Document:

Exhibit 10.1

    
      

    

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    Exhibit
      10.1

     

    

      APPENDIX
        X

      [Amendment
        Number 1]

      

      
        	
                Agency
                  Code 12000

              	
                Contract
                  No. C021236

              
	
                Period
                  1/1/07-12/31/07

              	
                Funding
                  Amount for Period Based
                  on approved capitation rates

              

      

      

       

      This
        is
        an AGREEMENT between THE STATE OF NEW YORK, acting by and through The
        New York State Department of Health,
        having
        its principal office at Corning
        Tower. Room 2001. Empire State Plaza. Albany NY 12237.
        (hereinafter referred to as the STATE), and WellCare
        of New York. Inc..
        (hereinafter referred to as the CONTRACTOR), to modify Contract
        Number C021236
        as set
        forth below and to extend the contract period through December 31, 2007.
        The
        effective date of these modifications is January 1, 2007.

       

      1.
        The
        attached "Table of Contents" will be applicable for the period beginning
        January
        1. 2007.

       

      2.
        Amend
        Section 9.3 "Covered Services During Guaranteed Eligibility" to read as
        follows:

       

      9.3
        Covered Services During Guaranteed Eligibility

       

      The
        services covered during the Guaranteed Eligibility period shall be those
        contained in the Medicaid Advantage Benefit Package, as specified in Appendix
        K-2, and free access to family planning and reproductive health services
        as set
        forth in Section 10.6 of this Agreement. During the Guaranteed Eligibility
        period, Enrollees are also eligible for Medicaid pharmacy benefits as allowed
        by
        State law (select drug categories excluded from the Medicare Part D benefit
        and
        certain medications included in the Part D benefit when the Enrollee is unable
        to receive them from his/her Medicare Advantage plan) on a Medicaid
        fee-for-service basis.

       

      3.
        Amend
        Section 10.7 "Emergency and Post Stabilization Care Services" to read as
        follows:

       

      10.7
        Emergency and Post Stabilization Care Services

       

      a)
        The
        Contractor shall provide Emergency and Post Stabilization Care Services in
        accordance with applicable federal and state requirements, including 42 CFR
        §422.113.

       

      b)
        The
        Contractor shall ensure that Enrollees are able to access Emergency Services
        twenty four (24) hours per day, seven (7) days per week.

       

      c)
        The
        Contractor agrees that it will not require prior authorization for services
        in a
        medical or behavioral health emergency. The Contractor agrees to inform its
        Enrollees that access to Emergency Services is not restricted and that Emergency
        Services may be obtained from a Non-Participating Provider without penalty.
        Nothing herein precludes the Contractor from entering into contracts with
        providers or facilities that require providers or facilities to provide
        notification to the Contractor after Enrollees present for Emergency Services
        and are subsequently stabilized. The Contractor must pay for services for
        Emergency Medical Conditions whether provided by a Participating Provider
        or a
        Non-Participating Provider, and may not deny payments for failure of the
        Emergency Services provider or Enrollee to give notice.

      

      

      

      Appendix
        X 

      Medicaid
        Advantage Contract Amendment

      January
        1, 2007 

      Page
        l

      

      d)
        The
        Contractor shall advise its Enrollees how to obtain Emergency Services when
        it
        is not feasible for Enrollees to receive Emergency Services from or through
        a
        Participating Provider.

       

      e)
        Coverage and payment for Emergency Services that meet the prudent layperson
        definition shall be covered and paid in accordance with the requirements
        of the
        federal Medicare program.

       

      f)
        In
        addition, the Contractor shall cover and reimburse for general hospital
        emergency department services and physician services provided to an Enrollee
        while the Enrollee is receiving general hospital emergency department services,
        in accordance with the following requirements when such services do not meet
        the
        prudent layperson standard:

       

      i)
        Participating Providers

       

      A)
        Payment by the Contractor for general hospital emergency department services
        provided to an Enrollee by a Participating Provider shall be at the rate
        of
        payment specified in the contract between the Contractor and the general
        hospital for emergency services.

       

      B)
        Payment by the Contractor for physician services provided to an Enrollee
        by

      a
        Participating Provider while the Enrollee is receiving general hospital
        emergency department services shall be at the rate of payment
        specified in the
        contract between the Contractor and the physician.

       

      ii)
        Non-Participating Providers

       

      A)
        Payment by the Contractor for general hospital emergency department services
        provided to an Enrollee by a Non-Participating Provider shall be at the Medicaid
        fee-for-service rate, inclusive of the capital component, in effect on the
        date
        that the service was rendered.

       

      B)
        Payment by the Contractor for physician services provided to an Enrollee
        by a
        Non-Participating Provider while the Enrollee is receiving general hospital
        .
        emergency department services shall be at the Medicaid fee-for-service rate
        in
        effect on the date that the service was rendered.

       

      4.
        Amend
        Subsection 10.15 (a) (i) "Persons Requiring Chemical Dependence Services"
        to
        read as follows:

      i)
        Satisfactory methods for identifying persons requiring such services and
        encouraging self-referral and early entry into treatment and methods for
        referring Enrollees to the New York Office of . Alcohol and Substance Abuse
        Services (OASAS) for appropriate services beyond the Contractor's Benefit
        Package (e.g., halfway houses).

      

      

      

      Appendix
        X

      Medicaid
        Advantage Contract Amendment

      January
        1, 2007

      Page
        2

      

      5.
        Amend
        Subsection 16.3 "Quality Management and Performance Improvement" to read
        as
        follows:

       

      16.3
        The
        Contractor agrees to conduct performance improvement projects and to measure
        performance using standard measures required by CMS, and to report results
        to
        CMS and SDOH. Standard Measures will include, but not be limited
        to:

       

      •
Health
        Plan and Employer Data Information Set (HEDIS);

       

      •
        Consumer Assessment of Health Plans Survey (CAHPS); and

       

      •
Health
        Outcomes Survey (HOS).

       

      6.
        Amend
        Section 18.3 "SDOH Instructions for Report Submissions" to read as
        follows:

       

      18.3
        SDOH
        Instructions for Report Submissions

       

      SDOH
        will
        provide Contractor with instructions for submitting the reports required
        by
        Section 18.5 (a) (i) through (x) of this Agreement, including time frames,
        and
        requisite formats. The instructions, time frames and formats may be modified
        by
        SDOH upon sixty (60) days written notice to the Contractor.

       

      7.
        Delete
        Section 18.4 "Liquidated Damages. " and renumber Sections 18.5 "Notification
        of
        Changes in Report Due Dates, Requirements or Formats;" 18.6 "Reporting
        Requirements;" 18.7 "Ownership and Related Information Disclosure:" 18.8
        "Public
        Access to Reports:" 18.9 "Certification Regarding Individuals Who Have Been
        Debarred Or Suspended By Federal. State, or Local Government;" 18.10 "Conflict
        of Interest Disclosure;" and 18.11 "Physician Incentive Plan Reporting:"
        as
        Sections 18.4. 18.5. 18.6. 18.7. 18.8. 18.9. and 18.10
        respectively.

       

      8.
        Amend
        Section 21.5 "Dental Networks " to read as follows:

       

      21.5
        Dental Networks

       

      If
        the
        Contractor includes dental services in its Medicaid Advantage Benefit Package,
        the Contractor's dental network shall include geographically accessible general
        dentists sufficient to offer each Enrollee a choice of two (2) primary care
        dentists in his or her Service Area and to achieve a ratio of at least one
        (1)
        primary care dentist for each 2,000 Enrollees. Networks must also include
        at
        least one (1) oral surgeon. Orthognathic surgery, temporal mandibular disorders
        (TMD) and oral/maxillofacial prosthodontics must be provided through any
        qualified dentist, either in-network or by referral. Periodontists and
        endodontists must also be available by referral. The network should include
        dentists with expertise in serving special needs populations (e.g., HP/+
        and
        developmentally disabled patients).

       

      

       

      

      Appendix
        X

      Medicaid
        Advantage Contract Amendment 

      January
        1,2007 

      Page
        3

      

      9.
        Add
        a
        new Section 22.7 "Recovery of Overpayments to Providers" to read as
        follows:

       

      22.7
        Recovery of Overpayments to Providers

       

      Consistent
        with the exception language in Section 3224-b of the Insurance Law, the
        Contractor shall retain the right to audit participating providers' claims
        for a
        six year period from the date the care, services or supplies were provided
        or
        billed, whichever is later, and to recoup any overpayments discovered as
        a
        result of the audit. This six year limitation does not apply to situations
        in
        which fraud may be involved or in which the provider or an agent of the provider
        prevents or obstructs the Contractor's auditing.

       

      10.
        Renumber
        Section 22.7 "Physician Incentive Plan" as Section 22.8.

       

      11.
        Amend
        Section 3(b) (iii) "LDSS Responsibilities" of Appendix H "New York State
        Department of Health Guidelines for the Processing of Medicaid Advantage
        Enrollments and Disenrollments" to read as follows:

       

      iii)
        In
        the event that the LDSS learns of an Enrollee's pregnancy prior to the
        Contractor, the LDSS is to establish MA eligibility and pre-enroll the unborn
        into Medicaid managed care in cases where an enrollment form is
        received.

       

      12.
        The
        attached Appendix K "Medicare and Medicaid Advantage Products and Non-Covered
        Services" will be applicable for the period beginning January 1,
        2007.

       

      13.
        The
        attached Appendix L "Approved Capitation Payment Rates" will be applicable
        for
        the period beginning January 1, 2007.

       

      14.
        The
        attached Appendix M "Service Area" will be applicable for the period beginning
        January 1. 2007.

       

      15.
        Add
        a
        Section 13 "Provisions Related to New York State Procurement Lobbying Law"
        to
        Appendix R "Additional Specifications for the Medicaid Advantage Agreement"
        to
        read as follows:

       

      13.
        Provisions Related to New York State Procurement Lobbying Law

       

      The
        State
        reserves the right to terminate this Agreement in the event it is found that
        the
        certification filed by the Contractor in accordance with New York State Finance
        Law § 139-k was intentionally false or intentionally incomplete. Upon such
        finding, the State may exercise its termination right by providing written
        notice to the Contractor in accordance with the written notification terms
        of
        this Agreement.

       

      All
        other
        provisions of said AGREEMENT shall remain in full force and effect.

       

      Appendix
        X

      Medicaid
        Advantage Contract Amendment 

      January
        1,2007 

      Page
        4

      

      IN
        WITNESS WHEREOF, the parties hereto have executed this AGREEMENT as of the
        dates
        appearing under their signatures.

      

      
        	
                CONTRACTOR
                  SIGNATURE

              	
                STATE
                  AGENCY SIGNATURE

              
	
                By:
                  /s/
                  Todd Farha 

                 

              	
                By:
                  /s/ Donna Frescatore

              
	
                Todd
                  Farha

                Print
                  Name

                 

              	
                Donna Frescatore

                Print Name

              
	
                Title:
                  President & CEO

                 

              	
                Title:
                  Deputy Director, OMC

              
	
                Date:
                  11/13/2006

              	
                Date:
                  11/27/2006

                 

                State
                  Agency Certification:

                In
                  addition to the acceptance of this contract, I also certify that
                  original
                  copies of this signature page will be attached to all other exact
                  copies
                  of this contract.

              

      

      

      

      

      

      STATE
        OF
        NEW YORK 

      SS.:

      County
        of
        New York

      

      

      On
        the
        13th day of  November  2006, before me personally appeared Todd S.
        Farha, to me known, who being by me duly sworn, did depose and say that
        he’she resides at Tampa, Florida , that he/she is the President and
        CEO of WellCare of New York, Inc.  the corporation described
        herein which executed the foregoing instrument; and that he/she signed his/her
        name thereto by order of the board of directors of said
        corporation.

      

      
        	
                /s/ 
                  Ronald Piedmonte

                (Notary)

                 

                 

              	 
	
                STATE
                  COMPTROLLER'S SIGNATURE

              	
                Title:
                  ________________________

              
	
                _______________________________

              	
                Date:
                  ________________________

              

      

      

       

      Appendix
        X

      Medicaid
        Advantage Contract Amendment

      January
        1,2007

      Page
        5

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      Table
        of Contents for Medicaid Advantage Model Contract

      

      Recitals

      

      Section
        1
        Definitions

      

      Section
        2
        Agreement Term, Amendments, Extensions, and General Contract 

      

      Administration
        Provisions

      2.1
        Term

      2.2
        Amendments

      2.3
        Approvals

      2.4
        Entire Agreement

      2.5
        Renegotiation

      2.6
        Assignment and Subcontracting

      2.7
        Termination

      a.
        SDOH
        Initiated Termination

      b.
        Contractor and SDOH Initiated Termination

      c.
        Contractor Initiated Termination

      d.
        Termination Due to Loss of Funding

      2.8
        Close-Out Procedures

      2.9
        Rights and Remedies

      2.10
        Notices

      2.11
        Severability

      

      Section
        3
        Compensation

      3.1
        Capitation Payments

      3.2
        Modification of Rates During Contract Period

      3.3
        Rate
        Setting Methodology

      3.4
        Payment of Capitation

      3.5
        Denial of Capitation Payments

      3.6
        SDOH
        Right to Recover Premiums

      3.7
        Third
        Party Health Insurance Determination

      3.8
        Contractor Financial Liability

      3.9
        Tracking Services Provided by Indian Health Clinics

      

      Section
        4
        Service Area

      

      Section
        5
        Eligibility For Enrollment in Medicaid Advantage

      5.1
        Eligible to Enroll in the Medicaid Advantage Program

      5.2
        Not
        Eligible to Enroll in the Medicaid Advantage Program

      5.3
        Change in Eligibility Status

      Section
        6
        Enrollment

      6.1
        Enrollment Requirements

      6.2
        Equality of Access to Enrollment

      6.3
        Enrollment Decisions

      6.4
        Prohibition Against Conditions on Enrollment

      

      

      Medicaid
        Advantage

      Contract

      TABLE
        OF
        CONTENTS

      State
        2007 Amendment
        

      1

      

      Table
        of Contents for Medicaid Advantage Model Contract

      

      

      6.5
        Effective Date of Enrollment

      6.6
        Contractor Liability

      6.7
        Roster

      6.8
        Automatic Re-Enrollment

      6.9
        Failure to Enroll in Contractor's Medicare Advantage Product

      6.10
        Medicaid Managed Care Enrollees Who Will Gain Medicare Eligibility

      6.11
        Newborn Enrollment

      

      Section
        7
        RESERVED

      

      Section
        8
        Disenrollment

      8.1
        Disenrollment Requirements

      8.2
        Disenrollment Prohibitions

      8.3
        Disenrollment Requests

      a.
        Routine Disenrollment Requests b. Non-Routine Disenrollment
        Requests

      8.4
        Contractor Notification of Disenrollments

      8.5
        Contractor's Liability

      8.6
        Enrollee Initiated Disenrollment

      8.7
        Contractor Initiated Disenrollment

      8.8
        LDSS
        Initiated Disenrollment

      

      Section
        9
        Guaranteed Eligibility

      9.1
        General Requirements

      9.2
        Right
        to Guaranteed Eligibility

      9.3
        Covered Services During Guaranteed Eligibility

      9.4
        Disenrollment During Guaranteed Eligibility

      

      Section
        10 Benefit Package, Covered and Non-Covered Services

      10.1
        Contractor Responsibilities

      10.2
        SDOH
        Responsibilities

      10.3
        Benefit Package and Non-Covered Services Descriptions

      10.4
        Adult Protective Services

      10.5
        Court-Ordered Services

      10.6
        Family Planning and Reproductive Health Services

      10.7
        Emergency and Post Stabilization Care Services

      10.8
        Medicaid Utilization Thresholds (MUTS)

      10.9
        Services for Which Enrollees Can Self-Refer 

      a.
        Diagnosis and Treatment of Tuberculosis 

      b.
        Family
        Planning and Reproductive Health Services 

      c.
        Article 28 Clinics Operated by Academic Dental Centers

      10.10
        Coordination with Local Public Health Agencies

      10.11
        Public Health Services

      a.
        Tuberculosis Screening, Diagnosis and Treatment; Directly Observed Therapy
        (TB/DOT)

      

      Medicaid
        Advantage Contract

      TABLE
        OF
        CONTENTS

      State
        2007 Amendment
        

      2

      

      Table
        of Contents for Medicaid Advantage Model Contract

      

      b.
        Immunizations 

      c.
        Prevention and Treatment of Sexually Transmitted Diseases

      10.12
        Adults with Chronic Illnesses and Physical or Developmental
        Disabilities

      10.13
        Persons Requiring Ongoing Mental Health Services

      10.14
        Member Needs Relating to HP/

      10.15
        Persons Requiring Chemical Dependence Services

      10.16
        Native Americans

      10.17
        Urgently Needed Services

      10.18
        Dental Services Provided by Article 28 Clinics Operated by Academic Dental
        Centers Not Participating in Contractor's Network

      10.19
        Coordination of Services

      

      Section
        11 Marketing

      11.1
        Marketing Requirements

      

      Section
        12 Member Services

      12.1
        General Functions

      12.2
        Translation and Oral Interpretation

      12.3
        Communicating with the Visually, Hearing and Cognitively Impaired

      

      Section
        13 Enrollee Notification

      13.1
        General Requirements

      13.2
        Member ID Cards

      13.3
        Member Handbooks

      

      Section
        14 Organization Determinations, Actions, and Grievance System

      14.1
        General Requirements

      14.2
        Filing and Modification of Medicaid Advantage Action and Grievance System
        Procedures

      14.3
        Medicaid Advantage Action and Grievance System Additional
        Provisions

      14.4
        Notification of Medicaid Advantage Action and Grievance System
        Procedures

      14.5
        Complaint, Complaint Appeal and Action Appeal Investigation
        Determinations

      

      Section
        15 Access Requirements 

      

      Section
        16 Quality Management and Performance Improvement

      Section
        17 Monitoring and Evaluation

      17.1
        Right To Monitor Contractor Performance

      17.2
        Cooperation During Monitoring And Evaluation

      17.3
        Cooperation During On-Site Reviews

      17.4
        Cooperation During Review of Services by External Review Agency

      

      

      Medicaid
        Advantage Contract

      TABLE
        OF
        CONTENTS

      State
        2007 Amendment
        

      3

      

      Table
        of Contents for Medicaid Advantage Model Contract

      

      Section
        18 Contractor Reporting Requirements

      18.1
        General Requirements

      18.2
        Time
        Frames for Report Submissions

      18.3
        SDOH
        Instructions for Report Submissions

      18.4
        Notification of Changes in Report Due Dates, Requirements or
        Formats

      18.5
        Reporting Requirements

      18.6
        Ownership and Related Information Disclosure

      18.7
        Public Access to Reports

      18.8
        Certification Regarding Individuals Who Have Been Debarred or Suspended by
        Federal, State or Local Government

      18.9
        Conflict of Interest Disclosure 18.10 Physician Incentive Plan
        Reporting

      

      Section
        19 Records Maintenance and Audit Rights

      19.1
        Maintenance of Contractor Performance Records

      19.2
        Maintenance of Financial Records and Statistical Data

      19.3
        Access to Contractor Records

      19.4
        Retention Periods

      

      Section
        20 Confidentiality

      20.1
        Confidentiality of Identifying Information about Enrollees, Eligible Persons
        and
        Prospective Enrollees

      20.2
        Confidentiality of Medical Records

      20.3
        Length of Confidentiality Requirements

      

      Section
        21 Participating Providers

      21.1
        General Requirements

      21.2
        Medicaid Advantage Network Requirements

      21.3
        SDOH
        Exclusion or Termination of Providers

      21.4
        Payment in Full

      21.5
        Dental Networks

      

      Section
        22 Subcontracts and Provider Agreements for Medicaid Only Covered
        Services

      22.1
        Written Subcontracts

      22.2
        Permissible Subcontracts

      22.3
        Provision of Services through Provider Agreements

      22.4
        Approvals

      22.5
        Required Components

      22.6
        Timely Payment

      22.7
        Recovery of Overpayments to Providers

      22.8
        Physician Incentive Plan

      

      Section
        23 Americans With Disabilities Act Compliance Plan

      

      

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      Section
        24 Fair Hearings

      24.1
        Enrollee Access to Fair Hearing Process

      24.2
        Enrollee Rights to a Fair Hearing

      24.3
        Contractor Notice to Enrollees

      24.4
        Aid
        Continuing

      24.5
        Responsibilities of SDOH

      24.6
        Contractor's Obligations

      

      Section
        25 External! Appeal

      25.1
        Basis for External Appeal

      25.2
        Eligibility for External Appeal

      25.3
        External Appeal Determination

      25.4
        Compliance with External Appeal Laws and Regulations

      25.5
        Member Handbook

      

      Section
        26 Intermediate Sanctions

      26.1
        General

      26.2
        Unacceptable Practices

      26.3
        Intermediate Sanctions

      26.4
        Enrollment Limitations

      26.5
        Due
        Process

      

      Section
        27 Environmental Compliance 

      

      Section
        28 Energy Conservation 

      

      Section
        29 Independent Capacity of Contractor 

      

      Section
        30 No Third Party Beneficiaries

      

      Section
        31 Indemnification

      31.1
        Indemnification by Contractor

      31.2
        Indemnification by SDOH

      

      Section
        32 Prohibition on Use of Federal Funds for Lobbying

      32.1
        Prohibition of Use of Federal Funds for Lobbying

      32.2
        Disclosure Form to Report Lobbying

      32.3
        Requirements of Subcontractors

      

      Section
        33 Non-Discrimination

      33.1
        Equal Access to Benefit Package

      33.2
        Non-Discrimination

      33.3
        Equal Employment Opportunity

      33.4
        Native Americans Access to Services From Tribal or Urban Indian Health
        Facility

      

      

      Medicaid
        Advantage Contract

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        of Contents for Medicaid Advantage Model Contract

      

      

      Section
        34 Compliance with Applicable Laws and Regulations

      34.1
        Contractor and SDOH Compliance with Applicable Laws

      34.2
        Nullification of Illegal, Unenforceable, Ineffective or Void Contract
        Provisions

      34.3
        Certificate of Authority Requirements

      34.4
        Notification of Changes in Certificate of Incorporation

      34.5
        Contractor's Financial Solvency Requirements

      34.6
        Non-Liability of Enrollees for Contractor's Debts

      34.7
        SDOH
        Compliance with Conflict of Interest Laws

      34.8
        Compliance Plan

      

      Section
        35 New York State Standard Contract Clauses

      

      

      Medicaid
        Advantage Contract

      TABLE
        OF
        CONTENTS

      State
        2007

      Amendment
        6

       

      

      Table
        of Contents for Medicaid Advantage Model Contract

      APPENDICES

       

      A.
        New
        York State Standard Contract Clauses

       

      B.
        Certification Regarding Lobbying

       

      B-l.
        Certification Regarding MacBride Fair Employment Principles

       

      C.
        New
        York State Department of Health Requirements for Provision of Free Access
        to
        Family Planning and Reproductive Health Services

       

      D.
        New
        York State Department of Health Medicaid Advantage Marketing
        Guidelines

       

      E.
        New
        York State Department of Health Medicaid Advantage Model Member Handbook
        Guidelines

       

      F.
        New
        York State Department of Health Medicaid Advantage Action and Grievance Systems
        Requirements

       

      G.
        RESERVED

       

      H.
        New
        York State Department of Health Guidelines for the Processing of Medicaid
        Advantage Enrollments and Disenrollments

       

      I.
        RESERVED

       

      J.
        New
        York State Department of Health Guidelines of Federal Americans with
        Disabilities Act

       

      K.
        Medicare and Medicaid Advantage Products and Non-Covered Services

       

      L.
        Approved Capitation Payment Rates

       

      M.
        Service Area

       

      N.
        RESERVED

       

      O.
        Requirements for Proof of Workers' Compensation and Disability Benefits
        Coverage

       

      P.
        RESERVED

       

      Q.
        RESERVED

       

      R.
        Additional Specifications for the Medicaid Advantage Agreement

       

      

       

      Medicaid
        Advantage Contract 

      TABLE
        OF
        CONTENTS 

      State
        2007 Amendment

      7

       

      

      Table
        of Contents for Medicaid Advantage Model Contract

       

      X. Modification
        Agreement Form

       

      

       

      

      Medicaid
        Advantage Contract 

      TABLE
        OF
        CONTENTS

      State
        2007  Amendment
        

      8

       

      

      APPENDIX
        K

       

      Medicare
        and Medicaid Advantage Products And Non-Covered Services

       

      

       

      

      Medicaid
        Advantage Contract 

      APPENDIX
        K 

      State
        2007 Amendment 

      K-l

       

      

      APPENDIX
        K

       

      Appendix
        K is organized into three parts:

       

      I.
        Appendix K-l

       

      Medicare
        Advantage Product

       

      II.
        Appendix K-2

       

      Medicaid
        Advantage Product

       

      Contractor/County
        Election of Coverage for Optional Services

       

      Description
        of Medicaid Only Covered Services

       

      III.
        Appendix K-3

       

      Non-Covered
        Services

       

      

       

      

      Medicaid
        Advantage Contract 

      APPENDIX
        K 

      State
        2007 Amendment
        

      K-2

      

      

       

      

        
          	
                  APPENDIX
                    Kl

                
	
                  MEDICARE
                    ADVANTAGE PRODUCT

                
	
                  Medicare
                    Advantage Benefit Package for Dual Eligibles - Upstate
                    Counties

                
	
                  Category
                    of Service

                	
                  Included
                    in Medicare Capitation

                
	
                  Inpatient
                    Hospital Care Including Substance Abuse and Rehabilitation
                    Services

                	
                  Up
                    to 365 days per year (366 days for leap year) $300 per stay
                    co-payment.

                
	
                  Inpatient
                    Mental Health

                	
                  Medically
                    necessary care. $300 per stay co-payment. 190-day lifetime limit
                    in a
                    psychiatric hospital.

                
	
                  Skilled
                    Nursing Facility

                	
                  Care
                    provided in a skilled nursing facility. Covered for 100 days
                    each benefit
                    period. No prior hospital stay required. No co-payment.

                
	
                  Home
                    Health

                	
                  Medically
                    necessary intermittent skilled nursing care, home health aide
                    services and
                    rehabilitation services. $10 per visit co-payment.

                
	
                  PCP
                    Office Visits

                	
                  Primary
                    care doctor office visits. Subject to $10 co-payment per
                    visit

                
	
                  Specialist
                    Office Visits

                	
                  Specialist
                    office visits. Subject to $20 co-payment for each specialist
                    office
                    visit.

                
	
                  Chiropractic

                	
                  Manual
                    manipulation of the spine to correct subluxation provided by
                    chiropractors
                    or other qualified providers. Subject to $20 co-payment

                
	
                  Podiatry

                	
                  Medically
                    necessary foot care, including care for medical conditions affecting
                    lower
                    limbs, subject to $20 co-payment. Visits for routine foot care
                    up to 4
                    visits per year, not subject to co-payment.

                
	
                  Outpatient
                    Mental Health

                	
                  Individual
                    and group therapy visits, subject to co-payment of $20 per individual
                    or
                    group visit. Enrollee must be able to self-refer for one assessment
                    from a
                    network provider in a twelve (12) month period.

                
	
                  Outpatient
                    Substance Abuse

                	
                  Individual
                    and group visits subject to $20 co-payment per group or individual
                    visit.
                    Enrollee must be able to self-refer for one assessment from a
                    network
                    provider in a twelve (12) month period.

                
	
                  Outpatient
                    Surgery

                	
                  Medically
                    necessary visits to an ambulatory surgery center or outpatient
                    hospital
                    facility. $35 per visit to ambulatory surgery or outpatient
                    hospital.

                
	
                  Ambulance

                	
                  Transportation
                    provided by an ambulance service, including air ambulance. Emergency
                    transportation if for the purpose of obtaining hospital service
                    for an
                    enrollee who suffers from severe, life-threatening or potentially
                    disabling conditions

                

        

      

      

      

      Medicaid
        Advantage Contract 

      APPENDIX
        K 

      State
        2007 

      Amendment
        K-3

      

      
        	
                Medicare
                  Advantage Benefit Package for Dual Eligibles - Upstate
                  Counties

              
	
                Category
                  of Service

              	
                Included
                  in Medicare Capitation

              
	 	
                which
                  require the provision of emergency services while the enrollee
                  is being
                  transported. Includes transportation to a hospital emergency room
                  generated by a "Dial 911". $50 co-payment.

              
	
                Emergency
                  Room

              	
                Care
                  provided in an emergency room subject to prudent layperson standard.
                  $50
                  co-payment per visit. Co-payment waived if admitted to the hospital
                  within
                  24 hours for the

                same
                  condition.

              
	
                Urgent
                  Care

              	
                Urgently
                  needed care in most cases outside the plan's service

                area.
                  Subject to $20 co-payment.

              
	
                Outpatient
                  Rehabilitation (OT, PT, Speech)

              	
                Occupational
                  therapy, physical therapy and speech and language therapy subject
                  to $20
                  co-payment.

              
	
                Durable
                  Medical Equipment (DME)

              	
                Medicare
                  and Medicaid covered durable medical equipment, including devices
                  and
                  equipment other than medical/surgical supplies, enteral formula,
                  and
                  prosthetic or orthotic appliances having the following characteristics:
                  can withstand repeated use for a protracted period of time; are
                  primarily
                  and customarily used for medical purposes; are generally not useful
                  to a
                  person in the absence of illness or injury and are usually fitted,
                  designed or fashioned for a particular individual's use. Must be
                  ordered
                  by a qualified practitioner. No homebound prerequisite and including
                  non-Medicare DME covered by Medicaid (e.g. tub stool; grab bars).
                  No
                  co-payment or coinsurance.

              
	
                Prosthetics

              	
                Medicare
                  and Medicaid covered prosthetics, orthotics and orthopedic footwear.
                  No
                  diabetic or temporary impairment prerequisite for orthotics. Not
                  subject
                  to co-payment or coinsurance.

              
	
                Diabetes
                  Monitoring

              	
                Diabetes
                  self-monitoring and management training and supplies including
                  coverage
                  for glucose monitors, test strips, and lancets. None of which are
                  subject
                  to co-payments. OTC diabetic supplies such as 2x2 gauze pads, alcohol
                  swabs/pads, insulin syringes and needles are covered by Part
                  D.

              
	
                Diagnostic
                  Testing

              	
                Diagnostic
                  tests, x-rays, lab services and radiation therapy. No
                  co-payment.

              
	
                Bone
                  Mass Measurement

              	
                Bone
                  Mass Measurement for people at risk. No co-payment.

              
	
                Colorectal
                  Screening

              	
                Colorectal
                  screening for people, age 50 and older. No co-payment.

              
	
                Immunizations

              	
                Flu,
                  hepatitis B vaccine for people who are at risk, Pneumonia vaccine.
                  Vaccines/Toxoids. No co-payment.

              
	
                Mammograms

              	
                Annual
                  screening for women age 40 and older. No referral necessary. No
                  co-payment.

              

      

      

      

      

      Medicaid
        Advantage Contract 

      APPENDIX
        K 

      State
        2007 

      Amendment
        K-4

       

      

       

      
        	
                Medicare
                  Advantage Benefit Package for Dual Eligibles - Upstate
                  Counties

              
	
                Category
                  of Service

              	
                Included
                  in Medicare Capitation

              
	
                Pap
                  Smear and Pelvic Exams

              	
                Pap
                  smears and Pelvic Exams for women. No co-payment

              
	
                Prostate
                  Cancer Screening

                Outpatient
                  Drugs

              	
                Prostate
                  Cancer Screening exams for men age 50 and older. No
                  co-payment

              
	
                Outpatient
                  Drugs

              	
                Medicare
                  Part B covered prescription drugs and other drugs obtained by a
                  provider
                  and administered in a physician office or clinic setting that are
                  covered
                  by Medicaid. (No Part D)

              
	
                Hearing
                  Services

              	
                Medicaid
                  and Medicare hearing services and products when medically necessary
                  to
                  alleviate disability caused by the loss or impairment of hearing.
                  Services
                  include hearing aid selecting, fitting, and dispensing; hearing
                  aid checks
                  following dispensing, conformity evaluations and hearing aid repairs;
                  audiology services including examinations and testing, hearing
                  aid
                  evaluations and hearing aid prescriptions;

                and
                  hearing aid products including hearing aids, earmolds, special
                  fittings
                  and replacement parts. No co-payment or limitations.

              
	
                Vision
                  Care Services

              	
                Services
                  of optometrists, ophthalmologists and ophthalmic dispensers including
                  eyeglasses, medically necessary contact lenses and poly-carbonate
                  lenses,
                  artificial eyes (stock or custom-made), low vision aids and low
                  vision
                  services. Coverage includes the replacement of lost or destroyed
                  glasses
                  and the repair or replacement of parts. Coverage also includes
                  examinations for diagnosis and treatment for visual defects and/or
                  eye
                  disease. Examinations for refraction are limited to every two (2)
                  years
                  unless otherwise justified as medically necessary. Eyeglasses do
                  not
                  require changing more frequently than every two (2) years unless
                  medically
                  necessary or unless the glasses are lost, damaged or destroyed.
                  No
                  prerequisite of cataract surgery. No co-payment

              
	
                Routine
                  Physical Exam I/year

              	
                Up
                  to one routine physical per year. Subject to $10 co-payment per
                  visit.

              
	
                Health/Wellness
                  Education

              	
                Coverage
                  for the following: general health education classes, parenting
                  classes,
                  smoking cessation classes, childbirth education and nutrition counseling,
                  plus additional benefits at plan option including but not limited
                  to items
                  such as newsletters, nutritional training, congestive heart program,
                  health club membership/fitness classes, nursing hotline, disease
                  management, other wellness services. No co-payments

              
	
                Additional
                  Part C Benefits, if any Medicare Part D Prescription Drug Benefit
                  as
                  Approved by CMS

              	 

      

      

      

      Medicaid
        Advantage Contract 

      APPENDIX
        K 

      State
        2007 Amendment 

      K-5

       

      

      
        	
                Medicare
                  Advantage Benefit Package for Dual Eligibles

                NYC,
                  Nassau, Suffolk, Westchester, Rockland, Orange and Putnam
                  Counties

              
	
                Category
                  of Service

              	
                Included
                  in Medicare Capitation

              
	
                Inpatient
                  Hospital Care Including Substance Abuse and Rehabilitation
                  Services

              	
                Up
                  to 365 days per year (366 days for leap year) with no deductible
                  or
                  co-payment

              
	
                Inpatient
                  Mental Health

              	
                Medically
                  necessary care with no deductible or co-payment. 190-day lifetime
                  limit in
                  a psychiatric hospital.

              
	
                Skilled
                  Nursing Facility

              	
                Care
                  provided in a skilled nursing facility. Covered for 100 days each
                  benefit
                  period. No prior hospital stay required. No co-payment.

              
	
                Home
                  Health

              	
                Medically
                  necessary intermittent skilled nursing care, home health aide services
                  and
                  rehabilitation services. No co-payment.

              
	
                PCP
                  Office Visits

              	
                Primary
                  care doctor office visits. No co-payment.

              
	
                Specialist
                  Office Visits

              	
                Specialist
                  office visits. Subject to $10 co-payment for each specialist office
                  visit.

              
	
                Chiropractic

              	
                Manual
                  manipulation of the spine to correct subluxation provided by chiropractors
                  or other qualified providers. Subject to $10
                  co-payment.

              
	
                Podiatry

              	
                Medically
                  necessary foot care, including care for medical conditions affecting
                  lower
                  limbs, subject to $10 co-payment. Visits for routine foot care
                  up to 4
                  visits per year, not subject to co-payment.

              
	
                Outpatient
                  Mental Health

              	
                Individual
                  and group therapy visits, subject to co-payment of $20 per individual
                  or
                  group visit. Enrollee must be able to self-refer for one assessment
                  from a
                  network provider in a twelve (12) month period.

              
	
                Outpatient
                  Substance Abuse

              	
                Individual
                  and group visits subject to $20 co-payment per group or individual
                  visit.
                   Enrollee must be able to self-refer for one assessment from a
                  network
                  provider in a twelve (12) month period.

              
	
                Outpatient
                  Surgery

              	
                Medically
                  necessary visits to an ambulatory surgery center or outpatient
                  hospital
                  facility. No co-payment.

              
	
                Ambulance

              	
                Transportation
                  provided by an ambulance service, including air ambulance. Emergency
                  transportation if for the purpose of obtaining hospital services
                  for an
                  enrollee who suffers from severe, life-threatening or potentially
                  disabling conditions which require the provision of emergency services
                  while the enrollee is being transported. Includes transportation
                  to a
                  hospital emergency room generated by a "Dial 911". No
                  co-payment.

              

      

      

      Medicaid
        Advantage Contract 

      APPENDIX
        K 

      State
        2007 

      Amendment
        K-7

       

      

      
        	
                Medicare
                  Advantage Benefit Package for Dual Eligibles

                NYC,
                  Nassau, Suffolk, Westchester, Rockland, Orange and Putnam
                  Counties

              
	
                Category
                  of Service

              	
                Included
                  in Medicare Capitation

              
	
                Emergency
                  Room

              	
                Care
                  provided in an emergency room subject to prudent layperson standard.
                  $50
                  co-payment per visit. Co-payment waived if admitted to the hospital
                  within
                  24 hours for the same condition.

              
	
                Urgent
                  Care

              	
                Urgently
                  needed care in most cases outside the plan's service

                area.
                  Subject to $10 co-payment.

              
	
                Outpatient
                  Rehabilitation (OT, PT, Speech)

              	
                Occupational
                  therapy, physical therapy and speech and language therapy subject
                  to $10
                  co-payment.

              
	
                Durable
                  Medical Equipment (DME)

              	
                Medicare
                  and Medicaid covered durable medical equipment, including devices
                  and
                  equipment other than medical/surgical supplies, enteral formula,
                  and
                  prosthetic or orthotic appliances having the following characteristics:
                  can withstand repeated use for a protracted period of time; are
                  primarily
                  and customarily used for medical purposes; are generally not useful
                  to a
                  person in the absence of illness or injury and are usually not
                  fitted,
                  designed or fashioned for a particular individual's use. Must be
                  ordered
                  by a qualified practitioner. No homebound prerequisite and including
                  non-Medicare DME covered by Medicaid (e.g., tub stool; grab bar).
                  No
                  co-payment or coinsurance.

              
	
                Prosthetics

              	
                Medicare
                  and Medicaid covered prosthetics, orthotics and orthopedic footwear.
                  No
                  diabetic prerequisite for orthotics. Not subject to co-payment
                  or
                  coinsurance.

              
	
                Diabetes
                  Monitoring

              	
                Diabetes
                  self-monitoring and management training and supplies including
                  coverage
                  for glucose monitors, test strips, and lancets. None of which are
                  subject
                  to co-payments. OTC diabetic supplies such as 2x2 gauze pads, alcohol
                  swabs/pads, insulin syringes and needles are covered by Part
                  D.

              
	
                Diagnostic
                  Testing

              	
                Diagnostic
                  tests, x-rays, lab services and radiation therapy.

                No
                  co-payments.

              
	
                Bone
                  Mass Measurement

              	
                Bone
                  Mass Measurement for people at risk. No co-payment

              
	
                Colorectal
                  Screening

              	
                Colorectal
                  screening for people, age 50 and older. No co-payment.

              
	
                Immunizations

              	
                Flu,
                  hepatitis B vaccine for people who are at risk, Pneumonia

                vaccine.
                  No co-payment.

              
	
                Mammograms

              	
                Annual
                  screening for women age 40 and older. No referral necessary. No
                  co-payment.

              
	
                Pap
                  Smear and Pelvic Exams

              	
                Pap
                  smears and Pelvic Exams for women. No co-payment.

              
	
                Prostate
                  Cancer Screening

              	
                Prostrate
                  Cancer Screening exams for men age 50 and older.

                No
                  co-payment.

              
	
                Outpatient
                  Drugs

              	
                Medicare
                  Part B covered prescription drugs and other drugs obtained by a
                  provider
                  and administered in a physician office or clinic setting that are
                  covered
                  by Medicaid. (No Part D).

                 

              

      

      

      Medicaid
        Advantage Contract 

      APPENDIX
        K 

      State
        2007 Amendment 

      K-8

       

       

      
        	
                Medicare
                  Advantage Benefit Package for Dual Eligibles

                NYC,
                  Nassau, Suffolk, Westchester, Rockland, Orange and Putnam
                  Counties

              
	
                Category
                  of Service

              	
                Included
                  in Medicare Capitation

              
	 	 
	
                Hearing
                  Services

              	
                Medicare
                  and Medicaid hearing services and products when medically necessary
                  to
                  alleviate disability caused by the loss or impairment of hearing.
                  Services
                  include hearing aid selecting, fitting, and dispensing; hearing
                  aid checks
                  following dispensing, conformity evaluations and hearing aid repairs;
                  audiology services including examinations and testing, hearing
                  aid
                  evaluations and hearing aid prescriptions; and hearing aid products
                  including hearing aids, earmolds, special fittings and replacement
                  parts.
                  No co-payment or limitations.

              
	
                Vision
                  Care Services

              	
                Services
                  of optometrists, ophthalmologists and ophthalmic dispensers including
                  eyeglasses, medically necessary contact lenses and poly-carbonate
                  lenses,
                  artificial eyes (stock or custom-made), low vision aids and low
                  vision
                  services. Coverage includes the replacement of lost or destroyed
                  glasses
                  and the repair or replacement of parts. Coverage also includes
                  examinations for diagnosis and treatment for visual defects and/or
                  eye
                  disease. Examinations for refraction are limited to every two (2)
                  years
                  unless otherwise justified as medically necessary. Eyeglasses do
                  not
                  require changing more frequently than every two (2) years unless
                  medically
                  necessary or unless the glasses are lost, damaged or destroyed.
                  No
                  prerequisite of cataract services. No co-payment.

              
	
                Routine
                  Physical Exam I/year

              	
                Up
                  to one routine physical per year. No co-payment.

              
	
                Health/Wellness
                  Education

              	
                Coverage
                  for the following: general health education classes, parenting
                  classes,
                  smoking cessation classes, childbirth education and nutrition counseling,
                  plus additional benefits at plan option including but not limited
                  to items
                  such as newsletters, nutritional training, congestive heart, program,
                  health club membership/fitness classes, nursing hotline, disease
                  management, other wellness services. No co-payments.

              
	
                Additional
                  Part C Benefits, if any

              
	
                Medicare
                  Part D Prescription Drug Benefit as Approved by
                  CMS

              

      

      

      

      Medicaid
        Advantage Contract 

      APPENDIX
        K 

      State
        2007 Amendment 

      K-9

       

      

      APPENDIX
        K2

       

      MEDICAID
        ADVANTAGE PRODUCT

       

      
        	
                Medicaid
                  Advantage Benefit Package for Dual Eligibles
                  - Upstate Counties

              
	
                Category
                  of Service

              	
                Included
                  in Medicaid Capitation

              
	
                Inpatient
                  Hospital Care Including Substance Abuse and Rehabilitation
                  Services

              	
                Elimination
                  of $300 per stay co-payment.

              
	
                Inpatient
                  Mental Health

              	
                Elimination
                  of $300 per stay co-payment, plus days in excess of the Medicare
                  190-day
                  lifetime maximum.

              
	
                Home
                  Health

              	
                Elimination
                  of $10 co-payment per Medicare covered visit. Non-Medicare covered
                  home
                  health services (e.g. home health aide services with nursing supervision
                  to

                medically
                  unstable individuals).

              
	
                PCP
                  Office Visits

              	
                Elimination
                  of $10 co-payment

              
	
                Specialist
                  Office Visits

              	
                Elimination
                  of $20 co-payment

              
	
                Podiatry

              	
                Elimination
                  of $20 co-payment for medically necessary foot care

              
	
                Outpatient
                  Mental Health

              	
                Elimination
                  of $20 co-payment

              
	
                Outpatient
                  Substance Abuse

              	
                Elimination
                  of $20 co-payment

              
	
                Outpatient
                  Surgery

              	
                Elimination
                  of $35 co-payment

              
	
                Ambulance

              	
                Elimination
                  of $50 co-payment

              
	
                Emergency
                  Room

              	
                Elimination
                  of $50 co-payment

              
	
                Urgent
                  Care

              	
                Elimination
                  of $20 co-payment

              
	
                Outpatient
                  Rehabilitation (OT, PT, Speech)

              	
                Elimination
                  of $20 co-payment

              
	
                Dental
                  (Optional
                  benefit)

              	
                Medicaid
                  covered dental services including necessary preventive, prophylactic
                  and
                  other routine dental care, services and supplies and dental prosthetics
                  to
                  alleviate a serious health condition. Ambulatory or inpatient surgical
                  dental services subject to prior authorization.

              
	
                Routine
                  Physical Exam I/year

              	
                Elimination
                  of $10 co-payment

              
	
                Transportation
                  - Routine (Optional
                  benefit)

              	
                Transportation
                  essential for an enrollee to obtain necessary medical care and
                  services
                  under the plan's benefits or Medicaid fee-for-service. Includes
                  ambulette,
                  invalid coach, taxicab, livery, public transportation, or other
                  means
                  appropriate to the enrollee's medical condition and a transportation
                  attendant to accompany the enrollee, if necessary.

              
	
                Private
                  Duty Nursing

              	
                Medically
                  necessary private duty nursing services in accordance with the
                  ordering
                  physician, registered physician assistant or certified nurse
                  practitioner's written treatment
                  plan.

              

      

      

      

      Medicaid
        Advantage Contract 

      APPENDIX
        K 

      State
        2007 Amendment 

      K-10

       

      

      
        	
                Medicaid
                  Advantage Benefit Package for Dual Eligibles

                NYC,
                  Nassau, Suffolk, Westchester, Rockland, Orange and Putnam
                  Counties

              
	
                Category
                  of Service

              	
                Included
                  in Medicaid Capitation

              
	
                Inpatient
                  Mental Health

              	
                Days
                  in excess of the Medicare 190-day lifetime maximum.

              
	
                Home
                  Health

              	
                Non-Medicare
                  covered home health services (e.g. home health aide services with
                  nursing
                  supervision to medically unstable individuals).

              
	
                Specialist
                  Office Visits

              	
                Elimination
                  of $10 co-payment.

              
	
                Podiatry

              	
                Elimination
                  of $10 co-payment for medically necessary footcare.

              
	
                Outpatient
                  Mental Health

              	
                Elimination
                  of $20 co-payment.

              
	
                Outpatient
                  Substance Abuse

              	
                Elimination
                  of $20 co-payment.

              
	
                Emergency
                  Room

              	
                Elimination
                  of $50 co-payment

              
	
                Urgent
                  Care

              	
                Elimination
                  of $10 co-payment.

              
	
                Outpatient
                  Rehabilitation (OT, PT, Speech)

              	
                Elimination
                  of $10 co-payment.

              
	
                Dental
                  (Optional
                  benefit outside of NYC )

              	
                Medicaid
                  covered dental services including necessary preventive, prophylactic
                  and
                  other routine dental care, services and supplies and dental prosthetics
                  to
                  alleviate a serious health condition. Ambulatory or inpatient surgical
                  dental services subject to prior authorization.

              
	
                Transportation
                  - Routine (Optional
                  benefit outside of NYC)

              	
                Transportation
                  essential for an enrollee to obtain necessary medical care and
                  services
                  under the plan's benefits or Medicaid fee-for-service. Includes
                  ambulette,
                  invalid coach, taxicab, livery, public transportation, or other
                  means
                  appropriate to the enrollee's medical condition and a transportation
                  attendant to accompany the enrollee, if necessary.

              
	
                Private
                  Duty Nursing

              	
                Medically
                  necessary private duty nursing services in accordance with the
                  ordering
                  physician, registered physician assistant or certified nurse
                  practitioner's written treatment
                  plan.

              

      

      

      

      

      Medicaid
        Advantage Contract 

      APPENDIX
        K 

      State
        2007

      Amendment
        K-ll

       

      

      MCO
        COVERAGE OF OPTIONAL SERVICES MEDICAID ADVANTAGE BENEFIT
        PACKAGE

       

      MCO:
        WellCare
        of New York, Inc.

       

      
        	
                 

                Service
                  Area

              	
                 

                Medicaid
                  Advantage Coverage Status

              
	
                 

                Dental
                  Services

              	
                 

                Non-Emergency
                  Transportation

              
	
                 

                Albany

              	
                 

                Not
                  Covered

              	
                 

                Not
                  Covered

              

      

      

      

      Medicaid
        Advantage Contract 

      APPENDIX
        K 

      State
        2007 Amendment

      K-12

       

      

      DESCRIPTION
        OF MEDICAID ONLY SERVICES IN MEDICAID ADVANTAGE BENEFIT
        PACKAGE:

       

      Inpatient
        Mental
        Health
        Over 190-Day Lifetime Limit

       

      All
        inpatient mental health services, including voluntary or involuntary admissions
        for mental health services over the Medicare 190-Day Lifetime Limit. The
        Contractor may provide the covered benefit for medically necessary mental
        health
        impatient services through hospitals licensed pursuant to Article 28 of the
        New
        York State P.H.L.

       

      Non-Medicare
        Covered Home Health Services

       

      Medicaid
        covered home health services include the provision of skilled services not
        covered by Medicare (e.g. physical therapist to supervise maintenance program
        for patients who have reached their maximum restorative potential or nurse
        to
        pre-fill syringes for disabled individuals with diabetes) and /or home health
        aide services as required by an approved plan of care developed by a certified
        home health agency.

       

      Private
        Duty Nursing Services

       

      Private
        duty nursing services provided by a person possessing a license and current
        registration from the NYS Education Department to practice as a registered
        professional nurse or licensed practical nurse. Private duty nursing services
        can be provided through an approved certified home health agency, a licensed
        home care agency, or a private Practitioner.

       

      Private
        duty nursing services are covered when determined by the attending physician
        to
        be medically necessary. Nursing services may be intermittent, part-time or
        continuous and must be provided in an Enrollee's home in accordance with
        the
        ordering physician, registered physician assistant or certified nurse
        practitioner's written treatment plan.

       

      Dental
        Services (optional benefit outside of NYC)

       

      Dental
        services include, but shall not be limited to, preventive, prophylactic and
        other routine dental care, services, supplies and dental prosthetics required
        to
        alleviate a serious health condition, including one which affects
        employability.

       

      Dental
        surgery performed in an ambulatory or inpatient setting is the responsibility
        of
        the Contractor whether dental services are a covered plan benefit, or not.
        Inpatient claims and referred ambulatory claims for dental services ancillary
        to
        dental surgery provided in an inpatient or outpatient hospital setting are
        the
        responsibility of the Contractor. In these situations, the professional services
        of the dentist are covered by Medicaid fee-for-service. The Contractor should
        set up procedures to prior approve dental services provided in inpatient
        and
        ambulatory settings.

      

      

      

      Medicaid
        Advantage Contract 

      APPENDIX
        K 

      State
        2007 Amendment 

      K-13

       

      

      As
        described in Sections 10.9 and 10.18 of this Agreement, Enrollees may self-refer
        to Article 28 clinics'operated by academic dental centers to obtain covered
        dental services,

       

      If
        Contractor's Benefit Package excludes dental services:

       

      i)
        Enrollees may obtain routine exams, orthodontic services and appliances,
        dental
        office surgery, fillings, prophylaxis, and other Medicaid covered dental
        services from any qualified Medicaid provider who shall claim reimbursement
        from
        eMedNY; and

      ii)
        Inpatient and referred ambulatory claims for medical services provided in
        an
        inpatient or outpatient hospital setting in conjunction with a dental procedure
        (e.g. anesthesiology, x-rays), are the responsibility of the Contractor.
        In
        these situations, the professional services of the dentist are covered Medicaid
        fee-for-service.

       

      Non-Emergency Transportation
        (optional benefit outside of NYC)

       

      Transportation
        expenses are covered when transportation is essential in order for an Enrollee
        to obtain necessary medical care and services which are covered under the
        Medicaid program (either as part of the Contractor's Benefit Package or by
        fee-for-service Medicaid). Non-emergent transportation guidelines may be
        developed in conjunction with the LDSS, based on the LDSS' approved
        transportation plan.

       

      Transportation
        services means transportation by ambulance, ambulette, fixed wing or airplane
        transport, invalid coach, taxicab, livery, public transportation, or other
        means
        appropriate to the Enrollee's medical condition; and a transportation attendant
        to accompany the Enrollee, if necessary. Such services may include the
        transportation attendant's transportation, meals, lodging and salary; however,
        no salary will be paid to a transportation attendant who is a member of the
        Enrollee's family.

       

      When
        the
        Contractor is capitated for non-emergency transportation, the Contractor
        is also
        responsible for providing transportation for an Enrollee to obtain Medicaid
        covered services that are not part of the Contractor's Benefit
        Package.

       

      For
        Contractors that cover non-emergency transportation in the Medicaid Advantage
        Benefit Package, transportation costs to MMTP services may be reimbursed
        by
        Medicaid FFS in accordance with the LDSS transportation policies in local
        districts in which there is a systematic method to discretely identify and
        reimburse such transportation costs.

       

      For
        Enrollees with disabilities, the method of transportation must reasonably
        accommodate their needs, taking into account the severity and nature of the
        disability.

      

      

      Medicaid
        Advantage Contract 

      APPENDIX
        K

      State
        2007 Amendment

      K-14

       

      

       

      

      APPENDIX
        K3

       

      NON
        COVERED SERVICES

       

      The
        following services will not be the responsibility of the MCO under the
        Medicare/Medicaid program:

       

      Services
        Covered by Direct Reimbursement from Original Medicare

       

      •
Hospice
        services provided to Medicare Advantage members

       

      •
        Other
        services deemed to be covered by Original Medicare by CMS

       

      Services
        Covered by Medicaid Fee
        for Service

      •
Out
        of
        network Family Planning services provided under the direct access provisions
        of
        the waiver

      •
Skilled
        Nursing Facility (SNF) days not covered by Medicare

       

      •
        Personal Care Services

      •
        Medicaid Pharmacy Benefits allowed by State Law (select drug categories excluded
        from the Medicare Part D benefit and certain medications included in the
        Part D
        benefit when the Enrollee is unable to receive them from his/her Medicare
        Advantage Plan), also certain Medical Supplies and Enteral Formula when not
        covered by Medicare.

       

      •
        Methadone Maintenance Treatment Programs

       

      •
Certain
        Mental Health Services, including:

      o
        Intensive Psychiatric Rehabilitation Treatment Programs 

      o
        Day
        Treatment o Continuing Day Treatment o Case Management for Seriously and
        Persistently Mentally 111 (sponsored by state or local mental health units)
        

      o
        Partial
        Hospitalizations o Assertive Community Treatment (ACT) o Personalized Recovery
        Oriented Services (PROS)

      •
        Rehabilitation Services Provided to Residents of OMH Licensed Community
        Residences (CRs) and Family Based Treatment Programs

       

      •
Office
        of Mental Retardation and Developmental Disabilities (OMRDD)
        Services

      •
        Comprehensive Medicaid Case Management

       

      •
        Directly Observed Therapy for Tuberculosis Disease

       

      •
AIDS
        Adult Day Health Care

       

      •
HP/
        COBRA Case Management

       

      •
Adult
        Day Health Care

       

      •
        Personal Emergency Response Services (PERS)

       

      

       

      

       

      

      Medicaid
        Advantage Contract 

      APPENDIX
        K 

      State
        2007 Amendment 

      K-15

       

      

      Medicaid
        Advantage Program Optional Benefits

      Optional
        benefits will be covered Medicaid fee for service if the MCO elects not to
        cover
        these

      services
        in their Medicaid Advantage Product. Currently the only two (2) optional
        benefits are:

       

      •
        .Non-Emergency Transportation Services

       

      •
Dental
        Service

       

      Both
        of
        these services, however, are mandatory in NYC.

      

      

      

      

      Medicaid
        Advantage Contract 

      APPENDIX
        K 

      State
        2007 Amendment 

      K-16

       

      

      DESCRIPTION
        OF NON-COVERED SERVICES

       

      The
        following services are excluded from the Contractor's Medicare and Medicaid
        Benefit Packages, and are covered, in most instances, by Medicare or Medicaid
        fee-for-service:

       

      1.
        Hospice Services Provided to Medicaid Advantage Enrollees

       

      Hospice
        services provided to Medicare Advantage Enrollees by Medicare approved hospice
        providers are directly reimbursed by Medicare. Hospice is a coordinated program
        of home and inpatient care that provides non-curative medical and support
        services for persons certified by a physician to be terminally ill with a
        life
        expectancy of six (6) months or less. Hospice programs provide patients and
        families with palliative and supportive care to meet the special needs arising
        out of physical, psychological, spiritual, social and economic stresses which
        are experienced during the final stages of illness and during dying and
        bereavement.

       

      Hospices
        are organizations which must be certified under Article 40 of the NYS P.H.L.
        and
        approved by Medicare. All services must be provided by qualified employees
        and
        volunteers of the hospice or by qualified staff through contractual arrangements
        to the extent permitted by federal and state requirements. All services must
        be
        provided according to a written plan of care which reflects the changing
        needs
        of the patient/family.

       

      If
        an
        Enrollee in the Contractor's plan becomes terminally ill and receives Hospice
        Program services, he or she may remain enrolled and continue to access the
        Contractor's Benefit Package while Hospice costs are paid for by Medicare
        fee-for-service.

       

      2.
        Other Services Deemed to be Covered by Original
        Medicare by CMS

       

      3.
        Personal Care Agency Services

       

      Personal
        care services (PCS) involve the provision of some or total assistance with
        personal hygiene, dressing and feeding and nutritional and environmental
        support
        (meal preparation and housekeeping). Such services must be essential to the
        maintenance of the Enrollee's health and safety in his or her own home. The
        services must be ordered by a physician, and there has to be a medical need
        for
        the services. Licensed home care services agencies, as opposed to certified
        home
        health agencies, are the primary providers of PCS. Enrollees receiving PCS
        must
        have a stable medical condition and are generally expected to be in receipt
        of
        such services for an extended period of time (years).

       

      Services
        rendered by a personal care agency which are approved by the LDSS are not
        covered under the Medicare or Medicaid Benefit Packages. Should it be medically
        necessary for the PCP to order personal care agency services, the PCP (or
        the
        Contractor on the physician's behalf) must first contact the Enrollee's LDSS
        contact person for personal care. The district will determine the Enrollee's
        need for personal care agency services and coordinate a plan of care with
        the
        personal care agency.

      

      

      Medicaid
        Advantage Contract 

      APPENDIX
        K State 2007 

      Amendment
        

      K-17

      

      4.
        Skilled Nursing Facility Days Not Covered by Medicare

       

      Skilled
        nursing facility days for Medicaid Advantage Enrollees in excess of the first
        one hundred (100) days in the benefit period are covered by Medicaid on a
        fee
        for service basis.

       

      5.
        Prescription Drugs Permitted by State Law, Certain Medical Supplies and Enteral
        Formulas Not Covered by Medicare

       

      NYS
        Medicaid continues to provide coverage for categories of drugs excluded from
        the
        Medicare Part D benefit such as barbiturates, benzodiazepines, and some
        prescription vitamins, and some non-prescription drugs. NYS also provides
        a wrap
        around program which covers medications that are included in the Part D benefit
        when the recipient is unable to receive them from his or her Part D plan.
        Effective January 1, 2007, drugs which are covered through this Medicaid
        wrap-around benefit will be limited to the following four categories of drugs:
        1) atypical antipsychotics, 2) antidepressants, 3) antiretrovirals used in
        the
        treatment of HTV/AIDS, and 4) anti-rejection drugs used in the treatment
        of
        tissue and organ transplants, but only when 1) these drugs are not covered
        by
        the specific plan, 2) the patient does not meet the plan's utilization
        management requirements, or 3) there are quantity limits inconsistent with
        the
        prescribed amount. Certain medical/surgical supplies and enteral formula
        covered
        by Medicaid and not included in the Contractor's Medicare Advantage Benefit
        Package also will be paid for by Medicaid fee-for-service. Medical/surgical
        supplies are items other than drugs, prosthetic or orthotic appliances, or
        DME,
        which have been ordered by a qualified practitioner in the treatment of a
        specific medical condition and which are: consumable, non-reusable, disposable,
        or for a specific rather than incidental purpose, and generally have no
        salvageable value (e.g. gauze pads, bandages and diapers). Pharmaceuticals
        and
        medical supplies routinely furnished or administered as part of a clinic
        or
        office visit are covered by the Contractor.

       

      6.
        Out of Network Family Planning Services

       

      As
        described in Sections 10.6 and 10.9 of this Agreement, out of network family
        planning services provided by qualified Medicaid providers to plan enrollees
        will be directly reimbursed by Medicaid fee-for-service at the Medicaid fee
        schedule. "Family Planning and Reproductive Health Services" means those
        health
        services which enable Enrollees, including minors who may be sexually active,
        to
        prevent or reduce the incidence of unwanted pregnancy. These
        include:

      diagnosis
        and all medically necessary treatment, sterilization, screening and treatment
        for sexually transmissible diseases and screening for disease and
        pregnancy.

       

      Also
        included are HP/ counseling and testing when provided as part of a family
        planning visit. Additionally, reproductive health care includes coverage
        of all
        medically necessary abortions. Elective induced abortions must be covered
        for
        New York City recipients. Fertility services are not covered.

       

      7.
        Dental (when not in benefit package)

       

      (See
        description in Appendix K-2)

       

      8.
        Non-Emergency Transportation (when not in benefit package)

       

      

       

      

       

      Medicaid
        Advantage Contract 

      APPENDIX
        K 

      State
        2007 Amendment 

      K-18

       

      

      (See
        description in Appendix K-2)

       

      9.
        Methadone Maintenance Treatment Program (MMTP)

       

      MMTP
        consists of drug detoxification, drug dependence counseling, and rehabilitation
        services which include chemical management of the patient with methadone.
        Facilities authorized to provide methadone maintenance treatment certified
        by
        the Office of Alcohol and Substance Abuse Services (OASAS) under Part 828
        of 14
        NYCRR.

       

      10.
        Certain Mental Health Services

       

      The
        Contractor is not responsible for the provision and payment of the following
        services, which are reimbursed through Medicaid fee-for-service.

       

      a.
        Intensive Psychiatric Rehabilitation Treatment Programs (IPRT)

       

      IPRT
        is a
        time-limited active psychiatric rehabilitation designed to assist a patient
        in
        forming and achieving mutually agreed upon goals in living, learning, working
        and social environments and to intervene with psychiatric rehabilitative
        technologies to overcome functional disabilities. IPRT services are certified
        by
        OMH under Part 587 of 14 NYCRR.

       

      b.
        Day
        Treatment

       

      Day
        Treatment is a combination of diagnostic, treatment, and rehabilitative
        procedures which, through supervised and planned activities and extensive
        client-staff interaction, provides the services of the clinic treatment program,
        as well as social training, task and skill training and socialization
        activities. These services are certified by OMH under Part 587 of 14
        NYCRR.

       

      c.
        Continuing Day Treatment

       

      Continuing
        Day Treatment is designed to maintain or enhance current levels of functioning
        and skills, maintain community living, and develop self-awareness and
        self-esteem. It includes:

      assessment
        and treatment planning, discharge planning, medication therapy, medication
        education, case management, health screening and referral, rehabilitative
        readiness development, psychiatric rehabilitative readiness determination
        and
        referral, and symptom management. These services are certified by OMH under
        Part
        587 of 14 NYCRR.

       

      d.
        Case
        Management for Seriously and Persistently Mentally 111 Sponsored by State
        or
        Local Mental Health Units

       

      The
        target population consists of individuals who are seriously and persistently
        mentally ill (SPMI), require intensive, personal and proactive intervention
        to
        help them obtain those services which will permit functioning in the community
        and either have symptomology which is difficult to treat in the existing
        mental
        health care system or are unwilling or unable to adapt to the existing mental
        health care system. Three case management models are currently
        operated

      

      

      Medicaid
        Advantage Contract 

      APPENDIX
        K 

      State
        2007 Amendment

      K-19

       

      

      pursuant
        to an agreement with OMH or a local governmental unit, and receive Medicaid
        reimbursement pursuant to Part 506 of 14 NYCRR.

       

      Please
        note: See generic definition of Comprehensive Medicaid Case Management (CMCM)
        in
        this section.

       

      e.
        Partial Hospitalization Not Covered by Medicare

       

      Provides
        active treatment designed to stabilize and ameliorate acute systems, serves
        as
        an alternative to inpatient hospitalization, or reduces the length of a hospital
        stay within a medically supervised program by providing the following:
        assessment and treatment planning; health screening and referral; symptom
        management; medication therapy; medication education; verbal therapy; case
        management; psychiatric rehabilitative readiness determination and referral
        and
        crisis intervention. These services are certified by OMH under Part 587 of
        14
        NYCRR.

       

      f.
        Assertive Community Treatment (ACT)

       

      ACT
        is a
        mobile team-based approach to delivering comprehensive and flexible treatment,
        rehabilitation, case management and support services to individuals in their
        natural living setting. ACT programs deliver integrated services to recipients
        and adjust services over time to meet the recipient's goals and changing
        needs.
        They are operated pursuant to approval or certification by OMH; and receive
        Medicaid reimbursement pursuant to Part 508 of 14 NYCRR.

       

      g.
        Personalized Recovery Oriented Services (PROS)

       

      PROS,
        licensed and reimbursed pursuant to Part 512 of 14 NYCRR, are designed to
        assist
        individuals in recovery from the disabling effects of mental illness through
        the
        coordinated delivery of a customized array of rehabilitation, treatment,
        and
        support services in traditional settings and in off-site locations. Specific
        components of PROS include Community Rehabilitation and Support, Intensive
        Rehabilitation, Ongoing Rehabilitation and Support and Clinical
        Treatment.

       

      11.
        Rehabilitation Services Provided to Residents of OMH Licensed Community
        Residences (CRs) and Family Based Treatment Programs, as follows:

       

      a.
        OMH
        Licensed CRs*

       

      Rehabilitative
        services in community residences are interventions, therapies and activities
        which are medically therapeutic and remedial in nature, and are medically
        necessary for the maximum reduction of functional and adaptive behavior defects
        associated with a person's mental illness.

       

      b.
        Family-Based Treatment*

       

      Rehabilitative
        services in family-based treatment programs are intended to provide treatment
        to
        seriously emotionally disturbed children and youth to promote their successful
        functioning and integration into the family, community, school or independent
        living situations. Such services are provided in consideration of a child's
        developmental stage. Children determined eligible for

       

      

       

      

       

      Medicaid
        Advantage Contract 

      APPENDIX
        K 

      State
        2007 Amendment

      K-20

       

      

      admission
        are placed in surrogate family homes for care and treatment. These services
        are
        certified by OMH under Section 586.3, and Parts 594 and 595 of 14 NYCRR
        .

       

      12.
        Office of Mental Retardation and Developmental Disabilities (OMRDD)
        Services

       

      a.
        Long
        Term Therapy Services Provided by Article 16-Clinic Treatment Facilities
        or
        Article 28 Facilities

       

      These
        services are provided to persons with developmental disabilities including
        medical or remedial services recommended by a physician or other licensed
        practitioner of the healing arts for a maximum reduction of the effects of
        physical or mental disability and restoration of the person to his or her
        best
        possible functional level. It also includes the fitting, training, and
        modification of assistive devices by licensed practitioners or trained others
        under their direct supervision. Such services are designed to ameliorate
        or
        limit the disabling condition and to allow the person to remain in or move
        to,
        the least restrictive residential and/or day setting. These services are
        certified by OMRDD under Part 697 of 14 NYCRR (or they are provided by Article
        28 Diagnostic and Treatment Centers that are explicitly designated by the
        SDOH
        as serving primarily persons with developmental disabilities). If care of
        this
        nature is provided in facilities other than Article 28 or Article 16 centers,
        it
        is a covered service.

       

      b.
        Day
        Treatment

       

      A
        planned
        combination of diagnostic, treatment and rehabilitation services provided
        to
        developmentally disabled individuals in need of a broad range of services,
        but
        who do not need intensive twenty-four (24) hour care and medical supervision.
        The services provided as identified in the comprehensive assessment may include
        nutrition, recreation, self-care, independent living, therapies, nursing,
        and
        transportation services. These services are generally provided in an
        Intermediate Care Facility (1CF) or a comparable setting. These services
        are
        certified by OMRDD under Part 690 of 14 NYCRR.

       

      c.
        Medicaid Service Coordination (MSC)

       

      Medicaid
        Service Coordination (MSC) is a Medicaid State Plan service provided by OMRDD
        which assists persons v/ith developmental disabilities and mental retardation
        to
        gain access to necessary services and supports appropriate to the needs of
        the
        needs of the individual. MSC is provided by qualified service coordinators
        and
        uses a person centered planning process in developing, implementing and
        maintaining an Individualized Service Plan (ISP) with and for a person with
        developmental disabilities and mental retardation. MSC promotes the concepts
        of
        a choice, individualized services and consumer satisfaction.

       

      MSC
        is
        provided by authorized vendors who have a contract with OMRDD, and who are
        paid
        monthly pursuant to such contract. Persons who receive MSC must not permanently
        reside in an ICF for persons with developmental disabilities, a developmental
        center, a skilled nursing facility or any other hospital or Medical Assistance
        institutional setting that provides service coordination. They must also
        not
        concurrently be enrolled in any other comprehensive Medicaid long term service
        coordination program/service, including the Care at Home Waiver.

      

      

      

      Medicaid
        Advantage Contract

      APPENDIX
        K 

      State
        2007 Amendment

      K-21

       

      

      Please
        note: See generic definition of Comprehensive Medicaid Case Management
        (CMCM) in this
        section.

       

      d.
        Home
        And Community Based Services Waivers (HCBS)

       

      The
        Home
        and Community-Based Services Waiver serves persons with developmental
        disabilities who would otherwise be admitted to an ICF/MR if waiver services
        were not provided. HCBS waivers services include residential habilitation,
        day
        habilitation, prevocational, supported work, respite, adaptive devices,
        consolidated supports and services, environmental modifications, family
        education and training, live-in caregiver, and plan of care support services.
        These services are authorized pursuant to a waiver under Section 1915(c)
        of the
        Social Security Act (SSA).

       

      e.
        Services Provided Through the Care At Home Program (OMRDD)

       

      The
        OMRDD
        Care at Home III, Care at Home IV, and Care at Home VI waivers, serve children
        who would otherwise not be eligible for Medicaid because of their parents'
        income and resources, and who would otherwise be eligible for an ICF/MR level
        of
        care. Care at Home waiver services include service coordination, respite
        and
        assistive technologies. Care at Home waiver services are authorized pursuant
        to
        a waiver under Section 1915(c) of the (SSA).

       

      13.
        Comprehensive Medicaid Case
        Management (CMCM)

       

      A
        program
        which provides "social work" case management referral services to a targeted
        population (e.g.: teens, mentally ill). A CMCM case manager will assist a
        client
        in accessing necessary services in accordance with goals contained in a written
        case management plan. CMCM programs do not provide services directly, but
        refer
        to a wide range of service providers. The nature of these services include:
        medical, social, psycho-social, education, employment, financial, and mental
        health. CMCM referral to community service agencies and/or medical providers
        requires the case manager to work out a mutually agreeable case coordination
        approach with the agency/medical providers. Consequently, if an Enrollee
        of the
        Contractor is participating in a CMCM program, the Contractor should work
        collaboratively with the CMCM case manager to coordinate the provision of
        services covered by the Contractor. CMCM programs will be instructed on how
        to
        identify a managed care Enrollee on eMedNY so that the program can contact
        the
        Contractor or to coordinate service provision.

       

      14.
        Directly Observed Therapy for Tuberculosis Disease

       

      Tuberculosis
        directly observed therapy (TB/DOT) is the direct observation of oral ingestion
        of TB medications to assure patient compliance with the physician's prescribed
        medication regimen. While the clinical management of tuberculosis is covered
        in
        the Benefit Package, TB/DOT where applicable, can be billed directly to MMIS
        by
        any SDOH approved fee-for-service Medicaid TB/DOT Provider. The Contractor
        remains responsible for communicating, cooperating and coordinating clinical
        management of TB with the TB/DOT Provider.

       

      

      Medicaid
        Advantage Contract 

      APPENDIX
        K 

      State
        2007 Amendment 

      K-22

       

      

      15.
        AIDS Adult Day Health Care

       

      Adult
        Day
        Health Care Programs (ADHCP) are programs designed to assist individuals
        with
        HIV disease to live more independently in the community or eliminate the
        need
        for residential health care services. Registrants in ADHCP require a greater
        range of comprehensive health care services than can be provided in any single
        setting, but do not require the level of services provided in a residential
        health care setting. Regulations require that a person enrolled in an ADHCP
        must
        require at least three (3) hours of health care delivered on the basis of
        at
        least one (1) visit per week. While health care services are broadly defined
        in
        this setting to include general medical care, nursing care, medication
        management, nutritional services, rehabilitative services, and substance
        abuse
        and mental health services, the latter two (2) cannot be the sole reason
        for
        admission to the program. Admission criteria must include, at a minimum,
        the
        need for general medical care and nursing services.

       

      16.
        HIV COBRA Case Management

       

      The
        HIV
        COBRA (Community Follow-up Program) Case Management Program is a program
        that
        provides intensive, family-centered case management and community follow-up
        activities by case managers, case management technicians, and community
        follow-up workers. Reimbursement is through an hourly rate billable to Medicaid.
        Reimbursable activities include intake, assessment, reassessment, service
        plan
        development and implementation, monitoring, advocacy, crisis intervention,
        exit
        planning, and case specific supervisory case-review conferencing.

       

      17.
        Adult Day Health Care

       

      Adult
        Day Health
        Care
        means care and services provided to a registrant in a residential health
        care
        facility or approved extension site under the medical direction of a physician
        and which is provided by personnel of the adult day health care program in
        accordance with a comprehensive assessment of care needs and an individualized
        health care plan, and providing ongoing implementation and coordination of
        the
        health care plan, and transportation.

       

      Registrant
        means a
        person who is a nonresident of the residential health care facility, who
        is
        functionally impaired and not homebound, and who requires certain preventive,
        diagnostic, therapeutic, rehabilitative or palliative items or services provided
        by a general hospital, or residential health care facility; and whose assessed
        social and health care needs, in the professional judgment of the physician
        of
        record, nursing staff, Social Services and other professional personnel of
        the
        adult day health care program can be met satisfactorily in whole or in part
        by
        delivery of appropriate services in such program.

       

      18.
        Personal Emergency Response Services (PERS)

       

      Personal
        Emergency Response Services (PERS) are not covered by the Benefit Package.
        PERS
        are covered on a fee-for-service basis through contracts between the LDSS
        and
        PERS vendors.

      

      

      

      Medicaid
        Advantage Contract 

      APPENDIX
        K 

      State
        2007 Amendment 

      K-23

       

      

      APPENDIX
        L

       

      Approved
        Capitation Payment Rates

       

      

       

      

       

      

      Medicaid
        Advantage Contract

      APPENDIX
        L 

      State
        200
        7 Amendment 

      L-l

      

      WellCare
        of
        New York, Inc

       

      Dual
        Eligible Medicaid Managed Care Rates

       

      

      
        	
                MMISID#: 02645710

              	 	
                Effective
                  Date: 01/01/07

              
	
                Region: Upstate

              	 	 
	
                County: Albany

              	 	 

      

       

      

       

      

      
        	
                Rate
                  Code

              	
                Premium
                  Group

              	
                Rate
                  Amount

              
	
                2370

              	
                DUALLY
                  ELIGIBLE SSI 21-64 MALE/FEMALE

              	
                $84.04

              
	
                2371

              	
                DUALLY
                  ELIGIBLE SSI 65+ MALE/FEMALE

              	
                $85.64

              

      

       

      Optional
        Benefits Offered:

       

      £
        Dental

       

      £
        Non-Emergent Transportation

       

      

       

      Box
        will be checked if the optional benefit is covered by the
        plan

       

      

      APPENDIX
        M 

      Service
        Area

      

      

      Medicaid
        Advantage Contract 

      APPENDIX
        M 

      State
        2007 Amendment

      M-l

       

      

      The
        Contractor's Medicaid Advantage service area is comprised of the following
        counties in their entirety:

       

      Albany

      

      

      

      

      

      

      

      

      Medicaid
        Advantage Contract 

      APPENDIX
        M 

      State
        2007 Amendment 

      M-2Exhibit 10.2

    
      

    

    Back
      to Form 8-K

     

    Exhibit
      10.2

     

    

      PROVIDER
        AGREEMENT BETWEEN 

      STATE
        OF OHIO

      DEPARTMENT
        OF JOB AND FAMILY SERVICES AND

      WELLCARE
        OF OHIO, INC. 

      Amendment
        No. 1

       

      Pursuant
        to Article IX.A. the Provider Agreement between the State of Ohio, Department
        of
        Job and Family Services, (hereinafter referred to as "ODJFS") and WELLCARE
        OF
        OHIO, INC. (hereinafter referred to as "MCP") for the Covered Families and
        Children (hereinafter referred to as "CFC") population dated November 1,
        2006,
        is hereby amended as follows:

       

      1.
        Baseline, Index and Appendices A, B, C, D, E, F, G, H, I, J, K, L, M, N,
        O and P
        are modified as attached.

       

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

       

      The
        amendment contained herein shall be effective January 1, 2007.

       

      

      
        	
                WELLCARE
                  OF OHIO, INC.:

                 

                BY:
                  /s/
                  Todd S. Farha

                TODD
                  S. FARHA, PRESIDENT & CEO

              	
                 

                Date:
                  12/18/2006

              
	
                 

                OHIO
                  DEPARTMENT OF JOB AND FAMILY SERVICES:

                 

                BY:
                  /s/
                  Barbara E. Riley  

                BARBARA
                  E. RILEY, DIRECTOR

              	
                 

                Date:
                  12/22/2006

              

      

      
         

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        

         

        Covered
          Families and Children (CFC) population

        

        

        OHIO
          DEPARTMENT OF JOB AND FAMILY SERVICES

        OHIO
          MEDICAL ASSISTANCE PROVIDER AGREEMENT

        FOR
          MANAGED CARE PLAN

        CFC
          ELIGIBLE POPULATION

         

        This
          provider agreement is entered into this first day of January, 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 Covered Families and Children (CFC) eligible population described in
          OAC
          rule 5101:3-26-02 (B).

         

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

         

        

        Covered
          Families and Children (CFC) population 

        Page
          2 of
          10

         

        This
          provider agreement is a contract between the ODJFS and the undersigned
          Managed
          Care Plan (MCP), provider of medical assistance, pursuant to the federal
          contracting provisions of 42 CFR 434.6 and 438.6 in which the MCP agrees
          to
          provide comprehensive medical services through the managed care program
          as
          provided in Chapter 5101:3-26 of the Ohio Administrative Code, assuming
          the risk
          of loss, and complying with applicable state statutes, Ohio Administrative
          Code,
          and Federal statutes, rules, regulations and other requirements, including
          but
          not limited to title VI of the Civil Rights Act of 1964; title IX of the
          Education Amendments of 1972 (regarding education programs and activities);
          the
          Age Discrimination Act of 1975; the Rehabilitation Act of 1.973; 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.

         

        

        Covered
          Families and Children (CFC) population

        Page
          3 of
          l0

         

        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 OD.1FS of the disqualification and MCP shall
          immediately cease performance of its obligation hereunder in accordance
          with OAC
          Chapter 5101:3-26.

         

        ARTICLE
          V
          - CONFLICT OF INTEREST; ETHICS LAWS

         

        A.
          In
          accordance with the safeguards specified in section 27 of the Office of
          Federal
          Procurement Policy Act (41 U.S.C. 423) and other applicable federal
          requirements, no officer, member or employee of MCP. the Chief of BMHC,
          or other
          ODJFS employee who exercises any functions or responsibilities in connection
          with the review or approval of this provider agreement or provision of
          services
          under this provider agreement shall, prior to the completion of such services
          or
          reimbursement, acquire any interest, personal or otherwise, direct or indirect,
          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.

         

        

        Covered
          Families and Children (CFC) population

        Page
          4 of
          10

         

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

         

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

         

        ARTICLE
          VI - EQUAL EMPLOYMENT OPPORTUNITY

         

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

         

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

         

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

         

        ARTICLE
          VII - RECORDS, DOCUMENTS AND INFORMATION

         

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

         

        B.
          All
          information provided by MCP to ODJFS that is proprietary shall be held
          to be
          strictly

         

        Covered
          Families and Children (CFC) population 

        Page
          5 of
          10

         

        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
          [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.

         

        

        Covered
          Families and Children (CFC) population

        Page
          6 of
          10

         

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

         

        ARTICLE
          IX - AMENDMENT AND RENEWAL

         

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

         

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

         

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

         

        ARTICLE
          X
          - LIMITATION OF LIABILITY

         

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

         

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

         

        C.
          In the
          event that, due to circumstances not reasonably within the control of MCP
          or
          ODJFS, a major disaster, epidemic, complete or substantial destruction
          of
          facilities, war, riot or civil insurrection occurs, neither ODJFS nor MCP
          will
          have any liability or obligation on account of reasonable delay in the
          provision
          or the arrangement of covered

         

        

        Covered
          Families and Children (CFC) population 

        Page
          7 of
          10

         

        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.

         

        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

         

        Covered
          Families and Children (CFC) population 

        Page
          8 of
          10

         

        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 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). 

         

        

        Covered
          Families and Children (CFC) population 

        Page
          9 of
          10

         

         

         

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

         

        

        Covered
          Families and Children (CFC) population

        

         

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

         

        

        
          	
                  WELLCARE
                    OF OHIO, INC.:

                   

                  BY:
                    _______________________

                  TODD
                    S. FARHA, PRESIDENT & CEO

                	
                   

                  Date:
                    

                
	
                   

                  OHIO
                    DEPARTMENT OF JOB AND FAMILY SERVICES:

                   

                  BY:
                    __________________________ 

                  BARBARA
                    E. RILEY, DIRECTOR

                	
                   

                  Date:

                

        

        

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        CFC
          PROVIDER AGREEMENT INDEX

         

        JANUARY
          1, 2007

         

        

        

        
          	
                  APPENDIX

                	
                  TITLE

                
	
                  APPENDIX
                    A

                	
                  OAC
                    RULES 5101:3-26

                
	
                  APPENDIX
                    B

                	
                  SERVICE
                    AREA SPECIFICATIONS - CFC
                    ELIGIBLE POPULATION

                
	
                  APPENDIX
                    C

                	
                  MCP
                    RESPONSIBILITIES - CFC ELIGIBLE POPULATION

                
	
                  APPENDIX
                    D

                	
                  ODJFS
                    RESPONSIBILITIES - CFC ELIGIBLE POPULATION

                
	
                  APPENDIX
                    E

                	
                  RATE
                    METHODOLOGY - CFC ELIGIBLE POPULATION

                
	
                  APPENDIX
                    F

                	
                  REGIONAL
                    RATES - CFC ELIGIBLE POPULATION

                
	
                  APPENDIX
                    G

                	
                  COVERAGE
                    AND SERVICES - CFC ELIGIBLE POPULATION

                
	
                  APPENDIX
                    H

                	
                  PROVIDER
                    PANEL SPECIFICATIONS - CFC ELIGIBLE POPULATION

                
	
                  APPENDIX
                    I

                	
                  PROGRAM
                    INTEGRITY- CFC ELIGIBLE POPULATION

                
	
                  APPENDIX
                    J

                	
                  FINANCIAL
                    PERFORMANCE - CFC ELIGIBLE POPULATION

                
	
                  APPENDIX
                    K

                	
                  QUALITY
                    ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM - CFC ELIGIBLE
                    POPULATION

                
	
                  APPENDIX
                    L

                	
                  DATA
                    QUALITY - CFC ELIGIBLE POPULATION

                
	
                  APPENDIX
                    M

                	
                  PERFORMANCE
                    EVALUATION - CFC ELIGIBLE POPULATION

                
	
                  APPENDIX
                    N

                	
                  COMPLIANCE
                    ASSESSMENT SYSTEM - CFC ELIGIBLE POPULATION

                
	
                  APPENDIX
                    O

                	
                  PAY-FOR-PERFORMANCE
                    (P4P) - CFC ELIGIBLE POPULATION

                
	
                  APPENDIX
                    P

                	
                  MCP
                    TERMINATIONS/NONRENEWALS/ AMENDMENTS - CFC 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 

         

        CFC
          ELIGIBLE POPULATION

         

        MCP:
          WELLCARE OF OHIO, INC.

         

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

         

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

         

        

        APPENDIX
          C

         

        MCP
          RESPONSIBILITIES CFC ELIGIBLE POPULATION

         

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

         

        General
          Provisions

         

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

         

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

         

        3
          The MCP
          must designate the following:

         

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

         

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

         

        As
          long
          as the MCP serves both the CFC and ABD populations, they are not required
          to
          have separate provider relations representatives or Medicaid
          coordinators.

         

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

         

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

         

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

         

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

         

        

        Appendix
          C 

        Page
          2

         

        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 ^500 of the
          MCP's
          CFC members. The MCP must provide notification within one working day of
          the MCP
          becoming aware of the termination.

         

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

         

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

         

        

        Appendix
          C 

        Page
          3

         

        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 members. MCPs shall include a requirement in its contracts with affiliated
          providers that such providers also adhere to applicable Federal and State
          laws
          when providing services to members.

         

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

         

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

         

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

         

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

         

        a.
          When
          10% or more of the CFC eligible individuals in the MCP's service area have
          a
          common primary language other than English, the MCP must

         

        

        Appendix
          C

        Page
          4

         

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

         

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

         

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

         

        

        Appendix
          C

        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(0),
          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.

         

        24.
          New
          Member Materials

         

        

        Appendix
          C

        Page
          7

         

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

         

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

         

        b.
          The ID
          card and new member letter must be mailed together to the member via a
          method
          that will ensure 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 no more than 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 all times during the hours
          of
          7:00 a.m to 7:00 p.m Eastern Time, except for the following major
          holidays:

         

        •
New
          Year's Day

        •
Martin
          Luther King's Birthday

        •
          Memorial Day

        •
          Independence Day

        •
Labor
          Day

        •
          Thanksgiving Day

        •
          Christmas Day

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

         

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

        

        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 (24/7) toll-free call-in system, available
          nationwide, pursuant to OAC rule 5101:3-26-03.1(A)(6). The 24/7 call-in
          system
          must be staffed by appropriately trained medical personnel. For the purposes
          of
          meeting this requirement, trained medical professionals are defined as
          physicians, physician assistants, licensed practical nurses, and registered
          nurses.

         

        MCPs
          must
          meet the current American Accreditation HealthCare Commission/URAC-designed
          Health Call Center Standards (HCC) for call center abandonment rate, blockage
          rate and average speed of answer. By the 10th
          of each
          month, MCPs must self-report their prior month performance in these three
          areas
          for their member services and 24/7 toll-free call-in systems to ODJFS.
          ODJFS
          will inform the MCPs of any changes/updates to these URAC call center
          standards.

         

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

         

        26.
          Notification
          of Optional MCP Membership

         

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

        -
          Indians
          who are members of federally-recognized tribes. 

        -
          Children under 19 years of age who are:

        o
          Eligible for Supplemental Security Income under title XVI;

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

        o
          Receiving foster care of adoption assistance;

        o
          Receiving services through the Ohio Department of Health's Bureau
          for

        

        Appendix
          C

        Page
          9

         

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

         

        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.

         

         

        Appendix
          C 

        Page
          10

        

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

         

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

         

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

         

        29.
          MCP
          Membership acceptance, documentation and reconciliation

         

        a.
          Selection
          Services Contractor:
          The MCP
          shall provide to the selection services contractor (SSC) ODJFS prior-approved
          MCP materials and directories for distribution to eligible individuals
          who
          request additional information about the MCP.

         

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

         

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

         

        Appendix
          C

        Page
          11

         

        d.
          Hospital
          Deferment Requests:
          When the
          MCP learns of a new member's hospitalization that is eligible for deferment
          prior to that member's discharge, the MCP shall notify the hospital and
          treating
          providers of the potential that the MCP may not be the payer. The MCP shall
          work
          with hospitals, providers and the ODJFS to assure that discharge planning
          assures continuity of care and accurate payment. Notwithstanding the MCP's
          right
          to request a hospital deferment up to six (6) months following the member's
          effective date, when the MCP leams of a deferment-eligible hospitalization,
          the
          MCP shall make every effort to notify the ODJFS and request the deferment
          as
          soon as possible. When the MCP is notified by ODJFS of a potential hospital
          deferment, the MCP must make every effort to respond to ODJFS within 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.
          Newborn
          Notifications:
          The MCP
          is required to submit newborn notifications to ODJFS in accordance with
          the
          ODJFS Newborn Notification File and Submissions Specifications.

         

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

         

        h.
          Pending
          Member

         

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

         

         

        Appendix
          C 

        Page
          12

         

         

        i.
          Transition
          of Fee-For-Service Members

         

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

         

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

         

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

         

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

         

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

         

        d.
          The
          member has appointments within the initial month of MCP

        membership
          with specialty physicians that were scheduled prior to the effective date
          of
          membership; or

         

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

         

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

         

        iii.
          Document the provision of transition of services as follows:

         

        a.
          As
          expeditiously as the situation warrants, contact the

        provider's
          office via telephone to confirm that the service(s) meet(s) the above
          criteria.

        

        Appendix
          C 

        Page
          13

         

        b.
          For
          services that meet the above criteria, inform the provider 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
          authorization and ensure that the 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.

         

        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.

         

        30.
          Health
          Information System Requirements

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

         

        a.
          Health
          Information System

         

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

         

        Appendix
          C 

        Page
          14

         

        data
          received from providers is accurate and complete by verifying the accuracy
          and
          timeliness of reported data; screening the data for completeness, logic,
          and
          consistency; and collecting service information in standardized formats
          to the
          extent feasible and appropriate.

         

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

         

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

         

        a.
          Before
          an MCP may submit production files 

         

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

        

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

         

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

         

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

        

        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

         

        Appendix
          C

        Page
          15

         

        must
          be
          provided to non-contracting providers within thirty (30) days of a request.
          MCPs
          must inform providers of its ability to electronically process and adjudicate
          claims and the process for submission. Such information must be initiated
          by the
          MCP and not only in response to provider requests.

         

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

         

        Electronic
          Data Interchange

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

        Health
          care claims;

        Health
          care claim status request and response;

        Health
          care payment and remittance status; 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.

         

         

        Appendix
          C 

        Page
          16

         

        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
          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 (ASCX12N 837&NCPDP5.1)

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

        c.
          Referral Certification and Authorization (ASC X 12N 278) 

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

        e.
          Enrollment and Disenrollment in a Health Plan (ASC XI 2N 834) 

        f.
          Health
          Care Payment and Remittance Advice (ASC X12N 835) 

        g.
          Health
          Plan Premium Payments (ASC X 12N 820) 

        h.
          Coordination of Benefits

         

        Trading
          Partner Agreement with ODJFS

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

         

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

         

        c.
          Encounter
          Data Submission Requirements

         

        General
          Requirements

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

        

        Appendix
          C 

        Page
          17

         

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

         

        •
          Institutional Claims - UB92 flat file

         

        •
          Noninstitutional Claims - National standard format

         

        •
          Prescription Drug Claims - NCPDP

         

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

         

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

         

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

         

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

         

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

         

        Appendix
          C 

        Page
          18

         

        Acceptance
          Testing

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

         

        Acceptance
          testing of encounter data is required as specified in Section

        29(a)(v)
          of this Appendix.

         

        Encounter
          Data File Submission Procedures

        A
          certification letter must accompany the submission of an encounter data
          file in
          the ODJFS-specified medium. The certification letter must be signed by
          the MCP's
          Chief Executive Officer (CEO), Chief Financial Officer (CFO), or an individual
          who has delegated authority to sign for, and who reports directly to, the
          MCP's
          CEO or CFO.

         

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

         

         

        Appendix
          C 

        Page
          19

         

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

         

        ii.
          Review the completed ISCA and accompanying documents;

         

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

         

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

         

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

         

        vi.
          Examine MCP processes for data transfers;

         

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

         

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

         

        ix.
          Assess the claims adjudication process and capabilities of the MCP.

         

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

         

        Appendix
          C

        Page
          20

         

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

         

        31.
          Delivery
          Payments

         

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

         

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

         

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

         

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

         

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

         

        Rejections

        If
          a
          delivery encounter is not submitted according to ODJFS specifications,
          it will
          be rejected and MCPs will receive this information on the exception report
          (or
          error report) that accompanies every file in the ODJFS-specified format.
          Tracking, correcting and resubmitting all rejected encounters is the
          responsibility of the MCP and is required by ODJFS.

        

        Appendix
          C

        Page
          21

         

        

        Timing
          of Delivery Payments

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

         

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

         

        Updating
          and Deleting Delivery Encounters

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

         

        The
          process for deleting delivery encounters can be found on page 35 of the
          UB-92
          technical specifications (record/field 20-7) and page 111-47 of the NSF
          technical specifications (record/field CAO-31 .Oa).

         

        Auditing
          of Delivery Payments

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

         

        32.
          If
          the MCP will be using the Internet functions that will allow approved users
          to
          access member information (e.g., eligibility verification), the MCP must
          receive
          prior approval from ODJFS that verifies that the proper safeguards, firewalls,
          etc., are in place to protect member data.

         

        33.
          MCPs
          must receive prior written approval from ODJFS before adding any information
          to
          their website that would require ODJFS prior approval in hard copy form
          (e.g.,
          provider listings, member handbook information).

         

        34.
          Pursuant to 42 CFR 438.106(b), the MCP acknowledges that it is prohibited
          from
          holding a member liable for services provided to the member in the event
          that
          the ODJFS fails to make payment to the MCP.

         

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

         

        Appendix
          C 

        Page
          22

        

         

        36.
          Franchise Fee Assessment Requirements

         

        a.
          Each
          MCP is required to pay a franchise permit fee to ODJFS for each calendar
          quarter
          as required by ORC Section 5111.176. The current fee to be paid is an amount
          equal to 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.

         

        37.
          Information
          Required for MCP Websites

         

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

         

        b.
          On-line
          Member Website
          - MCPs
          must have a secure internet-based website which is regularly updated to
          include
          the most current ODJFS approved materials. The website at a minimum must
          include: (1) a list of the counties that are covered 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

        

        Appendix
          C

        Page
          23

         

        must
          be
          given the option of a return e-mail or phone call) within one working day
          of
          receipt. MCPs must ensure that all member materials designated specifically
          for
          CFC and/or ABD consumers (i.e. the MCP member handbook) are clearly labeled
          as
          such. The MCP's member website cannot be used as the only means to notify
          members of new and/or revised MCP information (e.g., change in holiday
          closures,
          change in additional benefits, revisions to approved member materials etc.).
          ODJFS may require MCPs to include additional information on the member
          website,
          as needed.

         

        c.
          On-line
          Provider Website -
          MCPs
          must have a secure internet-based website for 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 member materials designated specifically for CFC and/or
          ABD
          consumers are clearly labeled as such. ODJFS may require MCPs to include
          additional information on the provider website, as needed.

         

        38.
          MCPs
          must provide members with a printed version of their PDL and PA lists,
          upon
          request.

         

        39.
          MCPs
          must not use, or propose to use, any offshore programming or call center
          services in fulfilling the program requirements.

         

        

        APPENDIX
          D

        ODJFS
          RESPONSIBILITIES CFC ELIGIBLE POPULATION

         

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

         

        General
          Provisions

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

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

         

        9.
          On a
          monthly basis, ODJFS will provide MCPs with an electronic file containing
          their
          MCP's provider panel as reflected in the ODJFS Provider Verification System
          (PVS) database.

         

        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

         

        Appendix
          D 

        Page
          2

        

        Provider
          Number, as well as all providers who have been assigned a provider reporting
          number
          for current encounter data purposes.

         

         

        11.
          It is
          the intent of ODJFS to utilize electronic commerce for many processes and
          procedures
          that are now limited by H1PAA 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'cun-ent 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 ensure market and program stability, ODJFS may limit an MCP's
          auto-assignments if they meet any of the following enrollment
          thresholds:

         

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

         

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

         

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

         

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

         

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

         

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

         

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

        

        Appendix
          D 

        Page
          4

         

         

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

         

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

         

        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 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.

        

        APPENDIX
          E

         

        RATE
          METHODOLOGY CFC ELIGIBLE POPULATION

         

        

        MERCER

        Government
          Human Services Consulting

        333
          South
          7th Street, Suite 1600

        Minneapolis,
          MN 55402-2427 

        www.mercerHR.com

        

        

         

        October
          20, 2006

         

        Mr.
          Jon
          Barley

         

        State
          of
          Ohio

        Bureau
          of
          Managed Health Care

        Ohio
          Department of Job and Family Services

        255
          East
          Main Street, 2nd Floor

        Columbus.OH43215.5222

         

        Subject:

        Calendar
          Year 2007 Rate-Setting Methodology: Healthy Families and Healthy
          Start

         

        Dear
          Jon:

         

        The
          Ohio
          Department of Job and Family Services (State) contracted with Mercer Government
          Human Services Consulting (Mercer) to develop actuarially sound capitation
          rates
          for Calendar Year (CY) 2007 for the Healthy Families and Healthy Start
          (CFC)
          managed care populations. Mercer developed
          CY
          2007
          capitation rates for the following seven managed care regions:

        Central,
          East Central. Northeast, Northwest. Southeast. Southwest, and West Central.
          At
          this time, Mercer has not developed rates for the eighth region, Northeast
          Central, because managed care implementation has been put on hold for this
          region. Once the implementation date is determined for Northeast Central,
          a
          supplemental certification with the Northeast Central rates will be
          provided.

         

        The
          basic
          rate-setting methodology is similar to the county-specific rate methodology
          used
          in previous years. This methodology letter outlines the rate-setting process,
          provides information on data adjustments, and includes a final rate
          summary.

         

        The
          key
          components in the CY 2007 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

        October
          20, 2006

        Mr.
          Jon
          Barley

        Ohio
          Department of Job and Family Services

         

        Base
          Data Development

         

        The
          major
          steps in the development of the base data are similar to previous years.
          Mercer
          and the State have discussed the available data sources for rate development
          and
          the applicability of these data sources for each region.

         

        The
          data
          sources used for CY 2007 rate setting were:

         

        •
Ohio
          historical FFS data,

         

        •
MCP
          encounter data, and

         

        • MCP
          financial cost report data.

         

        Validation
          Process

        As
          part
          of the rate-setting process. Mercer validated each of the data sources
          that were
          used to develop rates. The validations included a review of the data to
          be used
          in the rate setting process. During the validation process. Mercer adjusted
          the
          data for any data miscodes (e.g., males in the delivery rate cohort) that
          were
          found.

         

        Data
          Sources

        As
          Ohio's
          Medicaid program matures, the rate-setting methodology for those counties
          within
          each region with stable managed care programs can focus more on plan-reported
          managed care data, including encounter data and cost reports. For counties
          within each region without established managed care programs. Mercer continued
          to use the FFS data as a direct data source. The data sources used in each
          region depended on the most credible data sources available within the
          region.
          In regions where there are stable managed care programs, managed care data
          for
          those counties was combined with the FFS data for those counties without
          established managed care programs. The process to prepare these three data
          sources for rate-setting is detailed below.

         

        Appendix
          B includes a chart detailing how each region's counties have been bucketed
          into
          mandatory, Preferred Option, voluntary, or new based on the delivery system
          in
          place during the base period. This determined which data sources were used
          in
          determining regional CY 2007 rates. Also included in Appendix B is a map
          that
          shows the counties included within each region.

         

        Other
          sources of information that were used, as necessary, included state enrollment
          reports, state financial reports, projected managed care penetration rates,
          information from prior MCP surveys, encounter data issues log, and other
          ad hoc
          sources.

         

        

        MERCER

        Government
          Human Services Consulting

         

        Page
          3

        October
          20, 2006

        Mr.
          Jon
          Barley

        Ohio
          Department of Job and Family Services

         

        Fee-for-Service
          Data

        FFS
          experience from the base time period of State Fiscal Year (SFY) 2004 (July
          1,
          2003-June 30, 2004) and SFY 2005 (July 1, 2004-June 30, 2005) was used
          as a
          direct data source for the counties described below:

         

        •
Those
          that had a voluntary managed care program during the base time period,
          and

         

        •
Those
          that did not have a managed care program during the base time
          period.

         

        In
          addition to the SFY 2004 and SFY 2005 data, SFY 2003 data supplemented
          the FFS
          base data development as a reasonability measure. For the above counties,
          the
          FFS data was considered the most credible data source and, in some cases,
          was
          the only data available for rate setting.

         

        As
          in
          previous years, 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 program. The State Medicaid Management Information
          System (MM1S) includes data for populations and/or services excluded from
          managed care and the actual FFS paid claims may be net or gross of certain
          factors (e.g., gross adjustments or third party liability (TPL)). As a
          result,
          it is necessary to make adjustments to the FFS base data as documented
          in
          Appendix C and outlined in Appendix A.

         

        Encounter
          Data

         

        MCP
          encounter experience from the base time period of SFY 2004 and SFY 2005
          was used
          as a direct data source for the counties described below:

         

        •
Those
          that had a mandatory managed care program during the base time period,
          and

         

        •
Those
          that had a Preferred Option managed care program during the base time
          period.

         

        For
          the
          above counties, the encounter data was considered a credible data source
          and was
          used along with the financial cost report data as a direct data
          source.

         

        Although
          encounter data is generally reflective of the populations and services
          that are
          the responsibility of the MCPs, adjustments were applied to the encounter
          data,
          as appropriate. Those adjustments, and other considerations, include the
          following items:

         

        •
Claims
          completion factors,

         

        MERCER

        Government
          Human Services Consulting

         

        Page
          4

         

        October
          20, 2006

        Mr.
          Jon
          Barley

        Ohio
          Department of Job and Family Services

         

        •
Program
          changes in the historical base time period (SFY 2004-SFY 2005), and

         

        •
Other
          actuarially appropriate adjustments, as needed, and according to the State's
          direction to reflect such things as incomplete encounter reporting or other
          known data issues.

         

        The
          adjustments to the encounter data are further documented in Appendix C
          and
          outlined in Appendix A.

         

        During
          the rate setting process, shadow pricing was used to assign unit costs
          to the
          encounter data. This process was necessary since, during the base period,
          paid
          amounts were not a required field for reporting encounters. Additional
          information on shadow pricing is presented on page six of this
          letter.

         

        Financial
          Cost Reports

        MCP-submitted
          financial cost reports from the base time period CY 2004 and CY 2005 were
          used
          as a direct data source for the counties described below:

        •
Those
          that had a mandatory managed care program during the base time period,
          and "
          Those that had a Preferred Option managed care program during the base
          time
          period.

         

        For
          all
          of the above counties, except Mahoning and Trumbull who entered into managed
          care on October 1, 2005, the cost reports were considered a credible data
          source. In addition, for counties with voluntary managed care programs
          during
          the base time period, the cost reports were taken into consideration when
          setting rates, although not used as a direct data source.

         

        As
          with
          the encounter data, the cost report data typically reflects the populations
          and
          services that are the responsibility of the MCPs. However, adjustments
          were
          applied to the cost report data, as appropriate. Those adjustments, and
          other
          considerations, include the following items:

        

        -  Program
          changes in the historical base time period (CY 2004-CY 2005), 

        	-  	
                Incurred
                  claims estimates based on review of claims lag triangles,
                  and

              

         

        	-  	
                Other
                  actuarially appropriate adjustments, as needed, to reflect such
                  things as
                  incomplete reporting or other known data
                  issues.

              

         

        Mercer
          considered the CY 2004 and CY 2005 cost reports both in the development
          of
          completion factors for the base time period (CY 2004-CY 2005) and in the
          development of the final rate.

         

        

        MERCER

        Government
          Human Services Consulting

         

        Page
          5

        October
          20, 2006

        Mr.
          Jon
          Barley

        Ohio
          Department of Job and Family Services

         

        The
          adjustments for the cost report data are further documented in Appendix
          C and
          outlined in Appendix A.

         

        Managed
          Care Rate Development

         

        This
          section explains how Mercer developed the final capitation rates paid to
          contracted MCPs after the base data was developed and multiple years of
          data
          were blended for each data source. First, Mercer applied trend, programmatic
          changes and other adjustments to each data source to project the program
          cost
          into the contract year. Next, the various data sources were blended into
          a
          single managed care rate and an administrative component was applied. Finally,
          relational modeling was used to smooth the results within each region.
          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

        As
          the
          programs have matured, we have collected multiple years ofFFS and managed
          care
          data. In order to utilize all available current information. Mercer combined
          the
          yearly data within each data source using a weighted average methodology
          similar
          to that used in previous years. Prior to blending these years of data,
          the base
          time period experience was trended to a common time period ofCY 2005. Mercer
          applied greater credibility on 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 ofMCP programs on FFS experience.
          Mercer reviewed Ohio's historical FFS experience, CY 2004 and CY 2005 cost
          report data, SPY 2004 and SFY 2005 encounter data, 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,
          rate cohort 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

         

        

        MERCER

        Government
          Human Services Consulting

         

        Page
          6

         

        October
          20, 2006

        Mr.
          Jon
          Barley

        Ohio
          Department of Job and Family Services

         

        related
          to discount rates, dispensing fees, rebates, encounter data and MCP cost
          report
          data to make these adjustments. The rates are reflective of MCP contracting
          for
          these services.

         

        Shadow
          Pricing

        During
          our base period, MCPs were not required to report the amount paid for a
          particular service in their encounter submissions. Therefore, Mercer developed
          assumed unit costs that were applied to encounter utilization data. For
          the
          inpatient category of service, unit costs were calculated by region based
          on the
          average daily cost for each hospital peer group. Unit costs for other COSs
          were
          calculated based on Ohio Medicaid FFS reimbursement levels. The unit costs
          were
          then adjusted by rate cohort to reflect the age/sex unit cost differential
          apparent in the statewide FFS data. In addition, a unit cost managed care
          assumption was applied in the shadow pricing step for the pharmacy
          COS.

         

        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 (CY 2005) and the contract period (CY
          2007).

         

        The
          State
          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. In addition, other potential program changes are being
          discussed in the current legislative session. Final programmatic changes
          approved for SFY 2007 are reflected in the CY 2007 rates, as appropriate.
          Please
          refer to Appendix D for more information on these programmatic
          changes.

         

        Clinical
          Measures/Incentives

         

        Per
          Appendix M of the Provider Agreement, the State expects the MCPs to reach
          certain

        performance
          levels for selected clinical measures. Mercer reviewed the impact of these
          standards and incentives on the managed care rates and developed a set
          of
          adjustments based upon the State's expected improvement rates. These utilization
          targets were built into the capitation rates. The individual measures/incentives
          are outlined in Appendix D.

         

        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

         

        

        MERCER

        Government
          Human Services Consulting

         

        Page
          7

        October
          20, 2006

        Mr.
          Jon
          Barley

         

        Ohio
          Department of Job and Family Services

         

        evaluated
          recent and expected 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 for either the
          non-delivery or delivery rate cells.

         

        Selection
          Issues

        There
          are
          two selection adjustments that were made in the development of the rates.
          The
          first is adverse selection, which accounts for the "missing" managed care
          data
          and is applied to historical FFS data. This adjustment is explained in
          more
          detail in Appendix C.

         

        The
          second selection adjustment is voluntary selection, which accounts for
          the fact
          that costs associated with individuals who elect to 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 selecting
          managed care.

         

        Both
          selection adjustments are reductions to paid claims and utilization for
          non-delivery data. Appendix D provides more detail around the voluntary
          selection adjustment.

         

        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 CY 2004 and 2005 cost reports contain information from
          the
          MCPs that was used to adjust the base data for non-state plan services
          reported
          in the cost reports and the encounter data. Please refer to Appendix D
          for more
          information concerning this adjustment.

         

        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
          base
          data costs for CY 2005 to project the data forward to the CY 2007 contract
          period.

         

        Cost
          report data was reviewed for overall per member per month (PMPM) trend
          levels
          while the FFS data continued to be a primary source in projecting trend.
          Because
          of its role in the rate-setting process, the encounter data was available
          to
          study utilization trend drivers. Mercer integrated the specific data sources'
          trend analysis with a broader analysis of other trend resources. These
          resources
          included health care economic factors (e.g., as Consumer Price
          Index

         

        

        MERCER

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        Page
          8

        October
          20, 2006

        Mr.
          Jon
          Barley

         

        Ohio
          Department of Job and Family Services

         

        (CPI)
          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.

         

        As
          in the
          past. Mercer discussed all trend recommendations with the State. 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.

         

        Credibility
          Assignment

        For
          regions composed of only new and voluntary counties, 100% credibility was
          placed
          on the FFS data. For regions with available FFS and managed care data,
          the FFS,
          encounter and cost report data was blended together.

         

        Cesarean
          Delivery Rate

        Mercer
          reviewed historical FFS delivery data. recent MCP delivery data, and other
          program experience to determine an expected cesarean delivery rate under
          the
          managed care program. Please refer to Appendix D for additional information
          on
          cesarean delivery rates.

         

        Relational
          Modeling

        Relational
          modeling was used to adjust the premiums by rate cohort to produce a relatively
          consistent age/sex slope among the regions. The relational modeling adjustments
          shift dollars across rate cohorts within a region but do not change the
          composite results by region or in aggregate. Through the use of the adjustments,
          the range of variances among the regions and rate cohorts was reduced while
          maintaining budget neutrality.

         

        The
          relational modeling adjustments were applied to the net medical rates in
          the
          Capitation. Rate Calculation Sheets (CRCS) to develop new adjusted medical
          rates. An administration load factor was then applied as a percent of
          premium.

         

        Administration/Contingencies

         

        Mercer
          reviewed the components of the administration/contingencies allowance and
          evaluated

        the
          administration/contingencies rates paid to the MCPs. Factors that were
          taken
          into consideration in determining the final administration/contingencies
          percentages included the State's expectations, Ohio health plan experience,
          other Medicaid program

         

        

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        Page
          9

        October
          20, 2006

        Mr.
          Jon
          Barley

         

        Ohio
          Department of Job and Family Services

         

        administration/contingencies
          allowances, and Ohio health plans' lengths of participation in the program.
          In
          addition, the MCP franchise fee of 4.5% was incorporated into the final
          capitation rate.

         

        Certification
          of Final Rates

         

        The
          following capitation rates were developed for each of the seven regions
          for the
          CY 2007 contract period:

        •
Healthy
          Families/Healthy Start, Less Than 1, Male & Female, " Healthy
          Families/Healthy Start, 1 Year Old, Male & Female,

        •
Healthy
          Families/Healthy Start, 2-13 Years Old, Male & Female, " Healthy
          Families/Healthy Start, 14-18 Years Old, Female,

        •
Healthy
          Families/Healthy Start, 14-18 Years Old, Male, " Healthy Families, 19-44
          Years
          Old, Female, " Healthy Families, 19-44 Years Old, Male,

         

        •
Healthy
          Families, 45 and Over, Male & Female,

         

        •
Healthy
          Start, 19-64 Years Old, Female, and

         

        •
          Delivery Payment.

         

        A
          summary
          of the rates is included in Appendix E.

         

        Mercer
          certifies the above 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 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.

         

        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 those stated may not be appropriate.

         

        

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        Page
          10

         

        October
          20,
          2006

        Mr.
          Jon
          Barley

         

        Ohio
          Department of Job and Family Services

        

        

        

        

        Sincerely,

        

         

        
          	
                  /s/
                    Angela WasDyke

                  Angela
                    WasDyke, MAAA, ASA

                	
                  /s/
                    Wendy Radunz

                  Wendy
                    Radunz, MAAA, FSA

                   

                
	
                  Copy:

                  Chuck
                    Betley, Mitali Ghatak, Tracy Williams - State of Ohio Katie Olecik,
                    Jon
                    Rasmussen - Mercer

                

        

         

        

         

         

        

         

        MMC
          Marsh
& McLennan Companies

        MERCER

        Government
          Human Services Consulting

        

        

        

        

        Appendix
          A - CY 2007 Rate-Setting Methodology

        

        

        [Chart]

        

        

        

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        Appendix
          B - Regional Delivery System Definition

         

        Regional
          Delivery System Definitions

        For
          regional rate development, counties were bucketed into mandatory. Preferred
          Option, voluntary, or new as outlined below. The data for all counties
          within
          the region was used to develop the regional rate. Please see page B-2 for
          a map
          defining the counties within each region.

         

        Mandatory
          and Preferred Option Counties

         

        Encounter
          and cost report data was used for counties that were either mandatory or
          Preferred

         

        Option
          during the base data period*. These counties include:

         

        
          	
                  Mandatory:

                	
                  Preferred
                    Option:

                
	
                  Cuyahoga

                	
                  Butler

                
	
                  Lucas

                	
                  Clark

                
	
                  Stark

                	
                  Franklin

                
	
                  Summit

                	
                  Hamilton

                
	
                   

                	
                  Lorain

                
	
                   

                	
                  Montgomery

                

        

         

        *
          Please
          note Mahoning and Trumbull are not included in the above table due to a
          lack of
          credible data. Both counties entered into managed care in October of
          2005.

         

        Voluntary
          Counties

        FFS
          data
          was used for voluntary counties during the base period and new counties
          entering
          the managed care program since the time of the base data. The voluntary
          counties
          include:

        

        Voluntary:

        Clermont
          

        Greene

        Pickaway
          

        Warren
          

        Wood

         

        New
          counties include all counties that were not mandatory. Preferred Option
          or
          voluntary during the base data period.

         

        B-
          1

         

        

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

         

        B-2

         

        

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        Appendix
          C - FFS Data Adjustments

         

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

         

        Completion
          Factors

        
          	
                  SFY

                	
                  Paid
                    Through

                
	
                  2004

                	
                  03/31/05

                
	
                  2005

                	
                  12/31/05

                

        

         

        The
          claims data was adjusted to account for the value of claims incurred but
          unpaid
          on a COS basis. Mercer used claims for SFY 2004 and SPY 2005 that reflect
          payments through the dates included in the following table.

         

        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 all base data
          reflects
          the policy changes. All policy changes implemented during SFY 2004 and
          SFY 2005
          were applied to the FFS data.

         

        The
          following table shows the specific policy changes for which Mercer adjusted
          the
          SFY 2004 and SFY 2005 delivery (where applicable) and non-delivery data.
          Mercer
          calculated the adjustments based on information supplied by the
          State.

         

        
          	
                  Policy
                    Changes

                	
                  Effective
                    Date

                	
                  Category
                    of Service Affected

                	
                  Rate
                    Cohorts Affected

                
	
                   

                  Independently-practicing
                    psychologist services eliminated for adults (>21) and pregnant
                    women

                	
                   

                  1/1/2004

                	
                   

                  PCP,
                    OB/GYN and Specialists

                	
                   

                  Ages
                    19+, including delivery

                
	
                   

                  All
                    chiropractic services eliminated for adults (>21) and pregnant
                    women

                	
                   

                  1/1/2004

                	
                   

                  Other

                	
                  HF,
                    Age 19-44, M

                
	
                  HF,Age
                    19-44, F

                
	
                  HF,Age45+,
                    M & F

                
	
                  HST,
                    Age 19-64, F

                
	
                  Implementation
                    of $3.00 Copay on Prior-Authorized Drugs

                	
                  1/1/2004

                	
                  Pharmacy

                	
                  All

                

        

         

        C-
          1

         

        

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          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.
            These
            TPL recoveries are not reflected in the FFS MMIS data. Since MCPs are
            also
            expected to take similar recovery actions, the FFS experience was adjusted
            to
            reflect "pay and chase" recoveries. Mercer made adjustments to both the
            paid
            claims and utilization for all non-delivery and delivery COS. Since MCPs
            do not
            collect tort recoveries, the data excludes tort collections.

           

          Hospital
            Cost Settlements

          The
            State
            provided Mercer with SPY 2004 and SPY 2005 interim cost settlements for
            Diagnosis Related Group (DRG) and DRG-exempt hospitals. The DRG-exempt
            hospital
            information included inpatient and outpatient settlements. However, the
            DRG
            hospitals only include capital settlements, which were incorporated into
            the
            adjustment. Therefore, an adjustment has been applied to non-delivery
            and
            delivery 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. Since the MCPs are required to pursue fraud and abuse cases, an
            adjustment
            was applied to the FFS claims and utilization in both the delivery and
            non-delivery 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
            non-delivery FFS data has been adjusted to reflect only the time periods
            for
            which the MCPs are at risk. Since newborns are automatically eligible
            for the
            Medicaid program and are enrolled into their mother's MCP at birth, no
            adjustment will be applied to the '"Less Than 1" age group.

           

          Adverse
            Selection

          An
            adverse selection adjustment was applied to the historical FFS data to
            account
            for the "missing" managed care data. The adverse selection factor adjusts
            the
            associated risk of the FFS members to the entire Medicaid population's
            risk by
            accounting for the cost of the managed care population. This adjustment
            varies
            by historical managed care penetration and includes a

           

          C-2

           

          

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          credibility
            factor which accounts for differences in State enrollment patterns and
            data
            sources. It has been applied to the paid claims and utilization for non-delivery
            FFS base data.

           

          Dual
            Eligibles

          Dual
            eligible persons are not enrolled in managed care and. therefore, are
            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. TMo 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
            for the
            rate computations.

           

          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

           

          

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          Appendix
            C - Encounter Data Adjustments

           

          

           

          Claims
            Completion 

           

          Mercer
            used CY 2005 cost report lag triangles to complete the MCP encounter
            utilization
            data.

           

          Historical
            Policy Changes

          As
            part
            of the rate-setting process, the data must reflect any policy changes
            that
            occurred during the base data time period. Changes only reflected in
            a portion
            of the base data must be applied to the remaining base data to keep the
            data
            similar. Mercer made adjustments to the encounter data to include consideration
            for the following policy changes.

           

          
            	
                    Policy
                      Change

                  	
                    Effective
                      Date

                  	
                    Category
                      of Service Affected

                  	
                    Rate
                      Cohorts Affected

                  
	
                    Independently-practicing
                      psychologist services eliminated for adults (>21) and pregnant
                      women

                  	
                     1/1/2004

                  	
                    PCP,
                      OB/GYN and
                      Specialists

                  	
                    Ages
                      19+, including delivery

                  
	
                    All
                      chiropractic services eliminated for adults (>21) and pregnant
                      women

                  	
                    1/1/2004

                  	
                    Other

                  	
                    HF,
                      Age 19-44, M

                  
	
                    HF,
                      Age 19-44, F

                  
	
                    HF,Age45+,
                      M & F

                  
	
                    HST,
                      Age 19-64, F

                  

          

           

          The
            adjustment for the $3.00 copay on Prior-Authorization Drugs cannot be
            directly
            applied to the encounter data because it only contains utilization. The
            unit
            cost reduction was, however, reflected in the encounter data shadow
            prices.

           

          Data
            Anomaly Corrections

          As
            directed by the State, Mercer made adjustments to the encounter data
            to account
            for incomplete reporting or other known data issues.

           

          Non-State
            Plan Services

           

          Mercer
            reviewed NSPS information included in the MCP cost reports. This information
            was
            used

          to
            calculate an adjustment for NSPS. including eye examinations, chiropractic
            and
            psychological services, and routine transportation. The adjustment was
            applied
            to the Specialists, Dental and Other categories of service in the encounter
            data, as appropriate.

           

          Third
            Party Liability Recoveries

          Mercer
            reviewed TPL recoveries information contained in Report I of the cost
            reports to
            remove these from the encounters reported by each health plan. Mercer
            made MCP
            specific adjustments to the data.

           

          C-4

           

          

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          Appendix
            C - Cost Report Data Adjustments

           

          IBNR
            Review/Adjustment

           

          Mercer
            used CY 2005 cost report claims restatement Report IV and lag triangles
            to
            adjust the

          MCP
            IBNR
            estimates in the CY 2004 and CY 2005 financial experience.

           

          Historical
            Policy Changes

          As
            part
            of the rate-setting process, the data must reflect any policy changes
            that
            occurred during the base data time period. Changes only reflected in
            a portion
            of the base data must be applied to the remaining base data to keep the
            data
            similar. There were no rate-impacting policy changes implemented after
            1/1/2004
            and before 12/31/05. Therefore, no policy change adjustments were applied
            to the
            cost report data.

           

          Data
            Anomaly Corrections

          Mercer
            made cost-neutral adjustments to the CY 2004 cost report data to account
            for
            receding of expenses by category of service. For example, the delivery
            costs
            associated with the "Other" COS in report 111-A were shifted to the non-delivery
            "Other" COS.

           

          Non-State
            Plan Services

          Mercer
            reviewed NSPS information included in the MCP cost reports. This information
            was
            used to calculate an adjustment for "NSPS. including eye examinations,
            chiropractic and psychological services, and routine transportation.
            The
            adjustment was applied to the Specialists, Dental and Other categories
            of
            service in the cost report data, as appropriate.

           

          Third
            Party Liability Recoveries

          Mercer
            reviewed TPL recoveries information contained in Report I of the cost
            reports to
            remove these from the medical costs reported by each health plan.

           

          C-5

           

          

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          Appendix
            D - Calendar Year 2007 CFC Rate Development

           

          Credibility
            By Year Mercer placed more credibility on the most recent year of data
            for each
            data source.

           

          FFS
            Historical and Managed Care Historical/Prospective Trend

          Historical
            FFS trend assumptions were used to trend SFY 2004 and SFY 2005 FFS data
            to the
            base period (CY 2005) for voluntary and new counties. Credibility was
            then
            applied to blend together the trended SFY 2004 and the SFY 2005 FFS
            data.

           

          Managed
            care historical trend was used to trend SFY 2004 and SFY 2005 encounter
            data and
            CY 2004 cost report data to the base period (CY 2005) for Preferred Option
            and
            mandatory counties. Credibility was then applied to blend together the
            trended
            SFY 2004 and the SFY 2005 encounter data and the trended CY 2004 and
            CY 2005
            cost report data.

           

          Prospective
            managed care trend assumptions were then applied to the blended FFS,
            cost
            report, and encounter data to develop the CY 2007 regional rates.

           

          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 the contract
            period. Therefore, Mercer made rate-setting adjustments for each item
            in the
            following table.

           

          Adjustments
            Affecting Unit Cost

           

          
            	
                     

                    Policy
                      Change

                  	
                     

                    Effective
                      Date

                  	
                     

                    Category
                      of Service Affected

                  	
                     

                    Rate
                      Cohorts Affected

                  
	
                     

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

                  	
                     

                    1/1/2006

                  	
                     

                    Pharmacy

                  	
                     

                    HF,
                      Age 19-44, F

                  
	
                     

                    HF,
                      Age 19-44, M

                  
	
                     

                    HF,
                      Age 45+, M & F

                  
	
                     

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

                  	
                     

                    1/1/2006

                  	
                     

                    Dental

                  	
                     

                    HF,
                      Age 19-44, F

                  
	
                     

                    HF,Age
                      19-44, M

                  
	
                     

                    HF,Age45+,M&F

                  
	
                     

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

                  	
                     

                    1/1/2006

                  	
                     

                    Other

                  	
                     

                    HF,
                      Age 19-44, F

                  
	
                     

                    HF,
                      Age 19-44, M

                  
	
                     

                    HF,
                      Age 45+, M&F

                  
	
                     

                    HST,
                      Age 19-64, F

                  
	
                     

                    Inpatient
                      recalibration and outlier policies

                  	
                     

                    1/1/2006

                  	
                     

                    Inpatient

                  	
                     

                    All

                  
	
                     

                    Inpatient
                      rate freeze

                  	
                     

                    1/1/2006

                  	
                     

                    Inpatient

                  	
                     

                    All

                  

          

           

          D-l

           

          

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          Adjustments
            Affecting Utilization

           

          
            	
                    Policy
                      Change

                  	
                    Effective
                      Date

                  	
                    Category
                      of Service Affected

                  	
                    Rate
                      Cohorts Affected

                  
	
                     

                    Reduction
                      in coverage of dental services for adults (S21)

                  	
                     

                    1/1/2006

                  	
                     

                    Dental

                  	
                     

                    HF,
                      Age 19-44, F

                  
	
                     

                    HF,
                      Age 19-44, M

                  
	
                     

                    HF,Age45+,M&F

                  
	
                     

                    HST,
                      Age 19-64, F

                  

          

           

          

           

          The
            1/1/2006 policy change in the Federal Poverty Level (FPL) from 100% to
            90% did
            not have an impact on the rates.

           

          Clinical
            Measures/Incentives

          Since
            the
            State requires the plans to reach, at minimum, the performance standard
            for each
            of the indicators from Appendix M of the SPY 2007 Provider Agreement,
            Mercer
            built this expectation into the capitation rates. To calculate the adjustments,
            Mercer reviewed MCP clinical measures percentages for the CY 2005 base
            year and
            projected these rates forward by building in the State's expected improvement
            rate for counties in managed care as of January 1, 2006. Mercer then
            calculated
            the percent change from base year to the rating period, and applied the
            adjustment as a portion of COS. The following chart provides additional
            detail
            on each clinical measure.

           

          D-2

           

          

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                    Clinical
                      Measure

                  	
                    Rate
                      Cohort

                  	
                    Category
                      of Service Affected

                  
	
                    Prenatal
                      Care - Frequency of Ongoing Prenatal Care

                    Target:
                      80% of eligible population must receive 81% or more of expected
                      number of
                      prenatal visits.

                  	
                    HF/HST,
                      14-18F 

                    HST,
                      19-64F 

                    HF.19-44F

                  	
                     

                    OB/GYN
                      Physician

                  
	
                     

                    Prenatal
                      Care - Post Par-turn Visits

                     

                    Target:
                      80% of the eligible population must receive a post partum
                      visit.

                  	
                    HF/HST,
                      14-18F

                    HST,
                      19-64F 

                    HF,19-44F

                  	
                     

                    OB/GYN

                  
	
                     

                    Preventive
                      Care for Children -Well-Child Visits

                     

                    Target:
                      80% of children receive expected number of visits: Children
                      who turn 15
                      mos. old; 6+ visits. Children who were 3-6 years old; 1+ visit.
                      Children
                      who were 12-21 years old; 1+ visit.

                  	
                    HF/HST,
                      <1 M&F 

                    HF/HST,
                      1 M&F 

                    HF/HST,
                      2-13 M&F 

                    HF/HST,
                      14-18 M 

                    HF/HST,
                      14-18F

                  	
                     

                    Physician

                  
	
                     

                    Use
                      of Appropriate Medications for People with Asthma

                     

                    Target:
                      95% of eligible Asthma members receive prescribed medications
                      acceptable
                      as primary therapy for long-term control of asthma.

                  	
                     

                    HF/HST,
                      2-13 

                    M&F
                      HF/HST, 14-18 M

                     HF/HST,
                      14-18F

                    HF,
                      19-44M

                    HF,
                      19-44F

                    HF,
                      45+ M&F 

                    HST,
                      19-64F

                  	
                     

                    Pharmacy

                  
	
                     

                    Annual
                      Dental Visits

                     

                    Target:
                      60% of enrolled children age 4-21 receive 1 dental visit.

                  	
                     

                    HF/HST,
                      2-13 

                    M&F
                      HF/HST, 14-18 M 

                    HF/HST,
                      14-18F

                  	
                     

                    Dental

                  
	
                     

                    Lead
                      Screening

                     

                    Target:
                      80% of children age 1-2 receive a blood lead screening.

                  	
                     

                    HF/HST,
                      1 M&F

                     HF/HST,
                      2-13 M&F

                  	
                     

                    Physician

                  

          

           

          Voluntary
            Selection

          As
            a
            result of the adverse selection adjustment that was applied in the FFS
            Data
            Summaries, the FFS data already reflects the risk of the entire Medicaid
            program
            (i.e., FFS and managed care individuals). To solely reflect the risk
            of the
            managed care program. Mercer modified the FFS data based on the projected
            managed care penetration levels for CY 2007. 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).

           

          For
            the
            encounter and cost report data, the original base data reflects the historical
            penetration levels in SPY 2004-SFY 2005 and CY 2004-CY 2005, respectively.
            Where
            projected managed

           

          D-3

           

          

          MERCER

          Government
            Human Services Consulting

           

          care
            penetration levels differ from the historical values, the data was brought
            back
            to reflect the risk of the entire Medicaid program, and then adjusted
            forward
            (as the FFS data was) to reflect projected managed care levels.

           

          Credibility
            by Data Source

          For
            regions composed of only new and voluntary counties, 100% credibility
            was placed
            on the FFS data. For regions with available FFS and managed care data,
            the FFS
            data was used for the new and voluntary counties within the region, w^hile
            the
            encounter and cost report data were used for the mandatory and Preferred
            Option
            counties within the region.

           

          C-Section/Vaginal
            Percent

          Mercer
            received MCP cesarean and vaginal rates from CY 2005 encounter data.
            Based on
            the analysis for all MCPs combined, Mercer determined C-section and vaginal
            rate
            assumptions.

           

          MCP
            Administration/Contingencies

          Based
            on
            a review of MCP reported administration expenses, the MCP administration/
            contingencies allowance will remain at 12% of premium prior to the franchise
            fee. For existing health plans, 1% of the pre-franchise fee capitation
            rate will
            be put at risk, contingent upon MCPs meeting performance requirements
            for
            counties with managed care enrollment as of January 1, 2006. The at-risk
            amount
            for counties entering managed care after January 1, 2006 will be 0% for
            the
            first two plan years.

           

          For
            plans
            new to managed care in 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 above 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-4

           

          

          MERCER

           

          Government
            Human Services Consulting

           

          Appendix
            E - Calendar Year 2007 CFC Regional Rate Summary

          
 

          
            State
              of
              Ohio

            

            Appendix
              E Calendar Year 2007 CFC Regional Rate Summary

            

            
              	
                      Region

                    	
                      Rate
                        Cohort

                    	
                      Annualized
                        April 2006

                      MM/Deliveries

                    	
                      %
                        of MM

                    	
                      CY
                        2007 Guaranteed

                      Rate

                    	
                      CY
                        2007 Rate At Risk

                    	
                      CY
                        2007 Rate

                    
	
                      Central
                        

                    	
                      HF/HST,
                        Age 0, M & F

                    	
                      171,818

                    	
                      6.0%

                    	
                      $
                        564.92

                    	
                      $
                        5.45

                    	
                      $
                        570.36

                    
	
                      Central

                    	
                      HF/HST,
                        Age 1,M & F

                    	
                      146,106

                    	
                      5.1%

                    	
                      $
                        149.56

                    	
                      $
                        1.44

                    	
                      $
                        151.01

                    
	
                      Central

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

                    	
                      1,335,641

                    	
                      46.6%

                    	
                      $
                        99.74

                    	
                      $
                        0.96

                    	
                      $
                        100.70

                    
	
                      Central

                    	
                      HF/HST,
                        Age 14-18, M

                    	
                      191,907

                    	
                      6.7%

                    	
                      $
                        118.11

                    	
                      $
                        1.14

                    	
                      $
                        119.25

                    
	
                      Central

                    	
                      HF/HST,
                        Age 14-18, F

                    	
                      208,187

                    	
                      7.3%

                    	
                      $
                        166.07

                    	
                      $
                        1.60

                    	
                      $
                        167.68

                    
	
                      Central

                    	
                      HF
                        Age 19-44, M

                    	
                      172,314

                    	
                      6.0%

                    	
                      $
                        206.93

                    	
                      $
                        2.00

                    	
                      $
                        208.92

                    
	
                      Central

                    	
                      HF
                        Age 19-44, F

                    	
                      531,797

                    	
                      18.5%

                    	
                      $
                        299.33

                    	
                      $
                        2.89

                    	
                      $
                        302.21

                    
	
                      Central

                    	
                      HP
                        Age 45+, M & F

                    	
                      59,319

                    	
                      2.1%

                    	
                      $
                        487.07

                    	
                      $
                        4.70

                    	
                      $
                        491.77

                    
	
                      Central

                    	
                      HST
                        Age 19-64, F

                    	
                      50,975

                    	
                      1.8%

                    	
                      $
                        340.59

                    	
                      $
                        3.28

                    	
                      $
                        343.87

                    
	
                      Central

                    	
                      Subtotal

                    	
                      2,868,064

                    	
                      100.0%

                    	
                      $
                        191.93

                    	
                      $
                        1.85

                    	
                      $
                        193.78

                    
	
                      Central

                    	
                      Delivery
                        Payment

                    	
                      9,465

                    	
                      0.3%

                    	
                      $
                        4,023.39

                    	
                      $
                        38.79

                    	
                      $
                        4,062.19

                    
	
                      Central

                    	
                      Total

                    	
                      2,868.064

                    	
                      100.0%

                    	
                      $
                        205.21

                    	
                      $
                        1.98

                    	
                      $
                        207.19

                    
	
                      East-Central
                        

                    	
                      HF/HST,
                        Age 0, M & F 

                    	
                      95,509
                        

                    	
                      5.6%
                        

                    	
                      $
                        554.55 

                    	
                      $
                        5.35 

                    	
                      $
                        559.90 

                    
	
                      East-Central

                    	
                      HF/HST,
                        Age 1,M&F

                    	
                      78,227

                    	
                      4.6%

                    	
                      $
                        145.80

                    	
                      $
                        1.41

                    	
                      $
                        147.21

                    
	
                      East-Central

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

                    	
                      786,577

                    	
                      46.4%

                    	
                      $
                        98.24

                    	
                      $
                        0.95

                    	
                      $
                        99.19

                    
	
                      East-Central

                    	
                      HF/HST,
                        Age 14-18, M

                    	
                      122,231

                    	
                      7.2%

                    	
                      $
                        114.36

                    	
                      $
                        1.10

                    	
                      $
                        115.47

                    
	
                      East-Central

                    	
                      HF/HST,
                        Age 14-18, F

                    	
                      126,757

                    	
                      7.5%

                    	
                      $
                        158,66

                    	
                      $
                        1.53

                    	
                      $
                        160.19

                    
	
                      East-Central

                    	
                      HF
                        Age 19-44, M

                    	
                      98,371

                    	
                      5.8%

                    	
                      $
                        200.66

                    	
                      $
                        1.93

                    	
                      $
                        202.59

                    
	
                      East-Central

                    	
                      HF
                        Age 19-44, F

                    	
                      320,557

                    	
                      18.9%

                    	
                      $
                        290.72

                    	
                      $
                        2.80

                    	
                      $
                        293.52

                    
	
                      East-Central

                    	
                      HF,
                        Age 45 +,M & F

                    	
                      38,258

                    	
                      2.3%

                    	
                      $
                        470.93

                    	
                      $
                        4,54

                    	
                      $
                        475.47

                    
	
                      East-Central

                    	
                      HST
                        Age 19-64, F

                    	
                      29,264

                    	
                      1.7%

                    	
                      $
                        331.03

                    	
                      $
                        3.19

                    	
                      $
                        334.22

                    
	
                      East-Central

                    	
                      Subtotal

                    	
                      1.695,750

                    	
                      100.0%

                    	
                      $
                        186.57

                    	
                      $
                        1.80

                    	
                      $
                        188.37

                    
	
                      East-Central

                    	
                      Delivery
                        Payment

                    	
                      5,596

                    	
                      0.3%

                    	
                      $
                        4,132.16

                    	
                      $
                        39.84

                    	
                      $
                        4,172.00

                    
	
                      East-Central

                    	
                      Total

                    	
                      1,695,750

                    	
                      100.0%

                    	
                      $
                        200.20

                    	
                      $
                        1.93

                    	
                      $
                        202.13

                    
	
                      Northeast

                    	
                      HF/HST,
                        Age 0, M & F

                    	
                      152,915

                    	
                      5.2%

                    	
                      $
                        529.07

                    	
                      $
                        5.10

                    	
                      $
                        534.17

                    
	
                      Northeast

                    	
                      HF/HST,
                        Age 1, M&F

                    	
                      133,744

                    	
                      4.5%

                    	
                      $
                        140.45

                    	
                      $
                        1.35

                    	
                      $
                        141.80

                    
	
                      Northeast

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

                    	
                      1,381,832

                    	
                      46.7%

                    	
                      $
                        94.02

                    	
                      $
                        0.91

                    	
                      $
                        94.93

                    
	
                      Northeast

                    	
                      HF/HST,
                        Age 14-18, M

                    	
                      223,275

                    	
                      7.5%

                    	
                      $
                        111.31

                    	
                      $
                        1.07

                    	
                      $
                        112.38

                    
	
                      Northeast

                    	
                      HF/HST,
                        Age 14-18, F

                    	
                      236,299

                    	
                      8.0%

                    	
                      $
                        153.26

                    	
                      $
                        1.48

                    	
                      $
                        154.74

                    
	
                      Northeast

                    	
                      HF.Age
                        19-44, M

                    	
                      136,730

                    	
                      4.6%

                    	
                      $
                        193.74

                    	
                      $
                        1.87

                    	
                      $
                        195.61

                    
	
                      Northeast

                    	
                      HF
                        Age 19-44, F

                    	
                      576,329

                    	
                      19.5%

                    	
                      $
                        279.38

                    	
                      $
                        2.69

                    	
                      $
                        282.08

                    
	
                      Northeast

                    	
                      HF,
                        Age45+. M&F

                    	
                      75,738

                    	
                      2,6%

                    	
                      $
                        453.99

                    	
                      $
                        4.38

                    	
                      $
                        458.37

                    
	
                      Northeast

                    	
                      HST,
                        Age 19-64, F

                    	
                      41,229

                    	
                      1.4%

                    	
                      $
                        318.02

                    	
                      $
                        3.07

                    	
                      $
                        321.09

                    
	
                      Northeast

                    	
                      Subtotal

                    	
                      2.958,090

                    	
                      100,0%

                    	
                      $
                        177.71

                    	
                      $
                        1.71

                    	
                      $
                        179.42

                    
	
                      Northeast

                    	
                      Delivery
                        Payment

                    	
                      9,762

                    	
                      0.3%

                    	
                      S
                        4.620.33

                    	
                      $
                        44.55

                    	
                      $
                        4,664.87

                    
	
                      Northeast

                    	
                      Total

                    	
                      2,958,090

                    	
                      100.0%

                    	
                      $
                        192.96

                    	
                      S
                        1.86

                    	
                      $
                        194.82

                    
	
                      Northwest

                    	
                      HF/HST,
                        Age 0, M & F

                    	
                      95,817

                    	
                      6.3%

                    	
                      $
                        559.84

                    	
                      $
                        5.40

                    	
                      $
                        565.23

                    
	
                      Northwest

                    	
                      HF/HST,
                        Age 1, M & F

                    	
                      77,885

                    	
                      5.1%

                    	
                      $
                        148.68

                    	
                      $
                        1.43

                    	
                      $
                        150.11

                    
	
                      Northwest

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

                    	
                      703,072

                    	
                      45.9%

                    	
                      $
                        97.75

                    	
                      $
                        0.94

                    	
                      $
                        98.69

                    
	
                      Northwest

                    	
                      HF/HST,
                        Age 14-18, M

                    	
                      102,361

                    	
                      6.7%

                    	
                      $
                        115.24

                    	
                      $1.11

                    	
                      $
                        116.35

                    
	
                      Northwest

                    	
                      HF/HST,
                        Age 14-18, F

                    	
                      111,868

                    	
                      7.3%

                    	
                      $
                        162.33

                    	
                      $
                        1.57

                    	
                      $
                        163.89

                    
	
                      Northwest

                    	
                      HF,
                        Age 19-44, M

                    	
                      91,211

                    	
                      6.0%

                    	
                      $
                        202.82

                    	
                      $
                        1.96

                    	
                      $
                        204.77

                    
	
                      Northwest

                    	
                      HF
                        Age 19-44. F 

                    	
                      289,036

                    	
                      18.9%

                    	
                      $
                        299,30

                    	
                      $
                        2.89

                    	
                      $
                        302.18

                    
	
                      Northwest

                    	
                      HF,
                        Age 45+, M&F

                    	
                      29,822

                    	
                      1.9%

                    	
                      $
                        483.93

                    	
                      $
                        4.67

                    	
                      $
                        488.60

                    
	
                      Northwest

                    	
                      HST,
                        Age 19-64.F

                    	
                      30,803

                    	
                      2,0%

                    	
                      $
                        338.79

                    	
                      $
                        3.27

                    	
                      $
                        342.06

                    
	
                      Northwest

                    	
                      Subtotal

                    	
                      1,531,875

                    	
                      100,0%

                    	
                      $
                        191.78

                    	
                      $
                        1.85

                    	
                      $
                        193.63

                    
	
                      Northwest

                    	
                      Delivery
                        Payment

                    	
                      5.055

                    	
                      0.3%

                    	
                      $
                        4,254,97

                    	
                      $
                        41.03

                    	
                      $
                        4,295.99

                    
	
                      Northwest

                    	
                      Total

                    	
                      1,531,875

                    	
                      100.0%

                    	
                      $
                        205.82

                    	
                      $
                        1.98

                    	
                      $
                        207.80

                    

            

             

            Mercer
              Government Human Services Consulting 

            E-1

             

            

            State
              of
              Ohio

            Appendix
              E Calendar Year 2007 CFC Regional Rate Summary

            
              	
                      Region

                    	
                      Rate
                        Cohort

                    	
                      Annualized
                        April 2006

                      MM/Deliveries

                    	
                      %of
                        MM

                    	
                      CY
                        2007 Guaranteed

                      Rate

                    	
                      CY
                        2007 Rate At Risk

                    	
                      CY
                        2007 Rate

                    
	
                      Southeast

                    	
                      HF/HST,
                        Age 0, M & F

                    	
                      54,686

                    	
                      4.9%

                    	
                      $
                        523.86

                    	
                      $
                        5.05

                    	
                      $
                        528.91

                    
	
                      Southeast

                    	
                      HF/HST,
                        Age 1, M & F

                    	
                      47,093

                    	
                      4.2%

                    	
                      $
                        138.49

                    	
                      $
                        1.34

                    	
                      $
                        139.82

                    
	
                      Southeast

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

                    	
                      487,601

                    	
                      43.9%

                    	
                      $
                        93.56

                    	
                      $
                        0.90

                    	
                      $
                        94.46

                    
	
                      Southeast

                    	
                      HF/HST,
                        Age 14-18, M

                    	
                      82,844

                    	
                      7.5%

                    	
                      $
                        109.68

                    	
                      $
                        1.06

                    	
                      $
                        110.74

                    
	
                      Southeast

                    	
                      HF/HST,
                        Age 14-18, F

                    	
                      84,280

                    	
                      7.6%

                    	
                      $
                        153.88

                    	
                      $
                        1.48

                    	
                      $
                        155.37

                    
	
                      Southeast

                    	
                      HF,
                        Age 19-44.M 

                    	
                      98,747

                    	
                      8.9%

                    	
                      $
                        195.17

                    	
                      $
                        1.88

                    	
                      $
                        197.06

                    
	
                      Southeast

                    	
                      HF,
                        Age 19-44, F

                    	
                      211,664

                    	
                      19.0%

                    	
                      $
                        281.12

                    	
                      $
                        2.71

                    	
                      $
                        283.83

                    
	
                      Southeast

                    	
                      HF,
                        Age 45+, M&F

                    	
                      27,930

                    	
                      2.5%

                    	
                      $
                        458.74

                    	
                      $
                        4.42

                    	
                      $
                        463.16

                    
	
                      Southeast

                    	
                      HST,
                        Age 19-64, F

                    	
                      16,667

                    	
                      1.5%

                    	
                      $
                        320.31

                    	
                      $
                        3.09

                    	
                      $
                        323.40

                    
	
                      Southeast

                    	
                      Subtotal

                    	
                      1,111,511

                    	
                      100,0%

                    	
                      $
                        179.73

                    	
                      $
                        1.73

                    	
                      $
                        181.46

                    
	
                      Southeast

                    	
                      Delivery
                        Payment

                    	
                      3,668

                    	
                      0.3%

                    	
                      $
                        4,128.68

                    	
                      $
                        39.81

                    	
                      $
                        4,168.49

                    
	
                      Southeast

                    	
                      Total

                    	
                      1,111,511

                    	
                      100.0%

                    	
                      $
                        193.36

                    	
                      $
                        1.86

                    	
                      $
                        195.22

                    
	
                      Southwest

                    	
                      HF/HST,
                        Age 0, M & F

                    	
                      121,364

                    	
                      6.5%

                    	
                      $
                        570.51

                    	
                      $
                        5.50

                    	
                      $
                        576.01

                    
	
                      Southwest

                    	
                      HF/HST,
                        Age 1, M&F

                    	
                      97,721

                    	
                      5.3%

                    	
                      $
                        148.69

                    	
                      $
                        1.43

                    	
                      $
                        150.13

                    
	
                      Southwest

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

                    	
                      876,398

                    	
                      47.1%

                    	
                      $
                        99.74

                    	
                      $
                        0.96

                    	
                      $
                        100.70

                    
	
                      Southwest

                    	
                      HF/HST,
                        Age 14-18, M

                    	
                      126,346

                    	
                      6.8%

                    	
                      $
                        116.29

                    	
                      $
                        1.12

                    	
                      $
                        117.41

                    
	
                      Southwest

                    	
                      HF/HST,
                        Age 14-18, F

                    	
                      140,619

                    	
                      7.6%

                    	
                      $
                        163.87

                    	
                      $
                        1.58

                    	
                      $
                        165.45

                    
	
                      Southwest

                    	
                      HF,
                        Age 19-44, M

                    	
                      91,907

                    	
                      4.9%

                    	
                      $
                        206.77

                    	
                      $
                        1.99

                    	
                      $
                        208.77

                    
	
                      Southwest

                    	
                      HF,
                        Age 19-44, F

                    	
                      335,867

                    	
                      18.0%

                    	
                      $
                        298.60

                    	
                      $
                        2.88

                    	
                      $
                        301.48

                    
	
                      Southwest

                    	
                      HF,
                        Age 45+, M&F

                    	
                      35,032

                    	
                      1.9%

                    	
                      $
                        485.99

                    	
                      $
                        4.69

                    	
                      $
                        490.68

                    
	
                      Southwest

                    	
                      HST,
                        Age 19-64, F

                    	
                      35,739

                    	
                      1.9%

                    	
                      $
                        340.78

                    	
                      $
                        3.29

                    	
                      $
                        344.06

                    
	
                      Southwest

                    	
                      Subtotal

                    	
                      1.860,993

                    	
                      100.0%

                    	
                      $
                        192.06

                    	
                      $
                        1.85

                    	
                      $
                        193.91

                    
	
                      Southwest

                    	
                      Delivery
                        Payment

                    	
                      6,141

                    	
                      0.3%

                    	
                      $
                        4,690.50

                    	
                      $
                        45.23

                    	
                      $
                        4,735.73

                    
	
                      Southwest

                    	
                      Total

                    	
                      1,860,993

                    	
                      100.0%

                    	
                      $
                        207.53

                    	
                      $
                        2.00

                    	
                      $
                        209.54

                    
	
                      West-Central

                    	
                      HF/HST,
                        Age 0, M & F

                    	
                      81,065

                    	
                      6.3%

                    	
                      $
                        580.47

                    	
                      $
                        5.60

                    	
                      $
                        586.06

                    
	
                      West-Central

                    	
                      HF/HST.
                        Age 1.M&F

                    	
                      64,022

                    	
                      5.0%

                    	
                      $
                        155.39

                    	
                      $
                        1.50

                    	
                      $
                        156.89

                    
	
                      West-Central

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

                    	
                      599,936

                    	
                      46.5%

                    	
                      $
                        102.85

                    	
                      $
                        0.99

                    	
                      $
                        103.85

                    
	
                      West-Central

                    	
                      HF/HST,
                        Age 14-18, M

                    	
                      86,948

                    	
                      6.7%

                    	
                      $
                        122.06

                    	
                      $
                        1.18

                    	
                      $
                        123.24

                    
	
                      West-Central

                    	
                      HF/HST,
                        Age 14-18, F

                    	
                      95,920

                    	
                      7.4%

                    	
                      $
                        169.37

                    	
                      $
                        1.63

                    	
                      $
                        171.01

                    
	
                      West-Central

                    	
                      HF,
                        Age 19-44.M

                    	
                      68,617

                    	
                      5.3%

                    	
                      $
                        211.40

                    	
                      $
                        2.04

                    	
                      $
                        213.43

                    
	
                      West-Central

                    	
                      HF,
                        Age 19-44, F

                    	
                      244,883

                    	
                      19.0%

                    	
                      $
                        310.07

                    	
                      $
                        2.99

                    	
                      $
                        313.06

                    
	
                      West-Central

                    	
                      HF,
                        Age 45+, M&F

                    	
                      24,806

                    	
                      1.9%

                    	
                      $
                        505.52

                    	
                      $
                        4.87

                    	
                      $
                        510.40

                    
	
                      West-Central

                    	
                      HST,
                        Age 19-64, F

                    	
                      23,655

                    	
                      1.8%

                    	
                      $
                        352.42

                    	
                      $
                        3.40

                    	
                      $
                        355.82

                    
	
                      West-Central

                    	
                      Subtotal

                    	
                      1.289,853

                    	
                      100,0%

                    	
                      $
                        199,16

                    	
                      $
                        1.92

                    	
                      $
                        201.08

                    
	
                      West-Central

                    	
                      Delivery
                        Payment

                    	
                      4,257

                    	
                      0.3%

                    	
                      $
                        4,509.84

                    	
                      $
                        43.48

                    	
                      $
                        4,553.32

                    
	
                      West-Central

                    	
                      Total

                    	
                      1,289,853

                    	
                      100.0%

                    	
                      $
                        214.04

                    	
                      $
                        2.06

                    	
                      $
                        216.10

                    
	
                      All
                        Regions

                    	
                      HF/HST,
                        Age 0, M&F

                    	
                      773,175

                    	
                      5.8%

                    	
                      $
                        555.52

                    	
                      $
                        5.36

                    	
                      $
                        560.88

                    
	
                      All
                        Regions

                    	
                      HF/HST,
                        Age 1, M & F

                    	
                      644,798

                    	
                      4.8%

                    	
                      $
                        146.75

                    	
                      $
                        1.41

                    	
                      $
                        148.16

                    
	
                      All
                        Regions

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

                    	
                      6,171,057

                    	
                      46.3%

                    	
                      $
                        97.86

                    	
                      $
                        0.94

                    	
                      $
                        98.80

                    
	
                      All
                        Regions

                    	
                      HF/HST,
                        Age 14-18, M

                    	
                      935,911

                    	
                      7.0%

                    	
                      $
                        115.06

                    	
                      $
                        1.11

                    	
                      $
                        116.17

                    
	
                      All
                        Regions

                    	
                      HF/HST,
                        Age 14-18, F

                    	
                      1,003,930

                    	
                      7.5%

                    	
                      $
                        160.69

                    	
                      $
                        1.55

                    	
                      $
                        162.24

                    
	
                      All
                        Regions

                    	
                      HF,
                        Age 19-44, M

                    	
                      757,896

                    	
                      5.7%

                    	
                      $
                        202.09

                    	
                      $
                        1.95

                    	
                      $
                        204.04

                    
	
                      All
                        Regions

                    	
                      HF,Age
                        19-44, F

                    	
                      2,510,133

                    	
                      18.9%

                    	
                      $
                        293.06

                    	
                      $
                        2.83

                    	
                      $
                        295.89

                    
	
                      All
                        Regions

                    	
                      HF,
                        Age 45+, M&F

                    	
                      290,906

                    	
                      2.2%

                    	
                      $
                        474.74

                    	
                      $
                        4.58

                    	
                      $
                        479.32

                    
	
                      All
                        Regions

                    	
                      HST
                        Age 19-64, F

                    	
                      228,331

                    	
                      1.7%

                    	
                      $
                        334.82

                    	
                      $
                        3.23

                    	
                      $
                        338.05

                    
	
                      All
                        Regions

                    	
                      Subtotal

                    	
                      13,316,137

                    	
                      100.0%

                    	
                      $
                        187.77

                    	
                      $
                        1.81

                    	
                      $
                        189.58

                    
	
                      All
                        Regions

                    	
                      Delivery
                        Payment

                    	
                      43,943

                    	
                      0.3%

                    	
                      $
                        4,345.63

                    	
                      $
                        41,90

                    	
                      $
                        4,387.53

                    
	
                      All
                        Regions

                    	
                      Total

                    	
                      13,316,137

                    	
                      100.0%

                    	
                      $
                        202.11

                    	
                      $
                        1.95

                    	
                      $
                        204.06

                    

            

            

             

            Mercer
              Government Human Services Consulting

          APPENDIX
            F

           REGIONAL
            RATES

           

          1.
            PREMIUM RATES WITHOUT THE AT-RISK PAYMENT AMOUNTS FOR 01/01/07, THROUGH
            06/30/07, SHALL BE AS FOLLOWS:

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

           

          MCP:
            WellCare of Ohio, Inc.

           

          
            	
                    SERVICE
                      ENROLLMENT AREA

                  	
                    VOLUNTARY/
                      MANDATORY**

                  	
                    HF/HST
                      

                    Age<
                      1

                  	
                    HF/HST
                      

                    Age
                      1

                  	
                    HF/HST

                    Age
                      2-13

                  	
                    HF/HST
                      

                    Age
                      14-18 Male

                  	
                    HF/HST
                      

                    Age
                      14-18 Female

                  	
                    HF
                      

                    Age
                      19-44 Male

                  	
                    HF
                      

                    Age
                      19-44 Female

                  	
                    HF
                      

                    Age
                      45 and over

                  	
                    HST
                      

                    Age
                      19-64 Female

                  	
                    Delivery
                      Payment

                  
	
                     

                    Northeast

                  	
                     

                    Mandatory

                  	
                     

                    $540.31

                  	
                     

                    $143.43

                  	
                     

                    $96.02

                  	
                     

                    $113.67

                  	
                     

                    $156.52

                  	
                     

                    $197.86

                  	
                     

                    $285.32

                  	
                     

                    $463.64

                  	
                     

                    $324.78

                  	
                     

                    $4,718.49

                  
	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  
	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  
	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  
	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  

          

           

          List
            of Eligible Assistance Groups (AGs)

           

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

          -
            MA-T
            Children under 21

          -
            MA-Y
            Transitional Medicaid

           

          Healthy
            Start: - MA-P Pregnant Women and Children

           

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

           

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

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

           

          Page
            1 of
            3

           

          

          APPENDIX
            F

           REGIONAL
            RATES

           

          2.
            AT-RISK AMOUNTS FOR 01/01/07, THROUGH 06/30/07, SHALL BE AS
            FOLLOWS:

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

           

          MCP:
            WellCareofOhio,lnc.

          AT-RISK
            AMOUNTS*

          
            	
                     

                    SERVICE
                      ENROLLMENT AREA

                  	
                     

                    VOLUNTARY/
                      MANDATORY**

                  	
                     

                    HF/HST
                      

                    Age
                      < 1

                  	
                     

                    HF/HST
                      

                    Age
                      1

                  	
                     

                    HF/HST
                      

                    Age
                      2-13

                  	
                     

                    HF/HST
                      Age 14-18 Male

                  	
                     

                    HF/HST
                      Age 14-18 Female

                  	
                     

                    HF
                      Age 19-44 Male

                  	
                     

                    HF
                      Age 19-44 Female

                  	
                     

                    HF
                      Age 45 and over

                  	
                     

                    HST
                      Age 19-64 Female

                  	
                     

                    Delivery
                      Payment

                  
	
                     

                    Northeast

                  	
                     

                    Mandatory

                  	
                     

                    $0.00

                  	
                     

                    $0.00

                  	
                     

                    $0.00

                  	
                     

                    $0.00

                  	
                     

                    $0.00

                  	
                     

                    $0.00

                  	
                     

                    $0.00

                  	
                     

                    $0.00

                  	
                     

                    $0.00

                  	
                     

                    $0.00

                  
	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  
	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  
	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  
	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  
	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  

          

           

          List
            of Eligible Assistance Groups (AGs)

           

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

          -
            MA-T
            Children under 21

          -
            MA-Y
            Transitional Medicaid

           

          Healthy
            Start: - MA-P Pregnant Women and Children

           

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

           

          For
            the
            SFY 2007 contract period, MCPs will be put at-risk for a portion of the
            premiums
            received for members in counties they served as of

          January
            1, 2006, provided the MCP has participated in the program for more than
            twenty-four months. MCPs will be put at-risk for a portion of the premiums
            received for members in counties they began serving after January 1,
            2006,
            beginning

          with
            the
            MCP's twenty-fifth month of membership in each county's region.

           

          Page
            2 of
            3

           

          

          APPENDIX
            F

          REGIONAL
            RATES

           

          3.
            PREMIUM RATES* FOR 01/01/07, THROUGH 06/30/07, SHALL BE AS
            FOLLOWS:

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

           

          MCP:
            WellCare of Ohio, Inc.

           

          
            	
                     

                    I
                      SERVICE ENROLLMENT AREA

                  	
                     

                    VOLUNTARY/
                      MANDATORY**

                  	
                     

                    HF/HST
                      

                    Age
                      < 1

                  	
                     

                    HF/HST
                      

                    Age
                      1

                  	
                     

                    HF/HST
                      

                    Age
                      2-13

                  	
                     

                    HF/HST
                      

                    Age
                      14-18 

                    Male

                  	
                     

                    HF/HST
                      

                    Age
                      14-18 Female

                  	
                     

                    HF
                      

                    Age
                      19-44 

                    Male

                  	
                     

                    HF
                      

                    Age
                      19-44 Female

                  	
                     

                    HF
                      

                    Age
                      45 

                    and
                      over

                  	
                     

                    HST
                      

                    Age
                      19-64 Female

                  	
                     

                    Delivery
                      Payment

                  
	
                    Northeast

                  	
                    Mandatory

                  	
                    $540.31

                  	
                    $143.43

                  	
                    $96.02

                  	
                    $113.67

                  	
                    $156.52

                  	
                    $197.86

                  	
                    $285.32

                  	
                    $463.64

                  	
                    $324.78

                  	
                    $4,718.49

                  
	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  
	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  
	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  
	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  
	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  

          

           

          

           

          List
            of Eligible Assistance Groups (AGs)

           

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

          -
            MA-T
            Children under 21

          -
            MA-Y
            Transitional Medicaid

           

          Healthy
            Start: - MA-P Pregnant Women and Children

           

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

           

          For
            the
            SFY 2007 contract period, MCPs will be put at-risk for a portion of the
            premiums
            received for members in counties they served as of January 1, 2006, provided
            the
            MCP has participated in the program for more than twenty-four months.
            MCPs will
            be put at-risk for a portion of the premiums received for members in
            counties
            they began serving after January 1, 2006, beginning with the MCP's twenty-fifth
            month of membership in each county's region.

           

          Page
            3 of
            3

           

          

          APPENDIX
            G

           

          COVERAGE
            AND SERVICES CFC ELIGIBLE POPULATION

           

          1.
            Basic
            Benefit Package

           

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

           

          •
            Inpatient hospital services

           

          •
            Outpatient hospital services

           

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

           

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

           

          •
            Laboratory and x-ray services

           

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

           

          •
Family
            planning services and supplies

           

          •
Home
            health services

           

          •
            Podiatry

           

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

           

          •
            Physical therapy, occupational therapy, and speech therapy

           

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

           

          •
            Prescription drugs

           

          •
            Ambulance and ambulette services

           

          •
Dental
            services

           

          •
Durable
            medical equipment and medical supplies

           

          •
Vision
            care services, including eyeglasses

           

          

          Appendix
            G 

          Page
            2

           

          •
            Short-term rehabilitative stays in a nursing facility

           

          •
Hospice
            care

           

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

          Independent
            psychologist services not covered for adults age twenty-one (21) and
            older.

          

          2.
            Exclusions,
            Limitations and Clarifications 

           

          a.
            Exclusions

           

          MCPs
            are
            not required to pay for Ohio Medicaid FFS program (Medicaid) non-covered
            services. For information regarding Medicaid noncovered services, MCPs
            must
            refer to the 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 OD.IFS.

           

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

           

          

          b.
            Limitations
            & Clarifications 

           

          i.
            Member
            Cost-Sharing

           

          As
            specified in OAC rules 5101:3-26-05(0) and 5101:3-26-12, MCPs are permitted
            to
            impose the applicable member co-payment amount(s) for dental services,
            vision
            services, non-emergency emergency department services, or prescription
            drugs,
            other than generic drugs. MCPs must notify OD.IFS if they intend to impose
            a
            co-payment. OD.IFS 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. IfODJFS
            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 are unwilling to access services through community
            providers.

           

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

           

          Appendix
            G 

          Page
            5

          

          Where
            an
            MCP is responsible for providing MH services for their members, the MCP
            is
            responsible for ensuring access to counseling and psychotherapy,
            physician/psychologist/psychiatrist services, outpatient clinic services,
            general hospital outpatient psychiatric services, pre-hospitalization
            screening,
            diagnostic assessment (clinical evaluation), crisis intervention, psychiatric
            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/psychologist/psychiatrist AOD treatment services, outpatient
            clinic
            AOD treatment services, general hospital outpatient AOD treatment services,
            crisis intervention, inpatient detoxification services in a general hospital,
            and Medicaid-covered prescription drugs and laboratory services. MCPs
            are not
            required to cover outpatient detoxification and methadone
            maintenance.

           

          Financial
            Responsibility:
            MCPs are
            responsible for the payment of Medicaid-covered prescription drugs prescribed
            by
            a CMHC or ODADAS-certified provider when obtained through an MCP's panel
            pharmacy. MCPs are also responsible for the payment of Medicaid-covered
            services
            provided by an MCP's panel laboratory when referred by a CMHC or
            ODADAS-certified provider. Additionally. MCPs are responsible for the
            payment of
            all other behavioral health services obtained through providers other
            than those
            who are CMHC or ODADAS-certified providers when an-anged/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.

           

          3. Care
            Coordination

           

          a.
            Utilization
            Management (Modification) Programs

           

          General
            Provisions
            -
            Pursuant to OAC rule 5101:3-26-03.1(A)(7), MCPs must implement the
            ODJFS-required emergency department diversion (EDD) utilization management
            program to maximize the effectiveness of the care provided to members
            and may
            develop other utilization management programs, subject to prior approval
            by
            ODJFS. For the purposes of 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.

           

          Appendix
            G 

          Page
            7

          

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

           

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

           

          MCPs
            must
            comply with the provisions of 1927(d)(5) of the Social Security Act,
            42 USC
            1396r-8(k)(3), and OAC rule 5101:3-26-03.1 regarding the timeframes for
            prior
            authorization of covered outpatient drugs.

           

          MCPs
            may
            also, 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 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.

           

          Appendix
            G 

          Page
            8

          

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

           

          b.
            Case
            Management

           

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

           

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

           

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

           

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

           

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

           

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

           

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

           

          Appendix
            G 

          Page
            9

           

          e.
            a
            process to facilitate, maintain, and

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

           

          iii.
            MCPs
            must submit a monthly electronic report to the Case Management System
            (CAMS) for
            all members who are case managed by the MCP as outlined in the OD.IFS
            ''Case
            Management File and Submission Specifications^
            The CAMS
            files are due the 10th
            business
            day of each month.

           

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

           

          c.
            Children
            with Special Health Care Needs

           

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

           

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

           

          Appendix
            G 

          Page
            10

          

          i.
            Definition of CSHCN

           

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

           

          ·  Asthma

          ·  HIV/AIDS

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

          ·  receiving
            treatment or counseling Supplemental security income (SSI) for a health-related
            condition

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

           

          ii.
            Identification of CSHCN

           

          All
            MCPs
            must implement mechanisms to identify CSHCN.

           

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

           

          iii.
            Assessment of CSHCN

           

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

           

          This
            assessment mechanism must include, at a minimum:

           

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

           

          

          Appendix
            G 

          Page
            11

          See
            ODJFS
            CSHCN Program Requirements for a description of the ODJFS
            CSHCN Standard Assessment Tool.

           

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

           

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

           

          iv.
            Case
            Management of CSHCN

           

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

           

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

           

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

           

          v.
            Access
            to Specialists for CSHCN

           

          All
            MCPs
            must implement mechanisms -to notify all CSHCN with a positive assessment
            and
            determined to need case management of their right to directly access
            a
            specialist. Such access may be assured through, for example, a standing
            referral
            or an approved number of visits, and documented in the care treatment
            plan.

           

          Appendix
            G 

          Page
            12

           

          vi.
            Submission of Data on CSHCN

           

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

           

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

           

          d.
            Care
            Coordination with ODJFS-Designated Providers

           

          Per
            OAC
            rule 5101:3-26-03.1(A)(4). MCPs are required to share specific information
            with
            certain ODJFS-designated non-contracting providers in order to ensure
            that these
            providers have been supplied with specific information needed to coordinate
            care
            for the MCP's members. Within the first month of operation, after an
            MCP has
            obtained a provider agreement, the MCP must provide to the ODJFS-designated
            providers (i.e., ODMH Community Health Centers. ODADAS-certified Medicaid
            providers. FQHCs/RHCs. QFPPs. CNMs, CNPs [if applicable], and hospitals)
            a quick
            reference information packet which includes the following:

           

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

           

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

           

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

           

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

           

          •
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

           

          Appendix
            G 

          Page
            13

          

          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 29.i.e. of Appendix C.

           

          

          APPENDIX
            H

           

          PROVIDER
            PANEL SPECIFICATIONS CFC ELIGIBLE POPULATION

           

          1.
            GENERAL
            PROVISIONS

           

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

           

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

           

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

           

          2.
            PROVIDER SUBCONTRACTING

           

          Unless
            otherwise specified in this appendix or OAC rule 5101:3-26-05, all MCPs
            are
            required to enter into fully-executed subcontracts with their providers.
            These
            subcontracts must include a baseline contractual agreement, as well as
            the
            appropriate ODJFS-approved Model Medicaid Addendum. The Model Medicaid
            Addendum
            incorporates all applicable Ohio Administrative Code rule requirements
            specific
            to provider subcontracting and therefore cannot be modified except to
            add
            personalizing information such as the MCP's name.

           

          Appendix
            H 

          Page
            2

           

          ODJFS
            must prior approve all MCP providers in the ODJFS- required provider
            type
            categories before they can begin to provide services to that MCP's members.
            MCPs
            may not employ or contract with providers excluded from participation
            in Federal
            health care programs under either section 1128 or section 1128A of the
            Social
            Security Act. As part of the prior approval process, MCPs must submit
            documentation verifying that all necessary contract documents have been
            appropriately completed. ODJFS will verify the approvability of the submission
            and process this information using the ODJFS 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,
            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 (PCPs)

           

          Primary
            Care Physicians (PCPs) may be individuals or group practices/clinics
            [Primary
            Care Clinics (PCCs)]. Acceptable specialty types for PCPs are family/general
            practice, internal medicine, pediatrics and obstetrics/gynecology(OB/GYNs).
            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.

           

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

           

          Appendix
            H 

          Page
            3

           

          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.

           

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

           

          ODJFS
            recognizes that MCPs will need to utilize specialty physicians to serve
            as PCPs
            for some special needs members. Also. in some situations (e.g.. continuity
            of
            care) a PCP may only want to serve a very small number of members for
            an MCP. In
            these situations it will not be necessary for the MCP to submit these
            PCPs to
            ODJFS for prior approval. These PCPs will not be included in the ODJFS
            PVS
            database and therefore may not appear as PCPs in the MCP's provider directory.
            Also, no PCP capacity will be counted for these providers. These PCPs
            will,
            however, need to execute a subcontract with the MCP which includes the
            appropriate Model Medicaid Addendum.

           

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

           

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

           

          A
            pediatric PCP must maintain a general pediatric practice (e.g., a pediatric
            neurologist would not meet this definition unless this physician also
            operated a
            practice as a general pediatrician) at a site(s) located within the
            county/region and be listed as a pediatrician with the Ohio State Medical
            Board.
            In addition, half of the required number ofpediatric PCPs must also be
            certified

           

          Appendix
            H

          Page
            4

          

           

          by
            the
            American Board of Pediatrics. The provider panel requirements for pediatricians
            are included
            in the practitioner charts in this appendix.

           

          b.
            Non-PCP
            Provider Network

           

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

           

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

           

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

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

           

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

           

          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).

           

          Appendix
            H 

          Page
            5

           

          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 ofOB/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
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. In order to assure
            sufficient access to adult MCP members, no more than two-thirds of the
            dentists
            used to meet the provider panel requirement may be pediatric
            dentists.

           

          Federally
            Qualified Health Centers/Rural Health Clinics (FQHCs/RHCs) -
            MCPs are
            required to ensure member access to any federally qualified health center
            or
            rural health clinic (FQHCs/RHCs), regardless of contracting status. Contracting
            FQHC/RHC providers must be submitted for ODJFS approval via the PVS process.
            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.

           

          Appendix
            H 

          Page
            6

           

          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-tf& refer to family planning services
            provided by a QFPP. A QFPP is defined as any public or not-^- tor-profit
            health
            care provider that complies with Title X guidelines/standards, and receives
            either Title X funding or family planning funding from the Ohio Department
            of
            Health. MCPs must reimburse all medically-necessary Medicaid-covered
            family
            planning services provided to eligible members by a QFPP provider (including
            on-site pharmacy and diagnostic services) on a patient self-referral
            basis,
            regardless of the provider's status as a panel or non-panel provider.
            MCPs will
            be required to work with QFPPs in the region to develop mutually-agreeable
            H1PAA
            compliant policies and procedures to preserve patient/provider confidentiality,
            and convey pertinent information to the member's PCP and/or MCP.

           

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

           

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

           

          Appendix
            H

          Page
            7

          

           

          specified
            county/region. Contracting general surgeons, orthopedists and otolaryngologists
            must have admitting privileges at a hospital under contract with the
            MCP in the
            region.

           

          4.
            PROVIDER
            PANEL EXCEPTIONS

           

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

           

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

           

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

                

           

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

                

           

          If
            an MCP
            is unable to contract with or maintain a sufficient number of providers
            to meet
            the ^^ ODJFS-speciMed 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.

           

          Appendix
            H 

          Page
            8

           

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

           

          The
            directory must also specify:

           

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

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

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

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

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

          •
any
            PCP
            or specialist practice limitations.

           

          Printed
            Provider Directory

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

           

          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 deleted from the internet
            directory within one week of notification from the provider to the MCP.
            Providers being deleted from the MCP's panel must be posted to the internet
            directory within one week of notification from the provider to the
            MCP

           

          

          Appendix
            H

          Page
            9

           

          

           

          of
            the
            deletion. These deleted providers must be included in the inserts to
            the MCP's
            provider directory
            referenced above.

           

          6.
            FEDERAL
            ACCESS STANDARDS

           

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

           

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

           

          •
The
            anticipated Medicaid membership.

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

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

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

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

           

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

           

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

           

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

           

          Appendix
            H 

          Page
            10

           

          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 Region - Hospitals

           

          
            	
                    Minimum
                      Provider Panel Requirements

                  
	 	
                     

                    Total
                      Required Hospitals

                  	
                     

                    Ashtabula

                  	
                     

                    Cuyahoga

                  	
                     

                    Erie

                  	
                     

                    Geauga

                  	
                     

                    Huron

                  	
                     

                    Lake

                  	
                     

                    Lorain

                  	
                     

                    Medina

                  	
                     

                    Additional
                      Required Hospitals: Out-of-Region

                  
	
                     

                    General
                      Hospital3

                  	
                     

                    84

                  	
                     

                    1

                  	
                     

                    14

                  	
                     

                    1

                  	
                     

                    1

                  	
                     

                    1

                  	
                     

                    1

                  	
                     

                    1

                  	
                     

                    1

                  	 
	
                     

                    Hospital
                      System

                  	
                     

                    1

                  	 	
                     

                    1

                  	 	 	 	 	 	 	 

          

           

          1
            Preferred Providers are the additional provider contracts that must be
            secured
            in order for the MCP to receive bonus points.

          2
            These
            hospitals cannot be included under any subcontract used to meet the minimim
            required provider panel requirements.

          3
            These
            hospitals must provide obstetrical services if such a hospital is available
            in
            the county/region.

          4
            The
            Cuyahoga hospital requirement may be met by either contracting with (1)
            a single
            hospital system that includes fifty (50) pediatric beds and five (5)
            pediatric
            intensive care unit (PICU) beds OR
            (2) a
            single general hospital that includes fifty (50) pediatric beds and five
            (5)
            pediatric intensive
            care unit (PICU) beds and a hospital system.

          

          North
            East Central Region -
            Hospitals

          

          

          
            	
                    Minimum
                      Provider Panel Requirements

                  
	 	
                     

                    Total
                      Required Hospitals

                  	
                     

                    Columbiana

                  	
                     

                    Mahoning

                  	
                     

                    Trumbull

                  	
                     

                    Additional
                      Required Hospitals: Out-of-Region

                  
	
                     

                    General
                      Hospital3

                  	
                     

                    3

                  	
                     

                    1

                  	
                     

                    14

                  	
                     

                    1

                  	 
	
                     

                    Hospital
                      System

                     

                     

                  	 	 	 	 	 

          

          

          

          1
            Preferred Providers are the additional provider contracts that must be
            secured
            in order for the MCP to receive bonus points.

          2
            These
            hospitals cannot be included under any subcontract used to meet the minimim
            required provider panel requirements.

          3
            These
            hospitals must provide obstetrical services if such a hospital is available
            in
            the county/region, except where a hospital must meet the criteria specified
            in
            footnote #4 below.

          4
            Must be
            a hospital that includes thirty (30) pediatric
            beds and five (5) pediatric intensive care unit (PICU) beds.

          

          East
            Central Region - Hospitals

           

          
            	
                    Minimum
                      Provider Panel Requirements

                  
	 	
                     

                    Total
                      Required

                    Hospitals

                  	
                     

                    Ashland

                  	
                     

                    Carroll

                  	
                     

                    Holmes

                  	
                     

                    Portage

                  	
                     

                    Richland

                  	
                     

                    Start

                  	
                     

                    Summit

                  	
                     

                    Tuscarawas

                  	
                     

                    Wayne

                  	
                     

                    Additional
                      Required
                      Hospitals: Out-of-Region

                  
	
                     

                    General
                      Hospital3

                  	
                     

                    8

                  	
                     

                    1

                  	 	
                     

                    1

                  	
                     

                    1

                  	
                     

                    1

                  	
                     

                    1

                  	
                     

                    14

                  	
                     

                    1

                  	
                     

                    1

                  	 
	
                     

                    Hospital
                      System

                  	
                     

                    1

                  	 	 	 	 	 	 	
                     

                    1

                  	 	 	 

          

           

          1
            Preferred Providers are the additional provider contracts that must be
            secured
            in order for the MCP to receive bonus points.

          2
            These
            hospitals cannot be included under any subcontract used to meet the minimim
            required provider panel requirements.

          3
            These
            hospitals must provide obstetrical services if such a hospital is available
            in
            the county/region, except where a hospital must meet the criteria specified
            in
            footnote #4 below.

          4
            Must be
            a hospital that includes one hundred (100) pediatric
            beds and five (5) pediatric intensive care unit (PICU) beds.

          

          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

                  	
                    Vinton

                  	
                     

                    Washington

                  	
                    Additional

                    Required
                      Hospitals: Out-of-Region

                  
	
                     

                    General

                    Hospital3

                  	
                     

                    11

                  	
                     

                    1

                  	
                     

                    1

                  	
                     

                    1

                  	
                     

                    1

                  	
                     

                    1

                  	 	 	
                     

                    1

                  	 	 	 	 	
                     

                    1

                  	 	 	
                     

                    1

                  	
                     

                    Cabell
                      AND King's Daughter AND Children's Hospital

                     

                    Columbus

                  
	
                    Hospital
                      System

                     

                     

                  	 	
                     

                  	
                     

                  	
                     

                  	
                     

                  	 	 	 	 	 	
                     

                  	 	
                     

                  	 	
                     

                  	
                     

                  	 	
                     

                  

          

           

          1
            Preferred Providers are the additional provider contracts that must be
            secured
            in order for the MCP to receive bonus points.

           

          2
            These
            hospitals cannot be included under any subcontract used to meet the minimim
            required provider panel requirements.

           

          3
            These
            hospitals must provide obsetrical services if such a hospital is available
            in
            the county/region.

           

          

          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
                      Hospitals:
                      Out-of-Region

                  
	
                     

                    General
                      Hospital3

                  	
                     

                    14

                  	
                     

                    1

                  	 	
                     

                    1

                  	
                     

                    1

                  	
                     

                    1
                      4

                  	 	
                     

                    1

                  	
                     

                    1

                  	
                     

                    1

                  	
                     

                    1

                  	
                     

                    1

                  	 	 	
                     

                    1

                  	 	
                     

                    1

                  	
                     

                    1

                  	
                     

                    1

                  	
                     

                    Genesis
                      Health Care System, Inc.

                  
	
                     

                    Hospital
                      System

                  	
                     

                    2

                  	 	 	 	 	
                     

                    2

                  	 	 	 	 	 	 	 	 	 	 	 	 	 	 

          

           

          1
            Preferred Providers are the additional provider contracts that must be
            secured
            in order for the MCP to receive bonus points.

          2
            These
            hospitals cannot be included under any subcontract used to meet the minimim
            required provider panel requirements.

          3
            These
            hospitals must provide obstetrical services if such a hospital is available
            in
            the county/region, except where a hospital must meet the criteria specified
            in
            footnote #4 below.

          4
            Must be
            a hospital that includes one hundred fifty (150) pediatric beds and twenty-five
            (25) pediatric intensive care unit (PICU) beds.

          

          South
            West Region - Hospitals

           

          
            	
                    Minimum
                      Provider Panel Requirements

                  
	 	
                     

                    Total
                      Required Hospitals

                  	
                     

                    Adams

                  	
                     

                    Brown

                  	
                     

                    Butler

                  	
                     

                    Clermont

                  	
                     

                    Clinton

                  	
                     

                    Hamilton

                  	
                     

                    Highland

                  	
                     

                    Warren

                  	
                     

                    Additional
                      Required Hospitals: Out-of-Region

                  
	
                    General
                      Hospital3

                  	
                     

                    6

                  	 	
                     

                    1

                  	
                     

                    1

                  	 	
                     

                    1

                  	
                     

                    1
                      4

                  	
                     

                    1

                  	 	
                     

                    Grandview
                      or Miami Valley

                  
	
                    Hospital
                      System

                  	
                    2

                  	 	 	 	 	 	
                    2

                  	 	 	 

          

          

          1
            Preferred
            Providers are the additional provider contracts that must be secured
            in order
            for the MCP to receive bonus points.

          2
            These
            hospitals cannot be included under any subcontract used to meet the minimim
            required provider panel requirements.

          3
            These
            hospitals must provide obstetrical services if such a hospital is available
            in
            the county/region, except where a hospital must meet the criteria specified
            in
            footnote #4
            below.

          4
            Must be
            a hospital that includes two-hundred (200)

          pediatric
            beds and thirty-five (35) pediatric intensive care unit (PICU)
            beds.

          

          West
            Central Region - Hospitals

           

          
            	
                    Minimum
                      Provider Panel Requirements

                  
	 	
                     

                    Total
                      Required Hospitals

                  	
                     

                    Champaign

                  	
                     

                    Clark

                  	
                     

                    Darke

                  	
                     

                    Greene

                  	
                     

                    Miami

                  	
                     

                    Montgomery

                  	
                     

                    Preble

                  	
                     

                    Shelby

                  	
                     

                    Additional
                      Required Hospitals: Out-of-Region

                  
	
                     

                    General
                      Hospital3

                  	
                     

                    6

                  	 	
                     

                    1

                  	
                     

                    1

                  	
                     

                    1

                  	
                     

                    1

                  	
                     

                    14

                  	 	
                     

                    1

                  	 
	
                     

                    Hospital
                      System

                  	
                     

                    1

                  	 	 	 	 	 	
                     

                    1

                  	 	 	 

          

           

          1
            Preferred Providers are the additional provider contracts that
            must be
            secured in order for the MCP to receive bonus points.

           

          2
            These
            hospital cannot be included under any subcontract used to meet the minimim
            required provider panel requirements.

           

          3
            These
            hospitals must provide obsetrical services if such a hospital is available
            in
            the county/region, except where a hospital must meet the criteria specified
            in footnote #4 below.

           

          4
            Must be
            a hospital that includes seventy-five

          (75)
            pediatric beds and ten (10) pediatric intensive care unit (PICU)
            beds.

          

          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

                    Hospitals:
                      Out-of-Region

                  
	
                    General
                      Hospital3

                  	
                     

                    10

                  	
                     

                    1

                  	 	
                     

                    1

                  	
                     

                    1

                  	
                     

                    1

                  	 	 	 	
                     

                    1

                  	 	 	 	
                     

                    1

                  	 	
                     

                    1

                  	
                     

                    1

                  	 	
                     

                    1

                  	
                    Bellevue
                      Hospital
                      Association

                  
	
                    Hospital
                      System

                  	
                     

                    1

                  	
                     

                  	 	 	 	 	 	 	
                     

                    14

                  	 	 	 	 	 	 	
                     

                  	 	
                     

                  	 	 

          

           

          1
            Preferred Providers are the additional provider contracts that must be
            secured
            in order for the MCP to receive bonus points.

          2
            These
            hospitals cannot be included under any subcontract used to meet minimim
            required
            provider panel requirements.

          3
            These
            hospitals must provide obsetrical services if such a hospital is available
            in
            the county/region.

          4
            Must be
            a hospital system that includes forty-five (45) pediatric beds and ten
            (10)
            pediatric intensive care unit (PICU) beds.

          

          North
            East Region - PCP Capacity

           

          
            	 	
                    Minimum
                      PCP Capacity Requirements

                  	 
	
                     

                    PCPs

                  	
                     

                    Total
                      Required

                  	
                    Ashtabula

                  	
                    Cuyahoga

                  	
                    Erie

                  	
                    Geauga

                  	
                    Huron

                  	
                    Lake

                  	
                    Lorain

                  	
                    Medina

                  	
                     

                    Additional
                      Required:

                    In-Region
                      *

                  
	
                     

                    Capacity
                      1

                  	
                     

                    146,000

                  	
                     

                    6,560

                  	
                     

                    111,520

                  	
                     

                    3,680

                  	
                     

                    2,080

                  	
                     

                    3,960

                  	
                     

                    3,680

                  	
                     

                    11,320

                  	
                     

                    3,200

                  	 
	
                     

                    FTEs

                  	
                     

                    73.00

                  	
                     

                    3.28

                  	
                     

                    55.76

                  	
                     

                    1.84

                  	
                     

                    1.04

                  	
                     

                    1.98

                  	
                     

                    1.84

                  	
                     

                    5.66

                  	
                     

                    1.60

                  	 

          

           

          1Based
            on an FTE of 2000 members

           

          *
            Must be
            located within the region.

           

          

          North
            East Central Region - PCP Capacity

           

          
            	 	
                    Minimum
                      PCP Capacity Requirements

                  
	
                     

                    PCPs

                  	
                     

                    Total
                      Required

                  	
                    Columbiana

                  	
                    Mahoning

                  	
                    Trumbull

                  	
                    Additional
                      Required: In-Region *

                  
	
                     

                    Capacity
                      1

                  	
                     

                    39,140

                  	
                     

                    6,440

                  	
                     

                    16,340

                  	
                     

                    11,360

                  	
                     

                    5,000

                  
	
                     

                    FTEs

                  	
                     

                    19.57

                  	
                     

                    3.22

                  	
                     

                    8.17

                  	
                     

                    5.68

                  	
                     

                    2.50

                  

          

          

          

          Based
            on
            an FTE of 2000 members

           

          *
            Must be
            located within the region.

           

          

          East
            Central Region - PCP Capacity

           

          
            	 	 	
                    Minimum
                      PCP Capacity Requirements

                  	 
	
                     

                    PCPs

                  	
                     

                    Total
                      Required

                  	
                     

                    Ashland

                  	
                     

                    Carroll

                  	
                     

                    Holmes

                  	
                     

                    Portage

                  	
                     

                    Richland

                  	
                     

                    Stark

                  	
                     

                    Summit

                  	
                     

                    Tuscarawas

                  	
                     

                    Wayne

                  	
                     

                    Additional
                      Required: In-Region *

                  
	
                     

                    Capacity
                      1

                  	
                     

                    84,000

                  	
                     

                    2,940

                  	
                     

                    2,000

                  	
                     

                    2,000

                  	
                     

                    4,520

                  	
                     

                    7,400

                  	
                     

                    22,660

                  	
                     

                    33,560

                  	
                     

                    4,360

                  	
                     

                    4,560

                  	 
	
                    FTEs

                  	
                    42.00

                  	
                    1.47

                  	
                    1.00

                  	
                    1.00

                  	
                    2.26

                  	
                    3.70

                  	
                    11.33

                  	
                    16.78

                  	
                    2.18

                  	
                    2.28

                  	 

          

          

          

          Based
            on
            an FTE of 2000 members

           

          *
            Must be
            located within the region.

           

          

          South
            East Region - PCP Capacity

          

          

          
            	
                    County

                  	
                    Capacity

                  	
                    FTEs

                  
	
                    Total
                      Required

                  	
                    53,000

                  	
                    26.50

                  
	
                    Athens

                  	
                    5,000

                  	
                    2.50

                  
	
                    Belmont

                  	
                    2,880

                  	
                    1.44

                  
	
                    Coshocton

                  	
                    2,400

                  	
                    1.20

                  
	
                    Gallia

                  	
                    7,220

                  	
                    3.61

                  
	
                    Guernsey

                  	
                    3,820

                  	
                    1.91

                  
	
                    Harrison

                  	
                    940

                  	
                    0.47

                  
	
                    Jackson

                  	
                    1,000

                  	
                    0.50

                  
	
                    Jefferson

                  	
                    4,340

                  	
                    2.17

                  
	
                    Lawrence

                  	
                    4,020

                  	
                    2.01

                  
	
                    Meigs

                  	
                    700

                  	
                    0.35

                  
	
                    Monroe

                  	
                    780

                  	
                    0.39

                  
	
                    Morgon

                  	
                    1,260

                  	
                    0.63

                  
	
                    Muskingum

                  	
                    7,400

                  	
                    3.70

                  
	
                    Noble

                  	
                    600

                  	
                    0.30

                  
	
                    Vinton

                  	
                    820

                  	
                    0.41

                  
	
                    Washington

                  	
                    2,820

                  	
                    1.41

                  
	
                    Additional
                      Required:   In-Region
                      *

                  	
                    7,000

                  	
                    3.50

                  

          

          

          

          Based
            on
            an FTE of 2000 members

          Must
            be
            located within the region.

           

          

          Central
            Region - PCP Capacity

           

          
            	
                    County

                  	
                    Capacity1

                  	
                    FTEs

                  
	
                    Total
                      Required

                  	
                    138,000

                  	
                    69.00

                  
	
                    Crawford

                  	
                    2,720

                  	
                    1.36

                  
	
                    Delaware

                  	
                    1,900

                  	
                    0.95

                  
	
                    Fairfield

                  	
                    5,660

                  	
                    2,83

                  
	
                    Fayette

                  	
                    1,320

                  	
                    0.66

                  
	
                    Franklin

                  	
                    84,200

                  	
                    42.10

                  
	
                    Hocking

                  	
                    1,860

                  	
                    0.93

                  
	
                    Knox

                  	
                    2,800

                  	
                    1.40

                  
	
                    Licking

                  	
                    6,740

                  	
                    3.37

                  
	
                    Logan

                  	
                    2,380

                  	
                    1.19

                  
	
                    Madison

                  	
                    980

                  	
                    0.49

                  
	
                    Marion

                  	
                    4,080

                  	
                    2.04

                  
	
                    Morrow

                  	
                    1,620

                  	
                    0.81

                  
	
                    Perry

                  	
                    2,200

                  	
                    1.10

                  
	
                    Pickaway

                  	
                    2,000

                  	
                    1.00

                  
	
                    Pike

                  	
                    2,400

                  	
                    1,20

                  
	
                    Ross

                  	
                    6,620

                  	
                    3.31

                  
	
                    Scioto

                  	
                    6,940

                  	
                    3.47

                  
	
                    Union

                  	
                    1,580

                  	
                    0.79

                  
	
                    Additional
                      Required: In-Region *

                  	 	 

          

           

          Based
            on
            an FTE of 2000 members

           

          *
            Must be
            located within the region.

           

          

          South
            West Region - PCP Capacity

           

          
            	 	
                    Minimum
                      PCP Capacity Requirements

                  	 
	
                     

                    PCPs

                  	
                     

                    Total
                      Required

                  	
                    Adams

                  	
                    Brown

                  	
                    Butler

                  	
                    Clermont

                  	
                    Clinton

                  	
                    Hamilton

                  	
                    Highland

                  	
                    Warren

                  	
                     

                    Additional
                      Required: 

                    In
                      Region
                      *

                  
	
                     

                    Capacity
                      1

                  	
                     

                    88,000

                  	
                     

                    2,420

                  	
                     

                    2,540

                  	
                     

                    12,500

                  	
                     

                    2,860

                  	
                     

                    2,940

                  	
                     

                    59,680

                  	
                     

                    2,620

                  	
                     

                    2,440

                  	 
	
                    FTEs

                  	
                    44.00

                  	
                    1.21

                  	
                    1.27

                  	
                    6.25

                  	
                    1.43

                  	
                    1.47

                  	
                    29.84

                  	
                    1.31

                  	
                    1.22

                  	 

          

          

          

          Based
            on
            an FTE of 2000 members

           

          Must
            be
            located within the region.

           

          

          West
            Central Region - PCP Capacity

          

          

          
            	 	
                    Minimum
                      PCP Capacity Requirements

                  	 
	
                     

                    PCPs

                  	
                     

                    Total
                      Required

                  	
                     

                    Champaign

                  	
                     

                    Clark

                  	
                     

                    Darke

                  	
                     

                    Greene

                  	
                     

                    Miami

                  	
                     

                    Montgomery

                  	
                     

                    Preble

                  	
                     

                    Shelby

                  	
                     

                    Additional
                      Required: 

                     

                    In-Region
                      *

                  
	
                    Capacity
                      1

                  	
                    59,600

                  	
                    1,140

                  	
                    9,360

                  	
                    1,320

                  	
                    4,700

                  	
                    4,020

                  	
                    35,660

                  	
                    1,400

                  	
                    2,000

                  	 
	
                    FTEs

                  	
                    29.80

                  	
                    0.57

                  	
                    4.68

                  	
                    0.66

                  	
                    2.35

                  	
                    2.01

                  	
                    17.83

                  	
                    0.70

                  	
                    1.00

                  	 

          

           

           

          1
            Based
            on an FTE of 2000 members

          

          *
            Must be
            located within the region

          As
            of November 20, 2006

          North
            West Region - PCP Capacity

           

           

          
            	
                    County

                  	
                    Capacity1

                  	
                    FTEs

                  
	
                    Total
                      Required

                  	
                    90,860

                  	
                    45.43

                  
	
                    Alien

                  	
                    7,780

                  	
                    3.89

                  
	
                    Auglaize

                  	
                    1,260

                  	
                    0.63

                  
	
                    Defiance

                  	
                    2,600

                  	
                    1,30

                  
	
                    Fulton

                  	
                    1,300

                  	
                    0.65

                  
	
                    Hancock

                  	
                    3,620

                  	
                    1.81

                  
	
                    Hardin

                  	
                    1,220

                  	
                    0,61

                  
	
                    Henry

                  	
                    1,200

                  	
                    0.60

                  
	
                    Lucas

                  	
                    38,620

                  	
                    19,31

                  
	
                    Mercer

                  	
                    1,080

                  	
                    0.54

                  
	
                    Ottawa

                  	
                    1,200

                  	
                    0,60

                  
	
                    Paulding

                  	
                    900

                  	
                    0.45

                  
	
                    Putnam

                  	
                    960

                  	
                    0.48

                  
	
                    Sandusky

                  	
                    2,700

                  	
                    1.35

                  
	
                    Seneca

                  	
                    2,340

                  	
                    1.17

                  
	
                    Van
                      Wert

                  	
                    1,020

                  	
                    0.51

                  
	
                    Williams

                  	
                    1,900

                  	
                    0.95

                  
	
                    Wood

                  	
                    2,000

                  	
                    1.00

                  
	
                    Wyandot

                  	
                    960

                  	
                    0.48

                  
	
                    Additional
                      Required: In-Region *

                  	
                    18,200

                  	
                    9.10

                  

          

          

          Based
            on
            an FTE of 2000 members

          Must
            be
            located within the region.

           

          

          North
            East Region - Practitioners

           

          
            	
                    Minimum
                      Provider Panel Requirements

                  
	
                     

                    Provider
                      Types

                  	
                     

                    Total
                      Required Providers1

                  	
                     

                    Ashtabula

                  	
                     

                    Cuyahoga

                  	
                     

                    Erie

                  	
                     

                    Geauga

                  	
                     

                    Huron

                  	
                     

                    Lake

                  	
                     

                    Lorain

                  	
                     

                    Medina

                  	
                     

                    Additional
                      Required Providers2

                  
	
                     

                    Pediatricians4

                  	
                     

                    90

                  	
                     

                    1

                  	
                     

                    66

                  	
                     

                    2

                  	 	 	
                     

                    3

                  	
                     

                    8

                  	
                     

                    3

                  	
                     

                    7

                  
	
                     

                    OB/GYNs

                  	
                     

                    25

                  	
                     

                    1

                  	
                     

                    16

                  	
                     

                    1

                  	 	
                     

                    1

                  	
                     

                    1

                  	
                     

                    2

                  	
                     

                    1

                  	
                     

                    2

                  
	
                     

                    Vision

                  	
                     

                    33

                  	
                     

                    1

                  	
                     

                    25

                  	
                     

                    1

                  	 	 	
                     

                    1

                  	
                     

                    2

                  	
                     

                    1

                  	
                     

                    2

                  
	
                     

                    General
                      Surgeons

                  	
                     

                    20

                  	 	
                     

                    12

                  	
                     

                    1

                  	 	
                     

                    1

                  	
                     

                    1

                  	
                     

                    2

                  	
                     

                    1

                  	
                     

                    2

                  
	
                     

                    Otolaryngologist

                  	
                     

                    6

                  	 	
                     

                    2

                  	 	 	 	 	
                     

                    1

                  	 	
                     

                    3

                  
	
                     

                    Allergists

                  	
                     

                    5

                  	 	
                     

                    2

                  	 	 	 	 	
                     

                    1

                  	 	
                     

                    2

                  
	
                     

                    Orthopedists

                  	
                     

                    16

                  	 	
                     

                    8

                  	
                     

                    1

                  	 	 	
                     

                    1

                  	
                     

                    2

                  	
                     

                    1

                  	
                     

                    3

                  
	
                     

                    Dentists5

                  	
                     

                    90

                  	
                     

                    3

                  	
                     

                    65

                  	
                     

                    1

                  	
                     

                    1

                  	
                     

                    1

                  	
                     

                    5

                  	
                     

                    10

                  	
                     

                    3

                  	
                     

                    1

                  

          

           

          1
            All
            required providers must be located within the region.

           

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

          3
            Preferred Providers are the additional provider contracts that must be
            secured
            in order for the MCP to receive bonus points.

          4
            Half of
            this number must be certified by the American Board of Pediatrics.

          5
            No more
            than two-thirds of this number can be pediatric dentists.

           

          North
            East Central- Practitioners

           

          
            	
                    Minimum
                      Provider Panel Requirements

                  
	
                     

                    Provider
                      Types

                  	
                     

                    Total
                      Required Providers1

                  	
                     

                    Columbiana

                  	
                     

                    Mahoning

                  	
                     

                    Trumbull

                  	
                     

                    Additional
                      Required Providers2

                  
	
                     

                    Pediatricians4

                  	
                     

                    23

                  	
                     

                    2

                  	
                     

                    10

                  	
                     

                    6

                  	
                     

                    5

                  
	
                     

                    OB/GYNs

                  	
                     

                    7

                  	
                     

                    1

                  	
                     

                    3

                  	
                     

                    2

                  	
                     

                    1

                  
	
                     

                    Vision

                  	
                     

                    7

                  	 	
                     

                    3

                  	
                     

                    2

                  	
                     

                    2

                  
	
                     

                    General
                      Surgeons

                  	
                     

                    6

                  	
                     

                    1

                  	
                     

                    3

                  	
                     

                    1

                  	
                     

                    1

                  
	
                     

                    Otolaryngologist

                  	
                     

                    2

                  	 	
                     

                    1

                  	 	
                     

                    1

                  
	
                     

                    Allergists

                  	
                     

                    1

                  	 	 	 	
                     

                    1

                  
	
                     

                    Orthopedists

                  	
                     

                    4

                  	 	
                     

                    2

                  	
                     

                    1

                  	
                     

                    1

                  
	
                     

                    Dentists5

                  	
                     

                    23

                  	
                     

                    2

                  	
                     

                    11

                  	
                     

                    8

                  	
                     

                    2

                  

          

           

          1
            All
            required providers must be located within the region.

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

          3
            Preferred Providers are the additional provider contracts that must be
            secured
            in order for the MCP to receive bonus points.

          4
            Half of
            this number must be certified by the American Board of Pediatrics.

          5
            No more
            than two-thirds of this number can be pediatric dentists.

           

          

          East
            Central - Practitioners

           

          
            	
                    Minimum
                      Provider Panel Requirements

                  
	
                     

                    Provider
                      Types

                  	
                     

                    Total
                      Required Providers1

                  	
                     

                    Ashland

                  	
                     

                    Carroll

                  	
                     

                    Holmes

                  	
                     

                    Portage

                  	
                     

                    Richland

                  	
                     

                    Stark

                  	
                     

                    Summit

                  	
                     

                    Tuscarawas

                  	
                     

                    Wayne

                  	
                     

                    Additional
                      Required Providers2

                  
	
                     

                    Pediatricians4

                  	
                     

                    49

                  	
                     

                    1

                  	
                     

                  	
                     

                  	
                     

                    2

                  	
                     

                    3

                  	
                     

                    14

                  	
                     

                    20

                  	
                     

                    2

                  	
                     

                    2

                  	
                     

                    5

                  
	
                     

                    OB/GYNs

                  	
                     

                    17

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                    1

                  	
                     

                    5

                  	
                     

                    8

                  	
                     

                  	
                     

                    1

                  	
                     

                    2

                  
	
                     

                    Vision

                  	
                     

                    18

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                    1

                  	
                     

                    5

                  	
                     

                    8

                  	
                     

                  	
                     

                  	
                     

                    4

                  
	
                     

                    General
                      Surgeons

                  	
                     

                    13

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                    1

                  	
                     

                    2

                  	
                     

                    3

                  	
                     

                    4

                  	
                     

                    1

                  	
                     

                    1

                  	
                     

                    1

                  
	
                     

                    Otolaryngologist

                  	
                     

                    7

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                    2

                  	
                     

                    2

                  	
                     

                  	
                     

                  	
                     

                    3

                  
	
                     

                    Allergists

                  	
                     

                    3

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                    1

                  	
                     

                    1

                  	
                     

                  	
                     

                  	
                     

                    1

                  
	
                     

                    Orthopedists

                  	
                     

                    9

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                    1

                  	
                     

                    2

                  	
                     

                    2

                  	
                     

                  	
                     

                    1

                  	
                     

                    3

                  
	
                     

                    Dentists5

                  	
                     

                    48

                  	
                     

                    2

                  	
                     

                  	
                     

                  	
                     

                    3

                  	
                     

                    5

                  	
                     

                    13

                  	
                     

                    17

                  	
                     

                    3

                  	
                     

                    3

                  	
                     

                    2

                  

          

           

          1
            All
            required providers must be located within the region,

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

          3
            Preferred Providers are the additional provider contracts that must be
            secured
            in order for the MCP to receive bonus points. 

          4
            Half of
            this number must be certified by the American Board of Pediatrics.

          5
            No more
            than two-thirds of this number can be pediatric dentists.

           

          

          South
            East-practitioners

          

          
            	
                    Minimum
                      Provider Panel Requirements

                  
	
                    Provider
                      Types

                  	
                    Total
                      Required Providers1

                  	
                    Athens

                  	
                    Belmont

                     

                  	
                    Coshocton

                  	
                    Gallia

                     

                  	
                    Guernsey

                  	
                    Harrison

                     

                  	
                    Jackson

                  	
                    Jefferson

                     

                  	
                    Lawrence

                  	
                    Meigs

                     

                  	
                    Monroe

                  	
                    Morgon

                     

                  	
                    Muskingum

                  	
                    Noble

                     

                  	
                    Vinton

                  	
                    Washington

                     

                  	
                    Additional
                      Required Providers2

                  
	
                    Pediatricians4

                  	
                     

                    31

                  	
                     

                    1

                  	
                     

                    1

                  	
                     

                  	
                     

                    2

                  	
                     

                    1

                  	
                     

                  	
                     

                  	
                     

                    1

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                    2

                  	
                     

                  	
                     

                  	
                     

                    1

                  	
                     

                    22

                  
	
                    OB/GYNs

                  	
                     

                    9

                  	
                     

                    1

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                    1

                  	
                     

                  	
                     

                  	
                     

                    1

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                    1

                  	
                     

                  	
                     

                  	
                     

                    1

                  	
                     

                    4

                  
	
                     

                    Vision

                  	
                     

                    13

                  	
                     

                    1

                  	
                     

                    1

                  	
                     

                  	
                     

                    1

                  	
                     

                    1

                  	
                     

                  	
                     

                    1

                  	
                     

                    1

                  	
                     

                    1

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                    2

                  	
                     

                  	
                     

                  	
                     

                    1

                  	
                     

                    3

                  
	
                     

                    General
                      Surgeons

                  	
                     

                    8

                  	
                     

                  	
                     

                    1

                  	
                     

                  	
                     

                    1

                  	
                     

                    1

                  	
                     

                  	
                     

                  	
                     

                    1

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                    1

                  	
                     

                  	
                     

                  	
                     

                    1

                  	
                     

                    2

                  
	
                     

                    Otolaryngologist

                  	
                     

                    3

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                    1

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                    1

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                    1

                  
	
                     

                    Allergists

                  	
                     

                    1

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                    1

                  
	
                     

                    Orthopedists

                  	
                     

                    5

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                    1

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                    1

                  	
                     

                  	
                     

                  	
                     

                    1

                  	
                     

                    2

                  
	
                     

                    Dentists5

                  	
                     

                    30

                  	
                     

                    2

                  	
                     

                    3

                  	
                     

                    1

                  	
                     

                    1

                  	
                     

                    3

                  	
                     

                  	
                     

                    1

                  	
                     

                    3

                  	
                     

                    2

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                    3

                  	
                     

                  	
                     

                  	
                     

                    2

                  	
                     

                    9

                  

          

           

          1
            All
            required providers must be located within the region.

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

          3
            Preferred Providers are the additional provider contracts that must be
            secured
            in order for the MCP to receive bonus points.

          4
            Half of
            this number must be certified by the American Board of Pediatrics.

          5
            No more
            than two-thirds of this number can be pediatric dentists.

           

          Central
            - Practitioners

          

          
            	
                    Minimum
                      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

                  
	
                     

                    Pediatricians4

                  	
                     

                    86

                  	 	
                     

                    4

                  	
                     

                    3

                  	 	
                     

                    55

                  	 	
                     

                    1

                  	
                     

                    2

                  	
                     

                    1

                  	
                     

                    1

                  	
                     

                    2

                  	 	 	
                     

                    1

                  	 	
                     

                    2

                  	
                     

                    2

                  	
                     

                    1

                  	
                     

                    11

                  
	
                     

                    OB/GYNs

                  	
                     

                    24

                  	 	
                     

                    2

                  	
                     

                    2

                  	 	
                     

                    12

                  	 	
                     

                    1

                  	
                     

                    1

                  	 	 	
                     

                    1

                  	 	 	 	 	
                     

                    1

                  	
                     

                    1

                  	 	
                     

                    3

                  
	
                     

                    Vision

                  	
                     

                    31

                  	
                     

                    1

                  	
                     

                    2

                  	
                     

                    2

                  	 	
                     

                    15

                  	 	
                     

                    1

                  	
                     

                    1

                  	
                     

                    1

                  	 	
                     

                    1

                  	 	 	
                     

                    1

                  	 	
                     

                    1

                  	
                     

                    1

                  	
                     

                    1

                  	
                     

                    3

                  
	
                     

                    General
                      Surgeons

                  	
                     

                    22

                  	
                     

                    1

                  	
                     

                    1

                  	
                     

                    1

                  	 	
                     

                    10

                  	 	
                     

                    1

                  	
                     

                    1

                  	
                     

                    1

                  	 	
                     

                    1

                  	 	 	 	 	
                     

                    1

                  	
                     

                    1

                  	
                     

                    1

                  	
                     

                    2

                  
	
                     

                    Otolaryngologist

                  	
                     

                    6

                  	 	
                     

                    1

                  	 	 	
                     

                    4

                  	 	 	 	 	 	 	 	 	 	 	 	 	 	
                     

                    1

                  
	
                     

                    Allergists

                  	
                     

                    4

                  	 	 	 	 	
                     

                    2

                  	 	 	 	 	 	 	 	 	 	 	 	 	 	
                     

                    2

                  
	
                     

                    Orthopedists

                  	
                     

                    13

                  	 	 	
                     

                    1

                  	 	
                     

                    7

                  	 	 	
                     

                    1

                  	 	 	
                     

                    1

                  	 	 	 	 	
                     

                    1

                  	 	 	
                     

                    2

                  
	
                     

                    Dentists5

                  	
                     

                    77

                  	
                     

                    1

                  	
                     

                    2

                  	
                     

                    3

                  	
                     

                    1

                  	
                     

                    45

                  	
                     

                    1

                  	
                     

                    2

                  	
                     

                    3

                  	
                     

                    1

                  	
                     

                    1

                  	
                     

                    2

                  	
                     

                    1

                  	
                     

                    1

                  	
                     

                    1

                  	
                     

                    1

                  	
                     

                    3

                  	
                     

                    2

                  	
                     

                    1

                  	
                     

                    5

                  

          

           

          1
            All
            required providers must be located within the region.

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

          3
            Preferred Providers are the additional provider contracts that must be
            secured
            in order for the MCP to receive bonus points.

          4
            Half of
            this number must be certified by the American Board of Pediatrics.

          5
            No more
            than two-thirds of this number can be pediatric dentists.

           

           

          South
            West - Practitioners

           

          
            	
                    Minimum
                      Provider Panel Requirements

                  
	
                     

                    Provider
                      Types

                  	
                     

                    Total
                      Required Providers1

                  	
                     

                    Adams

                  	
                     

                    Brown

                  	
                     

                    Butler

                  	
                     

                    Clermont

                  	
                     

                    Clinton

                  	
                     

                    Hamilton

                  	
                     

                    Highland

                  	
                     

                    Warren

                  	
                     

                    Additional
                      Required Providers2

                  
	
                     

                    Pediatricians4

                  	
                     

                    59

                  	
                     

                  	
                     

                  	
                     

                    7

                  	
                     

                    2

                  	
                     

                    1

                  	
                     

                    39

                  	
                     

                  	
                     

                  	
                     

                    10

                  
	
                     

                    OB/GY

                  	
                     

                    16

                  	
                     

                  	
                     

                    1

                  	
                     

                    2

                  	
                     

                    1

                  	
                     

                    1

                  	
                     

                    9

                  	
                     

                  	
                     

                    1

                  	
                     

                    1

                  
	
                     

                    Vision

                  	
                     

                    21

                  	
                     

                  	
                     

                  	
                     

                    3

                  	
                     

                    1

                  	
                     

                    1

                  	
                     

                    11

                  	
                     

                    1

                  	
                     

                    1

                  	
                     

                    3

                  
	
                     

                    General
                      Surgeons

                  	
                     

                    13

                  	
                     

                  	
                     

                  	
                     

                    2

                  	
                     

                    1

                  	
                     

                    1

                  	
                     

                    7

                  	
                     

                  	
                     

                    1

                  	
                     

                    1

                  
	
                     

                    Otolaryngologist

                  	
                     

                    6

                  	
                     

                  	
                     

                  	
                     

                    1

                  	
                     

                  	
                     

                  	
                     

                    3

                  	
                     

                  	
                     

                    1

                  	
                     

                    1

                  
	
                     

                    Allergists

                  	
                     

                    7

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                  	
                     

                    4

                  	
                     

                  	
                     

                  	
                     

                    3

                  
	
                     

                    Orthopedists

                  	
                     

                    9

                  	
                     

                  	
                     

                  	
                     

                    2

                  	
                     

                  	
                     

                  	
                     

                    5

                  	
                     

                  	
                     

                  	
                     

                    2

                  
	
                     

                    Dentists5

                  	
                     

                    50

                  	
                     

                    1

                  	
                     

                    1

                  	
                     

                    10

                  	
                     

                    4

                  	
                     

                    1

                  	
                     

                    26

                  	
                     

                    2

                  	
                     

                    2

                  	
                     

                    3

                  

          

           

          1
            All
            required providers must be located within the region.

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

          3
            Preferred Providers are the additional provider contracts that must be
            secured
            in order for the MCP to receive bonus points.

          4
            Half of
            this number must be certified by the American Board of Pediatrics.

          5
            No more
            than two-thirds of this number can be pediatric dentists.

           

          

          West
            Central - Practitioners

           

          
            	
                     

                    Minimum
                      Provider Panel Requirements

                  
	
                     

                    Provider
                      Types

                  	
                     

                    Total
                      Required Providers1

                  	
                     

                    Champaign

                  	
                     

                    Clark

                  	
                     

                    Darke

                  	
                     

                    Greene

                  	
                     

                    Miami

                  	
                     

                    Montgomery

                  	
                     

                    Prebe

                  	
                     

                    Shelby

                  	
                     

                    Additional
                      Required Providers2

                  
	
                     

                    Pediatricians4

                  	
                     

                    36

                  	 	
                     

                    2

                  	 	
                     

                    3

                  	
                     

                    1

                  	
                     

                    22

                  	 	 	
                     

                    8

                  
	
                     

                    OB/GYNs

                  	
                     

                    12

                  	 	
                     

                    2

                  	 	
                     

                    1

                  	
                     

                    1

                  	
                     

                    6

                  	 	
                     

                    1

                  	
                     

                    1

                  
	
                     

                    Vision

                  	
                     

                    20

                  	 	
                     

                    2

                  	
                     

                    1

                  	
                     

                    2

                  	
                     

                    2

                  	
                     

                    10

                  	 	
                     

                    1

                  	
                     

                    2

                  
	
                     

                    General
                      Surgeons

                  	
                     

                    10

                  	 	
                     

                    2

                  	 	
                     

                    2

                  	
                     

                    1

                  	
                     

                    3

                  	 	 	
                     

                    2

                  
	
                     

                    Otolaryngologist

                  	
                     

                    7

                  	 	
                     

                    1

                  	 	 	 	
                     

                    3

                  	 	 	
                     

                    3

                  
	
                     

                    Allergists

                  	
                     

                    4

                  	 	 	 	 	 	
                     

                    2

                  	 	 	
                     

                    2

                  
	
                     

                    Orthopedists

                  	
                     

                    6

                  	 	 	 	
                     

                    2

                  	 	
                     

                    2

                  	 	 	
                     

                    2

                  
	
                     

                    Dentists5

                  	
                     

                    39

                  	
                     

                    1

                  	
                     

                    5

                  	
                     

                    1

                  	
                     

                    3

                  	
                     

                    3

                  	
                     

                    20

                  	
                     

                    1

                  	
                     

                    1

                  	
                     

                    4

                  

          

           

          1
            All
            required providers must be located within the region.

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

          3
            Preferred Providers are the additional provider contracts that must be
            secured
            in order for the MCP to receive bonus points.

          4
            Half of
            this number must be certified by the American Board of Pediatrics.

          5
            No more
            than two-thirds of this number can be pediatric dentists.

           

          

          North
            West - Practitioners

           

          
            	
                    Minimum
                      Provider Panel Requirements

                  
	
                     

                    Provider
                      Types

                  	
                     

                    Total
                      Required Providers1

                  	
                    Allen

                  	
                    Auglaize

                     

                  	
                    Defiance

                  	
                    Fulton

                     

                  	
                    Hancock

                  	
                    Hardin

                     

                  	
                    Henry

                  	
                    Lucas

                     

                  	
                    Mercer

                  	
                    Ottawa

                     

                  	
                    Paulding

                  	
                    Putnam

                     

                  	
                    Sandusky

                  	
                    Seneca

                     

                  	
                    Van
                      Wert

                  	
                    Williams

                     

                  	
                    Wood

                  	
                    Wyandot

                     

                  	
                     

                    Additional
                      Required Providers2

                  
	
                     

                    Pediatricians4

                  	
                     

                    45

                  	
                     

                    4

                  	 	 	 	
                     

                    1

                  	 	 	
                     

                    23

                  	 	 	 	 	
                     

                    1

                  	 	 	
                     

                    1

                  	
                     

                    2

                  	 	
                     

                    13

                  
	
                     

                    OB/GYNs

                  	
                     

                    13

                  	
                     

                    2

                  	 	 	 	
                     

                    1

                  	 	 	
                     

                    5

                  	 	 	 	 	
                     

                    1

                  	
                     

                    1

                  	 	 	
                     

                    1

                  	 	
                     

                    2

                  
	
                     

                    Vision

                  	
                     

                    18

                  	
                     

                    2

                  	
                     

                    1

                  	
                     

                    1

                  	 	
                     

                    1

                  	 	 	
                     

                    7

                  	
                     

                    1

                  	 	 	 	
                     

                    1

                  	 	 	
                     

                    1

                  	
                     

                    2

                  	 	
                     

                    1

                  
	
                     

                    General
                      Surgeons

                  	
                     

                    13

                  	
                     

                    2

                  	 	 	 	
                     

                    1

                  	 	 	
                     

                    4

                  	 	 	 	 	
                     

                    1

                  	 	 	
                     

                    1

                  	
                     

                    2

                  	 	
                     

                    2

                  
	
                     

                    Otolaryngologist

                  	
                     

                    7

                  	
                     

                    1

                  	 	 	 	
                     

                    1

                  	 	 	
                     

                    2

                  	 	 	 	 	 	 	 	 	 	 	
                     

                    3

                  
	
                     

                    Allergists

                  	
                     

                    3

                  	
                     

                    1

                  	 	 	 	 	 	 	
                     

                    1

                  	 	 	 	 	 	 	 	 	 	 	
                     

                    1

                  
	
                     

                    Orthopedists

                  	
                     

                    7

                  	
                     

                    2

                  	 	 	 	
                     

                    1

                  	 	 	
                     

                    2

                  	 	 	 	 	
                     

                    1

                  	 	 	 	
                     

                    1

                  	 	 
	
                     

                    Dentists5

                  	
                     

                    45

                  	
                     

                    4

                  	
                     

                    1

                  	
                     

                    1

                  	
                     

                    1

                  	
                     

                    2

                  	
                     

                    1

                  	
                     

                    1

                  	
                     

                    20

                  	
                     

                    1

                  	
                     

                    1

                  	 	
                     

                    1

                  	
                     

                    2

                  	
                     

                    2

                  	
                     

                    1

                  	
                     

                    1

                  	
                     

                    2

                  	
                     

                    1

                  	
                     

                    2

                  

          

           

          1
            All
            required providers must be located within the region.

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

          3
            Preferred Providers are the additional provider contracts that must be
            secured
            in order for the MCP to receive bonus points.

          4
            Half of
            this number must be certified by the American Board of Pediatrics.

          5
            No more
            than two-thirds of this number can be pediatric dentists.

           

          As
            of
            November 20, 2006

           

          

          APPENDIX
            I

           

          PROGRAM
            INTEGRITY

           

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

           

          In
            addition to the requirements in OAC rule 5101:3-26-06, the MCP's compliance
            program which safeguards against fraud and abuse must, at a minimum,
            specifically address the following:

           

          a.
            Employee
            education about false claims recovery:
            In order
            to comply with Section 6032 of the Deficit Reduction Act of 2005 MCPs
            must, as a
            condition of Medicaid participation, do the following:

           

          i.
            establish and make available to all employees through the MCP's employee
            handbook the following written materials regarding false claims
            recovery:

           

          a.
            policies that provide detailed information about the federal False Claims
            Act
            and other state and federal laws related to the prevention and detection
            of
            fraud, waste, and abuse, including administrative remedies for false
            claims and
            statements as well as civil or criminal penalties;

           

          b.
            policies and procedures for detecting and preventing fraud, waste, and
            abuse;
            and

           

          c.
            the
            laws governing the rights of employees to be protected as
            whistleblowers.

           

          ii.
            establish written policies for subcontractors that provide detailed information
            about the federal False Claims Act and other state and federal laws related
            to
            the prevention and detection of fraud, waste, and abuse, including
            administrative remedies for false claims and statements as well as civil
            or
            criminal penalties, and the MCP's policies and procedures for detecting and
            preventing fraud, waste, and abuse. MCPs must make such information available
            to
            their subcontractors.

           

          

          Appendix
            I 

          Page
            2

           

          b.
            Monitoring
            for fraud and abuse:
            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.

           

          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.

           

          c.
            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.

           

          d.
            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:

           

          

          Appendix
            I 

          Page
            3

           

          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 ofMCP'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.

           

          e.
            Monitoring
            for prohibited affiliations:
            The
            MCP's policies and procedures for ensuring that. pursuant to 42 CFR 438.610.
            the
            MCP will not knowingly have a relationship with individuals debarred
            by Federal
            Agencies, as specified in Article ^& XII of the Agreement.

           

          2.
            Data
            Certification:

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

           

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

           

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

           

          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

           

          

          Appendix
            I 

          Page
            4

          

          

          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.

           

          

          APPENDIX
            J

          FINANCIAL
            PERFORMANCE

          1.
            SUBMISSION OF FINANCIAL STATEMENTS AND REPORTS

           

          MCPs
            must
            submit the following financial reports to ODJFS:

           

          a.
            The
            National Association of Insurance Commissioners (NAIC) quarterly and
            annual
            Health Statements (hereafter referred to as the "Financial Statements"),
            as
            outlined in Ohio Administrative Code (OAC) rule 5101:3-26-09(8). The
            Financial
            Statements must include all required Health Statement filings, schedules
            and
            exhibits as stated in the NAIC Annual Health Statement Instructions including,
            but not limited to, the following sections: Assets, Liabilities, Capital
            and
            Surplus Account. Cash Flow, Analysis of Operations by Lines of Business,
            Five-Year Historical Data, and the Exhibit of Premiums, Enrollment and
            Utilization. The Financial Statements must be submitted to BMHC even
            if the Ohio
            Department of Insurance (ODI) does not require the MCP to submit these
            statements to ODI. A signed hard copy and an electronic copy of the reports
            in
            the NAIC-approved format must both be provided to ODJFS;

           

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

           

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

           

          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);

           

          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.

           

          

           

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

           

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

           

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

        

      Appendix
        J 

      Page
        3

       

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

       

      b.
        Indicator: Administrative Expense Ratio

       

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

       

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

       

      c.
        Indicator: Overall Expense Ratio

       

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

       

      Administrative
        Expense Ratio = Administrative Expenses divided by Total Revenue

       

      Medical
        Expense Ratio = Medical Expenses divided by Total Revenue

       

      Standard:
        Overall
        Expense Ratio not to exceed 100% as determined frorr 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 nan-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 TMAIC 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
        5

       

      The
        annual deductible or retention amount for such insurance must be specified
        in
        the reinsurance agreement and must not exceed $75,000.00, except as provided
        below. Except for transplant services, and as provided below, this reinsurance
        must cover, at a minimum, 80% of inpatient costs incurred by one member in
        one
        year, in excess of $75,000.00.

       

      For
        transplant services, the reinsurance must cover, at a minimum, 50% of transplant
        related costs incurred by one member in one year, in excess of
        $75,000.00.

       

      An
        MCP
        may request a higher deductible amount and/or that the reinsurance cover
        ess
        than 80% of inpatient costs in excess of the deductible amount. If the MCP
        does
        not have more than 75,000 members in Ohio, but does have more than 75,000
        members between Ohio and other states, ODJFS may consider alternate reinsurance
        arrangements. However, depending on the corporate structures of the Medicaid
        MCP, other forms of security may be required in addition to reinsurance.
        These
        other security tools may include parental guarantees, letters of credit,
        or
        performance bonds. In determining whether or not the request will be approved,
        the ODJFS may consider any or all of the following:

       

      a.
        whether the MCP has sufficient reserves available to pay unexpected
        claims;

       

      b.
        the
        MCP's history in complying with financial indicators 2.a., 2.b., and 2.c.,
        as
        specified in this Appendix.

       

      c.
        the
        number of members covered by the MCP;

       

      d.
        how
        long the MCP has been covering Medicaid or other members on a full risk
        basis.

       

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

       

      Penalty
        for noncompliance:
        If it is
        determined that an MCP failed to have reinsurance coverage, that an MCP's
        deductible exceeds $75,000.00 without approval from ODJFS, or that the MCP's
        reinsurance for non-transplant services covers less than 80% of inpatient
        costs
        in excess of the deductible incurred by one member for one year without approval
        from ODJFS, then the MCP will be required to pay a monetary penalty to ODJFS.
        The amount of the penalty will be the difference between the estimated amount,
        as determined by ODJFS, of what the MCP would have paid in premiums for the
        reinsurance policy if it had been in compliance and what the MCP did actually
        pay while it was out of compliance plus 5%. For example, if the MCP paid
        $3.000,000.00 in premiums during the period of non-compliance and would have
        paid $5,000,000.00 if the requirements had been met, then the penalty would
        be
        $2,100,000.00.

       

      

      Appendix
        J 

      Page
        6

       

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

       

      4.
        PROMPT PAY REQUIREMENTS

       

      In
        accordance with 42 CFR 447.46, MCPs must pay 90% of all submitted clean claims
        within 30 days of the date of receipt and 99% of such claims within 90 days
        of
        the date of receipt, unless the MCP and its contracted 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 c aim 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-

      

      Appendix
        J 

      Page
        7

       

      patient
        stop-loss protection in accordance with paragraph (f) of 42 CFR 422.208,
        and
        conduct periodic surveys in accordance with paragraph (h) of 42 CFR
        422.208.

       

      In
        accordance with 42 CFR 417.479 and 42 CFR 422.210, MCPs must maintain copies
        of
        the following required documentation and make this information available
        to
        ODJFS upon request:

       

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

       

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

       

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

       

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

       

      6.
        NOTIFICATION OF REGULATORY ACTION

       

      Any
        MCP
        notified by the ODI of proposed or implemented regulatory action must report
        such notification and the nature of the action to ODJFS no later than one
        workingi 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 CFC ELIGIBLE POPULATION

       

      1.
        As
        required by federal regulation, 42 CFR 438.240, each managed care plan (MCP)
        mpst 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 w.'ill assist MCPs with
        conducting PIPs by providing technical assistance and will annually validate
        the
        PIPs. In addition, the MCP must annually submit to ODJFS the status and results
        of each PIP.

       

      MCPs
        must
        initiate the following PIPs:

      

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

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

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

      

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

       

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

       

      b.
        UNDER-
        AND OVER-UTILIZATION

       

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

       

      

      Appendix
        K 

      Page
        2

       

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

       

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

       

      c.
        SPECIAL
        HEALTH CARE NEEDS

       

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

       

      d.
        SUBMISSION
        OF PERFORMANCE MEASUREMENT DATA

       

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

       

      Each
        MCP
        must also submit clinical performance measurement data as required by ODJFS
        that
        uses standard measures as specified by ODJFS. MCPs are required to submit
        Health
        Employer Data Information Set (HED1S) audited data for the following
        measures:

       

      i.
        Comprehensive Diabetes Care

      ii.
        Child
        Immunization Status

      iii.
        Adolescent Immunization Status

       

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

       

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

       

      2.
        EXTERNAL QUALITY REVIEW

       

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

       

      

      Appendix
        K

      Page
        3

       

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

       

      c.
        EXTERNAL
        QUALITY REVIEW PERFORMANCE

       

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

       

      

      APPENDIX
        L

       

      DATA
        QUALITY

       

      CFC
        ELIGIBLE POPULATION

       

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

       

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

       

      1.
        ENCOUNTER DATA

       

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

       

      l.a.
        Encounter Data Completeness

       

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

       

      l.a.i.
        Encounter Data Volume

       

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

       

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

       

      Appendix
        L 

      Page
        2

       

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

       

      
        	
                Quarterly
                  Report Periods

              	
                Data
                  Source: Estimated Encounter Data File Update

              	
                Quarterly
                  Report Estimated Issue Date

              	
                Contract
                  Period

              
	
                 

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

              	
                 

                July
                  2006

              	
                 

                August
                  2006

              	
                 

                SFY
                  2007

              
	
                 

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

              	
                 

                October
                  2006

              	
                 

                November
                  2006

              
	
                 

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

              	
                 

                January
                  2007

              	
                 

                February
                  2007

              
	
                 

                Qtr
                  1 thru Qtr 4: 2004, 2005. 2006

              	
                 

                April
                  2007

              	
                 

                May
                  2007

              
	
                 

                Qtr
                  2 thru Qtr 4 2004, Qtr 1 thru Qtr4: 2005, 2006 Qtrl 2007

              	
                 

                July
                  2007

              	
                 

                August
                  2007

              	
                 

                SFY
                  2008

              
	
                 

                Qtr
                  3. Qtr4:2004, Qtrl thru Qtr 4: 2005, 2006 Qtrl, Qtr 2 2007

              	
                 

                October
                  2007

              	
                 

                November
                  2007

              
	
                 

                Qtr4:2004.
                  Qtr I thru Qtr 4: 2005,2006 Qtr 1 thru Qtr 3 2007

              	
                 

                January
                  2008

              	
                 

                February
                  2008

              
	
                 

                Qtr
                  1 thru Qtr 4: 2005, 2006, 2007

              	
                 

                April
                  2008

              	
                 

                May
                  2008

              

      

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

      

       

      Appendix
        L 

      Page
        3

      

      
        	
                 

                Category

              	
                Measure
                  per 1,000/MM

              	
                 

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

              	
                 

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

              	
                 

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

              	
                 

                Description

              
	
                 

                Inpatient
                  Hospital

              	
                 

                Discharges

              	
                 

                5.4

              	
                 

                5.0

              	
                 

                5.4

              	
                 

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

              
	
                 

                Emergency
                  Department

              	
                 

                Visits

              	
                 

                51.6

              	
                 

                51.4

              	
                 

                50.7

              	
                 

                Includes
                  physician and hospital emergency department encounters

              
	
                 

                Dental

              	
                 

                38.2

              	
                 

                41.7

              	
                 

                50.9

              	
                 

                Non-institutional
                  and hospital dental visits

              
	
                 

                Vision

              	
                 

                11.6

              	
                 

                11.6

              	
                 

                10.6

              	
                 

                Non-institutional
                  and hospital outpatient optometry and ophthalmology
                  visits

              
	
                 

                Primary
                  and Specialist Care

              	
                 

                220.1

              	
                 

                225.7

              	
                 

                233.2

              	
                 

                Physician/practitioner
                  and hospital outpatient visits

              
	
                 

                Ancillary
                  Services

              	
                 

                144.7

              	
                 

                123.0

              	
                 

                133.6

              	
                 

                Ancillary
                  visits

              
	
                 

                Behavioral
                  Health

              	
                 

                Service

              	
                 

                7.6

              	
                 

                8.6

              	
                 

                10.5

              	
                 

                Inpatient
                  and outpatient behavioral encounters

              
	
                 

                Pharmacy

              	
                 

                Prescriptions

              	
                 

                388.5

              	
                 

                457.6

              	
                 

                492.2

              	
                 

                Prescribed
                  drugs

              

      

      

       

      County-Based
        Approach:
        All
        counties with managed care membership as of February 1.2006, will be included
        in
        a county-based encounter data volume measure until regional evaluation is
        implemented for the county's applicable region.. Upon implementation of
        regional-based evaluation for a particular county's region, the county will
        be
        included in the MCP's regional-based results and will no longer be included
        in
        the MCP's county-based results. County-based results will be determined by
        MCP
        (i.e., one utilization rate per service category for all applicable counties)
        and must be equal to or greater than the standards established in Table 2
        above.
        [Example: The county-based result for MCP AAA, which has contracts in the
        Central and West Centra) regions, will include Franklin, Pickaway, Montgomery,
        Greene and dark counties (i.e., counties with managed care membership as
        of
        February 1, 2006). When the regional-based evaluation is implemented for
        the
        Central region. Franklin and Pickaway counties, along with all other counties
        in
        the region, will then be included in the Central region results for MCP AAA;
        Montgomery, Greene. and dark counties will remain in the county-based results
        for MCP AAA until the West Central regional measure is
        implemented.]

       

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

       

      Appendix
        L

      Page
        4

       

      Interim
        Regional-Based Approach:

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

       

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

       

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

       

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

       

      
        	
                Category

              	
                Measure
                  per 1,000/MM

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

              	
                Description

              
	
                 

                Inpatient
                  Hospital

              	
                 

                Discharges

              	
                 

                2.7

              	
                 

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

              
	
                 

                Emergency
                  Department

              	
                 

                Visits

              	
                 

                25.3

              	
                 

                Includes
                  physician and hospital emergency department encounters

              
	
                 

                Dental

              	
                 

                25.5

              	
                 

                Non-institutional
                  and hospital dental visits

              
	
                 

                Vision

              	
                 

                5.3

              	
                 

                Non-institutional
                  and hospital outpatient optometry and ophthalmology
                  visits

              
	
                 

                Primary
                  and Specialist Care

              	
                 

                116.6

              	
                 

                Physician/practitioner
                  and hospital outpatient visits

              
	
                 

                Ancillary
                  Services

              	
                 

                66.8

              	
                 

                Ancillary
                  visits

              
	
                 

                Behavioral
                  Health

              	
                 

                Service

              	
                 

                5.2

              	
                 

                Inpatient
                  and outpatient behavioral encounters

              
	
                 

                Pharmacy

              	
                 

                Prescriptions

              	
                 

                246.1

              	
                 

                Prescribed
                  drugs

              

      

      

      

      Appendix
        L

      Page
        5

       

      

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

       

       

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

       

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

       

      l.a.ii.
        Encounter Data Omissions

       

      Omission
        studies will evaluate the completeness of the encounter data.

       

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

       

      The
        encounters documented in the medical record that do not appear in the encounter
        data will be counted as omissions.

       

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

       

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

       

      

      Appendix
        L

      Page
        6

       

      

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

       

      with
        time
        periods ending in the CY 2006 and CY 2007 contract periods.

       

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

       

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

       

      l.a.iii.
        Incomplete Outpatient Hospital Data

       

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

       

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

       

      Report
        Period:
        For the
        SPY 2007 and SPY 2008 contract periods, performance will be evaluated using
        the
        report periods listed in 1 .a.i.. Table 1.

       

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

       

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

       

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

       

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

       

      

      Appendix
        L 

      Page
        7

       

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

       

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

       

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

       

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

       

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

       

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

       

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

       

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

       

      l.a.v.
        Rejected Encounters

       

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

       

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

       

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

       

      

      Appendix
        L 

      Page
        8

       

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

       

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

       

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

       

      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
        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
        v be
        calculated per MCP (i.e., to include all counties serviced by the
        MCP).

       

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

       

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

       

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

       

      

      Appendix
        L

      Page
        9

       

      

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

       

      the
        determination 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 Qualify 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.

       

      l.a.vi. Acceptance
        Rate

       

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

       

      Measure:
        The rate
        of encounters that are submitted to ODJFS and accepted (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 for NSF 

       

      20
        encounters per 1,000 MM for UB-92

       

      Seventh
        through twelfth month of membership: 

       

      250
        encounters per 1,000 MM for NCPDP 

       

      350
        encounters per 1.000 MM for NSF 

       

      100
        encounters per 1,000 MM for UB-92

       

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

       

      Penalty/or
        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

       

      

      Appendix
        L

      Page
        10

       

      

       

      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.

       

      l.a.vii.
        Incomplete Birth Weight Data

       

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

       

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

       

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

       

      Penalty/or
        noncompliance:
        If an
        MCP is determined to be noncompliant with the standard. ODJFS will impose
        a
        monetary sanction (see Section 6.) of one percent of the current month's
        premium
        payment. Once the MCP is performing at standard levels and
        violations/deficiencies are resolved to the satisfaction of ODJFS. The money
        will be refunded.

       

      l.b.
        Encounter Data Accuracy

       

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

       

      l.b.i.
        Encounter Data Accuracy Studies

       

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

       

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

       

      

      Appendix
        L 

      Page
        11

       

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

       

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

       

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

       

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

       

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

       

      Measure
        2:
        This
        accuracy study will compare the accuracy and completeness of payment cata
        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 2:
        TBD for
        SFY 2008 based on study conducted in SPY 2007

       

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

       

      

      Appendix
        L

      Page
        12

       

      

       

      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 MM1S provider number
        must be 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
        SFY 2007 and SFY 2008 contract periods, performance will be evaluated using
        the
        report periods listed in 1 .a.i.. Table 1.

       

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

       

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

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

      

      I.c.
        Timely Submission of Encounter Data 

      

      l.c.i.
        Timeliness

      

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

       

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

       

      MCP
        submissions of encounter data files in the ODJFS-specified medium per format
        to
        ODJFS are limited to two per format per month. Should an MCP wish to send
        additional files in the ODJFS-specified medium per format, permission to
        do so
        must be obtained by contacting BMHC.

       

      

      Appendix
        L 

      Page
        13

       

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

       

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

       

      2.
        CASE MANAGEMENT
        DATA

       

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

      

      2.a.
        Case Management System Data Accuracy 

      2.a.i.
        Open Case Management Spans for Disenrolled Members

       

      Measure:
        The
        percentage of the MCP's adult and children case management records in the
        Screening, Assessment, and Case Management System that have open case management
        date spans for members who have disenrolled from the MCP. 

       

      Report
        Period:
        For the
        SPY 2007 contract period. July - September 2006, October - December 2006,
        January - March 2007, and April - June 2007 report periods. For the SFY 2008
        contract period, July - September 2007. October-December 2007, January -
        March
        2008, and April-June 2008 report periods. 

       

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

       

      For
        an MCP which had membership as of February 1. 2006:
        Performance will be evaluated using:

      1)
        region-based results for any active region in which all selected MCPs had
        at
        least 10.000 members during each month of the entire report period; and/or
        2)
        the statewide result for all counties that were not included in the region-based
        results, but in which the MCP had managed care membership as of February
        1,
        2006.

      

      Appendix
        L

      Page
        14

       

      

       

      For
        any MCP which did not have membership as a/February 1, 2006:
        Performance will begin to be

       

      evaluated
        using region-based results for any active region in which all selected MCPs
        had
        at least

       

      10,000
        members during each month of the entire report period. |

       

      Regional-Based
        Approach:
        MCPs
        will be evaluated by region, using results for all counties included in the
        region.

       

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

       

      2.b.
        Timely Submission of Case Management Files

       

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

       

      Penalty/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. TheOAC rule
        5101:3-26-07(C) requires MCPs to submit data and information as requested
        by
        ODJFS or its designee for the annual external quality review.

       

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

       

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

       

      If
        an MCP
        does not complete a study because either their encounter data is of insufficient
        quality or too few medical records are submitted, accurate evaluation of
        clinical quality in the study area cannot be determined for the individual
        MCP
        and the assurance of adequate clinical quality for the program as a whole
        is
        jeopardized.

       

      

      Appendix
        L 

      Page
        15

      

       

      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

       

      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/or
        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 CFC} members, including those who have case management needs. The MCP
        must
        submit a Members" Designated PCP file every month. Specialists may and should
        be
        identified as the PCP as appropriate for the member's condition; however,
        no CFC
        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 file on a monthly basis according
        to
        the specifications established in ODJFS
        Member's PCP Data File and Submission Specifications.

       

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

       

      4.b.
        Designated PCP for newly enrolled members

       

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

       

      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

       

      

      Appendix
        L

      Page
        16

      

      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
        Qualify Standard:
        SFY 2007
        will be informational only. A minimum rate of 75% of new members with PCP
        designation by their effective date of enrollment for quarter 1 and quarter
        2 of
        SFY 2008. A minimum rate of 85% of new members w ith 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 CFC membership.

       

      Penalty
        for noncompliance:
        If an
        MCP is noncompliant with the standard, ODJFS will impose a monetary sanction
        of
        one-half of one percent the current month's premium payment. Once the MCP
        is
        performing at standard levels and violations/deficiencies are resolved to
        the
        satisfaction of ODJFS. the money will be refunded. As stipulated in OAC rule
        5101:3-26-08.2. each new member must have a designated primary care 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 Hies must be submitted in the
        ODJFS-specified format and with the ODJFS-specified filename in order to
        be
        successfully processed. 

       

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

       

      6.
        NOTES

       

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

       

      Penalties
        for noncompliance with standards outlined in this appendix, including monetary
        sanctions. will be imposed as the results are finalized. With the exception
        of
        Sections 1 .a.i., 1 .a.v., and 1 .a.vi., no monetary sanctions described
        in this
        appendix will be imposed if the MCP is in its first contract

       

      

      Appendix
        L

      Page
        17

       

      

       

      year
        of
        Medicaid program participation. Notwithstanding the penalties specified in
        this
        Appendix, ODJFS reserves the right to apply the most appropriate penalty
        to the
        area of deficiency identified when an MCP is determined to be noncompliant
        with
        a standard. Monetary penalties for noncompliance with any individual measure,
        as
        determined in this appendix, shall not exceed $300,000 during each evaluation
        period.

       

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

       

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

       

      6.b.
        Combined Remedies

       

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

       

      6.c.
        Membership Freezes

       

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

       

      6.d.
        Reconsideration

       

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

       

      6.e.
        Contract Termination, Nonrenewals, or Denials

       

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

       

      

      APPENDIX
        M

       

      PERFORMANCE
        EVALUATION

       

      CFC
        ELIGIBLE POPULATION

       

      This
        appendix establishes minimum performance standards for managed care plans
        (MCPs)
        in key program areas. The intent is to maintain accountability for contract
        requirements. Standards are subject to change based on the revision or update
        of
        applicable national standards, methods or benchmarks. Performance will be
        evaluated in the categories of Quality of Care, Access, Consumer Satisfaction.
        and Administrative Capacity. Each performance measure has an accompanying
        minimum performance standard. MCPs with performance levels below the minimum
        performance standards will be required to take corrective action. The Ohio
        Medicaid managed care program will transition to a regional-based system
        as
        managed care expands statewide, beginning in SFY 2007. Evaluation of performance
        will transition to a regional-based approach after completion of the statewide
        expansion. If statewide expansion is not complete by December 31. 2006. OD.IFS
        may adjust performance measure reporting periods based on the number of months
        an MCP has had regional membership. Due to differences in data and reporting
        requirements, transition to the regional-based approach will vary by performance
        measure. Unless otherwise noted, performance measures and standards (see
        Sections 1. 2. 3 and 4) will be applicable for all counties in which the
        MCP has
        membership as of February 1, 2006. until the regional-based approach is
        developed.

       

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

       

      1.
        QUALITY OF CARE

       

      l.a.i
        Independent External Quality Review [Only use in SFY2006 Incentive System;
        only
        applicable for MCPs with membership as of February I,
        2006]

       

      In
        accordance with federal law and regulations state Medicaid agencies must
        annually provide for an external review of the quality outcomes and timeliness
        of. and access to. services provided by Medicaid-contracting MCPs [(42 CFR
        438.204(d)]. The external review assists the state in assuring MCP compliance
        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 component
        and
        clinical focus areas of study. The overall score is weighted to emphasize
        clinical performance.

       

      Report
        Period:
        For the
        SFY 2006 contract period, performance will be evaluated using the review's
        that
        are finalized during SFY 2006. 

       

      Minimum
        Performance Standard 1:
        A
        minimum score of 75% for each clinical study and the administrative component.
        |

       

      Action
        Required for Noncompliance with the Minimum Performance Standard
        1:
        For all
        studies that are finalized during this contract period, if an MCP is
        noncompliant with the standard, then the MCP is required to complete a
        Performance Improvement Project, as described in Appendix K.

       

      

      Appendix
        M 

      Page
        2

       

      Quality
        Assessment and Performance Improvement Program,
        to
        address the area(s) of noncompliance.

       

      Minimum
        Performance Standard 2:
        Each MCP
        must achieve an overall
        score of
        at least 75%.

       

      Penalty
        for Noncompliance with the Minimum Performance Standard 2:
        A
        serious deficiency may result in immediate termination or nonrenew al of
        the
        provider agreement. (Examples of an external quality review serious deficiency
        are a score of less than 75 percent for each clinical study or a score of
        less
        than 75 percent for the administrative component with a score of less than
        75
        percent on the preponderance of clinical studies).

       

      l.a.ii
        Independent External Quality Review (Effective SFY 2007]

       

      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
        2007.

       

      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. Serious deficiencies may result in immediate termination or
        non-renewal of the provider agreement.

       

      l.b.
        Children with Special Health Care Needs (CSHCN)

       

      In
        order
        to ensure state compliance with theprovisionsof42CFR438.208.the Bureau of
        Managed Health Care established Children w'ith Special Health Care Needs
        (CSHCN)
        basic program requirements in Appendix G, Coverage
        and Services,
        and
        corresponding minimum performance standards as described below. The purpose
        of
        these measures is to provide appropriate and targeted case management services
        to CSHCN.

       

      l.b.i.
        Case Management of Children (Use
        in SFY2006 Incentive System; only applicable/or MCPs with membership as of
        January
        7, 2006)

       

      Measure:
        The
        average monthly case management rate for children 6 months and over and under
        21
        years of age.

       

      

      Appendix
        M 

      Page
        3

       

      Report
        Period:
        For the
        SFY 2006 contract period, performance will be evaluated using the January
        - June
        2005 and July - December 2005 report periods. For the SFY 2007 contract period,
        performance will be evaluated using the January - June 2006 report
        period

       

      Performance
        Target:
        A
        minimum case management rate of 5.0%.

       

      Minimum
        Performance Standard:
        For
        results that are below the performance target the performance standard is
        an
        improvement level that results in a 20% decrease between the target and the
        previous reporting period's results. For MCPs that reach or surpass the
        performance target, then the standard is to keep the results at or above
        the
        performance target, 

       

      Penalty/or
        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 ODJFS imposing
        a
        monetary sanction. Upon all subsequent semi-annual measurements of performance,
        if an MCP is again determined to be noncompliant with the standard for this
        measure. ODJFS will impose a monetary sanction (see Section 5) of one half
        of
        one percent of the current month's premium payment. Once the MCP is performing
        at standard levels and the violations/deficiencies are resolved to the
        satisfaction of ODJFS, the money will be refunded.

       

      l.b.ii.
        Case Management of Children

       

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

       

      Report
        Period:
        For the
        SFY 2007 contract period. July - September 2006, October - December 2006,
        January - March 2007. and April - June 2007 report periods. For the SFY 2008
        contract period. July - September 2007. October - December 2007. January
        - March
        2008, and April - June 2008 report periods.

       

      County-Based
        Approach:
        MCPs
        with managed care membership as of February 1. 2006 w'ill be evaluated using
        their county-based statewide result until regional evaluation is implemented
        for
        the county's applicable region. The county-based statewide result will include
        data for all counties in which the MCP had membership as of February 1.2006
        that
        are not included in any regional-bdsed result. Regional-based results will
        not
        be used for evaluation until all selected MCPs in an active region have at
        least
        10.000 members during each month of the entire report period. Upon
        implementation of regional-based evaluation for a particular county's region,
        the county will be included in the MCP's regional-based result and will no
        longer be included in the MCP's county-based statewide result. [Example:
        The
        county-based statewide result for MCP AAA, which has contracts in the Central
        and West Central regions, will include Franklin. Pickaway. Montgomery. Greene
        and dark counties (i.e., counties in which MCP AAA had managed care membership
        as of February 1,2006). When regional-based evaluation is implemented for
        the
        Central region, Franklin and Pickaway counties, along with all other counties
        in
        the region, will then be included in the Central region results for MCP AAA;
        Montgomery. Greene. and dark counties will remain in the county-based statewide
        result for evaluation of MCP AAA until the West Central regional-based approach
        is implemented.]

       

      

      Appendix
        M

      Page
        4

       

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

       

      Minimum
        Performance Standard:
        For the
        first and second quarters of SFY 2007, a case management rate of 4.5%. For
        the
        third and fourth quarters of SFY 2007, a case management rate of 5.0%. For
        SFY
        2008, a case management rate of 6.0%.

       

      Penally
        for Noncompliance:
        The
        first time an MCP is noncompliant with the standard for this measure. ODJFS
        w'ill issue a Sanction Advisory informing the MCP that any future noncompliance
        instances with the standard for this measure will result in new member selection
        freezes or a reduction of assignments will occur as outlined in Appendix
        N of
        the Provider Agreement. Once the MCP is performing at standard levels and
        the
        violations/deficiencies are resolved to the satisfaction of ODJFS, the new
        member selection freeze/reduction of assignments will be lifted.

       

      l.b.iii. Case
        Management of Children with an ODJFS-Mandated Condition (only
        applicable for MCPs with membership as of January
        7, 2006)

       

      Measure
        I:
        The
        percent of children 6 months and over and under 21 years of age with a positive
        identification through an ODJFS administrative review of data for the
        ODJFS-mandated case management condition of asthma that are case
        managed.

       

      Report
        Period:
        For the
        SFY 2006 contract period, performance will be evaluated using the July
        -September 2005 and January - March 2006 report periods. Measure
        2:
        The
        percent of children age 17 and under with a positive identification through
        an
        ODJFS administrative review of data for the ODJFS-mandated case management
        condition of teenage
        pregnancy
        that are
        case managed.

       

      Report
        Period:
        For the
        SFY 2006 contract period, performance will be evaluated using the -January
        -
        June 2005 and July - December 2005 report periods. For the SFY 2007 contract
        period. performance will be evaluated using the January - June 2006 report
        period.

       

      Measure
        3:
        The
        percent of children 6 months and over and under 21 years of age with a positive
        identification through an ODJFS administrative review of data for the
        ODJFS-mandated case management condition ofP-HV/AIDS that are case
        managed.

       

      Report
        Period:
        For the
        SFY 2006 contract period, performance will be evaluated using the July September
        2005 and January - March 2006 report periods.

       

      Performance
        Target for Measures 1. 2, and 3:
        A
        minimum case management rate of 80%.

       

      Minimum
        Performance Standard for Measures I. 2, and 3:
        For
        results that are below the performance target the performance standard is
        an
        improvement level that results in a 20% decrease between the target and the
        previous reporting period's results. For MCPs that reach or surpass the
        performance target, then the standard is to keep the results at or above
        the
        performance target.

       

      Appendix
        M

      Page
        5

       

      Penalty
        for Nonconipliance for Measures 1 and 2:
        The
        first time an MCP is noncompliant with the standard for this measure. ODJFS
        will
        issue a Sanction Advisory informing the MCP that any future noncompliance
        instances with the standard for this measure will result in ODJFS imposing
        a
        monetary sanction . Upon all subsequent semi-annual measurements of performance,
        if an MCP is again determined to be noncompliant with the standard (see Section
        5) for measures 1 or 2, ODJFS will impose a monetary sanction of one half
        of one
        percent of the current month's premium payment. Once the MCP is performing
        at
        standard levels and the violations/deficiencies are resolved to the satisfaction
        of ODJFS, the money will be refunded. Note: For SFY 2006, measure 3 is a
        reporting-only measure.

       

      l.b.iv. Case
        Management of Children with an ODJFS-Mandated Condition

       

      Measure
        3:
        The
        percent of children under 21 years of age with a positive identification
        through
        an ODJFS administrative review of data for the ODJFS-mandated case management
        condition of asthma
        that are
        case managed.

       

      Measure
        2:
        The
        percent of children age 17 and under with a positive identification through
        an
        ODJFS administrative review of data for the ODJFS-mandated case management
        condition of teenage
        pregnancy
        that are
        case managed.

       

      Measure
        3:
        The
        percent of children under 21 years of age with a positive identification
        through
        an ODJFS administrative review of data for the ODJFS-mandated case management
        condition of HIV/AIDS
        that are
        case managed.

       

      Report
        Periods for Measures 1, 2. and 3:
        For the
        SFY 2007 contract period. July - September 2006. October- December 2006.
        January
        - March 2007. and April -June 2007 report periods. For the SFY 2008 contract
        period. July - September 2007. October - December 2007. January - March 2008,
        and April - June 2008 report periods. 

       

      County-Based
        Approach:
        MCPs
        with managed care membership as of February 1. 2006 will be evaluated using
        their county-based statewide result until regional evaluation is implemented
        for
        the county's applicable region. The county-based statewide result will include
        data for all counties in which the MCP had membership as of February 1.2006
        that
        are not included in any regional-based result. Regional-based results will
        not
        be used for evaluation until all selected MCPs in an active region have at
        least
        10.000 members during each month of the entire report period. Upon
        implementation of regional-based evaluation for a particular county's region,
        the county will be included in the MCP's regional-based result and will no
        longer be included in the MCP's county-based statewide result. [Example:
        The
        county-based statewide result for MCP AAA, which has contracts in the Central
        and West Central regions, w'ill include Franklin. Pickaway. Montgomery. Greene
        and dark counties (i.e., counties in which MCP AAA had managed care membership
        as of February 1, 2006). When regional-based evaluation is implemented for
        the
        Central region. Franklin and Pickaway counties, along with all other counties
        in
        the region, will then be included in the Central region results for MCP AAA;
        Montgomery, Greene, and dark counties will remain in the county-based statewide
        result for evaluation of MCP AAA until the West Central regional-based approach
        is implemented.]

       

      

      Appendix
        M 

      Page
        6

       

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

       

      Minimum
        Performance Standard/or Measures 1 and 3:
        For the
        first and second quarters of SFY 2007, a case management rate of 65%. For
        the
        third and fourth quarters of SFY 2007. a case management rate of 70%. For
        SFY
        2008, a case management rate of 80%. 

       

      Minimum
        Performance Standard/or Measure 2:
        For the
        first and second quarters of SFY 2007. a case management rate of 55%. For
        the
        third and fourth quarters of SFY 2007, a case management rate of 60%. For
        SFY
        2008, a case management rate of 70%. 

       

      Penalty
        for Noncompliance for Measures 1 and 2:
        The
        first time an MCP is noncompliant with the standard for this measure. OD.IFS
        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 OD.IFS the new
        member selection freeze/reduction of assignments will be lifted. Note: For
        the
        first reporting period during which regional results are used to evaluate
        performance, measures 1. 2. and 3 are reporting-only measures. For both SFY
        2007
        and 2008. measure 3 is a reporting-only measure.

       

      I.e.
        Clinical Performance Measures

       

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

       

      The
        clinical performance measures described below closely follow the National
        Committee for Quality Assurance's Health Plan Employer Data and Information
        Set(HEDIS). Minor adjustments to HEDIS measures were required to account
        forthe
        differences between the commercial population and the Medicaid population
        such
        as shorter and interrupted enrollment periods. NCQA may annually change its
        method for calculating a measure. These changes can make it difficult to
        evaluate whether improvement occurred from a prior year. For this reason,
        OD.IFS
        will use the same methods to calculate the baseline results and the results
        for
        the period in which the MCP is being held accountable. For example, the same
        methods were being used to calculate calendar year 2003 results (the baseline
        period) and calendar year 2004 results. The methods will be updated and a
        new
        baseline will be created during 2005 for calendar year 2004 results. These
        results will then serve as the baseline to evaluate whether improvement occurred
        from calendar year 2004 to calendar year 2005. Clinical performance measure
        results will be calculated after a sufficient amount of time has passed after
        the end of the report period in order to allow for claims runout. For a
        comprehensive description of the clinical performance measures below, see
        ODJFS
        Methods for

       

      

      Appendix
        M 

      Page
        7

       

      Clinical
        Performance Measures/or (he Medicaid CFC Managed Care Program.
        Performance standards are subject to change based on the revision or update
        ofNCQA methods or other national standards, methods or benchmarks.

       

      For
        an MCP which had membership as of February51,
        2006:
        Prior to
        the transition to the regional-based approach. MCP performance will be evaluated
        using an MCP's statewide result for the counties in which the MCP had membership
        as of February 1,2006. For reporting periods CY 2007 and CY 2008, targets
        and
        performance standards for Clinical
        Performance Measures in this Appendix (l.c.i - l.c.vii)
        will be
        applicable to all counties in which MCPs had membership as of February 1,
        2006.
        The final reporting year for the counties in which an MCP had membership
        as of
        February 1, 2006, will be CY 2008.

       

      For
        any MCP which did not have membership as of
        February
        7, 2006:
        Performance will be evaluated using a regional-based approach for any active
        region in which the MCP had membership.

       

      Regional-BasedApproach:
        MCPs
        will be evaluated by region, using results for all counties included in the
        region. CY 2008 will be the first reporting year that MCPs will be held
        accountable to the performance standards for an active region, and penalties
        will be applied for noncompliance. CY 2007 will be the first baseline reporting
        year for an active region. 

       

      ODJFS
        will use a sufficient amount of data needed per performance measure from
        all
        MCPs serving an active region to determine performance standards and targets
        for
        that region. For example, should a measure call for one calendar year of
        baseline data. first full calendar year data will be used. CY 2008 will be
        the
        first reporting year for measures that call for one year of baseline data.
        Should a measure call for two calendar years of baseline data, the first
        two
        full calendar years of data will be used. CY 2009 will be the first reporting
        year for measures that call for tw''o years of baseline data. 

       

      Report
        Period:
        In order
        to adhere to the statewide expansion timeline. reporting periods may be adjusted
        based on the number of months of managed care membership. For the SPY 2006
        contract period, performance will be evaluated using the January - December
        2005
        report period. For the SFY 2007 contract period, performance will be evaluated
        using the January - December 2006 report period. For the SFY 2008 contract
        period, performance will be evaluated using the January -December 2007 report
        period.

       

      l.c.i.
        Perinatal Care- Frequency of Ongoing Prenatal Care

       

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

       

      Target:
        80% of
        the eligible population must receive 81% or more of the expected number of
        prenatal visits.

       

      

      Appendix
        M 

      Page
        8

       

      Minimum
        Performance Standard:
        The
        level of improvement must result in at least a 10% decrease in the difference
        between the target and the previous report period's results. (For example,
        if
        last year's results were 20%, then the difference between the target and
        last
        year's results is 60%. In this example, the standard is an improvement in
        performance of 10% of this difference or 6%. In this example, results of
        26% or
        better would be compliant with the standard.) 

       

      Action
        Required for Noncompliance:
        If the
        standard is not met and the results are below 42%, then the MCP is required
        to
        complete a Performance Improvement Project, as described in Appendix K.
Quality
        Assessment and Performance Improvement Program,
        to
        address the area of noncompliance.

       

      If
        the
        standard is not met and the results are at or above 42%, 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.
        Perinatal Care - Initiation of Prenatal Care

       

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

       

      Target:
        90% of
        the eligible population initiate prenatal care within the specified
        time.

       

      Minimum
        Performance Standard:
        The
        level of improvement must result in at least a 10% decrease in the difference
        between the target and the previous year's results.

       

      Action
        Required for Noncompliance:
        If the
        standard is not met and the results are below 71 %, then the MCP is required
        to
        complete a Performance Improvement Project, as described in Appendix K,
Quality
        Assessment and Performance Improvement Program,
        to
        address the area of noncompliance. If the standard is not met and the results
        are at or above 71%, then ODJFS will issue a Quality Improvement Directive
        which
        will notify the MCP of noncompliance and may outline the steps that the MCP
        must
        take to improve the results.

       

      l.c.iii.
        Perinatal Care - Postpartum Care

       

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

       

      Target:
        At least
        80% of the eligible population must receive a postpartum visit.

       

      Minimum
        Performance Standard:
        The
        level of improvement must result in at least a 5% decrease in

       

      the
        difference between the target and the previous year's results.

       

      Action
        Required for Noncompliance:
        If the
        standard is not met and the results are below 48%, then the MCP is required
        to
        complete a Performance Improvement Project, as described in Appendix K.
Quality
        Assessment and Performance Improvement Program,
        to
        address the area of noncompliance. If the standard is not met and the results
        are at or above 48%, then ODJFS will issue a Quality

       

      

      Appendix
        M 

      Page
        9

       

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

       

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

       

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

       

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

       

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

       

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

       

      Target:
        At least
        80% of
        the eligible children receive the expected number of well-child
        visits.

       

      Minimum
        Performance Standard/or Each of the Age Groups:
        The
        level of improvement must result in at least a 10% decrease in the difference
        between the target and the previous year's results.

       

      Action
        Required for Noncompliance (15 month old age group):
        If the
        standard is not met and the results are below 34%. then the MCP is required
        to
        complete a Performance Improvement Project, as described in Appendix K.
Quality
        Assessment and Performance Improvement Program,
        to
        address the area ofnoncompliance. If the standard is not met and the results
        are
        at or above 34%. then OD.IFS will issue a Quality Improvement Directive which
        will notify the MCP ofnoncompliance and may outline the steps that the MCP
        must
        take to improve the results.

       

      Action
        Required for Noncompliance (3-6 year old age group):
        If the
        standard is not met and the results are below 50%. then the MCP is required
        to
        complete a Performance Improvement Project, as described in Appendix K,
        Qua!
        fly Assessment and Performance Improvement Program,
        to
        address the area of noncompliance. If the standard is not met and the results
        are at or above 50%. then OD.IFS will issue a Quality Improvement Directive
        which will notify the MCP ofnoncompliance and may outline the steps that
        the MCP
        must take to improve the results.

      

      Action
        Required for Noncompliance (12-21 year old age group):
        If the
        standard is not met and the results are below 30%. then the MCP is required
        to
        complete a Performance Improvement Project, as described in Appendix K,
Quality
        Assessment and Performance Improvement Program,
        to
        address the area ofnoncompliance. If the standard is not met and the results
        are
        at or above 30%, then ODJFS will issue a Quality Improvement Directive which
        will notify the MCP ofnoncompliance and may outline the steps that the MCP
        must
        take to improve the results.

       

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

       

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

       

      

      Appendix
        M 

      Page
        10

       

      Target:
        95% of
        the eligible population must receive the recommended medications.

       

      Minimum
        Performance Standard:
        The
        level of improvement must result in at least a 10% decrease in the difference
        between the target and the previous year's results.

       

      Action
        Required for Noncompliance:
        If the
        standard is not met and the results are below 83%, then the MCP is required
        to
        complete a Performance Improvement Project, as described in Appendix K,
Quality
        Assessment and Performance Improvement Program,
        to
        address the area of noncompliance. If the standard is not met and the results
        are at or above 83%, then ODJFS will 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.
        Annual Dental Visits

       

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

       

      Target:
        At least
        60% of the eligible population receive a dental visit.

       

      Minimum
        Performance Standard:
        The
        level of improvement must result in at least a 10% decrease in the difference
        between the target and the previous year's results.

       

      Action
        Required for Noncompliance:
        If the
        standard is not met and the results are below 40%. then the MCP is required
        to
        complete a Performance Improvement Project, as described in Appendix K,
Quality
        Assessment and Performance Improvement Program,
        to
        address the area of noncompliance. If the standard is not met and the results
        are at or above 40%. then ODJFS will issue a Quality Improvement Directive
        which
        will notify the MCP of noncompliance and may outline the steps that the MCP
        must
        take to improve the results.

       

      l.c.vii.
        Lead Screening

       

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

       

      Target:
        At least
        80% of the eligible population receive a blood lead screening.

       

      Minimum
        Performance Standard for Each of the Age Groups:
        The
        level of improvement must result in at least a 10% decrease in the difference
        between the target and the previous year's results.

       

      Action
        Required for Noncompliance (1 year olds):
        If the
        standard is not met and the results are below 45% then the MCP is required
        to
        complete a Performance Improvement Project, as described in Appendix K.
Quality
        Assessment and Performance Improvement Program,
        to
        address the area of noncompliance. If the standard is not met and the results
        are at or above 45%. then 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.

       

      

      Appendix
        M 

      Page
        11

       

      Action
        Required for Noncompliance (2 year olds):
        If the
        standard is not met and the results are below 28% then the MCP is required
        to
        complete a Performance Improvement Project, as described in Appendix K,
Quality
        Assessment and Performance Improvement Program,
        to
        address the area of noncompliance.

       

      If
        the
        standard is not met and the results are at or above 28%. then ODJFS will
        issue a
        Quality Improvement Directive which will notify the MCP of noncompliance
        and may
        outline the steps that the MCP must take to improve the results.

       

      2.
        ACCESS

       

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

       

      2.a.
        PCP Turnover

       

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

       

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

       

      For
        an MCP which had membership as of February 1, 2006:
        Prior to
        the transition to the regional-based approach, MCP performance will be evaluated
        using an MCP's statewide result for the counties in which the MCP had membership
        as of February 1. 2006. The minimum performance standard in the
        Appendix (2.a)
        will be
        applicable to the MCP's statewide result for the counties in which the MCP
        had
        membership as of February 1. 2006, The last reporting year using the MCP's
        statewide result for the counties in which the MCP had membership as of February
        1, 2006 for performance
        evaluation
        is CY
        2007; the last reporting year using the MCP's statewide result for the counties
        in which the MCP had membership as of February 1. 2006 for P4P(Appendix
        0)
        is CY
        2008.

       

      For
        any MCP which did not hare membership as of February J, 2006:
        Performance will be evaluated using a regional-based approach for any active
        region in which the MCP had membership.

       

      Regional-Based
        Approach:
        MCPs
        will be evaluated by region, using results for all counties included in the
        region. ODJFS will use the first full calendar year of data (which may be
        adjusted based on the number of months of managed care membership), from
        all
        MCPs serving an active region to determine a minimum performance standard
        for
        that region. CY 2008 will be the first reporting year that MCPs will be held
        accountable to the performance standards for an active region, and penalties
        will be applied for noncompliance.

       

      

      Appendix
        M 

      Page
        12

       

      Report
        Period:
        In order
        to adhere to the statew ide expansion timeline. reporting periods may be
        adjusted based on the number of months of managed care membership. For the
        SPY
        2006 contract period, performance will be evaluated using the January - December
        2005 report period. For the SFY 2007 contract period, performance will be
        evaluated using the January - December 2006 report period. For the SFY 2008
        contract period, performance will be evaluated using the January -December
        2007
        report period.

       

      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 end implement an action plan to address the findings.

       

      2.b.
        Children's Access to Primary Care

       

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

       

      Measure:
        The
        percentage of members age 12 months to 11 years who had a visit with an MCP
        PCP-type provider. 

       

      For
        an MCP which had membership as of February 1. 2006:
        Prior to
        the transition to the regional-based approach, MCP performance will be evaluated
        using an MCP's statewide result for the counties in which the MCP had membership
        as of February 1, 2006. The minimum performance standard in the
        Appendix (2.b)
        will be
        applicable to the MCP's statewide result for the counties in which the MCP
        had
        membership as of February 1. 2006. The last reporting year using the MCP's
        statewide result for the counties in which the MCP had membership as of February
        1, 2006 is CY 2008. 

       

      For
        any MCP which did not have membership as of February 1, 2006:
        Performance will be evaluated using a regional-based approach for any active
        region in which the MCP had membership.

       

      Regional-Based
        Approach:
        MCPs
        will be evaluated by region, using results for all counties included in the
        region. ODJFS will use the first tw'o full calendar years of data (which
        may be
        adjusted based on the number of months of managed care membership) from all
        MCPs
        serving an active region to determine a minimum performance standard for
        that
        region. CY 2009 will be the first reporting year that MCPs will be held
        accountable to the performance standards for an active region, and penalties
        will be applied for noncompliance. Performance measure results for that region
        w'ill be calculated after a sufficient amount of time has passed after the
        end
        of the report period in order to allow for claims runout. 

       

      Report
        Period:
        In order
        to adhere to the statewide expansion timeline, reporting periods may be adjusted
        based on the number of months of managed care membership. For the SFY 2006
        contract period, performance will be evaluated using the January - December
        2005
        report period. For the

       

      

      Appendix
        M 

      Page
        13

       

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

       

      Minimum
        Performance Standards:

       

      CY
        2005
        report period - 70% of the children must receive a visit. CY 2006 report
        period
        - 70% of the children must receive a visit. CY 2007 report period - 71% of
        the
        children must receive a visit.

       

      Penaltyfor
        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 w'hether adult members are accessing health
        services.

       

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

       

      For
        an MCP which had membership as of February 1, 2006:
        Prior to
        the transition to the regional-based approach. MCP performance will be evaluated
        using an MCP's statewide result for the counties in which the MCP had membership
        as of February 1. 2006. The minimum performance standard in the Appendix
        (2.c)
        will be
        applicable to the MCP's statewide result for the counties in which the MCP
        had
        membership as of February 1. 2006. The last reporting year using the MCP's
        statewide result for the counties in which the MCP had membership as of February
        1. 2006 for performance
        evaluation
        is
        CY2007; the last reporting year using the MCP's statewide result for the
        counties in which the MCP had membership as of February 1. 2006 for P4P
(Appendix
        0}
        is CY
        2008.

       

      For
        any MCP which did not have membership as of February 1. 2006:
        Performance will be evaluated using a regional-based approach for any active
        region in which the MCP had membership.

       

      Regional-Based
        Approach:
        MCPs
        will be evaluated by region, using results for all counties included in the
        region. ODJFS will use the first full calendar year of data (which may be
        adjusted based on the number of months of managed care membership) from all
        MCPs
        serving an active region to determine a minimum performance standard for
        that
        region. CY 2008 will be the first reporting year that MCPs will be held
        accountable to the performance standards for an active region, and penalties
        will be applied for noncompliance. Performance measure results for that region
        will be calculated after a sufficient amount of time has passed after the
        end of
        the report period in order to allow for claims runout.

       

      Report
        Period:
        In order
        to adhere to the statew ide expansion timeline. reporting periods may be
        adjusted based on the number of months of managed care membership. For the
        SFY
        2006 contract period, performance will be evaluated using the January - December
        2005 report period. For the SFY 2007 contract period, performance will be
        evaluated using the January - December 2006 report

      
 

      Appendix
        M 

      Page
        14

       

      period.
        For the SFY 2008 contract period, performance will be evaluated using the
        January December 2007 report period.

       

      Minimum
        Performance Standards:
        63% of
        the adults must receive a visit.

       

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

       

      2.d.
        Adults' Access to Designated PCP (new measure pending
        review)

       

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

       

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

       

      Regional-Based
        Approach:
        MCPs w
        ill be evaluated by region, using results for all counties included in the
        region. ODJFS will use the first full calendar year of data as a baseline
        from
        all MCPs serving CFC membership to determine a minimum performance standard
        for
        that region. CY 2008 will be the first reporting year that MCPs will be held
        accountable to the performance standards for an active region and penalties
        w'ill be applied for noncompliance. Performance measure results for that
        region
        will be calculated after a sufficient amount of time has passed after the
        end of
        the report period in order to allow for claims runout.

       

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

       

      Minimum
        Performance Standards: TBD

       

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

       

      3.
        CONSUMER SATISFACTION

       

      The
        regional approach for this measure is to be determined for SFY 2008. The
        county-based approach remains effective in SFY 2007; the county-based approach
        is only applicable for MCPs with membership as of February 1,2006 and for
        the
        counties in which the MCPs had membership as of February 1. 2006.

       

      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

      

      Appendix
        M 

      Page
        15

       

      performance
        measure below, see ODJFS
        Methods for Consumer Satisfaction Performance Measures for the Medicaid CFC
        Managed Care Program.

       

      Measure:
        Overall Satisfaction with MCP:
        The
        average rating of the respondents to the Consuner Satisfaction Survey who
        were
        asked to rate their overall satisfaction with their MCP. The results of this
        measure are reported annually. 

       

      Report
        Period:
        For the
        SFY 2006 contract period, performance will be evaluated using the results
        from
        the most recent consumer satisfaction survey completed prior to the end of
        the
        SFY 2006. For the SFY 2007 contract period, performance will be evaluated
        using
        the results from the most recent consumer satisfaction survey completed prior
        to
        the end of the SFY 2007. For the SFY 2008 contract period, the measure is
        under
        review and the report period has not been determined.

       

      Minimum
        Performance Standard:
        An
        average score of no less than 7.0.

       

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

       

      4.
        ADMINISTRATIVE CAPACITY

       

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

       

      4.a.
        Compliance Assessment System

       

      Measure:
        The
        number of points accumulated for one contract year (one state fiscal year)
        through the Compliance Assessment System.

      Report
        Period:
        For the
        SFY 2005 contract period, performance will be evaluated using the July 2004
        -
        June 2005 report period. For the SFY 2006 contract period, performance will
        be
        evaluated using the July 2005 - June 2006 report period.

       

      Minimum
        Performance Standard:
        No more
        than 25 points

       

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

       

      4.b.
        Emergency Department Diversion

      Appendix
        M

      Page
        16

       

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

       

      Measure:
        The
        percentage of members who had four or more ED visits during the six month
        reporting period.

       

      For
        an MCP which had membership as of February 1, 2006:
        Prior to
        the transition to the regioral-based approach. MCP performance will be evaluated
        using an MCP's statewide result for the counties in which the MCP had membership
        as of February!. 2006. The minimum performance standard and the target in
        the.
        Appendix (4.b)
        will be
        applicable to the MCP's statewide result for the counties in which the MCP
        had
        membership as of February 1,2006. The last reporting period using the MCP's
        statewide result for the counties in which the MCP had membership as of February
        1, 2006 for performance evaluation is July-December 2007; the last reporting
        period using the MCP's statewide result for the counties in which the MCP
        had
        membership as of February 1. 2006 for P4P (Appendix
        0)
        is
        July-December 2008.

       

      For
        any MCP which did not have membership as of February I, 2006:
        Performance will be evaluated using a regional-based approach for any active
        region in which the MCP had membership.

       

      Regional-Based
        Approach:
        MCPs
        will be evaluated by region, using results for all counties included in the
        region. The reporting period will be a full calendar year. ODJFS will use
        the
        first full calendar year of data, which may be adjusted based on the number
        of
        months of managed care membership, as a baseline from all MCPs serving an
        active
        region to determine a minimum performance standard and a target for that
        region.
        CY 2008 will be the first reporting year that MCPs will be held accountable
        to
        the performance standards for an active region, and penalties will be applied
        for noncompliance. Performance measure results for that region will be
        calculated after a sufficient amount of time has passed after the end of
        the
        report period in order to allow for claims runout.

       

      Regional-Based
        Measure:
        The
        percentage of members who had TBD or more ED visits during the 12 month
        reporting period.

       

      Report
        Period:
        In order
        to adhere to the statew'ide expansion timeline, reporting periods may be
        adjusted based on the number of months of managed care membership. For the
        SFY
        2006 contract period, a baseline level of performance will be set using the
        January - June 2005 report period. Results will be calculated for the reporting
        period of July-December 2005 and compared to the baseline results to determine
        if the minimum performance standard is met. For the SFY 2007 contract period,
        a
        baseline level of performance will be set using the January - June 2006 report
        period. Results will be calculated for the reporting period of July - December
        2006 and compared to the baseline results to determine if the minimum
        performance standard is met. For the SFY 2008 contract period, a baseline
        level
        of performance will be set using the January - June 2007 report period (which
        may be adjusted based on the number of months of managed care membership).
        Results will be calculated for the reporting period of July - December 2007
        and
        compared to the

       

       

      Appendix
        M

      Page
        17

       

      baseline
        results to determine if the minimum performance standard is met. SFY 2008
        is
        also the first year for regional based reporting, using January - December
        2007
        as a baseline.

       

      Target:
        A
        maximum of 0.70% of the eligible population will have four or more ED visits
        during reporting period.

       

      Minimum
        Performance Standard:
        The
        level of improvement must result in at least a 10% decrease in the difference
        between the target and the baseline period results.

       

      Penaltyfor
        NoncompJiance:
        If the
        standard is not met and the results are above 1.1%. then the MCP must develop
        a
        corrective action plan. for which ODJFS may direct the MCP to develop the
        components of their EDD program as specified by ODJFS. If the standard is
        not
        met and the results are at or below 1.1%, then the MCP must develop a Quality
        Improvement Directive.

      

      5.
        NOTES 

      5.a.
        Report Periods

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

       

      5.b.
        Monetary Sanctions

       

      Penalties
        for noncompliance with individual standards in this appendix will be imposed
        as
        the results are finalized. Penalties for noncompliance with individual standards
        for each period compliance is determined in this appendix will not exceed
        $250.000. I

       

      Refundable
        monetary sanctions will be based on the capitation payment in the month of
        the
        cited deficiency and due within 30 days of notification by ODJFS to the MCP
        of
        the amount. Any monies collected through the imposition of such a sanction
        would
        be returned to the MCP (minus any applicable collection fees owed to the
        Attorney General's Office, if the MCP has been delinquent in submitting payment)
        after they have demonstrated improved performance in accordance with this
        appendix. If an MCP does not comply within two years of the date of notification
        of noncompliance, then the monies will not be refunded.

       

      5.c.
        Combined Remedies

       

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

       

      5.d.
        Enrollment Freezes

       

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

       

      Appendix
        M 

      Page
        18

       

      5.e.
        Reconsideration

       

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

       

      5.f.
        Contract Termination, Nonrenewals or Denials

       

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

       

      

      APPENDIX
        N

      

      COMPLIANCE
        ASSESSMENT SYSTEM (CAS)

      CFC
        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' abi|lity 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 ihe 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 OD.IFS-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 01-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
        

      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 the 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.

       

      All
        required submissions to be received by their specified deadline. Unless
        otherwise specified, late submissions will initially be addressed through
        CAPs.
        with repeated instances of untimely

       

      

      Appendix
        N

      Page
        4

      

       

      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 EST 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 the 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.
        I

       

      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
        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 deten|nine 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
        ma^
        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.27.
        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 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 w7!!!
        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 all areas of noncompliance if ODJFS determines,
        in its
        sole discretion, that (1) one systemic problem is responsible for multiple
        areas
        of noncompliance and/or (2) that there are a number of repeated instances
        of
        noncompliance with the same program requirement.

       

      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 ODilFS 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 time frame in
                  writing.

              

      

       

      •
All
        requests for reconsideration must be submitted by either facsimile transmission
        or overnight mail to the Chief. Bureau of Managed Health Care, and received
        by
        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
        of
        unapproved 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,
        the
        following:

       

      •
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 OD.IFS 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)

      CFC
        ELIGIBLE POPULATION

       

      This
        Appendix establishes P4P for managed care plans (MCPs) to improve performance
        in
        specific areas important to the Medicaid MCP members. P4P include the at-risk
        amount included with the monthly premium payments (see Appendix F, Rate
        Chart),
        and
        possible additional monetary rewards up to $250.000. 

       

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

       

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

      1.
        SFY 2006 P4P l.a. Qualifying Performance Levels

       

      To
        qualify for consideration of the SFY 2006 P4P, an MCP's performance level
        must:

       

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

       

      2)
        Meet
        the P4P standards established for the Emergency Department Diversion and
        Clinical Performance Measures below. 

       

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

       

      Measures
        for which the minimum performance standard for SFY 2006 established in Appendix
        M, Performance
        Evaluation,
        must be
        met to qualify for consideration of P4P are as follows:

       

      1.
        Independent External Quality Review (Appendix M, Section l.a.i. - Minimum
        Performance Standard 2)

       

      

      Appendix
        O

      Page
        2

       

      

      Report
        Period:
        The most
        recent Independent External Quality Review completed prior to the end of
        the SPY
        2006 contract period.

      

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

      Report
        Period:
        CY
        2005

      

      3.
        Children's Access to Primary Care (Appendix M, Section 2.b.) 

      Report
        Period:
        CY
        2005

      

      4.
        Adults' Access to Preventive/Ambulatory Health Services (Appendix M, Section
        2.c.) 

      Report
        Period:
        CY
        2005

      

      5.
        Overall Satisfaction with MCP (Appendix M. Section 3.)

      Report
        Period:
        The most
        recent consumer satisfaction survey completed prior to the end of the SFY
        2006
        contract period.

       

      For
        the
        EDD performance measure, the MCP must meet the P4P standard for the report
        period of July - December. 2005 to be considered for SFY 2006 P4P. The MCP
        meets
        the P4P standard if one of two criteria are met. The P4P standard is a
        performance level of either:

       

      1)
        The
        minimum performance standard established in Appendix M. Section 4.b.:
        or

       

      2)
        The
        Medicaid benchmark of a performance level at or below 1.1%.

       

      For
        each
        clinical performance measure listed below, the MCP must meet the P4P standard
        to
        be considered for SFY 2006 P4P. The MCP meets the P4P standard if one of
        two
        criteria are met. The P4P standard is a performance level of
        either:

       

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

      2)
        The
        Medicaid benchmarks for seven of the nine clinical performance measures listed
        below.

      

      
        	
                Clinical
                  Performance Measure

              	
                Medicaid
                  Benchmark

              
	
                1.
                  Perinatal Care - Frequency of Ongoing Prenatal Care 

              	
                42%

              
	
                2.
                  Perinatal Care - Initiation of Prenatal Care

              	
                71%

              
	
                3.
                  Perinatal Care - Postpartum Care

              	
                48%

              
	
                4.
                  Well-Child Visits - Children who turn 15 months old

              	
                34%

              
	
                5.
                  Well-Child Visits - 3, 4, 5. or 6, years old 

              	
                50%

              
	
                6.
                  Well-Child Visits - 12 through 21 years old

              	
                30%

              
	
                7.
                  Use of Appropriate Medications for People with Asthma

              	
                59%

              
	
                8.
                  Annual Dental Visits

              	
                40%

              
	
                9.
                  Blood Lead - 1 year olds

              	
                45%

              

      

       

      Appendix
        O 

      Page
        3

       

       

      l.b.
        Excellent and Superior Performance Levels

       

      For
        qualifying MCPs as determined by Section 2.a.. performance will be evaluated
        on
        the measures below to determine the status of the at-risk amount or any
        additional P4P that may be awarded. Excellent and Superior standards are
        set for
        the three measures described below.

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

      

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

      

      Report
        Period:
        July -
        December 2005

      Excellent
        Standard:
        2.5%

      Superior
        Standard:
        3.8%

      

      2.
        Use of
        Appropriate Medications for People with Asthma (Appendix M. Section 1 .c.vi.)
        

      

      Report
        Period:
        CY 2005

      Excellent.
        Standard:
        59%

      Superior
        Standard:
        68%

      

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

      

      Report
        Period:
        CY
        2005

      Excellent
        Standard:
        76%

      Superior
        Standard:
        83%

      

      

      I.e.
        Determining SFY 2006 P4P

       

      MCP's
        reaching the minimum performance standards described in Section 2.a. will
        be
        considered for P4P including retention of the at-risk amount and any additional
        P4P. For each Excellent standard established in Section 2.b. that an MCP
        meets,
        one-third of the at-risk amount may be retained. For MCPs meeting all of
        the
        Excellent and Superior standards established in Section 2.b., additional
        P4P may
        be awarded. For MCPs receiving additional P4P, the amount in the P4P fund
        (see
        section 3.) will be divided equally, up to the maximum amount, among all
        MCPs'
        Aged. Blind or Disabled (ABD) and/or Covered Families and Children (CFC)
        receiving additional P4P. The maximum amount to be awarded to a single plan
        P4P
        additional to the at-

       

      

      Appendix
        O

      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.
        SFY 2007 P4P 

      2.a.
        Qualifying Performance Levels

       

      To
        qualify for consideration of the SFY 2007 P4P, an MCP's performance level
        must:

       

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

       

      2)
        Meet
        the P4P standards established for the Emergency Department Diversion
        and

       

      Clinical
        Performance Measures below.

      

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

       

      Measures
        for which the minimum performance standard for SFY 2007 established in Appendix
        M, Performance
        Evaluation,
        must be
        met to qualify for consideration of P4P are as follows:

      

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

      Report
        Period:
        CY
        2006

      

      2.
        Children's Access to Primary Care (Appendix M. Section 2.b.) 

      Report
        Period:
        CY
        2006

      

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

      Report
        Period:
        CY
        2006

      

      4.
        Overall Satisfaction with MCP (Appendix M, Section 3.)

      Report
        Period:
        The most
        recent consumer satisfaction survey completed prior to the end of the SFY
        2007
        contract period.

       

      For
        the
        EDD performance measure, the MCP must meet the P4P standard for the report
        period of July - December. 2006 to be considered for SFY 2007 P4P. The MCP
        meets
        the P4P standard if one of two criteria are met. The P4P standard is a
        performance level of either:

       

      1)
        The
        minimum performance standard established in Appendix M, Section 4.b.;
        or

       

      2)
        The
        Medicaid benchmark of a performance level at or below 1.1%.

       

      

      Appendix
        0 

      Page
        5

       

      For
        each
        clinical performance measure listed below, the MCP must meet the P4P standard
        to
        be considered for SFY 2007 P4P. The MCP meets the P4P standard if one of
        two
        criteria are met. The P4P standard is a performance level of
        either:

       

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

       

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

       

      
        	
                Clinical
                  Performance Measure 

              	
                Medicaid
                  Benchmark

              
	
                 

                1.
                  Perinatal Care - Frequency of Ongoing Prenatal Care

              	
                 

                42%

              
	
                 

                2.
                  Perinatal Care - Initiation of Prenatal Care

              	
                 

                71%

              
	
                 

                3.
                  Perinatal Care - Postpartum Care 

              	
                 

                48%

              
	
                 

                4.
                  Well-Child Visits - Children who turn 15 months old

              	
                 

                34%

              
	
                 

                5.
                  Well-Child Visits - 3, 4, 5. or 6. years old 

              	
                 

                50%

              
	
                 

                6.
                  Well-Child Visits - 12 through 21 years old

              	
                 

                30%

              
	
                 

                7.
                  Use of Appropriate Medications for People with Asthma

              	
                 

                83%

              
	
                 

                8.
                  Annual Dental Visits

              	
                 

                40%

              
	
                 

                9.
                  Blood Lead - 1 year olds 

              	
                 

                45%

              

      

       

       

       

      2.b.
        Excellent and Superior Performance Levels

       

      For
        qualifying MCPs as determined by Section 2.a., performance will be evaluated
        on
        the measures below to determine the status of the at-risk amount or any
        additional P4P that may be awarded. Excellent and Superior standards are
        set for
        the three measures described below. The standards are subject to change based
        on
        the revision or update of applicable national standards, methods or
        benchmarks.

       

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

      

      1.
        Case
        Management of Children (Appendix M, Section l.b.ii.) 

      

      Report
        Period:
        April -
        June 2007

      

      Excellent
        Standard:
        5.5%

      Superior
        Standard:
        6.5%

      

      2.
        Use of
        Appropriate Medications for People with Asthma (Appendix M, Section 1 .c.vi.)
        

      

      Report
        Period:
        CY
        2006

      

      Appendix
        O 

      Page
        6

      

      Excellent
        Standard:
        86%

      Superior
        Standard:
        88%

      

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

      

      Report
        Period:
        CY 2006

      

      Excellent
        Standard:
        76%

      Superior
        Standard:
        83%

      

      2.c.
        Determining SFY 2007 P4P

       

      MCP's
        reaching the minimum performance standards described in Section 2.a. will
        be
        considered for P4P including retention of the at-risk amount and any additional
        P4P. For each Excellent standard established in Section 2.b. that an MCP
        meets,
        one-third of the at-risk amount may be retained. For MCPs meeting all of
        the
        Excellent and Superior standards established in Section 2.b., additional
        P4P may
        be awarded. For MCPs receiving additional P4P, the amount in the P4P fund
        (see
        section 3.) will be divided equally, up to the maximum amount, among: all
        MCPs'
        Aged, Blind or Disabled (ABD) and/or Covered Families and Children (CFC)
        receiving additional P4P. The maximum amount to be awarded to a single plan
        P4P
        additional to the at-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.

       

      3.
        NOTES

       

      3.a.
        Initiation of the P4P System

       

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

       

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

       

      Appendix
        O 

      Page
        7

       

      3.b.
        Determination ofat-risk amounts and additional P4P
        payments

       

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

       

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

       

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

       

      3.C.L
        County-based P4P system

       

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

       

      3.c.ii.
        Regional-based P4P system

       

      All
        MCPs
        will be included in the regional-based P4P system. The at-risk amount will
        be
        determined separately for each region an MCP serves.

       

      The
        status of the at-risk amount for counties not included in the county-based
        P4P
        system will not be determined for the first twenty-four months of regional
        membership. Starting with the twenty-fifth month of regional membership,
        the
        MCP's at-risk amount will be included in the P4P system. The determination
        of
        the status of this at-risk amount will be after at least three full calendar
        years of regional membership as many of the performance standards require
        three
        fu|ll calendar years to determine an MCP's performance level. If statewide
        expansion is not complete by December 3 I, 2006. ODJFS may adjust performance
        measure reporting periods based on the number of months an MCP has had regional
        membership. Because of this requirement, more than 12 months ofat-risk dollars
        may be included in an MCP's first regional at-risk status | determination
        depending on w'hen regional membership starts relative to the calendar year.
        Regional premium payments for months prior to July 2009 for members in counties
        included in the county-based P4P system for the SFY 2009 P4P determination,
        will
        be excluded from the at-risk dollars included in the first regional P4P
        determination.

       

      3.d.
        Contract Termination, Nonrenewals, or Denials

       

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

       

      Appendix
        O 

      Page
        8

       

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

       

      3.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

       

      CFC
        EEIGIBLE POPULATION

       

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

       

      MCP-1N1T1ATEDTERMINAT10NS/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 iss-ied, 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
        termination/nonrenewal is issued and the end date of the provider agreement
        will
        be estimated as the MCP membership for the month the termination/nonrenewal
        is
        issued. Any over payment will be determined by comparing actual to estimated
        MCP
        membership and will be returned to the MCP following the end date of the
        provider agreement.

       

      The
        MCP
        must remit the monetary assurance and the at-risk amount in the specified
        amounts via separate electronic fund transfers (EFT) payable to Treasurer
        of State, 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 wi 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-INIT1ATED
        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 $15,300 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 3P1V1 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 denies the
          appeal, the MCP membership termination will proceed at the first possible
          effective date. The date may be retroactive if the ODJFS determines that
          it
          would be in the best interest of the members.

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