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exhibit10-1.htm

    
      

    

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    Exhibit
      10.1

    
 

    PROVIDER
      AGREEMENT

                          
      

    BETWEEN

    

    STATE
      OF
      OHIO

    

    DEPARTMENT
      OF JOB AND FAMILY SERVICES

    

    AND

    

    WELLCARE
      OF OHIO, INC.

    

    Amendment
      No.
      1

    

    

    

    Pursuant
      to Article IX.A. the Provider Agreement between the State of Ohio, Department
      of
      Job and Family Services, (hereinafter referred to as “ODJFS”) and WELLCARE OF
      OHIO, INC. (hereinafter
      referred to as “MCP”) for the Covered Families and Children (hereinafter
      referred to as “CFC”) population dated July 1, 2007, is hereby amended as
      follows:

    

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

    

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

    

    The
      amendment contained herein shall be
      effective January 1, 2008.

    

    
      	
              WELLCARE
                OF OHIO, INC.:

              
              

            	 
	
              BY: /s/  Thad
                Bereday

            	
              DATE:
                1/4/08

            
	
              THAD
                BEREDAY,  SENIOR VICE PRESIDENT 

            	 
	 	 
	
              OHIO
                DEPARTMENT OF JOB AND FAMILY SERVICES:

              
              

            	 
	
              BY:  Helen
                Jones-Kelley

            	
              DATE:
                1/7/08

            
	
              HELEN
                E. JONES-KELLEY, DIRECTOR

            	 

    

     

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

    

    

    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.

    

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

    

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

    

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

    

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

    

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

    

    13. The
      MCP must notify the BMHC of
      the termination of an MCP panel
      provider that is   designated
      as the primary care
provider for 500
      or more of the MCP’s CFC members.
The
      MCP must provide notification within
      one working day of the MCP
 becoming aware of
      the
      termination.

    

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

    

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

    

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

    

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

    

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

    

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

    

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

    

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

    

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

    

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

     

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

    

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

    

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

    

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

    

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

    

    22.
 Pursuant
      to OAC rules 5101:3-26-08 and
      5101:3-26-08.2, the MCP is responsible for ensuring that all MCP marketing
      and
      member materials are prior approved by ODJFS before being used or shared with
      members.  Marketing and member materials are defined as
      follows:

    

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

    

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

    

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

    

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

    

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

    

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

    

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

    

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

    

    i.
      Provides written information to all adult members concerning:

     

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

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

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

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

     

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

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

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

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

    

    24. New
      Member
      Materials

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

    

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

     

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

     

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

     

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

    

    25. Call
      -Center
      Standards

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

    · 
      New Year’s
      Day 

    · 
      Martin Luther
      King’s Birthday 

    ·  Memorial
      Day

    ·  Independence
      Day 

    ·  Labor
      Day

    ·  Thanksgiving
      Day 

    ·  Christmas
      Day

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

     

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

     

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

    

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

    

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

    

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

     

    26.      Notification
      of Optional MCP Membership

    

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

    - Indians
      who are members of
      federally-recognized tribes.

    - Children
      under 19 years of age who
      are:

    o Eligible
      for Supplemental Security
      Income under title XVI;

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

    o Receiving
      foster care of adoption
      assistance;

    o Receiving
      services through the Ohio
      Department of Health’s Bureau for Children with Medical Handicaps (BCMH) or any
      other family-centered, community-based, coordinated care system that receives
      grant funds under section 501(a)(1)(D) of title V, and is defined by the State
      in terms of either program participation or special health care
      needs.

    

    27. HIPAA
      Privacy Compliance Requirements

    

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

    

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

    

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

     

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

    

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

    

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

    

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

    

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

    

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

    

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

    

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

    

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

    

    29. MCP
      Membership acceptance, documentation and reconciliation

    

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

     

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

    

    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.

    

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

    

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

    

    When
      an
      MCP learns that a new member who was previously on Medicaid fee for
  service was admitted prior to the effective date of enrollment and
      remains an inpatient on the effective date of enrollment, the enrolling MCP
      shall notify the hospital/ inpatient facility and treating providers that
      the MCP may not be the payer. The MCP shall work with hospital/inpatient
      facility, treating providers and   the ODJFS to assure that discharge
      planning assures continuity of care and accurate payment. Notwithstanding
      the MCP’s right to request a hospital deferment up to six (6) months following
      the member’s effective date, when the  enrolling MCP learns of a
      deferment-eligible hospitalization, the MCP shall notify the ODJFS and request the deferment
      within five (5) business days of  learning of the potential
      deferment.

    

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

       

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

    

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

    

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

    

    i.   Transition
      of
      Fee-For-Service Members

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

    

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

    

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

    

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

    

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

    

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

    

    If
      contacted by the member, the MCP must
      contact the provider’s office as expeditiously as the situation warrants to
      confirm that the service(s) meets the above criteria.

    

    ii. Allow
      their new members that are
      transitioning from Medicaid fee-for-service
      to continue receiving
      home care services (i.e., nursing, aide,
      and skilled therapy services) and
      private duty nursing (PDN) services if the member or provider contacts the
      MCP
      to discuss the health services in advance of the service date.  These
      services must be covered from the date of the member or provider contact at
      the
      current service level, and with the current provider, whether a panel or
      out-of-panel provider, until the MCP conducts a medical necessity review and
      renders an authorization decision pursuant to OAC rule
      5101:3-26-03.1.  As soon as the MCP becomes aware of the member’s
      current home care services, the MCP must initiate contact with the current
      provider and member as applicable to ensure continuity of care and coordinate
      a
      transfer of services to a panel provider, if appropriate.

    

    iii. Honor
      any current fee-for-service prior
      authorization to allow their new members that are transitioning from Medicaid
      fee-for-service to receive services from the authorized provider, whether a
      panel or out-of-panel provider, for the following approved
      services:

    

    a. an
      organ, bone marrow, or hematapoietic
      stem cell transplant pursuant to OAC rule 5101:3-2-07.1;

    

    b. dental
      services that have not yet been
      received;

    

    c. vision
      services that have not yet been
      received;

    

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

    

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

    

    As
      soon as the MCP becomes aware of the
      member’s current fee-for-service authorization approval, the MCP must initiate
      contact with the authorized provider and member as applicable to ensure
      continuity of care.  The MCP must implement a plan to meet the
      member’s immediate and ongoing medical needs and, with the exception of organ,
      bone marrow, or hematapoietic stem cell transplants, coordinate the transfer
      of
      services to a panel provider, if appropriate.

    

    When
      an MCP medical necessity review
      results in a decision to reduce, suspend, or terminate services previously
      authorized by fee-for-service Medicaid, the MCP must notify the member of their
      state hearing rights no less than 15 calendar days prior to the effective date
      of the MCP’s proposed action, per rule 5101:3-26-08.4 of the Administrative
      Code.

    

    iv. Reimburse
      out-of-panel providers that
      agree to provide the transition services at 100% of the current Medicaid
      fee-for-service provider rate for the service(s) identified in Section 29.i.
      (i., ii., and iii.) of this appendix.

    

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

    

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

    

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

    

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

    

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

     

    30. Health
      Information System Requirements

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

    

    a. Health
      Information
      System

    

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

    

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

    

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

    

    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 ODJFS-specified
      formats;
      and/or

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

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

    

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

    

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

    

    b. Electronic
      Data Interchange and Claims Adjudication Requirements

    

    Claims
      Adjudication

    

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

    

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

     

    Electronic
      Data
      Interchange

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

    Health
      care claims;

    Health
      care claim status request and response;

    Health
      care payment and remittance status;

    Standard
      code sets;
      and

    National
      Provider Identifier
      (NPI).

    

    Each
      EDI
      transaction processed by the MCP shall be implemented in  conformance with the appropriate version
      of the
      transaction implementation  guide,
      as specified by applicable
      federal rule or regulation.

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

    

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

    

    ASC
      X12
      834 - Benefit Enrollment and Maintenance.

    

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

    

      Documentation
      of Compliance
      with Mandated EDI Standards

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

    

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

     MCPs
      shall comply with the transaction
      standards and code sets for sending  and
      receiving applicable transactions as
      specified in 45 CFR Part 162 – Health  Insurance
      Reform:  Standards
      for Electronic Transactions (HIPAA regulations).  In
      addition the MCP must enter into the
      appropriate trading partner agreement and  implemented
      standard code
      sets.  If the MCP has obtained third-party certification  of
      HIPAA compliance for any of the items
      listed below, that certification may be  submitted
      in lieu of the MCP’s written
      verification for the applicable item(s).

    i. Trading
      Partner
      Agreements

    ii. Code
      Sets

    iii. Transactions

    

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

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

    c. Referral
      Certification and Authorization (ASC X12N 278)

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

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

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

    g. Health
      Plan Premium Payments (ASC X12N 820)

    h. Coordination
      of Benefits 

      

    Trading
      Partner Agreement
      with ODJFS

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

    

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

    

    c. Encounter
      Data Submission
      Requirements

     

    General
      Requirements

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

    

    · 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.

    

    Acceptance
      Testing

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

    

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

    

    Encounter
      Data File
      Submission Procedures

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

    

    Timing
      of Encounter Data
      Submissions

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

    

    d. Information
      Systems
      Review

    

    ODJFS
      or
      its designee may review the information system capabilities of each MCP, before
      ODJFS enters into a provider agreement with a new MCP, when a participating
      MCP
      undergoes a major information system upgrade or change, when there is
      identification of significant information system problems, or at ODJFS’
discretion. Each MCP must participate in the review. The review will assess
      the
      extent to which MCPs are capable of maintaining a health information system
      including producing valid encounter data, performance measures, and other data
      necessary to support quality assessment and improvement, as well as managing
      the
      care delivered to its members.

    

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

    

    ii. Review
      the completed ISCA and
      accompanying documents;

    

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

    

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

    

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

    

    vi. Examine
      MCP processes for data
      transfers;

    

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

    

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

    

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

    

    31.
 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 stillborns where the MCP
      incurred costs related to the delivery.

    

    Rejections

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

    

    Timing
      of Delivery
      Payments

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

    

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

    

    Updating
      and Deleting
      Delivery Encounters

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

    

    The
      process for deleting delivery encounters can be found on page 35 of the UB-92
      technical specifications (record/field 20-7) and page III-47 of the NSF
      technical specifications (record/field CA0-31.0a).

    

    Auditing
      of Delivery
      Payments

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

    

    32. If
      the MCP will be using the Internet
      functions that will allow approved users to access member information (e.g.,
      eligibility verification), the MCP must 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. 

    

    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 41⁄2 percent of the
      managed care premiums, minus  Medicare
 premiums
      that the MCP received from any
      payer in the quarter to which the fee  applies.  Any
      premiums the MCP
      returned or refunded to members or  premium
      payers during that quarter are
      excluded from the fee.

    

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

    

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

     

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

    

    37. Information
      Required for MCP Websites

    

    a.
 On-line
      ProviderDirectory–
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 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 contracting providers
      where they will be able to confirm a consumer’s MCP enrollment and through
      this website (or through e-mail process) allow providers to electronically
      submit and receive responses to prior authorization
      requests.   This website must also include: (1) a list of the
      counties that are covered in their service area; (2) the MCP’s provider
      manual;(3) MCP contact information; (4) a link to the MCP’s on-line
      provider directory as referenced in section 37(a) of this  appendix;
      (5) the MCP’s current PDL list, including an explanation of the list, which
      drugs require PA, and the PA process; (6) the MCP’s current list
      of  drugs covered only with PA, the PA process, and the MCP’s policy
      for covering generic for brand-name drugs.  MCPs must ensure
      that all provider materials  designated specifically for CFC and/or
      ABD consumers (i.e. the MCP’s provider    manual) are clearly
      labeled as such; and (7) information regarding the availability of
      expedited prior authorization requests, as well as the information that is
       required from that provider in order to substantiate an expedited prior
authorization
      request.

    

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

    

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

    

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

    

    40. Coordination
      of
      Benefits

    

    When
      a
      claim is denied due to third party liability, the managed care plan must timely
       share appropriate and available information regarding the third party to
      the provider for  the purposes of coordination of benefits, including, but
      not  limited to third party liability  information received from the
      Ohio Department of Job and  Family Services.

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    APPENDIX
      D

    

    ODJFS
      RESPONSIBILITIES

    CFC
      ELIGIBLE
      POPULATION

     

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

    

    General
      Provisions

    

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

    

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

    

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

    

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

    

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

    

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

    

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

    

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

    

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

    

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

    

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

    

    

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

    

    13.  Service
      Area
Designation

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

    

    14. Consumer
      information

     

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

    

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

     

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

    

    15. Membership
      Selection and Premium Payment

    

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

      

    The
MCEC
shalldistribute 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 MCEC
      initiated MCP assignment processed through the MCEC.  The CCR contains information
      that is not included on the monthly member roster.

    

     d. Monthly
      member roster (MR): ODJFS
      verifies managed care plan enrollment on a monthly
      basis via the monthly membership
      roster.  ODJFS or its designated entityprovides
      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.

    

    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 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

             

             

             

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          
            	 	
                    
                      Chase
                        Center/Circle

                    

                  
	
                    
                      111
                        Monument Circle

                    

                  
	
                    
                      Suite
                        601

                    

                  
	
                    
                      Indianapolis,
                        IN 46204-5128

                    

                  
	
                    
                      USA

                    

                  
	
                    
                      Tel    +1
                        317 639 1000

                    

                    
                      Fax   +1
                        317 639 1001

                    

                  
	
                    
                      milliman.com

                    

                  

          

          
            

          

          
            FINAL
              and CONFIDENTIAL

          

          
            

          

          
            

          

          
            December
              12, 2007

          

          
            

          

          
            

          

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

          

          
            Bureau
              of
              Managed Health Care

          

          
            Ohio
              Department of Job and Family Services

          

          
            Lazarus
              Building

          

          
            50
              West
              Town St., Suite 400

          

          
            Columbus,
              OH 43215

          

          
            

          

          
            

          

          
            
              	
                       

                    	
                      RE:CY
                        2008 RATE
                        DEVELOPMENT METHODOLOGY - COVERED FAMILIES AND
                        CHILDREN

                    

            

          

          
            

          

          
            Dear
              Jon:

          

          
            

          

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

          

          
            

          

          
            

          

          
            LIMITATIONS

          

          
            

          

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

          

          
            

          

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

          

          
            

          

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

          

          
            

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

          

           

          
            FINAL
              and CONFIDENTIAL

          

          
             

            SUMMARY
              OF
              METHODOLOGY

          

          
            

          

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

          

          
            

          

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

          

          
            

          

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

          

          
            

          

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

          

          
            

          

          
            

          

          
            DETAILS
              OF
              METHODOLOGY

          

          
            

          

          
            I.    COVERED
              POPULATION

          

          
            

          

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

          

           

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

           

          FINAL
            and CONFIDENTIAL

          
            

          

          
            

          

          
            

          

          
            Table
              1

          

          
            

          

          
            STATE
              OF OHIO

          

          
            DEPARTMENT
              OF JOB AND FAMILY SERVICES

          

          
            Summary
              of Managed Care Eligible Population

          

          
            

          

          
            

          

          
            	
                    
                      Program
                        Assignment

                    

                  	
                    
                      Description

                    

                  
	
                    
                      PREG

                    

                  	
                    
                      Healthy
                        Start Pregnant Women

                    

                  
	
                    
                      PREGE

                    

                  	
                    
                      Healthy
                        Start Pregnant Women Expansion

                    

                  
	
                    
                      PREGEX

                    

                  	
                    
                      Healthy
                        Start Expedited Pregnant Women

                    

                  
	
                    
                      RPREGEX

                    

                  	
                    
                      Healthy
                        Start Expedited Pregnant Women RMF

                    

                  
	
                    
                      HSC

                    

                  	
                    
                      Healthy
                        Start Children

                    

                  
	
                    
                      HSCE

                    

                  	
                    
                      Healthy
                        Start Expansion <=150%

                    

                  
	
                    
                      RHSC

                    

                  	
                    
                      Healthy
                        Start Children RMF

                    

                  
	
                    
                      CHIP1

                    

                  	
                    
                      Healthy
                        Start CHIP 1 <=150%

                    

                  
	
                    
                      CHIP2

                    

                  	
                    
                      Healthy
                        Start CHIP 2 151-200%

                    

                  
	
                    
                      RCHIP1

                    

                  	
                    
                      Healthy
                        Start CHIP 1 <=150% RMF

                    

                  
	
                    
                      RCHIP2

                    

                  	
                    
                      Healthy
                        Start CHIP 2 151-200% RMF

                    

                  
	
                    
                      RCHSUP

                    

                  	
                    
                      Healthy
                        Family Child Support Extended RMF

                    

                  
	
                    
                      CHSUP

                    

                  	
                    
                      Healthy
                        Family Child Support Extended

                    

                  
	
                    
                      OWFFAM

                    

                  	
                    
                      Ohio
                        Works First Families - Cash

                    

                  
	
                    
                      ROWFFAM

                    

                  	
                    
                      Ohio
                        Works First Families - Cash RMF

                    

                  
	
                    
                      LIFAM

                    

                  	
                    
                      Low
                        Income Families

                    

                  
	
                    
                      RLIFAM

                    

                  	
                    
                      Low
                        Income Families RMF

                    

                  
	
                    
                      HYFAM

                    

                  	
                    
                      Healthy
                        Families (Expansion 7/00 Reduced 1/06)

                    

                  
	
                    
                      TRANS

                    

                  	
                    
                      Transitional

                    

                  
	
                    
                      LIIND

                    

                  	
                    
                      Low
                        Income Individuals

                    

                  
	
                    
                      RLIIND

                    

                  	
                    
                      Low
                        Income Individuals RMF

                    

                  

          

          
             

          

          
            Milliman
              extracted the eligible population information from historical data.
              The eligible
              population includes the Healthy Start and Healthy Families populations.
              If a
              member was ineligible during a month, all claims and eligibility for
              the month
              were excluded from the actuarial models.

          

          
            

          

          
            

          

          
            II.           
              CATEGORY OF SERVICE DEFINITIONS

          

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

          

          
            

          

          
            

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

          

          
            FINAL
              and CONFIDENTIAL

          

          
            

          

          
            

          

          
            Table
              2

          

          
            

          

          
            STATE
              OF OHIO

          

          
            DEPARTMENT
              OF JOB AND FAMILY SERVICES

          

          
            Categories
              of Service

          

          
            

          

          
            	
                    
                      Categories
                        of ServiceType
                        of Service

                    

                  	
                    
                      Service
                        Category

                    

                  	
                    
                      Utilization
                        Units

                    

                  	
                    
                      Classification
                        Basis

                    

                  
	
                    
                      Inpatient
                        Hospital

                    

                  	
                    
                      Medical/Surgical

                    

                  	
                    
                      Admits/Days

                    

                  	
                    
                      
                      

                    

                    
                      
                      

                    

                    
                      
                      

                    

                    
                       

                       

                      COS,
                        DRG

                    

                  
	
                    
                      MH/SA

                    

                  	
                    
                      Admits/Days

                    

                  
	
                    
                      Well
                        Newborn

                    

                  	
                    
                      Admits/Days

                    

                  
	
                    
                      Maternity
                        Non-Deliveries

                    

                  	
                    
                      Admits/Days

                    

                  
	
                    
                      Nursing
                        Facility

                    

                  	
                    
                      Admits/Days

                    

                  
	
                    
                      Other
                        Inpatient

                    

                  	
                    
                      Admits/Days

                    

                  
	
                    
                      Outpatient
                        Hospital

                    

                  	
                    
                      Emergency
                        Room

                    

                  	
                    
                      Claims

                    

                  	
                    
                      
                      

                    

                    
                      
                      

                    

                    
                      
                      

                    

                    
                       

                       

                       

                      COS,
                        Revenue Code

                    

                  
	
                    
                      Surgery/ASC

                    

                  	
                    
                      Services

                    

                  
	
                    
                      Cardiovascular

                    

                  	
                    
                      Services

                    

                  
	
                    
                      PT/ST/OT

                    

                  	
                    
                      Services

                    

                  
	
                    
                      Clinic

                    

                  	
                    
                      Services

                    

                  
	
                    
                      Other

                    

                  	
                    
                      Services

                    

                  
	
                    
                      Professional

                    

                  	
                    
                      Inpatient/Outpatient
                        Surgery

                    

                  	
                    
                      Services

                    

                  	
                    
                      
                      

                    

                    
                      
                      

                    

                    
                      
                      

                    

                    
                      
                      

                    

                    
                       

                       

                       

                       

                       

                      COS,
                        Provider Type, Procedure, Modifier

                    

                  
	
                    
                      Anesthesia

                    

                  	
                    
                      Line
                        Items

                    

                  
	
                    
                      Obstetrics

                    

                  	
                    
                      Services

                    

                  
	
                    
                      Office
                        Visits/Consults

                    

                  	
                    
                      Services

                    

                  
	
                    
                      Hospital
                        Inpatient Visits

                    

                  	
                    
                      Services

                    

                  
	
                    
                      Periodic
                        Exams

                    

                  	 
	
                    
                      Emergency
                        Room Visits

                    

                  	
                    
                      Services

                    

                  
	
                    
                      Immunization
                        & Injections

                    

                  	
                    
                      Services

                    

                  
	
                    
                      Physical
                        Medicine

                    

                  	
                    
                      Services

                    

                  
	
                    
                      Miscellaneous
                        Services

                    

                  	
                    
                      Line
                        Items, Services

                    

                  
	
                    
                      Rad/Path/Lab

                    

                  	
                    
                      Radiology

                    

                  	
                    
                      Services

                    

                  	
                    
                      COS,
                        Revenue Code, Provider Type. Procedure

                    

                  
	
                    
                      Pathology/Laboratory

                    

                  	
                    
                      Services

                    

                  
	
                    
                      Ancillaries

                    

                  	
                    
                      MH/SA

                    

                  	
                    
                      Services

                    

                  	
                    
                      COS,
                        Provider Type, Procedure

                    

                  
	
                    
                      FQHC/RHF/OP
                        Health Facility

                    

                  	
                    
                      Services

                    

                  	
                    
                      COS

                    

                  
	
                    
                      Pharmacy

                    

                  	
                    
                      Line
                        Items

                    

                  	
                    
                      COS

                    

                  
	
                    
                      Dental

                    

                  	
                    
                      Services

                    

                  	
                    
                      COS

                    

                  
	
                    
                      Vision

                    

                  	
                    
                      Services

                    

                  	
                    
                      COS,
                        Provider Type, Procedure

                    

                  
	
                    
                      Home
                        Health

                    

                  	
                    
                      Line
                        Items

                    

                  	
                    
                      COS

                    

                  
	
                    
                      Non-Emergent
                        Transportation

                    

                  	
                    
                      Line
                        Items

                    

                  	
                    
                      COS

                    

                  
	
                    
                      Ambulance

                    

                  	
                    
                      Line
                        Items

                    

                  	
                    
                      COS,
                        Procedure Code

                    

                  
	
                    
                      Supplies
                        and DME

                    

                  	
                    
                      Line
                        Items

                    

                  	
                    
                      COS,
                        Provider Type, Procedure

                    

                  
	
                    
                      Miscellaneous
                        Services

                    

                  	
                    
                      Line
                        Items

                    

                  	
                    
                      COS

                    

                  

          

          
            

          

          
            

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

          

          
             

            FINAL
              and CONFIDENTIAL

          

          
            

          

          
            

          

          
            III.           
              RATE GROUPS

          

          
            

          

          
            The
              CY
              2008 CFC capitation rates are segmented by region and rate group. Table
              3
              contains the rate groups
              used for the CFC population.  The non-delivery rate groups vary by
              age, gender, and program assignment.  The delivery rate group is determined
              based on the
              CFC Program Delivery Payment Reporting Procedures for ODJFS
              Managed Care Plans, effective September 7, 2005.

          

           

          
             

          

          
            

          

          
            Table
              3

          

          
            STATE
              OF OHIO

          

          
            DEPARTMENT
              OF JOB AND FAMILY SERVICES

          

          
            Rate
              Groups

          

          
            

          

          
            	
                    
                      Age/Gender
                        Groups

                    

                  	
                    
                      Benefit
                        Type

                    

                  	
                    
                      Population

                    

                  
	
                    
                      M/F
                        - <1

                    

                  	
                    
                      Non
                        - Delivery

                    

                  	
                    
                      Healthy
                        Start / Healthy Families

                    

                  
	
                    
                      M/F
                        - 1

                    

                  	
                    
                      Non
                        - Delivery

                    

                  	
                    
                      Healthy
                        Start / Healthy Families

                    

                  
	
                    
                      M/F
                        - 2 to 13

                    

                  	
                    
                      Non
                        - Delivery

                    

                  	
                    
                      Healthy
                        Start / Healthy Families

                    

                  
	
                    
                      M-
                        14 to 18

                    

                  	
                    
                      Non
                        - Delivery

                    

                  	
                    
                      Healthy
                        Start / Healthy Families

                    

                  
	
                    
                      F-
                        14 to 18

                    

                  	
                    
                      Non
                        – Delivery

                    

                  	
                    
                      Healthy
                        Start / Healthy Families

                    

                  
	
                    
                      M
                        -
                        19 to 44

                    

                  	
                    
                      Non
                        – Delivery

                    

                  	
                    
                      Healthy
                        Families

                    

                  
	
                    
                      F
                        -
                        19 to 44

                    

                  	
                    
                      Non
                        – Delivery

                    

                  	
                    
                      Healthy
                        Families

                    

                  
	
                    
                      M/F
                        - 45 to 64

                    

                  	
                    
                      Non
                        – Delivery

                    

                  	
                    
                      Healthy
                        Families

                    

                  
	
                    
                      F
                        -
                        19 to 64

                    

                  	
                    
                      Non
                        – Delivery

                    

                  	
                    
                      Healthy
                        Start

                    

                  
	
                    
                      F
                        -
                        All Ages

                    

                  	
                    
                      Delivery

                    

                  	
                    
                      Healthy
                        Start / Healthy Families

                    

                  

          

          
            

          

          
            IV.           
              DEVELOPMENT OF CY 2006 ADJUSTED FFS DATA

          

          
            

          

          
            a.           
              Historical Data Summaries

          

          
            

          

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

          

          
            

          

          
            
              	
                      §

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

                    

            

          

          
            
              	
                      §

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

                    

            

          

          
            

          

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

          

          
            

          

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

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

          

          
            

          

          
            FINAL
              and CONFIDENTIAL

          

          
            

          

          
            

          

          
            The
              FFS
              data summaries represent historical experience for those services that
              re
              included in the capitation payment.  Services that are not covered
              under the capitation payment have been excluded from the
              experience.  The excluded services were identified by the ODJFS
              defined category of service field, as shown in Table 4

          

          
            

          

          
            Table
              4

          

          
            

          

          
            STATE
              OF OHIO

          

          
            DEPARTMENT
              OF JOB AND FAMILY SERVICES

          

          
            Claims
              Excluded from the FFS Data Summaries

          

          
            

          

          
            	
                    COS
                      Field Value

                  	
                    Description

                  
	
                    08

                  	
                    PACE

                  
	
                    13

                  	
                    ICF/MR
                      Public

                  
	
                    18

                  	
                    ICF/MR
                      Private

                  
	
                    35

                  	
                    Core
                      Services

                  
	
                    36

                  	
                    Home
                      Care Facilitator Services

                  
	
                    41

                  	
                    Mental
                      Health Services

                  
	
                    42

                  	
                    Mental
                      Retardation

                  
	
                    46

                  	
                    Model
                      50 Waiver Services

                  
	
                    58

                  	
                    HMO
                      Services

                  
	
                    59

                  	
                    Mental
                      Health Support Services

                  
	
                    60

                  	
                    Mental
                      Retardation Support Services

                  
	
                    63

                  	
                    PPO
                      Services

                  
	
                    64

                  	
                    Passport

                  
	
                    66

                  	
                    Passport
                      Waiver III

                  
	
                    67

                  	
                    OBRA
                      MR/DD Waiver

                  
	
                    80

                  	
                    Alcohol
                      and Drug Abuse

                  
	
                    82

                  	
                    Department
                      of Education

                  
	
                    84

                  	
                    ODADAS

                  

          

          
            

          

          
            

          

          
            b.           
              Completion Factors

          

          
            

          

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

          

          
            

          

          
            c.           
              Historical Program Adjustments

          

          
            

          

          
            The
              base
              FFS data summaries represent a historical time period from which projections
              were developed. Certain
              program changes have occurred during and subsequent to the base data
              time
              period.  The program adjustments were estimated and applied to the
              portion of the base experience data prior to the program

          

          
            

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

          

          
            FINAL
              and CONFIDENTIAL

          

          
            

          

          
            

          

          
            change
              effective date.  For example, a program change implemented on January
              1, 2006 will only be reflected in the second half of SFY 2006.  As
              such, an adjustment was applied to all of SFY 2005 and half of SFY
              2006 to
              include the program change in all periods of the base experience
              data.

          

          
            

          

          
            ODJFS
              has
              provided a listing of all program changes impacting the base experience
              data.  Table 5 summarizes the historical program changes that were
              reflected in the development of the CY 2008 capitation rates.

          

          
            

          

          
            

          

          
            Table
              5

          

          
            

          

          
            STATE
              OF OHIO

          

          
            DEPARTMENT
              OF JOB AND FAMILY SERVICES

          

          
            Historical
              Program Adjustments – FFS

          

          
            

          

          

          
            	
                    
                      Program
                        Adjustment

                    

                  	
                    
                      Effective
                        Date

                    

                  	
                    
                      Service
                        Category(s)

                    

                  	
                    
                      Rate
                        Group

                    

                  
	
                    
                      Inpatient
                        Market Basket Increase

                    

                  	
                    
                      1/1/2005

                    

                  	
                    
                      Inpatient
                        Hospital

                    

                  	
                    
                      All
                        Rate Groups (incl Delivery)

                    

                  
	
                    
                      Dental
                        Fee Schedule Reduction

                    

                  	
                    
                      1/1/2006

                    

                  	
                    
                      Dental

                    

                  	
                    
                      All
                        Rate Groups (incl. Delivery)

                    

                  
	
                    
                      Inpatient
                        Recalibration and Outlier Policy

                    

                  	
                    
                      1/1/2006

                    

                  	
                    
                      Inpatient

                    

                  	
                    
                      All
                        Rate Groups  (incl. Delivery)

                    

                  
	
                    
                      Pharmacy
                        Co-pay

                    

                    
                      ($2
                        Per Brand Prescription)

                    

                  	
                    
                      1/1/2006

                    

                  	
                    
                      Pharmacy

                    

                  	
                    
                      HF
                        M -19 to 44

                    

                  
	
                    
                      HF
                        F-19 to 44

                    

                  
	
                    
                      HF
                        M/F- 45 to 64

                    

                  
	
                    
                      Dental
                        Co-pay

                    

                    
                      ($3
                        Per Date of Service)

                    

                  	
                    
                      1/1/2006

                    

                  	
                    
                      Dental

                    

                  	
                    
                      HF
                        M -19 to 44

                    

                  
	
                    
                      HFF-19
                        to 44

                    

                  
	
                    
                      HF
                        M/F-45 to 64

                    

                  
	
                    
                      HSTF-19
                        to 64

                    

                  
	
                    
                      Vision
                        Exam Co-Pay ($2 Per Exam)

                    

                  	
                    
                      1/1/2006

                    

                  	
                    
                      Vision
                        / Optometric

                    

                  	
                    
                      HF
                        M-19 to 44

                    

                  
	
                    
                      HF
                        F-19 to 44

                    

                  
	
                    
                      HF
                        M/F-45 to 64

                    

                  
	
                    
                      HSTF-19
                        to 64

                    

                  
	
                    
                      Vision
                        Hardware Co-Pay ($1 Per Item)

                    

                  	
                    
                      1/1/2006

                    

                  	
                    
                      Vision
                        / Optometric

                    

                  	
                    
                      HFM-19
                        to 44

                    

                  
	
                    
                      HFF-19
                        to 44

                    

                  
	
                    
                      HF
                        M/F-45 to 64

                    

                  
	
                    
                      HSTF-19
                        to 64

                    

                  
	
                    
                      ER
                        Co-Pay

                    

                    
                      ($3
                        Per Non-Emergency Visit)

                    

                  	
                    
                      1/1/2006

                    

                  	
                    
                      Emergency
                        Room

                    

                  	
                    
                      HF
                        M -I9 to 44

                    

                  
	
                    
                      HF
                        F-19 to 44

                    

                  
	
                    
                      HF
                        M/F-45 to 64

                    

                  
	
                    
                      HSTF-19
                        to 64

                    

                  
	
                    
                      Dental
                        Benefit Reduction

                    

                  	
                    
                      1/1/2006

                    

                  	
                    
                      Dental

                    

                  	
                    
                      HFM-19
                        to 44

                    

                  
	
                    
                      HFF-19
                        to 44

                    

                  
	
                    
                      HF
                        M/F- 45 to 64

                    

                  
	
                    
                      HST
                        F – 19 to 64

                    

                  
	
                    
                      HSTF-19
                        to 64

                    

                  

          

          
            
              
                

                
                  
                    
                    

                  

                  
                    
                    

                    
                      

                    

                  

                  
                    
                    

                  

                

              

              
                FINAL
                  and CONFIDENTIAL

              

              
                

              

            

          

          
            d.           
              Third-Party Liability

          

          
            

          

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

          

          
            

          

          
            e.           
              Fraud and Abuse

          

          
            

          

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

          

          
            

          

          
            f.           
              Gross Adjustments

          

          
            

          

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

          

          
            

          

          
            g.           
              Non-State Plan Services

          

          
            

          

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

          

          
             

          

          
            h.           
              Historical Selection Adjustments

          

          
            

          

          
            Milliman
              applied a historical selection adjustment to the base FFS data to reflect
              that
              the base period contains a combination of FFS and managed care enrollment.
              The
              historical selection adjustment is intended to normalize the FFS experience
              to
              the morbidity level of the entire managed care eligible population
              and is
              similar in methodology to previous years.

          

          
            
              
                

                
                  
                    
                    

                  

                  
                    
                    

                    
                      

                    

                  

                  
                    
                    

                  

                

              

              
                FINAL
                  and CONFIDENTIAL

              

              
                

              

            

            i.           
              Trends/Inflation to CY 2006

          

          
            

          

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

          

          
            

          

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

          

          
            

          

          
            j.           
              Blend Base Experience Years

          

          
            

          

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

          

          
            

          

          
            k.           
              Managed Care Adjustments

          

          
            

          

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

          

          
            

          

          
            Utilization

          

          
            

          

          
            Milliman
              adjusted the FFS utilization and cost per service to reflect the managed
              care
              environment. After reviewing utilization benchmarks in the Milliman
              Medicaid
              Guidelines (Guidelines)
as well as
              other sources, Milliman calculated percentage adjustments to
              reflect the utilization differential between an economic and efficiently
              managed
              plan and the FFS base experience.

          

          
            

          

          
            Cost
              Per
              Service

          

          
            

          

          
            Milliman
              adjusted the cost per service amounts to reflect changes in the mix
              / intensity
              of services due to the management of health care. The reimbursement
              rate changes
              were also developed following a review of benchmark in the Guidelines as well as
              other
              sources.

          

          
            

          

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

          

          
            
              
                

                
                  
                    
                    

                  

                  
                    
                    

                    
                      

                    

                  

                  
                    
                    

                  

                

              

              
                FINAL
                  and CONFIDENTIAL

              

              
                

              

            

          

          
            V.           
              DEVELOPMENT OF CY 2006 ADJUSTED ENCOUNTER DATA

          

          
            

          

          
            a.           
              Historical Data Summaries

          

          
            

          

          
            
              	
                       

                    	
                      The
                        CY 2008 CFC capitation rates were developed, in part, using
                        Encounter
                        claims for two SFY periods: 

                    

            

          

          
            

          

          
            
              	
                      ·

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

                    

            

          

          
            

          

          
            
              	
                      ·

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

                    

            

          

          
            

          

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

          

          
            

          

          
            The
              Encounter data summaries represent historical experience for those
              services that
              are included in the capitation payment. Services that are not covered
              under the
              capitation payment have been excluded from the experience. The excluded
              services
              were identified by the ODJFS defined category of service field, as
              shown in
              Section IV, Table 4.

          

          
            

          

          
            The
              historical data summaries for the base encounter experience reflect
              only region,
              county, health plan combinations with sufficient experience to be considered
              credible. As such, counties considered '"voluntary" and health plans
              with low
              enrollment were not included in the base data. Table 6 provides the
              region/county and health plan combinations contained in the capitation
              rate
              development.

          

          
            

          

          
            Table
              6

          

          
            

          

          
            STATE
              OF OHIO

          

          
            DEPARTMENT
              OF JOB AND FAMILY SERVICES

          

          
            Region/County
              and Health Plan Inclusions – Encounter

          

          

          
            	
                    
                      Region
                        - County

                    

                  	
                    
                      Health
                        Plans

                    

                  
	
                    
                      Central
                        - Franklin

                    

                  	
                    
                      Caresource;
                        Molina

                    

                  
	
                    
                      East
                        Central - Stark

                    

                  	
                    
                      Buckeye;
                        Caresource; Mediplan

                    

                  
	
                    
                      East
                        Central - Summit

                    

                  	
                    
                      Buckeye;
                        Caresource; Summacare

                    

                  
	 Northeast
                    - Cuyahoga    	Caresource;
                    Anthem/Qualchoice
	
                    
                      Northeast
                        - Lorain

                    

                  	
                    
                      Caresource;
                        Anthem/Qualchoice

                    

                  
	
                    
                      Northeast
                        Central - Mahoning

                    

                  	
                    
                      Caresource;
                        Gateway; Unison

                    

                  
	
                    
                      Northeast
                        Central - Trumbull

                    

                  	
                    
                      Caresource;
                        Gateway; Unison

                    

                  
	
                    
                      Northwest
                        - Lucas

                    

                  	
                    
                      Buckeye;
                        Paramount

                    

                  
	
                    
                      Southwest
                        - Butler

                    

                  	
                    
                      Amerigroup;
                        Caresource

                    

                  
	
                    
                      Southwest
                        - Hamilton

                    

                  	
                    
                      Amerigroup;
                        Caresource

                    

                  
	
                    
                      West
                        Central -
                        Clark

                    

                  	
                    
                      Caresource;
                        Molina

                    

                  
	
                    
                      West
                        Central - Montgomery

                    

                  	
                    
                      Caresource;
                        Molina

                    

                  

          

          
             

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

             

            FINAL
              and CONFIDENTIAL

          

          
            

          

          
            b.           
              Imputed Cost per Service

          

          
            

          

          
            Milliman
              applied a cost per service amount to the managed care encounter data
              to reflect
              the missing financial information in the base managed care encounter
              experience.
              The cost per service was applied by rate group on a statewide basis
              for all
              categories of service except for inpatient services. The cost per service
              was
              applied by rate group and region for inpatient services.

          

          
            

          

          
            Additionally,
              the cost per service was re-priced based on the mix/intensity of services
              included in the encounter base experience. The cost per service was
              developed
              from the Medicaid FFS reimbursement rates. In addition to reflecting
              the health
              plan mix of services, the cost per service was adjusted for other managed
              care
              factors as described below.

          

          
            

          

          
            c.           
              Completion Factors

          

          
            

          

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

          

          
            

          

          
            d.           
              Historical Program Adjustments

          

          
            

          

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

          

          
            

          

          
            ODJFS
              has
              provided a listing of all program changes impacting the base experience
              data.
              Section IV, Table 5 summarizes the historical program changes that
              were
              reflected in the development of the CY 2008 capitation rates.

          

          
            

          

          
            e.           
              Third-Party Liability and Fraud-Abuse Recoveries

          

          
            

          

          
            The
              cost
              reports submitted by the health plans contained information related
              to
              third-party liability and fraud-abuse recoveries.  Milliman calculated
              the average recoveries and applied the reduction to the base encounter
              data.

          

          
            

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

          

          
            FINAL
              and CONFIDENTIAL

          

          
            

          

          
            f.           
              Non-State Plan Services

          

          
            

          

          
            CMS
              requires removal of non-state plan services from
              rate-setting.   The encounter data contains certain claims that
              are considered non-state plan services.   The health plan
              submitted cost reports were used as the source of information for the
              non-state
              plan service adjustments.

          

          
            

          

          
            g.           
              Historical Selection Adjustments

          

          
            

          

          
            Milliman
              applied a historical selection adjustment to the base encounter data
              to reflect
              that the base period contains a combination of FFS and managed care
              enrollment.
              The historical selection adjustment is intended to normalize the encounter
              experience to the morbidity level of the entire managed care eligible
              population.

          

          
            

          

          
            h.           
              Trends/Inflation to CY 2006

          

          
            

          

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

          

          
            

          

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

          

          
            

          

          
            i.           
              Blend Base Experience Years

          

          
            

          

          
            Each
              of
              the base experience years was trended to CY 2006. At this point, each
              base year
              was on a comparable basis and could be aggregated. The weighting was
              developed
              with the intention of placing more credibility on the most recent experience.
              Generally, SFY 2006 was given 70% weight except where insufficient
              experience
              existed in either SFY 2005 or SFY 2006. In these situations, either
              SFY 2005 or
              SFY 2006 was given 100% credibility.

          

          
            

          

          
            j.           
              Managed Care Adjustments

          

          
            

          

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

          

          
            
              
                

                
                  
                    
                    

                  

                  
                    
                    

                    
                      

                    

                  

                  
                    
                    

                  

                

              

              
                FINAL
                  and CONFIDENTIAL

              

              
                

              

            

          

          
            Utilization

          

          
            

          

          
            Milliman
              adjusted the encounter utilization and cost per service to reflect
              changes
              anticipated in the managed care environment.  After reviewing
              utilization benchmarks in the Milliman Medicaid Guidelines (Guidelines) as well
              as other
              sources, Milliman calculated percentage adjustments to reflect utilization
              differential between an economic and efficiently managed plan and the
              encounter
              base experience.

          

          
            

          

          
            Cost
              Per
              Service

          

          
            

          

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

          

          
            

          

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

          

          
            

          

          
            VI.           
              DEVELOPMENT OF CY 2006 ADJUSTED COST REPORT DATA

          

          
            

          

          
            a.           
              Historical Data Summaries

          

          
            

          

          
            The
              CY
              2008 CFC capitation rates were developed, in part, using health plan
              submitted
              cost reports for two calendar year (CY) periods:

          

          
            

          

          
            
              	
                      §  

                    	
                      CY
                        2005 (Incurred during the 12 months ending December 31, 2005
                        paid through
                        December 31, 2006).

                    

            

          

          
            
              	
                      §  

                    	
                      CY
                        2006 (Incurred during the 12 months ending December 31, 2006
                        paid through
                        December 31, 2007).

                    

            

          

          
            

          

          
            The
              historical data summaries for the base cost report experience reflect
              only
              region, county, health plan combinations with sufficient experience
              to be
              considered credible. As such, counties considered "voluntary" and health
              plans
              with low enrollment were not included in the base data. Table 7 provides
              the
              region/county and health plan combinations contained in the capitation
              rate
              development.

          

          
            

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

          

          
             

            FINAL
              and CONFIDENTIAL

             

          

          
            
              	
                       

                    	
                      Table
                        7 

                    

            

          

          
            

          

          
            
              	
                       

                    	
                      STATE
                        OF OHIO 

                    

            

          

          
            
              	
                       

                    	
                      DEPARTMENT
                        OF JOB AND FAMILY SERVICES 

                    

            

          

          
            
              	
                       

                    	
                      Region/County
                        and Health Plan Inclusions – Cost Report

                    

            

          

          
             

          

          
            	
                    
                      Region
-
County

                    

                  	
                    
                      Health
                        Plans

                    

                  
	
                    
                      Central
                        - Franklin

                    

                  	
                    
                      Caresource;
                        Molina

                    

                  
	
                    
                      East
                        Central - Stark

                    

                  	
                    
                      Buckeye;
                        Caresource

                    

                  
	
                    
                      East
                        Central - Summit

                    

                  	
                    
                      Buckeye;
                        Caresource

                    

                  
	
                    
                      Northeast
                        - Cuyahoga

                    

                  	
                    
                      Caresource:
                        Anthem/Qualchoice

                    

                  
	
                    
                      Northeast
                        - Lorain

                    

                  	
                    
                      Caresource;
                        Anthem/Qualchoice

                    

                  
	
                    
                      Northeast
                        Central - Mahoning

                    

                  	
                    
                      Caresource;
                        Gateway; Unison

                    

                  
	
                    
                      Northeast
                        Central - Trumbull

                    

                  	
                    
                      Caresource;
                        Gateway; Unison

                    

                  
	
                    
                      Northwest
                        - Lucas

                    

                  	
                    
                      Buckeye;
                        Paramount

                    

                  
	
                    
                      Southwest
                        - Butler

                    

                  	
                    
                      Amerigroup;
                        Caresource

                    

                  
	
                    
                      Southwest
                        - Hamilton

                    

                  	
                    
                      Amerigroup;
                        Caresource

                    

                  
	
                    
                      West
                        Central - Clark

                    

                  	
                    
                      Caresource;
                        Molina

                    

                  
	
                    
                      West
                        Central - Montgomery

                    

                  	
                    
                      Caresource;
                        Molina

                    

                  

          

          
            

          

          
            b.  Completion
              Factors

          

          
            

          

          
            The
              cost
              reports contained claim experience incurred through December 31, 2006
              and paid
              through December 31, 2006, as well as health plan estimated 1BNR reserve
              amounts. Milliman reviewed the claims completion contained in the submitted
              cost
              reports for reasonableness. During this review, Milliman estimated
              a high and
              low completion percentage on a statewide basis. The claims completion
              implemented by the health plans in aggregate was within the range and,
              as such,
              no further adjustments were applied.

          

          
            

          

          
            c.   Historical
              Program Adjustments

          

          
            

          

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

          

          
            

          

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

          

          
            
              
                

                
                  
                    
                    

                  

                  
                    
                    

                    
                      

                    

                  

                  
                    
                    

                  

                

              

              
                FINAL
                  and CONFIDENTIAL

              

              
                

              

            

            d.  Third-Party
              Liability and Fraud-Abuse Recoveries

          

          
            

          

          
            The
              cost
              reports submitted by the health plans contained information related
              to
              third-party liability and fraud-abuse recoveries.  Milliman calculated
              the average recoveries and applied the reduction to the base cost report
              data.

          

          
            

          

          
            e.   Non-State
              Plan Services

          

          

          
            CMS
              requires removal of non-state plan services from rate-setting. The
              cost report
              claims that are considered non-state plan services. The health plan
              submitted
              cost the source of information for the non-state plan service
              adjustments.

          

          
            

          

          
            
              f. 
Historical
                Selection
                Adjustments 

          

          
            Milliman
              applied a historical selection adjustment to the base cost report data
              to
              reflect that the base period contains a combination of FFS and managed
              care
              enrollment. The historical selection adjustment is intended to normalize
              the
              cost report experience to the morbidity level of the entire managed
              care
              eligible population.

          

          
            

          

          
            g.     Trends/Inflation
              to CY 2006

          

          
            

          

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

          

          
            

          

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

          

          
            

          

          
            h.       Blend
              Base Experience Years

          

          
            

          

          
            The
              base
              CY 2005 year was trended to CY 2006. At this point, each base year
              was on a
              comparable basis and could be aggregated. The weighting was developed
              with the
              intention of placing more credibility on the most recent
              experience.  Generally, CY 2006 was given 70% weight except where
              insufficient experience existed in either CY 2005 or CY 2006.  In
              these situations, either CY 2005 or CY 2006 was given 100%
              credibility.

          

          
          

          
            
              
                

                
                  
                    
                    

                  

                  
                    
                    

                    
                      

                    

                  

                  
                    
                    

                  

                

              

              
                FINAL
                  and CONFIDENTIAL

              

              
                

              

            

          

          
            i.        Managed
              Care Adjustments

          

          
            

          

          
            Milliman
              adjusted the cost report experience data to reflect changes anticipated
              in the
              managed care environment.  The cost report base experience was
              adjusted using the same managed care adjustments as the base encounter
              data with
              the exception of the health plan provider contracting adjustment. The
              health
              plan rate of provider reimbursement is already included in the cost
              report base
              experience.

          

          
            

          

          
            Adjustments
              were developed for each rate group, service category, and
              region.

          

          
            

          

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

          

          
            

          

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

          

          
            

          

          
            a.      Trend
              to CY 2008

          

          
            

          

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

          

          
            

          

          
            b.     Prospective
              Program Adjustments

          

          
            

          

          
            The
              SFY
              2008/2009 Budget contains several program changes that impacted the
              development
              of the capitation rates. The program changes include items such as
              provider fee
              changes, benefit changes, and administrative changes. Adjustments to
              the CY 2006
              experience were developed for each item based on its expected impact
              to the
              prospective claims cost. Table 8 lists the program changes that were
              included in
              the CY 2008 capitation rate development.

          

          
          

          
            
              
                

                
                  
                    
                    

                  

                  
                    
                    

                    
                      

                    

                  

                  
                    
                    

                  

                

              

              
                FINAL
                  and CONFIDENTIAL

              

              
                

              

            

          

          
            Table
              8

          

          
            

          

          
            
              	
                       

                    	
                      STATE
                        OF OHIO 

                    

            

          

          
            
              	
                       

                    	
                      DEPARTMENT
                        OF JOB AND FAMILY SERVICES 

                    

            

          

          
            
              	
                       

                    	
                      Prospective
                        Program Adjustments 

                    

            

          

          
            

          

          
            	
                    Program
                      Adjustment

                  	
                    Effective
                      Date

                  	
                    Service
                      Category

                  	
                    Rate
                      Groups

                  
	
                    Nursing
                      Facility Fee Increase

                  	
                    7/1/2007

                    7/1/2008

                  	
                    Nursing
                      Facility

                  	
                    All
                      Rate Groups (excl. Delivery)

                  
	
                    Chiropractor
                      Benefit Restoration

                  	
                    1/1/2008

                  	
                    Miscellaneous
                      Services

                  	
                    HF
                      M – 19 to 44

                    HF
                      F – 19 to 44

                    HF
                      M/F – 45 to 64

                    HST
                      F – 19 to 64

                  
	
                    Independent
                      Psychologists Benefit Restoration

                  	
                    1/1/2008

                  	
                    Mental
                      Health / Substance Abuse

                  	
                    HF
                      M – 19 to 44

                    HF
                      F – 19 to 44

                    HF
                      M/F – 45 to 64

                    HST
                      F – 19 to 64

                  
	
                    Occupational
                      Therapy-Independent Provider Status

                  	
                    1/1/2008

                  	
                    Miscellaneous
                      Services

                  	
                    All
                      Rate Groups (excl. Delivery)

                  
	
                    Developmental
                      Therapies

                  	
                    1/1/2008

                  	
                    Miscellaneous
                      Services

                  	
                    HST
                      M/F - <
                      1

                  
	
                    Foster
                      Children Expansion

                  	
                    1/1/2008

                  	
                    All
                      Service Categories

                  	
                    HST
                      M – 14 to 18

                  
	
                    CHIP
                      III Expansion

                  	
                    1/1/2008

                  	
                    All
                      Service Categories

                  	
                    HST
                      F – 14 to 18

                    HF
                      M – 19 to 44

                    HF
                      F – 19 to 44

                    HST
                      F – 19 to 64

                    HST
                      M/F – 2 to 13

                  
	
                    Pregnant
                      Women Expansion

                  	
                    1/1/2008

                  	
                    All
                      Service Categories

                  	
                    HST
                      M – 14 to 18

                    HST
                      F – 14 to 18

                    HST
                      F – 19 to 64

                  
	
                    Improved
                      TPL Management

                  	
                    1/1/2008

                  	
                    All
                      Service Categories

                  	
                    Delivery

                    All
                      Rate Groups (incl. Delivery)

                  
	
                    Expedite
                      Managed Care Enrollment

                  	
                    1/1/2008

                  	
                    All
                      Service Categories

                  	
                    All
                      Rate Groups (incl. Delivery)

                  
	
                    Expedite
                      Newborn Enrollment

                  	
                    1/1/2008

                  	
                    All
                      Service Categories

                  	
                    HST
                      M/F - <
                      1

                  
	
                    Short
                      Term Nursing Facility Policy Change (consistent with ABD)

                  	
                    1/1/2008

                  	
                    Nursing
                      Facility

                  	
                    All
                      Rate Groups (excl. Delivery)

                  
	
                    Prior
                      Authorization Policy Change

                  	
                    1/1/2008

                  	
                    Pharmacy

                  	
                    All
                      Rate Groups (excl. Delivery)

                  
	
                    Prior
                      Authorization of Atypical Anti-Psychotic Medication

                  	
                    1/1/2008

                  	
                    Pharmacy

                  	
                    All
                      Rate Group (excl. Delivery)

                  

          

          
            
              
                

                
                  
                    
                    

                  

                  
                    
                    

                    
                      

                    

                  

                  
                    
                    

                  

                

              

              
                FINAL
                  and CONFIDENTIAL

              

              
                

              

            

          

          
            c.           
              Prospective Selection Adjustment

          

          
            

          

          
            Milliman
              adjusted the base experience data to reflect the morbidity of the entire
              managed
              care eligible population.  Subsequently, a prospective selection
              adjustment was deleloped to reflect that less than 100% of managed
              care
              eligibles will enroll in managed care.  Table 9 provides that taget
              managed care penetration used in the development of the CY 2008 capitation
              rates.

          

          
            

          

          
            

          

          
            Table
              9

          

          
            

          

          
            STATE
              OF OHIO

          

          
            DEPARTMENT
              OF JOB AND FAMILY SERVICES

          

          
            Prospective
              Selection Adjustments

          

          

          
            	
                    
                      Region

                    

                  	
                    
                      June
                        2007 MC Penetration

                    

                  	
                    
                      Target
                        MC Penetration

                    

                  
	
                    
                      Central

                    

                  	
                    
                      93.4%

                    

                  	
                    
                      95%

                    

                  
	
                    
                      East
                        Central

                    

                  	
                    
                      94.6%

                    

                  	
                    
                      95%

                    

                  
	
                    
                      Northeast

                    

                  	
                    
                      95.2%

                    

                  	
                    
                      95%

                    

                  
	
                    
                      Northeast
                        Central

                    

                  	
                    
                      75.8%

                    

                  	
                    
                      95%

                    

                  
	
                    
                      Northwest

                    

                  	
                    
                      94.5%

                    

                  	
                    
                      95%

                    

                  
	
                    
                      Southeast

                    

                  	
                    
                      94.9%

                    

                  	
                    
                      95%

                    

                  
	
                    
                      Southwest

                    

                  	
                    
                      93.6%

                    

                  	
                    
                      95%

                    

                  
	
                    
                      West
                        Central

                    

                  	
                    
                      94.0%

                    

                  	
                    
                      95%

                    

                  

          

          
            

          

          
            d.           
              Clinical Measures Adjustments

          

          
            

          

          
            Appendix
              M of the provider agreement between contracted health plans and ODJFS
              contains
              certain clinical measures that each health plan must achieve. The agreement
              stipulates that, at a minimum, the experience improvement must reduce
              the
              discrepancy between the ultimate target and the actual rate by a certain
              percentage. Milliman developed adjustments to the capitation rates
              to reflect
              this required improvement in performance based on the CY 2006 actual
              results.
              Table 10 illustrates the measures for which adjustment factors were
              applied by
              category of service and rate group.

             

          

          
            Table
              10

          

          
            

          

          
            STATE
              OF OHIO

          

          
            DEPARTMENT
              OF JOB AND FAMILY SERVICES

          

          
            Clinical
              Measures Adjustments

          

          
            

          

          
            	
                    Clinical
                      Measure Description

                  	
                    Measure

                  	
                    Service
                      Category

                  	
                    Rate
                      Groups

                  
	
                    Ongoing
                      Prenatal Care

                  	
                    80%
                      receive 81+% of expected visits

                  	
                    Office
                      Visits / Consults

                  	
                    HST
                      F – 14 to 18

                    HF
                      F – 19 to 44

                    HST
                      F – 19 to 64

                  
	
                    Postpartum
                      Care

                  	
                    80%
                      receive a visit

                  	
                    Obstetrics

                  	
                    HST
                      F – 14 to 18

                    HF
                      F – 19 to 44

                    HST
                      F – 19 to 64

                  
	
                    Well
                      Child Visits

                  	
                    80%
                      receive expected visits

                  	
                    Periodic
                      Exams

                  	
                    HST
                      M/F – <1

                    HST
                      M/F – 1

                    HST
                      M/F – 2 to 13

                    HST
                      F – 14 to 18

                    HST
                      M – 14 to 18

                  
	
                    Asthma
                      Medications

                  	
                    95%
                      receive appropriate medications

                  	
                    Pharmacy

                  	
                    HST
                      M/F – 2 to 13

                    HST
                      F – 14 to 18

                    HST
                      M – 14 to 18

                    HF
                      F – 19 to 44

                    HF
                      M – 19 to 44

                    HF
                      M/F – 45 to 64

                    HST
                      F – 19 to 64

                  
	
                    Annual
                      Dental Visits

                  	
                    60%
                      receive a visit

                  	
                    Dental

                  	
                    HST
                      M/F – 2 to 13

                    HST
                      F – 14 to 18

                    HST
                      M – 14 to 18

                  
	
                    Lead
                      Screening

                  	
                    80%
                      receive screening

                  	
                    Pathology
                      / Laboratory

                  	
                    HST
                      M/F – 1

                    HST
                      M/F – 2 to 13

                  

          

          
            

          

          e.           
            Delivery of Cesarean Section Rates

          

          Milliman
            reviewed the cesarean rates for both the FFS and managed care populations
            in the
            base period data summaries.  In the previous years, the capitation
            rates were adjusted to target a specific cesarean rate.  For 2008,
            Milliman did not adjust the regional cost summaries, up or down, to reflect
            a
            different cesarean rate.

          

          f.           
            Blend FFS / Encounter / Cost Report

          

          The
            FFS,
            encounter, and cost report data sets were projected to CY 2008 and composited
            to
            establish the CY 2008 total claims cost. The credibility between data
            sources
            was based upon the amount of managed care
            experience in the case data.  The encounter and cost report data
            sources were given equal weight in each region.

          
            
              

              
                
                  
                  

                

                
                  
                  

                  
                    

                  

                

                
                  
                  

                

              

            

            
              FINAL
                and CONFIDENTIAL

            

            
              
g.           
                Age/Gender Realignment

            

          

          

          
            Milliman
              developed the 2008 capitation rates by rate group and region. The resulting
              capitation rates by rate group were then adjusted within each region
              to realign
              the age/gender relativities among regions. The realignment maintains
              the
              composite capitation rates for each region and in aggregate while allowing
              for
              more consistent age/gender relativities.

          

          
            

          

          
            h.           
              Administrative Allowances

          

          
            

          

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

          

          
            

          

          
            For
              health plans in plan year 3 or later, 1% of the administrative component
              will be
              at-risk and contingent upon performance requirements defined in the
              ODJFS
              provider agreements. Table 11 provides the administrative cost allowance
              for
              each plan year.

          

          
             

            Table
              11

          

          
            

          

          
            STATE
              OF OHIO

          

          
            DEPARTMENT
              OF JOB AND FAMILY SERVICES

          

          
            Administrative
              Cost Allowance

          

          
             

            Non-Delivery

          

          

          
            	
                    
                      Plan
Year 

                    

                  	
                    
                      Guaranteed
                        %

                    

                  	
                    
                      At-Risk
                        %

                    

                  	
                    
                      Total
                        %

                    

                  
	
                    
                      Plan
                        Year 1 (1-12 Months)

                    

                  	
                    
                      12.5%

                    

                  	
                    
                      0.0%

                    

                  	
                    
                      12.5%

                    

                  
	
                    
                      Plan
                        Year 2 (13-24 Months)

                    

                  	
                    
                      11.5%

                    

                  	
                    
                      0.0%

                    

                  	
                    
                      11.5%

                    

                  
	
                    
                      Plan
                        Year 3 (25 + Months)

                    

                  	
                    
                      10.5%

                    

                  	
                    
                      1.0%

                    

                  	
                    
                      11.5%

                    

                  

          

          
            
              

              
                
                  
                  

                

                
                  
                  

                  
                    

                  

                

                
                  
                  

                

              

            

            
              FINAL
                and CONFIDENTIAL

            

            
              

            

          

          Delivery

          

          
            	
                    
                      Plan
                        Year

                    

                  	
                    
                      Guaranteed
                        %

                    

                  	
                    
                      At-Risk
                        %

                    

                  	
                    
                      Total
                        %

                    

                  
	
                    
                      Plan
                        Year 1 (142 Months)

                    

                  	
                    
                      6.0%

                    

                  	
                    
                      0.0%

                    

                  	
                    
                      6.0%

                    

                  
	
                    
                      Plan
                        Year 2 (13-24 Months)

                    

                  	
                    
                      5.0%

                    

                  	
                    
                      0.0%

                    

                  	
                    
                      5.0%

                    

                  
	
                    
                      Plan
                        Year 3 (25 + Months)

                    

                  	
                    
                      4.0%

                    

                  	
                    
                      1.0%

                    

                  	
                    
                      5.0%

                    

                  

          

          
            

          

          
            The
              administrative cost allowance percentages contained in Table 11 reflect
              a change
              from the 2007 methodology.

          

          
            

          

          
            i.           
              Franchise Fee

          

          
            

          

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

          

          
            

          

          
            DATA
              RELIANCE

          

          
            

          

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

          

          
            

          

          
            

          

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

          

          
            

          

          
            Sincerely,

          

          
            

          

          
             
/s/ 
Robert
              M. Damler   

          

          
            Robert
              M.
              Damler, FSA, MAAA Principal and Consulting Actuary

          

          
            

          

          
            
              	
                       

                    	
                      RMD/mle
                        

                    

            

          

          
            
              	
                      cc:

                    	
                      Dan
                        Hecht (ODJFS) 

                    
	 	MitaliGhatak
                      (ODJFS)
	 	Robert
                      Monks (ODJF1 )

            

          

          
             

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          
            APPENDIX
              1

          

          
            

          

          
            Illustration
              of Rate Development Methodology

          

          
            

          

          
            [Graph]

             

             

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

          

          
            

          

          
            

          

          
            APPENDIX
              2

          

          
            

          

          
            STATE
              OF OHIO

          

          
            DEPARTMENT
              OF JOB AND FAMILY SERVICES

          

          
            Covered
              Families and Children – CY 2008 Capitation Rates

          

          
            

          

          
            Actuarial
              Certification

          

          
            

          

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

          

          
            

          

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

          

          
            

          

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

          

          
            

          

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

          

          
            

          

          
            •  the
              capitation rates have been developed in accordance with generally accepted
              actuarial principles and practices;

          

          
            

          

          
            •  the
              capitation rates are appropriate for the populations to be covered,
              and the
              services to be furnished under the contract; and,

          

          
            

          

          
            •  the
              capitation rates meet the requirements of 42 CFR 438.6(c).

          

          
            

          

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

          

          
            

          

          
              /s/  Robert
              M. Damler

          

          
            Robert
              M.
              Damler, FSA

          

          
            Member,
              American Academy of Actuaries

          

          
            

          

          
            
              	
                       

                    	
                      December
                        4,
                        2007

                    

            

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

          
            

          

          
            

          

          
            

          

          
            

          

          
            

          

          
            APPENDIX
              3

          

          
             

             

            FINAL
              AND CONFIDENTIAL

          

          
            

          

          
            

          

          
            State
              of Ohio

          

          
            

          

          
            Department
              of Job and Family Services

          

          
            

          

          
            Capitation
              Rate Summary – Rate Group Level

          

          
            

          

          
            [Table]

          

          
            

          

          
            

          

          
            

          

          
            

          

          

            
              
                
                

              

              
                
                

                
                  

                

              

              
                
                

              

            

        

      

      
        	
                APPENDIX
                  F

              
	
                REGIONAL
                  RATES

              
	 	 	 	 	 	 	 	 	 	 	 	 
	
                1.  PREMIUM
                  RATES  WITHOUT THE AT-RISK PAYMENT AMOUNTS FOR 01/01/08 THROUGH
                  06/30/08 SHALL BE AS FOLLOWS:

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

              
	 	 	 	 	 	 	 	 	 	 	 	 
	
                MCP:  WellCare
                  of Ohio,
                  Inc.

              	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	
                SERVICE

              	
                REGIONAL

              	
                HF/HST

              	
                HF/HST

              	
                HF/HST

              	
                HF/HST

              	
                HF/HST

              	
                HF

              	
                HF

              	
                HF

              	
                HST

              	
                Delivery

              
	
                ENROLLMENT

              	
                STATUS

              	
                Age
<
1

              	
                Age
                  1

              	
                Age
                  2-13

              	
                Age
                  14-18

              	
                Age
                  14-18

              	
                Age
                  19-44

              	
                Age
                  19-44

              	
                Age
                  45

              	
                Age
                  19-64

              	
                Payment

              
	
                AREA

              	 	 	 	 	
                Male

              	
                Female

              	
                Male

              	
                Female

              	
                and
                  over

              	
                Female

              	 
	
                Northeast

              	
                Mandatory

              	
                $537.65

              	
                $138.65

              	
                $93.78

              	
                $112.18

              	
                $156.32

              	
                $188.08

              	
                $287.97

              	
                $459.68

              	
                $356.04

              	
                $4,105.75

              
	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	
                List
                  of Eligible Assistance Groups
                  (AGs)

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

                -  MA-T   Children
                  under 21

                -  MA-Y   Transitional
                  Medicaid

              
	 	 	 	 	 	 	 	 	 	 	 	 
	 Healthy
                Start: 	-  MA-P  Pregnant
                Women and Children
	 	 	 	 	 	 	 	 	 	 	 	 
	
                 For
                  the SFY 2008 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  01/01/08 THROUGH 06/30/08 SHALL BE AS
                  FOLLOWS:

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

              
	 	 	 	 	 	 	 	 	 	 	 	 
	
                MCP:  WellCare
                  of Ohio,
                  Inc.

              	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	
                SERVICE

              	
                REGIONAL

              	
                HF/HST

              	
                HF/HST

              	
                HF/HST

              	
                HF/HST

              	
                HF/HST

              	
                HF

              	
                HF

              	
                HF

              	
                HST

              	
                Delivery

              
	
                ENROLLMENT

              	
                STATUS

              	
                Age
<
1

              	
                Age
                  1

              	
                Age
                  2-13

              	
                Age
                  14-18

              	
                Age
                  14-18

              	
                Age
                  19-44

              	
                Age
                  19-44

              	
                Age
                  45

              	
                Age
                  19-64

              	
                Payment

              
	
                AREA

              	 	 	 	 	
                Male

              	
                Female

              	
                Male

              	
                Female

              	
                and
                  over

              	
                Female

              	 
	
                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 TANF cash

                -  MA-T   Children
                  under 21

                -  MA-Y   Transitional
                  Medicaid

              
	 	 	 	 	 	 	 	 	 	 	 	 
	
                     

              	 	 	 	 	 	 	 
	 Healthy
                Start:   	-  MA-P   Pregnant
                Women and Children
	 	 	 	 	 	 	 	 	 	 	 	 
	
                 For
                  the SFY 2008 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
                  01/01/08 THROUGH 06/30/08 SHALL BE AS FOLLOWS:

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

              
	 	 	 	 	 	 	 	 	 	 	 	 
	
                MCP:  WellCare
                  of Ohio,
                  Inc.

              	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	
                SERVICE

              	
                REGIONAL

              	
                HF/HST

              	
                HF/HST

              	
                HF/HST

              	
                HF/HST

              	
                HF/HST

              	
                HF

              	
                HF

              	
                HF

              	
                HST

              	
                Delivery

              
	
                ENROLLMENT

              	
                STATUS

              	
                Age
<
1

              	
                Age
                  1

              	
                Age
                  2-13

              	
                Age
                  14-18

              	
                Age
                  14-18

              	
                Age
                  19-44

              	
                Age
                  19-44

              	
                Age
                  45

              	
                Age
                  19-64

              	
                Payment

              
	
                AREA

              	 	 	 	 	
                Male

              	
                Female

              	
                Male

              	
                Female

              	
                and
                  over

              	
                Female

              	 
	
                Northeast

              	
                Mandatory

              	
                $537.65

              	
                $138.65

              	
                $93.78

              	
                $112.18

              	
                $156.32

              	
                $188.08

              	
                $287.97

              	
                $459.68

              	
                $356.04

              	
                $4,105.75

              
	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	
                List
                  of Eligible Assistance Groups
                  (AGs)

                 

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

                -  MA-T   Children
                  under 21

                -  MA-Y   Transitional
                  Medicaid

              
	
                                            

              	 	 	 	 	 	 	 	 
	 Healthy
                Start:      	-  MA-P   Pregnant
                Women and Children
	
                 

              	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	
                 For
                  the SFY 2008 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
and private duty nursing
      services  

    · Podiatry

    · Chiropractic
      services

    · Physical
      therapy, occupational therapy, developmental therapy and speech
      therapy

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

    · Prescription
      drugs

    · Ambulance
      and
      ambulette services

    · Dental
      services 

    · Durable
      medical equipment and medical supplies

    · Vision
      care
      services, including eyeglasses

    · Short-term
      rehabilitative stays in a nursing facility as specified in OAC rule
      5101:3-26-03

    · Hospice
      care

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

    

    2. Exclusions,
      Limitations and
      Clarifications

    

    a. Exclusions

    

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

    

    · Services
      or
      supplies that are not medically necessary

    · Experimental
      services and procedures, including drugs and equipment, not covered by
      Medicaid

    · Organ
      transplants that are not covered by Medicaid

    · Abortions,
      except in the case of a reported rape, incest, or when medically necessary
      to  save the life of the mother

    · Infertility
      services for males or females

    · Voluntary
      sterilization if under 21 years of age or legally incapable of consenting to
      the  procedure

    ·
      Reversal of voluntary sterilization procedures

    · Plastic
      or cosmetic surgery that is
      not
      medically necessary*

    · Immunizations
      for travel outside of the United States

    · Services
      for
      the treatment of obesity unless medically necessary*

    · Custodial
      or
      supportive care not covered by
      Medicaid

    · Sex
      change
      surgery and related services

    · Sexual
      or
      marriage counseling

    · Acupuncture
      and biofeedback services

    · Services
      to
      find cause of death (autopsy)

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

    · Paternity
      testing

    

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

    

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

    

    b. Limitations
&
      Clarifications

       

    i. Member
      Cost-Sharing

    

    As
      specified in OAC rules 5101:3-26-05(D) and  5101:3-26-12, MCPs
      are permitted to impose the applicable member co-payment amount(s) for dental
      services, vision services, non-emergency emergency department services, or
      prescription drugs, other than generic drugs. MCPs must notify ODJFS if they
      intend to impose a co-payment.  ODJFS must approve the notice to be
      sent to the MCP’s members and the timing of when the co-payments will begin to
      be imposed.  If ODJFS determines that an MCP’s decision to impose a
      particular co-payment on their members would constitute a significant change
      for
      those members, ODJFS may require the effective date of the co-payment to
      coincide with the “Open
      Enrollment” month.

    

    Notwithstanding
      the preceding paragraph, MCPs must provide an ODJFS-approved notice to all
      their
      members 90 days in advance of the date that the MCP will impose the co-payment.
      With the exception of member co-payments the MCP has elected to implement in
      accordance with OAC rules 5101:3-26-05(D) and  5101:3-26-12, the MCP’s payment
      constitutes payment in full for any covered services and their subcontractors
      must not charge members
      or ODJFS any additional co-payment, cost sharing, down-payment, or similar
      charge, refundable or otherwise.

    

    ii. Abortion
      and
      Sterilization

    

    The
      use
      of federal funds to pay for abortion and sterilization services is prohibited
      unless the specific criteria found in 42 CFR 441 and OAC rules 5101:3-17-01
      and
      5101:3-21-01 are met.  MCPs must verify that all of the information on
      the required forms (JFS 03197, 03198, and 03199) is provided and that the
      service meets the required criteria before any such claim is paid.

    

    Additionally,
      payment must not be made for associated services such as anesthesia, laboratory
      tests, or hospital services if the abortion or sterilization itself does not
      qualify for payment.  MCPs are responsible for educating their
      providers on the requirements; implementing internal procedures including
      systems edits to ensure that claims are only paid once the MCP has determined
      if
      the applicable forms are completed and the required criteria are met, as
      confirmed by the appropriate certification/consent forms; and for maintaining
      documentation to justify any such claim payments.

    

    iii. Behavioral
      Health
      Services

    

    Coordination
      of Services:  MCPs must have a process
      to
      coordinate benefits of and referrals to the publicly funded community behavioral
      health system.  MCPs must ensure that members have access to all
      medically-necessary behavioral health services covered by the Ohio
      Medicaid FFS program and are responsible for coordinating those services with
      other medical and support services.  MCPs must notify members via the
      member handbook and provider directory of where and how to access behavioral
      health services, including the ability to self-refer to mental health services
      offered through ODMH community
      mental health centers (CMHCs) as well as substance abuse services offered
      through Ohio Department of Alcohol and Drug Addiction Services
      (ODADAS)-certified Medicaid providers. Pursuant to ORC Section 5111.16, alcohol,
      drug addiction and mental health services covered by Medicaid are not to be
      paid
      by the managed care program when the nonfederal share of the cost of those
      services is provided by a board of alcohol, drug addiction, and mental health
      services or a state agency other than ODJFS.  MCPs are also not
      responsible for providing mental health services to persons between 22
      and 64 years of age while residing in an institution for mental disease (IMD)
      as
      defined in Section 1905(i) of the Social Security Act.

    

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

    

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

    

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

    

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

    

    Where
      an
      MCP is responsible for providing substance abuse services for their members,
      the
      MCP is responsible for ensuring access to alcohol and other drug (AOD)
      urinalysis screening, assessment, counseling,
      physician/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
      for Behavioral Health Services:  MCPs are responsible
      for the
      following:

    

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

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

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

    

    Limitations:

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

    

    · MCPs
      are not responsible for paying for
      behavioral health services provided through ODMH CMHCs and ODADAS-certified
      Medicaid providers;

    · MCPs
      are not responsible for payment of
      partial hospitalization (mental health), inpatient psychiatric care in a private
      or public free-standing inpatient psychiatric hospital, outpatient
      detoxification, intensive outpatient programs (IOP) (substance abuse) or
      methadone maintenance.

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

    

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

    

     MCPs
      may establish a preferred drug list for members and providers which includes
      a
      listing of the drugs that they prefer to have prescribed. Preferred drugs
      requiring prior authorization approval must be clearly indicated as
      such.  Pursuant to ORC §5111.172, ODJFS may approve MCP-specific
      pharmacy program utilization management strategies (see appendix
      G.3.a).

    

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

    

    3. Care
      Coordination

    

    a. Utilization
      Management
      Programs

    

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

    

    i. Pharmacy
      Programs - Pursuant to ORC Sec. 5111.172 and OAC rule 5101:3-26-03(A) and
      (B), MCPs may, subject to ODJFS prior- approval, implement strategies for
      the management of pharmacy utilization.  Pharmacy utilization
      management strategies may include developing preferred drug lists,
      requiring prior authorization for certain drugs, placing limitations on the
      type
      of  provider and locations where certain medications may
      be administered, and developing and implementing a specialized pharmacy
      program to address the utilization of controlled substances, as defined in
      section 3719.01 of the Ohio Revised Code.

    

    Drug
      Prior Authorizations: MCPs must receive prior approval from  ODJFS for the
      medications that they wish to cover  through prior
 authorization.  MCPs must establish their prior authorization
 system so that it does not unnecessarily impede member access to
 medically-necessary Medicaid-covered services.  MCPs must
 make their approved list of drugs covered only with  prior
 authorization available to members and providers, as outlined  in
      paragraphs 37(b) and (c) of Appendix C.

    

     Beginning
      January 1, 2008, MCPs may require prior authorization  for  the
      coverage of antipsychotic drugs with ODJFS approval.  MCPs  must,
      however, allow any member to continue receiving a specific  antipsychotic
      drug if the member is stabilized on that particular
 medication.  The MCP must continue to cover that specific
 drug for the  stabilized member for as long as that medication
      continues  to be  effective for the member.  MCPs may also
      implement a drug  utilization review program designed to promote the
      appropriate clinical  prescribing of antipsychotic drugs.  This
      can be accomplished  through the MCP’s retrospective analysis of drug
      claims to identify  potential inappropriate use and provide education to
      those providers  who are outliers to acceptable standards for
      prescribing/dispensing  antipsychotic drugs.

    

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

    

    Controlled
      Substances and Member Management Programs: MCPs  may also, with ODJFS prior
      approval, develop and implement  Controlled Substances and Member
      Management  (CSMM)  programs designed to address use of
      controlled substances. Utilization management strategies may include prior
      authorization  as a condition of obtaining a controlled substance, as
      defined in  section 3719.01 of the Ohio Revised Code.  CSMM
      strategies may also include processes for requiring MCP members at high risk
      for
      fraud or abuse involving controlled substances to have their narcotic
      medications prescribed by a designated provider/providers and filled by a
      pharmacy, medical provider, or health care facility designated by the
      program.

    

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

    

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

    

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

    

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

    

    b. Case
Management
      Programs

    

    In
      accordance with 5101:3-26-03.1(A)(8),
      MCPs must offer and provide comprehensive case management services which
      coordinate and monitor the care of members with  specific diagnoses,
      or who require high-cost and/or extensive services.  The MCP’s
      comprehensive case management program must also include a Children with Special
      Health Care Needs component as specified below.

    

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

    

    ii. Children
      with Special Health Care Needs
      (CSHCN):   

    

    CSHCN
      are a particularly vulnerable
      population which often have chronic and complex medical health care
      conditions.  In order to ensure
      compliance with the provisions of
      42 CFR 438.208, each MCP must establish a CSHCN component as part of the MCP’s
      comprehensive case management program.  The MCP must establish a
      process for the timely identification, completion of a comprehensive needs
      assessment, and providing appropriate and targeted case management services
      for
      any 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 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

    

     iii.     Comprehensive
      Case
      Management Program

      

    1. The
      MCP must have 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.

    

    2.  The
      MCP must assure and coordinate the placement of the member into case management
      – including identification of the member’s need for case management services,
      completion of the comprehensive health needs assessment, and timely development
      of a care treatment plan.  This process must occur within the
      following timeframes for:

    

      a)
      newly enrolled members, 90 days from the effective date of enrollment;
      and

    

      b)
      existing members, 90 days from identifying their need for case
      management.

     

    3.  The
      MCP’s comprehensive case management program must include, at a minimum, the following
      components:

      

    a. Identification

    The
      MCP must have a variety of
      mechanisms in place to identify members potentially eligible for case
      management.  These mechanisms must include an administrative data
      review (e.g., diagnosis, cost threshold, and/or service utilization)
and may include
      provider/self referrals, telephone interviews, information as reported by MCEC
      during membership selection, or home visits.

     

    b. Assessment

    The
      MCP must arrange for or conduct a
      comprehensive assessment of the member’s physical and/or behavioral health
      condition(s) to confirm the results of a positive identification, and determine
      the need for case management services.  The assessment must be
      completed by a physician, physician assistant, RN, LPN, licensed social worker,
      or a graduate of a two- or four-year allied health program.  If the
      assessment is completed by another medical professional, there should be
      oversight and monitoring by either a registered nurse or
      physician.

    

    For
      CSHCN, the comprehensive assessment
      must include, at a minimum, the use of the ODJFS
      CSHCN Standard
      Assessment Tool.

          

    c. Care
      Treatment
      Plan

    

     The
      care treatment plan is defined by ODJFS as the one  developed by the MCP
      for the member.  The development of   the care treatment
      plan must be based on the comprehensive  health assessment and reflect the
      member's primary medical  diagnosis and health conditions, any
      co-morbidities, and the  member's psychological, behavioral health and
      community  support needs.  The care treatment plan must also
      include  specific provisions for periodic reviews (i.e., no less than
      semi- annually) of the member's condition and appropriate updates  to
      the plan.  The member and the member's PCP must be actively involved
      in the development of and revisions to the  care treatment
      plan.  The designated PCP is the provider, or  specialist, who
      will manage and coordinate the overall care for  the
      member.  Ongoing communication regarding the status of  the care
      treatment plan may be accomplished between the MCP  and the PCP's designee
      (i.e., qualified health professional).   Revisions to the
      clinical portion of the care treatment plan  should be completed in
      consultation with the PCP.

    

     The
      elements of a comprehensive care treatment plan include:

      

     Goals
      and actions that address medical, social, behavioral and  psychological
      needs;

    

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

    

     Continuous
      review, revision and contact follow-up, as needed,  to insure the care
      treatment plan is adequately monitored  including the
      following:

    ·
Documentation
      that
      services are provided in accordance with the care treatment plan;

    ·
Re-evaluation
      to
      determine if the care treatment plan is adequate to meet the member's current
      needs;

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

    ·
A
      change in needs
      or status from the re-evaluation that requires revisions to the care treatment
      plan;

    ·
Active
      participation by the member or representative in the care treatment plan
      development;

    ·
Monitoring
      of
      specific service delivery including service utilization; and

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

    

    4.  Coordination
      of Care and
      Communication

    

    The
      MCP
      must provide case management services for:

    

    ·
all
      CSHCN,
      including the ODJFS mandated conditions as specified in Appendix M, Case
      Management Program Performance Measures;

    ·
all
      members
      enrolled in an MCP’s CSMM program as specified in Section G(3)(a)(i);
      and

    ·
adults
      whose health
      conditions warrant case management services.

    

    Case
      management services should not be limited only to members with the mandated
      conditions.

    

     There
      should be an accountable point of contact (i.e., case manager) who can help
      obtain medically necessary care, assist with health-related services and
      coordinate care needs.  The MCP must arrange or provide for professional
      case management services that are performed collaboratively by a team of
      professionals appropriate for the member’s condition and health care
      needs.  At a minimum, the MCP’s case manager must attempt to
      coordinate with the member’s case manager from other health systems, including
      behavioral health.  The MCP must have a process to facilitate,
      maintain, and coordinate communication between service providers, the member,
      and the member’s family.  The MCP must have a provision to disseminate
      information to the member/caregiver concerning the health condition, types
      of
      services that may be  available, and how to access the
      services.

    

     The
      MCP must implement mechanisms to notify all   Members with
      Special Health Care Needs of their right to  directly access a
      specialist.  Such access may be assured  through, for example, a
      standing referral or an approved  number of visits, and documented in the
      care treatment  plan.

    

     iv.  Case
      Management Strategies

    

    The
      MCPmust follow best-practice
      and/or
      evidence based clinical guidelines when developing a member’s care treatment
      plan and coordinating the case management needs. The MCP must develop and
      implement mechanisms to educate and equip providers and case managers with
      evidence-based clinical guidelines or best practice approaches to assist in
      providing a high level of quality of care to members.

    

    v.   Case
      Management Program
      Staffing

    

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

    

    vi.   Case
      Management Data
      Submission

    

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

    

    The
      CAMS files are due the
      10th
      business day of each
      month.

    

    The
MCP
      must also have
      an ODJFS-approved case
      management program which includes the items in Section
      3.b.  Each MCP
      should 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 program description must be submitted to ODJFS in writing for
      review and approval prior to implementation.

     

    c. Care
      Coordination with ODJFS-Designated
      Providers

    

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

    

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

    

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

    

    · Claims
      submission information including
      the MCP’s Medicaid provider number for each region;   

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

    · A
      picture of the MCP’s member
      identification card (front and back);

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

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

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

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

    

    d. Care
      coordination with Non-Contracting Providers

    

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

    

    e. Integration
      of Member
      Care

     

    The
      MCP must ensure that a discharge
      plan is in place to meet a member’s healthcare
      needs following discharge from a
      nursing facility, and integrated
      into the member’s continuum
      of care.   The discharge plan must address the services to be
      provided for the member and must be developed prior to the date of
      discharge from the
      nursing facility.   The MCP must ensure
      follow-up contact occurs with the
      member, or authorized representative, within thirty (30) days of the member’s
      discharge from
      the nursing facility to ensure that
      the member’s health care needs are  being
      met.

    
 

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    APPENDIX
      H

    

    PROVIDER
      PANEL SPECIFICATIONS

    CFC
      ELIGIBLE
      POPULATION

    

    

    1.
       GENERAL
      PROVISIONS

    

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

    

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

    

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

    

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

    

    2. PROVIDER
      SUBCONTRACTING

    

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

    

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

    

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

    

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

    

    3. PROVIDER
      PANEL REQUIREMENTS

    

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

    

    a. Primary
      Care
      Providers (PCPs)

    

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

     

    Each
      PCP must have the capacity and
      agree to serve at least 50 Medicaid members at each practice site in order
      to be
      approved by ODJFS as a PCP.  The 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 aprovider
      who can serve as a PCP for 2000
      Medicaid MCP members as one full-time equivalent(FTE).

    

    ODJFS
      reviews the capacity totals for
      each PCP to determine if they appear excessive. ODJFS
      reserves the right to request
      clarification from an MCP for any PCP whose total stated capacity
      for all MCP networks added
      together exceeds 2000 Medicaid members (i.e., 1 FTE). Where indicated,
      ODJFS may set a cap on the
      maximum amount of capacity that we will recognize for a specific
      PCP. ODJFS may allow up to an
      additional 750 member capacity for each nurse practitioner
      or physician’s assistant
      that is used to provide clinical support for a PCP.

    

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

    

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

          

    The
      PCP requirement is based on an MCP
      having sufficient PCP capacity to serve 40%
      of the eligibles in the region if
      three MCPs are serving the region and 55% of the eligibles in the region if
      two
      MCPs are serving the region. At
      a minimum, each MCP must meet both
      the PCP FTE requirement for that region, and a ratio of one PCP FTEfor each 2,000 of their
      Medicaid members
      in that region.  MCPs must also satisfy a PCP geographic accessibility
      standard. ODJFS will match the PCP practice sites and the stated PCP capacity
      with the geographic location of the eligible population in that region (on
      a
      county-specific basis) and perform analysis using Geographic Information Systems
      (GIS) software. The analysis will be used to determine if at least 40% of the
      eligible population is located within 10 miles of PCP with available capacity
      in
      urban counties and 40% of the eligible population within 30 miles of a PCP
      with
      available capacity in rural counties. [Rural areas are defined pursuant to
      42
      CFR 412.62(f)(1)(iii).]

     

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

    

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

    

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

    

    b. Non-PCP
      Provider
      Network

    

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

    

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

    

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

     

    Hospitals
      -
MCPs must contract with
      the
      number and type of hospitals specified by ODJFS for each county/region. In
      developing these hospital requirements, ODJFS considered, on a county-by-county
      basis, the population size and utilization patterns of the Covered Families
      and

    

    Children
      (CFC) consumers and integrated
      the existing utilization patterns into the hospital network requirements to
      avoid disruption of care.  For this reason, ODJFS may require that
      MCPs contract with out-of-state hospitals (i.e. Kentucky,
West
      Virginia, etc.).

    

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

    

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

    

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

    

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

    

    Only
      CNMs
      with hospital delivery privileges at a hospital under contract with the MCP
      in
      the region can be submitted to the PVS, or other system, count towards MCP
      minimum panel requirements, and be listed in the MCPs’ provider directory.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, or
      other designated process.  Even if no FQHC/RHC is
      available within the region, MCPs must have mechanisms in place to ensure
      coverage for FQHC/RHC services in the event that a member accesses these
      services outside of the region. 

    

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

    

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

    

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

    

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

    

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

    

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

    

    either
      Title X funding or family planning funding from the Ohio Department of
      Health.  MCPs must reimburse all medically-necessary
      Medicaid-covered  family planning services provided to eligible
      members by a QFPP provider (including on-site pharmacy
      and
      diagnostic services) on a patient self-referral
      basis, regardless of the
      provider’s status as a panel or non-panel provider.  MCPs will be
      required to work with QFPPs in the region to develop mutually-agreeable HIPAA
      compliant policies and procedures to preserve patient/provider confidentiality,
      and conveypertinent
      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 areadvised
      not to contract with community
      mental health centers as all services they provide to MCP members are to be
      billed to ODJFS.

    

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

    

    4. PROVIDER
      PANEL
      EXCEPTIONS

    

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

    

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

    

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

    

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

    

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

    

    ODJFS
      will aggressively monitor
access to all services
      related to the approvalof
      a provider
      panel exception request through
      a variety of data sources, including: consumer satisfaction
      surveys; member
      appeals/grievances/complaints and state hearingnotifications/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
      tothe
      services in question.  If
      ODJFS determines that an MCP has not provided sufficient access to these
      services, the MCP may be subject to sanctions.

    

    5. PROVIDER
      DIRECTORIES

    

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

    

    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 toeach printed
      directory that lists those
      providers deleted
from
      the MCP’s provider panel during the
      previous three months.  Althoughthis
      insert does not need to be prior
      approved by ODJFS, copies of the insert must be submitted to ODJFS two weeks
      prior to distribution to members.

    

    Internet
      Provider Directory

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

    

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

    

    6
      . FEDERAL ACCESS
      STANDARDS

    

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

    

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

    

    • The
      anticipated Medicaid membership.

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

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

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

    • 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.

    

    

     

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    WellCare

    

    APPENDIX
      J

    

    FINANCIAL
      PERFORMANCE

    CFC
      ELIGIBLE POPULATION

    

    1. SUBMISSION
      OF FINANCIAL STATEMENTS AND REPORTS

    

     MCPs
      must submit the following financial reports to ODJFS:

    

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

    

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

    

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

    

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

    

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

    

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

    

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

    

    h. Prompt
      Pay Reports, in accordance with OAC rule 5101:3-26-09(B). A hard copy and an
      electronic copy of the reports in the ODJFS-specified format must be provided
      to
      ODJFS;

    

    i. Notification
      of requests for information and copies of information released pursuant to
      a
      tort action (i.e., third party recovery), as outlined in OAC rule
      5101:3-26-09.1;

    

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

    

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

    

    

    2. FINANCIAL
      PERFORMANCE MEASURES AND STANDARDS

    

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

    

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

    

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

    

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

       

    Standard: For
      the
      financial report that covers calendar year 2008, a minimum net worth per member
      of $151.00, 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

    

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

    

    b. Indicator: Administrative
      Expense Ratio

    

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

    

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

    

     c. Indicator: Overall
      Expense
      Ratio

    

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

    

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

    

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

    

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

    

    Penalty
      for noncompliance:
      Failure to meet any standard on 2.a., 2.b., or 2.c. above will result in ODJFS
      requiring the MCP to complete a corrective action plan (CAP) and specifying
      the
      date by which compliance must be demonstrated.  Failure to meet the
      standard or otherwise comply with the CAP by the specified date will result
      in a
      new 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.
      

    

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

    

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

     

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

    

     d. Indicator: Days
      Cash on Hand

    

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

    

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

    

     e. Indicator: Ratio
      of Cash to Claims
      Payable

    

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

    

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

     

    3. REINSURANCE
      REQUIREMENTS

    

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

    

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

    

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

    

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

    

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

    

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

    

    c. the
      number of members covered by the MCP;

    

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

    

    e.   risk
      based capital ratio greater than 2.5 calculated from the last annual ODI
      financial statement.

    

    f.   scatter
      diagram or bar graph from the last calendar year that shows the number of
      reinsurance claims that exceeded the current
      reinsurance  deductible.

    

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

    

    Penalty
      for noncompliance: If
      it is determined that an MCP failed to have reinsurance coverage, that an MCP’s
      deductible exceeds $75,000.00 without approval from ODJFS, or that the MCP’s
      reinsurance for non-transplant services covers less than 80% of inpatient costs
      in excess of the deductible incurred by one member for one year without approval
      from ODJFS, then the MCP will be required to pay a monetary penalty to
      ODJFS.  The amount of the penalty will be the difference between the
      estimated amount, as determined by ODJFS, of what the MCP would have paid in
      premiums for the reinsurance policy if it had been in compliance and what the
      MCP did actually pay while it was out of compliance plus 5%.  For
      example, if the MCP paid $3,000,000.00 in premiums during the period of
      non-compliance and would have paid $5,000,000.00 if the requirements had been
      met, then the penalty would be $2,100,000.00.

    

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

    

    4. PROMPT
      PAY REQUIREMENTS

    

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

    

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

    

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

    

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

    

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

    

    5. PHYSICIAN
      INCENTIVE PLAN DISCLOSURE REQUIREMENTS

    

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

    

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

    

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

    

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

    

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

    

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

    

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

    

    6. NOTIFICATION
      OF REGULATORY ACTION

    

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

    

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

APPENDIX
      K

    
      

      QUALITY
        ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM

      AND

      EXTERNAL
        QUALITY REVIEW

      CFC
        ELIGIBLE POPULATION

      

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

       

      a.  PERFORMANCE
        IMPROVEMENT
        PROJECTS

      

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

      

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

      

      MCPs
        must
        initiate 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.

      

      b.    UNDER-
        AND
        OVER-UTILIZATION

      

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

      

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

      

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

      

      c.  SPECIAL
        HEALTH CARE
        NEEDS

      

      Each
        MCP
        must have mechanisms in place to assess the quality and appropriateness of
        care
        furnished to 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 (HEDIS) audited data for the
        following measures:

      

      i.  Well
        Child Visits in the First 15 Months
        of Life

      ii. Child
        Immunization
        Status

      

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

      

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

      

      e.   QAPI
        PROGRAM
        SUBMISSION

      

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

      

      2.  EXTERNAL
        QUALITY REVIEW

      

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

      

      a.  EQRO
        ADMINISTRATIVE
        REVIEWS

      

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

      

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

      

      b.  EXTERNAL
        QUALITY REVIEW
        PERFORMANCE

      

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

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      APPENDIX
        L

      

      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.  The following
        measures, as specified in this appendix, will be calculated per MCP and include
        all Ohio Medicaid members receiving services from the MCP (i.e., Covered
        Families and Children (CFC) and Aged, Blind, or Disabled (ABD) membership,
        if
        applicable):  Incomplete Outpatient Hospital Data, Rejected
        Encounters, Acceptance Rate, Encounter Data Accuracy, and Generic Provider
        Number Usage. 

      

      Data
        sets
        collected from MCPs with data quality standards include: encounter data;
        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.

      

      1.a.  Encounter
        Data Completeness

      

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

      

      1.a.i.
        Encounter Data Volume

      

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

      

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

      

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

       

      
        	
                Quarterly
                  Report
                  Periods

              	
                Data
                  Source:

                Estimated
                  Encounter  Data File Update

              	
                Quarterly
                  Report

                Estimated
                  Issue
                  Date

              	
                Contract
                  Period

              
	
                Qtr  3
                  &  Qtr
                  4  2004, 2005,
                  2006

                Qtr
                  1 2007

                
                

              	
                July2007

              	
                August2007

              	
                SFY2008

              
	
                Qtr3
&Qtr
                  4  2004,
2005,
                  2006

                Qtr
                  1, Qtr 2
                  2007

              	
                October
2007

              	
                November
2007

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

              	
                January
2008

              	
                February
2008

              
	
                
                

                Qtr
                  1 thru Qtr 4: 2005, 2006,
                  2007

              	
                April  2008

              	
                May
                  2008

              
	
                Qtr
                  2 thru Qtr 4
                  2005,

                Qtr
                  1 thru Qtr 4: 2006,
                  2007

                Qtr
                  1 2008

              	
                July
                  2008

              	
                August
                  2008

              	
                SFY
                  2009

              
	
                Qtr
                  3, Qtr 4:
                  2005,

                Qtr
                  1 thru Qtr 4: 2006,
                  2007

                Qtr
                  1, Qtr 2
                  2008

              	
                October  2008

              	
                November  2008

              
	
                Qtr
                  4: 2005,

                Qtr
                  1 thru Qtr 4: 2006,
                  2007

                Qtr
                  1 thru Qtr 3:
                  2008

              	
                January  2009

              	
                February  2009

              
	
                
                

                Qtr
                  1 thru Qtr 4: 2006, 2007,
                  2008

              	
                April  2009

              	
                May  2009

              

      

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

      

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

      

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

      

      
        	
                Category

              	
                Measure
                  per 1,000/MM

              	
                Standard
                  for Dates of Service

                7/1/2003
thru
                  6/30/2004

              	
                Standard
                  for Dates of Service

                7/1/2004thru
                  6/30/2006

              	
                Standard
                  for Dates of
                  Service

                on
                  or after
                  7/1/2006

              	
                Description

              
	
                Inpatient
                  Hospital

              	
                Discharges

              	
                5.4

              	
                5.0

              	
                5.4

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

              
	
                Emergency
                  Department

              	
                Visits

              	
                51.6

              	
                51.4

              	
                50.7

              	
                Includes
                  physician and hospital emergency department encounters

              
	
                Dental

              	
                38.2

              	
                41.7

              	
                50.9

              	
                Non-institutional
                  and hospital dental visits

              
	
                Vision

              	
                11.6

              	
                11.6

              	
                10.6

              	
                Non-institutional
                  and hospital outpatient optometry and ophthalmology
                  visits

              
	
                Primary
                  and Specialist Care

              	
                220.1

              	
                225.7

              	
                233.2

              	
                Physician/practitioner
                  and hospital outpatient visits

              
	
                Ancillary
                  Services

              	
                144.7

              	
                123.0

              	
                133.6

              	
                Ancillary
                  visits

              
	
                Behavioral
                  Health

              	
                Service

              	
                7.6

              	
                8.6

              	
                10.5

              	
                Inpatient
                  and outpatient behavioral encounters

              
	
                Pharmacy

              	
                Prescriptions

              	
                388.5

              	
                457.6

              	
                492.2

              	
                Prescribed
                  drugs

              

      

      

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

      

      Interim
        Regional-Based
        Approach:

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

      

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

      

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

      

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

      

      
        	
                Category

              	
                Measure
                  per 1,000/MM

              	
                Standard
                  for Dates of
                  Service

                on
                  or after
                  7/1/2006

              	
                Description

              
	
                Inpatient
                  Hospital

              	
                Discharges

              	
                2.7

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

              
	
                Emergency
                  Department

              	
                Visits

              	
                25.3

              	
                Includes
                  physician and hospital emergency department encounters

              
	
                Dental

              	
                25.5

              	
                Non-institutional
                  and hospital dental visits

              
	
                Vision

              	
                5.3

              	
                Non-institutional
                  and hospital outpatient optometry and ophthalmology
                  visits

              
	
                Primary
                  and Specialist Care

              	
                116.6

              	
                Physician/practitioner
                  and hospital outpatient visits

              
	
                Ancillary
                  Services

              	
                66.8

              	
                Ancillary
                  visits

              
	
                Behavioral
                  Health

              	
                Service

              	
                5.2

              	
                Inpatient
                  and outpatient behavioral encounters

              
	
                Pharmacy

              	
                Prescriptions

              	
                246.1

              	
                Prescribed
                  drugs

              

      

      

      

      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.

      

      1.a.ii.
        Incomplete Outpatient Hospital Data

      

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

      

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

      

      Report
        Period:  For
        the SFY 2008
        and SFY 2009 contractperiods,
        performance will be evaluated
        using the report periods listed in
        1.a.i., Table 1.

      

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

      

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

      

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

      

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

       

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

      

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

      

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

      

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

      

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

      

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

      

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

      

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

      

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

      

      1.a.iv.
        Rejected Encounters

      

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

      

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

      

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

      

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

      

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

      

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

      

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

      

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

      

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

      

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

      

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

      

      
        	
                Third
                  through sixth months with
                  membership:         50%

              	
                 

              
	
                Seventh
                  through twelfth month with
                  membership:  25%

              	
                 

              

      

      

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

      

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

      

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

      

      1.a.v.
        Acceptance Rate

      

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

      

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

      

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

      

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

      

      
        	
                Third
                  through sixth month with
                  membership:

              	
                50
                  encounters per 1,000 MM for
                  NCPDP

              
	 	
                65
                  encounters per 1,000 MM for
                  NSF

              
	 	
                20
                  encounters per 1,000 MM for
                  UB-92

              
	 	 
	
                Seventh
                  through twelfth month of
                  membership:

              	
                250
                  encounters per 1,000 MM for
                  NCPDP

              
	 	
                350
                  encounters per 1,000 MM for
                  NSF

              
	 	
                100
                  encounters per 1,000 MM for
                  UB-92

              

      

      

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

      

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

      

      1.b.  Encounter
        Data
        Accuracy

      

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

      

      1.b.i.  Encounter
        Data
        Accuracy Studies

      

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

      

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

      

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

      

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

      

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

      

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

      

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

      

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

      

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

      

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

      

      Data
Quality
        Standard for
        Measure 2:   TBD
        for SFY 2008 and SFY 2009 based on study conducted in SFY 2007 (standard
        to be
        released in June, 2007).

      

      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.

      

      1.b.ii.  Generic
        Provider Number Usage

      

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

      

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

      

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

      

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

      

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

      

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

      

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

      

      1.c.
        Timely Submission of Encounter Data

      

      1.c.i.  Timeliness

      

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

      

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

      

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

      

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

      
         

        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 for Case
        Management
        Data Quality Measures.

      

      2.a.   Case
        Management System Data Accuracy

      

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

      

      Measure:  The
        percentage of the MCP’s 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 third and fourth
        quarters
        of  SFY 2007, January – March 2007, and April – June 2007 report
        periods.  For the SFY 2008 contract period,  July –
September 2007, and October – December 2007.

      

      Statewide
        and
        Regional 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.

      

      For
        any MCP which
        did not have membership as of
        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
        for
        noncompliance:   If an MCP is noncompliant with the
        standard, then the ODJFS will issue a Sanction Advisory informing the MCP
        that a
        monetary sanction will be imposed if the MCP is noncompliant for any future
        report periods.  Upon all subsequent semi-annual measurements of
performance,
        if an MCP is again determined to be noncompliant with the standard, ODJFS
        will
        impose a monetary sanction of one-half of one percent of the current month’s
        premium payment. Once the MCP is performing at standard levels and
        violations/deficiencies are resolved to the satisfaction of ODJFS, the money
        will be refunded.

      

      2.b.  Timely
        Submission of Case Management Files

      

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

      

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

      
         

        3.
          EXTERNAL QUALITY REVIEW DATA 

      

       

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

       

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

      

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

      

      3.a.
        Independent External Quality Review

      

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

      

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

      

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

      

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

      

      4.  MEMBERS’
        PCP DATA

      

      The
        designated PCP is the
provider who
        will manage and coordinate the
        overall care for 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 per the
        specialty types specified for the CFC population in ODJFS Member’s
        PCP Data
        File and Submission Specifications; however, no CFC member
        may have more
        than one PCP identified for a given month.

      

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

      

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

      

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

      

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

      

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

      

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

      

      Data
        Quality
        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 one
        and
        quarter two of SFY 2008.

      

      Statewide
        Approach:  MCPs
        will be evaluated using a statewide result, including all active regions
        and counties (Mahoning and Trumbull) 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
provider (PCP) prior to their effective date of
        coverage.  Therefore, MCPs are subject to additional corrective action
        measures under Appendix N, Compliance Assessment System, for failure to meet
        this requirement.

      

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

      

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

      

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

      

      

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

      

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

      

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

      

      5.
        APPEALS AND GRIEVANCES DATA

      

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

      

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

      

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

      

      6.  NOTES

      

      
        	
                6.a.

              	
                Penalties,
                  Including Monetary
                  Sanctions, for Noncompliance

              

      

      

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

      

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

      

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

      

      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.

      

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

      

      The
        statewide approach will be implemented beginning January 1, 2008.  Due
        to differences in data and reporting requirements, transition to statewide
        measurement will vary by performance measure. Given that the original intent
        of
        the SFY 2007 and SFY 2008
        Covered Families and Children Provider Agreements, Appendix M, was to
        transition to a regional-based system of evaluation, several performance
        measures have used regional-based results for performance monitoring.
        Regional-based performance monitoring will be discontinued for all measures
        in
        Appendix M for report periods from January, 2008 onward.  Unless
        otherwise noted, performance measures and standards (see Sections 1, 2, 3
        and 4
        of this appendix) will be applicable for all counties in which the MCP has
        membership as of February 1, 2006, until statewide measurement is
        implemented.

      

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

      

      1.  QUALITY
        OF CARE

      

      1.a.
        Independent External Quality
        Review

      

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

      

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

      

      Report
        Period:  Performance
        will be evaluated using the reviews conducted during SFY2008.

      

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

      

      1.b.  Children
        with Special Health Care Needs (CSHCN)

      

      In
        order
        to ensure state compliance with  the provisions of 42 CFR 438.208, the
        Bureau of Managed Health Care established Children with 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.

      

      1.b.i.
        Case Management
        of Children (applicable
        to performance
        evaluation through December 2007 and P4P through SFY 2009)

      

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

      

      Report
        Period:For the SFY 2007
        contract period, January – March 2007, and April – June 2007 report
        periods.  For the SFY 2008 contract period,  July –
September 2007, and October
–
December
        2007 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 anactive
        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 Clark 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
        Clark counties will remain in the county-based statewide result for evaluation
        of MCP AAA until the West Central regional-based approach is
        implemented.]  The last report period using the MCP’s
        county-based statewide result for the counties in which the MCP had membership
        as of  February 1, 2006 for P4P (Appendix O) is April-June
        2009.

      

      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.

      

      County
        and
        Regional-Based Minimum
        Performance
        Standard: For
        the third and fourth quarters of SFY
        2007, a case management rate of 5.0%.  For the
        first and second
        quarters of SFY
        2008, a case management
        rate of
        5.0%.

      

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

      

      1.b.ii.
        Case Management of Children
(applicable to
        performance evaluation as of  January, 2008)

      

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

      

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

      

      Regional-Based
        Statewide
        Approach:  Performance will be evaluated using a regional-based
        statewide approach for all active regions and counties (Mahoning and Trumbull)
        in which the MCP has membership.

      

      Regional-Based
        Statewide
        Target:  For the third and fourth quarters of SFY 2008, a case
        management rate of 5.0%.  For SFY 2009, a case management rate of
        5.0%.

      

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

      

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

      

      1.b.iii.
        Case Management
        of
        Children with an ODJFS-Mandated Condition (applicable
        to performance
        evaluation through December 2007)

      

      Measure
        1:  The percent
        of  children under 21 years of age with a positive identification
        through an ODJFS administrative review of data for the ODJFS-mandated case
        management condition of  asthma
        that are case
        managed.

      

      Measure
        2:  The percent
        of  children age 17 and under with a positive identification through
        an ODJFS administrative review of data for the ODJFS-mandated case management
        condition of teenage
        pregnancy that are case
        managed.

      

      Measure
        3:  The percent
        of  children under 21 years of age with a positive identification
        through an ODJFS administrative review of data for the ODJFS-mandated case
        management condition of HIV/AIDS
        that are case
        managed.

      

      Report
        Periods for
        Measures 1, 2, and 3: For
        the SFY 2007 contract period,
        January – March 2007, and April – June 2007 report periods.  For the
        SFY 2008 contract period, and July
–
September
        2007, October –
December 2007 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 membershipas 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’sregion, 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 Clark 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, Franklinnd
        Pickaway counties, along with all
        other counties in the region, will then be included in the Central region
        results for MCP AAA;
        Montgomery, Greene, and Clark counties will remain in the county-based statewide
        result for evaluation of MCP AAA until the West Central regional-based approach
        is implemented.]

      

      Regional-Based
        Approach: MCPs will be
        evaluated by region, using results for all counties included in the
        region.  Performance will begin to be evaluated using regional-based
        results for any active region  in which all selected MCPs had at least
        10,000 members during each month of the entire report
        period.

      

      County
        and
        Regional-Based Minimum
        Performance
        Standard for Measures 1 and 3: For the third and fourth
quarters
        of SFY 2007, a case management rate of 70%.  For the first and second
        quarters of SFY 2008, a case management rate of 70%.

      

      County
        and Regional-Based Minimum Performance Standard for Measure 2: For the third
        and
        fourth quarters of SFY 2007, a case management rate of 60%.  For the
        first and second quarters of SFY 2008, a case management rate of
        60%.

      

      Penalty
        for
        Noncompliance for Measures 1 and 2:  The first time an MCP
        is
        noncompliant with a standard for this measure, ODJFS will issue a Sanction
        Advisory informing the MCP that any future noncompliance instances with the
        standard for this measure will result in ODJFS imposing a monetary
        sanction.  Upon all subsequent measurements of performance, if an MCP
        is again determined to be noncompliant with the standard, ODJFS will impose
        a
        monetary sanction (see Section 5) of two percent of the current month’s premium
        payment. Monetary sanctions will not be levied for consecutive quarters that
        an
        MCP is determined to be noncompliant.  If an MCP is noncompliant for a
        subsequent quarter, new member selection freezes or a reduction of assignments
        will occur as outlined in Appendix N of the Provider Agreement.  Once the MCP is determined
        to be compliant with the standard and the violations/deficiencies are resolved
        to the satisfaction of ODJFS, the
        penalties will be lifted, if
        applicable, and monetary sanctions will be
        returned.  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 SFY 2008, measure 3 is a
        reporting-only measure.

      

      1.b.iv.
        Case Management of Children
        with an ODJFS-Mandated Condition (applicable
        to performance
        evaluation as of  January 2008)

      

      Measure
        1:  The
        percent of  children under 21 years of age with a positive
        identification through an ODJFS administrative review of data for the
        ODJFS-mandated case management condition of  asthma that are case
        managed.

      Measure
        2:  The
        percent of  children 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  and 2:   For the SFY 2008 contract period,
        January – March 2008, and April – June 2008 report periods.  For the
        SFY 2009 contract period,  July – September 2008, October – December
        2008, January – March 2009, and April – June 2009 report periods.

      

      Regional-Based
        Statewide Approach:
Performance will be evaluated using a regional-based statewide approach
        for all active regions and counties (Mahoning and Trumbull) in which the
        MCP has
        membership.

      

      Regional-Based
        Statewide Target for
        Measures 1 and 2:  For the third and fourth quarters of SFY
        2008, a case management rate of 70%.  For SFY 2009, a case management
        rate of 80%.

      

      Regional-Based
        Statewide Minimum
        Performance Standard for Measures 1 and  2:  The
        level of improvement must result in at least a 20% decrease in the difference
        between the target and the previous report period’s results.

      

      Penalty
        for Noncompliance for
        Measure  1:  The first time an MCP is noncompliant
        with a standard for this measure, ODJFS will issue a Sanction Advisory informing
        the MCP that any future noncompliance instances with the standard for this
        measure will result in ODJFS imposing a monetary sanction.  Upon all
        subsequent measurements of performance, if an MCP is again determined to
        be
        noncompliant with the standard, ODJFS will impose a monetary sanction (see
        Section 5) of two percent of the current month’s premium payment. Monetary
        sanctions will not be levied for consecutive quarters that an MCP is determined
        to be noncompliant.  If an MCP is noncompliant for a subsequent
        quarter, new member selection freezes or a reduction of assignments will
        occur
        as outlined in Appendix N of the Provider Agreement.  Once the MCP is
        determined to be compliant with the standard and the violations/deficiencies
        are
        resolved to the satisfaction of ODJFS, the penalties will be lifted, if
        applicable, and monetary sanctions will be returned. For SFY 2008 and SFY
        2009,
        measure 2 is a reporting-only measure.

      

      1.c.
        Clinical Performance
        Measures

      

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

      

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

      

      For
        an MCP which had membership as
        of February 1, 2006: MCP performance will be evaluated using an MCP’s
        county-based statewide result for the counties in which the MCP had membership
        as of February 1, 2006.  For reporting periods CY 2007 and CY 2008,
        targets and performance standards for Clinical Performance Measures
        in
        this Appendix (1.c.i – 1.c.vii) will be applicable to all counties in
        which MCPs had membership as of February 1, 2006.  The final reporting
        year for 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 1,
        2006:  Performance will be evaluated using a regional-based
        statewide approach for all active regions and counties (Trumbull and Mahoning)
        in which the MCP has membership.

      

      Regional-Based
        Statewide
        Approach: MCPs will be evaluated statewide, using results for all active
        regions and counties (Mahoning and Trumbull) in which the MCP has
        membership.

      

      For
        measures requiring one year of baseline data, ODJFS will use the first full
        calendar year of data (CY 2007 - which may be adjusted based on the number
        of
        months of managed care membership) from all MCPs serving CFC membership to
        determine statewide minimum performance standards.  CY 2008 will be
        the first reporting year that MCPs will be held accountable to the statewide
        performance standards for one year measures, and penalties will be applied
        for
        noncompliance.

      

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

      

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

      

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

      

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

      

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

      

      County-Based
        Statewide
        Target:  At
        least 80% of the eligible
        population must receive 81% or more of the expected number of prenatal
        visits.

      

      County-Based
        Statewide Minimum
        Performance Standard:  The level of improvement must result in
        at least a 10% 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.)

      

      Regional-Based
        Statewide
        Target:  TBD

      

      Regional-Based
        Statewide Minimum
        Performance Standard:  TBD

      

      Action
        Required for
        Noncompliance:  Beginning
        SFY
        2007, if
        the standard is not met and the results
        are below 42% (44% for SFY 2009), the MCP is required to complete a
Corrective Action Plan to
        address the area of noncompliance.  If the standard is not met and the
        results are at or above 42% (44% for SFY 2009), ODJFS will issue a Quality
        Improvement Directive which will notify the MCP of noncompliance and may
        outline
        the steps that the MCP must take to improve the results.

      

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

      

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

      

      County-Based
        Statewide Target:
At least 90% of the eligible population initiate prenatal care within
        the
        specified time.

      

      County-Based  Statewide
        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.

      

      Regional-Based
        Statewide
        Target:  TBD

      

      Regional-Based
        Statewide Minimum
        Performance Standard:  TBD

      

      Action
        Required for
        Noncompliance:  Beginning SFY 2007, 
        if the standard is not
        met and the
        results are below 71% (74% for SFY 2009), the MCP is required to complete
        a Corrective Action Plan to address the area of noncompliance. If the standard
        is not met and the results are at or above 71% (74% for SFY 2009), ODJFS
        will
        issue a Quality Improvement Directive which will notify the MCP of noncompliance
        and may outline the steps that the MCP must take to improve the
        results.

      

      1.c.iii.  Perinatal
        Care - Postpartum Care

      

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

      

      County-Based Statewide
        Target: At least
        80% of the eligible population must receive a postpartum visit.

      

      County-Based
        Statewide Minimum
Performance
        Standard: The
        level of improvement must result in
        at least a 5% decrease in the difference between the target and the previous
        year’s results.

      

      Regional-Based
        Statewide
        Target:  TBD

      

      Regional-Based
        Statewide Minimum
        Performance Standard:  TBD

      

      Action
        Required for Noncompliance:
Beginning SFY 2007,  if the standard
        is not
        met and the results are below 48% (50% for SFY 2009), the MCP is required
        to
        complete a Corrective Action Plan to address the area of noncompliance. If
        the
        standard is not met and the results are at or above 48% (50% for SFY 2009),
        ODJFS will issue a Quality Improvement Directive which will notify the MCP
        of
        noncompliance and may outline the steps that the MCP must take to improve the
        results.

      

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

      

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

      

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

      

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

      

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

      

      County-Based
        Statewide
        Target:  At least 80% of the eligible children receive the
        expected number of well-child visits.

      

      County-Based  Statewide
        Minimum Performance Standard for Each of the Age Groups:  The
        level of improvement must result in at least a 10% decrease in the difference
        between the target and the previous year’s results.

      

      Regional-Based
        Statewide
        Target:  TBD

      

      Regional-Based
        Statewide Minimum
        Performance Standard for Each of the Age
        Groups:  TBD

      

      Action
        Required for Noncompliance
        (15 month old age group):  Beginning SFY 2007,  if
        the standard is not met and the results are below 34% (42% for SFY 2009),
        the
        MCP is required to complete a Corrective Action Plan to address the area
        of
        noncompliance. If the standard is not met and the results are at or above
        34%
        (42% for SFY 2009), ODJFS will issue a Quality Improvement Directive which
        will
        notify the MCP of noncompliance and may outline the steps that the MCP must
        take
        to improve the results.

      

      Action
        Required for
Noncompliance (3-6
        year
        old age group):  Beginning SFY 2007,  if the standard
        is not met and the results are below 50% (57% for SFY 2009), the MCP is required
        to complete a Corrective Action Plan to address the area of noncompliance.
        If
        the standard is not met and the results are at or above 50% (57% for SFY
        2009),
        ODJFS will issue a Quality Improvement Directive which will notify the MCP
        of
        noncompliance and may outline the steps that the MCP must take to improve
        the
        results.

      

      Action
        Required
for
        Noncompliance (12-21
        year old age group):  Beginning SFY 2007, if the standard is
        not met and the results are below 30% (33% for SFY 2009), the MCP is required
        to
        complete a Corrective Action Plan to address the area of noncompliance. If
        the
        standard is not met and the results are at or above 30% (33% for SFY 2009),
        ODJFS will issue a Quality Improvement Directive which will notify the MCP
        of
        noncompliance and may outline the steps that the MCP must take to improve
        the
        results.

      

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

      

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

      

      County-Based
        Statewide
        Target: At least 95% of the eligible population must receive the
        recommended medications.

      

      County-Based
        Statewide Minimum
        Performance Standard: The level of improvement must result in at least a
        10% decrease in the difference between the target and the previous year’s
        results.

      

      Regional-Based
        Statewide
        Target:  TBD

      

      Regional-Based
        Statewide Minimum
        Performance Standard:  TBD

      

      Action
        Required for Noncompliance:
Beginning SFY 2007,  if the standard
        is not
        met and the results are below 83% (84% for SFY 2009), the MCP is required
        to
        complete a Corrective Action Plan to address the area of noncompliance. If
        the
        standard is not met and the results are at or above 83% (84% for SFY 2009),
        ODJFS will issue a Quality Improvement Directive which will notify the MCP
        of
        noncompliance and may outline the steps that the MCP must take to improve
        the
        results.

      

      1.c.vi.  Annual
        Dental Visits

      

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

      

      County-Based
        Statewide
        Target:At
        least 60% of the eligible population
        receive a dental visit.

      

      County-Based
        Statewide 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.

      

      Regional-Based
        Statewide
        Target:  TBD

      

      Regional-Based
        Statewide Minimum
        Performance Standard:  TBD

      

      Action
        Required for
        Noncompliance:  Beginning SFY 2007,  if the standard
        is not met and the results are below 40% (42% for SFY 2009), the MCP is required
        to complete a Corrective Action Plan to address the area of noncompliance.
        If
        the standard is not met and the results are at or above 40% (42% for SFY
        2009),
        ODJFS will issue a Quality Improvement Directive which will notify the MCP
        of
        noncompliance and may outline the steps that the MCP must take to improve
        the
        results.

      

      1.c.vii.  Lead
        Screening

      

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

      

      County-Based
        Statewide
        Target: At least 80% of the eligible population receive a blood lead
        screening.

      

      County-Based
        Statewide Minimum
        Performance Standard for Each of the Age Groups: The level of improvement
        must result in at least a 10% decrease in the difference between the target
        and
        the previous year’s results.

      

      Regional-Based
        Statewide
        Target:  TBD

      

      Regional-Based
        Statewide Minimum
        Performance Standard for Each of the Age
        Groups:  TBD

      

      Action
        Required for Noncompliance (1
        year olds): Beginning SFY 2007,  if the standard is not met and
        the results are below 45% the MCP is required to complete a Corrective Action
        Plan to address the area of noncompliance. If the standard is not met and
        the
        results are at or above 45%, ODJFS will issue a Quality Improvement Directive
        which will notify the MCP of noncompliance and may outline the steps that
        the
        MCP must take to improve the results.

      

      Action
        Required for Noncompliance (2
        year olds): Beginning SFY 2007, if the standard is not met and the
        results are below  28% the MCP is required to complete a Corrective
        Action Plan to address the area of noncompliance.  If the standard is
        not met and the results are at or above 28%, ODJFS will issue a Quality
        Improvement Directive which will notify the MCP of noncompliance and may
        outline
        the steps that the MCP must take to improve the results.

      

      2.  ACCESS

      

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

      

      2.a.
        PCP Turnover

      

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

      

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

      

      For
        an MCP which had membership as
        of February1, 2006:
MCP performance
        will be evaluated using an MCP’s county-based statewide
        result for the counties in which the MCP had membership as
        of  February 1, 2006.  The minimum performance standard in
        this Appendix (2.a)
        will be applicable to the MCP’s county-based statewide result for the counties
        in which the MCP had membership as of February 1, 2006.  The last
        reporting year using  the MCP’s county-based statewide result for the
        counties in which the MCP had membership as of February 1, 2006 for performance
        evaluation is CY 2007; the last reporting year using the MCP’s county-based
        statewide result for the counties in which the MCP had membership as of February
        1, 2006 for P4P (Appendix
        O) is CY 2008.

      

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

      

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

      

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

      

      County-Based
        Statewide Minimum
        Performance Standard:  A maximum PCP Turnover rate of
        18%.

      Regional-Based
        Statewide Minimum
        Performance Standard:  TBD

      

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

      

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

      

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

      

      Regional-Based
        Statewide
        Approach: MCPs will be evaluated statewide, using results for all active
        regions and counties (Mahoning and Trumbull) in which the MCP has membership.
        ODJFS will use the first two full calendar years of data (CY 2007 and CY
        2008 -
        which may be adjusted based on the number of months of managed care
        membership)  from all MCPs serving CFC membership as a
        baseline  to determine a statewide minimum performance
        standard.  CY 2009 will be the first reporting year that MCPs will be
        held accountable to the statewide performance standard for statewide reporting,
        and penalties will be applied for noncompliance.  Statewide
        performance measure results will be calculated after a sufficient amount
        of time
        has passed after the end of the report period in order to allow for claims
        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
        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.  For the SFY 2009 contract period, performance will be
        evaluated using the January - December 2008 report period.

      

      County-Based Statewide
        Minimum Performance
        Standards:

      

      CY
        2006
        report period – 70% of children must receive a visit.

      CY
        2007 report period – 71% of children
        must receive a visit

      CY
        2008
        report period – 74% of children must receive a visit

      

      Regional-Based
        Statewide Minimum Performance Standards: TBD

      

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

      

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

      

      This
        measure indicates whether adult members are accessing health
        services.

      

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

      

      For
        an MCP which had membership as
        of February1, 2006:
MCP performance
        will be evaluated using an MCP’s county-based statewide
        result for the counties in which the MCP had membership as of February 1,
        2006.  The minimum performance standard in this Appendix (2.c) will be
        applicable to the MCP’s county-based statewide result for the counties in which
        the MCP had membership as of  February 1, 2006.  The last
        reporting year using  the MCP’s county-based statewide result for the
        counties in which the MCP had membership as of February 1, 2006 for performance
        evaluation is CY 2007; the last reporting year using the MCP’s county-based
        statewide result for the counties in which the MCP had membership as
        of  February 1, 2006 for P4P (Appendix
        O) is CY 2008.

      

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

      

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

      

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

      

      County-Based
        Statewide Minimum
        Performance Standards:

      CY
        2006
        report period – 63% of adults must receive a visit.

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

      CY
        2008
        report period – 63% of adults must receive a visit.

      

      Regional-Based
        Statewide Minimum Performance Standards: TBD

      

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

      

      2.d.
        Members’ Access to Designated PCP

      

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

      

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

      

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

      

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

      

      Regional-Based
        Statewide Minimum
        Performance Standard:
        TBD

      

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

      

      3.
        CONSUMER SATISFACTION

      

      In
        accordance with federal requirements
        and in the interest of assessing enrollee satisfaction with MCP performance,
        ODJFS annually conducts
        independent consumer
        satisfaction surveys. Results are used to assist in identifying and correcting
        MCP performance overall and in the areas of access, quality of care, and
        member
        services.  For
        SFY 2007 and SFY 2008, performance in this
        category will be
        determined by the overall satisfaction score.  For a comprehensive
        description of the Consumer
        Satisfaction performance measure below, see ODJFS
        Methods for the Consumer
        Satisfaction Performance Measure for the CFC Program.

      

      Measure: Overall
        Satisfaction
        with MCP: The average
        rating of the respondents to the Consumer Satisfaction Survey who were asked
        to
        rate their overall satisfaction with their MCP.  The results of this
        measure are reported annually.

      

      For
        an MCP which had membership as
        of February 1, 2006: MCP performance will be evaluated using an MCP’s
        county-based statewide result for the counties in which the MCP had membership
        as of February 1, 2006.  The minimum performance standard in this
Appendix (3.) will be
        applicable to the MCP’s county-based statewide result for the counties in which
        the MCP had membership as of February 1, 2006.   For performance
        evaluation, the last year to use the county-based statewide approach for
        the
        counties in which the MCP had membership as of February 1, 2006 will be SFY
        2008, using CY 2008 data.  For P4P  (Appendix O),  the
        last year to use the county-based statewide approach for the counties in
        which
        the MCP had membership as of February 1, 2006 will be SFY 2009, using CY
        2009
        data.

      

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

      

      Regional-Based
        Statewide Approach:
MCPs will be evaluated statewide, using results for all active regions
        and counties (Mahoning and Trumbull) in which the MCP has
        membership.  ODJFS will use the first full calendar year of data (CY
        2008 adult and child survey results) from all MCPs serving CFC membership
        as a
        baseline to establish a measure and determine a minimum statewide performance
        standard.  For performance evaluation, the first year to use the
        statewide regional-based approach will be SFY 2009, using CY 2009
        data.  For P4P  (Appendix O),  the first year to
        use the statewide regional-based approach will be SFY 2010, using CY 2010
        data.

      

      Report
        Period: For the SFY
        2007
        contract period, performance will be evaluated using the results from the
        CY
        2007 consumer satisfaction survey.   For the SFY 2008 contract
        period, performance will be evaluated using the results from the CY 2008
        consumer satisfaction survey.  For the SFY 2009 contract period,
        performance will be evaluated using the results from the CY 2009 consumer
        satisfaction survey.

      

      County-Based
        Statewide Minimum Performance
        Standard:  An average score of no less than 7.0.

      

      Regional-Based
        Statewide Minimum Performance Standard: TBD

      

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

       

      4.
        ADMINISTRATIVE
        CAPACITY

      

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

      

      4.a.
        Compliance Assessment
        System 

      

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

      

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

      

      Performance
        Standard: A
        maximum of 15
points

      

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

      

      4.b. Emergency
        Department
        Diversion (applicable
        to performance
        evaluation through  SFY  2008 and P4P through SFY
        2007)

      

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

      

      Measure: The
        percentage of members who
        had four or more ED visits during
        the six month reporting period.

      

      For
        an MCP
which
        had membership as of February 1,
        2006:
MCP performance will
        be
        evaluated using an MCP’s county-based statewide result for the counties
        in which the MCP had membership as of February 1, 2006.  The minimum
        performance standard and the target in this Appendix (4.b) will be
        applicable to the MCP’s county-based statewide result for the counties in which
        the MCP had membership as of  February 1, 2006.  The last
        reporting period using  the MCP’s county-based statewide result for
        the counties in which the MCP had membership as of February 1, 2006 for
        performance evaluation is July-December 2007; the last reporting period using
        the MCP’s county-based statewide result for the counties in which the MCP had
        membership as of February 1, 2006 for P4P (Appendix O) is July-December
        2006.

       

      Report
        Period:  For
        the SFY 2007 contract period, a baseline level of performance will be set
        using
        the January - June 2006 report period.  Results will be calculated for
        the reporting period of July - December 2006 and compared to the baseline
        results to determine if the minimum performance standard is met. For the
        SFY
        2008 contract period, a baseline level of performance will be set using the
        January - June 2007 report period.  Results will be calculated for the
        reporting period of July - December 2007 and compared to the baseline results
        to
        determine if the minimum performance standard is met

      

      County-Based  Statewide
        Target:
A maximum of  0.70% of the eligible population will have four
        or more ED visits during the reporting period.

      

      County-Based
        Statewide Minimum
        Performance Standard: The level of improvement must result in at least a
        10% decrease in the difference between the target and the baseline period
        results.

      

      Penalty
        for
        Noncompliance:  If the standard is not met and the results are
        above 1.1%, then the MCP must develop a corrective action plan, for which
        ODJFS
        may direct the MCP to develop the components of their EDD program as specified
        by ODJFS.  If the standard is not met and the results are at or below
        1.1%, then the MCP must develop a Quality Improvement Directive.

      

      4.b.i.
        Emergency Department Diversion
(applicable to
        performance evaluation as of SFY 2009)

      

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

      

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

      

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

      

      Report
        Period: For the SFY
        2009 contract period, January – December 2008.

      

      Regional-Based
        Statewide Target:
A maximum of  TBD of the eligible population will have TBD or
        more targeted ED visits during the reporting period.

      

      Regional-Based
        Statewide Minimum
        Performance Standard: The level of improvement must result in at least a
        TBD decrease in the difference between the target and the baseline period
        results.

      

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

      

      5.
        NOTES

      

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

      

      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 of compliance, as determined in this appendix, will not exceed
        $250,000.

      

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

      

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

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      APPENDIX
        N

      

      COMPLIANCE
        ASSESSMENT SYSTEM 

      CFC
        ELIGIBLE POPULATION

      

      

      I.
        General Provisions of the Compliance Assessment System

      

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

      

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

      

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

      

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

      

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

      

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

      

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

      

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

      

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

      

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

      

      II.
        Types of Sanctions/Remedial Actions

      

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

      

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

      

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

      

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

      

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

      

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

      

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

      

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

      

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

      

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

      

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

      

      C.1.5
        Points -- Failures
        to meet program requirements, including but not limited to, actions which  could impair the member’s
        ability to obtain correct information
        regarding services or which could
        impair a consumer’s or member’s rights, as determined by ODJFS, will result in
        the assessment of 5 points.  Examples include, but are not limited to,
        the following:

      

      •  Violations
        which result in a member’s MCP selection or termination based on inaccurate
        provider panel information from the MCP.

      •  Failure
        to provide member materials to new members in a timely manner.

      •  Failure
        to comply with appeal, grievance, or state hearing
        requirements, including the failure to notify a member of their right to
        a state
        hearing when the MCP proposes to deny, reduce, suspend or terminate a
        Medicaid-covered service.

      •   Failure
        to staff 24-hour call-in system with appropriate trained medical
        personnel.

      •   Failure
        to meet the monthly call-center requirements for either the member services
        or
        the 24-hour call-in system lines.

      •   Provision
        of
        false, inaccurate or materially misleading information to health care providers, the MCP’s members, or any
        eligible individuals.

      •   Use
        of unapproved marketing or member
        materials.

      •   Failure
        to appropriately notify ODJFS or members of provider panel
        terminations.

      • 
        Failure
        to update website provider directories as required.

      

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

      

      •  
        Discrimination among members on the basis of their health status or need
        for
        health care services (this includes any practice that would reasonably be
        expected to encourage termination or discourage selection by individuals
        whose
        medical condition indicates probable need for substantial future medical
        services).

      •   Failure
        to assist a member in accessing needed services in a timely manner after
        request
        from the member.

      •   Failure
        to provide medically-necessary Medicaid covered services to
        members.

      •   Failure
        to process prior authorization requests within the prescribed time
        frames.

      

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

      

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

      

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

      

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

      

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

      

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

      

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

      

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

      

      
        	
                0
                  -15 Points

              	
                Corrective
                  Action Plan
                  (CAP)

              
	
                16-25
                  Points

              	
                CAP
                  + $5,000
                  fine

              
	
                26-50
                  Points

              	
                CAP
                  + $10,000
                  fine

              
	
                51-70
                  Points

              	
                CAP
                  + $20,000
                  fine

              
	
                71-100
                  Points

              	
                CAP
                  + $30,000
                  fine

              
	
                100+
                  Points

              	
                Proposed
                  Contract Termination

              

      

      

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

      

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

      

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

      

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

      

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

      

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

      

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

      

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

      

      J.
        Specific Pre-Determined
        Penalties

      

      I.1.
        Adequate
        network-minimum provider panel requirements - Compliance with provider
        panel requirements will be assessed quarterly.  Any deficiencies in
        the MCP’s provider network as specified in Appendix H of the Agreement or by
        ODJFS, will result in the assessment of a $1,000 nonrefundable fine for each
        category (practitioners, PCP capacity, hospitals), for each county, and for
        each
        population (e.g., ABD, CFC).  For example if the MCP did not meet the
        following minimum panel requirements, the MCP would be assessed (1) a $3,000
        nonrefundable fine for the failure to meet CFC panel requirements; and, (2)
        a
        $1,000 nonrefundable fine for the failure to meet ABD panel
        requirements).

      ·   practitioner
        requirements in Franklin county for the CFC population

      ·   practitioner
        requirements in Franklin county for the ABD population

      ·   hospital
        requirements in Franklin county for the CFC population

      ·   PCP
        capacity requirements in Fairfield county for the CFC population

      

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

      

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

      ·   GIS
        requirements in Franklin county for the CFC population

      ·   GIS
        requirements in Fairfield county for the CFC population

      ·   GIS
        requirements in Franklin county for the ABD population

      

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

      

      ·  Late
        required
        submissions

      o       
        Annual delegation
        assessments

      o       
        Call center
        report

      o       
        Franchise fee
        documentation

      o       
        Reinsurance
        information  (e.g., prior approval of changes)

      o       
        State hearing
        notifications

      ·  Late
        required data
        submissions

      o       
        Appeals and grievances, case
        management, or PCP data

      ·   Late
        required information
        requests

      o       
        Automatic call distribution
        reports

      o       
        Information/resolution regarding
        consumer or provider complaint

      o       
        Just cause or other coordination
        care request from ODJFS

      o       
        Provider panel documentation

      o       
        Failure to provide ODJFS with a required submission after ODJFS has notified
        the
        MCP that the prescribed deadline for that submission has passed

      

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

      

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

      

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

      

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

      

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

      

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

      

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

      

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

      

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

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

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

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

      

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

      

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

      

      J.9.
        Refusal to Comply with
        Program Requirements - If ODJFS has instructed an MCP that they must
        comply with a specific program requirement and the MCP refuses, such refusal
        constitutes documentation that the MCP is no longer operating in the best
        interests of the MCP’s members or the state of Ohio and ODJFS will move to
        terminate or nonrenew the MCP’s provider agreement.

      

      III.
        Request for
        Reconsiderations

      

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

      

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

      

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

      

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

      

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

      

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

      

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

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    
 

    
      APPENDIX
        O

      

      PAY-FOR
        PERFORMANCE (P4P)

      CFC
        ELIGIBLE
        POPULATION

      

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

      

      To
        qualify for consideration of any P4P,
        MCPs must meet minimum performance standards established in Appendix M,
Performance
        Evaluationon selected
        measures, and achieve P4P standards established for selected Clinical
        Performance Measures.  For qualifying MCPs, higher performance
        standards for three measures must be reached to be awarded a portion of the
        at-risk amount and any additional P4P (see Sections 1 and 2).  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 statewide P4P system (SFY 2006 through SFY 2009), the
        county-based statewide P4P system (sections 1 and 2 of this Appendix) will
        apply
        to MCPs with membership as of February 1, 2006.  Only
        counties with membership as of February 1, 2006 will be used
        to
        calculate performance levels for the county-based statewide P4P system.

      

      1.
        SFY 2007 P4P

      

      1.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 ODJFS
        website.

      

      Measures
        for which the minimum
        performance standard for SFY 2007 established in Appendix M, Performance
        Evaluation, must be met to
        qualify for consideration of  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%.

      

      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 P4Pstandard
        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

                6.
                  Well-Child Visits - 12 through
                  21 years old

                7.
                  Use of Appropriate Medications
                  for People with Asthma

                8.
                  Annual Dental
                  Visits

                9.
                  Blood Lead – 1 year
                  olds

              	
                50%

                30%

                83%

                40%

                45%

              

      

      

      

      

      1.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 1.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

      

      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%

      

      1.c.
        Determining SFY 2007 P4P

      

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

      

      2.
        SFY 2008 P4P

      

      2.a.
        Qualifying Performance
        Levels

      

      To
        qualify for consideration of the SFY
        2008 P4P,
        an MCP’s performance level must meet
        the minimum performance standards set in Appendix M, Performance
        Evaluation, for the
        measures listed below.  A detailed description of the methodologies
        for each measure can be found on the BMHC page of the ODJFS
        website.

      

      Measures
        for which the minimum
        performance standard for SFY 2008 established in Appendix M, Performance
        Evaluation, must be met to
        qualify for consideration of  P4P are
        as follows:

      

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

      

      Report
        Period: CY
        2007

      

      2.
        Children’s Access to Primary Care
        (Appendix M, Section 2.b.)

      

      Report
        Period: CY
        2007

      

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

      

      Report
        Period: CY
        2007                                                    

      

      4.
        Overall Satisfaction with MCP
        (Appendix M, Section 3.)

      

      Report
        Period: The most recent
        consumer satisfaction survey completed prior to the end of the SFY
        2008.

      

      For
        each clinical performance measure
        listed below, the MCP must meet the P4P standard to be considered for SFY
        2008P4P.  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

                6.
                  Well-Child Visits - 12 through
                  21 years old

                7.
                  Use of Appropriate Medications
                  for People with Asthma

                8.
                  Annual Dental
                  Visits

                9.
                  Blood Lead – 1 year
                  olds

              	
                50%

                30%

                83%

                40%

                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 1.b.i.)

      

      Report
        Period: April - June
        2008

      

      Excellent
        Standard:
        5.5%

      

      Superior
        Standard:
        6.5%

      

      2.
        Use of Appropriate Medications for
        People with Asthma (Appendix M, Section 1.c.v.)

      

      Report
        Period: CY
        2007

      

      Excellent
        Standard:
        86%

      

      Superior
        Standard:
        88%

      

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

      

      Report
        Period: CY
        2007

      

      Excellent
        Standard:
        76%

      

      Superior
        Standard:
        84%

      

      2.c.
        Determining SFY 2008
        P4P

      

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

      

      3.
        NOTES

      

      3.a.
        Transition from a county-based statewide to a regional-based statewide P4P
        system.

      

      The
        current county-based statewide P4P system will transition to a regional-based
        statewide system as managed care expands statewide.  The
        regional-based statewide approach will be fully phased in no later than SFY
        2010.  The regional-based statewide P4P system will be modeled after
        the county-based statewide system with adjustments to performance standards
        where appropriate.

      

      3.a.i.
        County-based statewide P4P system

      

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

      

      Starting
        with the twenty-fifth month of participation in the program, a new MCP’s at-risk
        amount will be included in the P4P system. The determination of the status
        of
        this at-risk amount will be after at least three full calendar years of
        membership as many of the performance standards require three full calendar
        years to determine an MCP’s performance level.  Because of this
        requirement, more than 12 months of at-risk dollars may be included in an
        MCP’s
        first at-risk status determination depending on when an MCP starts with the
        program relative to the calendar year.

      

      During
        the transition to a regional-based statewide system (SFY 2006 through SFY
        2009),
        MCPs with membership as of  February 1, 2006 will continue in the
        county-based statewide P4P system until the transition is
        complete.  These MCPs will be put at-risk for a portion of the
        premiums received for members in counties they are serving as of February
        1,
        2006.

      

      3.a.ii.
        Regional-based statewide P4P system

      

      All
        MCPs will be included in the
        regional-based statewide P4P system.  The at-risk amount will
        be determined separately for each region an MCP serves.

      

      The
        status of the at-risk amount for counties not included in the county-based statewide
        P4P
        system will not be determined for the first twenty-four months of regional
        membership.  Starting with the twenty-fifth month of regional
        membership, the MCP’s at-risk amount will be included in the P4P system. The
        determination of the status of this at-risk amount will be after at least
        three
        full calendar years of regional membership as many of the performance standards
        require three full calendar years to determine an MCP’s performance level. Given
        that statewide expansion was not complete by December 31, 2006, ODJFS may
        adjust
        performance measure reporting periods based on the number of months an MCP
        has
        had regional membership. Because of this requirement, more than 12 months
        of
        at-risk dollars may be included in an MCP’s first regional at-risk status
        determination depending on when regional membership starts relative to the
        calendar year.  Regional premium payments for months prior to July
        2009 for members in counties included in the county-based statewide P4P system
        for the SFY 2009 P4P determination, will be excluded from the at-risk dollars
        included in the first regional-based statewide
        P4P determination.

      

      3.b.
        Determination of at-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.
        Contract Termination, Nonrenewals, or Denials

      

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

      

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

      

      3.d.
        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.exhibit10-2.htm

    
      
        

      

    

    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 Aged, Blind or Disabled (hereinafter referred to
      as “ABD”) population dated July 1, 2007, is hereby amended as
      follows:

     

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

     

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

     

    The
      amendment contained herein shall be effective January 1,
      2008. 

    

    

    
      	
              WELLCARE
                OF OHIO, INC.

            	
               

               

            
	
              BY:  /s/  TODD
                S. FARHA

            	DATE:
              12/19/07
	
              TODD
                S. FARHA, PRESIDENT AND CEO

            
	 
	 
	
              OHIO
                DEPARTMENT OF JOB AND FAMILY SERVICES:

              
              

            
	
              BY:
                /s/ HELEN E.
                JONES-KELLEY

            	
              DATE:
                12/26/07

            
	
              HELEN
                E. JONES-KELLEY, DIRECTOR

            	 

    

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    

    APPENDIX
      C

    

    MCP
      RESPONSIBILITIES

    ABD
      ELIGIBLE
      POPULATION

    

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

     

     General
      Provisions

     

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

     

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

     

    3. The
      MCP must
      designate the following:

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

    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 ofmembers
      and
      eligible individuals in
      accordance
      with the following:

     

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

     

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

     

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

     

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

     

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

     

    22. Pursuant
      to OAC
      rules 5101:3-26-08 and 5101:3-26-08.2, the MCP is responsible
      for ensuring
      that
      all MCP marketing and member materials are prior approved by ODJFS before being
      used or shared with members.  Marketing and member materials are
      defined as follows:

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

    i. Provides
      written information to all adult members concerning:

     

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

     

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

     

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

     

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

     

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

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

    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. NewMember
      Materials

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

     

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

     

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

     

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

     

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

     

    25. Call CenterStandards

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

    ·      
      New Year’s Day 

    ·      
      Martin Luther King’s Birthday 

    ·      
      Memorial Day 

    ·      
      Independence Day 

    ·      
      Labor Day 

    ·      
      Thanksgiving Day 

    ·      
      Christmas Day 

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

     

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

     

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

     

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

     

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

     

    26.       Notification
      of Optional MCP Membership

     

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

     

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

     

    27. HIPAA
      Privacy Compliance Requirements

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

    29. MCP
      Membership acceptance, documentation and
      reconciliation

     

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

      

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

     

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

     

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

     

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

     

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

     

    When
      an MCP learns that a new member who was previously on Medicaid fee for
  service was admitted prior to the effective date of enrollment and
      remains an inpatient on the effective date of enrollment, the enrolling MCP
      shall notify the hospital/ inpatient facility and treating providers
      that the MCP may not be the payer. The MCP shall work with
      hospital/inpatient facility, treating providers and  the ODJFS to
      assure that discharge planning assures continuity of care and accurate
      payment. Notwithstanding the MCP’s right to request a hospital deferment up to
      six (6) months following the member’s effective date, when the enrolling MCP
      learns of a deferment-eligible hospitalization, the MCP shall notify the
      ODJFS
      and request the deferment within five (5) business days
      of  learning of the potential deferment.

     

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

     

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

     

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

     

     h. Transition
      of Fee-For-Service Members:
Providing
      care
      coordination, access to preventive and specialized care, case management,
      member services, and education with minimal disruption to members’ established
      relationships with providers and existing care treatment plans is critical
      for
      members transitioning from Medicaid fee-for-service to managed
      care.  MCPs must develop
      and
      implement a transition plan that outlines how the MCP will effectively address
      the unique care coordination issues of members in their first three months
      of
      MCP membership and how the various MCP departments will coordinate and share
      information regarding these new members. The transition plan must include at
      a
      minimum:

     

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

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

    If
      contacted by
      the member, the MCP must contact the provider’s office as expeditiously as the
      situation warrants to confirm that the service(s) meets the above
      criteria.

     

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

     

    c. Honoring
      any
      current fee-for-service prior authorization to allow their
      new
      members that are transitioning from Medicaid fee-for-service to receive services
      from the authorized provider, whether a panel
      or
      out-of-panel provider, for the following approved
      services:

     

     i. an
      organ, bone
      marrow, or hematapoietic stem cell transplant
      pursuant to OAC rule 5101:3-2-07.1;

     

    ii. dental
      services
      that have not yet been received;

     

    iii. vision
      services
      that have not yet been received;

     

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

     

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

     

    As
      soon as the
      MCP becomes aware of the member’s current fee-for-service authorization
      approval, the MCP must initiate contact with the authorized provider and member
      as applicable to ensure continuity of care.  The MCP must implement a
      plan to meet the member’s immediate and ongoing medical needs and, with the
      exception of organ, bone marrow, or hematapoietic stem cell transplants,
      coordinate the transfer of services to a panel provider, if
      appropriate.

     

    When
      an MCP
      medical necessity review results in a decision to reduce, suspend, or terminate
      services previously authorized by fee-for-service Medicaid, the MCP must notify
      the member of their state hearing rights no less than 15 calendar days prior
      to
      the effective date of the MCP’s proposed action, per rule 5101:3-26-08.4 of the
      Administrative Code.

     

    d. Reimbursing
      out-of-panel providers that agree to provide the transition
      services at 100% of the current Medicaid fee-for-service  provider
      rate
      for the service(s) identified in Section 29.h.ii.(a., b.,  and
      c.) of this
      appendix.

     

    e. Documenting
      the
      provision of transition services identified in Section
      29.h.ii.(a., b., and c.) of this appendix as follows:

     

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

     

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

     

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

     

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

      

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

     

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

     

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

     

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

     

    For
      those new members who are not utilizing ongoing medications for chronic
      conditions, no additional drug PA education is required beyond the MCP’s general
      new member education that includes what drugs require MCP
      PA.

     

    MCPs
      must receive ODJFS approval prior to implementing their transition of care
      drug
      PA process.  An MCP’s proposal must document how the MCP
      will:

     

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

     

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

     

    MCPs
      who have not received ODJFS approval for their transition of care drug PA
      process must not require PA of any prescription drug that does not require
      PA by
      Medicaid fee-for-service for the initial three months of a member’s MCP
      membership.

     

    g. Covering
      antipsychotic medications for new members as well as current members as
      stipulated in Appendix G(3)(a)(i).

     

    30. Health
      Information System Requirements

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

     

     a. Health
      Information System

     

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

     

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

     

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

     

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

     

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

     

    a. Before
      an MCP
      may submit production files ODJFS-specified formats;
      and/or

    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 havean
      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
      submitan
      acceptable
      test file and an acceptable production file.

     

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

     

    b. Electronic
      Data Interchange and Claims Adjudication Requirements

     

      Claims
      Adjudication

     

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

     

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

     

    Electronic
      Data Interchange

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

      Health
      care claims;

      Health
      care claim status request and response;

      Health
      care
      payment and remittance status;

      Standard
      code
      sets; and   

      National
      Provider Identifier (NPI).

     

    Each
      EDI transaction processed by the MCP shall be implemented in  conformance
      with the
      appropriate version of the transaction implementation guide,
      as
      specified by applicable federal rule or regulation.

     

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

     

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

     

     ASC
      X12 834 - Benefit Enrollment and Maintenance.

     

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

     

      Documentation
      of Compliance with Mandated EDI Standards

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

     

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

    MCPs
      shall
      comply with the transaction standards and code sets for sending and  receiving
      applicable transactions as specified
      in 45
      CFR Part 162 – Health  Insurance
      Reform:  Standards for Electronic
      Transactions (HIPAA  regulations)
      In
       addition
      the MCP must enterinto
      the
      appropriate trading partner
      agreement and  implemented
      standard
      code
      sets.  If the MCP has obtained
      third-party certification  of
      HIPAA
      compliance for any of the items  listed
      below,
 that
      certification may  be
      submitted
      in lieu of
      the MCP’s written verification
      for the applicable  item(s).

       

    i. Trading
      Partner
      Agreements

    ii. Code
      Sets

    iii. Transactions

     

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

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

    c. Referral
      Certification and Authorization (ASC X12N 278)

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

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

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

    g. Health
      Plan Premium Payments (ASC X12N 820)

    h. Coordination
      of Benefits 

      

    Trading
      Partner Agreement with ODJFS

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

     

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

     

    c. Encounter
      Data Submission Requirements

     

    General
      Requirements

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

     

    ·    Institutional
      Claims - UB92 flat file

    ·    Noninstitutional
      Claims - National standard format

    ·    Prescription
      Drug Claims - NCPDP

     

    ODJFS
      relies heavily on encounter data for monitoring MCP performance. The ODJFS
      uses
      encounter data to measure clinical performance, conduct access and utilization
      reviews, reimburse MCPs for newborn deliveries and
      aid in
      setting

     

    MCP
      capitation rates.  For these reasons, it is important that encounter
      data is timely, accurate, and complete. Data quality,
performance
      measures and standards are described in the
      Agreement.

     

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

     

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

     

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

     

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

     

    Acceptance
      Testing

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

     

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

     

    Encounter
      Data File Submission Procedures

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

     

    Timing
      of Encounter Data Submissions

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

     

    d. Information
      Systems Review

     

    ODJFS
      or its designee may review the information system capabilities of each MCP
      before ODJFS enters into a provider agreement with a new MCP, when a
      participating MCP undergoes a major information system upgrade or
      change,  when there is identification of significant information
      system problems, or at ODJFS’ discretion. Each MCP must participate in the
      review. The review will assess the extent to which MCPs are capable of
      maintaining a health information system including producing valid encounter
      data, performance measures, and other data necessary to support quality
      assessment and improvement, as well as managing the care delivered to its
      members.

     

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

     

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

     

    ii. Review
      the
      completed ISCA and accompanying documents;

     

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

     

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

     

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

     

    vi.
      Examine MCP
      processes for data transfers;

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

    35. Franchise
      Fee
      Assessment Requirements

     

    a. Each
      MCP is required to pay a franchise permit fee to ODJFS for each calendar
 quarter
      as
      required by ORC Section 5111.176.  The current  fee
      to be paid
      is an  amount
      equal to
      41⁄2 percent of the managed care premiums, minus Medicare  premiums
      that
      the MCP received from any payer in the quarter to which the fee  applies.  Any
      premiums the MCP returned or refunded to members or premium  payers
      during
      that quarter are excluded from the fee.

     

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

     

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

     

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

     

    36. Information
      Required for MCP Websites

     

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

     

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

     

    c. On-line
      Provider Website –
MCPs
      must have a secure internet-based website for contracting providers where
      they will be able to confirm a consumer’s MCP enrollment and through this
      website (or through e-mail process) allow providers    to
      electronically submit and receive responses to prior authorization
      requests.   This website must also include: (1) a list of the
      counties that are covered in their service area; (2) the MCP’s provider
      manual; (3) MCP contact information; (4) a link to the MCP’s on-line
      provider directory as referenced in section 37(a) of this appendix; (5) the
      MCP’s current PDL list, including an explanation of the list,  which
      drugs require PA, and the PA process; (6) the MCP’s current list
      of  drugs covered only with PA, the PA process, and the MCP’s policy
      for covering    generic for brand-name drugs.  MCPs
      must ensure that all provider materials designated specifically for CFC
      and/or ABD consumers (i.e. the MCP’s provider  manual) are clearly
      labeled as such; and (7) information regarding the availability of
      expedited prior authorization requests, as well as the information that
      is required from that provider in order to substantiate an expedited prior
 authorization request.

     

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

     

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

     

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

     

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

     

    41. Coordination
      of Benefits

     

     When
      a claim is denied due to third party liability, the managed care plan must
      timely  share appropriate and available information regarding the third
      party to the provider for  the purposes of coordination of benefits,
      including, but not  limited to third party liability  information
      received from the Ohio Department of Job and  Family
      Services.

    

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    APPENDIX
      D

    

    ODJFS
      RESPONSIBILITIES

    ABD
      ELIGIBLE
      POPULATION

    

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

     

    General
      Provisions

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

    13. Service
      Area Designation

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

     

    14. Consumer
      information

     

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

     

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

     

    c. If
      an MCP elects not to provide, reimburse, or cover a counseling service or
      referral service due to an objection to the service on moral or religious
      grounds, ODJFS will provide coverage and reimbursement for these services for
      the MCP’s members.

     

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

     

    15. Membership
      Selection and Premium Payment

     

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

      

     The
      MCEC shall
      distribute the most current
      Consumer Guide that includes the managed care program
      information as specified in 42 CFR 438.10, as well as ODJFS prior-approved
      MCP
      materials, such as solicitation brochures and provider directories, to consumers
      who request additional materials.

     

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

     

    ·  40%
      of statewideAged,
      Blind, or Disabled (ABD)
      managed care eligibles; and/or

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

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

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

     

    19.   Communications

     

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

     

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

     

    c. MCP
      delegated entities: In
      that MCPs are ultimately responsible for meeting  program
      requirements, the BMHC will
      not discuss MCP issues  with
      the MCPs’ delegated entities
      unless the applicable MCP is  also
      participating in the
      discussion.  MCP delegated entities, with the applicable    MCP
      participating, should only
      communicate with the specific CA assigned to that
      MCP.

     

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      APPENDIX
        E

    

    
      

      RATE
        METHODOLOGY ABD ELIGIBLE POPULATION

    

    

    

    

    

    

    

    

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

     

    

    
      

    

    
       

      Chase
        Center/Circle

    

    
      111
        Monument Circle

    

    
      Suite
        601

    

    
      Indianapolis,
        IN
        46204-5128

    

    
      USA

       

    

    
      Tel
        +1317 639 1000 

      Fax
        +1317 639 1001

    

    
       

      rniliiman.com

    

    
       

      FINAL
        and CONFIDENTIAL

    

     

    
       

      December
        12, 2007

    

    
       

       

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

    

    
      Bureau
        of Managed Health Care

    

    
      Ohio
        Department of Job and Family Services

    

    
      Lazarus
        Building

    

    
      50
        West Town St., Suite 400

    

    
      Columbus,
        OH 43215

    

    
       

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

    

    
       

      Dear
        Jon:

    

    
       

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

    

    
       

      LIMITATIONS

    

    
       

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

    

    
       

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

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

     

    
       

      Jon
        Barley, Ph.D.

    

    
      December
        12, 2007

    

    
      Page
        2

    

    
       

      FINAL
        and CONFIDENTIAL

    

    
       

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

    

    
       

      SUMMARY
        OF METHODOLOGY

    

    
       

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

    

    
       

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

    

    
       

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

    

    
       

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

    

    
       

      DETAILS
        OF METHODOLOGY

    

    
       

      I.           
        COVERED POPULATION

    

    
       

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

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      Mr.
        Jon Barley, Ph.D.

    

    
      December
        12, 2007

    

    
      Page
        3

    

    
       

      FINAL
        and CONFIDENTIAL

    

    
       

      Table
        I

    

    
       

      STATE
        OF OHIO

    

    
      DEPARTMENT
        OF JOB AND FAMILY SERVICES

    

    
      Summary
        of Managed Care Eligible Population

    

     

    
      	
              
                Program
                  Assignment

              

            	
              
                Description

              

            
	
              
                AGED

              

            	
              
                Aged

              

            
	
              
                RAGED

              

            	
              
                Aged
                  as defined on RMF

              

            
	
              
                BLIND

              

            	
              
                Blind

              

            
	
              
                RBLIND

              

            	
              
                Blind
                  as defined on RMF

              

            
	
              
                DISABLED

              

            	
              
                Disabled

              

            
	
              
                RDISABLED

              

            	
              
                Disabled
                  as defined on RMF

              

            
	
              
                RESMED

              

            	
              
                Residential
                  State Supplement &
                  Medicaid

              

            

    

    
       

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

    

    
       

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

       

    

    
      II.CATEGORY
        OF SERVICE DEFINITIONS

    

    
       

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

       

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

     

     

    
       

      Mr.
        Jon Barley, Ph.D.

    

    
      December
        12, 2007

    

    
      Page
        4

    

    
       

      FINAL
        and CONFIDENTIAL

    

    
       

      Table
        2

       

      STATE
        OF OHIO

    

    
      DEPARTMENT
        OF JOB AND FAMILY SERVICES

    

    
      Categories
        of Service

      
 

      
        
          	
                  
                    Type
                      of Service

                  

                	
                  
                    Service
                      Category

                  

                	
                  
                    Utilization
                      Units

                  

                	
                  
                    Classification
                      Basis

                  

                
	
                  
                    Inpatient
                      Hospital

                  

                	
                  
                    Medical/Surgical

                  

                	
                  
                    Admits/Days

                  

                	
                  
                    COS,
                      DRG

                  

                
	 	
                  
                    MH/SA

                  

                	
                  
                    Admits/Days

                  

                
	 	
                  
                    Maternity
                      Delivery

                  

                	
                  
                    Admits/Days

                  

                
	 	
                  
                    Well
                      Newborn

                  

                	
                  
                    Admits/Days

                  

                
	 	
                  
                    Maternity
                      Non-Deliveries

                  

                	
                  
                    Admits/Days

                  

                
	 	
                  
                    Nursing
                      Facility

                  

                	
                  
                    Admits/Days

                  

                
	 	
                  
                    Other
                      Inpatient

                  

                	
                  
                    Admits/Days

                  

                
	
                  
                    Outpatient
                      Hospital

                  

                	
                  
                    Emergency
                      Room

                  

                	
                  
                    Claims

                  

                	
                  
                    COS,
                      Revenue Code

                  

                
	 	
                  
                    Surgery/ASC

                  

                	
                  
                    Services

                  

                
	 	
                  
                    Cardiovascular

                  

                	
                  
                    Services

                  

                
	 	
                  
                    PT/ST/OT

                  

                	
                  
                    Services

                  

                
	 	
                  
                    Clinic

                  

                	
                  
                    Services

                  

                
	 	
                  
                    Other

                  

                	
                  
                    Services

                  

                
	
                  
                    Professional

                  

                	
                  
                    Inpatient/Outpatient
                      Surgery

                  

                	
                  
                    Services

                  

                	
                  
                    COS,
                      Provider Type, Procedure, Modifier

                  

                
	 	
                  
                    Anesthesia

                  

                	
                  
                    Line
                      Items

                  

                
	 	
                  
                    Obstetrics

                  

                	
                  
                    Services

                  

                
	 	
                  
                    Office
                      Visits/Consults

                  

                	
                  
                    Services

                  

                
	 	
                  
                    Hospital
                      Inpatient Visits

                  

                	
                  
                    Services

                  

                
	 	
                  
                    Emergency
                      Room Visits

                  

                	
                  
                    Services

                  

                
	 	
                  
                    Immunizations
                      & Injections

                  

                	
                  
                    Services

                  

                
	 	
                  
                    Physical
                      Medicine

                  

                	
                  
                    Services

                  

                
	 	
                  
                    Miscellaneous
                      Services

                  

                	
                  
                    Line
                      Items, Services

                  

                
	
                  
                    Rad/Path/Lab

                  

                	
                  
                    Radiology

                  

                	
                  
                    Services

                  

                	
                  
                    COS,
                      Revenue Code, Provider Type, Procedure

                  

                  
                    
                    

                  

                  
                    
                    

                  

                
	 	
                  
                    Pathology/Laboratory

                  

                	
                  
                    Services

                  

                
	
                  
                    Ancillaries

                  

                	
                  
                    MH/SA

                  

                	
                  
                    Services

                  

                	
                  
                    COS,
                      Provider Type, Procedure

                  

                
	 	
                  
                    FQHC/RHF/OP
                      Health Facility

                  

                	
                  
                    Services

                  

                	
                  
                    COS

                  

                
	 	
                  
                    Pharmacy

                  

                	
                  
                    Line
                      Items

                  

                	
                  
                    COS

                  

                
	 	
                  
                    Dental

                  

                	
                  
                    Services

                  

                	
                  
                    COS

                  

                
	 	
                  
                    Vision

                  

                	
                  
                    Services

                  

                	
                  
                    COS,
                      Provider Type, Procedure

                  

                
	 	
                  
                    Home
                      Health

                  

                	
                  
                    Line
                      Items

                  

                	
                  
                    COS

                  

                
	 	
                  
                    Non-Emergent
                      Transportation

                  

                	
                  
                    Line
                      Items

                  

                	
                  
                    COS

                  

                
	 	
                  
                    Ambulance

                  

                	
                  
                    Line
                      items

                  

                	
                  
                    COS,
                      Procedure Code

                  

                
	 	
                  
                    Supplies
                      and DME

                  

                	
                  
                    Line
                      Items

                  

                	
                  
                    COS,
                      Provider Type, Procedure

                  

                
	 	
                  
                    Miscellaneous
                      Services

                  

                	
                  
                    Line
                      Items

                  

                	
                  
                    COS

                  

                

        

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

    

    

    
      Mr.
        Jon Barley, Ph.D. 

      December
        12, 2007

    

    
      Page
        5

    

    
       

      FINAL
        and CONFIDENTIAL

    

    
       

      III.       RATE
        GROUPS

    

    
       

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

    

    
       

      IV.        DEVELOPMENT
        OF CY 2006 ADJUSTED FFS DATA

    

    
       

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

    

    
       

      a.           
        Historical Data Summaries

    

    
       

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

    

    
       

      
        	
                §  

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

              

      

    

    
       

      
        	
                §  

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

              

      

    

    
       

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

    

    
       

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

    

    
       

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

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      Mr.
        Jon Barley, Ph.D.

    

    
      December
        12, 2007

    

    
      Page
        6

    

    
       

      FINAL
        and CONFIDENTIAL

    

    
       

      Table
        3

    

    
       

      STATE
        OF OHIO

      DEPARTMENT
        OF JOB AND FAMILY SERVICES

    

    
      FFS
        Claim Exclusions

    

    
 

    
      
        	
                
                  COS
                    Field Value

                

              	
                
                  Description

                

              
	
                
                  08

                

              	
                
                  PACE

                

              
	
                
                  13

                

              	
                
                  ICF/MR
                    Public

                

              
	
                
                  18

                

              	
                
                  ICF/MR
                    Private

                

              
	
                
                  35

                

              	
                
                  Core
                    Services

                

              
	
                
                  36

                

              	
                
                  Home
                    Care Facilitator Services

                

              
	
                
                  41

                

              	
                
                  Mental
                    Health Services

                

              
	
                
                  42

                

              	
                
                  Mental
                    Retardation

                

              
	
                
                  46

                

              	
                
                  Model
                    50 Waiver Services

                

              
	
                
                  58

                

              	
                
                  HMO
                    Services

                

              
	
                
                  59

                

              	
                
                  Mental
                    Health Support Services

                

              
	
                
                  60

                

              	
                
                  Mental
                    Retardation Support Services

                

              
	
                
                  63

                

              	
                
                  PPO
                    Services

                

              
	
                
                  64

                

              	
                
                  Passport

                

              
	
                
                  66

                

              	
                
                  Passport
                    Waiver III

                

              
	
                
                  67

                

              	
                
                  OBRA
                    MR/DD Waiver

                

              
	
                
                  80

                

              	
                
                  Alcohol
                    and Drug Abuse

                

              
	
                
                  82

                

              	
                
                  Department
                    of Education

                

              
	
                
                  84

                

              	
                
                  ODADAS

                

              

      

       

    

    
      b.            
        Completion Factors

    

    
       

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

    

    
       

      c.            
        Historical Program Adjustments

    

    
       

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

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      Mr.
        Jon Barley, Ph.D.

    

    
      December
        12, 2007

    

    
      Page
        7

    

    
       

      FINAL
        and CONFIDENTIAL

    

    
       

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

    

    
       

      Table
        4

    

    
       

      STATE
        OF OHIO

    

    
      DEPARTMENT
        OF JOB AND FAMILY SERVICES

    

    
      Historical
        Program Adjustments - FFS

    

    
 

    
      
        	
                
                  Program
                    Adjustment

                

              	
                
                  Effective
                    Date

                

              	
                
                  Service
                    Category(s)

                

              
	
                
                  Inpatient
                    Market Basket Increase

                

              	
                
                  1/1/2005

                

              	
                
                  Inpatient
                    Hospital

                

              
	
                
                  Dental
                    Fee Schedule Reduction

                

              	
                
                  1/1/2006

                

              	
                
                  Dental

                

              
	
                
                  Inpatient
                    Recalibration and Outlier Policy

                

              	
                
                  1/1/2006

                

              	
                
                  Inpatient

                

              
	
                
                  Pharmacy
                    Co-pay ($2 Per Brand Prescription)

                

              	
                
                  1/1/2006

                

              	
                
                  Pharmacy

                

              
	
                
                  Dental
                    Co-pay ($3 Per Date of Service)

                

              	
                
                  1/1/2006

                

              	
                
                  Dental

                

              
	
                
                  Vision
                    Exam Co-Pay ($2 Per Exam)

                

              	
                
                  1/1/2006

                

              	
                
                  Vision
                    / Optometric

                

              
	
                
                  Vision
                    Hardware Co-Pay ($ 1 Per Item)

                

              	
                
                  1/1/2006

                

              	
                
                  Vision
                    / Optometric

                

              
	
                
                  ER
                    Co-Pay ($3 Per Non-Emergency Visit)

                

              	
                
                  1/1/2006

                

              	
                
                  Emergency
                    Room

                

              
	
                
                  Dental
                    Benefit Reduction

                

              	
                
                  1/1/2006

                

              	
                
                  Dental

                

              

      

    

    
       

      d.           
        Third-Party Liability

    

    
       

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

    

    
       

      e.           
        Fraud and Abuse

    

    
       

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

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      Mr.
        Jon Barley,
        Ph.D.

    

    
      December  12,
        2007

    

    
      Page
        8

    

    
       

      FINAL
        and CONFIDENTIAL

    

    
       

      f.            
        Gross Adjustments

    

    
       

      The
        FFS experience was calculated using the net paid claim data from the FFS
        data
        provided by ODJFS. Milliman adjusted the FFS experience to reflect
        payments/refunds occurring outside of normal claim adjudication. Milliman
        received a "gross adjustments" tile from ODJFS containing the additional
        adjustments.

    

    
       

      g.            
        Non-State Flan Services

    

    
       

      CMS
        requires removal of non-state plan services from rate-setting. The FFS data
        does
        not contain any such services. As such, no adjustment was applied to the
        base
        FFS data for non-state plan services.

    

    
       

      h.           
        Trends/Inflation to CY 2006

    

    
       

      Milliman
        developed trend rates to progress the historical experience from state fiscal
        years 2005 and 2006 forward to a common center point (CY 2006). Milliman
        reviewed historical experience and performed linear regression on the experience
        data to develop trend rates by category of service for both utilization and
        unit
        cost. Additionally, Milliman reviewed the resulting trends with internal
        data
        sources to develop the trends used to develop the CY 2008 ABD capitation
        rates.

    

    
       

      The
        base experience data was normalized for artificial program adjustments prior
        to
        the trend rate development. Milliman did not consider items such as fee schedule
        changes or benefit modifications as standard components of trend. Removing
        the
        impact of historical changes allows for transparent inclusion of prospective
        program changes for future periods.

    

    
       

      i.            
        Blend Base Experience Years

    

    
       

      Each
        of the base experience years was trended to CY 2006. At this point, each
        base
        year was on a comparable basis and could be aggregated. The weighting was
        developed with the intention of placing more credibility on the most recent
        experience and is consistent with the CY 2007 methodology. Specifically,
        SFY
        2005 received a weight of 30% and SFY 2006 received a weight of
        70%.

    

    
       

      j.            
        Managed Care Adjustments

    

    
       

      Utilization
        and cost per service adjustments were developed for each service category
        and
        region.

    

    
       

      Utilization

    

    
       

      Milliman
        adjusted the FFS utilization and cost per service to reflect the managed
        care
        environment. After reviewing utilization benchmarks in the Milliman Medicaid
        Guidelines (Guidelines)
        as well as other sources, Milliman calculated percentage adjustments
        to
        reflect the utilization differential between an economic and efficiently
        managed
        plan and the FFS base experience.

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      Mr.
        Jon Barley, Ph.D.

    

    
      December
        12, 2007

    

    
      Page
        9

    

    
       

      FINAL
        and CONFIDENTIAL

    

    
       

       

    

    
       

      Cost
        Per Service

    

    
       

      Milliman
        adjusted the average reimbursement rates to reflect changes in the mix /
        intensity of services due to the management of health care. The reimbursement
        rate changes were also developed following a review of benchmarks in the
Guidelines
        as well as other sources.

    

    
       

      In
        addition to the intensity adjustments applied to the cost per service amounts,
        Milliman also included adjustments to reflect the health plan contracted
        rates
        with providers in the managed care adjustments.

    

    
       

      V.           
        CY 2006 ADJUSTED BASE DATA TO CY 2008 CAPITATION
        RATES

    

    
       

      The
        adjusted CY 2006 utilization and cost per service rates are trended forward
        to
        CY 2008 and adjusted for prospective program changes that will be effective
        for
        the CY 2008 contract period. The resulting PMPM, after trend and prospective
        program changes establishes the regional adjusted claim cost for the health
        plans in CY 2008. The administrative cost allowance and franchise fee components
        are applied to the adjusted claim cost to develop the CY 2008 capitation
        rate.

    

    
       

      a.           
        Trend to CY 2008

    

    
       

      The
        trend rates that were used to progress the CY 2006 experience forward to
        the CY
        2008 rating period were developed from the historical experience, the experience
        from other Medicaid managed care programs, and our actuarial judgment. The
        trend
        rates include a component for utilization and unit cost by major category
        of
        service.

    

    
       

      b.           
        Prospective Program Adjustments

    

    
       

      The
        SFY 2008/2009 Budget contains several program changes that impacted the
        development of the capitation rates. The program changes include items such
        as
        provider fee changes, benefit changes, and administrative changes. Adjustments
        to the CY 2006 experience were developed for each item based on its expected
        impact to the prospective claims cost. Table 5 lists the program changes
        that
        were included in the CY 2008 capitation rate
        development.

       

       

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    
       

      Mr.
        Jon Barley, Ph.D.

    

    
      December
        12, 2007

    

    
      Page
        10

    

    
       

      FINAL
        and CONFIDENTIAL

    

    
       

      Table
        5

    

    
       

      STATE
        OF OHIO

    

    
      DEPARTMENT
        OF JOB AND FAMILY SERVICES

    

    
      Prospective
        Program Adjustments

       

    

    
      
        	
                
                  Program
                    Adjustment

                

              	
                
                  Effective
                    Date

                

              	
                
                  Service
                    Category(s)

                

              
	
                
                  Nursing
                    Facility Fee Increase

                

              	
                
                  7/1/2007

                

              	
                
                  Nursing
                    Facility

                

              
	
                
                  7/1/2008

                

              
	
                
                  Chiropractor
                    Benefit Restoration

                

              	
                
                  1/1/2008

                

              	
                
                  Miscellaneous
                    Services

                

              
	
                
                  Independent
                    Psychologists Benefit Restoration

                

              	
                
                  1/1/2008

                

              	
                
                  Mental
                    Health / Substance Abuse

                

              
	
                
                  Occupational
                    Therapy-Independent Provider Status

                

              	
                
                  1/1/2008

                

              	
                
                  Miscellaneous
                    Services

                

              
	
                
                  Improved
                    TPL Management

                

              	
                
                  1/1/2008

                

              	
                
                  All
                    Service Categories

                

              
	
                
                  Prior
                    Authorization Policy Change

                

              	
                
                  1/1/2008

                

              	
                
                  Pharmacy

                

              
	
                
                  Prior
                    Authorization of Atypical Anti-Psychotic Medication

                

              	
                
                  1/1/2008

                

              	
                
                  Pharmacy

                

              

      

       

    

    
      c.           
        Prospective Selection Adjustment

    

    
       

      Milliman
        adjusted the CY 2006 experience to reflect the expected penetration of managed
        care in CY 2008. Table 6 provides the target managed care penetration used
        in
        the development of the CY 2008 capitation
        rates.

    

    
       

      Table
        6

    

    
       

      STATE
        OF OHIO

    

    
      DEPARTMENT
        OF JOB AND FAMILY SERVICES

    

    
      Prospective
        Selection Adjustments

       

      

        
          
            	
                    
                      Region

                    

                  	
                    
                      June
                        2007 MC Penetration

                    

                  	
                    
                      Target
                        MC Penetration

                    

                  
	
                    
                      Central

                    

                  	
                    
                      89.5%

                    

                  	
                    
                      93%

                    

                  
	
                    
                      East
                        Central

                    

                  	
                    
                      88.8%

                    

                  	
                    
                      93%

                    

                  
	
                    
                      Northeast

                    

                  	
                    
                      89.7%

                    

                  	
                    
                      93%

                    

                  
	
                    
                      Northeast
                        Central

                    

                  	
                    
                      0.0%

                    

                  	
                    
                      93%

                    

                  
	
                    
                      Northwest

                    

                  	
                    
                      87.6%

                    

                  	
                    
                      93%

                    

                  
	
                    
                      Southeast

                    

                  	
                    
                      92.3%

                    

                  	
                    
                      93%

                    

                  
	
                    
                      Southwest

                    

                  	
                    
                      86.0%

                    

                  	
                    
                      93%

                    

                  
	
                    
                      West
                        Central

                    

                  	
                    
                      87.7%

                    

                  	
                    
                      93%

                    

                  

          

        

      

    

     

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      Mr.
        Jon Barley. Ph.D. 

    

    
      December
        12, 2007 

      Page
        11

    

    
       

      FINAL
        and CONFIDENTIAL

    

    
       

      d.           
        Administrative Allowance

    

    
       

      Milliman
        included an administrative cost allowance in the development of the actuarially
        sound capitation rates for CY 2008. The administrative cost allowance contains
        provision for administrative expenses, profit/contingency, and surplus
        contribution and was calculated as a percentage of the capitation rate prior
        to
        the franchise fee. As such, the pre-franchise fee capitation rate will be
        determined by dividing the projected managed care claim cost by one minus
        the
        administrative cost allowance. By determining the pre-franchise fee capitation
        rate in this manner, the administrative allowance may be expressed as a
        percentage of the pre-franchise fee capitation rate. Milliman developed the
        administrative cost allowance following a review of cost information from
        other
        representative Medicaid managed care
        organizations.

    

    
       

      For
        health plans in plan year 3 or later, 1% of the administrative component
        will be
        at-risk and contingent upon performance requirements defined in the ODJFS
        provider agreements. Table 7 provides the administrative cost allowance for
        each
        plan year.

    

    
       

      Table
        7

    

    
       

      STATE
        OF OHIO

    

    
      DEPARTMENT
        OF JOB AND FAMILY SERVICES

    

    
      Administrative
        Cost Allowance

    

    
 

    
      
        	
                
                  Plan
                    Year

                

              	
                
                  Guaranteed
                    %

                

              	
                
                  At-Risk
                    %

                

              	
                
                  Total  %

                

              
	
                
                  Plan
                    Year 1 (1-12 Months)

                

              	
                
                  11.5%

                

              	
                
                  0.0%

                

              	
                
                  11.5%

                

              
	
                
                  Plan
                    Year 2 (13-24 Months)

                

              	
                
                  10.5%

                

              	
                
                  0.0%

                

              	
                
                  10.5%

                

              
	
                
                  Plan
                    Year 3 (25 + Months)

                

              	
                
                  9.5%

                

              	
                
                  1.0%

                

              	
                
                  10.5%

                

              

      

    

    
       

      The
        administrative cost allowance percentages contained in Table 7 reflect a
        change
        from the 2007 methodology.

    

    
       

      e.           
        Franchise Fee

    

    
       

      Milliman
        included a franchise fee component in the development of the actuarially
        sound
        capitation rates for CY 2008. The franchise fee was calculated as a percentage
        of the capitation rates. Therefore, the capitation rate will be determined
        by
        dividing the pre-franchise fee capitation rate by one minus the franchise
        fee
        component. By determining the pre-franchise fee capitation rate in this manner,
        the franchise fee may be expressed as a percentage of the capitation rate.
        The
        franchise fee component is 4.5% of the capitation
        rate.

       

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    
       

      Mr.
        Jon Barley, Ph.D.

    

    
      December
        12, 2007

    

    
      Page
        12

    

    
       

      FINAL
        and CONFIDENTIAL

    

    
      VI. 
        CDPS
        RISK ADJUSTMENT

    

     

    
       

      The
        methodology described in this correspondence was used to develop the base
        capitation rates for CY 2008 for each region. Milliman will then apply the
        Chronic Illness and Disability Payment System (CDPS) to adjust the actuarially
        sound base capitation rates for the ABD population on a regional basis for
        each
        health plan. The CDPS risk adjustment will be updated each six month period
        for
        existing regions and plans. For the initial period of managed care within
        a
        region and plan, a monthly risk score will be developed for the first three
        months.

    

    
       

      The
        next anticipated risk score update will be January 1, 2008. The CDPS risk
        scores
        will be developed for ABD recipients enrolled in managed care during December
        2007 using diagnosis information from claims incurred in calendar year 2006
        with
        paid dates between January 1, 2006 and June 30, 2007. Health plan and region
        specific prevalence reports will be provided with the updated risk
        scores.

    

    
       

      DATA
        RELIANCE

    

    
       

      In
        developing the CY 2008 ABD capitation rates, we have relied upon certain
        data
        and information from ODJFS. While limited review was performed for
        reasonableness, the data and information was accepted without audit. To the
        extent that the data and information was not accurate or complete, the values
        shown in this letter will need to be revised.

    

    
       

      ♦♦♦♦

    

    
       

      If
        you have any questions regarding the enclosed information, please do not
        hesitate to contact me at
        (317)  524-3512.

    

    
       

      Sincerely,

    

    
       

    

    
      /s/
        Robert M. Damler

    

    
      Robert
        M. Damler, FSA, MAAA

    

    
      Principal
        and Consulting Actuary

    

    
       

      RMD/mle

    

    
      
        	
              	
                cc: 

              	
                Dan
                  Hecht (ODJFS) 

                Mitali
                  Ghatak (ODJFS)

                Robert
                  Monks (ODJFS)

              

      

    

    
       

    

    
 

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      FINAL
        and CONFIDENTIAL 

    

    
       

      APPENDIX
        1

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
       

       

    

     

     

    
       

      FINAL
        and CONFIDENTIAL

    

     

    
       

      Illustration
        of Rate Development Methodology

       

      [Graph]

    

    
       

      
        
        

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
                                                                                           
        FINAL and CONFIDENTIAL

    

    
       

      APPENDIX
        2

    

    
       

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

     

    
       

      FINAL
        and CONFIDENTIAL

    

    
       

    

    
       

    

    
      STATE
        OF OHIO

    

    
      DEPARTMENT
        OF JOB AND FAMILY SERVICES

    

    
      Aged,
        Blind, or Disabled - CY 2008 Capitation Rates

    

    
       

      Actuarial
        Certification

    

    
       

      I,
        Robert M. Damler, am a Principal and Consulting Actuary with the firm of
        Milliman, Inc. I am a Fellow of the Society of Actuaries and a Member of
        the
        American Academy of Actuaries. I was retained by the State of Ohio, Department
        of Job and Family Services to perform an actuarial review and certification
        regarding the development of the capitation rates to be effective for calendar
        year 2008. The capitation rates were developed for the Aged, Blind, or Disabled
        managed care eligible populations. I have experience in the examination of
        financial calculations for Medicaid programs and meet the qualification
        standards for rendering this opinion.

    

    
       

      I
        reviewed the historical claims experience for reasonableness and consistency.
        I
        have developed certain actuarial assumptions and actuarial methodologies
        regarding the projection of healthcare expenditures into future periods.
        I have
        complied with the elements of the rate setting checklist CMS developed for
        its
        Regional Offices regarding 42 CFR 438.6(c) for capitated Medicaid managed
        care
        plans.

    

    
       

      The
        capitation rates provided with this certification are effective for a one-year
        rating period beginning January 1, 2008 through December 31, 2008. At the
        end of
        the one-year period, the capitation rates will be updated for calendar year
        2009. The update may be based on fee-for-service experience, managed care
        utilization and trend experience, policy and procedure changes, and other
        changes in the health care market. A separate certification will be provided
        with the updated rates.

    

    
       

      The
        capitation rates provided with this certification are considered actuarially
        sound, defined as:

    

    
       

      
        	
                •  

              	
                the  capitation
                  rates have been
                  developed  in  accordance  with  generally  accepted  actuarial
                  principles and practices;

              

      

    

    
      
        	
                •  

              	
                the
                  capitation rates are appropriate for the populations to be covered,
                  and
                  the services to be furnished under the contract; and,

              
	•  	the
                capitation rates meet the requirements of 42 CFR
                438.6(c).

      

    

    
       

    

    
      This
        actuarial certification has been based on the actuarial methods, considerations,
        and analyses promulgated
        from time to time through the Actuarial Standards of Practice by the Actuarial
        Standards

    

    
       

      Board.

    

    
       

       

    

    
      /s/
        Robert M. Dalmer_

    

    
      Robert
        M. Damler, FSA

    

    
      Member,
        American Academy of Actuaries

    

    
       

      December
        4, 2007

    

    
      Date

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
       

    

    
       

      FINAL
        and CONFIDENTIAL

    

     

    
       

      APPENDIX
        3

       

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

     

    
       

      FINAL
        AND CONFIDENTIAL

    

    
       

      State
        of Ohio

    

    
      Department
        of Job and Family Services

    

    
      CY2008
        ABD Capitation Rate Development

    

     

    
      	 	 	
              
                Projected
                  CY

              

            	 	 	
              
                CY
                  2008

              

            	 	 	 	 	 	 	 
	 	 	
              
                2008
                  Member

              

            	 	 	
              
                Guaranteed

              

            	 	 	
              
                CY
                  2008 At

              

            	 	 	 	 
	
              
                Region

              

            	 	
              
                Months

              

            	 	 	
              
                Rate

              

            	 	 	
              
                Risk
                  Rate

              

            	 	 	
              
                CY
                  2008 Rate

              

            	 
	
              
                Central

              

            	 	 	
              284,169

            	 	 	 	$1,101.26	 	 	 	$10.62	 	 	 	$1,111.88	 
	
              
                East
                  Central

              

            	 	 	149,045	 	 	 	1,091.21	 	 	 	10.52	 	 	 	1,101.73	 
	
              
                Northeast

              

            	 	 	287,103	 	 	 	1,099.46	 	 	 	10.60	 	 	 	1,110.06	 
	
              
                Northeast
                  Central

              

            	 	 	85,309	 	 	 	1,098.34	 	 	 	10.59	 	 	 	1,108.93	 
	
              
                Northwest

              

            	 	 	137,407	 	 	 	1,107.94	 	 	 	10.68	 	 	 	1,118.62	 
	
              
                Southeast

              

            	 	 	152,735	 	 	 	981.68	 	 	 	9.47	 	 	 	991.15	 
	
              
                Southwest

              

            	 	 	174,390	 	 	 	1,120.61	 	 	 	10.80	 	 	 	1,131.41	 
	
              
                West
                  Central

              

            	 	 	123,260	 	 	 	1,133.13	 	 	 	10.93	 	 	 	1,144.06	 
	
              
                Statewide

              

            	 	 	1,393,418	 	 	 	$1,092.43	 	 	 	$10.53	 	 	 	$1,102.96	 

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

     

    
      Appendix
        F

       

    

    
       

      
        	
                 

              	
                PREMIUM
                  RATES WITHOUT THE AT-RISK PAYMENT AMOUNTS FOR 01/01/08 THROUGH
                  06/30/08
                  

                 

                MCP's
                  premiums will be at-risk starting the 25th month of the ABD Medicaid
                  Managed Care Program participation.

              

      

    

    
       

      MCP:  WellCare
        of Ohio, Inc.

    

     

    
      	
              
                Service
                  Enrollment
                  Area

              

            	Risk
              Adjusted Rate	
              At-Risk
                Amounts

            
	
              
                Northeast
                  Region

              

            	
              
                $1,125.45

              

            	
              
                $0.00

              

            

    

    
       

       

       

      
        	 List
                of Eligible Assistance Groups
                (AGs)	 
	 Aged,
                Blind or
                Disabled:   	MA-A
                Aged
	 	 MA-B
                Blind
                
	 	 MA-D
                Disabled

      

    

    
                                                        

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    

    APPENDIX
      G

    

    COVERAGE
      AND SERVICES

    ABD
      ELIGIBLE
      POPULATION

    

    1.
Basic
      Benefit
      Package

    

    Pursuant
      to OAC rule 5101:3-26-03(A), with limited exclusions (see section G.2 of this
      appendix), MCPs must ensure that members have access to medically-necessary
      services covered by the Ohio Medicaid fee-for-service (FFS)
      program.  For information on Medicaid-covered services, MCPs must
      refer to the
      ODJFS website. The following is a general list of the benefits pertinent to
      the
      ABD population covered by the MCPs:

    

    ·      
      Inpatient hospital services

    ·      
      Outpatient hospital services

    ·      
      Rural health clinics (RHCs)
      and
      Federally qualified health centers (FQHCs)

    ·      
      Physician services whether furnished in the physician’s office, the covered
      person’s home, a hospital, or elsewhere

    ·      
      Laboratory and x-ray services

    ·      
      Family planning services and supplies

    ·      
      Home health and private duty
      nursing services 

    ·      
      Podiatry

    ·      
      Physical therapy, occupational therapy, and speech therapy

    ·      
      Nurse-midwife, certified family nurse practitioner, and certified pediatric
      nurse practitioner services

    ·      
      Prescription drugs

    ·      
      Ambulance and ambulette services

    ·      
      Dental services

    ·      
      Durable medical equipment and medical supplies

    ·      
      Vision care services, including
      eyeglasses

    ·      
      Nursing facility stays as
      specified in OAC rule 5101:3-26-03

    ·      
      Hospice care

    ·      
      Behavioral health services (see section G.2.b.iii of this appendix)

    ·      
      Chiropractic services

    

    2. Exclusions,
      Limitations and
      Clarifications

    

    a. Exclusions

    

    MCPs
      are
      not required to pay for Ohio Medicaid FFS program (Medicaid) non-covered
      services. For information regarding Medicaid noncovered services, MCPs must
      refer to the ODJFS website. The following is a general list of the services
      not
      covered by the Ohio Medicaid fee-for-service program:

    

    ·      
      Services or supplies that are not medically necessary

    ·      
      Experimental services and procedures, including drugs and equipment, not covered
      by Medicaid

    ·      
      Organ transplants that are not covered by Medicaid

    ·      
      Abortions, except in the case of a reported rape, incest, or when medically
      necessary to save the life of the mother

    ·      
      Infertility services for males or females

    ·      
      Voluntary sterilization if under 21 years of age or legally incapable of
      consenting to the procedure

    ·      
      Reversal of voluntary sterilization procedures

    ·      
      Plastic or cosmetic surgery
      that is not
      medically necessary*

    ·      
      Immunizations for travel outside of the United States

    ·      
      Services for the treatment of obesity unless medically necessary*

    ·      
      Custodial or supportive care not
      covered by Medicaid

    ·      
      Sex change surgery and related services

    ·      
      Sexual or marriage counseling

    ·      
      Acupuncture and biofeedback services

    ·      
      Services to find cause of death (autopsy)

    ·      
      Comfort items in the hospital (e.g., TV or phone)

    ·      
      Paternity testing

    

    MCPs
      are
      also not required to pay for non-emergency services or supplies received without
      members following the directions in their MCP member handbook, unless otherwise
      directed by ODJFS.

    

      *These
      services
      could be deemed medically necessary if medical complications/conditions in
      addition to the obesity or physical imperfection are present.

    

    b. Limitations
&
      Clarifications

     

    i. Member
      Cost-Sharing

    

    As
      specified in OAC rules 5101:3-26-05(D) and  5101:3-26-12, MCPs
      are permitted to impose the applicable member co-payment amount(s) for dental
      services, vision services, non-emergency emergency department services, or
      prescription drugs, other than generic drugs. MCPs must notify ODJFS if they
      intend to impose a co-payment.  ODJFS must approve the notice to be
      sent to the MCP’s members and the timing of when the co-payments will begin to
      be imposed.  If ODJFS determines that an MCP’s decision to impose a
      particular co-payment on their members would constitute a significant change
      for
      those members, ODJFS may require the effective date of the co-payment to
      coincide with the “Open
      Enrollment” month.

    

    Notwithstanding
      the preceding paragraph, MCPs must provide an ODJFS-approved notice to all
      their
      members 90 days in advance of the date that the MCP will impose the co-payment.
      With the exception of member co-payments the MCP has elected to implement in
      accordance with OAC rules 5101:3-26-05(D) and  5101:3-26-12, the MCP’s payment
      constitutes payment in full for any covered services and their subcontractors
      must not charge members or ODJFS any additional co-payment, cost sharing,
      down-payment, or similar charge, refundable or otherwise.

    

    ii. Abortion
      and
      Sterilization

    

    The
      use
      of federal funds to pay for abortion and sterilization services is prohibited
      unless the specific criteria found in 42 CFR 441 and OAC rules 5101:3-17-01
      and
      5101:3-21-01 are met.  MCPs must verify that all of the information on
      the required forms (JFS 03197, 03198, and 03199) is provided and that the
      service meets the required criteria before any such claim is paid.

     

    Additionally,
      payment must not be made for associated services such as anesthesia, laboratory
      tests, or hospital services if the abortion or sterilization itself does not
      qualify for payment.  MCPs are responsible for educating their
      providers on the requirements; implementing internal procedures including
      systems edits to ensure that claims are only paid once the MCP has determined
      if
      the applicable forms are completed and the required criteria are met, as
      confirmed by the appropriate certification/consent forms; and for maintaining
      documentation to justify any such claim payments.

    

    iii. Behavioral
      Health
      Services

    

    Coordination
      of Services:  MCPs must have a process
      to
      coordinate benefits of and referrals to the publicly funded community behavioral
      health system. MCPs must ensure
      that
      members have access to all medically-necessary behavioral health services
      covered by the Ohio Medicaid FFS program and are responsible for coordinating
      those services with other medical and support services.  MCPs must
      notify members via the member handbook and provider directory of where and
      how
      to access behavioral health services, including the ability to self-refer to
      mental health services offered through ODMH community mental health
      centers (CMHCs) as well as substance abuse services offered through Ohio
      Department of Alcohol and Drug Addiction Services (ODADAS)-certified Medicaid
      providers. Pursuant to ORC Section 5111.16, alcohol, drug addiction and mental
      health services covered by Medicaid are not to be paid by the managed care
      program when the nonfederal share of the cost of those services is provided
      by a
      board of alcohol, drug addiction, and mental health services or a
      state agency
      other than ODJFS.  MCPs are also not responsible for providing mental
      health services to persons between 22 and 64 years of age while residing
      in an institution for mental disease (IMD) as defined in Section 1905(i) of
      the
      Social Security Act.

    

    MCPs
      must provide
      Medicaid-covered behavioral health
      services
      for members who are unable to timely access services or unwilling to access
      services through community providers.

    

    Mental
      Health
      Services: There are a number of Medicaid-covered mental health (MH) services available
      through
ODMH CMHCs.

    

    Where
      an
      MCP is responsible for providing MH services for their members, the MCP is
      responsible for ensuring access to counseling and psychotherapy,
      physician/psychiatrist services, outpatient clinic services, general hospital
      outpatient psychiatric services, pre-hospitalization screening, diagnostic
      assessment (clinical evaluation), crisis intervention, psychiatric
      hospitalization in general hospitals (for all ages), and Medicaid-covered
      prescription drugs and laboratory services.  MCPs are not required to
      cover partial hospitalization, or inpatient psychiatric care in a private or public
      free-standing psychiatric
      hospital.  However, MCPs are required to cover the payment of
      physician services in a private or public free-standing psychiatric hospital
      when such services are billed independent of the hospital.

    

    Substance
      Abuse
      Services:  There are a number of Medicaid-covered substance
      abuse services available through ODADAS-certified Medicaid
      providers.

    

    Where
      an
      MCP is responsible for providing substance abuse services for their members,
      the
      MCP is responsible for ensuring access to alcohol and other drug (AOD)
      urinalysis screening, assessment, counseling, physician/psychiatrist AOD
      treatment services, outpatient clinic AOD treatment services, general hospital
      outpatient AOD treatment services, crisis intervention, inpatient detoxification
      services in a general hospital, and Medicaid-covered prescription drugs and
      laboratory services. MCPs are not required to cover outpatient detoxification
      and methadone maintenance.

    

    Financial
Responsibility
      for Behavioral Health Services:  MCPs are responsible
      for the
      following:

    ·   payment
      of Medicaid-covered prescription
      drugs prescribed by an ODMH CMHC or ODADAS-certified provider when obtained
      through an MCP’s panel pharmacy;

    ·   payment
      of Medicaid-covered services
      provided by an MCP’s panel laboratory when referred by an ODMH CMHC or
      ODADAS-certified provider;

    ·   payment
      of all other Medicaid-covered
      behavioral health services obtained through providers other than those who
      are
      ODMH CMHCs or ODADAS-certified providers when arranged/authorized by the
      MCP.

    

    Limitations:

    ·   Pursuant
      to ORC Section 5111.16,
      alcohol, drug addiction and mental health services covered by Medicaid are
      not
      to be paid by the managed care program when the nonfederal share of the cost
      of
      those services is provided by a board of alcohol, drug addiction, and mental
      health services or a state agency other than ODJFS.  As part of this
      limitation:

    ·   MCPs
      are not responsible for paying for
      behavioral health services provided through ODMH CMHCs and ODADAS-certified
      Medicaid providers;

    ·   MCPs
      are not responsible for payment of
      partial hospitalization (mental health), inpatient psychiatric care in a private
      or public free-standing inpatient psychiatric hospital, outpatient
      detoxification, intensive outpatient programs (IOP) (substance abuse) or
      methadone maintenance.

    ·    However,
      MCPs are required to cover the
      payment of physician services in a private or public free-standing psychiatric
      hospital when such services are billed independent of the
      hospital.

    

    iv. Pharmacy
      Benefit:  In providing the Medicaid pharmacy benefit to their
      members, MCPs must cover the same
      drugs covered by the Ohio Medicaid
      fee-for-service program.

     

    MCPs
      may
      establish a preferred drug list for members and providers which includes a
      listing of the drugs that they prefer to have prescribed. Preferred drugs
      requiring prior authorization approval must be clearly indicated as
      such.  Pursuant to ORC §5111.172, ODJFS may approve MCP-specific
      pharmacy program utilization management strategies (see appendix
      G.3.a).

    

    v. Organ
      Transplants: MCPs
      must ensure coverage for organ
 transplants
      and related services in
      accordance with OAC 5101-3-2- 07.1
      (B)(4)&(5).  Coverage
      for all organ transplant services, except  kidney
      transplants, is contingent upon
      review and recommendation  by
      the “Ohio Solid Organ Transplant
      Consortium” based on  criteria
      established by Ohio organ
      transplant surgeons and
 authorization
      from the ODJFS prior
      authorization unit.  Reimbursement
      for bone marrow transplant
      and hematapoietic  stem
      cell transplant services, as
      defined in OAC 3701:84-01, is  contingent
      upon review and
      recommendation by the “Ohio  Hematapoietic
      Stem Cell Transplant
      Consortium” again based on criteria established
      by Ohio experts
      in the field of bone marrow
 transplant.  While
      MCPs may
      require prior authorization for these  transplant services,
      the
      approval criteria would be limited to  confirming the consumer is being
      considered and/or has been  recommended for a transplant by either
      consortium and authorized  by ODJFS.  Additionally, in accordance
      with OAC 5101:3-2-03  (A)(4) all services related to organ donations are
      covered for the  donor recipient when the consumer is Medicaid
      eligible. 

    

    3. Care
      Coordination

    

    a. Utilization
      Management  Programs

    

    General
      Provisions -
      Pursuant to OAC rule 5101:3-26-03.1(A)(7), MCPs must implement a utilization
      management (UM) program to maximize the effectiveness of the care provided
      to
      members and may develop other UM programs, subject to prior approval by
      ODJFS.  For the purposes of this requirement, the specific UM programs which
      require ODJFS prior-approval are an MCP’s general pharmacy program, a controlled
      substances and member management program, and any other program designed by
      the
      MCP with the purpose of redirecting or restricting access to a particular
      service or service location.

    

    i. Pharmacy
      Programs -
      Pursuant to ORC Sec. 5111.172 and OAC  rule 5101:3-26-03(A) and (B), MCPs
      may, subject to ODJFS prior- approval, implement strategies for the
      management of  pharmacy utilization.  Pharmacy utilization
      management strategies  may include developing preferred drug lists,
      requiring prior  authorization for certain drugs, placing limitations on
      the type of  provider and locations where certain medications may be
 administered, and developing and implementing a specialized  pharmacy
      program to address the utilization of controlled  substances, as defined in
      section 3719.01 of the Ohio Revised
 Code.              

                 

    Drug
      Prior
      Authorizations: MCPs must receive prior approval from  ODJFS for the
      medications that they wish to cover through prior
 authorization.  MCPs must establish their prior authorization
 system so that it does not unnecessarily impede member access to
 medically-necessary Medicaid-covered services.  As outlined in
 paragraph 29(i)(ii)(f) of Appendix C, MCPs must adhere to  specific
      prior-authorization limitations to assist with the  transition of new ABD
      members from FFS Medicaid. MCPs must  make their approved list of drugs
      covered only with prior  authorization available to members and providers,
      as outlined in  paragraphs 36(b) and (c) of Appendix C.

    

    Beginning
      January 1, 2008, MCPs may require prior authorization for  the coverage of
      antipsychotic  drugs with ODJFS approval.  MCPs  must,
      however, allow any member to continue receiving a specific  antipsychotic
      drug if the member is stabilized on that particular
 medication.  The MCP must continue to cover that specific drug
      for the  stabilized member for as long as that medication continues to be
 effective for the member.  MCPs may also implement a drug
      utilization review program designed to promote the appropriate clinical
 prescribing of antipsychotic drugs.  This can be accomplished
      through  the MCP’s retrospective analysis of drug claims to identify
      potential  inappropriate use and provide education to those providers who
      are  outliers to acceptable standards for prescribing/dispensing
 antipsychotic drugs.

    

    MCPs
      must comply with the provisions of
      1927(d)(5) of the Social Security Act, 42 USC 1396r-8(k)(3), and
      OAC rule 5101:3-26- 03.1
      regarding the timeframes for prior authorization of covered outpatient
      drugs.

    

    Controlled
      Substances and
      Member Management Programs: MCPs  may also, with ODJFS prior
      approval, develop and implement  Controlled Substances and Member
      Management (CSMM)  programs designed to address use of controlled
      substances. Utilization management strategies may include prior
      authorization  as a condition of obtaining a controlled substance, as
      defined in  section 3719.01 of the Ohio Revised Code.  CSMM
      strategies may  also include processes for requiring MCP members at high
      risk for  fraud or abuse involving controlled substances to have their
 narcotic medications prescribed by a designated provider/providers
 and filled by a pharmacy, medical provider, or health care facility
 designated by the program.

    

    ii. Emergency
      Department
      Diversion (EDD) – MCPs must
      provide
   access to services in a way that assures access to
      primary, specialist and  urgent care in the most appropriate settings
      and that    minimizes frequent, preventable utilization of
      emergency department (ED) services. OAC rule 5101:3-26-03.1(A)(7)(d) requires MCPs to
      implement the ODJFS-required emergency department diversion (EDD) program for
      frequent utilizers.

    

     Each
      MCP must establish an ED diversion  (EDD) program with the goal of
      minimizing frequent ED utilization. The MCP’s EDD program must include the
      monitoring of ED utilization, identification of frequent ED utilizers, and
      targeted approaches designed to reduce avoidable ED utilization. MCP EDD
      programs must, at a minimum, address those ED visits which could have been
      prevented through improved education, access, quality or care management
      approaches.

    

    Although
      there is often an assumption that frequent ED visits are solely the result
      of a
      preference on the part of the member and education is therefore the standard
      remedy, it is also
      important to ensure that a member’s frequent ED utilization is not due to
      problems such as their PCP’s lack of accessibility or failure to make
      appropriate specialist referrals.  The MCP’s EDD program must
      therefore also include the identification of providers who serve as PCPs for
      a
      substantial number of frequent ED utilizers and the implementation of corrective
      action with these providers as so indicated.

    

    This
      requirement does not replace the MCP’s responsibility to inform and educate all
      members regarding the appropriate use of the ED.

    

    MCPs
      must
      also implement the ODJFS-required emergency department diversion (EDD) program
      for frequent users.  In that ODJFS has developed the parameters for an
      MCP’s EDD program, it therefore does not require ODJFS prior approval
      (Moved).

    

    b. Integration
      of Member Care

     

    The
      MCP must ensure that a discharge
      plan is in place to meet a member’s  health
      care needs following discharge
      from a nursing facility, and integrated into the member’s continuum
      of care.   The discharge plan must address the services
      to be provided for
      the member and must be developed prior to the date of
      discharge from the
      nursing facility.  The MCP must ensure follow-up contact
      occurs with the
      member, or authorized representative, within
      thirty (30) days
      of the member’s discharge from the nursing facility
      to ensure that
      the member’s health care needs are being met.

    

    c. Care
      Coordination with
      ODJFS-Designated Providers

    

    Per
      OAC
      rule 5101:3-26-03.1(A)(4), MCPs are required to share specific information
      with
      certain ODJFS-designated non-contracting providers in order to ensure that
      these
      providers have been supplied with specific information needed to coordinate
      care
      for the MCP’s  members.  Within the first month of
      operation, after an MCP has obtained a provider agreement, the MCP must
      provide to the ODJFS-designated providers (i.e., ODMH Community Mental Health
      Centers, ODADAS-certified Medicaid providers, FQHCs/RHCs, QFPPs, CNMs, CNPs
      [if
      applicable], and hospitals) a quick reference information packet which
      includes the following:

    

    i. A
      brief cover letter explaining the
      purpose of the mailing; and

    

    ii. A
      brief summary document that includes the following
      information:

    

    ·   Claims
      submission information including the MCP’s Medicaid provider number for each
      region;   

    ·   The
      MCP’s prior authorization and referral procedures or the MCP’s
      website;  

    ·   A
      picture of the MCP’s member identification card (front and back);

    ·   Contact
      numbers and/or website location for obtaining information for eligibility
      verification, claims processing, referrals/prior authorization, and information
      regarding the MCP’s behavioral health administrator;

    ·  A
      listing of the MCP’s major pharmacy chains and the contact number for the MCP’s
      pharmacy benefit administrator (PBM);

    ·  A
      listing of the MCP’s laboratories and radiology providers; and

    ·  A
      listing of the MCP’s contracting behavioral health providers and how to access
      services through them (this information is only to be provided to
      non-contracting community mental health and substance abuse
      providers).

    

    d. Care
      coordination with Non-Contracting Providers

    

    Per
      OAC
      rule 5101:3-26-05(A)(9), MCPs authorizing the delivery of  services
      from a provider who does not have an executed subcontract must ensure that they have a mutually
      agreed
      upon compensation amount for the authorized service and notify the provider
      of
      the applicable provisions of paragraph D of OAC rule
      5101:3-26-05.  This notice is provided when an MCP authorizes a
      non-contracting provider to furnish services on a one-time or infrequent
      basis to an MCP member and must include required ODJFS-model language and
      information. This notice must also be included with the transition of services
      form sent to providers as outlined in paragraph 29.h. of Appendix
      C.

    

    4. Case
      Management

    

    In
      accordance with 5101:3-26-03.1(A)(8),
      MCPs must offer and provide comprehensive case
      management services which
      coordinate and monitor the care of members with specific diagnoses, or who
      require high-cost and/or extensive services.

    

    a. Each
      MCP must inform all members and contracting providers of the MCP’s case
      management services.

    

    b. The
      MCP must assure and coordinate the placement of the member into
      case management - including identification of the member's need for case
      management services, completion of the comprehensive health needs assessment,
      and timely development of a care treatment plan.  This process must
      occur within the following timeframes for:

    

    i.
      newly
      enrolled members – 90 days from the effective date of enrollment;
      and

    

    ii.
      existing members – 90 days from identifying their need for case
      management.

    

    c. The
      MCP’s comprehensive case management program must include, at a minimum, the
      following components:

    

    i. Identification
      –

    The
      MCP
      must have mechanisms in place to identify members potentially eligible for
      case
      management services.  These mechanisms must include an administrative
      data review (e.g. diagnosis, cost threshold, and/or service utilization) and
      may
      also include telephone interviews; provider/self-referrals; information as
      reported by the Managed Care Enrollment Center (MCEC) during membership
      selection; or
      home visits.

    

    ii. Assessment
      -

    The
      MCP must arrange for or conduct a
      comprehensive assessment of the member’s physical and/or behavioral health
      condition(s) to confirm the results of a positive identification, and to
      determine the need for case management services.    The
      goals of the assessment are to identify the member’s existing and/or potential
      health care needs and assess the member’s need for case management
      services.

    

    The
      assessment must be completed by a
      physician, physician assistant, RN, LPN, licensed social worker, or a graduate
      of a two or four year allied health program.  If the assessment is
      completed by another medical professional, there should be oversight and
      monitoring by either a registered nurse or a physician.

    

    The
      MCP must have a process to inform
      members and their PCPs that
      they have been identified as meeting the criteria for case management, including
      their enrollment into case management services.

    

    The
      MCP must develop a strategy to
      assign members to risk stratification levels, based on the member’s
      comprehensive needs assessment.

    

    iii.  Care
      Treatment Plan –

    The
      care treatment plan is defined by
      ODJFS as the one developed by the MCP for the member.

    

    The
      development of the care treatment
      plan must be based on the comprehensive health assessment and reflect the
      member’s primary medical diagnosis and health conditions, any comorbidities, and
      the member’s psychological, behavioral health and community support
      needs.  The care treatment plan must also include specific provisions
      for periodic reviews (i.e.,
      no less than semi-annually) of the member’s condition and
      appropriate updates to the plan.  The member and the member’s PCP must
      be actively involved in the development of and revisions to the care treatment
      plan.  The designated PCP is the provider, or specialist, who will
      manage and
      coordinate the overall care for the member.  Ongoing communication
      regarding the status of the care treatment plan may be accomplished between
      the
      MCP and the PCP’s designee (i.e., qualified health
      professional).  Revisions to the clinical portion of the care
      treatment plan should be completed in consultation with the
      PCP.

    

    The
      elements of a comprehensive care treatment plan include:

       

    Goals
      and
      actions that address medical, social, behavioral and psychological
      needs;

    

    Member
      level interventions, (i.e., referrals and making appointments) that assist
      members in obtaining services, providers and programs;

    

    Continuous
      review, revision and contact follow-up, as needed, to ensure the
      care treatment plan is adequately monitored including the
      following:

    

    ·  Documentation
      that services are provided in accordance with the care treatment
      plan;

    ·  Re-evaluation
      to determine if the care treatment plan is adequate to meet the member's current
      needs;

    ·  Identification
      of gaps between recommended care and actual care provided;

    ·  A
      change
      in needs or status from the re-evaluation that requires revisions to the care
      treatment plan;

    ·  Active
      participation by the member or representative in the care treatment plan
      development;

    ·  Monitoring
      of specific service delivery including service utilization; and

    ·  Re-evaluation
      of a member's risk stratification level with adjustment to the level of case
      management services provided.

    

    iv.    Coordination
      of Care and Communication

    There
      should be an accountable point of contact at the MCP for each member in case
      management who can help obtain medically necessary care, assist with
      health-related services and coordinate care needs, including behavioral
      health.  The MCP must
      arrange or provide for professional case management services that are performed
      collaboratively by a team ofprofessionals
      appropriate for the
      member’s condition and health care needs.  At a minimum, the MCP’s
      case manager must attempt to coordinate with the member’s case manager from
      other health systems, including behavioral health.  The MCP must have
      a process to facilitate, maintain, and coordinate both care and communication
      with the member, PCP, and other service providers and case
      managers.  The MCP must also have a process to coordinate care for a
      member that is receiving services from state sub-recipient agencies as
      appropriate [e.g., the Ohio Department of Mental Health (ODMH); the Ohio
      Department of Mental Retardation and Developmental Disabilities (ODMR/DD);
      and
      the Ohio Department of Alcohol and Drug Addiction Services
      (ODADAS)].

    

    The
      MCP must have a provision to
      disseminate information to the member/caregiver concerning the health condition,
      types of services that may be available, and how to access
      services.

    

    The
      MCP
      must implement mechanisms to notify all Members with Special Health Care Needs
      of their right to directly access a specialist.  Such access may be
      assured through, for example, a standing referral or an approved number of
      visits, and documented in the care treatment plan.

    

    v. ODJFS
      Targeted Case Management
      Conditions:

    The
      MCP must,
      at a minimum, case manage members with
      the following physical and behavioral health conditions:

    ·  Congestive
      Heart
      Failure

    ·  Coronary
      Artery
      Disease

    ·  Non-Mild
      Hypertension

    ·  Diabetes

    ·  Chronic
      Obstructive Pulmonary
      Disease

    ·  Asthma

    ·  Severe
      mental
      illness

    ·  High
      risk or high cost substance abuse
      disorders

    ·  Severe
      cognitive and/or developmental
      limitation

    

    The
      MCP
      must also case manage any member enrolled in an MCP’s CSMM as specified in
      section G(3)(a)(i).

    

    The
      MCP should also focus on all members
      whose health conditions warrant case management services and should not limit
      these services only to members with these conditions (e.g., cystic fibrosis,
      cerebral palsy and sickle cell anemia).

    

    Refer
      to Appendix
      M
for the performance
      measures and standards related to case management.

    

    vi. Case
      Management Program
      Staffing

    The
      MCP must identify the staff that
      will be involved in the operations of the case management program, including
      but
      not limited to:  case manager supervisors, case managers, and
      administrative support staff.  The MCP must identify the role and
      functions of each case management staff member as well as the educational
      requirements, clinical licensure standards, certification and relevant
      experience with case management standards and/or activities.  The MCP
      must provide case manager staff/member ratios based on the member risk
      stratification and different levels of care being provided to
      members.

    

    vii. Case
      Management
      Strategies

    The
      MCP must follow best-practice and/or
      evidence based clinical guidelines when devising a member’s care treatment plan
      and coordinating the case management needs.  If an MCP uses a disease
      management methodology to identify and/or stratify members in need of case
      management services, the methods must be validated by scientific research and/or
      nationally accepted in the health care industry.

    

    The
      MCP must develop and implement
      mechanisms to educate and equip providers and case managers with evidence-based
      clinical
      guidelines or best practice approaches to assist in providing a high level
      of
      quality of care to members.

    

    viii.
      Information Technology System
      for
      Case Management

    The
      MCP’s information technology system
      for its case management program must maximize the opportunity for communication
      between the plan, PCP, the member, and other service providers and case
      managers.  The MCP must have an integrated database that allows MCP
      staff that may be contacted by a member in case management to have immediate
      access to, and review of, the most recent information with the MCP’s information
      systems relevant to the case.  The integrated database may include the
      following: administrative data, call center communications, service
      authorizations, care treatment plans, patient assessments, case management
      notes, and PCP notes.  The information technology system must also
      have the capability to share relevant information with the member, the PCP,
      and
      other service providers and case managers.

    

    ix.
      Data Submission

    The
      MCP must submit a monthly electronic
      report to the Case
      Management System (CAMS) for all members that are case managed.  In
      order for a member to be submitted as case managed in CAMS, the MCP
      must:  (1)  complete the identification process, a
      comprehensive health needs assessment and development of a care treatment plan
      for the member; and (2) document the member's written or verbal confirmation
      of
      his/her case management status in the case management record.  ODJFS,
      or its designated entity, the external quality review vendor, will validate
      on
      an annual basis the accuracy of the information contained in CAMS with the
      member's case management record.  The
      CAMS files are due the
      10thbusiness
      day of each
      month.

    

    d. Annual
      Case Management Program Submission

    

    The
MCP
      must have an ODJFS-approved case
      management programwhich
      includes the items in Section
      4.  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
program description
      must be submitted to
      ODJFS in writing for review and approval prior to
      implementation.

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    APPENDIX
      H

    

    PROVIDER
      PANEL SPECIFICATIONS

    ABD
      ELIGIBLE
      POPULATION

    

    
      	
              1.

            	
              GENERAL
                PROVISIONS

            

    

    

    MCPs
      must
provide or arrange for the
      delivery of all medically necessary, Medicaid-covered health services, as well
      as assure that they meet all applicable provider panel requirements for their
      entire designated
      service area.  The
      ODJFS provider panel requirements are specified in the charts included with
      this
      appendix and must be met prior to the MCP receiving a provider agreement with
      ODJFS.  The MCP must remain in compliance with these requirements for
      the duration of the provider agreement.

    

    If
      an MCP is unable to provide the
      medically necessary, Medicaid-covered services through their contracted provider
      panel, the MCP must ensure access to these services on an as needed
      basis. For
      example, if an MCP meets
the gastroenterologist
      requirement but a member is unable to obtain a timely appointment from a
      gastroenterologist on the MCP’s provider panel, the MCP will be required to
      secure an appointment from a panel gastroenterologist or arrange for an
      out-of-panel referral to a gastroenterologist.

    

    MCPs
      are
required to make
      transportation available to any member requesting transportation when
      they
must travel 30
      miles or more from their home to
      receive a medically-necessary Medicaid-covered service.  If the MCP
      offers transportation to their members as an additional benefit and this
      transportation benefit only covers a limited number of trips, the required
      transportation listed above may not
      be counted toward this trip limit (as
      specified in Appendix C).

    

    In
      developing the provider panel requirements, ODJFS considered, on a
      county-by-county basis, the population size and utilization patterns of the
      Aged, Blind or Disabled (ABD)
      consumers, as well as the potential availability of the designated provider
      types.  ODJFS has integrated existing utilization patterns into the
      provider network requirements to avoid disruption of care.  Most
      provider panel requirements are county-specific but in certain circumstances,
      ODJFS requires providers to be located anywhere in the region.
      Although all provider types
      listed in this appendix are required provider types, only those listed on the
      attached charts must be submitted for ODJFS prior approval.

    

    2.           
      PROVIDER SUBCONTRACTING

    

    Unless
      otherwise specified in this appendix or OAC rule 5101:3-26-05, all MCPs are required to enter
      into
      fully-executed subcontracts with their providers.  These subcontracts
      must include
      a baseline contractual
      agreement, as well as the appropriate ODJFS-approved Model Medicaid Addendum.
      The Model Medicaid Addendum incorporates all applicable Ohio
      Administrative Code rule requirements specific to provider subcontracting and
      therefore cannot be modified except to add personalizing information such as
      the
      MCP’s name.

    

    ODJFS
      must prior approve all MCP providers in the ODJFS- required provider type
      categories before they can begin to provide services to that MCP’s
      members.  MCPs may not employ or contract with providers excluded from
      participation in Federal health care programs under either section 1128 or
      section 1128A of the Social Security Act.  As part of the prior
      approval process,  MCPs
      must submit  documentation verifying that all necessary contract
      documents have been appropriately completed.  ODJFS will verify the
      approvability of the submission and process this information using the ODJFS
      Provider Verification System (PVS), or other designated process.  The PVS is a centralized
      database system that maintains information on the status of all MCP-submitted
      providers.

    

    Only
      those providers who meet the
      applicable criteria specified in this document, and as determined by ODJFS,
      will
      be approved by ODJFS.   MCPs must credential/recredential
      providers in accordance with the standards specified by the National Committee
      for Quality Assurance (or receive approval from ODJFS to use an alternate
      industry standard) and must have completed the credentialing review before
      submitting any provider to ODJFS for approval.  Regardless of whether
      ODJFS has approved a provider, the MCP must ensure that the provider has met
      all
      applicable credentialing criteria before the provider can render services to
      the
      MCP’s members.

    

    MCPs
      must
      notify ODJFS of the addition and deletion of their contracting providers as
      specified in OAC rule 5101:3-26-05, and must notify ODJFS within one working
      day
      in instances where the MCP has identified that they are not in compliance with
      the provider panel requirements specified in this appendix.

    

    3.           
      PROVIDER
      PANEL REQUIREMENTS

    

    The
      provider network criteria that must be met by each MCP are as
      follows:

    

    a.           
      Primary Care
      Providers (PCPs)

    

    Primary
      Care Provider (PCP) means an individual physician (M.D. or D.O.), certain
      physician group practice/clinic (Primary Care Clinics [PCCs]), or an advanced
      practice nurse (APN) as defined in ORC 4723.43 or advanced practice nurse group
      practice within an acceptable specialty, contracting with an MCP to provide
      services as specified in paragraph (B) of OAC rule 5101:
      3-26-03.1.  Acceptable specialty types for PCPs include family/general
      practice, internal medicine, pediatrics, and obstetrics/gynecology
      (OB/GYN).  Acceptable
      PCCs include FQHCs, RHCs
      and the acceptable group practices/clinics specified by ODJFS.  As part
      of their subcontract with an MCP, PCPs
      must stipulate the total Medicaid member capacity that they can ensure for
      that
      individual MCP.  Each PCP must have the capacity and agree to serve at
      least 50 Medicaid members at each practice site in order to be approved by
      ODJFS
      as a PCP.  The capacity-by-site
      requirement must be met
      for all ODJFS-approved PCPs.

    

    ODJFS
      reviews the capacity totals for
      each PCP to determine if they appear excessive. DJFS
      reserves the right to request
      clarification from an MCP for any PCP whose total stated capacity
      for all MCP networks added
      together exceeds 2000 Medicaid members (i.e., 1 FTE). ODJFS may allow
      up to an additional 750 member
      capacity for each nurse practitioner
      or physician’s assistant
      that is used to provide clinical support for a PCP.

    

    For
      PCPs
      contracting with more than one MCP, the MCP must ensure that the capacity figure
      stated by the PCP in their subcontract reflects only the capacity the PCP
      intends to provide for that one MCP. ODJFS utilizes each approved PCP’s capacity
      figure to determine if an MCP meets the provider panel requirements and this
      stated capacity figure does not prohibit a PCP from actually having a caseload
      that exceeds the capacity figure indicated in their subcontract.

    

    ODJFS
      expects that
      MCPs will need to
      utilize specialty physicians to serve as PCPs for some special needs
      members.  In these
      situations it will not be necessary for the MCP to submit these
specialists to the PVS database, or other system, as PCPs, however,
      they
      must be submitted to PVS, or other system, as the appropriate required provider
      type.  Also, in some situations (e.g., continuity of care) a PCP may
      only want to serve a very small number of members for an MCP.  In
      these situations it will not be necessary for the MCP to submit these PCPs
      to
      ODJFS for prior approval.  These PCPs will not be included in the
      ODJFS PVS database, or other system and therefore may not appear as PCPs in
      the
      MCP’s provider directory.  These PCPs will, however, need to execute a
      subcontract with the MCP which includes the appropriate Model Medicaid
      Addendum.

    

    The
      PCP requirement is based on an MCP
      having sufficient PCP capacity to serve 40% of
      the eligibles in the
      region if
      three MCPs are serving the region and
      55% of the eligibles in the region if two MCPs are serving the
      region.  Each
      MCP must meet the PCP minimum FTE
      requirement for that region.  MCPs must also satisfy a PCP geographic
      accessibility standard. ODJFS will match the PCP practice sites and the stated
      PCP capacity with the geographic location of the eligible population in that
      region (on a county-specific basis) and perform analysis using Geographic
      Information Systems (GIS) software. The analysis will be used to determine
      if at
      least 40% of the eligible population is located within 10 miles of a PCP with
      available capacity in urban
      counties and 40% of the eligible population within 30 miles of a PCP with
      available capacity in rural counties. [Rural areas are defined pursuant to
      42
      CFR 412.62(f)(1)(iii).]

    

    Until
      July 1, 2008, MCPs may only use PCPs who are individual physicians (M.D. or
      D.O.), physician group practices, or PCCs to meet capacity and FTE
      requirements.

    

    b.           
      Non-PCP Provider
      Network

    

    In
      addition to the PCP capacity requirements, each MCP is also required to maintain
      adequate capacity in the remainder of its provider network within the following
      categories:  hospitals, cardiovascular, dentists,
      gastroenterology, nephrology, neurology, oncology, physical medicine, podiatry,
      psychiatry, urology, vision care providers, obstetricians/gynecologists
      (OB/GYNs), allergists, general surgeons, otolaryngologists, orthopedists,
      federally qualified health centers (FQHCs)/rural health centers (RHCs) and
      qualified family planning providers (QFPPs). CNMs,
      CNPs, FQHCs/RHCs and QFPPs are
      federally-required provider types.

    

    All
      Medicaid-contracting MCPs must provide all medically-necessary Medicaid-covered
      services to their members and therefore their complete provider network will
      include many other additional specialists and provider types.  MCPs
      must ensure that all non-PCP network providers follow community standards in
      the
      scheduling of routine appointments (i.e., the amount of time members must wait
      from the time of their request to the first available time when the visit can
      occur).

    

    Although
      there are currently no capacity requirements for the non-PCP required provider
      types, MCPs are required to ensure that adequate access is available to members
      for all required provider types.  Additionally, for certain non-PCP
      required provider types, MCPs must ensure that these providers maintain a
      full-time practice at a site(s) located in the
      specified county/region
      (i.e., the ODJFS-specified
      county within the region or anywhere within the region if no particular county
      is specified).  A full-time practice is defined as one where the
      provider is available to patients at their practice site(s) in the specified
      county/region for at least 25 hours a week. ODJFS will monitor access to
      services through a variety of data sources, including:  consumer
      satisfaction surveys; member appeals/grievances/complaints and state hearing
      notifications/requests; clinical quality studies; encounter data volume;
      provider complaints, and clinical performance measures.

    

    Hospitals
      -
MCPs must contract with
      the
      number and type of hospitals specified by ODJFS for each county/region. In
      developing these hospital
      requirements, ODJFS considered, on a county-by-county basis, the population
      size
      and utilization patterns of the Aged, Blind or Disabled (ABD) consumers and integrated
      the existing
      utilization patterns into the hospital network requirements to avoid disruption
      of care.  For this reason, ODJFS may require that MCPs contract with
      out-of-state hospitals (i.e. Kentucky,
West
      Virginia, etc.).

    

    For
      each Ohio hospital,
      ODJFS utilizes the hospital’s
      most current Annual Hospital Registration and Planning Report, as filed with
      the
      Ohio Department of Health, in verifying types of services that hospital
      provides.  Although ODJFS has the authority, under certain situations,
      to obligate a non-contracting hospital to provide non-emergency hospital
      services to an MCP’s members, MCPs must still contract with the specified number
      and type of hospitals unless ODJFS approves a provider panel exception (see
      Section 4 of this appendix – Provider Panel Exceptions).

    

    If
      an
      MCP-contracted hospital elects not to provide specific Medicaid-covered hospital
      services because of an objection on moral or religious grounds, the MCP must
      ensure that these hospital services are available to its members through another
      MCP-contracted hospital in the specified
      county/region.

    

    OB/GYNs-
      MCPs must contract with the
      specified  number of OB/GYNs for each county/region, all of whom must
      maintain a full-time obstetrical practice at a site(s) located in the
specified
      county/region.  Only MCP-contracting OB/GYNs with current
      hospital delivery privileges at a hospital under contract with the MCP in the
      region can be submitted to the PVS, or other system, count towards MCP minimum
      panel requirements, and be listed in the MCPs’ provider directory.

    

    Certified
      Nurse Midwives (CNMs)
and
      Certified Nurse Practitioners (CNPs) - MCPs must ensure access to CNM
      and CNP services in
      the region if such provider types are present within the
      region.  The
      MCP may contract directly with the CNM
      or CNP providers, or with a physician or other provider entity who is able
      to
      obligate the participation of a CNM or CNP.  If an MCP does not
      contract for CNM or CNP services and such providers are present within the
      region, the MCP will be required to allow members to receive CNM or CNP services
      outside of the MCP’s provider network.

    

    Only
      CNMs
      with hospital delivery privileges at a hospital under contract to the MCP in
      the
      region can be submitted to the PVS, or other system, count towards MCP minimum
      panel requirements, and be listed in the MCPs’ provider directory. The MCP must ensure a member’s access to CNM
      and CNP services if such providers are practicing within the
      region.

    

    Vision
      Care Providers - MCPs
      must contract with the specified number of ophthalmologists/optometrists
      for each
specified
      county/region, all
      of whom must maintain a full-time
      practice at a site(s) located in the specified county/region. All ODJFS-approved
      vision providers must regularly perform routine eye exams. (MCPs
      will be expected to contract with
      an adequate number of ophthalmologists as part of their overall provider panel,
      but only ophthalmologists who regularly perform routine eye exams can be used
      to
      meet the vision care provider panel requirement.) If optical dispensing
      is not
      sufficiently available in a region through the MCP’s contracting
      ophthalmologists/optometrists, the MCP must
      separately
contract with an adequate
      number of optical dispensers located in the region.

    

    Dental
      Care
      Providers - MCPs must
      contract with the specified number of dentists.

    

    Federally
      Qualified Health
      Centers/Rural Health Clinics(FQHCs/RHCs) - MCPs are
      required to ensure member access
      to any  federally qualified health center or rural health clinic
      (FQHCs/RHCs), regardless of contracting status.  Contracting FQHC/RHC
      providers must be submitted for ODJFS approval via the PVS process, or
      other designated process. Even if
      no FQHC/RHC is available within the region, MCPs must have mechanisms in place
      to ensure coverage for FQHC/RHC services in the event that a member accesses
      these services outside of the region. 

    

    In
      order
      to ensure that any FQHC/RHC has the ability
      to
      submit a claim to ODJFS for the state’s supplemental payment, MCPs must offer
      FQHCs/RHCs reimbursement pursuant to the following:

    

    
      	
               

            	
              •

            	
              MCPs
                must provide expedited reimbursement on a service-specific basis
                in an
                amount no less than the payment made to other providers for the same
                or
                similar service. 

            

    

    

    
      	
               

            	
              •

            	
              If
                the MCP has no comparable service-specific rate structure, the MCP
                must
                use the regular Medicaid
                fee-for-service payment schedule for non-FQHC/RHC providers.
                

            

    

    

    
      	
               

            	
              •

            	
              MCPs
                must make all efforts to pay FQHCs/RHCs as quickly as possible and
                not
                just attempt to pay these claims within the prompt pay time frames.
                

            

    

    

    MCPs
      are
      required to educate their staff and providers on the need to assure member
      access to FQHC/RHC services.

    

    Qualified
      Family Planning Providers
      (QFPPs) - All MCP members must be permitted to self-refer to family
      planning services provided by a QFPP.  A QFPP is defined as
      any public or not-for-profit health care provider that complies with Title
      X
      guidelines/standards, and receives either Title X funding or family planning
      funding from the Ohio Department of Health.  MCPs must reimburse all
      medically-necessary Medicaid-covered  family planning services
      provided to eligible members by a QFPP provider (including on-site pharmacy
      and
      diagnostic services) on a patient self-referral
      basis, regardless of the
      provider’s status as a panel or non-panel provider.  MCPs will be
      required to work with QFPPs in the region to develop mutually-agreeable HIPAA
      compliant policies and procedures to preserve patient/provider
      confidentiality, and convey pertinent information to the member’s PCP and/or
      MCP.

    

    Behavioral
      Health Providers –
MCPs must assure member access to all Medicaid-covered behavioral health
      services for members as specified in Appendix G.b.ii. herein.  Although
      ODJFS is aware that certain outpatient substance abuse services may only be
      available through Medicaid providers certified by  the
      Ohio Department of Drug and Alcohol Addiction
      Services  (ODADAS)  in some areas, MCPs must maintain an
      adequate number of contracted mental health providers in the region to assure
      access for members who are
      unable to timely access services or
      unwilling to access services through community mental health
      centers.  MCPs are advised not to contract with community mental
      health centers as all services they provide to MCP members are to be billed
      to
      ODJFS.

    

    Other
      Specialty
      Types(general
      surgeons,
      otolaryngologists, orthopedists, cardiologists, gastroenterologists,
      nephrologists, neurologists, oncologists, podiatrists, physiatrists,
      psychiatrists, and urologists ) - MCPs must contract
      with the specified
      number of all other ODJFS designated specialty provider types. In order to
      be
      counted toward meeting the provider panel requirements, these specialty
      providers must maintain a full-time practice at a site(s) located within the
      specified county/region. Only contracting general surgeons, orthopedists,
      otolaryngologists, cardiologists, gastroenterologists,
      nephrologists, neurologists, oncologists, podiatrists, physiatrists,
      psychiatrists, and urologists with admitting privileges at a hospital
under
      contract with the MCP in the region can be submitted to the PVS, or other
      system, count towards MCP minimum panel requirements, and be listed in the
      MCPs’
provider directory.

    

    4.           
      PROVIDER PANEL
      EXCEPTIONS

    

    ODJFS
      may specify provider panel
      criteria for a service area that deviates from that specified in this appendix
      if:

    

    
      	
               

            	
              -

            	
              the
                MCP presents sufficient
                documentation to ODJFS to verify that they have been unable to meet
                or
                maintain certain provider panel requirements in a particular service
                area
                despite all reasonable efforts on their part to secure such a contract(s),
                and

            

    

    

    
      	
               

            	
              -

            	
              if
                notified by ODJFS, the
                provider(s) in
                question fails to provide a reasonable argument why they would not
                contract with the MCP, and

            

    

    

    
      	
               

            	
              -

            	
              the
                MCP presents sufficient
                assurances to ODJFS that their members will have adequate access
                to the
                services in question.

            

    

    

    If
      an MCP is unable to contract with or
      maintain a sufficient number of providers to meet the ODJFS-specified provider
      panel criteria, the MCP may request an exception to these criteria by submitting
      a provider panel exception request as specified by ODJFS.  ODJFS will
      review the exception request and determine whether the MCP has sufficiently
      demonstrated that all reasonable efforts were made to obtain contracts with
      providers of the type in question and that they will be able to provide access
      to the services in question.

    

    ODJFS
      will aggressively monitor access
      to all services related
      to
the approval of
      a provider
      panel exception request through
      a variety of data sources, including: consumer satisfaction
      surveys; member
      appeals/grievances/complaints and state hearing notifications/requests;
      member
      just-cause for termination requests; clinical quality studies; encounter
      data volume; provider
      complaints, and clinical performance measures.  ODJFS approval of a
      provider panel exception request does not exempt the MCP from assuring access
      to
      the services in question.  If ODJFS determines that an MCP has not
      provided sufficient access to these services, the MCP may be subject to
      sanctions.

    

    
      	
              5.

            	
              PROVIDER
                DIRECTORIES

            

    

    

    MCP
      provider directories must include
      all MCP-contracted providers [except as specified by ODJFS] as well as certain
      non-contracted providers.  At the time of ODJFS’ review, the
      information listed in the MCP’s provider directory for all ODJFS-required
      provider types specified on the attached charts must exactly match the data
      currently on file in the ODJFS PVS, or other designated
      process.

    

    MCP
      provider directories must utilize a
      format specified by ODJFS. Directories may be region-specific or include
      multiple regions, however, the providers within the directory must be divided
      by
      region, county, and provider type, in that order.

    

    The
      directory must also specify:

    

    
      	
               

            	
              •

            	
              provider
                address(es) and phone
                number(s);

            

    

    
      	
               

            	
              •

            	
              an
                explanation of how to access
                providers (e.g. referral required vs.
                self-referral);

            

    

    
      	
               

            	
              •

            	
              an
                indication of which providers
                are available to members on a self-referral basis;

            

    

    
      	
               

            	
              •

            	
              foreign-language
                speaking PCPs and
                specialists and the specific foreign language(s) spoken;
                

            

    

    
      	
               

            	
              •

            	
              how
                members may obtain directory information in alternate formats that
                takes
                into consideration the special needs of eligible individuals including
                but
                not limited to, visually-limited, LEP, and LRP eligible individuals;
                and
                

            

    

    
      	
               

            	
              •

            	
              any
                PCP or specialist practice limitations.

            

    

    

    Printed
      Provider Directory

    Prior
      to receiving a provider agreement,
      all MCPs must develop a printed provider directory that shall be prior-approved
      by ODJFS for each population.  For example, an MCP who serves CFC and
      ABD in the Central Region would have two provider directories, one for CFC
      and
      one for ABD.  Once approved, this directory may be regularly updated
      with provider
      additions or deletions by the MCP without ODJFS prior-approval, however, copies
      of the revised directory (or inserts) must be submitted to ODJFS prior to
      distribution to members.

    

    On
      a quarterly basis, MCPs must
create
      an insert to each printed directory
      that lists those providers
deleted
      from the MCP’s provider
      panel during the previous three months.  Although this insert does not
      need to be prior approved by ODJFS, copies of the insert must be submitted
      to
      ODJFS two weeks prior to distribution to members.

    

    Internet
      Provider Directory

    MCPs
      are required to have an
      internet-based provider directory available in the same format as their
      ODJFS-approved printed directory.  This internet directory must allow
      members to electronically
      search for MCP panel providers based on name, provider type, and geographic
      proximity, and population (e.g. CFC and/or ABD).  If an MCP has one
      internet-based directory for multiple populations, each provider must include
      a
      description of which population they serve.

    

    The
      internet directory may be updated at
      any time to include providers who are not
one
      of the ODJFS-required provider types
      listed on the charts included with this appendix.  ODJFS-required
      providers must
be
      added to the internet directory
      within one week of the MCP’s notification of ODJFS-approval of the provider via
      the Provider Verification process.  Providers being deleted from the
      MCP’s panel must be deleted
      from the internet directory
      within one week of notification from the provider to the MCP. These
      deleted providers must be included
      in the inserts to the MCP’s provider directory referenced
      above.

    

    
      	
              6
                .

            	
              FEDERAL
                ACCESS
                STANDARDS

            

    

    

    MCPs
      must
      demonstrate that they are in compliance with the following federally
      defined  provider panel access standards as required by 42 CFR
      438.206:

    

    In
      establishing and maintaining their provider panel, MCPs must consider the
      following:

    

    
      	
              •

            	
              The
                anticipated Medicaid membership. 

            

    

    
      	
              •

            	
              The
                expected utilization of services, taking into consideration the
                characteristics and health care needs of specific Medicaid populations
                represented in the MCP. 

            

    

    
      	
              •

            	
              The
                number and types (in terms of training, experience, and specialization)
                of
                panel providers required to deliver the contracted
                Medicaid services. 

            

    

    
      	
              •

            	
              The
                geographic location of panel providers and Medicaid members, considering
                distance, travel time, the means of transportation ordinarily used
                by
                Medicaid members, and whether the location provides physical access
                for
                Medicaid members with disabilities.

            

    

    
      	
              •

            	
              MCPs
                must adequately and timely cover services to an out-of-network provider
                if
                the MCP’s contracted provider panel is unable to provide the services
                covered under the MCP’s provider agreement.  The MCP must cover
                the out-of-network services for as long as the MCP network is unable
                to
                provide the services. MCPs must coordinate
                with the out-of-network provider with respect to payment and ensure
                that
                the provider agrees with the applicable requirements.

            

    

    

    Contracting
      providers must offer hours of operation that are no less than the hours of
      operation offered to commercial members or comparable to Medicaid
      fee-for-service, if the provider serves only Medicaid members.  MCPs
      must ensure that services are available 24 hours a day, 7 days a week, when
      medically necessary.  MCPs must establish mechanisms to ensure that
      panel providers comply with timely access
      requirements, and
      must take corrective action
      if there is failure to comply.

    

    In
      order
      to demonstrate adequate provider panel capacity and services, 42 CFR 438.206
      and
      438.207 stipulates that the MCP must submit documentation to ODJFS, in a format
      specified by ODJFS, that demonstrates it offers an appropriate range of
      preventive, primary care and specialty services adequate for the anticipated
      number of members in the service
      area, while maintaining a provider panel that is sufficient in number,
      mix, and geographic distribution to meet the needs of the number of members
      in
      the service
      area.

    

    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
      K

    

    QUALITY
      ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM

    AND

    EXTERNAL
      QUALITY
      REVIEW

    ABD
      ELIGIBLE
      POPULATION

    

    1.    As
      required by federal regulation, 42 CFR 438.240, each managed care plan (MCP)
      must have an ongoing Quality Assessment and Performance Improvement Program
      (QAPI) that is annually prior-approved by the Ohio Department of Job and Family
      Services (ODJFS).  The program must include the following
      elements:

    

    a.  PERFORMANCE
      IMPROVEMENT
      PROJECTS

    

    Each
      MCP
      must conduct performance improvement projects (PIPs), including those specified
      by ODJFS.  PIPs must achieve, through periodic measurements and
      intervention, significant and sustained improvement in clinical and non-clinical
      areas which are expected to have a favorable effect on health outcomes and
      satisfaction.  MCPs must adhere to ODJFS PIP content and format
      specifications.

    

    All
      ODJFS-specified PIPs must be prior-approved by ODJFS.  As part of the
      external quality review organization (EQRO) process, the EQRO will assist MCPs
      with conducting PIPs by providing technical assistance and will annually
      validate the PIPs.  In addition, the MCP must annually submit to ODJFS
      the status and results of each PIP.

    

    ODJFS
      will identify the clinical and/or
      non-clinical study topics for the SFY 2009 Provider
      Agreement.  Initiation of the PIPs will begin in the second year of
      participation in the ABD Medicaid managed care program.

    

    b.    UNDER-
      AND
      OVER-UTILIZATION

    

    Each
      MCP
      must have mechanisms in place to detect under- and over-utilization of health
      care services.  The MCP must specify the mechanisms used to monitor
      utilization in its annual submission of the QAPI program to ODJFS.

    

    It
      should
      also be noted that pursuant to the program integrity provisions outlined in
      Appendix I, MCPs must monitor for the potential under-utilization of services
      by
      their members in order to assure that all Medicaid-covered services are being
      provided, as required.  If any under-utilized services are identified,
      the MCP must immediately investigate and correct the problem(s) which resulted
      in such under-utilization of services.

    

    The
      MCP must conduct an ongoing
      review of service denials and must monitor utilization on an ongoing basis
      in
      order to identify services which may be under-utilized.

    

    c.  SPECIALHEALTH
      CARE
      NEEDS

    

    Each
      MCP
      must have mechanisms in place to assess the quality and appropriateness of
care furnished to members with
      special
      health care needs.  The MCP must specify the mechanisms used in its
      annual submission of the QAPI program to ODJFS.

    

    d.  SUBMISSION OF
      PERFORMANCE MEASUREMENT DATA

    

    Each
      MCP
      must submit clinical performance measurement data as required by ODJFS that
      enables ODJFS to calculate standard measures.  Refer to Appendix M
“Performance Evaluation” for a more comprehensive description of the clinical
      performance measures.

    

    Each
      MCP
      must also submit clinical performance measurement data as required by ODJFS
      that
      uses standard measures as specified by ODJFS.  MCPs will be required
      to submit Health Employer Data Information Set (HEDIS) audited data for measures
      that will be identified by ODJFS for the SFY 2009 Provider
      Agreement.

    

    The
      measures must have received a “report” designation from the HEDIS certified
      auditor and must be specific to the Medicaid population.  Data must be
      submitted annually and in an electronic format.  Data will be used for
      MCP clinical performance monitoring and will be incorporated into comparative
      reports developed by the EQRO.

    

    Initiation
      of submission of performance
      data will begin in the second year of participation in the Medicaid managed
      care
      program.

    

    e.   QAPI
      PROGRAM
      SUBMISSION

    

    Each
      MCP
      must implement an evaluation process to review, revise, and/or update the
QAPI
      program.  The MCP must annually submit its QAPI program for review and
      approval by ODJFS.

     

    2.  EXTERNAL
      QUALITY
      REVIEW

    

    In
      addition to the following
      requirements, MCPs must participate in external quality review activities as
      outlined in OAC 5101:3-26-07.

     

    a.
EQRO
      ADMINISTRATIVE REVIEWS

    

    The
EQRO
      will conduct annual
      focused administrative
      compliance assessments
      for each MCP which will
      include, but not be limited to, the
      following domains as specified by ODJFS:  member rights and services,
      QAPI program, case
      management, provider
networks, grievance
      system, coordination and continuity of care, and
      utilization management.  In addition, the EQRO will complete a
      comprehensive administrative compliance assessment every three (3) years as
      required by 42 CFR 438.358 and specified by ODJFS.

    

    In
      accordance with 42 CFR 438.360 and
      438.362, MCPs with
      accreditation from a national accrediting organization approved by the Centers
      for Medicare and Medicaid Services (CMS) may request a non-duplication exemption
      from certain specified components of the administrative
      review.  Non-duplication exemptions may not be requested for SFY 2008.

    

    b.  EXTERNAL
      QUALITY
      REVIEW PERFORMANCE

    

    In
      accordance with OAC rule
      5101:3-26-07, each MCP must participate in an annual
      external quality review
      survey.  If the EQRO cites a deficiency in performance, the MCP will
      be required to complete a Corrective Action Plan (e.g., ODJFS technical
      assistance session) or Quality
      Improvement Directives depending
      on the severity of the deficiency.  (An example of a deficiency is if
      an MCP fails to meet certain clinical or administrative standards as supported
      by national evidence-based guidelines or best
      practices.)  Serious  deficiencies may result in immediate
      termination or non-renewal of the provider agreement.  These quality
      improvement measures recognize the importance of ongoing MCP performance
      improvement related to clinical care and service delivery.

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    APPENDIX
      L

    

    DATA
      QUALITY

    ABD
      ELIGIBLE
      POPULATION

    

    A
      high level of performance on the data
      quality measures established in this appendix is crucial in order for the Ohio
      Department of Job and Family Services (ODJFS) to determine the value of the
      Aged, Blind or Disabled
      (ABD) Medicaid Managed
      Health Care programand
      to evaluate Medicaid consumers’
access to and quality of services. Data collected from MCPs are used in key
      performance assessments such as the external quality review, clinical
      performance measures, utilization review, care coordination and case management,
      and in determining incentives.  The data will also be used in
      conjunction with the cost reports in setting the premium payment
      rates.  The
      following measures, as specified in this appendix, will be calculated per MCP
      and include all Ohio Medicaid members receiving services from the MCP (i.e.,
      Covered Families and Children (CFC) and ABD membership, if
      applicable):  Incomplete Outpatient Hospital
      Data,
Rejected
      Encounters, Acceptance
      Rate, Encounter Data
      Accuracy, and Generic Provider Number Usage. 

    

    Data
      sets
      collected from MCPs with data quality standards include: encounter data; case
      management data; data used in the external quality review; members’ PCP data;
      and appeal and grievance data.

    

    1.
      ENCOUNTER DATA

    

    For
      detailed descriptions of the
      encounter data quality measures below, see ODJFS
      Methods for
the
      ABD
      and CFC Medicaid Managed Care Programs DataQuality
      Measures.

    

    1.a.  Encounter
      Data Completeness

    

    Each
      MCP’s encounter data submissions will be assessed for
      completeness.  The MCP is responsible for collecting information from
      providers and reporting the data to ODJFS in accordance with program
      requirements established in Appendix C, MCP
      Responsibilities.  Failure to do so jeopardizes the MCP’s
      ability to demonstrate compliance with other performance standards.

    

    1.a.i.
      Encounter Data Volume

    

    Measure:  The
      volume measure for each
      service category, as listed in Table 2 below, is the rate of utilization (e.g.,
      discharges, visits) per 1,000 member months (MM) for the ABD
      program. The measure will be
      calculated per
      MCP.

    

    Report
      Period:  The
      report periods for the SFY
      2008 and
      SFY 2009 contract periods are listed
      in Table
      1. below.

    

    Table
      1. Report Periods for the
      SFY  2008 and
      2009 Contract Periods

     

    
      	
              Report
                Period

            	
              Data
                Source:

              Estimated
                Encounter  Data File Update

            	
              Quarterly
                Report

              Estimated
                Issue
                Date

            	
              Contract
                Period

            
	
              Qtr
                1 2007

            	
              July
                2007

            	
              August
                2007

            	
              SFY  2008

              
              

            
	
              Qtr
                1, Qtr 2
                2007

            	
              October
                2007

            	
              November2007

            
	
              Qtr
                1 thru Qtr 3
                2007

            	
              January
                2008

            	
              February
                2008

            
	
              Qtr
                1 thru Qtr 4
                2007

            	
              April
 2008

            	
              May 2008

            
	
              Qtr
                1 thru Qtr 4 2007, Qtr 1
                2008

            	
              July
                2008

            	
              August
                2008

            	
              SFY
                2009

            
	
              Qtr
                1 thru Qtr 4
                2007,

              Qtr
                1, Qtr 2
                2008

            	
              October
                2008

            	
              November
                2008

            
	
              Qtr
                1 thru Qtr 4
                2007,

              Qtr
                1 thru Qtr 3
                2008

            	
              January
                2009

            	
              February
                2009

            
	
              Qtr
                1 thru Qtr 4
                2007,

              Qtr
                1 thru Qtr 4
                2008

               

            	
              April
                2009

            	
              May
                2009

            
	 Qtr1
              = January to March    Qtr2 = April to
              June    Qtr3
              = July to  September    Qtr 4 = October
              to December

    

    

    Data
      Quality
      Standard:  The
      utilization rate for all service categories listed in Table 2 must be equal
      to
      or greater than the interim
standards
      established in Table 2. below (Interim
      Standards - Encounter Data
      Volume).

    

    Statewide
      Approach:  Prior
      to establishment of
statewide
      minimum
      performance standards,
ODJFS
      will evaluate MCP
      performance using the interim standards for Encounter data volume. ODJFS will use the first
      four quarters
      of data (i.e., full calendar year quarters) from all MCPs serving ABD program membership
      to determine statewide
      minimum encounter volume data quality standards.

    

    Table
      2. Interim
Standards–
Encounter
      Data Volume

    

    
      	
              Category

            	
              Measure
                per 1,000/MM

            	
              Standard
                for Dates of
                Service

              on
                or after 1/1/2007

            	
              Description

            
	
              Inpatient
                Hospital

            	
              Discharges

            	
              2.7

            	
              General/acute
                care, excluding newborns and mental health and chemical dependency
                services

            
	
              Emergency
                Department

            	
              Visits

            	
              25.3

            	
              Includes
                physician and hospital emergency department encounters

            
	
              Dental

            	
              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

            

    

    

    Determination
      of
      Compliance: Performance is
      monitored once every quarter for the entire report period.  If the
      standard is not met for every service category in all quarters of the report
      period, then the MCP will be determined to be noncompliant for the report
      period.

    

    Penalty
      for
      noncompliance:  The first time an MCP is noncompliant with a
      standard for this measure, ODJFS will issue a Sanction Advisory informing the
      MCP that any future noncompliance instances with the standard for this measure
      will result in ODJFS imposing a monetary sanction. Upon all subsequent
      measurements of performance, if an MCP is again determined to be noncompliant
      with the standard, ODJFS will impose a monetary sanction (see Section 6.) of
      two
      percent of the current month’s premium payment.  Monetary
      sanctions will
      not be levied for
      consecutive quarters
      that an MCP is determined to be
      noncompliant.  If an MCP is noncompliant for three consecutive quarters, membership
      will
      be frozen. Once
      the MCP is determined to be
      compliant with the standard and the violations/deficiencies are resolved to
      the
      satisfaction of ODJFS, the penalties will be lifted, if applicable, and monetary
      sanctions will be returned.

    

    1.a.ii.Incomplete
      Outpatient Hospital Data

    

    ODJFS
      will be monitoring, on a quarterly basis, the percentage of hospital encounters
      which contain  a revenue code and CPT/HCPCS code. A CPT/HCPCS code
      must accompany certain revenue center codes. These codes are listed in Appendix
      B of Ohio Administrative Code rule 5101:3-2-21 (fee-for-service outpatient
      hospital policies) and in the methods for calculating the completeness
      measures.

    

    Measure:
      The percentage of outpatient hospital
      line
      items with certain revenue center codes, as explained above, which had an
      accompanying valid procedure (CPT/HCPCS) code.  The measure will be
      calculated per MCP.

    

    Report
      Period: The report periods for
      the  SFY 2008 and SFY 2009 contract periods are listed
      in  Table 3. below.

     

    Table
      3. Report Periods
      for the SFY 2008 and 2009 Contract Periods 

     

    
      	
              Quarterly
                Report
                Periods

            	
              Data
                Source:

              Estimated
                Encounter  Data File Update

            	
              Quarterly
                Report

              Estimated
                Issue
                Date

            	
              Contract
                Period

            
	
              Qtr  3
                &  Qtr 4  2004,  2005,
                2006

              Qtr
                1  2007

            	
              July
                2007

            	
              August
                2007

            	
              SFY
                2008

            
	
              Qtr
                3 & Qtr 4 2004, 2005,
                2006

              Qtr
                1, Qtr 2
                2007

            	
              October
                2007

            	
              November
                2007

            
	
              Qtr
                4 2004, 2005,
                2006

              Qtr
                1 thru Qtr 3
                2007

            	
              January
                2008

            	
              February
                2008

            
	
               Qtr
                1 thru Qtr 4: 2005, 2006,
                2007

            	
              April
                2008

            	
              May
                2008

            
	
              Qtr
                2 thru Qtr 4
                2005,

              Qtr
                1 thru Qtr 4: 2006,
                2007

              Qtr
                1 2008

            	
              July
                2008

            	
              August
                2008

            	
              SFY
                2009

            
	
              Qtr
                3, Qtr 4:
                2005,

              Qtr
                1 thru Qtr 4: 2006,
                2007

              Qtr
                1, Qtr 2
                2008

            	
              October
                2008

            	
              November
                2008

            
	
              Qtr
                4: 2005,

              Qtr
                1 thru Qtr 4: 2006,
                2007

              Qtr
                1 thru Qtr 3:
                2008

            	
              January
                2009

            	
              February
                2009

            
	
              
              

              Qtr
                1 thru Qtr 4: 2006, 2007,
                2008

            	
              April
                2009

            	
              May
                2009

            

    

    Qtr1
      = January to March    Qtr2
      = April to June    Qtr3
      = July to September    Qtr4
      = October to
      December

    

    Data
      Quality Standard: The
      data quality standard is a minimum rate of 95%.

    

    Determination
      of
      Compliance: Performance is
      monitored once every quarterfor all report
      periods.

    For
      quarterly reports that are issued on
      or after July 1, 2007, an MCP will be determined to be noncompliant for the
      quarter if the standard is not met in any report period and the initial instance
      of noncompliance in a report period is determined on or after July 1,
      2007.  An initial instance of noncompliance means that the result for
      the applicable report period was in compliance as determined in the prior
      quarterly report, or the instance of noncompliance is the first determination
      for an MCP’s first quarter of measurement.

    

    Penalty
      for
      noncompliance:  The first time an MCP is noncompliant with a
      standard for this measure, ODJFS will issue a Sanction Advisory informing the
      MCP that any future noncompliance instances with the standard for this measure
      will result in ODJFS imposing a monetary sanction.

    

    Upon
      all
      subsequent quarterly measurements of performance, if an MCP is again determined
      to be noncompliant with the standard, ODJFS will impose a monetary sanction
      (see
      Section 6) of one percent
      of the current month’s premium payment.  Once the MCP is performing at
      standard levels and violations/deficiencies are resolved to the satisfaction
      of
      ODJFS, the money will be refunded.

    

    1.a.iii.  Rejected
      Encounters

    

    Encounters  submitted
      to ODJFS that are incomplete or inaccurate are rejected and  reported
      back to the MCPs on the Exception Report.  If an MCP does not resubmit
      rejected encounters, ODJFS’ encounter data set will be incomplete.

    

    Measure
      1 only applies to
      MCPs that have had Medicaid
      membership for more
      than one year.

    

    Measure
      1:  The
      percentage of encounters submitted to ODJFS that are rejected.  The
      measure will be calculated per MCP.

    

    Report
      Period:  For the
      SFY 2008 contract period, performance will be evaluated using the following report
      periods July
      - September 2007; October -
      December 2007;  January - March 2008; April – June 2008. For
      the SFY 2009 contract period,
      performance will be evaluated using the following report periods July -
      September 2008; October - December 2008;  January - March 2009; April
– June 2009.

    

    Data
      Quality
      Standard for
      measure 1:  Data Quality
      Standard 1 is a maximum encounter data rejection rate of 10% for each
      file in the ODJFS-specified medium per
      format.  The
      measure will be calculated per
      MCP.

     

    Files
      in the ODJFS-specified medium per
      format that are totally rejected will not be considered in  the
      determination of noncompliance.

    

    Determination
      of
      Compliance:  Performance is monitored once every quarter.
      Compliance determination with the standard applies only to the quarter under
      consideration and does not include performance in previous
      quarters.

    

    Penalty
      for noncompliance
      with
the
      Data
      Quality Standardfor
      measure
1:  The
      first time
      an MCP is noncompliant with a standard for this measure, ODJFS will issue a
      Sanction Advisory informing the MCP that any future noncompliance instances
      with
      the standard for this measure will result in ODJFS imposing a monetary sanction.
      Upon all subsequent measurements of performance, if an MCP is again determined
      to be noncompliant with the standard, ODJFS will impose a monetary sanction
      (see
      Section 6.) of one percent of the current month’s premium
      payment.  The monetary sanction will be applied for each file type
      in the ODJFS-specified medium per
      format that is determined to be out of compliance.

    

    Once
      the
      MCP is performing at standard levels and violations/deficiencies are resolved
      to
      the satisfaction of ODJFS, the money will be refunded.

    

    Measure
      2 only applies to
      MCPs that have had Medicaid membership for one year or less.

    

    Measure
      2:  The
      percentage of encounters submitted to ODJFS that are rejected. The measure will be calculated
      per
      MCP.

    

    Report
      Period: The report period
      for Measure 2 is monthly.  Results are calculated and performance is
      monitored monthly. The first reporting month begins with the third month of
      enrollment.

    

    Data
      Quality Standard for
      measure
2:  The data
      quality standard is a maximum encounter data rejection rate for each file in the ODJFS-specified
      medium per
      format as follows:

    

    Third
      through sixth month with
      membership:  
50%

    

    Seventh
      through twelfth month with
      membership:  25%

    

    Files
      in the ODJFS-specified medium per
      format that are totally rejected will not be considered in the
      determination of noncompliance.

    

    Determination
      of
      Compliance:  Performance is monitored once every
      month.  Compliance determination with the standard applies only to the
      month under consideration and does not include performance in previous
      quarters.

    

    Penalty
      for Noncompliance
      with the
Data
      Quality
      Standardfor
      measure
2:  If
      the MCP is determined to be noncompliant for either standard, ODJFS will impose
      a monetary sanction of one percent
      of the MCP’s current month’s
      premium  payment.  The monetary sanction
      will
      be applied for each file type  in the ODJFS-specified medium per
      format that is determined to be out of compliance.  The monetary sanction
      will be applied
      only once per file type
per
      compliance
      determination period and will not exceed a total of two percent of the MCP’s
      current month’s premium payment.  Once the MCP
      is performing at standard levels and violations/deficiencies are resolved to
      the
      satisfaction of ODJFS, the money will be refunded.  Special
      consideration will be made for MCPs with less than 1,000 members.

    

    1.a.iv.  Acceptance
      Rate

    

    This
      measure only applies to
      MCPs that have had Medicaid membership for one year or less.

    

    Measure:  The
      rate
      of encounters that
      are submitted to ODJFS
      and accepted (i.e. accepted encounters
      per 1,000 member months).  The
      measure will be calculated per
      MCP.

    

    Report
      Period:  The
      report period for this measure is monthly.  Results are calculated and
      performance is monitored monthly. The first reporting month begins with the
      third month of enrollment.

    

    Data
      Quality
      Standard:  The data quality standard is a monthly minimum
      accepted rate of encounters for each file in the ODJFS-specified
      medium
      per format as follows:

    

    
      	
              Third
                through sixth month with
                membership:

            	 
	 	
              50
                encounters per 1,000 MM for
                NCPDP

            
	 	
              65
                encounters per 1,000 MM for
                NSF

            
	 	
              20
                encounters per 1,000 MM for
                UB-92

            

    

    

    
      	
              Seventh
                through twelfth month
                of membership:

            	 
	 	
              250
                encounters per 1,000 MM for
                NCPDP

            
	 	
              350
                encounters per 1,000 MM for
                NSF

            
	 	
              100
                encounters per 1,000 MM for
                UB-92

            

    

    

    Determination
      of
      Compliance:  Performance is monitored
      once every month. Compliance determination with the standard applies only to
      the
      month under consideration and does not include performance in previous
      months.

    

    Penalty
      for
      Noncompliance:  If the MCP is determined to be noncompliant
      with the standard, ODJFS will impose a monetary sanction of one percent of
      the
      MCP’s current month’s premium payment.  The monetary sanction will be
      applied
      for each file type  in the ODJFS-specified medium per format that is
      determined to be out of compliance. The monetary sanction
      will be applied
      only once per file
      type per
      compliance determination period and
      will not exceed a total of two percent ofthe
      MCP’s current month’s premium
      payment.  Once the MCP is performing at standard levels and
      violations/deficiencies are resolved to the satisfaction of ODJFS, the money
      will be refunded.  Special consideration will be
      made for
      MCPs with less than 1,000 members.

    

    1.a.v.
      Informational Encounter Data
      Completeness Measure

    

    The
‘Incomplete
      Data for Last Menstrual
      Period’ measure is informational only for the ABD
      population.  Although there is no minimum performance standard for
      this measure, results will be reported and used as one component in monitoring
      the quality of data submitted to ODJFS by the MCPs.

    

    1.b.  Encounter
      Data
      Accuracy

    

    As
      with data completeness, MCPs are
      responsible for assuring the collection and submission of accurate data to
      ODJFS.  Failure to do so jeopardizes MCPs’ performance, credibility
      and, if not corrected, will be assumed to indicate a failure in actual
      performance.

    

    1.b.i.  Encounter
      Data
Accuracy Study

    

    Measure:  This
      accuracy study will
      compare the accuracy and completeness of  payment data stored
      in  MCPs’ claims systems during the study period to payment data
      submitted to and accepted by ODJFS. The measure will be calculated per
      MCP.

    

    Payment
      information found in MCPs’
claims systems for paid claims that does not match payment information found
      on
      a corresponding encounter will be counted as omissions.

    

    Report
      Period:  In order
      to provide timely feedback on the omission rate of encounters, the report period
      will be the most recent from when the measure is initiated.  This
      measure is conducted annually.

    

    Data
      Quality
      Standard for Measure:   TBD for SFY 2008 and
      SFY 2009.

    

    Penalty
      for
      Noncompliance:  The
      first time an MCP is noncompliant
      with a standard for this measure, ODJFS will issue a Sanction Advisory informing
      the MCP that any future noncompliance instances with the standard for this
      measure will result in ODJFS imposing a monetary sanction.

    

    Upon
      all subsequent measurements of
      performance, if an MCP is again determined to be noncompliant with the standard,
      ODJFS will impose a monetary sanction (see Section 6.)
      of one percent
      of the current month’s premium
      payment.  Once the MCP is performing at standard levels and
      violations/deficiencies are resolved to the satisfaction of ODJFS, the money
      will be refunded.

    

    1.b.ii.  Generic
      Provider Number Usage

    

    Measure:
      This measure is the
      percentage of non-pharmacy encounters with the generic provider
      number.  Providers submitting claims which do not have an MMIS
      provider number must be submitted to ODJFS with the generic provider number
      9111115.  The measure will be calculated per MCP.

    

    All
      other
      encounters are required to have the MMIS provider number of the servicing
      provider.  The report period for this measure
      is  quarterly.

    

    Report
      Period:  For
      the SFY 2008 and SFY 2009 contract
      period, performance will be evaluated using the report periods listed in
      1.a.iii., Table 3.

    

    Data
      Quality Standard: A
      maximum generic provider
number
usage
      rate of 10%.

    

    Determination
      of
      Compliance: Performance is
monitored
      once every
      quarter for all report periods.  For
      quarterly reports that are issued on
      or after July 1, 2007, an MCP will be determined to be noncompliant for the
      quarter if the standard is not met in any report period and the initial instance
      of noncompliance in a report period is determined on or after July 1,
      2007.  An initial instance of noncompliance means that the result for
      the applicable report period was in compliance as determined in the prior
      quarterly report, or the instance of noncompliance is the first determination
      for an MCP’s first quarter of measurement.

    

    Penalty
      for
      noncompliance:   The first time an MCP is noncompliant
      with a standard for this measure, ODJFS will issue a Sanction Advisory informing
      the MCP that any future noncompliance instances with the standard for this
      measure will result in ODJFS imposing a monetary sanction. Upon all subsequent
      measurements of performance, if an MCP is again determined to be noncompliant
      with the standard, ODJFS will impose a monetary sanction (see Section 6.) of
      three percent of the current month’s premium payment.  Once the MCP is
      performing at standard levels and violations/deficiencies are resolved to the
      satisfaction of ODJFS, the money will be refunded.

    

    1.c.
      Timely Submission of Encounter Data

    

    1.c.i.  Timeliness

    

    ODJFS
      recommends submitting encounters no later than thirty-five days after the end
      of
      the month in which they were paid.  ODJFS does not monitor standards
      specifically for timeliness, but the minimum claims volume (Section 1.a.i.)
      and
      the rejected encounter (Section 1.a.iv.) standards are based
      on
      encounters being submitted within this time frame.

    

    1.c.ii.  Submission
      of Encounter Data Files
      in the ODJFS-specified medium per
      format

    

    Information
      concerning the proper submission of encounter data may be obtained from the
      ODJFS Encounter Data File
      Submission Specifications document.  The MCP must submit a
      letter of certification, using the form required by ODJFS, with each
      encounter data file in the
      ODJFS-specified medium per format.

    

    The
      letter of certification must be signed by the MCP’s Chief Executive Officer
      (CEO), Chief Financial Officer (CFO), or an individual who has delegated
      authority to sign for, and who reports directly to, the MCP’s CEO or
      CFO.

    
       

      2.
        CASE MANAGEMENT DATA 

    ODJFS
      designed a case management system
      (CAMS) in order to monitor MCP compliance with program requirements
      specified in Appendix G, Coverage and
      Services.  Each MCP’s case management data submissions will be
      assessed for completeness and accuracy.   The MCP is responsible
      for submitting a case
      management file every
      month.  Failure to do so jeopardizes the MCP’s
      ability to demonstrate compliance
      with case management
requirements.   For
      detailed descriptions of the case management measures below, see ODJFS
      Methods for
      the ABD  and CFC Medicaid Managed Care Programs Data Quality
      Measures.

    

    2.a.   Case
      Management System Data Accuracy

    

    2.a.i.
      Open Case Management Spans for
      Disenrolled Members (this measure will
      be discontinued
      as of January 2008)

    

    Measure:  The
      percentage of the MCP’s case management records in
      CAMS for the ABD
      program that have open case
      management date spans for members who have disenrolled from the
      MCP.

    

    Report
      Period: For
      the third and fourth
      quarters of SFY 2007, January
–
March
      2007, and April – June
      2007 report periods. For
      the  SFY
      2008 contract period,  July – September
      2007, and October
–
December
      2007 report
      periods.

    

    Data
      Quality
      Standard:  A rate of open case management spans for disenrolled
      members of no more than 1.0%.

    

    Statewide Approach:  MCPs
      will be evaluated using
      a statewide resultspecific
      for the ABD program,
      including all regions in which an MCP has ABD membership.  An
      MCP will not
      be evaluated until the MCP has at least 3,000 ABD members
      statewide. As
      the ABD Medicaid managed care program
      expands statewide and regions become active in different months, statewide
      results will include
      every region in which an MCP has
      membership [Example:  MCP AAA has: 6,000 members in the South West
      region beginning in January 2007; 7,000 members in the West Central
      regionbeginning
      in February 2007; and 8,000
      members in the South East region beginning in March 2007. MCP AAA’s statewide
      results for the April-June 2007 report period will include data for the South
      West, West Central, and South East regions.] 

    

    Penalty
      for
      noncompliance:   If an MCP is noncompliant with the
      standard, then the ODJFS will issue a Sanction Advisory informing the MCP that
      a
      monetary sanction will be imposed if the MCP is noncompliant for any future
      report periods.  Upon all subsequent semi-annual measurements of
      performance, if an MCP is again determined to be noncompliant with the standard,
      ODJFS will impose a monetary sanction of one-half of one percent of the current
      month’s premium payment. Once the MCP is performing at standard levels and
      violations/deficiencies are resolved to the satisfaction of ODJFS, the money
      will be refunded.

    

    2.b.  Timely
      Submission of Case Management Files

    

    Data
      Quality Submission
      Requirement: The MCP must submit Case Management files on a monthly basis
      according to the specifications established in ODJFS’ Case Management File and
      Submission Specifications.

    

    Penalty
      for noncompliance:
      See Appendix N, Compliance
      Assessment System, for the
      penalty for noncompliance with this requirement.

    
       

      3.
        EXTERNAL QUALITY REVIEW DATA 

    In
      accordance with federal law and regulations, ODJFS  is required to
      conduct an independent quality review of contracting managed care
      plans.  The OAC rule 5101:3-26-07(C) requires MCPs  to
      submit data and information as requested by ODJFS or its designee for the annual
      external quality review.

    

    Two
      information sources are integral to these studies: encounter data and medical
      records. Because encounter data is used to draw samples for these studies,
      quality must be sufficient to ensure valid sampling.

    

    An
      adequate number of  medical records must then be retrieved from
      providers and submitted to ODJFS or its designee in order to generalize results
      to all applicable members.  To aid MCPs in achieving the required
      medical record submittal rate, ODJFS will give at least an eight week period
      to
      retrieve and submit medical records.

     

    3.a.
      Independent External Quality Review

    

    Measure:  The
      percentage of requested records for
      a study conducted by the External Quality Review Organization (EQRO) that are
      submitted by the managed care plan.

    

    Report
      Period:  The
      report period is one year. Results are calculated and performance is monitored
      annually.  Performance is measured with each review.

    

    Data
      Quality Standard: A
      minimum record submittal rate of 85% for each clinical measure.

    

    Penalty
      for noncompliance for Data
      Quality Standard:  For each study that is completed during this
      contract period, if an MCP is noncompliant with the standard, ODJFS will impose
      a non-refundable $10,000 monetary sanction.

    

    4.  MEMBERS’
      PCP DATA

    

    The
      designated PCP is the
provider who will manage
      and coordinate the overall care for ABD members including those who have case
      management needs.  The MCP must submit  a Members’
Designated PCP file every month.  Specialists may and should be
      identified as the PCP as appropriate for the member’s
      condition per the specialty
      types specified for the ABD population in ODJFS Member’s
      PCP Data
      File and Submission Specifications; however, no ABD member
      may have more
      than one PCP identified for
      a given month. 

    

    4.a.  Timely
      submission of Member’s PCP Data

    

    Data
      Quality Submission
      Requirement:  The MCP must submit a Members’ Designated PCP
      Data files on a monthly basis according to the specifications established in
      ODJFS Member’s
      PCP Data File and
      Submission Specifications.

    

    Penalty
      for
      noncompliance:  See Appendix N, Compliance
      Assessment
      System, for the penalty for noncompliance with this
      requirement.

    

    4.b.  Designated
      PCP for newly enrolled members (applicable
      for report periods prior
      to January 2008)

    

    Measure:  The
      percentage of MCP’s newly enrolled
      members who were designated a PCP by their effective date of
      enrollment.

    

    Report
      Periods:  For
      the third and fourth
      quarters
      of SFY 2007 contract period, performance will be evaluated quarterly using
      the
      January – March 2007 and April – June 2007 report periods. For the SFY 2008
      contract period, performance will be evaluated quarterly using the
      July-September 2007, and October–
December 2007 report
      periods.

    

    Data
      Quality
      Standard:  A
      minimum rate of  65% of new members with PCP designation by their
      effective date of enrollment for quarter 3 and quarter 4 of SFY
      2007.  A
      minimum rate of 75% of new members
      with PCP designation by their effective date of enrollment for quarter 1 and
      quarter 2 of SFY 2008.

    

    Statewide
      Approach:  MCPs
      will be evaluated using a statewide result, including all regions in which
      an
      MCP has ABD membership.  An MCP will not be evaluated until the
      MCP has at least 3,000 ABD members statewide.

    

    Penalty
      for
      noncompliance:  If an MCP is noncompliant
      with the
      standard, ODJFS will impose a monetary sanction of one-half of one percent of the
      current month’s premium
      payment.  Once the MCP is performing at standard levels and
      violations/deficiencies are resolved to the satisfaction of ODJFS, the money
      will be refunded.  As stipulated in OAC
      rule
      5101:3-26-08.2, each new member must have a designated primary care
      provider (PCP) prior to their
      effective date of coverage.  Therefore, MCPs are subject to additional
      corrective action measures
      under Appendix N, Compliance Assessment System, for failure to meet this
      requirement.

    

    4.b.i.  Designated
      PCP for
      newly enrolled members (applicable for report
      periods after
      December 2007)

    

    Measure:  The
      percentage of MCP’s newly enrolled members who were designated a PCP by their
      effective date of enrollment.

    

    Report
      Periods:  For the SFY 2009 contract period, performance will be
      evaluated annually using CY 2008.

    

    Data
      Quality Standards:  For SFY 2009, a minimum rate of 85% of new members
      with PCP designation by their effective date of enrollment.

    

    Statewide
      Approach:  MCPs will be evaluated using a statewide result,
      including all regions in which an MCP has ABD membership.  An MCP will
      not be evaluated until the MCP has at least 3,000 ABD members
      statewide.

    

    Penalty
      for
      noncompliance:  If an MCP is noncompliant with the standard,
      ODJFS will impose a monetary sanction of one-half of one percent of the current
      month’s premium payment.  Once the MCP is performing at standard
      levels and violations/deficiencies are resolved to the satisfaction of ODJFS,
      the money will be refunded.  As stipulated in OAC rule 5101:3-26-08.2,
      each new member must have a designated primary care provider (PCP) prior to
      their effective date ofcoverage.  Therefore,
      MCPs are subject to additional corrective action measures under Appendix N,
      Compliance Assessment System, for failure to meet this requirement.

     

    5.
      APPEALS AND GRIEVANCES DATA

    

    Pursuant
      to OAC rule 5101:3-26-08.4, MCPs are required to submit information at least
      monthly to ODJFS regarding appeal and grievance activity.  ODJFS
      requires these submissions to be in an electronic data file format pursuant
      to
      the Appeal File and Submission
      Specifications and Grievance File and
      Submission
      Specifications.

    

    The
      appeal data file and the grievance data file must include all appeal and
      grievance activity, respectively, for the previous month, and must be submitted
      by the ODJFS-specified due date.  These data files must be submitted
      in the ODJFS-specified format and with the ODJFS-specified filename in order
      to
      be successfully processed.

    

    Penalty
      for
      noncompliance:  MCPs who fail to submit their monthly
      electronic data files to the ODJFS by the specified due date or who fail to
      resubmit, by no later than the end of that month, a file which meets the data
      quality requirements will be subject to penalty as stipulated under the Compliance Assessment System
      (Appendix
      N).

    

    6.  NOTES

     

    
      6.a.  
Penalties,
        Including Monetary
        Sanctions, for Noncompliance

    Penalties
      for noncompliance with standards outlined in this appendix, including monetary
      sanctions, will be imposed as the results are finalized.  With the
      exception of  Sections
      1.a.i., 1.a.iii.,
      1.a.iv., 1.a.v.,
      and 1.b.ii no
      monetary sanctions described in
      this appendix will be imposed if the MCP is in its
      first
      contract year of Medicaid program participation.  Notwithstanding the
      penalties specified in this Appendix, ODJFS reserves the right to apply the
      most
      appropriate penalty to the area of deficiency identified when an MCP is
      determined to be noncompliant with a standard.  Monetary penalties for
      noncompliance with any individual measure,  as determined in this
      appendix,  shall not exceed $300,000 during each
      evaluation.

    

    Refundable
      monetary sanctions will be based on
      the
      premium payment in the month of  the cited deficiency and due within
      30 days of notification by ODJFS to the MCP of the amount.

    

    Any
      monies collected through the imposition of such a sanction will be returned
      to
      the MCP (minus any applicable collection fees owed to the Attorney General’s
      Office, if the MCP has been delinquent in submitting payment) after the MCP
      has
      demonstrated full compliance with the particular program requirement and the
      violations/deficiencies are resolved to the satisfaction of ODJFS.  If
      an MCP does not comply within two years of the date of notification of
      noncompliance, then the monies will not be refunded.

    

    6.b.
      Combined Remedies

    

    If
      ODJFS
      determines that one systemic problem is responsible for multiple deficiencies,
      ODJFS may impose a combined remedy which will address all areas of deficient
      performance.  The total fines assessed
      in any one month will not exceed
      15% of the MCP’s monthly premium payment for the Ohio Medicaid
      program.

    

    6.c.  Membership
      Freezes

    

    MCPs
      found to have a pattern of repeated or ongoing noncompliance may be subject
      to a
      membership freeze.

    

    6.d.  Reconsideration

    

    Requests
      for reconsideration of monetary
      sanctions and enrollment freezes may be submitted as provided in Appendix N,
      Compliance
      Assessment System.

    

    6.e.  Contract
      Termination, Nonrenewals, or Denials

    

    Upon
      termination either by the MCP or ODJFS, nonrenewal, or denial of an MCP provider
      agreement, all previously collected refundable monetary sanctions will be
      retained by ODJFS.

     

    

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

      APPENDIX
        M

      

      PERFORMANCE
        EVALUATION

      ABD
        ELIGIBLE
        POPULATION

      

      This
        appendix establishes minimum performance standards for
        managed care
        plans (MCPs) in key program areas, under the Agreement.  Standards
        are subject to
        change based on the revision or update of applicable national standards,
        methods, benchmarks,
        or other factors as deemed
        relevant.  Performance will be
        evaluated in the categories of Quality of Care, Access, Consumer Satisfaction,
        and Administrative Capacity.  Each performance measure has an
        accompanying minimum performance standard. MCPs with performance levels below
        the minimum performance standards will be required to take corrective
        action. All
        performance measures, as specified
        in this appendix, will be calculated per MCP and include only members in
        the ABD
        Medicaid managed
care
        program.

       

      Selected
        measures in this appendix will be used to determine incentives as specified
        in
Appendix O, Pay
        for Performance
        (P4P).

      

      1.  QUALITY
        OF CARE

      

      1.a.
        Independent External Quality
        Review

      

      In
        accordance with federal law and
        regulations, state Medicaid agencies must annually provide for an external
        quality review of the quality outcomes and timeliness of, and access to,
        services provided by Medicaid-contracting MCPs [(42 CFR
        438.204(d)].  The external review assists the state in assuring MCP
        compliance with program requirements and facilitates the collection of accurate
        and reliable information concerning MCP performance.

      

      Measure:  The
        independent
        external quality reviewcovers a review of
        clinical and
        non-clinical performance as outlined in Appendix K.

      

      Report
        Period:  Performance
        will be evaluated using the reviews conducted during SFY 2008.

      

      Action
        Required for
        Deficiencies:  For all reviews conducted during the contract period,
        if the EQRO cites a deficiency in performance the MCP will be required to
        complete a Corrective Action Plan or Quality Improvement Directive, depending
        on
        the severity of the deficiency. Serious deficiencies may result in immediate
        termination or non-renewal of the Agreement.

      

      1.b.  Members
        with Special Health Care Needs (MSHCN)

      

      Given
        the substantial proportion of
        members with chronic conditions and co-morbidities in the ABD population,
        one of
        the quality of care initiatives of the ABD Medicaid managed
care
        program focuses on case
        management.  In order to ensure state compliance with  the
        provisions of 42 CFR 438.208, the
        Bureau of Managed Health Care
        established Members with Special Health Care Needs (MSHCN) basic program
        requirements as set
        forth in Appendix G,
Coverage
        and
        Services of the
Agreement,  and
        corresponding minimum
        performance standards as described below. The purpose of these measures is
        to
        provide appropriate and targeted case management services to MSHCN who have
        specific diagnoses and/or who require high-cost or extensive
        services.  Given
        the expedited schedule for implementing the ABD Medicaid managed care program,
        coupled with the challenges facing a new Medicaid program in the State of
        Ohio,
        the minimum performance standards for
        the case management requirements for MSHCN are phased in throughout SFY 2007
        and
        SFY 2008.  The minimum standards for these performance measures will
        be fully phased in by no later than SFY 2009.  For detailed
        methodologies of each measure, see ODJFS
        Methods for
        the ABD Medicaid Managed Care Program’s Case Management Performance
        Measures.

      

      1.b.i
Case
Management
        of
        Members

      

      Measure:
        The average monthly
        case
management rate for
        members
        who have at least three months of consecutive enrollment in one MCP.

      

      Report
        Period: For
        the SFY 2007 contract period, April
– June 2007 report period. For
        the SFY 2008 contract
        period,  July – September 2007, October
– December 2007,
        January – March 2008, and April – June 2008 report periods. For the SFY 2009 contract
        period,  July – September 2008, October – December 2008, January –
March 2009, and April – June 2009 report periods.

      

      Statewide
        Approach:  MCPs
        will be evaluated using a statewide result, including all regions in which
        an
        MCP has membership.  An MCP will not be evaluated until the MCP has at
        least 3,000 members statewide who have had at least three months of continuous
        enrollment during each month of the entire report period.  As the ABD
        Medicaid managed care program expands statewide and regions become active
        in
        different months, statewide results will include every region in which an
        MCP
        has membership [Example:  MCP AAA has: 6,000 members in the South West
        region beginning in January 2007; 7,000 members in the West Central region
        beginning in February 2007; and 8,000 members in the South East region beginning
        in March 2007.  MCP AAA’s statewide results for the April-June 2007
        report period will include case management rates for all members who meet
        minimum continuous enrollment criteria for this measure in: the South West
        region for April 2007’s monthly rate calculation; the South West
        and  West Central regions for May 2007’s monthly rate calculation; and
        the South West, West Central, and South East regions for June 2007’s monthly
        rate calculation.]

      

      Statewide
        Target:  For the first and second quarters of SFY 2008, a case
        management rate of 30%.  For the third and fourth quarters of SFY
        2008, a case management rate of 35%.  For the first and second
        quarters of SFY 2009, a case management rate of 40%.  For the third
        and fourth quarters of SFY 2009, a case management rate of 45%.

      

      Statewide
        Minimum Performance
        Standard:  The level of improvement must result in at least a
        20% decrease in the difference between the target and the previous report
        period’s results.

      

      Penalty
        for
        Noncompliance: The
        first time an MCP is noncompliant
        with a standard for this measure, ODJFS will issue a Sanction Advisory informing
        the MCP that any future noncompliance instances with the standard for this
        measure will result in ODJFS imposing a monetary sanction.  Upon all
        subsequent measurements of performance, if an MCP is again determined to
        be
        noncompliant with the standard, ODJFS will impose a monetary sanction (see
        Section 5) of two percent of the current month’s premium payment. Monetary
        sanctions will not be levied for consecutive quarters that an MCP is determined
        to be noncompliant.  If an MCP is noncompliant for a subsequent
        quarter, new member selection freezes or a reduction of assignments will
        occur
        as outlined in Appendix N of the Provider Agreement. Once
        the MCP is performing at standard
        levels and the violations/deficiencies are resolved to the satisfaction of
        ODJFS, the penalties
        will be lifted, if applicable,
        and monetary sanctions will be returned.

      

      1.b.ii.
        Case Management of Members with
        an ODJFS-Mandated Condition

      

      Measure
        1:  The percent
        of members with a positive identification through an ODJFS administrative
        review
        of data for the ODJFS-mandated case management condition
        of  asthma who
        have had at least three consecutive
        months of enrollment in one MCP that are case
        managed.

      

      Measure
        2:  The percent
        of members with a positive identification through an ODJFS administrative
        review
        of data for the ODJFS-mandated case management condition
        of  chronic
        obstructive pulmonary disease who
        have had at least three consecutive
        months of enrollment in one MCP that are case
        managed.

      

      Measure
        3:  The percent
        of members with a positive identification through an ODJFS administrative
        review
        of data for the ODJFS-mandated case management condition
        of  congestive
        heart failure   who
        have had at least three
        consecutive months of enrollment in one MCP that are case
        managed.

      

      Measure
        4:  The
        percent of members with a positive identification through an ODJFS
        administrative review of data for the ODJFS mandated case management condition
        of behavioral health who have had at least three consecutive months of
        enrollment in one MCP that are case managed.

      

      Measure
        5:  The
        percent of members with a positive identification through an ODJFS
        administrative review of data for the ODJFS-mandated case management condition
        of  diabetes who have had at least three consecutive months of
        enrollment in one MCP that are case managed.

      

      Measure
        6:  The
        percent of members with a positive identification through an ODJFS
        administrative review of data for the ODJFS-mandated case management condition
        of  non-mild hypertension who have had at least three consecutive
        months of enrollment in one MCP that are case managed.

      

      Measure
        7:  The
        percent of members with a positive identification through an ODJFS
        administrative review of data for the ODJFS-mandated case management condition
        of  coronary arterial disease who have had at least three consecutive
        months of enrollment in one MCP that are case managed.

      

      Report
        Periods for Measures 1-
        7:   For the SFY 2007 contract period April – June 2007
        report periods.  For the SFY 2008 contract period,  July – September
        2007, October – December 2007, January – March 2008, and April – June 2008
        report periods.  For the SFY 2009 contract
        period,  July – September 2008, October – December 2008, January –
March 2009, and April – June 2009 report periods. 

      

      Statewide
Approach:  MCPs
        will be evaluated using
        a statewide result, including all regions in which an MCP has
        membership.  An MCP will not be evaluated until the MCP has at least
        3,000 members statewide who have had at least three months of continuous
        enrollment during each month of the entire report period.  As the ABD
        Medicaid managed care programs expands statewide and regions become active
        in
        different months, statewide results will include every region in which an
        MCP
        has membership [Example:  MCP AAA has: 6,000 members in the South West
        region beginning in January 2007; 7,000 members in the West Central region
        beginning in February 2007; and 8,000 members in the South East region beginning
        in March 2007.  MCP AAA’s statewide results
        for the
        April-June 2007 report period will include case management rates for all
        members
        in the South West, West Central, and South East regions who are identified
        through the administrative data review as having a mandated condition and
        are
        continuously enrolled for at least three consecutive months in one
        MCP.]

      

      Statewide
        Target for Measures 1, 2,
        3, 5, 6, and 7:  For the first and second quarters of SFY 2008,
        a case management rate of 60%.  For the third and fourth quarters of
        SFY 2008, a case management rate of 65%.  For SFY 2009, a case
        management rate of 75%.

      

      Statewide
        Minimum Performance
        Standard:  The level of improvement must result in at least a
        20% decrease in the difference between the target and the previous report
        period’s results.

      

      Statewide
        Target for Measure
        4:  For the first and second quarters of SFY 2008, a case
        management rate of 30%.  For the third and fourth quarters of SFY
        2008, a case management rate of 35%.  For SFY 2009, the case
        management rate is TBD.

      

      Statewide
        Minimum Performance
        Standard:  The level of improvement must result in at least a
        20% decrease in the difference between the target and the previous report
        period’s results.

      

      Penalty
        for
        Noncompliance for
Measures
        1-7:  The first
        time an MCP is noncompliant with a standard for this measure, ODJFS will
        issue a
        Sanction Advisory informing the MCP that any future noncompliance instances
        with
        the standard for this measure will result in ODJFS imposing a monetary
        sanction.  Upon all subsequent measurements of performance, if an MCP
        is again determined to be noncompliant with the standard, ODJFS will impose
        a
        monetary sanction (see Section 5) of two percent of the current month’s premium
        payment. Monetary sanctions will not be levied for consecutive quarters that
        an
        MCP is determined to be noncompliant.  If an MCP is noncompliant for a
        subsequent quarter, new member selection freezes or a reduction of assignments
        will occur as outlined in Appendix N of the Provider Agreement. Once
        the MCP is performing at
standard levels and
        the
        violations/deficiencies are resolved to the satisfaction of ODJFS, the
        penalties will be lifted, if
        applicable, and monetary sanctions will be returned.

      

      1.c.
        Clinical Performance
        Measures

      

      MCP
        performance will be assessed based on the analysis of submitted encounter
        data
        for each year. For certain measures, standards are established; the
        identification of these standards is not intended to limit the assessment
        of
        other indicators for performance improvement activities.  Performance
        on multiple measures will be assessed and reported to the MCPs and others,
        including Medicaid consumers.

      

      The
        clinical performance measures described below closely follow the National
        Committee for Quality Assurance’s
(NCQA)
        Health Plan
        Employer Data and Information Set (HEDIS).  NCQA may annually change
        its method for calculating a measure.  These changes can make it
        difficult to evaluate whether improvement occurred from a  prior
        year.  For this reason, ODJFS will use the same
        methods to calculate the baseline results and the results for the period
        in
        which the MCP is being held
        accountable.  For example, the same methods are used
        to calculate calendar year  2008 results
        (the baseline period) and
        calendar year  2009 results.  The methods will be updated
        and a new baseline will be created during  2009 for
        calendar  year 2010  results.  These results will
        then serve as the baseline to evaluate whether improvement occurred from
        calendar  year 2009 to calendar year  2010. 
        Clinical performance measure results
        will be calculated after a sufficient amount of time has passed after the
        end of
        the report period in order to allow for claims runout.  For a
        comprehensive description of the clinical performance measures below, see
        ODJFS
        Methods for Clinical Performance Measures, ABD
Medicaid
        Managed
        Care Program.  Performance standards
        are subject to
        change, based
        on the revision or update of NCQA
        methods or other national
        standards, methods or benchmarks.

      

      MCPs
        will be evaluated using a statewide
        result, including all regions in which an MCP has
        membership.  ODJFS will use the
        first calendar year
        of an MCP’s ABD managed care program membership as
        the baseline year (i.e.,
        CY2007).  The
        baseline year will be
        used to determine performance standards and targets; baseline data will
come
        from a combination of
        FFS claims data and MCP encounter
        data.  For those
        performance measures that require two calendar years of baseline data, the
        additional calendar year (i.e., the calendar year prior to the first calendar
        year of ABD managed care program
        membership, i.e.,
        CY2006)
        data will come
        from FFS claims data. 

      

      An
        MCP’s second calendar
        year of
        ABD managed care program membership
(i.e., CY2008)
will
        be the initial report period of
        evaluation for performance measures that require one calendar year of
baseline
        data(i.e., CY2007),
        and for performance measures that
        require two calendar years
of
        baseline data (i.e.,
        CY2006and
        CY2007).

      

      Report
        Period:  For the
        SFY 2008 contract
        period, performance will be
        evaluated using the January - December 2007 report
        period and may be adjusted
        based on the number
        of months of ABD managed care membership.  For the SFY 2009
contract
        period, performance will be
        evaluated using the January - December 2008 report
        period.

      

      1.c.i.  Congestive
        Heart
        Failure (CHF) – Inpatient Hospital
Discharge
        Rate

      

      Measure:  The
        number
        of  acute inpatient hospital discharges in the reporting year
        where the
        principal diagnosis was CHF, per thousand member
        months, for members
        who had a
        diagnosisof CHF in the year
        prior to the reporting year.

      

      Target:  TBD

      

      Minimum
        Performance
        Standard:  The
        level of improvement must result in at least a TBD% decrease
        in the difference between the
        target and the previous report period’s results. (For example, if last year’s
        results were TBD%,
then
        the difference between
        the target and last year’s results is TBD%.  In
        this example, the
        standard is an improvement in performance of TBD%
        of this difference or TBD%.
        In this example, results of
TBD%
        or better would be compliant with the
        standard.)

      

      

      Action
        Required for
        Noncompliance:  If the standard is
        not met and the
        results are below TBD%,
        the MCP is required to complete a
Corrective Action Plan  to address the area of
        noncompliance.  If the standard is not met and the results are at or
        above TBD%,  ODJFS will
        issue a Quality Improvement Directive which will notify the MCP of noncompliance
        and may outline the steps that the MCP must take to improve the
        results.

      

      1.c.ii.  Congestive
        Heart
        Failure (CHF) – Emergency Department (ED) Utilization Rate

      

      Measure:  The
        number of emergency department
visits
        inthe reporting year
        where the primary
        diagnosis was CHF, per
        thousand member months,
for
        members who had
a diagnosis of
 CHF
        in the year prior to the
        reporting year.

      

      Target:  TBD

      

      Minimum
        Performance
        Standard:  The
        level of improvement must result in at least a TBD%
        decrease in the difference between the
        target and the previous report period’s results.

      

      Action
        Required for
Noncompliance:  If
        the standard is not met and the results are below TBD%,  the MCP is
        required to complete a Corrective Action Plan  to address the area of
        noncompliance.  If the standard is not met and the results are at or
        above TBD%,  ODJFS will issue a Quality Improvement Directive which
        will notify the MCP of noncompliance and may outline the steps that the MCP must
        take to
        improve the results.

      

      1.c.iii.
Congestive
        Heart Failure (CHF) –
Cardiac Related Hospital
Readmission

      

      Measure:  The
rateof
        cardiac related readmissions
during the reporting
        period
for members who had
        a diagnosis of CHF
        in the year prior to the
        reporting period.  A readmission is defined as a cardiac related
        admission that occurs within 30 days of  a prior cardiac related
        admission.

      

      Target:  TBD.

      

      Minimum
        Performance
        Standard:  The
        level of improvement must result in
        at least a TBD%  decrease
        in the difference
        between the target and the previous year’s results.

      

      Action
        Required for
        Noncompliance:  If
        the standard is not met and the
        results are below TBD%,  the
        MCP is required to
        complete a Corrective Action Plan 
        to address the area of noncompliance.
        If the standard is not met and the results are at or above TBD%,  ODJFS
        will issue a Quality
        Improvement Directive which will notify the MCP of noncompliance and may
        outline
        the steps that the MCP must take to improve the results.

      

      1.c.iv.  Coronary
        Artery Disease
        (CAD) – Inpatient HospitalDischarge
        Rate

      

      Measure:  The
        number
        of  acute inpatient hospital discharges in the reporting year
        where the primary
        diagnosis was CAD,  per thousand member
        months,
        for members who had
a
        diagnosis of  CAD in the year prior
        to
        the reporting year.

      

      Target:  TBD

      

      Minimum
        Performance
        Standard:  The
        level of improvement must result in at least a TBD%
        decrease in the difference between the
        target and the previous report period’s results.

      

      Action
        Required for
        Noncompliance:  If the standard is
        not met and the
        results are below TBD%,  the
        MCP is required to
        complete a Corrective Action Plan 
        to address the area of
        noncompliance. If
        the standard is not met and the
        results are at or above TBD%,
        ODJFS will issue a Quality
        Improvement Directive which will notify the MCP of noncompliance and may
        outline
        the steps that the MCP must take to improve the results.

      

      1.c.v.  Coronary
        Artery Disease
        (CAD) – Emergency Department (ED) Utilization Rate

      

      Measure:  The
        number
        of  emergency department visitsin the reporting year
        where the
        principal diagnosis was CAD,  per thousand member
        months,
        for members who had a
        diagnosisof CAD in the year
        prior to the reporting year.

      

      Target:  TBD

      

      Minimum
        Performance
        Standard:  The
        level of improvement must result in at least a TBD%
        decrease in the difference between the
        target and the previous report period’s results.

      

      Action
        Required for
        Noncompliance:  If the standard is
        not met and the
        results are below TBD%,  the
        MCP is required to
        complete a Corrective Action Plan  to
        address the area of
        noncompliance.  If
        the standard is not met and the
        results are at or above TBD%,  ODJFS
        will issue a Quality
        Improvement Directive which will notify the MCP of noncompliance and may
        outline
        the steps that the MCP must take to improve the results.

      

      1.c.vi.
Coronary
        Artery Disease (CAD) –
Cardiac Related Hospital
Readmission

      

      Measure:  The
rate
of
        cardiac related readmissions
in the reporting year
        for members who had
        a diagnosis of
        CAD in the year prior to the
        reporting year.  A
        readmission is defined as
        a cardiac related admission that occurs within 30 days of  a prior
        cardiac related admission.

      

      Target:  TBD.

      

      Minimum
        Performance
        Standard:  The
        level of improvement must result in
        at least a TBD%
        decrease in the difference between the
        target and the previous year’s results.

      

      Action
        Required for
        Noncompliance:  If
        the standard is not met and the
        results are below TBD%,  the
        MCP is required to
        complete a Corrective Action
        Plan  to
        address the area of noncompliance. If
        the standard is not met and the results are at or above TBD%,  ODJFS
        will issue a Quality
        Improvement Directive which will notify the MCP of noncompliance and may
        outline
        the steps that the MCP must take to improve the results.

      

      1.c.vii.
        Coronary Artery Disease (CAD) –
Beta Blocker Treatment
        after Heart Attack

      

      The
        evaluation report period for this
        measure is CY 2008 only.

      

      Measure:  The
        percentage of members 35
years of
        age and older as of December
        31st
        of the
        reporting year who were hospitalized
        from January 1 – December 24th
        of the reporting year
        with
        a diagnosis of acute myocardial infarction (AMI) and who received an ambulatory
        prescription for beta blockers within seven days of
        discharge.

      

      Target:  TBD.

      

      Minimum
        Performance
        Standard:  The
        level of improvement must result in
        at least a TBD%
        decrease in the difference between the
        target and the previous year’s results.

      

      Action
        Required for
        Noncompliance:  If
        the standard is not met and the
        results are below TBD%,  the
        MCP is required to
        complete a Corrective Action Plan  
        to address the area of noncompliance.
        If the standard is not met and the results are at or above TBD%,  ODJFS
        will issue a Quality
        Improvement Directive which will notify the MCP of noncompliance and may
        outline
        the steps that the MCP must take to improve the results.

      

      1.c.viii.  Persistence
        of Beta
        Blocker Treatment after Heart Attack

      

      The
        initial report period of evaluation
        for this measure is CY 2009.  This measure will replace the
Coronary Artery Disease
        (CAD) – Beta Blocker Treatment after Heart Attack measure (1.c.vii.) in the P4P
        for SFY 2010.

      

      Measure:  The
        percentage of members 35
        years of age and older as of December 31stof
        the reporting year who were
        hospitalized and discharged alive from July 1 of the year prior to the reporting
        year to June 30 of the measurement year with a diagnosis of acute myocardial
        information  (AMI) and who received persistent beta-blocker treatment
        for six months after discharge.

      

      Target:  TBD.

      

      Minimum
        Performance
        Standard:  The
        level of improvement must result in
        at least a TBD% decrease in the difference between the target and the previous
        year’s results.

      

      Action
        Required for
        Noncompliance:  If the standard is
        not met and the
        results are below TBD%, the MCP is required to complete a Corrective Action
        Plan  to
        address the area of noncompliance. If
        the standard is not met and the results are at or above TBD%, ODJFS will
        issue a
        Quality Improvement Directive which will notify the MCP of noncompliance
        and may
        outline the steps that the MCP must take to improve the
        results.

      
         

        1.c.ix.
          Coronary Artery Disease (CAD) –
Cholesterol Management for Patients with Cardiovascular Conditions/LDL-C
          Screening Performed

      

      
      

      

      Measure:  The
        percentage of members
        who had a diagnosis
of 
CAD
        in the year
        prior to the reporting year, who were enrolled for at least 11 months in
        the
        reporting year, and
who
        received a lipid
        profile during the reporting year.

      

      Target:  TBD.

      

      Minimum
        Performance
        Standard:  The
        level of improvement must result in
        at least a TBD%  decrease
        in the difference
        between the target and the previous year’s results.

      

      Action
        Required for
        Noncompliance:  If
        the standard is not met and the
        results are below TBD%,  the
        MCP is required to
        complete a Corrective Action Plan to address the area
        of noncompliance. If
        the standard is not met and the results are at or above TBD%,  ODJFS
        will issue a Quality
        Improvement Directive which will notify the MCP of noncompliance and may
        outline
        the steps that the MCP must take to improve the results.

      

      1.c.x.  Hypertension  –
        Inpatient Hospital
        Discharge Rate

      

      Measure:  The
        number
        of  acute inpatient hospital dischargesin the reporting year
        where the primary
        diagnosis was non-mild hypertension,  per thousand member
        months,
        for members who had a
        diagnosis of non-mild
        hypertension in the year prior to the reporting year.

      

      Target:  TBD

      

      Minimum
        Performance
        Standard:  The
        level of improvement must result in at least a TBD%
        decrease in the difference between the
        target and the previous report period’s results.

      

      Action
        Required for
        Noncompliance:  If the standard is
        not met and the
        results are below TBD%,  the
        MCP is required to
        complete a Corrective Action Plan to address the area of
        noncompliance. If
        the standard is not met and the results are at or above TBD%,
        ODJFS will issue a Quality
        Improvement Directive which will notify the MCP of noncompliance and may
        outline
        the steps that the MCP must take to improve the results.

       

      1.c.xi.  Hypertension
–
Emergency
        Department (ED) Utilization Rate

      

      Measure:  The
        number
        of  emergency department visitsin the reporting year
        where the
        principal diagnosis was non-mild hypertension, per
        thousand member months, for members
        who had a diagnosis
of
        non-mild
        hypertension  in the year prior to the reporting
        year.

      

      Target:  TBD

      

      Minimum
        Performance
        Standard:  The
        level of improvement must result in at least a TBD%
        decrease in the difference between the
        target and the previous report period’s results.

      

      Action
        Required for
        Noncompliance:  If the standard is
        not met and the
        results are below TBD%,
        the MCP is required to complete a
Corrective Action Plan  to
        address the area of noncompliance.
 If
        the standard is not met and the
        results are at or above TBD%,  ODJFS
        will issue a Quality
        Improvement Directive which will notify the MCP of noncompliance and may
        outline
        the steps that the MCP must take to improve the results.

      

      1.c.xii.  Diabetes  –
        Inpatient Hospital
        Discharge Rate

      

      Measure:  The
        number of acute inpatient
        hospital discharges
in the reporting year
        where
        the principal diagnosis was diabetes, per thousand
        member months, for members
identified as diabetic
        in
the year prior
        to the reporting
        year.

      

      Target:  TBD

      

      Minimum
        Performance
        Standard:  The
        level of improvement must result in at least a TBD%
        decrease in the difference between the
        target and the previous report period’s results.

      

      Action
        Required for
        Noncompliance:  If the standard is
        not met and the
        results are below TBD%,  the
        MCP is required to
complete a Corrective Action Plan  to address the area of
        noncompliance.  If the standard is not met and the results are at or
        above TBD%,  ODJFS will
        issue a Quality Improvement Directive which will notify the MCP of noncompliance
        and may outline the steps that the MCP must take to improve the
        results.

      

      1.c.xiii.  Diabetes
–
Emergency
        Department (ED) Utilization Rate

      

      Measure:  The
        number of
        emergency department visits
in the reporting year
        where
        the primary  diagnosis was diabetes, per
        thousand member months, for members
identified as
        diabetic  in the
        year prior to the reporting year.

      

      Target:  TBD

      

      Minimum
        Performance
        Standard:  The
        level of improvement must result in at least a TBD%
        decrease in the difference between the
        target and the previous report period’s results.

      

      Action
        Required for
        Noncompliance:  If the standard is
        not met and the
        results are below TBD%,
        the MCP is required to complete a
Corrective Action Plan  to
        address the area of
        noncompliance. If
        the standard is not met and the
        results are at or above TBD%,  ODJFS
        will issue a Quality
        Improvement Directive which will notify the MCP of noncompliance and may
        outline
        the steps that the MCP must take to improve the results.

      

      1.c.xiv.  Diabetes
–
Eye
        Exam

      

      Measure:   The
        percentage of
diabetic members who
        were enrolled for at least 11 months
        during the reporting year, who received one or more retinal or dilated eye
        exams
        from an ophthalmologist or optometrist during the reporting
        year.

      

      Target:TBD.

      

      Minimum
        Performance
        Standard: The
        level of improvement must result in
        at least a TBD%  increase  in
        the
        difference between the target and the previous year’s
        results.

      

      Action
        Required for
        Noncompliance:  If the standard is
        not met and the
        results are below TBD%,  the
        MCP is required to
        complete a Corrective Action Plan to
        address the area of noncompliance. If
        the standard is not met and the results are at or above TBD%,  ODJFS
        will issue a Quality
        Improvement Directive which will notify the MCP of noncompliance and may
        outline
        the steps that the MCP must take to improve the results.

      

      1.c.xv.  Chronic
        Obstructive
        Pulmonary Disease  (COPD) – Inpatient Hospital
        Discharge Rate

      

      Measure:  The
        number
        of  acute inpatient hospital discharges in the reporting year
        where the primary
        diagnosis was COPD,  per thousand member
        months,
for
        members who had a diagnosis of
 COPD
        in the year prior to the
        reporting year.

      

      Target:  TBD

      

      Minimum
        Performance
        Standard:  The
        level of improvement must result in at least a TBD%
        decrease in the difference between the
        target and the previous report period’s results.

      

      Action
        Required for
        Noncompliance:  If the standard is
        not met and the
        results are below TBD%,  the
        MCP is required to
        complete a Corrective Action Plan  to
        address the area of
        noncompliance. If
        the standard is not met and the
        results are at or above TBD%,  ODJFS
        will issue a Quality
        Improvement Directive which will notify the MCP of noncompliance and may
        outline
        the steps that the MCP must take to improve the results.

       

      1.c.xvi.  Chronic
        Obstructive
        Pulmonary Disease  (COPD) – Emergency Department (ED) Utilization
        Rate

       

      Measure:  The
        number
        of  emergency department visits in the reporting year
        where the
        principal diagnosis was COPD,  per thousand member
        months,
        for members who had a
        diagnosis of
 COPD  in the year prior to
        the reporting
        year.

      

      Target:  TBD

      

      Minimum
        Performance
        Standard:  The
        level of improvement must result in at least a TBD%
        decrease in the difference between the
        target and the previous report period’s results.

      

      Action
        Required for
        Noncompliance:  If the standard is
        not met and the
        results are below TBD%,  the
        MCP is required to
        complete a Corrective Action Plan  to
        address the area of noncompliance.
If
        the standard is not met and the
        results are at or above TBD%,  ODJFS
        will issue a Quality
        Improvement Directive which will notify the MCP of noncompliance and may
        outline
        the steps that the MCP must take to improve the results.

      

      1.c.xvii.  Asthma
–
Inpatient Hospital
        Discharge Rate

      

      Measure:  The
        number of acute
        inpatient hospital discharges in the reporting year
        where the primary
        diagnosis was asthma, per
        thousand member months, for
        members with persistent asthma.

      

      Target:  TBD

      

      Minimum
        Performance
        Standard:  The
        level of improvement must result in at least a TBD%
        decrease in the difference between the
        target and the previous report period’s results.

      

      Action
        Required for
        Noncompliance:  If the standard is
        not met and the
        results are below TBD%,  the
        MCP is required to
        complete a Corrective Action Plan  to
        address the area of noncompliance.
 If
        the standard is not met and the
        results are at or above TBD%,  ODJFS
        will issue a Quality
        Improvement Directive which will notify the MCP of noncompliance and may
        outline
        the steps that the MCP must take to improve the results.

      
         

        1.c.xviii.  Asthma
–
Emergency
          Department (ED) Utilization Rate

      

      
      

      

      Measure:  The
        number
        of  emergency department visits in the reporting year
        where the
        principal diagnosis was asthma,  per thousand member
        months,
for members with persistent
        asthma.

      

      Target:  TBD

      

      Minimum
        Performance
        Standard:  The
        level of improvement must result in at least a TBD%
        decrease in the difference between the
        target and the previous report period’s results.

      

      Action
        Required for
        Noncompliance:  If the standard is
        not met and the
        results are below TBD%,  the
        MCP is required to
        complete a Corrective Action Plan   to
        address the area of
        noncompliance. If
        the standard is not met and the
        results are at or above TBD%,  ODJFS
        will issue a Quality
        Improvement Directive which will notify the MCP of noncompliance and may
        outline
        the steps that the MCP must take to improve the results.

      
         

        1.c.xix.  Asthma
–
Use
          of Appropriate
          Medications for People with Asthma

      

       

      Measure:  The
        percentage of members
        with persistent asthma who received prescribed medications acceptable as
        primary
        therapy for long-term control of asthma.

      

      Target:  TBD

      

      Minimum
        Performance
        Standard:  The
        level of improvement must result in at least a TBD%
        decrease in the difference between the
        target and the previous report period’s results.

      

      Action
        Required for
        Noncompliance:  If the standard is
        not met and the
        results are below TBD%,
        the MCP is required to
complete a Corrective Action Plan  to address the area of
        noncompliance.   If the standard is not met and the results are
        at or above TBD%, ODJFS will issue
        a Quality Improvement Directive which will notify the MCP of noncompliance
        and
        may outline the steps that the MCP must take to improve the
        results.

      

      1.c.xx.
        Mental Health, Severely
        Mentally Disabled (SMD) – Inpatient Hospital
        Discharge Rate

      

      Measure:  The
        number
        of  acute inpatient hospital discharges in the reporting year
where
        the primary diagnosis
        was SMD, per thousand member
        months, for members who
        had a primary diagnosis
        of SMD in the year prior
        to the reporting
        year.

      

      Target:  TBD

      

      Minimum
        Performance
        Standard:  The
        level of improvement must result in at least a TBD%
        decrease in the difference between the
        target and the previous report period’s results.

      

      Action
        Required for
        Noncompliance:  If the standard is
        not met and the
        results are below TBD%,
        the MCP is required to complete a
Corrective Action Plan  to
        address the area of noncompliance.
 If
        the standard is not met and the
        results are at or above TBD%,
        ODJFS will issue a Quality
        Improvement Directive which will notify the MCP of noncompliance and may
        outline
        the steps that the MCP must take to improve the results.

       

      
        1.c.xxi.  Mental
          Health, Severely
          Mentally Disabled (SMD) – Emergency
          Department Utilization Rate

      

      
      

      

      Measure:  The
        number
        of  emergency department visits in the reporting year
where
        the primary diagnosis
        was SMD, per thousand member
        months, for members who had
        a primary diagnosis of SMD in the year prior to the reporting
        year.

      

      Target:  TBD

      

      Minimum
        Performance
        Standard:  The
        level of improvement must result in at least a TBD%
        decrease in the difference between the
        target and the previous report period’s results.

      

      Action
        Required for
        Noncompliance:  If the standard is
        not met and the
        results are below TBD%,  the
        MCP is required to
        complete a Corrective Action Plan  to
        address the area of
        noncompliance. If
        the standard is not met and the
        results are at or above TBD%,
        ODJFS will issue a Quality
        Improvement Directive which will notify the MCP of noncompliance and may
        outline
        the steps that the MCP must take to improve the results.

       

      
        1.c.xxii.  Follow-up
          After Hospitalization for
          Mental Illness

      

      
      

      

      Measure:  The
        percentage of discharges
        for members enrolled from the date of discharge through 30 days after discharge,
        who were hospitalized for treatment of  selected mental health
        disorders and

      

      who
had
        a follow-up visit (i.e.,
were seen on an outpatient
        basis or were in intermediate treatment with a mental health
        provider) within:

      1)
        30 Days of discharge,
        and

      2)
        7 Days of
        discharge.

      

      Target:  TBD.

      

      Minimum
        Performance
        Standard For
        Each
        Measure:  The
        level of improvement must result in
        at least a TBD%  decrease
        in the difference
        between the target and the previous year’s results.

      

      Action
        Required for
        Noncompliance
        (Follow-up visits
        within 30 days of discharge):  If
        the standard is not met and the
        results are below TBD%,  the
        MCP is required to
        complete a Corrective Action Plan to
        address the area of noncompliance. If
        the standard is not met and the results are at or above TBD%, ODJFS
        will issue a Quality Improvement
        Directive which will notify the MCP of noncompliance and may outline the
        steps
        that the MCP must take to improve the results.

      

      Action
        Required for
        Noncompliance (Follow-up visits within 7 days of
        discharge):  If
        the standard is not met and the results are below TBD%, the MCP is required
        to
        complete a Corrective Action Plan to
        address the area of noncompliance. If
        the standard is not met and the results are at or above TBD%, ODJFS will
        issue a
        Quality Improvement Directive which will notify the MCP of noncompliance
        and may
        outline the steps that the MCP must take to improve the results.

      

      1.c.xxiii.
        Mental Health, Severely
        Mentally Disabled (SMD) – SMD Related Hospital
        Readmission

      

      Measure:  The
        number of SMD related
        readmissions for members who
        had a diagnosis
        of SMD in the year prior to
        the reporting year. A
        readmission is defined as a SMD
        related admission that occurs within 30 days of  a prior SMD related
        admission.

      Target:  TBD.

      

      Minimum
        Performance
        Standard:  The
        level of improvement must result in
        at least a TBD%  decrease
        in the difference
        between the target and the previous year’s results.

      

      Action
        Required for
        Noncompliance:  If
        the standard is not met and the
        results are below TBD%,  the
        MCP is required to
        complete a Corrective Action Plan to address the area
        of noncompliance. If
        the standard is not met and the results are at or above TBD%,  ODJFS
        will issue a Quality
        Improvement Directive which will notify the MCP of noncompliance and may
        outline
        the steps that the MCP must take to improve the results.

      

      1.c.xxiv.  Substance
        Abuse –
Inpatient Hospital
        Discharge Rate

      

      Measure:  The
        number of acute
        inpatient hospital discharges in the reporting year
where
        the primary diagnosis
        was alcohol and other drug
        abuse or dependence (AOD), per thousand member months, for members who
        had, in
        the year prior to the reporting year,
        a diagnosis of AOD and
        one of the following:
        AOD-related acute inpatient admission or two AOD related Emergency Department
        visits.

      

      Target:  TBD

      

      Minimum
        Performance
        Standard:  The
        level of improvement must result in at least a TBD%
        decrease in the difference between the
        target and the previous report period’s results.

      

      Action
        Required for
        Noncompliance:  If the standard is
        not met and the
        results are below TBD%,  the
        MCP is required to
        complete a Corrective Action Plan  to address the area of
        noncompliance. If
        the standard is not met and the
        results are at or above TBD%,
        ODJFS will issue a Quality
        Improvement Directive which will notify the MCP of noncompliance and may
        outline
        the steps that the MCP must take to improve the results.

       

      
        1.c.xxv. Substance
          Abuse – Emergency Department
          Utilization
          Rate

Measure:  The
        number
        of  emergency department visits in the reporting year
where
        the principal diagnosis was AOD,
        per thousand member months, for members who had, in the year
        prior to the
        reporting year, a diagnosis of AOD and
        one of the following:
        AOD-related acute inpatient admission or two AOD related Emergency Department
        visits .

      

      Target:  TBD

      

      Minimum
        Performance
        Standard:  The
        level of improvement must result in at least a TBD%
        decrease in the difference between the
        target and the previous report period’s results.

      

      Action
        Required for
        Noncompliance:  If the standard is
        not met and the
        results are below TBD%,
        the MCP is required to complete a
Corrective Action Plan  to
        address the area of
        noncompliance. If
        the standard is not met and the
        results are at or above TBD%,
        ODJFS will issue a Quality
        Improvement Directive which will notify the MCP of noncompliance and may
        outline
        the steps that the MCP must take to improve the results.

      

      1.c.xxvi.
        Substance Abuse – Inpatient Hospital
        Readmission Rate

      

      Measure:  The
        number of AOD related
        readmissions in
        the reporting year for members who
        had, in the year prior to the
        reporting year, a diagnosis of AOD and
        one of the following:
        AOD-related acute inpatient admission or two AOD related Emergency Department
        visits. A readmission is
        defined as an
        AOD-related admission that
        occurs within 30 days of  a prior AOD-related admission.

      

      Target:  TBD.

      

      Minimum
        Performance
        Standard:  The
        level of improvement must result in
        at least a TBD%  decrease
        in the difference
        between the target and the previous year’s results.

      

      Action
        Required for
        Noncompliance:  If
        the standard is not met and the
        results are below TBD%,  the
        MCP is required to
        complete a Corrective Action
        Plan  to
        address the area of noncompliance. If
        the standard is not met and the results are at or above TBD%,  ODJFS
        will issue a Quality
        Improvement Directive which will notify the MCP of noncompliance and may
        outline
        the steps that the MCP must take to improve the results.

      

      1.c.xxvii.
        Informational Clinical Performance
        Measures

      

      The
        clinical performance measures listed
        in Table 1 are informational only.  Although there are no performance
        targets or minimum performance standards for these measures, results will
        be
        reported and used as one component  in assessing the quality of care
        provided by MCPs to the ABD managed care population.

      

      Table
        1. Informational Clinical
        Performance Measures

       

      
        	
                Condition

              	
                Informational
                  Performance Measure

              
	
                CHF

              	
                Discharge
                  rate with age group
                  breakouts

              
	
                CAD

              	
                Discharge
                  rate with age group
                  breakouts

              
	
                Hypertension

              	
                Discharge
                  rate with age group
                  breakouts

              
	
                Diabetes

              	
                Discharge
                  rate with age group
                  breakouts

              
	
                Comprehensive
                  Diabetes Care
                  (CDC)/HbA1c testing

              
	
                CDC/kidney
                  disease
                  monitored

              
	
                CDC/LDL-C
                  screening
                  performed

              
	
                COPD

              	
                Discharge
                  rate with age group
                  breakouts

              
	
                Use
                  of Spirometry Testing in the
                  Assessment and Diagnosis of COPD

              
	
                Asthma

              	
                Discharge
                  rate with age group
                  breakouts

              
	
                Mental
                  Health
                  (SMD)

              	
                Discharge
                  rate with age group
                  breakouts

              
	
                Antidepressant
                  Medication
                  Management

              
	
                Substance
                  Abuse

              	
                Discharge
                  rate with age group
                  breakouts

              
	
                Initiation
                  and Engagement of
                  Alcohol and Other Drug Dependence
                  Treatment

              

      

      

      2.  ACCESS

      

      Performance
        in the Access category will
        be determined by the following measures: Primary Care Provider (PCP) Turnover, Adults’ Access to
        Preventive/Ambulatory Health Services, and Adults’ Access to Designated
        PCP.  For a comprehensive description of the access performance
        measures below, see ODJFS
        Methods
        for
        the
        ABD Medicaid Managed Care Program Access
        Performance
        Measures.

      

      2.a.
        PCP Turnover

      

      A
        high
        PCP turnover rate may affect continuity of care and may signal poor management
        of providers.  However, some turnover may be expected when MCPs end
        contracts with  providers  who are not adhering to the MCP’s standard of
        care.  Therefore, this measure is used in conjunction with the adult
        access and designated PCP measures to assess performance in the access
        category.

      

      Measure:
        The percentage of
        primary care providers affiliated with the MCP as of the beginning of the
        measurement year who were not affiliated with the MCP as of the end of the
        year.

      

      Statewide
        Approach:
MCPs will be evaluated
        using a statewide result, including all regions in which an MCP has
        membership.  ODJFS will use the
        first calendar year
        of ABD managed care program membership as the baseline year (i.e., CY2007).
        The
        baseline year will be used to determine a minimum statewide performance
        standard.  An MCP’s second calendar year of ABD managed care program
        membership (i.e., CY2008) will be the initial report period of evaluation,
        and
        penalties will be applied for noncompliance.

      

      Report
        Period: For the SFY 2008 contract
        period, a
        baseline level of performance will be established using the CY 2007
        report period (and may be adjusted
        based on the number of months of ABD managed care
        membership).  For
        the SFY 2009 contract period, performance will be evaluated using the CY
2008
        report period.  The first
        reporting period in which MCPs will be held accountable to the performance
        standards will be the SFY
        2009 contract
        period.

      

      Minimum
        Performance
        Standard:  A maximum PCP Turnover rate of TBD.

      

      Action
        Required for
        Noncompliance:  MCPs are required to perform a causal analysis
        of the high PCP turnover rate and assess the impact on timely access to health
        services, including continuity of care.  If access has been reduced or
        coordination of care affected, then the MCP must develop and implement a
        corrective action plan to address
        the
        findings. 

      

      2.b.  Adults’
Access
        to
        Designated PCP

      

      The
        MCP must encourage and assist ABD
        members without a designated primary care provider (PCP)
        to establish such a relationship,
        so that a designated PCP can coordinate and manage
        member’s health care
        needs.  This measure is used to assess MCPs’ performance in the access
        category.

      

      Measure:  The
        percentage of members who had a
        visit through the
        members’ designated
        PCPs.

      

      Statewide
        Approach: MCPs will be
        evaluated using a statewide result, including all regions in which an MCP
        has
        membership.  ODJFS will use the
        first calendar year of ABD managed care program
        membership as
        the baseline year (i.e.,
        CY2007). The
        baseline year will be used
to determine a minimum
        statewide performance standard.  An MCP’s second calendar year of ABD
        managed care program membership (i.e.,
        CY2008)
        will be the initial report period of
        evaluation, and penalties will be applied for noncompliance.

      

      Report
        Period:  For the
        SFY 2008 contract period, performance will be evaluated using the January
        -
        December 2007 report period (and may be adjusted
        based on the number
        of months of ABD managed care membership).  For the SFY 2009 contract
        period, performance will be evaluated using the January - December 2008 report
        period.  The first reporting period in which MCPs will be held
        accountable to the performance standards will be the SFY 2009 contract period.

      

      Minimum
        Performance Standards:
        TBD

      

      Penalty
        for
        Noncompliance:  If an MCP is noncompliant
        with the
        Minimum Performance Standard, then the MCP must develop and implement a
        corrective action plan.

      

      2.c.
        Adults’ Access to Preventive/Ambulatory Health Services

      

      This
        measure indicates whether adult members are accessing health
        services.

      

      Measure:
        The percentage of
members who had an ambulatory
        or
        preventive-care visit.

      

      Statewide
        Approach: MCPs will be
        evaluated using a statewide result, including all regions in which an MCP
        has
        membership.  ODJFS will use the
        first calendar year
        of ABD managed care program membership as the baseline year (i.e., CY2007).
        The
        baseline year will be used to determine
        a minimum statewide
        performance standard.  An MCP’s second calendar year of ABD managed
        care program membership (i.e., CY2008) will be the initial report period
        of
        evaluation, and penalties will be applied for noncompliance.

      

      Report
        Period:  For the
        SFY 2008 contract period, performance will be evaluated using the January
        -
        December 2007 report period(and may be adjusted
        based on the number
        of months of ABD managed care membership).  For the SFY 2009 contract
        period,
performance will be
        evaluated using the January - December 2008 report period.  The first
        reporting period in which MCPs will be held accountable to the performance
        standards will be the SFY
        2009 contract
period.

      

      Minimum
        Performance Standards:
        TBD

      

      Penalty
        for
        Noncompliance:   If an MCP is noncompliant with the Minimum
        Performance Standard,
        then the MCP must develop and implement a corrective action plan.

      

      3.
        CONSUMER SATISFACTION

      

      MCPs
        will be evaluated using a statewide
        result, including all regions in which an MCP has
        membership.

      

      In
        accordance with federal requirements and in the interest of assessing enrollee
        satisfaction with MCP performance, ODJFS annually conducts independent
        consumer satisfaction surveys. Results are used to assist in identifying
        and
        correcting MCP performance overall and in the areas of access, quality of
        care,
        and member services.  Results from the SFY 2009
evaluation
        will be used to set a
        standard.  For the SFY 2009
        contract period, this measure is
        a reporting only measure.  SFY 2010 will be the first contract period
        in which MCPs will be held accountable to the performance standards for this
        measure.

      

      Measure: TBD.
        The results of this measure are
        reported annually.

      

      Report
        Period: For
        the SFY 2009 contract period, the measure
        is under review and
        the report period has not been determined.

      

      Minimum
        Performance Standard: TBD.

      

      Penalty
        for
        noncompliance:  If an MCP is determined noncompliant with the
        Minimum Performance Standard, then the MCP must develop a corrective action
        plan
        and provider agreement renewals
        may be affected.

      

      4.
        ADMINISTRATIVE CAPACITY

      

      The
        ability of an MCP to meet
        administrative requirements has been found to be both an indicator of current
        plan performance and a predictor of future performance.  Deficiencies
        in administrative capacity make the accurate assessment of performance in
        other
        categories difficult, with findings uncertain.  Performance in this
        category will be determined by the Compliance
Assessment
        System,  and
        the emergency department diversion
        program.  For a comprehensive description of the Administrative Capacity
        performance
        measures below, see ODJFS
        Methods
for the ABD
        Medicaid Managed
        Care Program Administrative Capacity Performance Measure,
        which are incorporated in this
        Appendix.

      

      4.a.
        Compliance Assessment
        System

      

      Measure:  The
        number of points accumulated during
        a rolling 12-month period through the Compliance
        Assessment System.

      

      Report
        Period: For
        the SFY 2008 and SFY 2009 contract
        periods, performance will be evaluated using a rolling 12-month report
        period.

      

      Performance
        Standard:  A
        maximum of 15 points

      

      Penalty
        for
        Noncompliance: Penalties
        for points are established in Appendix N, Compliance
        Assessment System.

      

      4.b.
        Emergency Department
        Diversion

      

      Managed
        care plans must provide access
        to services in a way that assures access to primary and urgent care in the
        most
        effective settings and minimizes inappropriate utilization of emergency
department
        (ED) services.  MCPs are required to identify high utilizers of
        targeted ED services and implement action plans designed to minimize
        inappropriate, preventable and/or primary care sensitive ED
        utilization.

      

      Measure:
        The percentage of
        members who had TBD
        targeted ED visits during the twelve month reporting period.

      

      Statewide
        Approach: MCPs will be
        evaluated using a statewide result, including all regions in which an MCP
        has
        membership.  ODJFS will use the first calendar year of ABD managed care membership
        as the
        baseline year (i.e.,
        CY2007). The
        baseline year will be used
to determine a minimum
        statewide performance standard and a target.  The number of members
        with an ED visit
        used to calculate the measure for the baseline year will be adjusted based
        on
        the number of months of ABD managed care membership in the baseline
        year.   An
        MCP’s second calendar year of ABD managed care program membership (i.e.,
        CY2008)
        will be the initial report period
of
        evaluation, and penalties will be
        applied for noncompliance.

      

      Report
        Period:  For
        the SFY 2008 contract
        period, a baseline level of
        performance will be established using the CY 2007 report
        period (and may be adjusted
        based on the number
        of months of ABD managed care membership).  For the SFY 2009
contract
        period, results will be
        calculated for the reporting period of CY2008 and
        compared to the CY2007 baseline
        results to determine if the
        minimum performance standard is met.

      

      Target: TBD

      

      Minimum
        Performance Standard: TBD

      

      Penalty
        for
        Noncompliance: If the standard
        is not met
        and the results are above
        TBD%, then the MCP
        must develop a
        corrective action plan, for which ODJFS may direct the MCP to develop the
        components of their targeted EDD program as specified by ODJFS.  If
        the standard is not met and the results are at or below TBD%,
        then the MCP must develop a
        Quality Improvement Directive.

      

      5.
        Notes

      

      Given
        that unforeseen circumstances
        (e.g., revision or update
        of applicable national standards, methods or benchmarks, or issues related
        to program
        implementation) may impact
        performance assessment
        as specified in Sections 1
        through 4,  ODJFS
        reserves the right to apply the
        most appropriate penalty to the area of deficiency identified with any
        individual measure, notwithstanding the penalties specified in this
        Appendix.

      

      5.a.
        Monetary
        Sanctions

      

      Penalties
        for noncompliance with
        individual standards in this appendix will be imposed as the results are
        finalized. Penalties for noncompliance with individual standards for each
        period
        of compliance is determined in this appendix and will not exceed
        $250,000.

      

      Refundable
        monetary sanctions will be
        based on the capitation payment for the month of  the cited deficiency
        and will be due within 30 days of notification by ODJFS to the MCP of the
        amount.  Any monies collected through the imposition of such a
        sanction would be returned to the MCP (minus any applicable collection fees
        owed
        to the Attorney General’s Office, if the MCP has been delinquent in submitting
        payment) after they have demonstrated improved performance in accordance
        with
        this appendix.  If
        an MCP does not
        comply within two years of the date of notification of noncompliance, then
        the
        monies will not be refunded.  

      

      5.b.
        Combined
        Remedies

      

      If
        ODJFS determines that one systemic
        problem is responsible for multiple deficiencies, ODJFS may impose a combined
        remedy which will address all areas of deficient performance.  The
        total fines assessed in any one month will not exceed 15% of the MCP’s monthly
        capitation payment.

      

      5.c.
        Enrollment
        Freezes

      

      MCPs
        found to have a pattern of repeated
        or ongoing noncompliance may be subject to an enrollment
        freeze.

      

      5.d.
        Reconsideration

      

      Requests
        for reconsideration of monetary
        sanctions and enrollment freezes may be submitted as provided in Appendix
        N,
Compliance
        Assessment System.

      

      5.e.
        Contract Termination, Nonrenewals
        or Denials

      

      Upon
        termination, nonrenewal or denial
        of an MCP contract, all
        monetary sanctions collected under this appendix will be retained by ODJFS.
        The
        at-risk amount paid to the MCP under the current provider agreement will
        be
        returned to ODJFS  in accordance with Appendix P, Terminations,
        of  the provider
        agreement.

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      APPENDIX
        N

      

      COMPLIANCE
        ASSESSMENT SYSTEM 

      ABD
        ELIGIBLE POPULATION

      

      

      I.
        General Provisions of the Compliance Assessment System

      

      A.
        The
Compliance Assessment System
        (CAS) is designed
        to improve the
        quality of each managed care plan’s (MCP’s) performance through actions taken by
        the Ohio Department of Job and Family Services (ODJFS) to address identified
        failures to meet program requirements.  This appendix applies to the
        MCP specified in the baseline of this MCP Provider Agreement (hereinafter referred to as
        the
        Agreement).

      

      B.
        The
CAS assesses
        progressive remedies with
        specified values (e.g., points, fines, etc.) assigned for certain documented
        failures to satisfy the deliverables required by Ohio Administrative
        Code (OAC) rule or
the Agreement.  Remedies
        are progressive based upon the
        severity of the violation, or a repeated pattern of violations. The CAS
        allows the accumulated point total to
        reflect patterns of less serious violations as well as less frequent, more
        serious violations.

      

      C.
        The
CAS focuses on clearly
        identifiable deliverables and sanctions/remedial actions are only assessed
        in
        documented and verified instances of noncompliance.  The CAS
        does not include categories which
        require subjective assessments or which are not within the MCPs
        control.

      

      D.
        The
        CAS does not replace ODJFS’ ability to require corrective action plans (CAPs)
        and  program improvements, or to impose any of the sanctions specified
        in OAC rule 5101:3-26-10, including the proposed termination, amendment,
        or
        nonrenewal of the MCP’s Provider Agreement.

      

      E.
        As
        stipulated in OAC rule 5101:3-26-10(F), regardless of whether ODJFS imposes
        a
        sanction, MCPs are required to initiate corrective action for any MCP program
        violations or deficiencies as soon as they are identified by the MCP or
        ODJFS.

      

      F.
        In addition to the remedies imposed
        in Appendix N, remedies related to areas of financial performance,
data
        quality,and
performance
        management may also be imposed
        pursuant to
        Appendices J, L, and M respectively, of the Agreement.

      

      G.
        If
        ODJFS determines that an MCP has violated any of the requirements of sections
        1903(m) or 1932 of the Social Security Act which are not specifically identified
        within the CAS, ODJFS may, pursuant to the provisions of OAC rule
        5101:3-26-10(A), notify the MCP’s members that they may terminate from the MCP
        without cause and/or suspend any further new member selections.

      

      H.
        For
        purposes of the CAS, the date that ODJFS first becomes aware of an MCP’s program
        violation is considered the date on which the violation
        occurred.  Therefore, program violations that technically reflect
        noncompliance from the previous compliance term will be subject to remedial
        action under CAS at the time that ODJFS first becomes aware of this
        noncompliance.

      

      I.
        In
        cases where an MCP contracted healthcare provider is found to have violated
        a
        program requirement (e.g., failing to provide adequate contract termination
        notice, marketing to potential members, inappropriate member billing, etc.),
        ODJFS will not assess points if: (1) the MCP can document that they provided
        sufficient notification/education to providers of applicable program
        requirements and prohibited activities; and (2) the MCP takes immediate and
        appropriate action to correct
        the
        problem and to ensure that it does not happen again to the satisfaction of
        ODJFS.  Repeated incidents will be reviewed to determine if the MCP
        has a systemic problem in this area, and if so, sanctions/remedial actions
        may
        be assessed, as determined by ODJFS.

      

      J.
        All
        notices of noncompliance will be issued in writing via email and facsimile
        to
        the identified MCP contact.

      

      II.
        Types of Sanctions/Remedial Actions

      

      ODJFS
        may
        impose the following types of sanctions/remedial actions, including, but
        not
        limited to, the items listed below.  The following are examples of
        program violations and their related penalties.  This list is not all
        inclusive.  As with any instance of noncompliance, ODJFS retains the
        right to use their sole discretion to determine the most appropriate penalty
        based on the severity of the offense, pattern of repeated noncompliance,
        and
        number of consumers affected.  Additionally, if an MCP has received
        any previous written correspondence regarding their duties and obligations
        under
        OAC rule or the Agreement, such notice may be taken into consideration when
        determining penalties and/or remedial actions.

      

      A.
        Corrective Action Plans
        (CAPs)– A CAP is a structured activity/process implemented by the MCP to
        improve identified operational deficiencies.

      

      MCPs
        may
        be required to develop CAPs for any instance of noncompliance, and CAPs are
        not
        limited to actions taken in this Appendix.  All CAPs requiring ongoing
        activity on the part of an MCP to ensure their compliance with a program
        requirement remain in effect for twenty-four months.

      

      In
        situations where ODJFS has already determined the specific action which must
        be
        implemented by the MCP or if the MCP has failed to submit a CAP, ODJFS may
        require the MCP to comply with an ODJFS-developed or “directed”
CAP.

      

      In
        situations where a penalty is assessed for a violation an MCP has previously
        been assessed a CAP (or any penalty or any other related written
        correspondence), the MCP may be assessed escalating penalties.

      

      B.
        Quality Improvement Directives (QIDs) –  A QID is a general
        instruction that directs  the MCP to implement a quality improvement
        initiative to improve identified  administrative or clinical
        deficiencies.  All QIDs remain in effect for twelve months from
 the date of implementation.

      

      MCPs
        may
        be required to develop QIDs for any instance of noncompliance.

      

       In
        situations where ODJFS has already determined the specific action which must
        be
 implemented by the MCP or if the MCP has failed to submit a QID, ODJFS may
        require  the MCP to comply with an ODJFS-developed or “directed”
QID.

      

       In
        situations where a penalty is assessed for a violation an MCP has previously
        been  assessed a QID (or any penalty or any other related written
        correspondence), the MCP  may be assessed escalating
        penalties.

      

      C.
        Points - Points
        will accumulate over a rolling 12-month schedule.  Each month, points
        that are more than 12-months old will expire.  Points will be tracked
        and monitored separately for each Agreement the MCP concomitantly holds with
        the
        BMHC, beginning with the commencement of this Agreement (i.e., the MCP will
        have
        zero points at the onset of this Agreement).

      

      No
        points
        will be assigned for any violation where an MCP is able to document that
        the
        precipitating circumstances were completely beyond their control and could
        not
        have been foreseen (e.g., a construction crew severs a phone line, a lightning
        strike blows a computer system, etc.).

      

      C.1.
5
        Points -- Failures to meet
        program requirements, including but not limited to, actions
        which  could impair the member’s ability to obtain correct
information
        regarding services or which could
        impair a consumer’s or member’s rights, as determined by ODJFS, will result in
        the assessment of 5 points.  Examples include, but are not limited to,
        the following:

      

      
        •Violations
          which result in a member’s MCP selection or termination based on inaccurate
          provider panel information from the MCP. 

      

      
        •Failure
          to provide member materials to new members in a timely manner.

      

      
        •Failure
          to comply with appeal, grievance, or state hearing
          requirements, including the failure to notify a member of their right to
          a state
          hearing when the MCP proposes to deny, reduce, suspend or terminate a
          Medicaid-covered service. 

      

      
        •Failure
          to staff 24-hour call-in system with appropriate trained medical personnel.
          

      

      
        •Failure
          to meet the monthly call-center requirements for either the member services
          or
          the 24-hour call-in system lines. 

      

      
        •Provision
          of false, inaccurate or materially misleading information to health care
providers, the MCP’s members, or any
          eligible individuals.

      

      
        •Use
          of unapproved marketing or member
          materials.

      

      
        •Failure
          to appropriately notify ODJFS or members of provider panel terminations.
          

      

      
        •Failure
          to update website provider directories as required. 

      

      

      C.2.
        10 Points --
        Failures to meet program requirements, including but not limited to, actions
        which could affect the ability of the MCP to deliver or the consumer to access covered
        services, as determined by ODJFS.  Examples include, but are not
        limited to, the following:

      

      
        •Discrimination
          among members on the basis of their health status or need for health care
          services (this includes any practice that would reasonably be expected
          to
          encourage termination or discourage selection by individuals whose medical
          condition indicates probable need for substantial future medical services).
          

      

      
        •Failure
          to assist a member in accessing needed services in a timely manner after
          request
          from the member. 

      

      
        •Failure
          to provide medically-necessary Medicaid covered services to members.

      

      
        •Failure
          to process prior authorization requests within the prescribed time frames.
          

      

      
         

      

      D.
        Fines– Refundable
        or nonrefundable fines may be assessed as a penalty separate to or in
        combination with other sanctions/remedial actions.

      

      D.1.
        Unless otherwise
        stated, all fines are nonrefundable.

      

      D.2.
        Pursuant to procedures as established
        by ODJFS,
        refundable and nonrefundable monetary sanctions/assurances must be remitted
        to
        ODJFS within thirty (30) days of receipt of the invoice by the
        MCP.  In addition, per Ohio Revised Code Section 131.02, payments not
        received within forty-five (45) days will be certified to the Attorney General’s
        (AG’s) office. MCP payments certified to the AG’s office will be assessed the
        appropriate collection fee by the AG’s office.

      

      D.3.
        Monetary
        sanctions/assurances imposed by ODJFS will be based on the most recent premium
        payments.

      

      D.4.
        Any monies
        collected through the imposition of a refundable fine will be returned to
        the
        MCP (minus any applicable collection fees owed to the Attorney General’s Office
        if the MCP has been delinquent in submitting payment) after they have
        demonstrated full compliance, as determined by ODJFS, with the particular
        program requirement.  If an MCP does not comply within one (1) year of
        the date of notification of noncompliance involving issues of case management
        and two (2) years of the date of notification of noncompliance in issues
        involving encounter data, then the monies will not be refunded.

      

      D.5.
        MCPs are
        required to submit a written request for refund to ODJFS at the time they believe is appropriate before
        a refund
        of monies will be considered.

      

      E.
        Combined Remedies
        - Notwithstanding any other action ODJFS may take under this Appendix, ODJFS
        may
        impose a combined remedy which will address all areas of noncompliance if
        ODJFS
        determines, in its sole discretion, that (1) one systemic problem is responsible
        for multiple areas of noncompliance and/or (2) that there are a number of
        repeated instances of noncompliance with the same program
        requirement.

      

      F.
        Progressive
        Remedies - Progressive remedies will be based on the number of points
        accumulated at the time of the
        most recent incident.  Unless specifically otherwise indicated
        in this appendix, all fines are nonrefundable.  The designated fine
        amount will be assessed when the number of accumulated points falls within
        the
        ranges specified below:

      

      0
        -15
        Points   Corrective
        Action Plan (CAP)

      
        16-25Points   CAP
          + $5,000
          fine

      

      
        26-50Points   CAP
          + $10,000
          fine

      

      
        51-70
          Points   CAP
          + $20,000
          fine

      

      
        71-100
          Points   CAP
          + $30,000
fine

      

      100+
        Points   Proposed Contract Termination

      

      G.
        New Member Selection
        Freezes - Notwithstanding any other penalty or point assessment that
        ODJFS may impose on the MCP under this Appendix, ODJFS may prohibit an MCP
        from
        receiving new membership through consumer initiated selection or the assignment
        process if: (1) the MCP has accumulated a total of 51 or more points during
        a
        rolling 12-month period; (2) or
        the MCP fails to fully implement a CAP within the designated time frame;
        or  (3) circumstances exist which potentially jeopardize the MCP’s
        members’ access to care.  [Examples of circumstances that ODJFS may
        consider as jeopardizing member access to care include:

      

      - the
        MCP has been found by ODJFS to be
        noncompliant with the prompt payment or the non-contracting provider payment
         requirements;

      - the
        MCP has been found by ODJFS to be
        noncompliant with the provider panel requirements specified in Appendix H
        of the
        Agreement;

      - the
        MCP’s refusal to comply with a
        program requirement after ODJFS has directed the MCP to comply with the specific
        program requirement; or

      - the
        MCP has received notice of proposed
        or implemented adverse action by the Ohio Department of
        Insurance.]

      

      Payments
        provided for under the
        Agreement will be denied for new enrollees, when and for so long as, payments
        for those enrollees are denied by CMS in accordance with the requirements
        in 42
        CFR 438.730.

      

      H.
        Reduction of Assignments
– ODJFS has sole discretion over how member auto-assignments are
        made.  ODJFS may reduce the number of assignments an MCP receives to
        assure program stability within a region or if ODJFS determines that the
        MCP
        lacks sufficient capacity to meet the needs of the increased volume in
        membership.  Examples of circumstances which ODJFS may determine
        demonstrate a lack of sufficient capacity include, but are not limited to
        an
        MCP’s failure to: maintain an adequate provider network; repeatedly provide new
        member materials by the member’s effective date; meet the minimum call center
        requirements; meet the minimum performance standards for identifying and
        assessing children with special health care needs and members needing case
        management services; and/or provide complete and accurate appeal/grievance,
        member’s PCP and CAMS data files.

      

      I.
        Termination, Amendment,
        or Nonrenewal of MCP Provider Agreement - ODJFS can at any time move to
        terminate, amend or deny renewal of a provider agreement.  Upon such
        termination, nonrenewal, or denial of an MCP provider agreement, all previously
        collected monetary sanctions will be retained by ODJFS.

      

      J.
        Specific Pre-Determined
        Penalties

      

      I.1.
        Adequate network-minimum provider panel requirements- Compliance with provider
        panel
        requirements will be assessed quarterly.  Any deficiencies in
        the MCP’s provider network as specified in Appendix H of the Agreement or by
        ODJFS, will result in the assessment of a $1,000 nonrefundable fine for each
        category (practitioners, PCP capacity, hospitals), for each county, and for
        each
        population (e.g., ABD, CFC).  For example if the MCP did not meet the
        following minimum panel requirements, the MCP would be assessed (1) a $3,000
        nonrefundable fine for the failure to meet CFC panel requirements; and, (2)
        a
        $1,000 nonrefundable fine for the failure to meet ABD panel
        requirements).

      
        ·
practitioner
          requirements in Franklin county for the CFC population 

      

      
        ·
practitioner
          requirements in Franklin county for the ABD population 

      

      
        ·
hospital
          requirements in Franklin county for the CFC population 

      

      
        ·
PCP
          capacity requirements in Fairfield county for the CFC population

      

      

      In
        addition to the pre-determined penalties, ODJFS may assess additional penalties
        pursuant to this Appendix (e.g. CAPs, points, fines) if member specific access
        issues are identified resulting from provider panel noncompliance.

      

      J.2.
        Geographic Information
        System - Compliance with the Geographic Information System (GIS)
        requirements will be assessed semi-annually.  Any failure to meet GIS
        requirements as specified in Appendix H of the Agreement will result a $1,000
        nonrefundable fine for each county and for each population (e.g., ABD, CFC,
        etc.).  For example if the MCP did not meet GIS requirements in the
        following counties, the MCP would be assessed (1) a nonrefundable $2,000
        fine
        for the failure to meet GIS requirements for the CFC population and (2) a
        $1,000
        nonrefundable fine for the failure to meet GIS requirements for the ABD
        population.

      
        ·
GIS
          requirements in Franklin county for the CFC population 

      

      
        ·
GIS
          requirements in Fairfield county for the CFC population 

      

      
        ·
GIS
          requirements in Franklin county for the ABD population 

      

      

      J.3.
        Late Submissions
        - All required submissions/data and documentation requests must be received
        by
        their specified deadline and must represent the MCP in an honest and forthright
        manner.  Failure to provide ODJFS with a required submission or any
        data/documentation requested by ODJFS will result in the assessment of a nonrefundable fine of $100
        per day,
        unless the MCP requests and is granted an extension by
        ODJFS.  Assessments for late submissions will be done
        monthly.  Examples of such program violations include, but are not
        limited to:

      

      
        ·
Late
          required
          submissions

      

      
        o
          Annual
          delegation
          assessments

      

      
        o
          Call
          center
          report

      

      
        o
          Franchise
          fee
          documentation

      

      
        o
          Reinsurance
          information  (e.g., prior approval of
          changes)

      

      
        o
          State
          hearing
          notifications

      

      
         

        ·Late
          required data
          submissions

      

      
        o
          Appeals
          and grievances, case management,
          or PCP
          data

      

      
         

        ·Late
          required information
          requests

      

      
        o
          Automatic
          call distribution
          reports

      

      
        o
          Information/resolution
          regarding
          consumer or provider complaint

      

      
        o
          Just
          cause or other coordination care
          request from ODJFS

      

      
        o
          Provider
          panel documentation 

      

      
        o
          Failure
          to provide ODJFS with a required submission after ODJFS has notified the
          MCP
          that the prescribed deadline for that submission has passed 

      

      

      If
        an MCP
determines that they will
        be
        unable to meet a program deadline or data/documentation submission deadline,
        the
        MCP must submit a written request to its Contract Administrator
        for an extension of
        the
        deadline, as soon as possible, but no later than 3 PM EST on the date of
        the
        deadline in question. Extension requests should only be submitted in situations
        where unforeseeable circumstances have
        occurred which make it impossible
        for the MCP to
        meet an ODJFS-stipulated deadline and all such requests will be evaluated
        upon
        this standard.  Only
        written approval as may
        be granted by ODJFS of a deadline extension will preclude the assessment
        of
        compliance action for untimely submissions.

      

      J.4.
        Noncompliance with
        Claims Adjudication Requirements - If ODJFS finds that an MCP is unable
        to (1) electronically accept and adjudicate claims to final status and/or
        (2)
        notify providers of the status of their submitted claims, as stipulated in
        Appendix C of the Agreement, ODJFS will assess the MCP with a monetary sanction
        of $20,000 per day for the period of noncompliance.

      

      If
        ODJFS
        has identified specific instances where an MCP has failed to take the necessary
        steps to comply with the requirements specified in Appendix C of the Agreement
        for (1) failing to notify non-contracting providers of procedures for claims
        submissions when requested and/or (2) failing to notify contracting and
        non-contracting providers of the status of their submitted claims, the MCP
        will
        be assessed 5 points per incident of noncompliance.

      

      J.5.
        Noncompliancewith
        Prompt
        Payment:- Noncompliance
        with the prompt pay requirements as specified in Appendix J of the Agreement
        will result in progressive penalties.  The first violation during
a rolling 12-month
        period
will result in the
        submission of quarterly
        prompt pay and monthly
        status reports to ODJFS until the next quarterly report is due.  The
        second violation during
a
        rolling 12-month period will result in the
        submission of
        monthly status reports and a refundable fine equal to 5% of the MCP’s
        monthly premium payment or $300,000, whichever is less.  The
        refundable fine will be applied in lieu of a nonrefundable fine and the money
        will be refunded by ODJFS
        only
        after the MCP complies with the required standards for two (2) consecutive
        quarters.  Subsequent violations
        will
        result in an enrollment freeze.

       

      If
        an MCP is found to have not been in
        compliance with the prompt pay requirements for any time period for which
        a
        report and signed attestation have been submitted representing the MCP as
        being
        in compliance, the MCP will
        be subject to an enrollment freeze of not less
        than three (3) months
        duration.

      

      J.6.
        Noncompliance with
        Franchise Fee Assessment Requirements - In accordance with ORC Section
        5111.176, and in addition to the imposition of any other penalty, occurrence
        or
        points under this Appendix, an MCP that does not pay the franchise permit
        fee in
        full by the due date is subject to any or all of the following:

      

      
        ·
          A
          monetary penalty in the amount of $500 for each day any part of the fee
          remains
          unpaid, except the penalty will
          not exceed an amount equal to 5 % of the total fee that was due for the
          calendar
          quarter for which the penalty was imposed;

      

      

      
        ·
          Withholdings
          from future ODJFS
          capitation payments.  If an MCP fails to pay the full amount of its
          franchise fee when due, or the full amount of the imposed penalty, ODJFS
          may
          withhold an amount equal to the remaining amount due from any future ODJFS
          capitation payments. ODJFS will return all withheld capitation payments
          when the
          franchise fee amount has been paid in full;

      

      

      
        ·
          Proposed
          termination or non-renewal of
          the MCP’s Medicaid provider agreement may occur if the
          MCP:

      

      
        a.Fails
          to pay its franchise permit fee or
          fails to pay the fee promptly;

      

      
        b.Fails
          to pay a penalty imposed under
          this Appendix or fails to pay the penalty promptly;

      

      
        c.Fails
          to cooperate with an audit
          conducted in accordance with ORC Section 5111.176.

      

      

      J.7.
        Noncompliance with
        Clinical Laboratory Improvement Amendments - Noncompliance with CLIA
        requirements as specified by ODJFS will result in the assessment of a
        nonrefundable $1,000 fine for each violation.

      

      J.8.
        Noncompliance with
        Abortion and Sterilization Payment - Noncompliance with abortion and
        sterilization requirements as specified by ODJFS will result in the assessment
        of a nonrefundable $2,000 fine for each documented
        violation.  Additionally, MCPs must take all appropriate action to
        correct each ODJFS-documented violation.

      

      J.9.
        Refusal to
        Comply
        with Program Requirements - If ODJFS has instructed
        an MCP that they
        must comply with a specific program requirement and the MCP refuses, such
        refusal constitutes documentation that the MCP is no longer operating in
        the
        best interests of the MCP’s members or the state of Ohio and ODJFS will move to
        terminate or nonrenew the MCP’s provider agreement.

      

      III.
        Request
        for Reconsiderations

      

      MCPs
        may request a reconsideration of
        remedial action taken under the CAS for
        penalties that include points,
        fines, reductions in assignments and/or selection freezes.  Requests
        for reconsideration must be submitted on the ODJFS required form as
        follows:

      

      A.
        MCPs notified of ODJFS’ imposition of
        remedial  action taken under the CAS will have ten
        (10) working days from
        the date of receipt
        of the facsimile to request
        reconsideration, although ODJFS will impose enrollment
        freezes based on an access to care
        concern concurrent with initiating notification to the
        MCP.  Any information
        that the MCP would like reviewed as part of the reconsideration request must
        be
        submitted at the time of submission of the reconsideration request, unless
        ODJFS
        extends the time frame in writing.

      

      B.
        All requests for reconsideration must
        be submitted by either facsimile transmission or overnight mail to the Chief,
        Bureau of Managed Health Care, and received by ODJFS by the tenth business
        day after receipt of the
        faxed notification of the imposition of the remedial action by
        ODJFS.

      

      C.
        The
        MCP will be responsible for verifying timely receipt of all reconsideration
        requests.  All requests for reconsideration must explain in detail why
        the specified remedial action
        should not be imposed.  The MCP’s justification for reconsideration
        will be limited to a review of the written material submitted by the
        MCP.  The Bureau Chief will review all correspondence and materials
        related to the violation in question in making the final reconsideration
        decision.

      

      D.
        Final decisions or requests for
        additional information will be made by ODJFS within ten (10) business days
        of
        receipt of the request for reconsideration.

      

      E.
        If additional information is
        requested by ODJFS, a final reconsideration decision will be made within
        three
        (3) business days of the due date for the submission.  Should ODJFS
        require additional time in rendering the final reconsideration decision,
        the MCP
        will be notified of such in writing.

      

      F.
        If a reconsideration request is
        decided, in whole or in part, in favor of the MCP, both the penalty and the
        points associated
        with the incident, will be
        rescinded or reduced, in the sole discretion of ODJFS.  The MCP may
        still be required to submit a CAP if ODJFS, in its sole discretion, believes
        that a CAP is still warranted under the circumstances.

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      APPENDIX
        O

      

      PAY-FOR-PERFORMANCE
        (P4P)

      ABD
        ELIGIBLE
        POPULATION

      

      This
        Appendix establishes a
        Pay-for-performance (P4P)
incentive
        system for
        managed care plans (MCPs) to improve performance in specific areas important
        to
        the Medicaid MCP members.  P4P
        includes the at-risk amount included
        with the monthly premium payments (see Appendix F, Rate
        Chart), and possible
        additional monetary rewards up to $250,000.

      

      To
        qualify for consideration of any
P4P,
        MCPs must meet minimum performance
        standards established in Appendix M, Performance
        Evaluation on selected
        measures, and achieve P4P
standards
        established for
        selected Clinical Performance Measures, as set forth herein
        below.  For qualifying MCPs, higher performance standards for three
        measures must be reached to be awarded a portion of the at-risk amount and
        any
        additional P4P (see
        Sections 1).  An
        excellent and superior standard is set in this Appendix for each of the three
        measures.  Qualifying MCPs will be awarded a portion of the at-risk
        amount for each excellent standard met.  If an MCP meets all three
        excellent and superior standards, they may be awarded additional P4P (see
        Section 2).

      

      ODJFS
        will use the first calendar year
        of an MCP’s ABD managed care program membership as the baseline year (i.e.,
        CY2007).  The baseline year will be used to determine performance
        standards and targets; baseline data may come from a combination of FFS claims
        data and MCP encounter data.  As many of the performance measures used
        in the determination of P4P
require
        two calendar years
        of baseline data, the additional calendar year (i.e., the calendar year prior
        to
        the first calendar year of ABD managed care program membership, [i.e., CY2006])
        data will come from FFS
        claims.

      

      An
        MCP’s second calendar year of ABD
        managed care program membership (i.e., CY2008) will be the initial report
        period
        of evaluation for performance measures that require one calendar year of
        baseline data (i.e., CY2007), and for performance measures that require two
        calendar years of baseline data (i.e., CY2006 and CY2007).  CY2008
        will be the initial report period upon which compliance with the performance
        standards will be determined.  SFY 2009
        will become the first year an MCP’s
        performance level for P4Pcan
        be determined.

      

      1.
        SFY 2009 P4P

      

      1.a.
        Qualifying Performance
        Levels

      

      To
        qualify for consideration of the SFY
        2009 P4P, an MCP’s performance level must:

      

      1)
        Meet the minimum performance
        standards set in Appendix M, Performance
        Evaluation, for the
        measures listed below; and

      

      2)  Meet
        the  P4P
        standards established for the
        Clinical Performance Measures below.

       

      
        ·
          A
          detailed description of the
          methodologies for each measure can be found on the BMHC page of the ODJFS
          website.

      

      

      Measures
        for which the minimum
        performance standard for SFY 2009 established in Appendix M, Performance
        Evaluation, must be met to
        qualify for consideration of incentives are as follows:

      

      1.  PCP
        Turnover (Appendix M,
        Section 2.a.)

      

      Report
        Period: CY
        2008

      

      2.  Adults’
Access
        to
        Preventive/Ambulatory Health Services (Appendix M, Section
        2.c.)

      

      Report
        Period: CY
        2008                                                      

      

      For
        each clinical performance measure
        listed below, the MCP must meet the P4P standard
        to be considered for SFY 2009
P4P.  The
        MCP meets the P4P
        standard if one of two criteria is met.  The P4P standard is a
        performance level of either:

      

      1)
        The minimum performance standard
        established in Appendix M, Performance
        Evaluation, for five of
        eight clinical performance measures listed below; or

      

      2)
        The Medicaid benchmarks for five of
        eight clinical performance measures listed below.  The Medicaid
        benchmarks are subject to change based on the revision or update of applicable
        national standards, methods or benchmarks.

       

      
        	 	
                
                

                Clinical
                  Performance Measure

              	
                Medicaid

                Benchmark

              
	
                CHF:
Inpatient HospitalDischarge
                  Rate

              	
                TBD 

              
	
                1.
CAD:
                  Beta-Blocker Treatment after
                  Heart Attack (AMI -related admission)

              	
                TBD

              
	
                2.
CAD:
                  Cholesterol Management for
                  Patients with Cardiovascular Conditions/LDL-C screening
                  performed

              	
                TBD

              
	
                3.
Hypertension:
Inpatient HospitalDischarge
                  Rate

              	
                TBD

              
	
                4.
Diabetes:
                  Comprehensive Diabetes
                  Care (CDC)/Eye exam

              	
                TBD

              
	
                5.
COPD:
Inpatient HospitalDischarge
                  Rate

              	
                TBD

              
	
                6.
Asthma:
                  Use of Appropriate
                  Medications for People with Asthma

              	
                TBD

              
	
                7.
Mental
                  Health: Follow-up After
                  Hospitalization for Mental Illness

              	
                TBD

              

      

      

      1.b.
        Excellent and Superior Performance
        Levels

      

      For
        qualifying MCPs as determined by
        Section 1.a.. herein, performance will be evaluated on the measures below
        to
        determine the status of the at-risk amount or any additional P4P
        that may be awarded.  Excellent and
Superior
standards
        are set for the three measures
        described below.  The standards are subject to change based on the
        revision or update of applicable national standards, methods or
        benchmarks.

      

      A
        brief description of these measures is
        provided in Appendix M, Performance
        Evaluation.  A
        detailed description of the methodologies for each measure can be found on
        the
        BMHC page of the ODJFS website.

      

      1.
        Case Management of Members (Appendix
        M, Section
        1.b.i)

      

      Report
        Period: April – June
        2009

      

      Excellent
        Standard:  TBD

      

      Superior
        Standard:  TBD

      

      2.
Comprehensive
        Diabetes Care (CDC)/Eye
        exam (Appendix M, Section
        1.c.xiv.)

      

      Report
        Period: CY
        2008

      

      Excellent
        Standard:
        TBD

      

      Superior
        Standard:
        TBD

      

      3.
        Adults’ Access to
        Preventive/Ambulatory Health Services (Appendix M, Section
        2.c.)

      

      Report
        Period: CY
        2008

      

      Excellent
        Standard:
        TBD

      

      Superior
        Standard:
        TBD

      

      1.c.
        Determining SFY 2009
        P4P

      

      MCPs
reaching
        the minimum performance
        standards described in Section 1.a. herein, will be considered for P4P including
        retention of the at-risk amount and any additional P4P.  For each
        Excellent standard established in Section 1.b. herein,  that an MCP
        meets, one-third of the at-risk amount may be retained.  For MCPs
        meeting all of the Excellent and Superiorstandards
        established in Section 1.b.
        herein, additional P4P may be awarded.  For MCPs receiving additional
        P4P, the amount in the P4P fund
        (see section 2.) will be divided
        equally, up to the maximum
        additional amount,
        among all MCPs’ABD and/or CFC
        programs receiving
        additional P4P.  The maximum additional amount to be awarded per plan,
        per program, per contract year is $250,000.  An MCP may receive up to
        $500,000 should both of the MCP’s ABD and CFC programs achieve the Superior
        Performance Levels.

      

      2.
        NOTES

      

      2.a. Initiation
        of the P4P
        System

      

      For
        MCPs in their first twenty-four (24)
        months of Ohio Medicaid ABD Managed Care Program participation, the status
        of
        the at-risk amount will not be determined because compliance with many of
        the
        standards in the ABD program cannot be determined in an MCP’s first two contract
        years
        (see Appendix F., Rate
        Chart). In addition, MCPs
        in their first two (2) contract years in the ABD program are not eligible
        for
        the additional P4P
amount
        awarded for
        superior
        performance.

      

      Starting
        with the twenty-fifth
        (25th)
        month of participation in the ABD
        program, the MCP’s at-risk amount will be included in
        the  P4P
system.  The
        determination of the status of this at-risk amount will occur after two (2)
        calendar years of ABD membership. Because
        of this requirement, the number
        of months of at-risk dollars to be included in an MCP’s first at-risk status
        determination may vary depending on when an MCP starts with the ABD program
        relative to the calendar year.

      

      2.b.
        Determination of at-risk amounts
        and additional P4P payments

      

      For
        MCPs that have participated in the
        Ohio Medicaid ABD Managed Care Program long enough to calculate performance
        levels for all of the performance measures included in the P4P system,
        determination of the status of
        an MCP’s at-risk amount will occur within six (6) months of the end of the
        contract period.  Determination of additional P4P payments
        will be made at the same time
        the status of an MCP’s at-risk amount is determined.

      

      2.c.
        Statewide P4P
        system

      

      All
        MCPs will be included in a statewide
        P4P system for the ABD program.  The at-risk amount will be determined
        using a statewide result for all regions in which an MCP serves ABD
        membership.

      

      2.d.
        Contract Termination, Nonrenewals,
        or Denials

      

      Upon
        termination, nonrenewal or denial of an MCP contract, the at-risk amount
        paid to
        the MCP under the current provider agreement will be returned to
        ODJFS  in accordance with Appendix P., Terminations/Nonrenewals/Amendments,
        of the provider agreement.

      

      Additionally,
        in accordance with Article
        XI of the provider agreement, the return of the at-risk amount paid to the
        MCP
        under the current provider agreement will be a condition necessary for ODJFS’
approval of a provider agreement assignment.

      

      2.e.
        Report Periods

      

      The
        report period used in determining
        the MCP’s performance levels varies for each measure depending on the
        frequency of the report and the data source.  Unless otherwise noted,
        the most 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.

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