Document:

EX-10.3

    
      

    

    Back to Form 8-K

    Exhibit
      10.3

     

    

    OHIO
      DEPARTMENT OF JOB AND FAMILY SERVICES

     

    OHIO
      MEDICAL ASSISTANCE PROVIDER AGREEMENT FOR MANAGED CARE PLAN ABD ELIGIBLE
      POPULATION

     

    This
      provider agreement is entered into this first day of December, 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 for-profit corporation, whose principal office is located in the city
      of
      Beechwood, County of Cuyahoga, State of Ohio.

     

    MCP
      is
      licensed as a Health Insuring Corporation by the State of Ohio, Department
      of
      Insurance (hereinafter referred to as ODI), 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 Aged, Blind or Disabled (ABD) 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.

     

     

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    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 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.

     

    

    

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    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 LJ.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,
      which 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.

     

    

    

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    D.
      No
      officer, member or employee of MCP 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 of MCP 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

     

    

    

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    [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.

     

    

    

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

     

     

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    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 obligation with ODJFS. This
      certification is a material representation of fact upon which

     

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    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 (I) 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 6032 of The Deficit Reduction Act of 2005 (also see
      Section 5111.101 of the Revised Code).

     

     

    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

     

    

    

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    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 of inconsistence or ambiguity between the provisions of OAC 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 of OD-IFS.

     

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

    ABD
      PROVIDER AGREEMENT INDEX

    December
      1, 2006

    

    

    

    
      	
              APPENDIX
                

            	
              TITLE

            
	
              APPENDIX
                A

            	
              OCA
                RULES 5101 :3-26

            
	
              APPENDIX
                B

            	
              SERVICE
                AREA SPECIFICAITONS - ABD ELIGIBLE

            
	
              APPENDIX
                C

            	
              MCP
                RESPONSIBLITIES - ABD ELIGIBLE POPULATION

            
	
              APPENDIX
                D

            	
              ODJFS
                RESPONSIBILITIES - ABD ELIGIBLE POPULATION

            
	
              APPENDIX
                E

            	
              RATE
                METHODOLOGY - ABD ELIGIBLE POPULATION

            
	
              APPENDIX
                F

            	
              REGIONAL
                RATES - ABD ELIGIBLE 

              POPULATION

            
	
              APPENDIX
                G

            	
              COVERAGE
                AND SERVICES - ABD ELIGIBLE 

              POPULATION

            
	
              APPENDIX
                H

            	
              PROVIDER
                PANEL SPECIFICATIONS - ABD ELIGIBLE 

              POPULATION

            
	
              APPENDIX
                I

            	
              POPULATION
                INTEGRITY - ABD ELIGIBLE POPULATION

            
	
              APPENDIX
                J

            	
              FINANCIAL
                PERFORMANCE - ABD ELIGIBLE POPULATION

            
	
              APPENDIX
                K

            	
              QUALITY
                ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM AND EXTERNAL QUALITY
                REVIEW
                - AVD ELIGIBLE POPULATION

            
	
              APPENDIX
                L

            	
              DATA
                QUALITY - ABD ELIGIBLE POPULATION

            
	
              APPENDIX
                M

            	
              PERFORMANCE
                EVALUTAION - ABD ELIGIBLE POPULATION

            
	
              APPENDIX
                N

            	
              COMPLIANCE
                ASSESSMENT SYSTEM - ABD ELGIBLE POPULATION

            
	
              APPENDIX
                O

            	
              PAY-FOR-PERFORMANCE
                (P4P) - ABD ELIBIBLE POPULATION

            
	
              APPENDIX
                P

            	
              MCP
                TERMINATIONS/NONRENEWALS/AMENDMENTS - ABD ELIGIBLE
                POPULATION

            

    

    

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

    

    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

    ABD
      ELIGIBLE POPULATION

    

    MCP
      : WellCare of Ohio, Inc.

     

    

    The
      MCP agrees to provide services to Aged. Blind or Disabled (ABD) members
residing
      in the following service area(s):

     

    Service
      Area: Northeast Region:
      Ashtabula, Cuyahoga, Erie, Geauga, Huron, Lake, Lorain,
      Medina

     

    

    

    APPENDIX
      C

     

    MCP
      RESPONSIBILITIES ABD ELIGIBLE POPULATION

     

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

     

    General
      Provisions

     

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

     

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

     

    3
      The MCP
      must designate the following:

     

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

     

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

     

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

     

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

     

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

     

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

     

    

    

    Appendix
      C 

    Page
      2

    

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

     

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

     

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

     

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

     

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

     

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

     

    13.
      The
      MCP must notify their Contract Administrator of the termination of an MCP panel
      provider that is designated as the primary care physician for ^100 of the MCP's
      ABD members. The MCP must provide notification within one working day of the
      MCP
      becoming aware of the termination.

     

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

     

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

     

    

    

    Appendix
      C 

    Page
      3

    must
      ensure to the satisfaction of ODJFS that the services are readily available
      and
accessible
      to members who are eligible to receive them.

     

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

     

    b.
      Additional benefits may not vary by county within a region except out of
      necessity for transportation arrangements (e.g., bus versus cab). MCPs approved
      to serve consumers in more than one region may vary additional benefits between
      regions.

     

    c.
      MCPs
      must give ODJFS and members ninety (90) days prior notice when decreasing or
      ceasing any additional benefit(s). When it is beyond the control of the MCP,
      as
      demonstrated to ODJFS' satisfaction, ODJFS must be notified within one (1)
      working day.

     

    16.
      MCPs
      must comply with any applicable Federal and State laws that pertain to member
      rights and ensure that its staff adhere to such laws when furnishing services
      to
      its membrs. MCPs shall include a requirement in its contracts with affiliated
      providers that such providers also adhere to applicable Federal and State laws
      when providing services to members.

     

    17.
      MCPs
      must comply with any other applicable Federal and State laws (such as Title
      VI
      of the Civil rights Act of 1964, etc.) and other laws regarding privacy and
      confidentiality-;, as such may be applicable to this Agreement.

     

    18.
      Upon
      request, the MCP will provide members and potential members with a copy of
      their
      practice guidelines.

     

    19.
      The
      MCP is responsible for promoting the delivery of services in a culturally
      competent manner, as solely determined by ODJFS, to all members, including
      those
      with limited English proficiency (LEP) and diverse cultural and ethnic
      backgrounds.

     

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

     

    

    

    Appendix
      C

    Page
      4

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

            

    

     

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

     

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

     

    

    

    Appendix
      C

    Page
      5

    

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

     

    21.
      The
      MCP is responsible for ensuring that all member materials use easily understood
      language and format. The determination of what materials comply with this
      requirement is in the sole discretion of ODJFS.

     

    22.
      Pursuant to OAC rules 5101:3-26-08 and 5101:3-26-08.2, the MCP is responsible
      for

    ensuring
      that all MCP marketing and member materials are prior approved by ODJFS before
      being used or shared with members. Marketing and member materials are defined
      as
      follows:

     

    a.
      Marketing materials are those items produced in any medium, by or on behalf
      of
      an MCP, including gifts of nominal value (i.e., items worth no more than
      $15.00), which can reasonably be interpreted as intended to market to eligible
      individuals.

     

    b.
      Member
      materials are those items developed, by or on behalf of an MCP, to fulfill
      MCP
      program requirements or to communicate to all members or a group of members.
      Member health education materials that are produced by a source other than
      the
      MCP and which do not include any reference to the MCP are not considered to
      be
      member materials.

     

    c.
      All
      MCP marketing and member materials must represent the MCP in an honest and
      forthright manner and must not make statements which are inaccurate, misleading,
      confusing, or otherwise misrepresentative, or which defraud eligible individuals
      or ODJFS.

     

    d.
      All
      MCP marketing cannot contain any assertion or statement (whether written or
      oral) that the MCP is endorsed by CMS, the Federal or State government or
      similar entity.

     

    e.
      MCPs
      must establish positive working relationships with the CDJFS offices and must
      not aggressively solicit from local Directors, MCP County Coordinators, or
      or
      other staff. Furthermore, MCPs are prohibited from offering gifts of nominal
      value (i.e. clipboards, pens, coffee mugs, etc.) to CDJFS offices or SSE staff,
      as these may influence an individual's decision to select a particular
      MCP.

     

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

     

    a.
      Maintain written policies and procedures that meet the requirements for advance
      directives,
      as set forth in 42 CFR Subpart I of part 489.

     

    

    

    Appendix
      C 

    Page
      6

     

    b.
      Maintain written policies and procedures concerning advance directives with
      respect to all adult individuals receiving medical care by or through the MCP
      to
      ensure that the MCP:

     

    i.
      Provides written information to all adult members concerning:

     

    a.
      the
      member's rights under state law to make decisions concerning
      their medical care, including the right to accept or refuse medical or surgical
      treatment and the right to formulate advance directives. (In meeting this
      requirement, MCPs must utilize form JFS 08095 entitled You
      Have the Right,
      or
      include the text from JFS 08095 in their ODJFS-approved member
      handbook).

     

    b.
      the
      MCP's policies concerning the implementation of those rights including a clear
      and precise statement of any limitation regarding the implementation of advance
      directives as a matter of conscience;

     

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

     

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

     

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

     

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

     

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

     

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

     

    

    

    Appendix
      C 

    Page
      7

     

    24.   
      New
      Member Materials

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

     

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

     

    b.
      The ID
      card and new member letter must be mailed together to the member via a method
      that will ensure 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 twenty-four (24) hours of the MCP receiving the ODJFS-produced monthly
      membership roster (MMR). This is provided the materials are mailed via a method
      with an expected delivery date of five (5) days. If the MCP is unable to mail
      the materials within twenty-four (24) hours, the materials must be mailed via
      a
      method that will ensure receipt by no later than the effective date of
      coverage.

     

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

     

    25.
      Call
      Center Standards

    The
      MCP
      must provide assistance to members through a member services toll-free call-in
      system pursuant to OAC rule 5101:3-26-08.2(A)(1). MCP member services staff
      must
      be available nationwide to provide assistance to members through the toll-free
      call-in system every Monday through Friday, at ail times during the hours of
      7:00 am to 7:00 pm Eastern Time, except for the following major
      holidays:

     

    •
New
      Year's Day

     

    •
Martin
      Luther King's Birthday

     

    •
      Memorial Day

     

    •
      Independence Day

     

    •
Labor
      Day

     

    •
      Thanksgiving Day

     

    •
      Christmas Day

     

    •
2
      optional closure days: These days can be used independently or in combination
      with any of the major holiday closures but cannot both be used within the same
      closure period. Before announcing any optional closure dates to members and/or
      staff, MCPs must receive ODJFS prior-approval which verifies that the optional
      closure days meet the specified criteria.

    

    

    Appendix
      C

    Page
      8

     

     

    If
      a
      major holiday falls on a Saturday, the MCP member services line may be closed
      on
      the preceding Friday. If a major holiday falls on a Sunday, the member services
      line may be closed on the following Monday. MCP member services closure days
      must be specified in the MCP's member handbook, member newsletter, or other
      some
      general issuance to the MCP's members at least thirty (30) days in advance
      of
      the closure.

     

    The
      MCP
      must also provide access to medical advice and direction through a centralized
      twenty-four-hour, seven day, toll-free call-in system, available nationwide,
      pursuant to OAC rule 5101:3-26-03.1(A)(6). The twenty-four (24)/7 hour call-in
      system must be staffed by appropriately trained medical personnel. For the
      purposes of meeting this requirement, trained medical professionals are defined
      as physicians, physician assistants, licensed practical nurses, and registered
      nurses.

     

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

     

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

     

    26.
      Notification
      of Optional MCP Membership

     

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

     

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

    

    

    Appendix
      C

    Page
      9

    

    27.
      HIPAA
      Privacy Compliance Requirements

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

    

    

    Appendix
      C

    Page
      10

     

     

     

    28.
      Electronic
      Communications -
      MCPs are
      required to purchase/utilize Transport Layer

    Security
      (TLS) for all e-mail communication between ODJFS and the MCP. The MCP's e-mail
      gateway must be able to support the sending and receiving of e-mail using
      Transport Layer Security (TLS) and the MCP's gateway must be able to enforce
      the
      sending and receiving of email via TLS.

     

    29.
      MCP
      Membership acceptance, documentation and reconciliation

     

    a.
      Selection
      Services Contractor:
      The MCP
      shall provide to the 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 reported
      on
      the monthly remittance advice (RA).

     

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

     

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

     

    d.
      Hospital
      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 ODJFS to assure that discharge planning assures
      continuity of care and accurate payment. Notwithstanding the MCP's right to
      request a hospital deferment up to six (6) months following the member's
      effective date, when the MCP learns of a

     

    

    

    Appendix
      C

    Page
      11

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

     

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

     

    h.
      Transition
      of Fee-For-Service Members: Providing
      care coordination, access to preventive and specialized care, case management,
      member services, and education with minimal disruption to members' established
      relationships with providers and existing care treatment plans is critical
      for
      members transitioning from Medicaid fee-for-service to managed care. MCPs
      must:

     

    i.
      Develop a transition plan that outlines how the MCP will effectively address
      the
      unique care coordination issues for members in their first three months of
      MCP
      membership that includes at a minimum:

     

    

    Appendix
      C

    Page
      12

     

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

     

    a.
      Health
      care needs, including those services received through state sub-recipient
      agencies [e.g., the Ohio Department of Mental Health (ODMH), the Ohio Department
      of Mental Retardation and Developmental Disabilities (ODMR/DD), and the Ohio
      Department of Alcohol and Drug Addiction Services (ODADAS);

     

    b.
      Existing sources of care (i.e., primary physicians, specialists, case
      manager(s), ancillary and other care givers); and

     

    c.
      Current care therapies for all aspects of health care services, including
      scheduled health care appointments, planned and/or approved surgeries (inpatient
      or outpatient), ancillary or medical therapies, prescribed drugs, approved
      home
      health care, scheduled lab/radiology tests, necessary/approved durable medical
      equipment, supplies and needed/approved transportation
      arrangements.

     

    iii.
      Strategies for how each new member will obtain care therapies from appropriate
      sources of care as an MCP member including reported scheduled health services
      as
      described in Section 28.i.(ii-iv) of this Appendix.

     

    iv.
      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 one
      of
      the following applies:

     

    a.
      The
      member has appointments within the initial three months of the MCP membership
      with a primary physician or specialty physicians that were scheduled prior
      to
      the effective date of the MCP membership;

     

    b.
      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;

     

    

    

    Appendix
      C

    Page
      13

     

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

     

    d.
      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);

     

    e.
      The
      member is receiving ongoing chemotherapy or radiation treatment;

     

    f.
      The
      member has been released from the hospital within the last thirty (30) days
      and
      is following a treatment plan;

     

      
      g. The member has been pre-certified to receive durable medical equipment (DME)
      which has not yet been received.

     

    v.
      Reimburse out-of-panel providers that agree to provide the transition services
      identified in section 28.i.section ii at 100% of the current Medicaid
      fee-for-service provider rate for the service(s).

     

    vi.
      Document the provision of transition services as follows:

     

    a.
      As
      expeditiously as the situation warrants, contact the provider's offices via
      telephone to confirm that the service(s) meets the above criteria.

     

    b.
      For
      services that meet the above criteria, inform the provider that the MCP is
      sending a form for signature to document that they accept/do not accept the
      terms for the provision of the services and copy the member on the
      form.

     

    c.
      If the
      provider agrees to the terms, notify the member and provider of the MCP's
      authorization and ensure that the MCP's claims processing system will not deny
      the claim payment because the provider is out-of-panel. MCPs must include their
      non-contracting provider materials as outlined in Appendix G.4.e with the
      provider notice.

     

    d.
      If the
      provider does not agree to the terms, notify the member and assist the member
      with locating a provider as expeditiously as the member's condition
      warrants.

    

    Appendix
      C 

    Page
      14

    

     

    e.
      Use
      the ODJFS-specified model language for the provider and member
      notices.

     

    f.
      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.

     

    vii.
      Not
      require prior-authorization of any prescription drug that does not require
      prior
      authorization by Medicaid fee-for-service for the initial three months of a
      member's MCP membership. Additionally, all atypical anti-psychotic drugs must
      be
      exempted from prior authorization requirements for all MCP ABD members through
      December 2007, after which time ODJFS will re-evaluate the continuation of
      this
      pharmacy utilization strategy.

     

    30.
      Health
      Information System Requirements

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

     

    a.
      Health
      Information System

     

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

     

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

     

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

     

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

     

    

    

    Appendix
      C Page 15

     

     

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

    a.
      Before
      an MCP may submit production files 

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

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

     

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

     

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

     

    

    
      	b.  	
              Electronic
                Data Interchange and Claims Adjudication Requirements
                

            

    

     

    Claims
      Adjudication

     

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

     

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

     

    Appendix
      C 

    Page
      16

     

     

    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
      applicable federal rule or regulation.

     

    The
      MCP
      must have the capacity to accept the following transactions from the Ohio
      Department of Job and Family services consistent with EDI processing
      specifications in the transaction implementation guides and in conformance
      with
      the 820 and 834 Transaction Companion Guides issued by ODJFS:

     

    ASC
      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, to the satisfaction of ODJFS, as outlined below.

     

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

     

    MCPs
      shall submit written verification to ODJFS for transaction standards and code
      sets specified in 45 CFR Part 162 - Health Insurance Reform: Standards
      for

     

    

    

    Appendix
      C 

    Page
      17

    

    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).

    

    i.
      Trading Partner Agreements 

    ii.
      Code
      Sets 

    iii.
      Transactions

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

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

    c.
      Referral Certification and Authorization (ASC X12N 278) 

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

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

    f.
      Health
      Care Payment and Remittance Advice (ASC XI 2N 835)

    g.
      Health
      Plan Premium Payments (ASC X12N 820) 

    h.
      Coordination of Benefits

     

    Trading
      Partner Agreement with ODJFS

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

    if
      submission prior to entering into the Agreement is waived, the trading partner
      agreement must be submitted at a subsequent date determined by
      ODJFS.

     

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

     

    c.
      Encounter
      Data Submission Requirements

     

    General
      Requirements

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

    

    

    Appendix
      C 

    Page
      18

    

    •
      Institutional Claims - UB92 flat file

     

    •
      Noninstitutional Claims - National standard format

     

    •
      Prescription Drug Claims - NCPDP

     

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

     

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

     

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

     

    Encounters
      include services paid for retrospectively, through fee-for-service payment
      arrangements, and prospectively. through capitated arrangements. Only encounters
      with services (line items) that are paid by the MCP, fully or in part, and
      for
      which no further payment is anticipated, are acceptable encounter data
      submissions.

     

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

     

    Acceptance
      Testing

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

     

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

    

    Appendix
      C 

    Page
      19

    

     

     

    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 and receive permission to do so from their
      designated Contract Administrator.

     

    Timing
      of Encounter Data Submissions

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

     

    d.
      Information
      Systems Review

     

    Every
      two
      (2) 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, at a minimum, will be carried out during the review.
      ODJFS
      or its designee will:

     

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

     

    ii.
      Review the completed ISCA and accompanying documents;

    

    Appendix
      C 

    Page
      20

    

    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, or in such a timeframe as ODJFS, in their sole
      discretion, deems appropriate to ensure accuracy and efficiency of the MCP
      health information system.

     

    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
      the time when 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 with 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 who are
      determined to be exempt from the IS review must participate in subsequent
      information system reviews, as determined by ODJFS.

     

    

    

    Appendix
      C 

    Page
      21

     

    31.
      If
      the MCP will be using the Internet functions that will allow approved users
      to
      access member information (e.g., eligibility verification), the MCP must receive
      prior written approval from ODJFS that verifies that the proper safeguards,
      firewalls, etc., are in place to protect member data.

     

    32.
      MCPs
      must receive prior written approval from ODJFS before adding any information
      to
      their website that would require ODJFS prior approval in hard copy form (e.g.,
      provider listings, member handbook information).

     

    33.
      Pursuant to 42 CFR 438.106(b), the MCP acknowledges that it is prohibited from
      holding a member liable for services provided to the member in the event that
      the ODJFS fails to make payment to the MCP.

     

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

     

    35.
      Franchise
      Fee Assessment Requirements

     

    a.
      Each
      MCP is required to pay a franchise permit fee to ODJFS for each calendar quarter
      as required by ORC Section 5111.176. The current fee to be paid is an amount
      equal to 4'/2 percent of the managed care premiums, minus Medicare premiums
      that
      the MCP received from any payer in the quarter to which the fee applies. Any
      premiums the MCP returned or refunded to members or premium payers during that
      quarter are excluded from the fee.

     

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

     

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

     

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

     

    36.
      Information
      Required for MCP Websites

     

    a.
      On-line
      Provider Directory
      - MCPs
      must have an internet-based provider directory available in the same format
      as
      their ODJFS-approved provider directory, that allows members to electronically
      search for the MCP panel

     

    

    

    Appendix
      C 

    Page
      22

    

    providers
      based on name, provider type, geographic proximity, and population (as specified
      in Appendix H). MCP provider directories must include all MCP-contracted
      providers [except as specified by ODJFS] as well as certain ODJFS non-contracted
      providers.

     

    b.
      On-line
      Member Website
      - MCPs
      must have a secure internet-based website which is regularly updated to include
      the most current ODJFS approved materials. The website at a minimum must
      include: (1) a list of the counties that are covered in their service area;
      (2)
      the ODJFS-approved MCP member handbook, recent newsletters/announcements, MCP
      contact information including member services hours and closures; (3) the MCP
      provider directory as referenced in section 36(a) of this appendix; (4) the
      MCP's current preferred drug list (PDL), including an explanation of the list,
      which drugs require prior authorization (PA), and the PA process; (5) the MCP's
      current list of drugs covered only with PA, the PA process, and the MCP's policy
      for covering generic for brand-name drugs; and (6) the ability for members
      to
      submit questions/comments/grievances/appeals/etc. and receive a response
      (members must be given the option of a return e-mail or phone call). Responses
      regarding questions or comments are expected within one working day of receipt,
      whereas responses regarding grievances and appeals must be within the timeframes
      specified in OAC rule 5101:3-26-08.4. MCPs must ensure that all member materials
      designated specifically for CFC and/or ABD consumers (i.e. the MCP member
      handbook) are clearly labeled as such. The MCP's member website cannot be used
      as the only means to notify members of new and/or revised MCP information (e.g.,
      change in holiday closures, change in additional benefits, revisions to approved
      member materials etc.). ODJFS may require MCPs to include additional information
      on the member website, as needed.

     

    c.
      On-line
      Provider Website -
      MCPs
      must have a secure internet-based website for 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. MCPs
      must ensure that all provider materials designated specifically for CFC and/or
      ABD consumers (i.e. The MCP's provider manual) are clearly labeled as such.
      ODJFS may require MCPs to include additional information on the provider
      website, as needed.

     

    

    

    Appendix
      C 

    Page
      23

     

    37.
      MCPs
      must provide members with 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.

     

    39.
      PCP
      Feedback
      - The
      MCP must have the administrative capacity to offer feedback to individual
      providers on their: 1) adherence to evidence-based practice guidelines; and
      2)
      positive and negative care variances from standard clinical pathways that may
      impact outcomes or costs. In addition, the feedback information may be used
      by
      the MCP for activities such as physician performance improvement projects that
      include incentive programs or the development of quality improvement
      programs.

     

    

    

    APPENDIX
      D

     

    ODJFS
      RESPONSIBILITIES ABD ELIGIBLE POPULATION

     

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

     

    General
      Provisions

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

    

    

    Appendix
      D 

    Page
      2

    

    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 may revise data/information exchange policies and
      procedures for many functions that are now restricted to FAX, telephone, and
      hard copy, including, but not limited to, monthly membership and premium payment
      reconciliation requests, newborn reporting, Just Cause disenrollment requests,
      information requests etc. (as specified in Appendix C).

     

    12.
      ODJFS
      will immediately report to Center for Medicare and Medicaid Services (CMS)
      any
      breach in privacy or security that compromises protected health information
      (PHI), when reported by the MCP or ODJFS staff.

     

    13.
      Service
      Area Designation

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

     

    14.
      Consumer
      information

     

    a.
      ODJFS,
      or its delegated entity, will provide membership notices, informational
      materials, and instructional materials relating to members and eligible
      individuals in a manner and format that may be easily understood. At least
      annually, ODJFS 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

     

    

     

    15.
      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-Assignment
      Limitations -
      In order
      to promote market and program stability, ODJFS may limit an MCP's
      auto-assignments if they meet any of the following enrollment
      thresholds:

     

    •
40%
      of
      statewide
      Aged,
      Blind, or Disabled (ABD) managed care eligibles; and/or

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

    •
40%
      of
      the ABD managed care eligibles in
      any region with three MCPs.

     

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

     

    c.
      Consumer
      Contact Record (CCR):
      ODJFS or
      their designated entity shall forward CCRs to MCPs on no less than a weekly
      basis. The CCRs are a record of each consumer-initiated MCP enrollment, change,
      or termination, and each 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.

    

    Appendix
      D 

    Page
      4

    

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

     

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

     

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

     

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

     

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

     

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

     

    19.
      Communications

     

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

     

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

     

    c.
      MCP
      delegated entities:
      In that
      MCPs are ultimately responsible for meeting program requirements, the BMHC
      will
      not discuss MCP issues

     

    

    

    Appendix
      D 

    Page
      5

    

    with
      the
      MCPs' delegated entities unless the applicable MCP is also participating in
      the
      discussion. MCP delegated entities, with the applicable MCP participating,
      should only communicate with the specific CA assigned to that MCP.

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

    MERCER
      

    Government
      Human Services Consulting

    

    

     

    November
      17, 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:

    ABD
      Rate-Setting Methodology & Capitation Rate Certification for the 2007
      Contract Period

     

    Dear
      Jon:

     

    The
      Ohio
      Department of Job and Family Services (State) contracted with Mercer Government
      Human Services Consulting (Mercer) to develop actuarially sound regional
      capitation rates for the Aged, Blind or Disabled (ABD) managed care population.
      During calendar year (CY) 2007, the State will roll out statewide ABD mandatory
      managed care on a regional basis. It is anticipated that managed care will
      be
      implemented in all eight regions by May 2007. The specific contract period
      and
      effective dates vary by region. A summary of the regional rates for each region
      is included in Appendix E. This summary will be updated each time the contract
      period for a new region is determined.

     

    This
      methodology letter outlines the rate-setting process, provides information
      on
      the data adjustments and provides a final rate summary. The key components
      in
      the rate-setting process are:

     

    •
Base
      data development,

     

    •
Managed
      care rate development, and

     

    •
Centers
      for Medicare and Medicaid Services (CMS) documentation
      requirements.

     

    Each
      of
      these components is described further throughout the document and is depicted
      in
      the flowchart included as Appendix A.

     

    

    

    MERCER

    Government
      Human Services Consulting

     

    Page
      2

    November
      17, 2006

    Mr.
      Jon
      Barley

    Bureau
      of
      Managed Health Care

     

    Managed
      Care Eligible Population

     

    The
      following ABD individuals are not eligible to enroll in the managed care
      program.

     

    •
      Children under twenty-one years of age,

     

    •
      Individuals who are dually eligible under both the Medicaid and Medicare
      programs,

     

    •
      Institutionalized individuals,

     

    •
      Individuals eligible for Medicaid by spending down their income or resources
      to
      a level that meets the Medicaid program's financial eligibility requirements,
      or

     

    •
      Individuals receiving Medicaid services through a Medicaid Waiver.

     

    In
      addition, for managed care eligible individuals who enter a nursing facility,
      managed care plans (MCPs) are responsible for nursing facility payment and
      payment for all covered services until the last day of the second calendar
      month
      following the nursing facility admission.

     

    Base
      Data Development

     

    Data
      Sources

    Since
      ABD
      managed care has not yet been implemented in Ohio, FFS data was the only
      available data source for rate-setting. Mercer used FFS claims and eligibility
      data from State Fiscal Year (SFY) 2003 and from SFY 2004 as the basis for rate
      development. Once mandatory managed care is implemented and the program becomes
      stable, Mercer will incorporate plan-reported managed care data, including
      encounter and cost report data. Other sources of information used, as necessary,
      included State enrollment projections. State financial reports, projected
      managed care penetration rates and other ad hoc sources.

     

    Validation
      Process

    Mercer's
      validation process included reviewing SFY 2003 and SFY 2004 dollars, utilization
      and member months. Mercer also performed additional reasonability checks to
      ensure the base data was accurate and complete.

     

    FFS
      Data

    FFS
      experience from the base time period of SFY 2003 and SFY 2004 was used as a
      direct data source for rate-setting. Adjustments were applied to the FFS data
      to
      reflect the actuarially equivalent claims experience for the population that
      will be enrolled in the managed care

    

    

    MERCER

    Government
      Human Services Consulting

     

    Page
      3

    November
      17, 2006

    Mr.
      Jon
      Barley

    Bureau
      of
      Managed Health Care

     

    program.
      Mercer excluded claims and eligibility data for the ineligible populations
      outlined on the previous page. The State Medicaid Management Information System
      (MMIS) includes data for FFS paid claims, which may be net or gross of certain
      factors (e.g., gross adjustments or third party liability (TPL)). As a result
      of
      these conditions, it was necessary to make adjustments to the FFS base data
      as
      documented in Appendix C and outlined in Appendix A.

     

    Managed
      Care Rate Development

     

    This
      section explains how Mercer developed the final capitation rates for each of
      the
      eight managed care regions, as defined in Appendix B. After the FFS base data
      was developed and the two years were blended, Mercer applied trend, program
      changes and managed care adjustments to project the program cost into the
      contract year. Next, the MCP administrative component was applied. Appendix
      A
      outlines the managed care rate development process. Appendix D provides more
      detail behind each of the following adjustments.

     

    Blending
      Multiple Years of Data

    Prior
      to
      blending the two years of FFS data, the base time period experience was trended
      to a common time period ofSFY 2004. Mercer applied greater credibility to the
      most recent year of data to reflect the expectation that the most recent year
      may be more reflective of future experience and to reflect that fewer
      adjustments are needed to bring the data to the effective contract
      period.

     

    Managed
      Care Assumptions for the FFS Data Source

    In
      developing managed care savings assumptions. Mercer applied generally accepted
      actuarial principles that reflect the impact of MCP programs on FFS experience.
      Mercer reviewed Ohio's historical FFS experience and other state Medicaid
      managed care experience to develop managed care savings assumptions. These
      assumptions have been applied to the FFS data to derive managed care cost
      levels. The assumptions are consistent with an economic and efficiently operated
      Medicaid managed care plan. The managed care savings assumptions vary by region
      and Category of Service (COS). Specific adjustments were made in this step
      to
      reflect the differences between pharmacy contracting for the State and
      contracting obtained by the MCPs. Mercer reviewed information related to
      discount rates, dispensing fees, and rebates to make these adjustments. The
      rates are reflective of MCP contracting for these services. In addition, Mercer
      considered the impact of two pharmacy management restrictions on the MCPs when
      determining pharmacy managed care assumptions. These restrictions include the
      prohibition to prior

    

    

    MERCER

    Government
      Human Services Consulting

     

    Page
      4

    November
      17, 2006

    Mr.
      Jon
      Barley

     

    Bureau
      of
      Managed Health Care

     

    authorize
      any prescriptions during the first ninety days of managed care implementation
      and the restriction on prior authorization of any atypical antipsychotics (as
      defined by the State).

     

    Prospective
      Policy Changes

    CMS
      also
      requires that the rate-setting methodology incorporates the impact of any
      programmatic changes that have taken place, or are anticipated to take place,
      between the base period (SFY 2004) and the 2007 contract period.

     

    The
      State
      staff provided Mercer with a detailed list of program changes that may have
      a
      material impact on the cost, utilization, or demographic structure of the
      program prior to, or within, the contract period and whose impact was not
      included within the base period data. Final programmatic changes approved for
      SFY 2006 and SFY 2007 are reflected in the rates, as appropriate. Please refer
      to Appendix D for more information on these programmatic changes.

     

    Clinical
      Measures/Incentives

    As
      the
      ABD managed care program matures, the State will require MCPs to meet minimum
      performance standards for a defined set of clinical measures. The State expects
      the first full calendar year of the program will be used as a baseline year
      to
      determine performance standards and targets. Since the MCPs will not be at
      risk
      for this period, the rates have not been adjusted to account for improvement
      in
      performance on the clinical measures.

     

    Caseload

    Historically,
      the State has experienced significant changes in its Medicaid caseload. These
      shifts in caseload have affected the demographics of the remaining Medicaid
      population. Mercer evaluated these caseload variations to determine if an
      adjustment was necessary to account for demographic changes. Based on the data
      provided by the State, Mercer determined no adjustments were
      necessary.

     

    Selection
      Issue

    Mercer
      made an adjustment for voluntary selection, which accounts for the fact that
      costs associated with individuals who participate in managed care are generally
      lower than the remaining FFS population. Therefore, the voluntary selection
      adjustment adjusts for the risk of only those members participating in managed
      care. This adjustment is a reduction to paid claims and utilization. Appendix
      D
      provides more detail around the voluntary selection adjustment.

    

    

    MERCER

    Government
      Human Services Consulting

     

    Page
      5

    November
      17, 2006

    Mr.
      Jon
      Barley

    Bureau
      of
      Managed Health Care

     

    Non-State
      Plan Services

     

    According
      to the CMS Final Medicaid Managed Care Rule that was implemented

    August
      13, 2003, non-state plan services may not be included in the base data for
      rate
      setting.

    The
      FFS
      data does not include costs for non-state plan services. Therefore, no
      adjustment was necessary.

     

    Prospective
      Trend Development

    Trend
      is
      an estimate of the change in the overall cost of providing a specific benefit
      service over a finite period of time. A trend factor is necessary to estimate
      the expenses of providing health care services in some future year, based on
      expenses incurred in prior years. Trend was applied by COS to the blended costs
      for SFY 2004 to project the data forward to the 2007 contract
      period.

     

    Mercer
      integrated the FFS trend analysis with a broader analysis of other trend
      resources. These resources included health care economic factors (e.g., Consumer
      Price Index (CP1) and Data Resource, Inc. (DRI)), trends in neighboring states,
      the State FFS trend expectations and any Ohio market changes. Moreover, the
      trend component was comprised of both unit cost and utilization
      components.

     

    Mercer
      discussed all trend recommendations with State staff. We reviewed the potential
      impact of initiatives targeted to slow or otherwise affect the trends in the
      program. Final trend amounts were determined from the many trend resources
      and
      this additional program information. Appendix D provides more information on
      trend.

     

    Administration/Contingencies

    Since
      ABD
      managed care has not yet been implemented, other ABD Medicaid program
      administration/contingencies allowances and the State's expectations were
      factors that were taken into consideration in determining the final
      administration/contingencies percentages. Appendix D provides further detail
      on
      the allowance.

     

    Risk
      Adjustment

    The
      FFS
      data was not categorized by age/sex cohort because the base regional rates
      will
      undergo risk adjustment. Risk adjustment takes into account the demographics
      and
      diagnoses of the population. The risk adjusted rates (RAR) will be implemented
      into the ABD managed care program using a generally accepted risk adjustment
      method to adjust base capitation rates to

    

    

    MERCER

    Government
      Human Services Consulting

     

    Page
      6

    November
      17, 2006

    Mr.
      .Ion
      Barley

    Bureau
      of
      Managed Health Care

     

    reflect
      the different health status of the members enrolled in each MCP's program.
      ODJFS
      and its actuarial consultant will develop each MCP's risk score to reflect
      the
      health status of members enrolled in the contractor's program within a
      region.

     

    During
      the initial months of managed care implementation in each region, it is
      anticipated that ODJFS and its actuaries will calculate regional MCP case mix
      scores monthly until the enrollment in the region becomes relatively stable.
      Because enrollment for these months will not be known until after the start
      of
      the month, the initial payment will be made assuming the base capitation rates
      for all MCPs. An adjustment will be made in the subsequent month to reflect
      the
      appropriate risk adjustment reimbursement for the prior month. Once regional
      enrollment has stabilized, it is anticipated that the MCP case mix scores will
      be updated semi-annually. In the event that the ABD implementation is delayed
      or
      a change in methodology is required, the risk assessment schedule may be
      revised.

     

    Certification
      of Final Rates

     

    Base
      capitation rates were developed for the eight managed care regions, and a rate
      summary is provided in Appendix E. Upon receiving final contract period
      information for each region, Mercer will update Appendix E
      accordingly.

     

    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. Rates developed by Mercer
      are actuarial projections of future contingent events. Actual MCP costs will
      differ from these projections. Mercer has developed these rates on behalf of
      the
      State to demonstrate compliance with the CMS requirements under 42 CFR 438.6(c)
      and to demonstrate that rates are in accordance with applicable law and
      regulations.

     

    

    

    MERCER

    Government
      Human Services Consulting

     

    Page
      7

    November
      17, 2006

    Mr.
      Jon
      Barley

    Bureau
      of
      Managed Health Care

     

    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
      the State 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 the State. Use of these rates for purposes
      beyond that stated may not be appropriate.

     

    Sincerely,

    

    
      	
              /s/
                Wendy Radunz 

              Wendy
                Radunz, FSA, MAAA

            	
              /s/
                Angela WasDyke 

              Angela
                WasDyke, ASA, MAAA

            
	 	 
	
              Copy:

              Chuck
                Betley, Mitali Ghatak, Tracy Williams - ODJFS 

              Denise
                Blank, Katie Olecik - Mercer

            

    

     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

    MERCER

    Government
      Human Services Consulting 

     

    Appendix
      A - 2007 Contract Period ABD Rate-Setting Methodology

    

    [Flow
      Chart]

     

     

     

    

    MERCER

    Government
      Human Services Consulting

     

    Appendix
      B - Region Definition

     

    

    Please
      refer to the map below, which defines the counties within each of the eight
      managed care regions.

    

    [Medicaid
      Managed Care Program Regions for the ABD Population Map]

    

     

    B-l

     

    

    

    MERCER

    Government
      Human Services Consulting

     

    Appendix
      C - FFS Data Adjustments

     

    This
      section lists adjustments made to the FFS claims and eligibility information
      received from the State.

     

    Completion
      Factors

    The
      claims data was adjusted to account for the value of claims incurred but unpaid
      on a COS basis. Mercer used claims for SFY 2003 and SPY 2004 that reflect
      payments through the dates included in the following table.

     

    
      	
              State
                Fiscal
                Year

            	
              Paid
                Through

            
	
              2003

            	 03/31/04
	
              2004

            	 12/31/04

    

     

    The
      value
      of the claims incurred during each of these years, but unpaid, was estimated
      using completion factor analysis.

     

    Gross
      Adjustment File (GAF)

    To
      account for gross debit and credit amounts not reflected in the FFS data,
      adjustments were applied to the FFS paid claims.

     

    Historical
      Policy Changes

    As
      part
      of the rate-setting process, Mercer must account for policy changes that
      occurred during the base data time period. Changes only reflected in a portion
      of the data must be applied to the remaining data so that the base data reflects
      all of the policy changes. All policy changes implemented during SFY 2003 and
      SFY 2004 were applied to the FFS data.

     

    C-l

     

    

    

    MERCER

    Government
      Human Services Consulting

     

    The
      following table shows the specified policy changes for which Mercer adjusted
      the
      SFY 2003 and SFY 2004 data. Mercer calculated the adjustments based on the
      "History of Policy Changes" document and other information supplied by the
      State.

     

    
      	
              Policy
                Changes

            	
              Effective
                Date

            	
              Category
                of
                Service Affected

            
	
               

              Inpatient
                Outlier Payment Methodology - Exceptional cost outlier threshold
                increased
                from $250,000 to $443,463

            	
               

              8/1/2002

            	
               

              Inpatient

            
	
               

              Anesthesia
                Services -Conversion factor decreased to $8.13

            	
               

              9/1/2002

            	
               

              Specialists

            
	
               

              Independently-practicing
                psychologist services eliminated for adults (s21)

            	
               

              1/1/2004

            	
               

              PCP,
                Specialists

            
	
               

              All
                chiropractic services eliminated for adults (>21)

            	
               

              1/1/2004

            	
               

              Other

            
	
               

              $3.00
                Copay on Prior-Authorization Drugs

            	
               

              1/1/2004

            	
               

              Pharmacy

            

    

     

    Third
      Party Liability Recoveries

    TPL
      can
      be identified with two components: ''cost-avoidance'' and "pay and chase" type
      actions. "Cost-avoidance" occurs when the State initially denies paying a claim
      because another payer is the primary payer. The State may then pay a residual
      portion of the charged amount. Only the residual portion of the claim will
      be
      included in the FFS data. The portion of the claim paid by another payer has
      been avoided and not included in reported claim payments. Participating MCPs
      are
      expected to pay in a similar fashion and therefore, no adjustment to the FFS
      data will be required.

     

    In
      a "pay
      and chase" scenario, the State pays the claim as though it were the primary
      payer. Subsequent to payment, the State makes recovery from a third party.
      The
      State has indicated the FFS data does not reflect these recoveries. Since MCPs
      are also expected to take similar recovery actions, the FFS experience was
      adjusted for "pay and chase" recoveries. Mercer made adjustments to both the
      paid claims and utilization for all COSs. Since MCPs do not collect tort
      recoveries, the data excludes tort collections.

     

    Hospital
      Cost Settlements

    The
      State
      provided Mercer with SFY 2003 and SFY 2004 interim cost settlements for
      Diagnosis Related Group (DRG) and DRG-exempt hospitals. The DRG-exempt hospital
      information

     

    C-2

     

    

    

    MERCER

    Government
      Human Services Consulting

     

    included
      inpatient and outpatient settlements. However, the DRG hospitals only include
      capital settlements, which were incorporated into the adjustment. An adjustment
      has been applied to inpatient, outpatient, and emergency room (ER) claims to
      remove these additional costs.

     

    Fraud
      and
      Abuse

    The
      State
      does pursue recoveries from fraud and abuse cases. The dollars recovered are
      accounted for outside of the State's MMIS system and are not included in the
      FFS
      data. Therefore, Mercer applied adjustments to the FFS claims and utilization
      data.

     

    Excluded
      Time Periods

    The
      capitation rates paid to the MCPs reflect the risk of serving the eligible
      enrollees from the date of health plan enrollment forward. Therefore, the FFS
      data has been adjusted to reflect only the time periods for which the MCPs
      are
      at risk.

     

    Dual
      Eligibles

    Dual
      eligible persons are not enrolled in managed care and are therefore not included
      in the managed care rates. Their experience has been excluded from the base
      FFS
      data used to develop the rates.

     

    Catastrophic
      Claims

    Since
      the
      State does not provide reinsurance to the MCPs. the MCPs are expected to
      purchase reinsurance on their own. To reflect these costs, all claims, including
      claims above the reinsurance threshold, were included in the base FFS data.
      The
      final rates Mercer calculated reflect the total risk associated with the covered
      population and are expected to be sufficient to cover the cost of the required
      stop-loss provision.

     

    DSH
      Payments

     

    DSH
      payments are made by the State to providers and are not the responsibility
      of
      the MCPs;

    therefore,
      the information for these payments was excluded from the FFS data used to
      develop the rates. No rate adjustment was necessary.

     

    Spend
      Down

    Persons
      Medicaid eligible due to spend down are not enrolled in managed care and
      therefore not included in the managed care rates. The base FFS data is net
      of
      recipient spend down. Therefore, no additional adjustment was
      needed.

     

    Graduate
      Medical Education (GME)

    The
      State
      does not make supplemental GME payments for services delivered to individuals
      covered under the managed care program. Rather, the MCPs negotiate specific
      rates with the individual teaching hospitals for the daily cost of care.
      Therefore, the GME payments are included in the capitation rates paid to the
      MCPs.

     

    C-3

     

    

    

    MERCER

     

    Government
      Human Services Consulting

     

    Appendix
      D - 2007 Contract Period ABD Rate Development

     

    Credibility
      By Year 

     

    Mercer
      placed more credibility on the most recent year of FFS data.

     

    FFS
      Historical and Prospective Trend

    Historical
      FFS trend assumptions were used to trend SFY 2003 FFS data to the base period
      (SPY 2004). Credibility was then applied to blend together the trended SFY
      2003
      and the SFY 2004 FFS data. Next, prospective FFS trends were applied to the
      base
      period FFS data to trend it to the 2007 contract period.

     

    Prospective
      Policy Changes

    The
      following items are considered prospective policy changes. These changes were
      not reflected in the base data, but were implemented prior to or within the
      contract period. Therefore, Mercer made the rate-setting adjustments for each
      item in the following table.

     

    Adjustments
      Affecting Unit Cost

     

    
      	
              Policy
                Change

            	
              Effective
                Date

            	
              Category
                of
                 Service Affected

            
	
               

              Implementation
                of $2 copay for trade-name preferred drugs for adults
                (^21)

            	
               

              1/1/2006

            	
               

              Pharmacy

            
	
               

              Implementation
                of $3 copay for each dental date of service for adults
                (>21)

            	
               

              1/1/2006

            	
               

              Dental

            
	
               

              Implementation
                of $2 copay for vision exams and $1 copay for dispensing services
                for
                adults (^21)

            	
               

              1/1/2006

            	
               

              Other

            
	
               

              IP
                Recalibration

            	
               

              1/1/2006

            	
               

              Inpatient

            
	
               

              IP
                Rate Freeze

            	
               

              1/1/2006

            	
               

              Inpatient

            

    

     

    D-l

     

    

    

    MERCER

     

    Government
      Human Services Consulting

     

    Adjustments
      Affecting Utilization

     

    
      	
              Policy
                Change

            	
              Effective
                Date

            	
              Category
                of
                Service Affected

            
	
               

              Reduction
                in coverage of dental services for adults (S21)

            	
               

              1/1/2006

            	
               

              Dental

            
	
               

              Reduction
                in coverage of enteral products

            	
               

              1/1/2006

            	
               

              DME/
                Supplies

            

    

     

    Voluntary
      Selection

    The
      FFS
      data reflects the risk of the entire ABD Medicaid program. To solely reflect
      the
      risk of the managed care program, Mercer modified the FFS data based on the
      projected managed care penetration levels for the 2007 contract period. This
      voluntary selection adjustment modifies the FFS data to reflect the risk to
      the
      MCPs (i.e., only those individuals who enroll in a health plan).

     

    Administration/Contingencies

    For
      existing managed care plans in Ohio. the MCP administration/contingencies
      allowance will be 12% of premium prior to the franchise fee. After the initial
      two twelve month contract periods for new and existing plans, 1% of the
      pre-franchise fee capitation rate will be put at risk, contingent upon MCPs
      meeting performance requirements. The administration schedule will be as follows
      for managed care plans currently existing in Ohio:

     

    
      	 	
              Admin

            	
              At-Risk

            
	
               

              Plan
                Year 1 (months 1-12)

            	
               

              12%

            	
               

              0%

            
	
               

              Plan
                Year 2 (months 13-24)

            	
               

              12%

            	
               

              0%

            
	
               

              Plan
                Year 3 (months 25-36)

            	
               

              12%

            	
               

              1%

            

    

     

    D-2

     

    

    

    MERCER

     

    Government
      Human Services Consulting

     

    For
      managed care plans new to Ohio, the administration schedule will be as
      follows:

     

    
      	 	
              Admin

            	
              At-Risk

            
	
               

              Plan
                Year 1 (months 1-12)

            	
               

              13%

            	
               

              0%

            
	
               

              Plan
                Year 2 (months 13-24)

            	
               

              12%

            	
               

              0%

            
	
               

              Plan
                Year 3 (months 25-36)

            	
               

              12%

            	
               

              1%

            

    

     

    For
      plans
      entering Ohio through the acquisition of another Ohio health plan's membership,
      the administration schedule will continue as outlined in the chart on the
      previous page, based on the plan year of the acquired health plan membership.
      The administration schedule will not revert back to the Plan Year 1 schedule
      due
      to the membership acquisition.

     

    In
      addition, the total capitation rate was adjusted to incorporate the 4.5% MCP
      franchise fee requirement.

     

    D-3

    

    

    

    

    MERCER

    Government
      Human Services Consulting 

     

    Appendix
      E - 2007 Contract Period ABD Regional Rate Summary

    

    

    State
      of
      Ohio 

    Final
      & Confidential

    

    Appendix
      E 2007 Contact Period ABD Regional Rate Summary

    

    

    

    
      	
               

              Region

            	
               

              Contract
                Begin Date

            	
               

              Contract
                End Date

            	
               

              Final
                Base Rate

            
	
               

              Northeast

            	
               

              January
                1,2007

            	
               

              December
                31, 2007

            	
               

              $1,088.93

            

    

     

    

     

    Note:
      As
      the contract periods for the remaining regions are finalized, this exhibit
      will
      be updated to include the corresponding rates.

    

     

    

    E-1

    

    

    MERCER

     Government
      Human Services Consulting 

     

    

    

    Appendix
      F

    

    PREMIUM
      RATES WITHOUT THE AT-RISK PAYMENT AMOUNTS

    FOR
      01/01/07 THROUGH

    

    06/30/07
      MCP's premiums will be at-risk starting the 25th month of the ABD Medicaid
      Managed Care Program participation. 

    

    MCP:
      WellCare of Ohio, Inc.

    

    

    
      	
              Service
                Enrollment Area

            	
              Base
                Rates

            	
              At-Risk
                Amounts

            
	
               

              Northeast
                Region

            	
               

              $1,101.45

            	
               

              $0.00

            

    

     

    List
      of Eligible Assistance Groups (AGs)

    Aged,
      Blind or Disabled: 

    

    MA-A
      Aged

    MA-B
      Blind 

    MA-D
      Disabled

     

    Note:
      An
      MCP's regional membership for this program must not exceed their Primary Care
      Physician capacity for that region as verified by the BMHC provider
      database.

     

    

    

    Appendix
      G 

    Page
      2

     

    APPENDIX
      G

    COVERAGE
      AND SERVICES ABD ELIGIBLE POPULATION

     

    1.
      Basic
      Benefit Package

     

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

     

    •
      Inpatient hospital services

     

    •
      Outpatient hospital services

     

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

     

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

     

    •
      Laboratory and x-ray services

     

    •
Family
      planning services and supplies

     

    •
Home
      health services

     

    •
      Podiatry

     

    •
      Physical therapy, occupational therapy, and speech therapy

     

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

     

    •
      Prescription drugs

     

    •
      Ambulance and ambulette services

     

    •
Dental
      services

     

    •
Durable
      medical equipment and medical supplies

     

    •
Vision
      care services, including eyeglasses

     

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

     

    

    Appendix
      G 

    Page
      2

     

    •
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 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(D) and 5101:3-26-12, MCPs are permitted
      to
      impose the applicable member co-payment amount(s) for dental services, vision
      services, non-emergency emergency department services, or prescription drugs,
      other than generic drugs. MCPs must notify ODJFS if they intend to impose a
      co-payment. ODJFS must approve the notice to be sent to the MCP's members and
      the timing of when the co-payments will begin to be imposed. If ODJFS determines
      that an MCP's decision to impose a particular co-payment on their members would
      constitute a significant change for those members, ODJFS may require the
      effective date of the co-payment to coincide with the "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 have a process to coordinate benefits of and referrals to the publicly
      funded community behavioral health system. MCPs must ensure that members have
      access to all medically-necessary behavioral health services covered by the
      Ohio
      Medicaid FFS program and are responsible for coordinating those services with
      other medical and support services. MCPs must notify members via the member
      handbook and provider directory of where and how to access behavioral health
      services, including the ability to self-refer to mental health services offered
      through 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/psychiatrist services, outpatient clinic services, general hospital
      outpatient psychiatric services, pre-hospitalization screening, diagnostic
      assessment (clinical evaluation), crisis intervention, psychiatric
      hospitalization in general hospitals (for all ages), and Medicaid-covered
      prescription drugs and laboratory services. MCPs are not required to cover
      partial hospitalization, or inpatient psychiatric care in a 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/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 cover the
      same drugs covered by 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.

     

    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 this 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 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.

    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. As outlined in paragraph 29(i)
      of
      Appendix C, MCPs must adhere to specific prior-authorization limitations to
      assist with the transition of new ABD members from FFS Medicaid.

    

    MCPs
      must
      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, with 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

    

    

    Appendix
      G

    Page
      8

    

    PCP's
      lack of accessibility or failure to make appropriate specialist referrals.
      The
      MCP's EDD program must therefore also include the identification of providers
      who serve as PCPs for a substantial number of frequent ED utilizers and the
      implementation of corrective action with these providers as so
      indicated.

     

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

     

    4.
      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.

    

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

    b.
      The
      MCP's case management system must include, at a minimum, the following
      components:

     

    i.
      Identification -

    The
      MCP
      must have mechanisms in place to identify members potentially eligible for
      case
      management services. These mechanisms must include an administrative data review
      (e.g. diagnosis, cost threshold, and/or service utilization) and may also
      include telephone interviews; provider/self-referrals; or home
      visits.

     

    ii.
      Assessment-

    The
      MCP
      must arrange for or conduct a comprehensive assessment of the member's physical
      and/or behavioral health condition(s) to confirm the results of a positive
      identification, and to determine the need for case management services. The
      goals of the assessment are to identify the member's existing and/or potential
      health care needs and assess the member's need for case management
      services.

    The
      assessment must be completed by a physician, physician assistant, RN, LPN,
      licensed social worker, or a graduate of a two or four year allied health
      program. If the assessment is completed by another medical professional, there
      should be oversight and monitoring by either a registered nurse or a
      physician.

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

     

    iii.
      Case
      Management-

    Risk
      Stratification/Levels of Care

    The
      MCP
      must develop a strategy to assign members to risk stratification
      levels,

     

    based
      on
      the member's comprehensive needs assessment. Once the member's

    

    Appendix
      G 

    Page
      9

     

    risk
      level has been determined, the MCP must, at a minimum:

    -develop
      a care treatment plan (as described below);

    -implement
      member-level interventions;

    -continuously
      monitor the progress of the member;

    -identify
      gaps between care recommended and actual care provided,
      and propose
      and implement interventions to address the gaps; and

    -implement
      a system to monitor the delivery of specific services, including a review of
      service utilization, to re-evaluate the member's risk level and adjust the
      level
      of case management services accordingly.

     

    Care
      Treatment Plan

    The
      MCP
      must assure and coordinate the placement of the member into case-management-
      including identification of the member's need for services, completion of the
      comprehensive health needs assessment, and development of a care treatment
      plan
      - within ninety (90) days of membership. The care treatment plan is defined
      by
      ODJFS as the one developed by the MCP for the member.

    

    The
      development of the care treatment plan must be based on the comprehensive health
      assessment and reflect the member's primary medical diagnosis and health
      conditions, any comorbidities. and the member's psychological, behavioral health
      and community support needs. The care treatment plan must also include specific
      provisions for periodic reviews of the member's condition and appropriate
      updates to the plan. The member and the member's PCP must be actively involved
      in the development of and revisions to the care treatment plan. The designated
      PCP is the physician, or specialist, who will manage and coordinate the overall
      care for the member. Ongoing communication regarding the status of the care
      treatment plan may be accomplished between the MCP and the PCP's designee (i.e.,
      qualified health professional). Revisions to the clinical portion of the care
      treatment plan should be completed in consultation with the PCP.

     

    Coordination
      of Care and Communication

    The
      MCP
      must arrange or provide for professional case management services that are
      performed collaboratively by a team of professionals appropriate for the
      member's condition and health care needs. At a minimum, the MCP's case manager
      must attempt to coordinate with the member's case manager from other health
      systems, including behavioral health. The MCP must have a process to facilitate,
      maintain, and coordinate both care and communication with the member, PCP,
      and
      other service providers and case managers. The MCP must also have a process
      to
      coordinate care for a member that is receiving services from state sub-recipient
      agencies as appropriate [e.g., the Ohio Department of Mental Health (ODMH);
      the
      Ohio Department of Mental Retardation and Developmental Disabilities (ODMR/DD);
      and the Ohio Department of Alcohol and Drug Addiction Services (ODADAS)]. There
      should be an accountable point of contact at the MCP for each member in case
      management who can help obtain medically necessary care, assist with
      health-related services and coordinate care needs, including behavioral health.
      The MCP must have a provision to disseminate information to the member/caregiver
      concerning the health condition, types
      of
      services that may be available, and how to access services.

    

    

    Appendix
      G 

    Page
      10

     

     

    iv.
      ODJFS
      Targeted Case Management Conditions

     

    The
      MCP
      must,
      at a
      minimum, case manage members with the following physical and behavioral health
      conditions:

     

    •
      Congestive Heart Failure

     

    •
      Coronary Artery Disease

     

    •
      Non-Mild Hypertension

     

    •
      Diabetes

     

    •
Chronic
      Obstructive Pulmonary Disease

     

    •
      Asthma

     

    •
Severe
      mental illness

     

    •
High
      risk or high cost substance abuse disorders

     

    •
Severe
      cognitive and/or developmental limitation

    

    The
      MCP
      should also focus on all members whose health conditions warrant case management
      services and should not limit these services only to members with these
      conditions (e.g., cystic fibrosis, cerebral palsy and sickle cell
      anemia).

    

    Refer
      to
Appendix
      M for
      the
      performance measures and standards related to case management.

     

    v.
      Case
      Management Program Staffing

    The
      MCP
      must identify the staff that will be involved in the operations of the case
      management program, including but not limited to: case manager supervisors,
      case
      managers, and administrative support staff. The MCP must identify the role
      and
      functions of each case management staff member as well as the educational
      requirements, clinical licensure standards, certification and relevant
      experience with case management standards and/or activities. The MCP must
      provide case manager staff/member ratios based on the member risk stratification
      and different levels of care being provided to members.

     

    vi.
      Case
      Management Strategies

    The
      MCP
      must follow best-practice and/or evidence based clinical guidelines when
      devising a member's care treatment plan and coordinating the case management
      needs. If an MCP uses a disease management methodology to identify and/or
      stratify members in need of case management services, the methods must be
      validated by scientific research and/or nationally accepted in the health care
      industry.

    The
      MCP
      must develop and implement mechanisms to educate and equip physicians and case
      managers with evidence-based clinical guidelines or best practice approaches
      to
      assist in providing a high level of quality of care to members.

     

    vii.
      Information Technology System for Case Management

    The
      MCP's
      information technology system for its case management program

    

    

    Appendix
      G

    Page
      11

    must
      maximize the opportunity for communication between the plan, PCP, the member,
      and other service providers and case managers. The MCP must have an integrated
      database that allows MCP staff that may be contacted by a member in case
      management to have immediate access to, and review of, the most recent
      information with the MCP's information systems relevant to the case. The
      integrated database may include the following: administrative data, call center
      communications, service authorizations, care treatment plans, patient
      assessments, case management notes, and PCP notes. The information technology
      system must also have the capability to share relevant information with the
      member, the PCP, and other service providers and case managers.

     

    viii.
      Data Submission

    The
      MCP
      must submit a monthly electronic report to the Case Management System (CAMS)
      for
      all members that are case managed. In order for a member to be submitted as
      case
      managed in CAMS, the MCP must document the member's written or verbal
      confirmation of his/her case management status in the case management record.
      ODJFS, or its designated entity, the external quality review vendor, will
      validate the status of cases (e.g., closed, open, and/or active) in CAMS on
      an
      annual basis with the information contained in the member's case management
      record. The CAMS files are due the 10th
      business
      day of each month.

    

    c.   
      All MCPs must have an ODJFS-approved case management system which includes
      the
      items in Section 4(a) and (b) of Appendix G. 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. Refer to Appendix
      K for the
      requirements regarding the annual review of the case management
      program.

     

    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

     

    

    

    Appendix
      G Page 12

     

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

    

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

    •
The
      MCP's prior authorization and referral procedures or the MCP's
      website;

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

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

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

    •
A
      listing of the MCP's laboratories and radiology providers; and

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

    

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

     

    e.
      Care
      coordination with Non-Contracting Providers

    Per
      OAC
      rule 5101:3-26-05(A)(9), MCPs authorizing the delivery of services from a
      provider who does not have an executed subcontract must ensure that they have
      a
      mutually agreed upon compensation amount for the authorized service and notify
      the provider of the applicable provisions of paragraph D of OAC rule
      5101:3-26-05. This notice is provided when an MCP authorizes a non-contracting
      provider to furnish services on a one-time or infrequent basis to an MCP member
      and must include required ODJFS-model language and information. This notice
      must
      also be included with the transition of services form sent to providers as
      outlined in paragraph 28.i.e. of Appendix C.

    

    

    APPENDIX
      H

    PROVIDER
      PANEL SPECIFICATIONS ABD ELIGIBLE POPULATION

     

    1.
      GENERAL
      PROVISIONS

    

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

    

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

     

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

     

    2.
      PROVIDER SUBCONTRACTING

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

    

    

    Appendix
      H 

    Page
      2

    

    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 centralized database
      system that maintains information on the status of all MCP-submitted
      providers.

    

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

    

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

     

    3.
      PROVIDER
      PANEL REQUIREMENTS

     

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

     

    a.
      Primary
      Care Physicians fPCPs)

    Primary
      Care Physicians (PCPs) may be individuals or group practices/clinics [Primary
      Care Clinics (PCCs)]. Acceptable specialty types for PCPs are family/general
      practice, and internal medicine. Acceptable PCCs include FQHCs, RHCs and the
      acceptable group practices/clinics specified by ODJFS. As part of their
      subcontract with an MCP, PCPs must stipulate the total Medicaid member capacity
      that they can ensure for that individual MCP. Each PCP must have the capacity
      and agree to serve at least 50 Medicaid members at each practice site in order
      to be approved by ODJFS as a PCP, 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.

    

    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 may allow up to an additional 750 member capacity for each
      nurse practitioner or physician's assistant that is used to provide clinical
      support for a PCP.

    

    

    Appendix
      H 

    Page
      3

    

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

    

    ODJFS
      expects that MCPs will need to utilize specialty physicians to serve as PCPs
      for
      some special needs members. In these situations it will not be necessary for
      the
      MCP to submit these specialists to the PVS database as PCPs, however, they
      must
      be submitted to PVS as the appropriate required provider type. Also, in some
      situations (e.g., continuity of care) a PCP may only want to serve a very small
      number of members for an MCP. In these situations it will not be necessary
      for
      the MCP to submit these PCPs to ODJFS for prior approval. These PCPs will not
      be
      included in the ODJFS PVS database 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
      PCP
      requirement is based on an MCP having sufficient PCP capacity to serve 55%
      of
      the eligibles in the region. Each MCP must meet the PCP minimum FTE requirement
      for that region. MCPs must also satisfy a PCP geographic accessibility standard.
      ODJFS will match the PCP practice sites and the stated PCP capacity with the
      geographic location of the eligible population in that region (on a
      county-specific basis) and perform analysis using Geographic Information Systems
      (GIS) software. The analysis will be used to determine if at least 40% of the
      eligible population is located within 10 miles of a PCP with available capacity
      in urban counties and 40% of the eligible population within 30 miles of a PCP
      with available capacity in rural counties. [Rural areas are defined pursuant
      to
      42 CFR 412.62(f)(l)(iii).]

     

    b.
      Non-PCP
      Provider Network

     

    In
      addition to the PCP capacity requirements, each MCP is also required to maintain
      adequate capacity in the remainder of its provider network within the following
      categories: hospitals, cardiovascular, dentists, gastroenterology, nephrology,
      neurology, oncology, physical medicine, podiatry, psychiatry, urology, vision
      care providers, obstetricians/gynecologists (OB/GYNs), allergists, general
      surgeons, otolaryngologists, orthopedists, federally qualified health centers
      (FQHCs)/rural health centers (RHCs) and qualified family planning providers
      (QFPPs). CNMs, CNPs, FQHCs/RHCs and QFPPs are federally-required provider
      types.

     

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

     

    

    

    Appendix
      H 

    Page
      4

    

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

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

    

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

    

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

    

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

     

    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. 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

     

    

    

    Appendix
      H

    Page
      5

     

    

     

    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 will be expected
      to
      contract with an adequate number of ophthalmologists as part of their overall
      provider panel, but only ophthalmologists who regularly perform routine eye
      exams can be used to meet the vision care provider panel requirement.) If
      optical dispensing is not sufficiently available in a region through the MCP's
      contracting ophthalmologists/optometrists, the MCP must separately contract
      with
      an adequate number of optical dispensers located in the region.

     

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

    

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

    

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

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

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

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

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

     

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

     

    

    

    Appendix
      H

    Page
      6

    

    must
      reimburse all medically-necessary Medicaid-covered family planning services
      provided to

     

    eligible
      members by a QFPP provider (including on-site pharmacy and diagnostic services)
      on a

     

    patient
      self-referral basis, regardless of the provider's status as a panel or non-panel
      provider. MCPs will be required to work with QFPPs in the region to develop
      mutually-agreeable HIPAA compliant policies and procedures to preserve
      patient/provider confidentiality, and convey pertinent information to the
      member's PCP and/or MCP.

    

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

    

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

     

    4.
      PROVIDER
      PANEL EXCEPTIONS

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

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

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

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

    

    

    Appendix
      H

    Page
      7

     

    

     

    If
      an MCP
      is unable to contract with or maintain a sufficient number of providers to
      meet
      the

    ODJFS-specified
      provider panel criteria, the MCP may request an exception to these criteria
      by

    submitting
      a provider panel exception request as specified by ODJFS. ODJFS will review
      the
      exception request and determine whether the MCP has sufficiently demonstrated
      that all reasonable efforts were made to obtain contracts with providers of
      the
      type in question and that they will be able to provide access to the services
      in
      question.

    

    ODJFS
      will aggressively monitor access to all services related to the approval of
      a
      provider panel exception request through a variety of data sources, including:
      consumer satisfaction surveys; member appeals/grievances/complaints and state
      hearing notifications/requests; member just-cause for termination requests;
      clinical quality studies;

    encounter
      data volume; provider complaints, and clinical performance measures. ODJFS
      approval of a provider panel exception request does not exempt the MCP from
      assuring access to the services in question. If ODJFS determines that an MCP
      has
      not provided sufficient access to these services, the MCP may be subject to
      sanctions.

     

    5.
      PROVIDER
      DIRECTORIES

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

    

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

     

    The
      directory must also specify:

     

    •
      provider address(es) and phone number(s);

    •
an
      explanation of how to access providers (e.g. referral required vs.
      self-referral);

    •
an
      indication of which providers are available to members on a self-referral
      basis

    •
      foreign-language speaking PCPs and specialists and the specific foreign
      language(s) spoken;

    •
how
      members may obtain directory information in alternate formats that takes into
      consideration the special needs of eligible individuals including but not
      limited to, visually-limited, LEP, and LRP eligible individuals;
      and

    •
any
      PCP
      or specialist practice limitations.

     

    Printed
      Provider Directory

    Prior
      to
      receiving a provider agreement, all MCPs must develop a printed provider
      directory that shall be prior-approved by ODJFS for each population. For
      example, an MCP who serves CFC and ABD in the Central Region would have two
      provider directories, one for CFC and one for ABD. Once approved, this directory
      may be regularly updated with provider additions or

    

    

    Appendix
      H

    Page
      8

    

    deletions
      by the MCP without ODJFS prior-approval, however, copies of the revised
      directory

     

    (or
      inserts) must be submitted to ODJFS prior to distribution to
      members.

    

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

     

    Internet
      Provider Directory

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

    

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

     

    6.
      FEDERAL
      ACCESS STANDARDS

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

     

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

     

    •
The
      anticipated Medicaid membership.

    •
The
      expected utilization of services, taking into consideration the characteristics
      and health care needs of specific Medicaid populations represented in the
      MCP.

    •
The
      number and types (in terms of training, experience, and specialization) of
      panel
      providers required to deliver the contracted Medicaid services.

    •
The
      geographic location of panel providers and Medicaid members, considering
      distance, travel time, the means of transportation ordinarily used by Medicaid
      members, and whether the location provides physical access for Medicaid members
      with disabilities.

    •
MCPs
      must adequately and timely cover services to an out-of-network provider if
      the
      MCP's contracted provider panel is unable to provide the services covered under
      the MCP's provider agreement. The MCP must cover the out-of-network services
      for
      as long as the MCP network is unable to provide the services. MCPs must
      coordinate with the out-of-network provider with respect to payment and ensure
      that the provider agrees with the applicable requirements.

    

    Appendix
      H 

    Page
      9

    

     

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

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

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

     

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

     

    

    

    

    

    

    North
      East Central Region - Hospitals

    

    

    
      	
              Minimum
                Provider Panel Requirements

            
	 	
              Total
                Required Hospitals

            	
              Ashtabula

            	
              Cuyahoga

            	
              Erie

            	
              Geauga

            	
              Huron

            	
              Lake

            	
              Lorain

            	
              Medina

            	
              Additional
                Required Hospital In-Region

            
	
              General 
                Hospital

            	 	
              1

            	 	 	
              1

            	
              1

            	
              1

            	
              1

            	
              1

            	 
	
              Hospital
                System 1

            	 	 	
              1

            	 	 	 	 	 	 	
              1

            

    

    

    

    1.
      Hospital system includes; physician networks and therefore these physicians
      could be considered when fulfilling contracts for PCP and non-PCP provider
      panel
      requirements

    

    East
      Central Region - Hospitals

     

    
      	
              Minimum
                Provider Panel Requirements

            
	 	
              Total
                Required Hospitals

            	
              Columbiana

            	
              Mahoning

            	
              Trumbull

            	
              Additional
                Required Hospital In-Region

            
	
              General
                Hospital

            	
              3

            	
              1

            	
              1

            	
              1

            	 
	
              Hospital
                System 

            	 	 	 	 	 

    

     

    

     

    East
      Central Region - Hospitals

     

    

    
      	
              Minimum
                Provider Panel Requirements

            
	 	
              Total
                Required Hospitals

            	
              Ashland

            	
              Carroll

            	
              Holmes

            	
              Portage

            	
              Richland

            	
              Stark

            	
              Summit

            	
              Tuscarawas

            	
              Wayne

            	
              Additional
                Required Hospital In-Region

            
	
              General
                Hospital

            	
              7

            	 	 	 	
              1

            	
              1

            	
              1

            	 	
              1

            	
              1

            	
              2

            
	
              Hospital
                System 1

            	
              1

            	 	 	 	 	 	 	
              1

            	 	 	 

    

     

    1
      Hospital
      system includes; physician networks and therefore these physicians could be
      considered when fulfilling contracts for PCP and non-PCP provider panel
      requirements.

     

     

    South
      East Region - Hospitals

     

    
      	
              Minimum
                Provider Panel Requirements

            
	 	
              Total
                Required Hospitals

            	
              Athens

            	
              Belmont

            	
              Coshocton

            	
              Gallia

            	
              Guernsey

            	
              Harrison

            	
              Jackson

            	
              Jefferson

            	
              Lawrence

            	
              Meigs

            	
              Monroe

            	
              Morgon

            	
              Muskingum

            	
              Noble

            	
              Vintron

            	
              Washington

            	
              Additional
                Required Hospital: In-Region

            
	
              General
                Hospital

            	
              8

            	
              1

            	
              1

            	
              1

            	
              1

            	
              1

            	
               

            	
               

            	
              1

            	
               

            	
               

            	
               

            	
               

            	
              1

            	
               

            	
               

            	
              1

            	 
	
              Hospital
                System

            	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 

    

    

     

    Central
      Region - Hospitals

     

     

    
      	
               Minimum
                Provider Panel
                Requirements

            
	 	
              Total
                Required Hospitals

            	
              Crawford

            	
              Delaware

            	
              Fairfield

            	
              Fayette

            	
              Franklin

            	
              Hocking

            	
              Knox

            	
              Licking

            	
              Logan

            	
              Madison

            	
              Marion

            	
              Morrow

            	
              Perry

            	
              Pickaway

            	
              Pike

            	
              Ross

            	
              Scioto

            	
              Union

            	
              Additional
                Required Hospital: In-Region

            
	
              General
                Hospital

            	
              10

            	 	 	
              1

            	
               

              1

            	 	 	 	
               

              1

            	 	 	
               

              1

            	 	 	
              1

            	 	
              1

            	
              1

            	 	
               

              3

            
	
              Hospital
                System

            	
               

              2

            	 	 	 	 	
               

              2

            	 	 	 	 	 	 	 	 	 	 	 	 	 	 

    

     

    1
      Hospital
      system includes; physician networks and therefore these physicians could be
      considered when fulfilling contracts for PCP and non-PCP provider panel
      requirements.

     

    

    

    South
      West Region - Hospitals

    

    
      	
              Minimum
                Provider Panel Requirements

            
	 	
              Total
                Required Hospitals

            	
              Adams

            	
              Brown

            	
              Butler

            	
              Clemont

            	
              Clinton

            	
              Hamilton

            	
              Highland

            	
              Warren

            	
              Additional
                Required Hospital In-Region

            
	
              General
                Hospital

            	
              7

            	
               

            	
              1

            	
              1

            	
               

            	
              1

            	
              1

            	
              1

            	
               

            	
              1

            
	
              Hospital
                System 1

            	
              1

            	
               

            	
               

            	
               

            	
               

            	
               

            	
              2

            	
               

            	 	 

    

     

    

    1
      Hospital
      system includes; physician networks and therefore these physicians could be
      considered when fulfilling contracts for PCP and non-PCP provider panel
      requirements.

     

    

    

    West
      Central Region - Hospitals

    

    

      
        	
                
                  Minimum
                    Provider Panel Requirements

                

              
	 	
                Total
                  Required Hospitals

              	
                Champaign

              	
                Clark

              	
                Darke

              	
                Greene

              	
                Miami

              	
                Montgomery

              	
                Preble

              	
                Shelby

              	
                Additional
                  Required Hospital In-Region

              
	
                General
                  Hospital

              	
                 

              	
                 

              	
                1

              	
                 

              	
                1

              	
                 

              	
                 

              	
                 

              	
                 

              	
                2

              
	
                Hospital
                  System 2

              	 	 	 	 	 	 	
                1

              	 	 	 

      

    

    

    

    1
      Hospital
      system includes; physician networks and therefore these physicians could be
      considered when fulfilling contracts for PCP and non-PCP provider panel
      requirements.

     

    

    

    North
      West Region - Hospitals

     

    
      	
               Minimum
                Provider Panel Requirements

            
	 	
              Total
                required Hospitals

            	
              Allen

            	
              Auglaize

            	
              Defiance

            	
              Fulton

            	
              Hancock

            	
              Hardin

            	
              Henry

            	
              Lucas

            	
              Mercer

            	
              Ottawa

            	
              Paulding

            	
              Putnam

            	
              Sandusky

            	
              Seneca

            	
              Van
                Wert

            	
              Williams

            	
              Wood

            	
              Wyandot

            	
              Additional
                Required Hospital: In-Region

            
	
              General
                Hospital

            	 	
              1

            	 	
              1

            	 	
               

              1

            	 	 	 	 	 	 	 	
              1

            	 	 	 	 	 	
               

              3

            
	
              Hospital
                System1

            	 	 	 	 	 	 	 	 	
               

              1

            	 	 	 	 	 	 	 	 	 	 	 

    

    

    1
      Hospital
      system includes; physician networks and therefore these physicians could be
      considered when fulfilling contracts for PCP and non-PCP provider panel
      requirements.

     

    

    

    North
      East Region - PCP Capacity

     

    
      	
              Minimum
                PCP Capacity Requirements - ABD

            
	
              PCPs

            	
              Total
                Required

            	
              Ashtabula

            	
              Cuyahoga

            	
              Erie

            	
              Geauga

            	
              Huron

            	
              Lake

            	
              Lorain

            	
              Medina

            	
              Additional
                Required: In-Region *

            
	
              Capacity

            	
              14,196

            	
              799

            	
              10,587

            	
              283

            	
              117

            	
              228

            	
              541

            	
              1,372

            	
              269

            	
               

            
	
              PCPs1

            	
              31

            	
              4

            	
              16

            	
              2

            	
              1

            	
              1

            	
              2

            	
              4

            	
              1

            	
               

            
	
              Number
                of Eligibles

            	
              25,810

               

            	
              1453

            	
              19249

            	
              514

            	
              212

            	
              415

            	
              983

            	
              2495

            	
              489

            	 

    

     

    

     

    1
      Acceptable
      PCP specialty types include Family/General Practice or Internal
      Medicine

    

    

    North
      East Central Region - PCP Capacity

    

    
      	
              Minimum
                PCP Capacity Requirements - ABD

            
	
              PCPs

            	
              Total
                Required

            	
              Columbiana

            	
              Mahoning

            	
              Trumbull

            	
              Additional
                Required: In-Region
                *

            
	
              Capacity

            	
              4,230

            	
              798

            	
              2,028

            	
              1,405

            	 
	
              PCPs1

            	
              11

            	
              3

            	
              4

            	
              4

            	 
	
              Number
                of Eligibles

            	
              7,691.00

            	
              1,450

            	
              3,687

            	
              2,554

            	 

    

     

    1
      Acceptable PCP specialty types include Family/General Practice or Internal
      Medicine

     

    

    

    East
      Central Region - PCP Capacity

    

    
      	
              Minimum
                PCP Capacit y Requirements - ABD

            
	
              PCPs

            	
              Total
                Required

            	
              Ashland

            	
              Carroll

            	
              Holmes

            	
              Portage

            	
              Richland

            	
              Stark

            	
              Summit

            	
              Tuscarawas

            	
              Wayne

            	
              Additional
                Required: In-Region *

            
	
              Capacity

            	
              7,415

            	
              152

            	
              134

            	
              83

            	
              479

            	
              710

            	
              1,870

            	
              3,051

            	
              458

            	
              480

            	
               

            
	
              PCPs1

            	
              21

            	
              1

            	
              1

            	
              1

            	
              2

            	
              3

            	
              4

            	
              5

            	
              2

            	
              2

            	
               

            
	
              Number
                of Eligbles

            	
              13,482

            	
              276

            	
              243

            	
              150

            	
              871

            	
              1,290

               

            	
              3,400

               

            	
              5,547

               

            	
              833

               

            	
              872

               

            	 

    

     

    1
      Acceptable
      PCP specialty types include Family/General Practice or Internal
      Medicine

     

    

    

    South
      East Region - PCP Capacity

     

    
      	
              County

               

            	
              Capacity

            	
              PCPs
                1

            	
              Number
                of Eligibles

            
	
              Total
                Required

               

            	
              7,434

            	
              30

            	
              13,516

            
	
              Athens

               

            	
              724

            	
              2

            	
              1,317

            
	
              Belmont

               

            	
              654

            	
              2

            	
              1,189

            
	
              Coshocton

               

            	
              234

            	
              1

            	
              426

            
	
              Gallia

               

            	
              457

            	
              2

            	
              830

            
	
              Guernsey

            	
               

              395

            	
               

              2

            	
               

              718

            
	
              Harrison

            	
               

              172

            	
               

              1

            	
               

              313

            
	
              Jackson

            	
               

              483

            	
               

              2

            	
               

              879

            
	
              Jefferson

            	
               

              795

            	
               

              3

            	
               

              1,445

            
	
              Lawrence

            	
               

              1,154

            	
               

              4

            	
               

              2,098

            
	
              Meigs

            	
               

              393

            	
               

              2

            	
               

              714

            
	
              Monroe

            	
               

              134

            	
               

              1

            	
               

              244

            
	
              Morgon

            	
               

              175

            	
               

              1

            	
               

              319

            
	
              Muskingum

            	
               

              889

            	
               

              3

            	
               

              1,617

            
	
              Noble

            	
               

              86

            	
               

              1

            	
               

              157

            
	
              Vinton

            	
               

              197

            	
               

              1

            	
               

              359

            
	
              Washington

            	
               

              490

            	
               

              2

            	
               

              891

            
	
              Additional
                Required: In-Region *

            	
               

            	 	 
	
               

              1
                Acceptable
                PCP specialty types include Family/General Practice or Internal
                Medicine

            

    

    

    

    

    Central
      Region - PCP Capacity

     

    
      	
              Minimum
                PCP Capacity Requirements -ABD

            
	
               

              County

            	
               

              Capacity

            	
               

              PCPs1

            	
               

              Number
                of Eligibles

            
	
               

              Total
                Required

            	
               

              13,660

            	
               

              59

            	
               

              24,837

            
	
               

              Crawford

            	
               

              258

            	
               

              2

            	
               

              469

            
	
               

              Delaware

            	
               

              226

            	
               

              2

            	
               

              410

            
	
               

              Fairfield

            	
               

              528

            	
               

              3

            	
               

              960

            
	
               

              Fayette

            	
               

              207

            	
               

              2

            	
               

              377

            
	
               

              Franklin

            	
               

              6,592

            	
               

              17

            	
               

              11,985

            
	
               

              Hocking

            	
               

              237

            	
               

              2

            	
               

              431

            
	
               

              Knox

            	
               

              282

            	
               

              2

            	
               

              512

            
	
               

              Licking

            	
               

              682

            	
               

              4

            	
               

              1,240

            
	
               

              Logan

            	
               

              168

            	
               

              2

            	
               

              305

            
	
               

              Madison

            	
               

              149

            	
               

              1

            	
               

              270

            
	
               

              Marion

            	
               

              496

            	
               

              3

            	
               

              902

            
	
               

              Morrow

            	
               

              133

            	
               

              1

            	
               

              241

            
	
               

              Perry

            	
               

              334

            	
               

              3

            	
               

              608

            
	
               

              Pickaway

            	
               

              306

            	
               

              2

            	
               

              557

            
	
               

              Pike

            	
               

              524

            	
               

              3

            	
               

              952

            
	
               

              Ross

            	
               

              741

            	
               

              4

            	
               

              1,348

            
	
               

              Scioto

            	
               

              1,687

            	
               

              5

            	
               

              3,068

            
	
               

              Union

            	
               

              111

            	
               

              1

            	
               

              202

            
	
               

              Additional
                Required: In-Region

            	 	 	 
	
               

              1
                Acceptable PCP specialty types include Family/General Practice or
                Internal
                Medicine

            

    

    

    

    

    South
      West Region - PCP Capacity

    

    
      	
              Minimum
                PCP Capacity Requirements - ABD

            
	
              PCPs

            	
              Total
                Required

            	
              Adams

            	
              Brown

            	
              Butler

            	
              Clermont

            	
              Clinton

            	
              Hamilton

            	
              Highland

            	
              Warren

            	
              Additional
                Required: In Region *

            
	
               

              Capacity

            	
               

              8,615

            	
               

              502

            	
               

              248

            	
               

              1,581

            	
               

              717

            	
               

              212

            	
               

              4,696

            	
               

              315

            	
               

              344

            	 
	
               

              PCPs1

            	
               

              22

            	
               

              3

            	
               

              1

            	
               

              4

            	
               

              3

            	
               

              1

            	
               

              6

            	
               

              2

            	
               

              2

            	 
	
               

              Number
                of Eligibles

            	
               

              15,663

            	
               

              912

            	
               

              451

            	
               

              2,875

            	
               

              1,303

            	
               

              386

            	
               

              8,539

            	
               

              572

            	
               

              625

            	 

    

     

    1
      Acceptable
      PCP specialty types include Family/General Practice or Internal
      Medicine

     

    

    

    

    West
      Central Region - PCP Capacity

    

    
      	
              Minimum
                PCP Capacity Requirements - ABD

            
	
              PCPs

            	
              Total
                Required

            	
              Champaign

            	
              Clark

            	
              Darke

            	
              Greene

            	
              Miami

            	
              Montgomery

            	
              Preble

            	
              Shelby

            	
              Additional
                Required: In Region *

            
	
               

              Capacity

            	
               

              5,965

            	
               

              138

            	
               

              986

            	
               

              171

            	
               

              498

            	
               

              316

            	
               

              3,537

            	
               

              147

            	
               

              174

            	 
	
               

              PCPs1

            	
               

              17

            	
               

              1

            	
               

              4

            	
               

              1

            	
               

              2

            	
               

              2

            	
               

              6

            	
               

              1

            	
               

              1

            	 
	
               

              Number
                of Eligibles

            	
               

              10,846

            	
               

              250

            	
               

              1,793

            	
               

              311

            	
               

              905

            	
               

              574

            	
               

              6,430

            	
               

              267

            	
               

              316

            	 

    

     

    1
      Acceptable
      PCP specialty types include Family/General Practice or Internal
      Medicine

    

    

    North
      West Region - PCP Capacity

    

    

    
      	
              Minimum
                PCP Capacity Requirements - ABD

            
	
               

              County

            	
               

              Capacity

            	
               

              PCPs1

            	
               

              Number
                of Eligibles

            
	
               

              Total
                Required

            	
               

              6,748

            	
               

              33

            	
               

              12,269

            
	
               

              Alien

            	
               

              591

            	
               

              3

            	
               

              1,075

            
	
               

              Auglaize

            	
               

              105

            	
               

              1

            	
               

              190

            
	
               

              Defiance

            	
               

              150

            	
               

              1

            	
               

              272

            
	
               

              Fulton

            	
               

              93

            	
               

              1

            	
               

              169

            
	
               

              Hancock

            	
               

              212

            	
               

              2

            	
               

              385

            
	
               

              Hardin

            	
               

              182

            	
               

              2

            	
               

              330

            
	
               

              Henry

            	
               

              54

            	
               

              1

            	
               

              99

            
	
               

              Lucas

            	
               

              3,963

            	
               

              9

            	
               

              7,206

            
	
               

              Mercer

            	
               

              102

            	
               

              1

            	
               

              185

            
	
               

              Ottawa

            	
               

              103

            	
               

              1

            	
               

              188

            
	
               

              Paulding

            	
               

              90

            	
               

              1

            	
               

              163

            
	
               

              Putnam

            	
               

              72

            	
               

              1

            	
               

              130

            
	
               

              Sandusky

            	
               

              240

            	
               

              2

            	
               

              436

            
	
               

              Seneca

            	
               

              243

            	
               

              2

            	
               

              442

            
	
               

              Van
                Wert

            	
               

              111

            	
               

              1

            	
               

              202

            
	
               

              Williams

            	
               

              128

            	
               

              1

            	
               

              233

            
	
               

              Wood

            	
               

              253

            	
               

              2

            	
               

              460

            
	
               

              Wyandot

            	
               

              57

            	
               

              1

            	
               

              104

            
	
               

              Additional
                Required:
                In-Region *

            	
               

            	
               

            	
               

            
	
              1
                Acceptable PCP specialty types include family/General Practice or
                Internal
                Medicine

            

    

     

     

    This
      chart was finalized 10/14/05 and supercedes the one distributed 9/20/05. The
      provider panel charts are a summary of the provider panel requirements. For
      the
      complete requirements, see RFA - Regional
      Provider Panel Specifications.

     

     

    North
      East Region - Practitioners

     

    
      	
              ABD
                Provider Panel Requirements

            
	
              Provider
                Types

            	
              Total
                Required Providers1

            	
              Ashtabula

            	
              Cuyahoga

            	
              Erie

            	
              Geauga

            	
              Huron

            	
              Lake

            	
              Lorain

            	
              Medina

            	
              Additional
                Required Providers 2

            
	
               

              Cardiovascular

            	
               

              6

            	
               

            	
               

              3

            	
               

            	
               

            	
               

            	
               

            	
               

              1

            	
               

            	
               

              2

            
	
               

              Dentists

            	
               

              28

            	
               

              1

            	
               

              20

            	
               

            	
               

            	
               

            	
               

              2

            	
               

              3

            	
               

              1

            	
               

              1

            
	
               

              Gastroenterology

            	
               

              3

            	
               

            	
               

              2

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

              1

            
	
               

              General
                Surgeons

            	
               

              11

            	
               

            	
               

              6

            	
               

              1

            	
               

            	
               

              1

            	
               

              1

            	
               

              1

            	
               

              1

            	
               

            
	
               

              Nephrology

            	
               

              2

            	
               

            	
               

              1

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

              1

            
	
               

              Neurology

            	
               

              3

            	
               

            	
               

              2

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

              1

            
	
               

              OB/GYNs

            	
               

              12

            	
               

            	
               

              8

            	
               

              1

            	
               

            	
               

            	
               

            	
               

              1

            	
               

            	
               

              2

            
	
               

              Oncology

            	
               

              1

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

              1

            
	
               

              Orthopedists

            	
               

              7

            	
               

            	
               

              4

            	
               

            	
               

            	
               

            	
               

            	
               

              1

            	
               

            	
               

              2

            
	
               

              Otolaryngologist

            	
               

              3

            	
               

            	
               

              1

            	
               

            	
               

            	
               

            	
               

            	
               

              1

            	
               

            	
               

              1

            
	
               

              Physical
                Med Rehab

            	
               

              3

            	
               

            	
               

              2

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

              1

            
	
               

              Podiatry

            	
               

              8

            	
               

            	
               

              4

            	
               

            	
               

            	
               

            	
               

            	
               

              2

            	
               

            	
               

              2

            
	
               

              Psychiatry

            	
               

              11

            	
               

            	
               

              5

            	
               

            	
               

            	
               

            	
               

            	
               

              3

            	
               

            	
               

              3

            
	
               

              Urology

            	
               

              4

            	
               

            	
               

              2

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

              2

            
	
               

              Vision

            	
               

              14

            	
               

              1

            	
               

              7

            	
               

              1

            	
               

            	
               

            	
               

              1

            	
               

              1

            	
               

            	
               

              3

            

    

     

    1
      All
      required providers must be located within the region. 

    2
      Additional required providers may be located anywhere within the
      region.

     

     

    North
      East Central- Practitioners

     

    
      	
              ABD
                Provider Panel Requirements

            
	
               

              Provider
                Types

            	
               

              Total
                Required Providers1

            	
               

              Columbiana

            	
               

              Mahoning

            	
               

              Trumbull

            	
               

              Additional
                Required Providers 2

            
	
               

              Cardiovascular

            	
               

              2

            	
               

            	
               

              1

            	
               

            	
               

              1

            
	
               

              Dentists

            	
               

              7

            	
               

              1

            	
               

              3

            	
               

              3

            	
               

            
	
               

              Gastroenterology

            	
               

              1

            	
               

            	
               

            	
               

            	
               

              1

            
	
               

              General
                Surgeons

            	
               

              3

            	
               

              1

            	
               

              1

            	
               

              1

            	
               

            
	
               

              Nephrology

            	
               

              1

            	
               

            	
               

            	
               

            	
               

              1

            
	
               

              Neurology

            	
               

              1

            	
               

            	
               

            	
               

            	
               

              1

            
	
               

              OB/GYNs

            	
               

              4

            	
               

              1

            	
               

              1

            	
               

              1

            	
               

              1

            
	
               

              Oncology

            	
               

              1

            	
               

            	
               

            	
               

            	
               

              1

            
	
               

              Orthopedists

            	
               

              2

            	
               

            	
               

              1

            	
               

            	
               

              1

            
	
               

              Otolaryngologist

            	
               

              1

            	
               

            	
               

              1

            	
               

            	
               

            
	
               

              Physical
                Med Rehab

            	
               

              1

            	
               

            	
               

            	
               

            	
               

              1

            
	
               

              Podiatry

            	
               

              1

            	
               

            	
               

            	
               

            	
               

              1

            
	
               

              Psychiatry

            	
               

              6

            	
               

            	
               

              3

            	
               

              2

            	
               

              1

            
	
               

              Urology

            	
               

              1

            	
               

            	
               

            	
               

            	
               

              1

            
	
               

              Vision

            	
               

              5

            	
               

            	
               

              2

            	
               

              2

            	
               

              1

            

    

    

    

    1
      All
      required providers must be located within the region. 

     

    2
      Additional required providers may be located anywhere within the
      region.

     

     

    

    

    East
      Central - Practitioners

     

    
      	
              ABD
                Provider Panel Requirements

            
	
              Provider
                Types

            	
              Total
                Required Providers1

            	
              Ashland

            	
              Carroll

            	
              Holmes

            	
              Portage

            	
              Richland

            	
              Stark

            	
              Summit

            	
              Tuscarawas

            	
              Wayne

            	
              Additional
                Required Providers 2

            
	
               

              Cardiovascular

            	
               

              3

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

              1

            	
               

              1

            	
               

            	
               

            	
               

              1

            
	
               

              Dentists

            	
               

              14

            	
               

              1

            	
               

            	
               

            	
               

            	
               

              2

            	
               

              4

            	
               

              6

            	
               

              1

            	
               

            	
               

            
	
               

              Gastroenterology

            	
               

              2

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

              2

            
	
               

              General
                Surgeons

            	
               

              7

            	
               

            	
               

            	
               

            	
               

            	
               

              1

            	
               

              1

            	
               

              2

            	
               

            	
               

              1

            	
               

              2

            
	
               

              Nephrology

            	
               

              1

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

              1

            
	
               

              Neurology

            	
               

              2

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

              2

            
	
               

              OB/GYNs

            	
               

              6

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

              2

            	
               

              4

            	
               

            	
               

            	
               

            
	
               

              Oncology

            	
               

              1

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

              1

            
	
               

              Orthopedists

            	
               

              4

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

              1

            	
               

              1

            	
               

            	
               

            	
               

              2

            
	
               

              Otolaryngologist

            	
               

              2

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

              1

            	
               

              1

            	
               

            	
               

            	
               

            
	
               

              Physical
                Med Rehab

            	
               

              2

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

              2

            
	
               

              Podiatry

            	
               

              4

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

              1

            	
               

              2

            	
               

            	
               

            	
               

              1

            
	
               

              Psychiatry

            	
               

              6

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

              2

            	
               

              3

            	
               

            	
               

            	
               

              1

            
	
               

              Urology

            	
               

              2

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

              2

            
	
               

              Vision

            	
               

              8

            	
               

            	
               

            	
               

            	
               

            	
               

              1

            	
               

              2

            	
               

              3

            	
               

            	
               

            	
               

              2

            

    

     

    1
      All
      required providers must be located within the region. 

    2
      Additional required providers may be located anywhere within the
      region.

    

    

    

    

    

    
      	
              South
                East - Practitioners

            
	
               

              ABD
                Provider Panel Requirements

            
	
              Provider
                Types

            	
              Total
                Required Providers1

            	
              Athens

            	
              Belmont

            	
              Coshocton

            	
              Gallia

            	
              Guernsey

            	
              Harrison

            	
              Jackson

            	
              Jefferson

            	
              Lawrence

            	
              Meigs

            	
              Monroe

            	
              Morgon

            	
              Muskington

            	
              Noble

            	
              Vinton

            	
              Washington

            	
              Additional
                Required Providers2

            
	
              Cardiovascular

            	
              3

            	
               

            	
               

            	
               

            	
              1

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
              1

            	
               

            	
               

            	
               

            	
              1

            
	
              Dentists

            	
              8

            	
              1

            	
              1

            	
               

            	
               

            	
              1

            	
               

            	
               

            	
               

            	
              1

            	
               

            	
               

            	
               

            	
              1

            	
               

            	
               

            	
              1

            	
              2

            
	
              Gastroenterology

            	
              2

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
              2

            
	
              General
                Surgeons

            	
              5

            	
               

            	
              1

            	
               

            	
              1

            	
              1

            	
               

            	
               

            	
              1

            	
               

            	
               

            	
               

            	
               

            	
              1

            	
               

            	
               

            	
               

            	
               

            
	
              Nephrology

            	
              1

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
              1

            
	
              Neurology

            	
              2

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
              2

            
	
              OB/GYNs

            	
              6

            	
              1

            	
               

            	
               

            	
               

            	
              1

            	
               

            	
               

            	
              1

            	
               

            	
               

            	
               

            	
               

            	
              1

            	
               

            	
               

            	
              1

            	
              1

            
	
              Oncology

            	
              1

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
              1

            
	
              Orthopedists

            	
              4

            	
               

            	
               

            	
               

            	
              1

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
              1

            	
               

            	
               

            	
              1

            	
              1

            
	
              Otolaryngologist

            	
              2

            	
               

            	
               

            	
               

            	
              1

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
              1

            	
               

            	
               

            	
               

            	
               

            
	
              Physical
                Med Rehab

            	
              2

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
              2

            
	
              Podiatry

            	
              4

            	
               

            	
              1

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
              1

            	
               

            	
               

            	
               

            	
              2

            
	
              Psychiatry

            	
              6

            	
              2

            	
              1

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
              1

            	
               

            	
               

            	
               

            	
              2

            
	
              Urology

            	
              2

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
              2

            
	
              Vision

            	
              8

            	
              1

            	
              1

            	
               

            	
              1

            	
              1

            	
               

            	
              1

            	
               

            	
              1

            	
               

            	
               

            	
               

            	
              1

            	
               

            	
               

            	
              1

            	
               

            

    

     

    1
      All
      required providers must be located within the region. 

    2
      Additional required providers may be located anywhere within the
      region.

    

    

    
      	
              Central
                - Practitioners

            
	
               

              ABD
                Provider Panel Requirements

            
	
              Provider
                Types

            	
              Total
                Required Providers1

            	
              Crawford

            	
              Delaware

            	
              Fairfield

            	
              Fayette

            	
              Franklin

            	
              Hocking

            	
              Knox

            	
              Licking

            	
              Logan

            	
              Madison

            	
              Marion

            	
              Morrow

            	
              Perry

            	
              Pickaway

            	
              Pike

            	
              Ross

            	
              Scioto

            	
              Union

            	
               

              Additional
                Required Providers2

            
	
               

              Cardiovascular

            	
               

              5

            	
               

            	
               

            	
               

            	
               

            	
               

              2

            	 	 	 	 	 	 	 	 	 	 	 	 	 	
               

              3

            
	
               

              Dentists

            	
               

              21

            	 	
               

              1

            	
               

              1

            	 	
               

              15

            	 	
               

              1

            	
               

              1

            	 	 	
               

              1

            	 	 	 	 	
               

              1

            	 	 	 
	
               

              Gastroenterology

            	
               

              3

            	 	 	 	 	
               

              1

            	 	 	 	 	 	 	 	 	 	 	 	 	 	
               

              2

            
	
               

              General
                Surgeons

            	
               

              10

            	 	
               

              1

            	
               

              1

            	 	
               

              5

            	 	 	 	 	 	 	 	 	 	 	
               

              1

            	
               

              1

            	 	
               

              1

            
	
               

              Nephrology

            	
               

              2

            	 	 	 	 	
               

              1

            	 	 	 	 	 	 	 	 	 	 	 	 	 	
               

              1

            
	
               

              Neurology

            	
               

              3

            	 	 	 	 	
               

              1

            	 	 	 	 	 	 	 	 	 	 	 	
               

            	 	
               

              2

            
	
               

              OB/GYNs

            	
               

              10

            	 	
               

              1

            	
               

              1

            	 	
               

              6

            	 	 	 	 	 	 	 	 	 	 	 	 	 	
               

              2

            
	
               

              Oncology

            	
               

              1

            	 	 	 	 	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	 	 	
               

              1

            
	
               

              Orthopedists

            	
               

              7

            	 	 	
               

              1

            	 	
               

              3

            	 	 	
               

              1

            	 	 	
               

              1

            	 	 	 	 	
               

              1

            	 	 	 
	
               

              Otolaryngologist

            	
               

              3

            	 	
               

              1

            	 	 	
               

              2

            	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
               

              Physical
                Med Rehab

            	
               

              3

            	 	 	 	 	
               

              1

            	 	 	 	 	 	 	 	 	 	 	 	 	 	
               

              2

            
	
               

              Podiatry

            	
               

              7

            	 	
               

              1

            	 	 	
               

              3

            	 	 	 	 	 	 	 	 	 	 	 	 	 	
               

              3

            
	
               

              Psychiatry

            	
               

              11

            	 	
               

              1

            	
               

              1

            	 	
               

              5

            	 	 	 	 	 	 	 	 	 	 	 	 	 	
               

              4

            
	
               

              Urology

            	
               

              4

            	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
               

              Vision

            	
               

              14

            	
               

              1

            	
               

              1

            	
               

              1

            	 	
               

              5

            	 	
               

              1

            	
               

              1

            	
               

              1

            	 	
               

              1

            	 	 	 	 	
               

              1

            	
               

              1

            	 	 

    

     

    1
      All
      required providers must be located within the region.

    2
      Additional required providers may be located anywhere within the
      region.

    

    

    Last
      Revised May 25, 2006

    
      	
              South
                West - Practitioners

               

            
	
              ABD
                Provider Panel Requirements

            
	
               

              Provider
                Types

            	
               

              Total
                Required Providers1

            	
               

              Adams

            	
               

              Brown

            	
               

              Butler

            	
               

              Clemont

            	
               

              Clinton

            	
               

              Hamilton

            	
               

              Highland

            	
               

              Warren

            	
               

              Additional
                Required Providers 2

            
	
               

              Cardiovascular

            	
               

              4

            	 	 	 	 	 	
               

              1

            	 	
               

              1

            	
               

              2

            
	
               

              Dentists

            	
               

              15

            	 	 	
               

              3

            	
               

              1

            	 	
               

              8

            	
               

              1

            	
               

              1

            	
               

              1

            
	
               

              Gastroenterology

            	
               

              2

            	 	 	 	 	 	 	 	 	
               

              2

            
	
               

              General
                Surgeons

            	
               

              9

            	 	 	
               

              1

            	
               

              1

            	
               

              1

            	
               

              3

            	
               

              2

            	
               

              1

            	 
	
               

              Nephrology

            	
               

              1

            	 	 	 	 	 	 	 	 	
               

              1

            
	
               

              Neurology

            	
               

              2

            	 	 	 	 	 	 	 	 	
               

              2

            
	
               

              OB/GYNs

            	
               

              7

            	 	
               

              1

            	
               

              1

            	 	 	
               

              4

            	 	
               

              1

            	 
	
               

              Oncology

            	
               

              1

            	 	 	 	 	 	 	 	 	
               

              1

            
	
               

              Orthopedists

            	
               

              5

            	 	 	
               

              1

            	 	 	
               

              2

            	 	 	
               

              2

            
	
               

              Otolaryngologist

            	
               

              2

            	 	 	 	 	 	
               

              1

            	 	 	
               

              1

            
	
               

              Physical
                Med Rehab

            	
               

              2

            	 	 	 	 	 	 	 	 	
               

              2

            
	
               

              Podiatry

            	
               

              5

            	 	 	
               

              1

            	 	 	
               

              2

            	 	 	
               

              2

            
	
               

              Psychiatry

            	
               

              7

            	 	 	 	 	 	
               

              3

            	 	 	
               

              4

            
	
               

              Urology

            	
               

              3

            	 	 	 	 	 	 	 	 	
               

              3

            
	
               

              Vision

            	
               

              8

            	 	 	
               

              1

            	 	
               

              1

            	
               

              3

            	
               

              1

            	
               

              1

            	
               

              1

            

    

    

    1
      All
      required providers must be located within the region. 

    2
      Additional
      required providers may be located anywhere within the region.

     

    

    

    
      	
              West
                Central - Practitioners

               

            
	
              ABD
                Provider Panel Requirements

            
	
               

              Provider
                Types

            	
               

              Total
                Required Providers1

            	
               

              Champaign

            	
               

              Clarke

            	
               

              Darke

            	
               

              Greene

            	
               

              Miami

            	
               

              Montgomery

            	
               

              Preble

            	
               

              Shelby

            	
               

              Additional
                Required Providers 2

            
	
               

              Cardiovascular

            	
               

              3

            	 	 	 	 	 	
               

              1

            	 	 	
               

              2

            
	
               

              Dentists

            	
               

              5

            	 	
               

              1

            	 	 	 	
               

              3

            	 	 	
               

              1

            
	
               

              Gastroenterology

            	
               

              1

            	 	 	 	 	 	 	 	 	
               

              1

            
	
               

              General
                Surgeons

            	
               

              5

            	 	
               

              1

            	 	
               

              1

            	 	
               

              1

            	 	 	
               

              2

            
	
               

              Nephrology

            	
               

              1

            	 	 	 	 	 	 	 	 	
               

              1

            
	
               

              Neurology

            	
               

              2

            	 	 	 	 	 	 	 	 	
               

              2

            
	
               

              OB/GYNs

            	
               

              5

            	 	
               

              1

            	 	
               

              1

            	 	
               

              3

            	 	 	 
	
               

              Oncology

            	
               

              1

            	 	 	 	 	 	 	 	 	
               

              1

            
	
               

              Orthopedists

            	
               

              3

            	 	 	 	
               

              1

            	 	
               

              1

            	 	 	
               

              1

            
	
               

              Otolaryngologist

            	
               

              2

            	 	 	 	 	 	
               

              1

            	 	 	
               

              1

            
	
               

              Physical
                Med Rehab

            	
               

              2

            	 	 	 	 	 	 	 	 	
               

              2

            
	
               

              Podiatry

            	
               

              4

            	 	 	 	 	 	
               

              2

            	 	 	
               

              2

            
	
               

              Psychiatry

            	
               

              5

            	 	 	 	
               

              1

            	 	
               

              2

            	 	 	
               

              2

            
	
               

              Urology

            	
               

              2

            	 	 	 	 	 	 	 	 	
               

              2

            
	
               

              Vision

            	
               

              7

            	 	
               

              1

            	 	
               

              1

            	 	
               

              3

            	 	 	
               

              2

            

    

    

    

    1
      All
      required providers must be located within the region. 

    2
      Additional
      required roviders may be located anywhere within the region.

    

    

    Last
      Revised May 25, 2006

    
      	
              North
                West - Practitioners

            
	
               

              ABD
                Provider Panel Requirements

            
	
              Provider
                Types

            	
              Total
                Required Providers 1

            	
              Allen

            	
              Auglaize

            	
              Defiance

            	
              Fulton

            	
              Hancock

            	
              Hardin

            	
              Henry

            	
              Lucas

            	
              Mercer

            	
              Ottawa

            	
              Paulding

            	
              Putnam

            	
              Sandusky

            	
              Seneca

            	
              Van
                Wert

            	
              Williams

            	
              Wood
                

            	
              Wyandot

            	
              Additional
                Required Providers 2

            
	
              Cardiovascular

            	
               

              3

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

              1

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

              2

            
	
               

              Dentists

            	
               

              11

            	
               

              1

            	
               

            	
               

            	
               

              1

            	
               

            	
               

            	
               

            	
               

              6

            	
               

            	
               

            	
               

            	
               

              1

            	
               

              1

            	
               

            	
               

            	
               

              1

            	
               

            	
               

            	
               

            
	
               

              Gastroenterology

            	
               

              2

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

              1

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

              1

            
	
               

              General
                Surgeons

            	
               

              5

            	
               

              1

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

              2

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

              1

            	
               

            	
               

              1

            
	
               

              Nephrology

            	
               

              1

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

              1

            
	
               

              Neurology

            	
               

              2

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

              1

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

              1

            
	
               

              OB/GYNs

            	
               

              6

            	
               

              1

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

              2

            	
               

            	
               

            	
               

            	
               

            	
               

              1

            	
               

              1

            	
               

            	
               

            	
               

              1

            	
               

            	
               

            
	
               

              Oncology

            	
               

              1

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

              1

            
	
               

              Orthopedists

            	
               

              4

            	
               

              1

            	
               

            	
               

            	
               

            	
               

              1

            	
               

            	
               

            	
               

              1

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

              1

            	
               

            	
               

            
	
               

              Otolaryngologist

            	
               

              2

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

              1

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

              1

            
	
               

              Physical
                Med Rehab

            	
               

              2

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

              1

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

              1

            
	
               

              Podiatry

            	
               

              4

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

              2

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

              1

            	
               

            	
               

              1

            
	
               

              Psychiatry

            	
               

              6

            	
               

              1

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

              3

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

              1

            	
               

            	
               

              1

            
	
               

              Urology

            	
               

              2

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

              1

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

            	
               

              1

            
	
               

              Vision

            	
               

              7

            	
               

              1

            	
               

            	
               

              1

            	
               

            	
               

            	
               

            	
               

            	
               

              2

            	
               

              1

            	
               

            	
               

            	
               

            	
               

              1

            	
               

            	
               

              1

            	
               

            	
               

            	
               

            	 

    

    

     

    1
      All
      required providers must be located within the region.

     2
      Additional required

     

    
 

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    APPENDIX
      I

    PROGRAM
      INTEGRITY ABD ELIGIBLE POPULATION

     

    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
      addition to the specific requirements ofOAC 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, to the satisfaction ofODJFS.

    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 CDJFS. The MCP, at a minimum, must report the following
      information on cases where 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 (Appendix
      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
      J)]

     

    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,
      the MCP'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
      Agreement.

    

    

    APPENDIX
      J

    FINANCIAL
      PERFORMANCE ABD ELIGIBLE POPULATION

     

    1.
      SUBMISSION OF FINANCIAL STATEMENTS AND REPORTS

     

    MCPs
      must
      submit the following financial reports to ODJFS:

    a.
      The
      National Association of Insurance Commissioners (NAIC) quarterly and annual
      Health Statements (hereafter referred to as the "Financial Statements"), as
      outlined in Ohio Administrative Code (OAC) rule 5101:3-26-09(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(B);

     

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

    

    e.
      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;

     

    

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

     

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

     

    2.
      FINANCIAL PERFORMANCE MEASURES AND STANDARDS

     

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

    

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

     

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

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

    

    Standard:
      For the
      financial report that covers calendar year 2006, a minimum net worth per member
      of $156.00, as determined from the annual Financial Statement submitted to
      ODI
      and the ODJFS.

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

    

    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, excluding the at-risk amount, multiplied by the
      applicable proportion above.

     

    b.
      Indicator: Administrative Expense Ratio

    

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

    

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

     

    c.
      Indicator: Overall Expense Ratio

     

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

    

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

    

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

     

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

     

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

    

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

    

    

    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
      ODI
      and ODJFS.

     

    e.
      Indicator: Ratio of Cash to Claims Payable

     

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

    

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

     

    3.
      REINSURANCE REQUIREMENTS

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

    

    

    Appendix
      J 

    Page
      4

    

    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;

    

    e.
      risk
      based capital ratio of 2.5 or higher calculated from the last annual ODI
      financial statement;

    

    f.
      graph/chart showing the claims history for reinsurance above the previously
      approved deductible from the last calendar year.

    

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

    

    Penalty/or
      noncompliance:
      If it is
      determined that an MCP failed to have reinsurance coverage, that an MCP's
      deductible exceeds $75,000.00 without approval from ODJFS, or that the MCP's
      reinsurance for non-transplant services covers less than 80% of inpatient costs
      in excess of the deductible incurred by one member for one year without approval
      from ODJFS, then the MCP will be required to pay a monetary penalty to ODJFS.
      The amount of the penalty will be the difference between the estimated
      amount,

    

    

    Appendix
      J 

    Page
      6

     

    as
      determined by ODJFS, of what the MCP would have paid in premiums for the
      reinsurance policy if it had been in compliance and what the MCP did actually
      pay while it was out of compliance plus 5%. For example, if the MCP paid
      $3,000,000.00 in premiums during the period of non-compliance and would have
      paid $5,000,000.00 if the requirements had been met, then the penalty would
      be
      $2,100,000.00.

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

     

    4.
      PROMPT PAY REQUIREMENTS

    

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

    

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

    

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

    

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

    

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

     

    5.
      PHYSICIAN INCENTIVE PLAN DISCLOSURE REQUIREMENTS

    

    MCPs
      must
      comply with the physician incentive plan requirements stipulated in 42 CFR
      438.6(h). If the MCP operates a physician incentive plan, no specific payment
      can be made directly or indirectly under this physician incentive plan to a
      physician or physician

    

    

    group
      as
      an inducement to reduce or limit medically necessary services furnished to
      an
      individual.

    

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

    

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

    

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

     

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

     

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

    

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

     

    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

     

    

    

    Appendix
      J Page 8

     

    (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 ABD ELIGIBLE POPULATION

       

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

       

      a.
        PERFORMANCE
        IMPROVEMENT PROJECTS

       

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

       

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

       

      ODJFS
        will identify the clinical and/or non-clinical study topics for the SPY 2008
        Provider Agreement. Initiation of the PIPs will begin in the second year
        of
        participation in the ABD 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.

       

      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.

       

      

      Appendix
        K 

      Page
        2

       

      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 members with special health care needs. The MCP must specify
        the
        mechanisms used in its annual submission of the QAP1 program to
        ODJFS.

       

      d.
        SUBMISSION
        OF PERFORMANCE MEASUREMENT DATA

       

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

       

      Each
        MCP
        must also submit clinical performance measurement data as required by ODJFS
        that
        uses standard measures as specified by ODJFS. MCPs will be required to submit
        Health Employer Data Information Set (HEDIS) audited data for measures that
        .
        will be identified by ODJFS for the SFY 2008 Provider Agreement.

       

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

       

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

       

      2.
        EXTERNAL QUALITY REVIEW

       

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

       

      a.
        EORO
        ADMINISTRATIVE REVIEW AND NON-DUPLICATION OF MANDATORY
        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 OAPI 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 (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 ABD ELIGIBLE POPULATION

       

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

       

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

       

      1.
        ENCOUNTER DATA

       

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

       

      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 2 below, is
        the
        rate of utilization (e.g., discharges, visits) per 1.000 member months (MM)
        for
        the ABD program. The measure will be calculated per MCP (i.e., to include
        all
        counties with ABD memberships served by the MCP).

       

      Report
        Period:
        The
        report periods for the SFY 2007 and SPY 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

       

      

       

      

      
        	
                Report
                  Period

              	
                Data
                  Source:

                Estimated
                  Encounter Data
                  File Update

              	
                Quarterly
                  Report Estimated Issue Date

              	
                Contract
                  Period

              
	
                 

                Qtr
                  1 2007

              	
                 

                July
                  2007

              	
                 

                August
                  2007

              	
                 

                SFY
                  2007

              
	
                Qtr
                  l, Qtr 2 2007

              	
                October
                  2007

              	
                 

                November
                  2007

              	
                 

                SFY
                  2007

              
	
                 

                Qtr
                  1 thru Qtr 3 2007

              	
                 

                January
                  2008

              	
                 

                February
                  2008

              	
                 

                SFY
                  2008

              
	
                 

                Qtr
                  1 thru Qtr 4 2007

              	
                 

                April
                  2007

              	
                 

                May
                  2007

              	
                 

                SFY
                  2008

              
	
                 

                Qtr
                  1 thru Qtr 4 2007, Qtr 1 2008

              	
                 

                July
                  2008

              	
                 

                August
                  2008

              	
                 

                SFY
                  2008

              
	
                 

                Qtr
                  1 thru Qtr 4 2007, Qtr 1, Qtr 2 2008

              	
                October
                  2008

              	
                November
                  2008

              	
                SFY
                  2008

              

      

       

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

       

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

       

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

       

      Appendix
        L

      Page
        3

       

      Table
        2. Interim Standards

      Encounter
        Data Volume

       

      
        	
                Category

              	
                Measure
                  per 1,000/MM

              	
                Standard
                  for Dates of Service on or after 1/1/2007

              	
                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

              	
                Visits

              	
                25.5

              	
                Non-institutional
                  and hospital dental visits

              
	
                Vision

              	
                Visits

              	
                5.3

              	
                Non-institutional
                  and hospital outpatient optometry and ophthalmology
                  visits

              
	
                Primary
                  and Specialist Care

              	
                Visits

              	
                116.6

              	
                Physician/practitioner
                  and hospital outpatient visits

              
	
                Ancillary
                  Services

              	
                Visits

              	
                66.8

              	
                Ancillary
                  visits

              
	
                Behavioral
                  Health

              	
                Service

              	
                5.2

              	
                Inpatient
                  and outpatient behavioral encounters

              
	
                Pharmacy

              	
                Prescriptions

              	
                246.1

              	
                Prescribed
                  drugs

              

      

       

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

       

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

      

       

      Appendix
        L

      Page
        4

       

      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.

       

      Data
        Quality Standard:
        The data
        quality standard is a maximum omission rate of 15% for studies with time
        periods
        ending in CY 2008.

       

      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

       

      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).

       

      

      Appendix
        L 

      Page
        5

       

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

       

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

       

      Determination
        of Compliance:
        Performance is monitored once every quarter. If the standard is not met in
        all
        report periods, then the MCP will be determined to be noncompliant.

       

      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.

       

      l.a.iv. Rejected
        Encounters

       

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

       

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

       

      Measure
        1:
        The
        percentage of encounters submitted to ODJFS that are rejected. The measure
        will
        be calculated per MCP (i.e., to include all counties serviced by the
        MCP).

       

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

       

      October
        -
        December 2007; January - March 2008; April - June 2008.

       

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

       

      Appendix
        L 

      Page
        6

      

      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 will result in ODJFS imposing
        a
        monetary sanction. Upon all subsequent measurements of performance, if an
        MCP is
        again determined to be noncompliant with the standard, ODJFS will impose
        a
        monetary sanction (see Section 6.) of one percent of the current month's
        premium
        payment. The monetary sanction will be applied for each file 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%

       

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

       

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

       

      Penalty
        for Noncompliance with 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.

       

      Appendix
        L

      Page
        7

       

      l.a.v.
        Acceptance Rate

       

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

       

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

      20
        encounters per 1,000 MM for UB-92

       

      Seventh
        through twelfth month of membership:

      250
        encounters per 1,000 MM for NCPDP 

      350
        encounters per 1,000 MM for NSF 

      100
        encounters per 1,000 MM for UB-92

       

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

       

      Penalty
        for Noncompliance:
        If the
        MCP is determined to be noncompliant with the standard, ODJFS will impose
        a
        monetary sanction of one percent of the MCP's current month's premium payment.
        The monetary sanction will be applied 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.

       

      

      Appendix
        L 

      Page
        8

       

      l.a.vi. Informational
        Encounter Data Completeness Measures

       

      The
        encounter data quality measures listed below (section 1 .a.vi. (1) -(2))
        are
        informational only for the ABD population. Although there are no minimum
        performance standards for these measures, results will be reported and used
        as
        one component in monitoring the quality of data submitted to ODJFS by the
        MCPs.

       

      (1)
        Incomplete Data For Last Menstrual Period

       

      (2)
        Incomplete Birth Weight Data

       

      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 Study

       

      Measure:
        This
        accuracy study will compare the accuracy and completeness of payment data
        stored
        in MCPs' claims systems during the study period to payment data submitted
        to and
        accepted by ODJFS. The measure will be calculated per MCP (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/or Measure:TBD
        for SFY
        2008.

       

      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.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

       

      Appendix
        L

      Page
        9

      

      submitted
        to ODJFS 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
        SPY 2007 contract period, performance will be evaluated using the following
        report periods: January - March 2007; April - June 2007. 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; January - March
        2008;
        April -June 2008.

       

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

       

      Determination
        of Compliance:
        Performance is monitored once every quarter. If the standard is not met in
        all
        report periods, then the MCP will be determined to be noncompliant

       

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

      

      1.c.
        Timely Submission of Encounter Data 

       

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

       

      

      Appendix
        L

      Page
        10

       

       

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

       

      2.
        CASE MANAGEMENT DATA

       

      ODJFS
        designed a case management system (CAMS) in order to monitor MCP compliance
        with
        program requirements specified in Appendix G, Coverage
        and Services.
        Each
        MCP's case management data submissions will be assessed for completeness
        and
        accuracy. The MCP is responsible for submitting a case management file every
        month. Failure to do so jeopardizes the MCP's ability to demonstrate compliance
        with case management requirements. For detailed descriptions of the case
        management measures below, see ODJFS
        Methods for theABD andCFC Medicaid Managed Care Programs 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 case management records in CAMS for the ABD program
        that
        have open case management date spans for members who have disenrolled from
        the
        MCP.

       

      Report
        Period:
        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.

       

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

       

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

       

      Penalty
        for noncompliance:
        If an
        MCP is noncompliant with the standard, then the ODJFS will issue a Sanction
        Advisory informing the MCP that a monetary sanction will be imposed if the
        MCP
        is noncompliant for any future report periods. Upon all subsequent semi-annual
        measurements of performance, if an MCP is again determined to be noncompliant
        with the standard, ODJFS will impose a monetary sanction of one-half of one
        percent of the current month's premium payment.

       

      Appendix
        L

      Page
        11

       

      Once
        the
        MCP is performing at standard levels and violations/deficiencies are resolved
        to
        the

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

       

      3.
        EXTERNAL QUALITY REVIEW DATA

       

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

       

      Two
        information sources are integral to these studies: encounter data and medical
        records. Because encounter data is used to draw samples for 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

       

      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

       

      Appendix
        L 

      Page
        12

       

      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, ODJFS will impose a non-refundable $10,000 monetary
        sanction.

       

      Data
        Quality Standard 2:
        A
        minimum record submittal 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

       

      The
        designated PCP is the physician who will manage and coordinate the overall
        care
        for ABD members including those who have case management needs. The MCP must
        submit a Members' Designated PCP file every month. Specialists may and should
        be
        identified as the PCP as appropriate for the member's condition; however,
        no ABD
        member may have more than one PCP identified.

       

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

       

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

       

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

       

      4.b.
        Designated PCP for newly enrolled members

       

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

       

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

       

      Data
        Quality Standard:
        A
        minimum rate of 65% of new members with PCP designation by their effective
        date
        of enrollment for quarter 3 and quarter 4 of SFY 2007. A minimum rate of
        75% of
        new members with PCP designation by their effective date of enrollment for
        quarter 1 and quarter 2 of SFY 2008. A minimum rate of 85% of new members
        with
        PCP designation by their effective date of enrollment for quarter 3 and quarter
        4 of SFY 2008.

       

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

       

      Appendix
        L

      Page
        13

       

      3,000
        ABD
        members statewide who have had at least three months of continuous
        enrollment

      during
        each month of the entire report period.

       

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

       

      5.
        APPEALS AND GRIEVANCES DATA

       

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

       

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

       

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

       

      6.
        NOTES

       

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

       

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

       

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

       

      Appendix
        L 

      Page
        14

      

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

       

      6.c.
        Membership Freezes

       

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

       

      6.d.
        Reconsideration

       

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

       

      6.e.
        Contract Termination, Nonrenewals, or Denials

       

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

       

      

      APPENDIX
        M

       

      PERFORMANCE
        EVALUATION ABD ELIGIBLE POPULATION

       

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

       

      Selected
        measures in this appendix will be used to determine incentives as specified
        in
Appendix
        0, Pay for Performance (P4P).

      

      1.
        QUALITY OF CARE 

      l.a.
        Independent External Quality Review

       

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

       

      Measure:
        The independent external quality review covers both an administrative review
        and
        focused quality of care studies as outlined in Appendix K.

       

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

       

      Action
        Required for Deficiencies: For all reviews conducted during the contract
        period,
        if the EQRO cites a deficiency in the administrative review or quality of
        care
        studies, the MCP will be required to complete a Corrective Action Plan, Quality
        Improvement Directive, or Performance Improvement Project as outlined in
        Appendix K of the Agreement. Serious deficiencies may result in immediate
        termination or non-renewal of the Agreement.

       

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

       

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

       

      Appendix
        M

      Page
        2

       

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

       

      l.b.ii.
        Case Management of Members

       

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

       

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

       

      Statewide
        Approach:
        MCPs
        will be evaluated using a statewide result, including all regions in which
        an
        MCP has membership. An MCP will not be evaluated until the MCP has at least
        3,000 members statewide who have had at least three months of continuous
        enrollment during each month of the entire report period. As the ABD Medicaid
        managed care program expands statewide and regions become active in different
        months, statewide results will include every region in which an MCP has
        membership [Example: MCP AAA has: 6,000 members in the South West region
        beginning in January 2007; 7,000 members in the West Central region beginning
        in
        February 2007;

      and
        8,000
        members in the South East region beginning in March 2007. MCP AAA's statewide
        results for the April-June 2007 report period will include case management
        rates
        for all members who meet minimum continuous enrollment criteria for this
        measure
        in: the South West region for April 2007's monthly rate calculation; the
        South
        West and West Central regions for May 2007's monthly rate calculation; and
        the
        South West, West Central, and South East regions for June 2007's monthly
        rate
        calculation.]

       

      Minimum
        Performance Standard:
        For the
        fourth quarters of SFY 2007, a case management rate of 30%. For the first
        and
        second quarters of SFY 2008, a case management rate of 35%. For the third
        and
        fourth quarters of SFY 2008, a case management rate of 40%. ODJFS expects
        the
        minimum standard for this measure to increase to 50% by the fourth quarter
        of
        SFY 2009.

       

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

       

      Appendix
        M 

      Page
        3

       

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

       

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

       

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

       

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

       

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

       

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

       

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

       

      Measure
        8:
        The
        percent of members with a positive identification through an ODJFS
        administrative review of data for the ODJFS-mandated case management condition
        of non-mild
        hypertension
        who have
        had at least three consecutive months of enrollment in one MCP that are case
        managed.

       

      Measure
        9:
        The
        percent of members with a positive identification through an ODJFS
        administrative review of data for the ODJFS-mandated case management condition
        of coronary
        arterial disease who
        have
        had at least three consecutive months of enrollment in one MCP that are case
        managed.

       

      Report
        Periods/or Measures 1- 9: For the SFY 2007 contract period April - June 2007
        report periods. For the SFY 2008 contract period, July - September 2007,
        October
        - December 2007, January - March 2008, and April - June 2008 report
        periods.

       

      Appendix
        M 

      Page
        4

       

      Statewide
        Approach:
        MCPs
        will be evaluated using a statewide result, including all regions in which
        an
        MCP has membership. An MCP will not be evaluated until the MCP has at least
        3,000 members statewide who have had at least three months of continuous
        enrollment during each month of the entire report period. As the ABD Medicaid
        managed care programs expands statewide and regions become active in different
        months, statewide results will include every region in which an MCP has
        membership [Example: MCP AAA has: 6,000 members in the South West region
        beginning in January 2007; 7,000 members in the West Central region beginning
        in
        February 2007;

      and
        8,000
        members in the South East region beginning in March 2007. MCP AAA's statewide
        results for the April-June 2007 report period will include case management
        rates
        for all members in the South West, West Central, and South East regions who
        are
        identified through the administrative data review as having a mandated condition
        and are continuously enrolled for at least three consecutive months in one
        MCP.]

       

      Minimum
        Performance Standard/or Measures 1-9:
        For the
        fourth quarter of SFY 2007, a case management rate of 60%. For the first
        and
        second quarters of SFY 2008, a case management rate of 65%. For the third
        and
        fourth quarters of SFY 2008, a case management rate of 70%. ODJFS expects
        the
        minimum standard for this measure to increase to 80% by the fourth quarter
        of
        SFY 2009.

       

      Penalty
        for Noncompliance for Measures 1-9:
        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.

       

      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 (NCQA) Health Plan Employer Data and
        Information Set (HEDIS). NCQA may annually change its method for calculating
        a
        measure. These changes can make it difficult to evaluate whether improvement
        occurred from a prior year. For this reason, ODJFS will use the same methods
        to
        calculate the baseline results and the results for the period in which the
        MCP
        is being held accountable. For example, the same methods are used to calculate
        calendar year 2008 results (the baseline period) and calendar year 2009 results.
        The methods will be updated and a new baseline will be created during 2009
        for
        calendar year 2010 results. These results will then serve as the baseline
        to
        evaluate whether improvement occurred from calendar year 2009 to calendar
        year
        2010. Clinical performance measure results will be calculated after a sufficient
        amount of time has passed after the end of the report period in order to
        allow
        for claims runout. For a

       

      Appendix
        M 

      Page
        5

       

      comprehensive
        description of the clinical performance measures below, see ODJFS
        Methods for Clinical Performance Measures, ABD Medicaid Managed Care
        Program.
        Performance standards are subject to change, based on the revision or update
        ofNCQA methods or other national standards, methods or benchmarks.

       

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

       

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

       

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

       

      l.c.i.
        Congestive Heart Failure (CHF) - Inpatient Hospital Discharge
        Rate

       

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

       

      Target:
        TBD

       

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

       

      Action
        Required for Noncompliance:
        If the
        standard is not met and the results are below TBD%, 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 TBD%, 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.ii.
        Congestive Heart Failure (CHF) - Emergency Department (ED) Utilization
        Rate

       

      Appendix
        M 

      Page
        6

       

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

       

      Target:
        TBD

       

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

       

      Action
        Required for Noncompliance:
        If the
        standard is not met and the results are below TBD%, 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 TBD%, 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.iii.
        Congestive Heart Failure (CHF) - ACE Inhibitor/Angiotensin Receptor
        Blocker

       

      Measure:
        The
        percentage of members who had a diagnosis of CHF in the year prior to the
        reporting year, who were enrolled for six or more months in the reporting
        year,
        who received one or more prescriptions for an ACE Inhibitor or Angiotensin
        Receptor Blocker during the reporting year.

       

      Target:
        TBD.

       

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

       

      Action
        Required for Noncompliance:
        If the
        standard is not met and the results are below TBD%, 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 TBD%, 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.
        Congestive Heart Failure (CHF) - Cardiac Related Hospital
        Readmission

       

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

       

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

       

      Action
        Required for Noncompliance:
        If the
        standard is not met and the results are below TBD%, then the MCP is required
        to
        complete a Performance Improvement Project, as described in

       

      Appendix
        M 

      Page
        7

       

      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 TBD%, then ODJFS will issue a Quality Improvement Directive
        which w'ill notify the MCP of noncompliance and may outline the steps that
        the
        MCP must take to improve the results.

       

      l.c.v. Coronary
        Artery Disease (CAD) - Inpatient Hospital Discharge Rate

       

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

       

      Target:
        TBD

       

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

       

      Action
        Required for Noncompliance:
        If the
        standard is not met and the results are below TBD%, 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 TBD%, 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.vi.
        Coronary Artery Disease (CAD) - Emergency Department (ED) Utilization
        Rate

       

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

       

      Target:
        TBD

       

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

       

      Action
        Required for Noncompliance:
        If the
        standard is not met and the results are below TBD%, 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 TBD%, 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.vii.
        Coronary Artery Disease (CAD) - Cardiac Related Hospital
        Readmission

       

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

       

      Appendix
        M 

      Page
        8

       

      Target:
        TBD.

       

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

       

      Action
        Required for Noncompliance:
        If the
        standard is not met and the results are below TBD%, 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 TBD%, 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.viii.
        Beta Blocker Treatment after Heart Attack

       

      Measure:
        The
        percentage of members 35 years and older as of December 31st
        of the
        reporting year who were hospitalized from January 1 - December 241
        of the
        reporting year with a diagnosis of acute myocardial infarction (AMI) and
        who
        received an ambulatory prescription for beta blockers within seven days of
        discharge. Target:
        TBD.

       

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

       

      Action
        Required for Noncompliance:
        If the
        standard is not met and the results are below TBD%, 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 TBD%, 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.ix.
        Coronary Artery Disease (CAD) - Cholesterol Management for Patients with
        Cardiovascular Conditions/LDL-C Screening Performed

       

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

       

      Target:
        TBD.

       

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

       

      Action
        Required for Noncompliance:
        If the
        standard is not met and the results are below TBD%, 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

       

      Appendix
        M 

      Page
        9

       

      noncompliance.
        If the standard is not met and the results are at or above TBD%, 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.x. Hypertension
        - Inpatient Hospital Discharge Rate

       

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

       

      Target:
        TBD

       

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

       

      Action
        Required/or Noncompliance:
        If the
        standard is not met and the results are below TBD%, 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 TBD%, 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.xi.
        Hypertension - Emergency Department (ED) Utilization Rate

       

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

       

      Target:
        TBD

       

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

       

      Action
        Required for Noncompliance:
        If the
        standard is not met and the results are below TBD%, 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 TBD%, 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.xii.
        Diabetes - Inpatient Hospital Discharge Rate

       

      

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

       

      Target:
        TBD

       

      Appendix
        M 

      Page
        10

       

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

       

      Action
        Required/or Noncompliance:
        If the
        standard is not met and the results are below TBD%, 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 TBD%, 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.xiii.
        Diabetes - Emergency Department (ED) Utilization Rate

       

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

       

      Target:
        TBD

       

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

       

      Action
        Required for Noncompliance:
        If the
        standard is not met and the results are below TBD%, 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 TBD%, 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.xiv. Diabetes
        - Eye Exam

       

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

       

      Target:
        TBD.

       

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

       

      Action
        Required for Noncompliance:
        If the
        standard is not met and the results are below TBD%, 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 TBD%, 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.

       

      Appendix
        M

      Page
        11

       

      l.c.xv. Chronic
        Obstructive Pulmonary Disease (COPD) - Inpatient Hospital Discharge
        Rate

       

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

       

      Target:
        TBD

       

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

       

      Action
        Required/or Noncompliance:
        If the
        standard is not met and the results are below TBD%, 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 TBD%, 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.xvi.
        Chronic Obstructive Pulmonary Disease (COPD) - Emergency Department (ED)
        Utilization Rate

       

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

       

      Target:
        TBD

       

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

       

      Action
        Required for Noncompliance:
        If the
        standard is not met and the results are below TBD%, 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 TBD%, 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.xvii.
        Asthma - Inpatient Hospital Discharge Rate

       

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

       

      Target:
        TBD

       

      Appendix
        M 

      Page
        12

       

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

       

      Action
        Required/or Noncompliance:
        If the
        standard is not met and the results are below TBD%,

       

      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 TBD%, 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.xviii.
        Asthma -
        Emergency Department (ED) Utilization Rate

       

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

       

      Target:
        TBD

       

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

       

      Action
        Required for Noncompliance:
        If the
        standard is not met and the results are below TBD%, 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 TBD%, 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.xix. Asthma
        - Use of Appropriate Medications for People with Asthma

       

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

       

      Target:
        TBD

       

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

       

      Action
        Required for Noncompliance:
        If the
        standard is not met and the results are below TBD%, 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 TBD%, 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.xx.
        Mental Health, Severely Mentally Disabled (SMD) - Inpatient Hospital Discharge
        Rate

       

       

      Appendix
        M 

      Page
        13

       

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

       

      Target:
        TBD

       

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

       

      Action
        Required/or Noncompliance:
        If the
        standard is not met and the results are below TBD%, 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 TBD%, 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.xxi.
        Mental Health, Severely Mentally Disabled (SMD) - Emergency Department
        Utilization Rate

       

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

       

      Target:
        TBD

       

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

       

      Action
        Required for Noncompliance:
        If the
        standard is not met and the results are below TBD%, 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 TBD%, 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.xxii.
        Follow-up After Hospitalization for Mental Illness

       

      Measure:
        The
        percentage of discharges for members enrolled from the date of discharge
        through
        30 days after discharge, who were hospitalized for treatment of selected
        mental
        health disorders and who had a follow-up visit (i.e., were seen on an outpatient
        basis or were in intermediate treatment with a mental health provider)
        within:

       

      1)
        30
        Days of discharge, and

      2)
        7 Days
        of discharge.

       

      Target:
        TBD.

       

      

      Appendix
        M 

      Page
        14

       

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

       

      Action
        Required/or Noncompliance (Follow-up visits within 30 days of
        discharge):
        If the
        standard is not met and the results are below TBD%, 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 TBD%, 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 (Follow-up visits within 7 days of
        discharge):
        If the
        standard is not met and the results are below TBD%, 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 TBD%, 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.xxiii.
        Mental Health, Severely Mentally Disabled (SMD) - SMD Related Hospital
        Readmission

       

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

       

      Target:
        TBD.

       

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

       

      Action
        Required for Noncompliance:
        If the
        standard is not met and the results are below TBD%, 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 TBD%, 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.xxiv.
        Substance Abuse - Inpatient Hospital Discharge Rate

       

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

       

      

      Appendix
        M 

      Page
        15

       

      Target:
        TBD

       

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

       

      Action
        Required for Noncompliance:
        If the
        standard is not met and the results are below TBD%, 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 TBD%, 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.xxv. Substance
        Abuse - Emergency Department Utilization Rate

       

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

       

      Target:
        TBD

       

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

       

      Action
        Required for Noncompliance:
        If the
        standard is not met and the results are below TBD%, 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 TBD%, 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.xxvi. Substance
        Abuse - Inpatient Hospital Readmission Rate

       

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

       

      Target:
        TBD.

       

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

       

      Action
        Required for Noncompliance:
        If the
        standard is not met and the results are below TBD%, then the MCP is required
        to
        complete a Performance Improvement Project, as described in

       

      

      Appendix
        M 

      Page
        16

       

      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 TBD%, 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.xxvii.
        Informational Clinical Performance Measures

       

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

       

      Table
        1. Informational Clinical Performance Measures

       

       

      
        	
                 

                Condition

              	
                 

                Informational
                  Performance Measure

              
	
                 

                CHF

              	
                 

                Discharge
                  rate with age group breakouts

              
	
                 

                CAD

              	
                 

                Discharge
                  rate with age group breakouts

              
	
                 

                Hypertension

              	
                 

                Discharge
                  rate with age group breakouts

              
	
                 

                Diabetes

              	
                 

                Discharge
                  rate with age group breakouts

              
	
                 

                Comprehensive
                  Diabetes Care (CDC)/HbAlc testing

              
	
                 

                CDC/kidney
                  disease monitored

              
	
                 

                CDC/LDL-C
                  screening performed

              
	
                 

                COPD

              	
                 

                Discharge
                  rate with age group breakouts

              
	
                 

                Use
                  of Spirometry Testing in the Assessment and Diagnosis of
                  COPD

              
	
                 

                Asthma

              	
                 

                Discharge
                  rate with age group breakouts

              
	
                 

                Mental
                  Health (SMD)

              	
                 

                Discharge
                  rate with age group breakouts

              
	
                 

                Antidepressant
                  Medication Management

              
	
                 

                Substance
                  Abuse

              	
                 

                Discharge
                  rate with age group breakouts

              
	
                 

                Initiation
                  and Engagement of Alcohol and Other Drug Dependence
                  Treatment

              

      

       

      2.
        ACCESS

       

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

       

      

      Appendix
        M 

      Page
        17

       

      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.

       

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

       

      Report
        Period:
        For the
        SFY 2008 contract period, a baseline level of performance will be established
        using the CY2007 report period (and may be adjusted based on the number of
        months ofABD managed care membership). For the SFY 2009 contract period,
        performance will be evaluated using the January - December 2008 report period.
        The first reporting period in which MCPs will be held accountable to the
        performance standards will be the CY2008 reporting period.

       

      Minimum
        Performance Standard:
        A
        maximum PCP Turnover rate of 18%.

       

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

       

      2.b.
        Adults' Access to Designated PCP

       

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

       

      Measure:
        The
        percentage of members who had a visit through member's designated
        PCPs.

       

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

       

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

       

      

      Appendix
        M 

      Page
        18

       

      Minimum
        Performance Standards: TBD

       

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

       

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

       

      This
        measure indicates whether adult members are accessing health
        services.

       

      Measure:
        The
        percentage of members age 21 and older who had an ambulatory or preventive-care
        visit.

       

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

       

      Report
        Period:
        For the
        SPY 2008 contract period, performance will be evaluated using the January
        -
        December 2007 report period (and may be adjusted based on the number of months
        of ABD managed care membership). For the SFY 2009 contract period, performance
        will be evaluated using the January - December 2008 report period. The first
        reporting period in which MCPs will be held accountable to the performance
        standards will be the CY2008 reporting period.

       

      Minimum
        Performance Standards: TBD

       

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

       

      3.
        CONSUMER SATISFACTION

       

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

       

      In
        accordance with federal requirements and in the interest of assessing enrollee
        satisfaction with MCP performance, ODJFS 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 ABD Medicaid Managed Care Program Consumer Satisfaction Performance
        Measures,
        which
        are incorporated in this Appendix.

       

      Appendix
        M 

      Page
        19

       

      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 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/or
        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 ABD Medicaid Managed Care Program Administrative Capacity
        Performance Measures,
        which
        are incorporated in this Appendix.

       

      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 TBD ED visits during a twelve month reporting
        period.

       

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

       

      Report
        Period:
        For the
        SFY 2008 contract period, a baseline level of performance will be established
        using the CY2007 report period (and may be adjusted based on the number of
        months of ABD managed care membership). For the SFY 2009 contract period,
        results will be calculated for

       

      Appendix
        M 

      Page
        20

       

      the
        reporting period ofCY2008 and compared to the CY2007 baseline results to
        determine if the minimum performance standard is met.

       

      Target:
        TBD

       

      Minimum
        Performance Standard:
        TBD

       

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

       

      5.
        Notes

       

      Given
        that unforeseen circumstances (e.g., revision or update of applicable national
        standards, methods or benchmarks, or issues related to program implementation)
        may impact performance assessment as specified in Sections 1 through 4, ODJFS
        reserves the right to apply the most appropriate penalty to the area of
        deficiency identified with any individual measure, notwithstanding the penalties
        specified in this Appendix.

       

      

      APPENDIX
        N

       

      COMPLIANCE
        ASSESSMENT SYSTEM (CAS) ABD ELIGIBLE POPULATION

       

      The
        Compliance Assessment System (CAS) is designed to improve the quality of
        each
        MCP's performance through 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 Agreement. Remedies
        are
        progressive based upon the severity of the violation, or a repeated pattern
        of
        violations. The CAS does not include categories which require subjective
        assessments or which are not within the MCPs' control. CAS allows the
        accumulated point total to reflect both patterns of less serious violations
        as
        well as less frequent, more serious violations.

       

      The
        CAS
        focuses on clearly identifiable deliverables, and occurrences/points are
        only
        assessed in documented and verified instances ofnoncompliance. 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.

       

      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
        include: 

      -
        Use of
        unapproved 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
        include: 

       

      -
        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
        include: 

       

      -
        Failure
        to comply with the minimum provider panel requirements specified in Appendix
        H
        of the Agreement.

       

      -
        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 result in the assessment of occurrences
        or
        points based on the nature of the violation under correction.

       

      

      Appendix
        N

      Page
        3

      

      Notwithstanding
        the assessment of occurrences and/or points as a result of individual events,
        the

      following
        cumulative actions will be imposed for repeated violations.

       

      •
After
        accumulating a total of three occurrences within a contract term, 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 a contract term,
        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 a contract term, all
        subsequent 10-point violations during the period will be assessed as 15-point
        violations.

       

      Occurrences
        and points will accumulate over the contract term of the Agreement. Upon
        the
        beginning of a new Agreement, the MCP will begin a new contract term 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 contract term of a prior provider agreement will
        carry
        these points over for the first three (3) months of their next provider
        agreement. If the MCP does not accrue any additional points during this three
        (3) month period the MCP will then have their point total reduced to zero
        and
        continue on in the new contract term. 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 contract term.

       

      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 to the satisfaction of ODJFS. Repeated incidents will be reviewed to
        determine if the MCP has a systemic problem in this area, and if so, occurrences
        or points may be assessed, as determined by ODJFS.

       

      

      Appendix
        N

      Page
        4

       

      

      All
        required submissions are 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, as may be determined by
        ODJFS.

       

      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 as soon as possible, but no later than 3 PM Eastern Time
        (ET) 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 and all such
        requests will be evaluated upon that basis and with that in mind. Only written
        approval as may be granted 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 specifically 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:

       

      Notwithstanding
        any other penalty- occurrence or point assessment that ODJFS may impose on
        an
        MCP under this Appendix, 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 a contract term;

      (2)
        or
        the MCP fails to fully implement a CAP within the designated time frame;
        or (3)
        circumstances exist which potentially jeopardize the MCP's members' access
        to
        care. [Examples of circumstances that ODJFS may consider as jeopardizing
        member
        access to care include:

       

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

       

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

       

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

       

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

       

      Payments
        provided for under the Agreement will be denied for new enrollees, when and
        for
        so long as, payments for those enrollees 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, in its sole
        discretion, 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 failure 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,
        member's PCP and CAMS 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
        N 

      Page
        6

       

      Appendix
        C of the Agreement, ODJFS will assess the MCP with a 10-point penalty and
        a
        monetary sanction of $20,000 per day for the period of noncompliance. ODJFS
        may
        assess additional penalty points based on the length of noncompliance, as
        it may
        determine in its sole discretion.

       

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

       

      Noncompliance
        with Prompt Payment:

       

      Noncompliance
        with the prompt pay requirements as specified in Appendix J of the Agreement,
        will result in progressive penalties. The first violation during 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 (2) 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 (3) months duration.

       

      Noncompliance
        with Franchise Fee Assessment Requirements

       

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

       

      •
A
        monetary penalty in the amount of $500 for each day any part of the fee remains
        unpaid, except the penalty will not exceed an amount equal to 5 % of the
        total
        fee that was due for the calendar quarter for which the penalty was
        imposed;

      •
        Withholdings from future ODJFS capitation payments. If an MCP fails to pay
        the
        full amount of its franchise fee when due, or the full amount of the imposed
        penalty, ODJFS may withhold an amount equal to the remaining amount due from
        any
        future ODJFS capitation payments. ODJFS will return all withheld capitation
        payments when the franchise fee amount has been paid in full.

       

      •
A
        10
        point penalty assessment for the period of noncompliance.

       

      Appendix
        N Page 7

       

      •
        Proposed termination or non-renewal of the MCP's Medicaid provider agreement
        may
        occur if the MCP:

      a.
        Fails
        to pay its franchise permit fee or fails to pay the fee promptly;

      b.
        Fails
        to pay a penalty imposed under this Appendix or fails to pay the penalty
        promptly;

      c.
        Fails
        to cooperate with an audit conducted in accordance with ORC Section
        5111.176.

       

      Noncompliance
        with Clinical Laboratory Improvement Amendments:

       

      Noncompliance
        with CLIA requirements as specified by ODJFS will result in the assessment
        of a
        nonrefundable $1,000 fine for each violation.

       

      '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
        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.

       

      'Negligent
        Breach of Protected Health Information (PHI) Standards

       

      Non-compliance
        with the HIPAA Privacy Regulations and negligent breach of protected health
        information (PHI) standards will be assessed in accordance with Appendix
        C.
        Therefore, the progressive remedies specified under Appendix N, Compliance
        Assessment System will not be utilized for assessing non-compliance with
        the
        HIPAA Privacy Regulations and negligent breach of PHI.

       

      Refusal
        to Comply with Program Requirements

       

      If
        ODJFS
        has instructed an MCP that they must comply with a specific program requirement
        and the MCP refuses, such refusal constitutes documentation that the MCP
        is no
        longer operating in the best interests of the MCP's members or the state
        of Ohio
        and ODJFS will move to terminate or nonrenew the MCP's provider
        agreement.

       

      General
        Provisions:

       

      All
        notifications of the imposition by ODJFS of a fine or freeze will be made
        via
        certified or overnight mail to the identified MCP Medicaid
        Coordinator.

       

      

      Appendix
        N

      Page
        8

       

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

       

      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 fine will be returned to the MCP
        (minus any applicable collection fees owed to the Attorney General's Office
        if
        the MCP has been delinquent in submitting payment) after they have demonstrated
        full compliance, as determined by ODJFS, with the particular program
        requirement.

       

      If
        an MCP
        does not comply within one (1) year of the date of notification of noncompliance
        involving issues of case management and two (2) years of the date of
        notification of noncompliance in issues involving encounter data, then the
        monies will not be refunded. MCPs are required to submit a written request
        for
        refund to ODJFS at the time they believe is appropriate before a refund of
        monies will be considered.

       

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

       

      In
        addition, ODJFS can at any time move to terminate, amend or deny renewal
        of a
        provider agreement.

       

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

       

      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, of the Agreement.

       

      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.

       

      

      Appendix
        N Page 9

       

      REQUESTS
        FOR RECONSIDERATIONS

       

      Requests
        for reconsiderations of remedial action taken under the CAS shall be submitted
        to ODJFS as follows:

       

      •
MCPs
        notified of ODJFS' imposition of remedial action taken under the CAS (i.e.,
        occurrences, points, fines, assignment reductions and selection freezes),
        will
        have five (5) 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 request must be submitted at the time of submission
        of the reconsideration request, unless ODJFS extends the timeframe 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
        ODJFS by the fifth business day after receipt of notification of the imposition
        of the remedial action by ODJFS.

       

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

       

      •
Final
        decisions or requests for additional information will be made by ODJFS within
        five (5) business days of receipt of the request for
        reconsideration.

       

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

       

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

       

      

      Appendix
        N 

      Page
        10

       

      POINT
        COMPLIANCE SYSTEM - POINT VALUES

       

      OCCURRENCES:
        Failures
        to meet program requirements, including but not limited to, noncompliance
        with
        administrative requirements, as determined by ODJFS. Examples include, but
        are
        not limited to, the following:

       

      •
        Unapproved use of marketing/member materials.

      •
Failure
        to attend ODJFS-required meetings or training sessions.

      •
Failure
        to maintain ODJFS-required documentation.

      •
Use
        ofunapproved 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 ODJFS.

      •
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 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
        physician 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, as determined
        by
        ODJFS. Examples include, but are not limited to, the following:

       

      •
        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 a 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 CAMS file (as specified in Appendix L of the
        Agreement) 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 of the Agreement) 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 as determined by ODJFS. Examples include, but are not limited
        to:

       

      •
Failure
        to meet any of the provider panel requirements as specified in Appendix H
        of the
        Agreement.

      •
        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 within 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 of the Agreement) 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.

      

      APPENDIX
        0

       

      PAY-FOR-PERFORMANCE
        (P4P) ABD ELIGIBLE POPULATION

       

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

       

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

       

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

       

      An
        MCP's
        second calendar year of ABD managed care program membership (i.e., CY2008)
        will
        be the initial report period of evaluation for performance measures that
        require
        one calendar year of baseline data (i.e., CY2007), and for performance measures
        that require two calendar years of baseline data (i.e., CY2006 and CY2007).
        CY2008 will be the initial report period upon which compliance with the
        performance standards will be determined. SFY2009 will become the first year,
        an
        MCP's performance level for P4P can be determined.

      

      1.
        SFY 2009 P4P 

      l.a.
        Qualifying Performance Levels

       

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

       

      1)
        Meet
        the minimum performance standards set in Appendix M, Performance
        Evaluation,
        for the
        measures listed below; and

       

      2)
        Meet
        the P4P standards established for the Clinical Performance Measures
        below.

       

      

      Appendix
        0 Page 2

       

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

       

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

      

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

      Report
        Period:
        CY
        2008

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

      Report
        Period:
        CY
        2008

      3.
        Satisfaction with MCP Customer Service (Appendix M, Section 3.)

      Report
        Period:
        The most
        recent consumer satisfaction survey completed prior to the end of the SFY
        2009
        contract period.

       

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

       

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

       

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

       

      Clinical
        Performance Measure Medicaid Benchmark

       

      1.
        CHF:
        ACE Inhibitor/Angiotensin Receptor B locker TBD

      2.
        CAD:
        Beta-Blocker Treatment after Heart Attack (AMI -related TBD
        admission)

      3.
        CAD:
        Cholesterol Management for Patients with Cardiovascular TBD Conditions/LDL-C
        screening performed

      4.
        Hypertension: Inpatient Hospital Discharge Rate TBD

      5.
        Diabetes: Comprehensive Diabetes Care (CDC)/Eye exam TBD

      6.
        COPD:
        Inpatient Hospital Discharge Rate TBD

      7.
        Asthma: Use of Appropriate Medications for People with Asthma TBD

      8.
        Mental
        Health: Follow-up After Hospitalization for Mental Illness TBD

       

      

      Appendix
        0 

      Page
        3

       

      l.b.
        Excellent and Superior Performance Levels

       

      For
        qualifying MCPs as determined by Section 1 .a.. herein, performance will
        be
        evaluated on the measures below to determine the status of the at-risk amount
        or
        any additional P4P that may be awarded. Excellent and Superior standards
        are set
        for the three measures described below. The standards are subject to change
        based on the revision or update of applicable national standards, methods
        or
        benchmarks.

       

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

      

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

      

      Period:
        April - June 2008

      Excellent
        Standard: TBD 

      Superior
        Standard:
        TBD

      

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

      Report
        Period:
        CY 2008

      Excellent
        Standard:
        TBD

      Superior
        Standard:
        TBD

       

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

      

      Report
        Period: CY 2008

      Excellent
        Standard: TBD

      Superior
        Standard: TBD

       

      1.c.
        Determining SFY 2009 P4P

       

      MCP's
        reaching the minimum performance standards described in Section l.a. herein,
        will be considered for P4P including retention of the at-risk amount and
        any
        additional P4P. For each Excellent standard established in Section l.b. herein,
        that an MCP meets, one-third of the at-risk amount may be retained. For MCPs
        meeting all of the Excellent and Superior standards established in Section
        l.b.
        herein, additional P4P may be awarded as determined by ODJFS. For MCPs receiving
        additional P4P, the amount in the P4P fund (see section 2.) will be divided
        equally, up to the maximum amount, among all MCPs'ABD and/or CFC programs
        receiving additional P4P. The maximum amount to be awarded to a single plan
        in
        P4P additional to the at

       

      Appendix
        0 

      Page
        4

       

      risk
        amount is $250,000 per contract year. An MCP may receive up to $500,000 should
        both of the MCP's ABD and CFC programs achieve the Superior Performance
        Levels.

      

      2.
        NOTES 

      2.a.
        Initiation of the P4P System

       

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

       

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

       

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

       

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

       

      2.c.
        Statewide P4P system

       

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

       

      2.d.
        Contract Termination, Nonrenewals, or Denials

       

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

       

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

       

      Appendix
        0 

      Page
        5

       

      2.e.
        Report Periods

       

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

       

      

      APPENDIX
        P

       

      MCPTERMINATIONS/NONRENEWALS/AMENDMENTS
        ABD ELIGIBLE POPULATION

       

      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-INITIATEDTERMINATIONS/NONRENEWALS

       

      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 between the month the
        ten-ninatioi-i/noni-enewal 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, State 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 3PM Eastern Time (ET) on the third working day following receipt of the
        ODJFS
        notification of termination. The address and fax number to be used in making
        these requests will be specified in the ODJFS notification of termination
        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.

       

      •
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.EX-10.1

[COOPER]

FIRST AMENDMENT TO

RECEIVABLES PURCHASE AGREEMENT

THIS FIRST AMENDMENT TO RECEIVABLES PURCHASE AGREEMENT (this “Amendment”), dated as of
November 30, 2006, is entered into among COOPER RECEIVABLES LLC (the “Seller”), COOPER TIRE
& RUBBER COMPANY (the “Servicer”), MARKET STREET FUNDING LLC, as Related Committed
Purchaser and as Conduit Purchaser and PNC BANK, NATIONAL ASSOCIATION, as administrator (the
“Administrator”) and as Purchaser Agent for the Market Street Purchaser Group.

RECITALS

1. The parties hereto are parties to the Receivables Purchase Agreement, dated as of August
30, 2006 (as amended, amended and restated, supplemented or otherwise modified through the date
hereof, the “Agreement”); and

2. The parties hereto desire to amend the Agreement as hereinafter set forth.

NOW THEREFORE, for good and valuable consideration, the receipt and sufficiency of which are
hereby acknowledged, the parties agree as follows:

SECTION 1. Certain Defined Terms. Capitalized terms that are used but not defined
herein shall have the meanings set forth in the Agreement.

SECTION 2. Amendment to the Agreement. Clause (m) of Exhibit V to the
Agreement is hereby amended and restated in its entirety to read as follows:

Cooper Tire or any of its respective Subsidiaries shall breach, default on or fail to
comply with the covenant set forth in Section 5.1 (titled “Percentage of Consolidated
Indebtedness to Consolidated Capitalization”) of that certain Amended and Restated Credit
Agreement, dated as of September 1, 2000, among Cooper Tire, as borrower thereunder, the
lenders from time to time thereto, PNC as the agent for the lenders thereunder, as such
agreement has been amended, modified, waived or supplemented through the Closing Date, and
without giving effect to any future amendment, modification, waiver or supplement thereto
(whether or not consented to or waived by the required parties thereunder) unless PNC has
given its affirmative consent thereto, as agent thereunder; provided,
however, that solely for purposes of this clause (m), (x) the covenant in
such Section 5.1 of such agreement shall be calculated without giving effect to any change in
the unfunded post-retirement benefit liability and Consolidated Stockholder’s Equity
resulting from FASB Statement No. 158, and (y) such Section 5.1 in such agreement, including
any defined terms used, directly or indirectly, in such Section 5.1 of such agreement (as
amended, modified, waived or supplemented consistent with the terms of this clause
(m)), shall, for the purposes of this Agreement and each other Transaction Document,
survive any termination of such agreement

SECTION 3. Representations and Warranties. Each of the Seller and the Servicer hereby
represents and warrants to the Administrator, the Purchaser and the Purchaser Agent as follows:

(a) Representations and Warranties. The representations and warranties made by
it in the Transaction Documents are true and correct as of the date hereof (unless stated to
relate solely to an earlier date, in which case such representations or warranties were true
and correct as of such earlier date).

(b) Enforceability. The execution and delivery by such Person of this
Amendment, and the performance of each of its obligations under this Amendment and the
Agreement, as amended hereby, are within each of its organizational powers and have been
duly authorized by all necessary organizational action on its part. This Amendment and the
Agreement, as amended hereby, are such Person’s valid and legally binding obligations,
enforceable in accordance with its terms.

(c) No Default. Both before and immediately after giving effect to this
Amendment and the transactions contemplated hereby, no Termination Event or Unmatured
Termination Event exists or shall exist.

SECTION 4. Effect of Amendment. All provisions of the Agreement, as expressly amended
and modified by this Amendment, shall remain in full force and effect. After this Amendment becomes
effective, all references in the Agreement (or in any other Transaction Document) to “this
Agreement”, “hereof”, “herein” or words of similar effect referring to the Agreement shall be
deemed to be references to the Agreement as amended by this Amendment. This Amendment shall not be
deemed, either expressly or impliedly, to waive, amend or supplement any provision of the Agreement
other than as set forth herein.

SECTION 5. Effectiveness. This Amendment shall become effective as of the date hereof
upon receipt by the Administrator of counterparts of this Amendment (whether by facsimile or
otherwise) executed by each of the other parties hereto.

SECTION 6. Counterparts. This Amendment may be executed in any number of counterparts
and by different parties on separate counterparts, each of which when so executed shall be deemed
to be an original and all of which when taken together shall constitute but one and the same
instrument.

SECTION 7. Governing Law. This Amendment shall be governed by, and construed in
accordance with, the internal laws of the State of New York.

SECTION 8. Section Headings. The various headings of this Amendment are included for
convenience only and shall not affect the meaning or interpretation of this Amendment, the
Agreement or any provision hereof or thereof.

[Signatures begin on next page]

1

IN WITNESS WHEREOF, the parties have executed this Amendment as of the date first
written above.

COOPER RECEIVABLES LLC, as Seller

By: /s/Charles F. Nagy

Name: Charles F. Nagy

Title: Assistant Treasurer

By: /s/Stephen O. Schroeder

Name: Stephen O. Schroeder

Title: President and Treasurer

COOPER TIRE & RUBBER COMPANY, as Servicer

By: /s/Philip G. Weaver

Name: Philip G. Weaver

Title: Vice President & Chief Financial Officer

By: /s/Stephen O. Schroeder

Name: Stephen O. Schroeder

Title: Vice President and Treasurer

2

	 	 	 	Consented and Agreed:

	 	 	 	PNC
BANK, NATIONAL ASSOCIATION,

	 	 	 	as
Administrator

	 	 	 	By:
/s/John T. Smathers

	 	 	Name: John T. Smathers

Title: Vice President

	 	 	 	PNC
BANK, NATIONAL ASSOCIATION,

	 	 	 	as
Purchaser Agent for the Market Street Purchaser
Group

	 	 	 	By:
/s/John T. Smathers

	 	 	Name: John T. Smathers

Title: Vice President

	 	 	 	MARKET STREET FUNDING LLC,

	 	 	 	as a
Related Committed Purchaser and as Conduit
Purchaser

	 	 	 	By:
/s/Doris J. Hearn

	 	 	Name: Doris J. Hearn

Title: Vice President

3

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