,
      ODJFS will withhold the MCP's next month's capitation payment until such time
      that ODJFS receives documentation that the monetary assurance and the at-risk
      amount are received by the Treasurer of State. If within one year of the date
      of
      issuance of the invoice, an MCP does not submit all outstanding monies owed
      and
      required submissions, including, but not limited to. grievance, appeal,
      encounter and cost report data related to time periods through the final date
      of
      service under the MCP's provider agreement, the monetary assurance will not
      be
      refunded to the MCP.

    

    

    

    

    Appendix
      P 

    Page
      2

    

    ODJFS-INITIATED
      TERMINATIONS

    

    If
      ODJFS
      initiates the proposed termination, nonrenewal or amendment of an MCP's provider
      agreement pursuant to OAC rule 5101:3-26-10 and the MCP appeals that proposed
      action, the MCP's provider agreement will be extended through the duration
      of
      the appeals process.

    

    During
      this time, the MCP will continue to accrue points and be assessed penalties
      for
      each subsequent compliance assessment occurrence/violation under Appendix N
      of
      the provider agreement. If the MCP exceeds 69 points, each subsequent point
      accrual will result in a $15.000 nonrefundable fine.

    

    Pursuant
      to OAC rule 5101:3-26-10(H). if ODJFS has proposed the termination, nonrenewal.
      denial or amendment of a provider agreement. ODJFS may notify the MCP's members
      of this proposed action and inform the members of their right to immediately
      terminate their membership with that MCP without cause. IfODJFS has proposed
      the
      termination, nonrenewal, denial or amendment of a provider agreement and access
      to medically-necessary covered services is jeopardized, ODJFS may propose to
      terminate the membership of all of the MCP's members. The appeal process for
      reconsideration of either of these proposed actions is as follows:

    

    •
All
      notifications of such a proposed MCP membership termination will be made by
      ODJFS via certified or overnight mail to the identified MCP
      Contact.

    •
MCPs
      notified by ODJFS of such a proposed MCP membership termination will have three
      working days from the date of receipt to request reconsideration.

    •
All
      reconsideration requests must be submitted by either facsimile transmission
      or
      overnight mail to the Deputy Director, Office of Ohio Health Plans, and received
      by 5 PM on the third working day follov^ing receipt of the ODJFS notification.
      (For example, if ODJFS notification is received on August 6 the MCP's request
      for reconsideration must be delivered to the Deputy Director by no later than
      5
      PM on August 9.) The address and fax number to be used in making these requests
      will be specified in the ODJFS notification document.

    •
The
      MCP
      will be responsible for verifying timely receipt of all reconsideration
      requests. All requests must explain in detail why the proposed MCP membership
      termination is not justified. The MCP's justification for reconsideration will
      be limited to a review of the written material submitted by the
      MCP.

    

    

    Appendix
      P

    Page
      3

    

    •
       A
      final
      decision or request for additional information will be made by the Deputy
      Director within three working days of receipt of the request for
      reconsideration. Should the Deputy Director require additional time in rendering
      the final reconsideration decision, the MCP will be notified of such in
      writing.

    •
       The
      proposed MCP membership termination will not occur while an appeal is under
      review and pending the Deputy Director's decision. If the Deputy Director denies
      the appeal, the MCP membership termination will proceed at the first possible
      effective date. The date may be retroactive if the ODJFS determines that it
      would be in the best interest of the members.

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