Document:

Ohio Medicaid Medical Assistance Provider Agreement  for CFC Eligible Population

 Covered Families and Children (CFC) population 
  

 Exhibit 10.21 
 OHIO DEPARTMENT OF JOB AND FAMILY SERVICES 
 OHIO MEDICAL ASSISTANCE PROVIDER AGREEMENT

 FOR MANAGED CARE PLAN 
 CFC ELIGIBLE POPULATION 
 This provider agreement is entered into this first day of January, 2007, at Columbus, Franklin
County, Ohio, between the State of Ohio, Department of Job and Family Services, (hereinafter referred to as ODJFS) whose principal offices are located in the City of Columbus, County of Franklin, State of Ohio, and Molina Healthcare of Ohio, Inc.,
Managed Care Plan (hereinafter referred to as MCP), an Ohio for-profit corporation, whose principal office is located in the city of Columbus, County of Franklin, State of Ohio. 
 MCP is licensed as a Health Insuring Corporation by the State of Ohio, Department of Insurance (hereinafter referred to as ODI), pursuant to Chapter
1751. of the Ohio Revised Code and is organized and agrees to operate as prescribed by Chapter 5101:3-26 of the Ohio Administrative Code (hereinafter referred to as OAC), and other applicable portions of the OAC as amended from time to time.

 MCP is an entity eligible to enter into a provider agreement in accordance with 42 CFR 438.6 and is engaged in the business of providing
prepaid comprehensive health care services as defined in 42 CFR 438.2 through the managed care program for the Covered Families and Children (CFC) eligible population described in OAC rule 5101:3-26-02 (B). 
 ODJFS, as the single state agency designated to administer the Medicaid program under Section 5111.02 of the Ohio Revised Code and Title XIX of the
Social Security Act, desires to obtain MCP services for the benefit of certain Medicaid recipients. In so doing, MCP has provided and will continue to provide proof of MCP’s capability to provide quality services, efficiently, effectively and
economically during the term of this agreement. 

 Covered Families and Children (CFC) population 
  Page
 2
 of 10 
  

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

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

  

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

  

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

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

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

 ARTICLE III - REIMBURSEMENT

  

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

 Covered Families and Children (CFC) population 
  Page
 3
 of 10 
  

 ARTICLE IV - MCP INDEPENDENCE 
  

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

 ARTICLE V - CONFLICT OF INTEREST; ETHICS LAWS 
  

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

  

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

  

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

 Covered Families and Children (CFC) population 
  Page
 4
 of 10 
  

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

  

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

 ARTICLE VI -
EQUAL EMPLOYMENT OPPORTUNITY 
  

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

  

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

  

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

 ARTICLE VII -
RECORDS, DOCUMENTS AND INFORMATION 
  

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

  

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

 Covered Families and Children (CFC) population 
  Page
 5
 of 10 
  

	 	 
confidential by ODJFS. Proprietary information is information which, if made public, would put MCP at a disadvantage in the market place and trade of which
MCP is a part [see Ohio Revised Code Section 1333.61(D)]. MCP is responsible for notifying ODJFS of the nature of the information prior to its release to ODJFS. ODJFS reserves the right to require reasonable evidence of MCP’s assertion of
the proprietary nature of any information to be provided and ODJFS will make the final determination of whether this assertion is supported. The provisions of this Article are not self-executing. 

  

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

 ARTICLE VIII - SUSPENSION AND TERMINATION 
  

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

  

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

  

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

  

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

 Covered Families and Children (CFC) population 
  Page
 6
 of 10 
  

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

 ARTICLE
IX - AMENDMENT AND RENEWAL 
  

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

  

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

 

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

 ARTICLE X - LIMITATION OF LIABILITY 
  

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

  

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

  

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

 Covered Families and Children (CFC) population 
  Page
 7
 of 10 
  

	 	 
services; provided that so long as MCP’s certificate of authority remains in full force and effect, MCP shall be liable for the covered services
required to be provided or arranged for in accordance with this agreement. 

 ARTICLE XI - ASSIGNMENT 
  

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

  

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

 ARTICLE XII - CERTIFICATION MADE BY MCP 
  

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

  

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

 

	C.	 By executing this agreement, MCP certifies that neither MCP nor any principals of MCP (i.e., a director, officer, partner, or person with beneficial ownership of
more than 5% of the MCP’s equity) is presently debarred, suspended, proposed for debarment, declared ineligible, or otherwise excluded from participation in transactions by any Federal 

 Covered Families and Children (CFC) population 
  Page
 8
 of 10 
  

	 	 
agency. The MCP also certifies that the MCP has no employment, consulting or any other arrangement with any such debarred or suspended person for the
provision of items or services or services that are significant and material to the MCP’s contractual obligation with ODJFS. This certification is a material representation of fact upon which reliance was placed when this provider agreement was
entered into. If it is ever determined that MCP knowingly executed this certification erroneously, then in addition to any other remedies, this provider agreement shall be terminated pursuant to Article VII, and ODJFS must advise the Secretary of
the appropriate Federal agency of the knowingly erroneous certification. 

  

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

  

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

  

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

 

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

  

	H.	By executing this agreement, MCP certifies and affirms that, as applicable to MCP, no party listed in Division (I) or (J) of Section 3517.13 of the Ohio Revised Code
or spouse of such party has made, as an individual, within the two previous calendar years, one or more contributions in excess of $1,000.00 to the Governor or to his campaign committees. This certification is a material representation of fact upon
which reliance was placed when this provider agreement was entered into. If it is ever determined that MCP’s certification of this requirement is false or misleading, and not withstanding any criminal or civil liabilities imposed by law, MCP
shall return to ODJFS all monies paid to MCP under this provider agreement. The provisions of this section shall survive the expiration or termination of this provider agreement. 

  

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

  

	J.	By executing this agreement, MCP agrees to comply with the false claims recovery requirements of Section 6032 of The Deficit Reduction Act of 2005 (also see Section 5111.101 of
the Revised Code). 

 Covered Families and Children (CFC) population 
  Page
 9
 of 10 
  

 ARTICLE XIII - CONSTRUCTION 
  

	A.	This provider agreement shall be governed, construed and enforced in accordance with the laws and regulations of the State of Ohio and appropriate federal statutes and regulations.
If any portion of this provider agreement is found unenforceable by operation of statute or by administrative or judicial decision, the operation of the balance of this provider agreement shall not be affected thereby; provided, however, the absence
of the illegal provision does not render the performance of the remainder of the provider agreement impossible. 

 ARTICLE XIV - INCORPORATION
BY REFERENCE 
  

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

  

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

  

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

 Covered Families and Children (CFC) population 
  

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

							
	 MOLINA HEALTHCARE OF OHIO, INC.:
	  	
				
	BY:	 	  
	  		  	DATE:                         
		 	JESSE THOMAS, PRESIDENT & CEO	  	
		
	OHIO DEPARTMENT OF JOB AND FAMILY SERVICES:	  	
				
	BY:	 	  
	  		  	DATE:                         
		 	BARBARA E. RILEY, DIRECTOR	  	

 CFC PROVIDER AGREEMENT INDEX 
 JANUARY 1, 2007 
  

					
	 APPENDIX
	    	 TITLE
	  	 
	APPENDIX A	    	OAC RULES 5101:3-26	  	
			
	APPENDIX B	    	SERVICE AREA SPECIFICATIONS – CFC ELIGIBLE	  	
		    	POPULATION	  	
			
	APPENDIX C	    	MCP RESPONSIBILITIES – CFC ELIGIBLE	  	
		    	POPULATION	  	
			
	APPENDIX D	    	ODJFS RESPONSIBILITIES – CFC ELIGIBLE	  	
		    	POPULATION	  	
			
	APPENDIX E	    	RATE METHODOLOGY – CFC ELIGIBLE	  	
		    	POPULATION	  	
			
	APPENDIX F	    	REGIONAL RATES – CFC ELIGIBLE	  	
		    	POPULATION	  	
			
	APPENDIX G	    	COVERAGE AND SERVICES – CFC ELIGIBLE	  	
		    	POPULATION	  	
			
	APPENDIX H	    	PROVIDER PANEL SPECIFICATIONS – CFC	  	
		    	ELIGIBLE POPULATION	  	
			
	APPENDIX I	    	PROGRAM INTEGRITY– CFC ELIGIBLE	  	
		    	POPULATION	  	
			
	APPENDIX J	    	FINANCIAL PERFORMANCE – CFC ELIGIBLE	  	
		    	POPULATION	  	
			
	APPENDIX K	    	QUALITY ASSESSMENT AND	  	
		    	PERFORMANCE IMPROVEMENT PROGRAM – CFC	  	
		    	ELIGIBLE POPULATION	  	
			
	APPENDIX L	    	DATA QUALITY – CFC ELIGIBLE POPULATION	  	
			
	APPENDIX M	    	PERFORMANCE EVALUATION – CFC ELIGIBLE	  	
		    	POPULATION	  	
			
	APPENDIX N	    	COMPLIANCE ASSESSMENT SYSTEM – CFC	  	
		    	ELIGIBLE POPULATION	  	
			
	APPENDIX O	    	PAY-FOR-PERFORMANCE	  	
		    	(P4P) – CFC ELIGIBLE POPULATION	  	
			
	APPENDIX P	    	MCP TERMINATIONS/NONRENEWALS/	  	
		    	AMENDMENTS – CFC ELIGIBLE POPULATION	  	

 APPENDIX A 
 OAC RULES 5101:3-26 
 The managed care program rules can be accessed electronically through the BMHC page of the
ODJFS website. 

 APPENDIX B 
 SERVICE AREA SPECIFICATIONS 
 ABD ELIGIBLE POPULATION 
 MCP : Molina Healthcare of Ohio, Inc. 
 The MCP
agrees to provide services to Aged, Blind or Disabled (ABD) members residing in the following service area(s): 
 Service Area: Southwest Region:
Adams, Brown, Butler, Clermont, Clinton, Hamilton, Highland, and Warren counties. 
 Service Area: West Central Region: Champaign, Clark, Darke,
Greene, Miami, Montgomery, Preble, and Shelby counties. 
 Service Area: Southeast Region: Athens, Belmont, Coshocton, Gallia, Guernsey, Harrison,
Jackson, Jefferson, Lawrence, Meigs, Monroe, Morgan, Muskingum, Noble, Vinton, and Washington counties. 

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

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

  

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

  

	3	The MCP must designate the following: 

 a. A primary
contact person (the Medicaid Coordinator) who will dedicate a majority of their time to the Medicaid product line and coordinate overall communication between ODJFS and the MCP. ODJFS may also require the MCP to designate contact staff for specific
program areas. The Medicaid Coordinator will be responsible for ensuring the timeliness, accuracy, completeness and responsiveness of all MCP submissions to ODJFS. 
 b. A provider relations representative for each service area included in their ODJFS provider agreement. This provider relations representative can serve in this capacity for only one service area (as specified in
Appendix H). 
 As long as the MCP serves both the CFC and ABD populations, they are not required to have separate provider relations
representatives or Medicaid coordinators. 
  

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

  

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

  

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

  

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

 Appendix C 
 Page 2

  

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

  

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

  

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

  

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

  

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

  

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

  

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

  

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

 Appendix C 
 Page 3

  

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

  

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

  

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

  

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

  

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

  

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

  

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

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

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

 Appendix C 
 Page 4

  

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

  

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

  

	20.	The MCP must utilize a centralized database which records the special communication needs of all MCP members (i.e., those with limited English proficiency, limited reading
proficiency, visual impairment, and hearing impairment) and the provision of related services (i.e., MCP materials in alternate format, oral interpretation, oral translation services, written translations of MCP materials, and sign language
services). This database must include all MCP member primary language information (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). 

 Appendix C 
 Page 5

  

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

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

  

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

  

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

  

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

  

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

  

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

  

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

  

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

  

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

 Appendix C 
 Page 6

  

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

  

	 	i.	Provides written information to all adult members concerning: 

  

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

  

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

  

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

  

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

  

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

  

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

  

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

  

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

 Appendix C 
 Page 7

  

	24.	New Member Materials 

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

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

  

	 	b.	The ID card and new member letter must be mailed together to the member via a method that will ensure its receipt prior to the member’s effective date of coverage. No other
materials may be included with this mailing. 

  

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

  

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

  

	25.	Call Center Standards 

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

	 	•	 	 New Year’s Day 

  

	 	•	 	 Martin Luther King’s Birthday 

  

	 	•	 	 Memorial Day 

  

	 	•	 	 Independence Day 

  

	 	•	 	 Labor Day 

  

	 	•	 	 Thanksgiving Day 

  

	 	•	 	 Christmas Day 

  

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

 Appendix C 
 Page 8

  

 If a major holiday falls on a Saturday, the MCP member services line may be closed on the preceding
Friday. If a major holiday falls on a Sunday, the member services line may be closed on the following Monday. MCP member services closure days must be specified in the MCP’s member handbook, member newsletter, or other some general issuance to
the MCP’s members at least (thirty) 30 days in advance of the closure. 
 The MCP must also provide access to medical advice and
direction through a centralized twenty-four-hour, seven day (24/7) toll-free call-in system, available nationwide, pursuant to OAC rule 5101:3-26-03.1(A)(6). The 24/7 call-in system must be staffed by appropriately trained medical personnel.
For the purposes of meeting this requirement, trained medical professionals are defined as physicians, physician assistants, licensed practical nurses, and registered nurses. 
 MCPs must meet the current American Accreditation HealthCare Commission/URAC-designed Health Call
Center Standards (HCC) for call center abandonment rate, blockage rate and average speed of answer. By the 10th of
each month, MCPs must self-report their prior month performance in these three areas for their member services and 24/7 toll-free call-in systems to ODJFS. ODJFS will inform the MCPs of any changes/updates to these URAC call center standards.

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

	26.	Notification of Optional MCP Membership 

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

	 	-	Indians who are members of federally-recognized tribes. 

  

	 	-	Children under 19 years of age who are: 

  

	 	•	 	 Eligible for Supplemental Security Income under title XVI; 

  

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

  

	 	•	 	 Receiving foster care of adoption assistance; 

  

	 	•	 	 Receiving services through the Ohio Department of Health’s Bureau for 

 Appendix C 
 Page 9

  

	 	 
Children with Medical Handicaps (BCMH) or any other family-centered, community-based, coordinated care system that receives grant funds under section
501(a)(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. 

 Appendix C 
 Page 10

  

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

  

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

  

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

  

	29.	MCP Membership acceptance, documentation and reconciliation 

  

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

  

	 	b.	Monthly Reconciliation of Membership and Premiums: The MCP shall reconcile member data as reported on the SSC-produced consumer contact record (CCR) with the ODJFS-produced
monthly member roster (MMR) and report to the ODJFS any difficulties in interpreting or reconciling information received. Membership reconciliation questions must be identified and reported to the ODJFS prior to the first of the month to assure that
no member is left without coverage. The MCP shall reconcile membership with premium payments and delivery payments as reported on the monthly remittance advice (RA).The MCP shall work directly with the ODJFS, or other ODJFS-identified entity, to
resolve any difficulties in interpreting or reconciling premium information. Premium reconciliation questions must be identified within thirty (30) days of receipt of the RA. 

  

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

 Appendix C 
 Page 11

  

	 	d.	Hospital Deferment Requests: When the MCP learns of a new member’s hospitalization that is eligible for deferment prior to that member’s discharge, the MCP shall
notify the hospital and treating providers of the potential that the MCP may not be the payer. The MCP shall work with hospitals, providers and the ODJFS to assure that discharge planning assures continuity of care and accurate payment.
Notwithstanding the MCP’s right to request a hospital deferment up to six (6) months following the member’s effective date, when the MCP learns of a deferment-eligible hospitalization, the MCP shall make every effort to notify the
ODJFS and request the deferment as soon as possible. When the MCP is notified by ODJFS of a potential hospital deferment, the MCP must make every effort to respond to ODJFS within ten (10) business days of the receipt of the deferment
information. 

  

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

  

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

  

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

  

	 	h.	Pending Member 

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

 Appendix C 
 Page 12

  

	 	i.	Transition of Fee-For-Service Members 

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

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

  

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

  

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

  

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

  

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

  

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

  

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

  

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

  

	 	a.	As expeditiously as the situation warrants, contact the provider’s office via telephone to confirm that the service(s) meet(s) the above criteria. 

 Appendix C 
 Page 13

  

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

  

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

  

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

  

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

  

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

  

	30.	Health Information System Requirements 

 The ability
to develop and maintain information management systems capacity is crucial to successful plan performance. 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 

 Appendix C 
 Page 14

  

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

  

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

  

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

  

	 	a.	Before an MCP may submit production files 

  

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

  

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

 MCPs that change or modify information systems that are involved in producing any type of electronically submitted files, either internally or by
changing vendors, are required to submit to ODJFS for review and approval a transition plan including the submission of test files in the ODJFS-specified formats. Once an acceptable test file is submitted to ODJFS, as determined solely by ODJFS, the
MCP can return to submitting production files. ODJFS will inform MCPs in writing when a test file is acceptable. Once an MCP’s new or modified information system is operational, that MCP will have up to ninety (90) days to submit an
acceptable test file and an acceptable production file. 
 Submission of test files can start before the new or modified information system
is in production. ODJFS reserves the right to verify any MCP’s capability to report elements in the minimum data set prior to executing the provider agreement for the next contract period. Penalties for noncompliance with this requirement are
specified in Appendix N, Compliance Assessment System of the Provider Agreement. 
  

	 	b.	Electronic Data Interchange and Claims Adjudication Requirements 

 Claims Adjudication 
 The MCP must have the capacity to electronically accept and adjudicate all claims to final status
(payment or denial). Information on claims submission procedures 

 Appendix C 
 Page 15

  

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

Standard code sets. 
 Each EDI transaction
processed by the MCP shall be implemented in conformance with the appropriate version of the transaction implementation guide, as specified by applicable federal rule or regulation. 
 The MCP must have the capacity to accept the following transactions from the Ohio Department of Job and Family services consistent with EDI processing
specifications in the transaction implementation guides and in conformance with the 820 and 834 Transaction Companion Guides issued by ODJFS: 
 ASC 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. 

 Appendix C 
 Page 16

  

 Verification of Compliance with HIPAA (Health Insurance Portability and Accountability Act of
1995) 
 MCPs shall submit written verification to ODJFS for transaction standards and code sets specified in 45 CFR Part 162 –
Health Insurance Reform: Standards for Electronic Transactions (HIPAA regulations), that the MCP has established the capability of sending and receiving applicable transactions in compliance with the HIPAA regulations. The written verification shall
specify the date that the MCP has: 1) achieved capability for sending and/or receiving the following transactions, 2) entered into the appropriate trading partner agreements, and 3) implemented standard code sets. If the MCP has obtained third-party
certification of HIPAA compliance for any of the items listed below, that certification may be submitted in lieu of the MCP’s written verification for the applicable item(s). 
  

	 	i.	Trading Partner Agreements 

  

	 	ii.	Code Sets 

  

	 	iii.	Transactions 

  

	 	a.	Health Care Claims or Equivalent Encounter Information (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 

 Appendix C 
 Page 17

  

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

	 	•	 	 Institutional Claims - UB92 flat file 

  

	 	•	 	 Noninstitutional Claims - National standard format 

  

	 	•	 	 Prescription Drug Claims - NCPDP 

 ODJFS relies heavily on encounter data for monitoring MCP performance. The ODJFS uses encounter data to measure clinical performance, conduct access and utilization reviews, reimburse MCPs for newborn deliveries and aid in setting MCP
capitation rates. For these reasons, it is important that encounter data is timely, accurate, and complete. Data quality, performance measures and standards are described in the Agreement. 
 An encounter represents all of the services, including medical supplies and medications, provided to a member of the MCP by a particular provider,
regardless of the payment arrangement between the MCP and the provider. For example, if a member had an emergency department visit and was examined by a physician, this would constitute two encounters, one related to the hospital provider and one
related to the physician provider. However, for the purposes of calculating a utilization measure, this would be counted as a single emergency department visit. If a member visits their PCP and the PCP examines the member and has laboratory
procedures done within the office, then this is one encounter between the member and their PCP. 
 If the PCP sends the member to a lab to
have procedures performed, then this is two encounters; one with the PCP and another with the lab. For pharmacy encounters, each prescription filled is a separate encounter. 
 Encounters include services paid for retrospectively through fee-for-service payment arrangements, and prospectively through capitated arrangements. Only
encounters with services (line items) that are paid by the MCP, fully or in part, and for which no further payment is anticipated, are acceptable encounter data submissions, except for immunization services. Immunization services submitted to the
MCP must be submitted to ODJFS if these services were paid for by another entity (e.g., free vaccine program). 
 All other services that are
unpaid or paid in part and for which the MCP anticipates further payment (e.g., unpaid services rendered during a delivery of a newborn) may not be submitted to ODJFS until they are paid. Penalties for noncompliance with this requirement are
specified in Appendix N, Compliance Assessment System of the Agreement. 

 Appendix C 
 Page 18

  

 Acceptance Testing 
 The MCP must have the capability to report all elements in the Minimum Data Set as set forth in the ODJFS Encounter Data Specifications and must submit a
test file in the ODJFS-specified medium in the required formats prior to contracting or prior to an information systems replacement or update. 
 Acceptance testing of encounter data is required as specified in Section 29(a)(v) of this Appendix. 
 Encounter Data File
Submission Procedures 
 A certification letter must accompany the submission of an encounter data file in the ODJFS-specified medium. The
certification letter must be signed by the MCP’s Chief Executive Officer (CEO), Chief Financial Officer (CFO), or an individual who has delegated authority to sign for, and who reports directly to, the MCP’s CEO or CFO. 
 No more than two production files in the ODJFS-specified medium per format (e.g., NSF) should be submitted each month. If it is necessary for an MCP to
submit more than two production files in the ODJFS-specified medium for a particular format in a month, they must request and receive permission to do so from their designated Contract Administrator. 
 Timing of Encounter Data Submissions 
 ODJFS recommends that MCPs submit encounters no more than thirty-five (35) days after the end of the month in which they were paid. For example, claims paid in January are due March 5. ODJFS recommends that MCPs submit files in
the ODJFS-specified medium by the 5th of each month. This will help to ensure that the encounters are included in the ODJFS master file in the same month in which they were submitted. 
  

	 	d.	Information Systems Review 

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

  

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

 Appendix C 
 Page 19

  

	 	ii.	Review the completed ISCA and accompanying documents; 

  

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

  

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

  

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

  

	 	vi.	Examine MCP processes for data transfers; 

  

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

  

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

  

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

 As noted above, the information system review may be performed every two years. However, if ODJFS or its designee identifies significant information system problems, then ODJFS or its designee may conduct, and the MCP
must participate in, a review the following year or in such a timeframe as ODJFS, in their sole discretion, deems appropriate to ensure accuracy and efficiency of the MCP health information system. 
 If an MCP had an assessment performed of its information system through a private sector accreditation body or other independent entity within the two
years preceding the time when ODJFS or its designee will be conducting its review, and has not made significant changes to its information system since that time, and the information gathered is the same as or consistent with the ODJFS or its
designee’s proposed review, as determined by the ODJFS, then the MCP will not required to undergo the IS review. The MCP must provide ODJFS or its designee with a copy of the review that was performed so that ODJFS can determine whether or not
the MCP will be required to participate in the IS review. 

 Appendix C 
 Page 20

  

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

	31.	Delivery Payments 

 MCPs will be reimbursed for paid
deliveries that are identified in the submitted encounters using the methodology outlined in the ODJFS Methods for Reimbursing for Deliveries (as specified in Appendix L). The delivery payment represents the facility and professional service
costs associated with the delivery event and postpartum care that is rendered in the hospital immediately following the delivery event; no prenatal or neonatal experience is included in the delivery payment. 
 If a delivery occurred, but the MCP did not reimburse providers for any costs associated with the delivery, then the MCP shall not submit the delivery
encounter to ODJFS and is not entitled to receive payment for the delivery. MCPs are required to submit all delivery encounters to ODJFS no later than one year after the date of the delivery. Delivery encounters which are submitted after this time
will be denied payment. MCPs will receive notice of the payment denial on the remittance advice. 
 If an MCP is denied payment through
ODJFS’ automated payment system because the delivery encounter was not submitted within a year of the delivery date, then it will be necessary for the MCP to contact BMHC staff to receive payment. Payment will be made for the delivery, at the
discretion of ODJFS if a payment had not been made previously for the same delivery. 
 To capture deliveries outside of institutions (e.g.,
hospitals) and deliveries in hospitals without an accompanying physician encounter, both the institutional encounters (UB-92) and the noninstitutional encounters (NSF) are searched for deliveries. 
 If a physician and a hospital encounter is found for the same delivery, only one payment will be made. The same is true for multiple births; if multiple
delivery encounters are submitted, only one payment will be made. The method for reimbursing for deliveries includes the delivery of 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. 

 Appendix C 
 Page 21

  

 Timing of Delivery Payments 
 MCPs will be paid monthly for deliveries. For example, payment for a delivery encounter submitted with the required encounter data submission in March,
will be reimbursed in March. The delivery payment will cover any encounters submitted with the monthly encounter data submission regardless of the date of the encounter, but will not cover encounters that occurred over one year ago. 
 This payment will be a part of the weekly update (adjustment payment) that is in place currently. The third weekly update of the month will include the
delivery payment. The remittance advice is in the same format as the capitation remittance advice. 
 Updating and Deleting Delivery
Encounters 
 The process for updating and deleting delivery encounters is handled differently from all other encounters. See the ODJFS
Encounter Data Specifications for detailed instructions on updating and deleting delivery encounters. 
 The process for deleting delivery
encounters can be found on page 35 of the UB-92 technical specifications (record/field 20-7) and page 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. 

 Appendix C 
 Page 22

  

	36.	Franchise Fee Assessment Requirements 

  

	 	 a.
	 Each MCP is required to pay a franchise permit fee to ODJFS for each calendar quarter as required by ORC
Section 5111.176. The current fee to be paid is an amount equal to 4 1/2 percent of the managed care
premiums, minus Medicare premiums that the MCP received from any payer in the quarter to which the fee applies. Any premiums the MCP returned or refunded to members or premium payers during that quarter are excluded from the fee.

  

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

  

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

  

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

  

	37.	Information Required for MCP Websites 

  

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

  

	 	b.	 On-line Member Website – MCPs must have a secure internet-based website which is regularly updated to include the most current ODJFS approved materials.
The website at a minimum must include: (1) a list of the counties that are covered in their service area; (2) the ODJFS-approved MCP member handbook, recent newsletters/announcements, MCP contact information including member services hours
and closures; (3) the MCP provider directory as referenced in section 36(a) of this appendix; (4) the MCP’s current preferred drug list (PDL), including an explanation of the list, which drugs require prior authorization (PA), and the
PA process; (5) the MCP’s current list of drugs covered only with PA, the PA process, and the MCP’s policy for covering generic for brand-name drugs; and (6) the ability for members to submit
questions/comments/grievances/appeals/etc. and receive a response (members 

 Appendix C 
 Page 23

  

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

  

	 	c.	On-line Provider Website – MCPs must have a secure internet-based website for providers where they will be able to confirm a consumer’s MCP enrollment and through
this website (or through e-mail process) allow providers to electronically submit and receive responses to prior authorization requests. This website must also include: (1) a list of the counties that are covered in their service area;
(2) the MCP’s provider manual; (3) MCP contact information; (4) a link to the MCP’s on-line provider directory as referenced in section 36(a) of this appendix; (5) the MCP’s current PDL list, including an
explanation of the list, which drugs require PA, and the PA process; and (6) the MCP’s current list of drugs covered only with PA, the PA process, and the MCP’s policy for covering generic for brand-name drugs. MCPs must ensure that
all member materials designated specifically for CFC and/or ABD consumers are clearly labeled as such. ODJFS may require MCPs to include additional information on the provider website, as needed. 

  

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

  

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

 APPENDIX D 
 ODJFS RESPONSIBILITIES 
 CFC ELIGIBLE POPULATION 
 The following are ODJFS responsibilities or clarifications that are not otherwise specifically stated in OAC Chapter 5101: 3-26 or elsewhere in the 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.

  

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

 Appendix D 
 Page 2

  

	11.	It is the intent of ODJFS to utilize electronic commerce for many processes and procedures that are now limited by HIPAA privacy concerns to FAX, telephone, or hard copy. The use 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 will provide MCP eligible individuals, including current MCP members, with a Consumer Guide. The Consumer Guide will describe the managed care program and include information on the MCP
options in the service area and other information regarding the managed care program as specified in 42 CFR 438.10. 

  

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

  

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

 Appendix D 
 Page 3

  

	15.	Membership Selection and Premium Payment 

  

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

 The SSC shall distribute the most current Consumer Guide that includes the managed care program information as specified in 42 CFR 438.10, as well as
ODJFS prior-approved MCP materials, such as solicitation brochures and provider directories, to consumers who request additional materials. 
  

	 	b.	Auto-Assignment Limitations – In order to ensure market and program stability, ODJFS may limit an MCP’s auto-assignments if they meet any of the following
enrollment thresholds: 

  

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

  

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

  

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

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

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

  

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

  

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

 Appendix D 
 Page 4

  

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

  

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

  

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

  

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

  

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

  

	19.	Communications 

  

	 	a.	ODJFS/BMHC: The Bureau of Managed Health Care (BMHC) is responsible for the oversight of the MCPs’ provider 

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

	 	b.	ODJFS contracting-entities: ODJFS-contracting entities should never be contacted by the MCPs unless the MCPs have 

 been specifically instructed to contact the ODJFS contracting entity directly. 
  

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

 Appendix D 
 Page 5

  

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

 APPENDIX E 
 RATE METHODOLOGY 
 CFC ELIGIBLE POPULATION 

 

 
  

	
	333 South 7th Street, Suite 1600
	Minneapolis, MN 55402-2427
	www.mercerHR.com

 October 20, 2006 
 Mr. Jon Barley 
 State of Ohio 
 Bureau of Managed
Health Care 
 Ohio Department of Job and Family Services 
 255
East Main Street, 2nd Floor 
 Columbus, OH 43215-5222 
 Subject:

 Calendar Year 2007 Rate-Setting Methodology: Healthy Families and Healthy Start 
 Dear Jon: 
 The Ohio Department of Job and Family Services (State) contracted with Mercer Government Human Services
Consulting (Mercer) to develop actuarially sound capitation rates for Calendar Year (CY) 2007 for the Healthy Families and Healthy Start (CFC) managed care populations. Mercer developed CY 2007 capitation rates for the following seven managed care
regions: Central, East Central, Northeast, Northwest, Southeast, Southwest, and West Central. At this time, Mercer has not developed rates for the eighth region, Northeast Central, because managed care implementation has been put on hold for this
region. Once the implementation date is determined for Northeast Central, a supplemental certification with the Northeast Central rates will be provided. 
 The basic rate-setting methodology is similar to the county-specific rate methodology used in previous years. This methodology letter outlines the rate-setting process, provides information on data adjustments, and includes a final rate
summary. 
 The key components in the CY 2007 rate-setting process are: 
  

	•	 	 Base data development, 

  

	•	 	 Managed care rate development, and 

  

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

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

 

 

 
 Page 2 
 October 20,
2006 
 Mr. Jon Barley 
 Ohio Department of Job and Family
Services 
  

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

The data sources used for CY 2007 rate setting were: 
  

	•	 	 Ohio historical FFS data, 

  

	•	 	 MCP encounter data, and 

  

	•	 	 MCP financial cost report data. 

 Validation Process

 As part of the rate-setting process, Mercer validated each of the data sources that were used to develop rates. The validations included a review of the
data to be used in the rate setting process. During the validation process, Mercer adjusted the data for any data miscodes (e.g., males in the delivery rate cohort) that were found. 
 Data Sources 
 As Ohio’s Medicaid program matures, the rate-setting methodology for those counties within each region
with stable managed care programs can focus more on plan-reported managed care data, including encounter data and cost reports. For counties within each region without established managed care programs, Mercer continued to use the FFS data as a
direct data source. The data sources used in each region depended on the most credible data sources available within the region. In regions where there are stable managed care programs, managed care data for those counties was combined with the FFS
data for those counties without established managed care programs. The process to prepare these three data sources for rate-setting is detailed below. 
 Appendix B includes a chart detailing how each region’s counties have been bucketed into mandatory, Preferred Option, voluntary, or new based on the delivery system in place during the base period. This determined which data sources
were used in determining regional CY 2007 rates. Also included in Appendix B is a map that shows the counties included within each region. 
 Other sources
of information that were used, as necessary, included state enrollment reports, state financial reports, projected managed care penetration rates, information from prior MCP surveys, encounter data issues log, and other ad hoc sources. 

 

 

 
 Page 3 
 October 20, 2006

 Mr. Jon Barley 
 Ohio Department of Job and Family Services

  

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

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

  

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

 In addition to the SFY 2004 and SFY 2005 data, SFY 2003 data supplemented the FFS base data development as a reasonability measure. For the above counties, the FFS data was considered the most credible data source
and, in some cases, was the only data available for rate setting. 
 As in previous years, adjustments were applied to the FFS data to reflect the
actuarially equivalent claims experience for the population that will be enrolled in the managed care program. The State Medicaid Management Information System (MMIS) includes data for populations and/or services excluded from managed care and the
actual FFS paid claims may be net or gross of certain factors (e.g., gross adjustments or third party liability (TPL)). As a result, it is necessary to make adjustments to the FFS base data as documented in Appendix C and outlined in Appendix A.

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

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

  

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

 For the above counties, the encounter data was considered a credible data source and was used along with the financial cost report data as a direct data source. 
 Although encounter data is generally reflective of the populations and services that are the responsibility of the MCPs, adjustments were applied to the encounter data,
as appropriate. Those adjustments, and other considerations, include the following items: 
  

	•	 	 Claims completion factors, 

 

 

 

 
 Page 4 
 October 20, 2006

 Mr. Jon Barley 
 Ohio Department of Job and Family Services

  

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

  

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

 The adjustments to the encounter data are further documented in Appendix C and outlined in Appendix A. 
 During the rate setting process, shadow pricing was used to assign unit costs to the encounter data. This process was necessary since, during the base period, paid
amounts were not a required field for reporting encounters. Additional information on shadow pricing is presented on page six of this letter. 
 Financial
Cost Reports 
 MCP-submitted financial cost reports from the base time period CY 2004 and CY 2005 were used as a direct data source for the counties
described below: 
  

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

  

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

 For all of the above counties, except Mahoning and Trumbull who entered into managed care on October 1, 2005, the cost reports were considered a credible data source. In addition, for counties with voluntary
managed care programs during the base time period, the cost reports were taken into consideration when setting rates, although not used as a direct data source. 
 As with the encounter data, the cost report data typically reflects the populations and services that are the responsibility of the MCPs. However, adjustments were applied to the cost report data, as appropriate. Those adjustments, and
other considerations, include the following items: 
  

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

  

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

  

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

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

 

 

 
 Page 5 
 October 20,
2006 
 Mr. Jon Barley 
 Ohio Department of Job and Family
Services 
  

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

Managed Care Rate Development 
 This section explains how Mercer
developed the final capitation rates paid to contracted MCPs after the base data was developed and multiple years of data were blended for each data source. First, Mercer applied trend, programmatic changes and other adjustments to each data source
to project the program cost into the contract year. Next, the various data sources were blended into a single managed care rate and an administrative component was applied. Finally, relational modeling was used to smooth the results within each
region. Appendix A outlines the managed care rate development process. Appendix D provides more detail behind each of the following adjustments. 
 Blending
Multiple Years of Data 
 As the programs have matured, we have collected multiple years of FFS and managed care data. In order to utilize all available
current information, Mercer combined the yearly data within each data source using a weighted average methodology similar to that used in previous years. Prior to blending these years of data, the base time period experience was trended to a common
time period of CY 2005. Mercer applied greater credibility on the most recent year of data to reflect the expectation that the most recent year may be more reflective of future experience and to reflect that fewer adjustments are needed to bring the
data to the effective contract period. 
 Managed Care Assumptions for the FFS Data Source 
 In developing managed care savings assumptions, Mercer applied generally accepted actuarial principles that reflect the impact of MCP programs on FFS experience. Mercer reviewed Ohio’s historical FFS experience,
CY 2004 and CY 2005 cost report data, SFY 2004 and SFY 2005 encounter data, and other state Medicaid managed care experience to develop managed care savings assumptions. These assumptions have been applied to the FFS data to derive managed care cost
levels. The assumptions are consistent with an economic and efficiently operated Medicaid managed care plan. The managed care savings assumptions vary by region, rate cohort and category of service (COS). 
 Specific adjustments were made in this step to reflect the differences between pharmacy contracting for the State and contracting obtained by the MCPs. Mercer reviewed
information related to discount rates, dispensing fees, rebates, encounter data and MCP cost report data to make these adjustments. The rates are reflective of MCP contracting for these services. 
 

 

 

 
 Page 6 
 October 20, 2006

 Mr. Jon Barley 
 Ohio Department of Job and Family Services

  

 Shadow Pricing 
 During
our base period, MCPs were not required to report the amount paid for a particular service in their encounter submissions. Therefore, Mercer developed assumed unit costs that were applied to encounter utilization data. For the inpatient category of
service, unit costs were calculated by region based on the average daily cost for each hospital peer group. Unit costs for other COSs were calculated based on Ohio Medicaid FFS reimbursement levels. The unit costs were then adjusted by rate cohort
to reflect the age/sex unit cost differential apparent in the statewide FFS data. In addition, a unit cost managed care assumption was applied in the shadow pricing step for the pharmacy COS. 
 Prospective Policy Changes 
 CMS also requires that the rate-setting
methodology incorporates the impact of any programmatic changes that have taken place, or are anticipated to take place, between the base period (CY 2005) and the contract period (CY 2007). 
 The State provided Mercer with a detailed list of program changes that may have a material impact on the cost, utilization, or demographic structure of the program prior
to, or within, the contract period and whose impact was not included within the base period data. In addition, other potential program changes are being discussed in the current legislative session. Final programmatic changes approved for SFY 2007
are reflected in the CY 2007 rates, as appropriate. Please refer to Appendix D for more information on these programmatic changes. 
 Clinical
Measures/Incentives 
 Per Appendix M of the Provider Agreement, the State expects the MCPs to reach certain performance levels for selected clinical
measures. Mercer reviewed the impact of these standards and incentives on the managed care rates and developed a set of adjustments based upon the State’s expected improvement rates. These utilization targets were built into the capitation
rates. The individual measures/incentives are outlined in Appendix D. 
 Caseload 
 Historically, the State has experienced significant changes in its Medicaid caseload. These shifts in caseload have affected the demographics of the remaining Medicaid population. Mercer 
 

 

 

 
 Page 7 
 October 20,
2006 
 Mr. Jon Barley 
 Ohio Department of Job and Family
Services 
  

 
evaluated recent and expected caseload variations to determine if an adjustment was necessary to account for demographic changes. Based on the data provided
by the State, Mercer determined no adjustments were necessary for either the non-delivery or delivery rate cells. 
 Selection Issues 
 There are two selection adjustments that were made in the development of the rates. The first is adverse selection, which accounts for the “missing” managed
care data and is applied to historical FFS data. This adjustment is explained in more detail in Appendix C. 
 The second selection adjustment is voluntary
selection, which accounts for the fact that costs associated with individuals who elect to participate in managed care are generally lower than the remaining FFS population. Therefore, the voluntary selection adjustment adjusts for the risk of only
those members selecting managed care. 
 Both selection adjustments are reductions to paid claims and utilization for non-delivery data. Appendix D provides
more detail around the voluntary selection adjustment. 
 Non-State Plan Services 
 According to the CMS Final Medicaid Managed Care Rule that was implemented August 13, 2003, non-state plan services may not be included in the base data for rate-setting. The CY 2004 and 2005 cost reports contain
information from the MCPs that was used to adjust the base data for non-state plan services reported in the cost reports and the encounter data. Please refer to Appendix D for more information concerning this adjustment. 
 Prospective Trend Development 
 Trend is an estimate of the change in the
overall cost of providing a specific benefit service over a finite period of time. A trend factor is necessary to estimate the expenses of providing health care services in some future year, based on expenses incurred in prior years. Trend was
applied by COS to the blended base data costs for CY 2005 to project the data forward to the CY 2007 contract period. 
 Cost report data was reviewed for
overall per member per month (PMPM) trend levels while the FFS data continued to be a primary source in projecting trend. Because of its role in the rate-setting process, the encounter data was available to study utilization trend drivers. Mercer
integrated the specific data sources’ trend analysis with a broader analysis of other trend resources. These resources included health care economic factors (e.g., as Consumer Price Index 
 

 

 

 
 Page 8 
 October 20, 2006

 Mr. Jon Barley 
 Ohio Department of Job and Family Services

  

 
(CPI) and Data Resource Inc. (DRI)), trends in neighboring states, the State FFS trend expectations and any Ohio market changes. Moreover, the trend
component was comprised of both unit cost and utilization components. 
 As in the past, Mercer discussed all trend recommendations with the State. We
reviewed the potential impact of initiatives targeted to slow or otherwise affect the trends in the program. Final trend amounts were determined from the many trend resources and this additional program information. Appendix D provides more
information on trend. 
 Credibility Assignment 
 For regions
composed of only new and voluntary counties, 100% credibility was placed on the FFS data. For regions with available FFS and managed care data, the FFS, encounter and cost report data was blended together. 
 Cesarean Delivery Rate 
 Mercer reviewed historical FFS delivery data, recent
MCP delivery data, and other program experience to determine an expected cesarean delivery rate under the managed care program. Please refer to Appendix D for additional information on cesarean delivery rates. 
 Relational Modeling 
 Relational modeling was used to adjust the premiums by
rate cohort to produce a relatively consistent age/sex slope among the regions. The relational modeling adjustments shift dollars across rate cohorts within a region but do not change the composite results by region or in aggregate. Through the use
of the adjustments, the range of variances among the regions and rate cohorts was reduced while maintaining budget neutrality. 
 The relational modeling
adjustments were applied to the net medical rates in the Capitation Rate Calculation Sheets (CRCS) to develop new adjusted medical rates. An administration load factor was then applied as a percent of premium. 
 Administration/Contingencies 
 Mercer reviewed the components of the
administration/contingencies allowance and evaluated the administration/contingencies rates paid to the MCPs. Factors that were taken into consideration in determining the final administration/contingencies percentages included the State’s
expectations, Ohio health plan experience, other Medicaid program 
 

 

 

 
 Page 9 
 October 20,
2006 
 Mr. Jon Barley 
 Ohio Department of Job and Family
Services 
  

 
administration/contingencies allowances, and Ohio health plans’ lengths of participation in the program. In addition, the MCP franchise fee of 4.5% was
incorporated into the final capitation rate. 
 Certification of Final Rates 
 The following capitation rates were developed for each of the seven regions for the CY 2007 contract period: 
  

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

  

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

  

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

  

	•	 	 Healthy Families/Healthy Start, 14-18 Years Old, Female, 

  

	•	 	 Healthy Families/Healthy Start, 14-18 Years Old, Male, 

  

	•	 	 Healthy Families, 19-44 Years Old, Female, 

  

	•	 	 Healthy Families, 19-44 Years Old, Male, 

  

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

  

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

  

	•	 	 Delivery Payment. 

 A summary of the rates is
included in Appendix E. 
 Mercer certifies the above rates were developed in accordance with generally accepted actuarial practices and principles by
actuaries meeting the qualification standards of the American Academy of Actuaries for the populations and services covered under the managed care contract. Rates developed by Mercer are actuarial projections of future contingent events. Actual MCP
costs will differ from these projections. Mercer developed these rates on behalf of the State to demonstrate compliance with the CMS requirements under 42 CFR 438.6(c) and to demonstrate that rates are in accordance with applicable law and
regulations. 
 MCPs are advised that the use of these rates may not be appropriate for their particular circumstance and Mercer disclaims any responsibility
for the use of these rates by MCPs for any purpose. Mercer recommends any MCP considering contracting with the State should analyze its own projected medical expense, administrative expense, and any other premium needs for comparison to these rates
before deciding whether to contract with the State. Use of these rates for purposes beyond those stated may not be appropriate. 
 

 

 

 
 Page 10 
 October 20,
2006 
 Mr. Jon Barley 
 Ohio Department of Job and Family
Services 
  

			
	Sincerely,	 	 
	

	 	

	Angela WasDyke, MAAA, ASA	 	Wendy Radunz, MAAA, FSA

 Copy: 
 Chuck Betley,
Mitali Ghatak, Tracy Williams – State of Ohio 
 Katie Olecik, Jon Rasmussen – Mercer 
 

 

 

 
  

 Appendix A – CY 2007 Rate-Setting Methodology 
 

 

 

 
  

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

 Mandatory and Preferred Option Counties 
 Encounter and cost
report data was used for counties that were either mandatory or Preferred Option during the base data period*. These counties include: 
  

			
	 Mandatory:
	 	 Preferred Option:

	 Cuyahoga
	 	Butler
	 Lucas
	 	Clark
	 Stark
	 	Franklin
	 Summit
	 	Hamilton
		 	Lorain
		 	Montgomery

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

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

	
	 Voluntary:

	 Clermont

	 Greene

	 Pickaway

	 Warren

	 Wood

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

 B - 1 

 

 
  

 

 
  

 B - 2 

 

 
  

 Appendix C – FFS Data Adjustments 
 This section lists adjustments made to the FFS claims and eligibility information received from the State. 
 Completion
Factors 
 The claims data was adjusted to account for the value of claims incurred but unpaid on a COS basis. Mercer used claims for SFY 2004 and SFY 2005
that reflect payments through the dates included in the following table. 
  

			
	 SFY
	 	Paid Through
	2004	 	03/31/05
	2005	 	12/31/05

 The value of the claims incurred during each of these years, but unpaid, was estimated using completion factor
analysis. 
 Gross Adjustment File (GAF) 
 To account for gross
debit and credit amounts not reflected in the FFS data, adjustments were applied to the FFS paid claims. 
 Historical Policy Changes 
 As part of the rate-setting process, Mercer must account for policy changes that occurred during the base data time period. Changes only reflected in a portion of the
data must be applied to the remaining data so that all base data reflects the policy changes. All policy changes implemented during SFY 2004 and SFY 2005 were applied to the FFS data. 
 The following table shows the specific policy changes for which Mercer adjusted the SFY 2004 and SFY 2005 delivery (where applicable) and non-delivery data. Mercer calculated the adjustments based on information
supplied by the State. 
  

							
	 Policy Changes
	  	 Effective
 Date
	  	 Category of
 Service
 Affected
	  	 Rate Cohorts Affected

	 Independently-practicing psychologist services eliminated for adults (>21) and pregnant women
	  	1/1/2004	  	PCP, OB/GYN
and Specialists	  	Ages 19+, including delivery
	 All chiropractic services eliminated for adults (>21) and pregnant women
	  	1/1/2004	  	Other	  	HF, Age 19-44, M
	  	  	  	HF, Age 19-44, F
	  	  	  	HF, Age 45+, M & F
	  	  	  	HST, Age 19-64, F
	 Implementation of $3.00 Copay on Prior-Authorized Drugs
	  	1/1/2004	  	Pharmacy	  	All

  

 C - 1 

 

 
  

 Third Party Liability Recoveries 
 TPL can be identified with two components: “cost-avoidance” and “pay and chase” type actions. “Cost-avoidance” occurs when the State initially denies paying a claim because another payer is the primary payer.
The State may then pay a residual portion of the charged amount. Only the residual portion of the claim will be included in the FFS data. The portion of the claim paid by another payer has been avoided and not included in reported claim payments.
Participating MCPs are expected to pay in a similar fashion and therefore, no adjustment to the FFS data will be required. 
 In a “pay and chase”
scenario, the State pays the claim as though it were the primary payer. Subsequent to payment, the State makes recovery from a third party. These TPL recoveries are not reflected in the FFS MMIS data. Since MCPs are also expected to take similar
recovery actions, the FFS experience was adjusted to reflect “pay and chase” recoveries. Mercer made adjustments to both the paid claims and utilization for all non-delivery and delivery COS. Since MCPs do not collect tort recoveries, the
data excludes tort collections. 
 Hospital Cost Settlements 
 The State provided Mercer with SFY 2004 and SFY 2005 interim cost settlements for Diagnosis Related Group (DRG) and DRG-exempt hospitals. The DRG-exempt hospital information included inpatient and outpatient settlements. However, the DRG
hospitals only include capital settlements, which were incorporated into the adjustment. Therefore, an adjustment has been applied to non-delivery and delivery inpatient, outpatient, and emergency room (ER) claims to remove these additional costs.

 Fraud and Abuse 
 The State does pursue recoveries from fraud
and abuse cases. The dollars recovered are accounted for outside of the State’s MMIS system and are not included in the FFS data. Since the MCPs are required to pursue fraud and abuse cases, an adjustment was applied to the FFS claims and
utilization in both the delivery and non-delivery data. 
 Excluded Time Periods 
 The capitation rates paid to the MCPs reflect the risk of serving the eligible enrollees from the date of health plan enrollment forward. Therefore, the non-delivery FFS data has been adjusted to reflect only the time
periods for which the MCPs are at risk. Since newborns are automatically eligible for the Medicaid program and are enrolled into their mother’s MCP at birth, no adjustment will be applied to the “Less Than 1” age group. 
 Adverse Selection 
 An adverse selection adjustment was applied to the
historical FFS data to account for the “missing” managed care data. The adverse selection factor adjusts the associated risk of the FFS members to the entire Medicaid population’s risk by accounting for the cost of the managed care
population. This adjustment varies by historical managed care penetration and includes a credibility factor which accounts for differences in State enrollment patterns and data sources. It has been applied to the paid claims and utilization for
non-delivery FFS base data. 
  

 C - 2 

 

 
  

 Dual Eligibles 
 Dual
eligible persons are not enrolled in managed care and, therefore, are not included in the managed care rates. Their experience has been excluded from the base FFS data used to develop the rates. 
 Catastrophic Claims 
 Since the State does not provide reinsurance to the
MCPs, the MCPs are expected to purchase reinsurance on their own. To reflect these costs, all claims, including claims above the reinsurance threshold, were included in the base FFS data. The final rates Mercer calculated reflect the total risk
associated with the covered population and are expected to be sufficient to cover the cost of the required stop-loss provision. 
 DSH Payments 

DSH payments are made by the State to providers and are not the responsibility of the MCPs; therefore, the information for these payments was excluded from the FFS
data used to develop the rates. No rate adjustment was necessary. 
 Spend Down 
 Persons Medicaid eligible due to spend down are not enrolled in managed care and therefore not included in the managed care rates. The base FFS data is net of recipient spend down. Therefore, no additional adjustment
was needed for the rate computations. 
 Graduate Medical Education (GME) 
 The State does not make supplemental GME payments for services delivered to individuals covered under the managed care program. Rather, the MCPs negotiate specific rates with the individual teaching hospitals for the
daily cost of care. Therefore, the GME payments are included in the capitation rates paid to the MCPs. 
  

 C - 3 

 

 
  

 Appendix C – Encounter Data Adjustments 
 Claims Completion 
 Mercer used CY 2005 cost report lag triangles to complete the MCP encounter utilization data. 

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

							
	 Policy Change
	  	Effective
Date	  	Category
of Service
Affected	  	 Rate Cohorts
Affected

	 Independently-practicing psychologist services eliminated for adults (>21) and pregnant women
	  	1/1/2004	  	PCP, OB/
GYN and
Specialists	  	Ages 19+, including delivery
	 All chiropractic services eliminated for adults (>21) and pregnant women
	  	1/1/2004	  	Other	  	 HF, Age 19-44, M
 HF, Age 19-44, F
 HF, Age 45+, M & F
 HST, Age 19-64, F

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

 As directed by the State, Mercer made adjustments to the encounter data to account for incomplete reporting or other known data issues. 
 Non-State Plan Services 
 Mercer reviewed NSPS information included in the
MCP cost reports. This information was used to calculate an adjustment for NSPS, including eye examinations, chiropractic and psychological services, and routine transportation. The adjustment was applied to the Specialists, Dental and Other
categories of service in the encounter data, as appropriate. 
 Third Party Liability Recoveries 
 Mercer reviewed TPL recoveries information contained in Report I of the cost reports to remove these from the encounters reported by each health plan. Mercer made MCP
specific adjustments to the data. 
  

 C - 4 

 

 
  

 Appendix C – Cost Report Data Adjustments 
 IBNR Review/Adjustment 
 Mercer used CY 2005 cost report claims restatement Report IV and lag triangles to adjust the MCP
IBNR estimates in the CY 2004 and CY 2005 financial experience. 
 Historical Policy Changes 
 As part of the rate-setting process, the data must reflect any policy changes that occurred during the base data time period. Changes only reflected in a portion of the base data must be applied to the remaining base
data to keep the data similar. There were no rate-impacting policy changes implemented after 1/1/2004 and before 12/31/05. Therefore, no policy change adjustments were applied to the cost report data. 
 Data Anomaly Corrections 
 Mercer made cost-neutral adjustments to the CY
2004 cost report data to account for recoding of expenses by category of service. For example, the delivery costs associated with the “Other” COS in report III-A were shifted to the non-delivery “Other” COS. 
 Non-State Plan Services 
 Mercer reviewed NSPS information included in the
MCP cost reports. This information was used to calculate an adjustment for NSPS, including eye examinations, chiropractic and psychological services, and routine transportation. The adjustment was applied to the Specialists, Dental and Other
categories of service in the cost report data, as appropriate. 
 Third Party Liability Recoveries 
 Mercer reviewed TPL recoveries information contained in Report I of the cost reports to remove these from the medical costs reported by each health plan. 
  

 C - 5 

 

 
  

 Appendix D – Calendar Year 2007 CFC Rate Development 
 Credibility By Year 
 Mercer placed more credibility on the most recent year
of data for each data source. 
 FFS Historical and Managed Care Historical/Prospective Trend 
 Historical FFS trend assumptions were used to trend SFY 2004 and SFY 2005 FFS data to the base period (CY 2005) for voluntary and new counties. Credibility was then applied to blend together the trended SFY 2004 and
the SFY 2005 FFS data. 
 Managed care historical trend was used to trend SFY 2004 and SFY 2005 encounter data and CY 2004 cost report data to the base
period (CY 2005) for Preferred Option and mandatory counties. Credibility was then applied to blend together the trended SFY 2004 and the SFY 2005 encounter data and the trended CY 2004 and CY 2005 cost report data. 
 Prospective managed care trend assumptions were then applied to the blended FFS, cost report, and encounter data to develop the CY 2007 regional rates. 
 Prospective Policy Changes 
 The following items are considered prospective
policy changes. These changes were not reflected in the base data, but were implemented prior to the contract period. Therefore, Mercer made rate-setting adjustments for each item in the following table. 
 Adjustments Affecting Unit Cost 
  

							
	 Policy Change
	    	 Effective
Date
	    	 Category
of Service
 Affected
	    	 Rate Cohorts
 Affected

	 Implementation of $2 copay for trade-name preferred drugs for adults (321)
	    	1/1/2006	    	Pharmacy	    	HF, Age 19-44, F
	    	    	    	HF, Age 19-44, M
	    	    	    	HF, Age 45+, M & F
	 Implementation of $3 copay for each dental date of service for adults (321)
	    	1/1/2006	    	Dental	    	HF, Age 19-44, F
	    	    	    	HF, Age 19-44, M
	    	    	    	HF, Age 45+, M & F
	 Implementation of $2 copay for vision exams and $ 1 copay for dispensing services for adults (321)
	    	1/1/2006	    	Other	    	HF, Age 19-44, F
	    	    	    	HF, Age 19-44, M
	    	    	    	HF, Age 45+, M&F
	    	    	    	HST, Age 19-64, F
	 Inpatient recalibration and outlier policies
	    	1/1/2006	    	Inpatient	    	All
	 Inpatient rate freeze
	    	1/1/2006	    	Inpatient	    	All

  

 D - 1 

 

 
  

 Adjustments Affecting Utilization 
  

							
	 Policy Change
	  	Effective
Date	  	Category
of Service
Affected	  	 Rate Cohorts
Affected

	 Reduction in coverage of dental services for adults (321)
	  	1/1/2006	  	Dental	  	 HF, Age 19-44, F
 HF, Age 19-44, M
 HF, Age 45+, M & F
 HST, Age 19-64, F

 The 1/1/2006 policy change in the Federal Poverty Level (FPL) from 100% to 90% did not have an impact on the
rates. 
 Clinical Measures/Incentives 
 Since the State requires
the plans to reach, at minimum, the performance standard for each of the indicators from Appendix M of the SFY 2007 Provider Agreement, Mercer built this expectation into the capitation rates. To calculate the adjustments, Mercer reviewed MCP
clinical measures percentages for the CY 2005 base year and projected these rates forward by building in the State’s expected improvement rate for counties in managed care as of January 1, 2006. Mercer then calculated the percent change
from base year to the rating period, and applied the adjustment as a portion of COS. The following chart provides additional detail on each clinical measure. 
  

 D - 2 

 

 
  

					
	 Clinical Measure
	  	Rate Cohort	  	Category of
Service Affected
	 Prenatal Care – Frequency of Ongoing Prenatal Care
  
 Target: 80% of eligible population must receive 81% or more
of expected number of prenatal visits.
	  	HF/HST, 14-18 F
HST, 19-64 F
HF, 19-44 F	  	OB/GYN
Physician
	 Prenatal Care – Post Partum Visits
  
 Target: 80% of the eligible population must receive a post
partum visit.
	  	HF/HST, 14-18 F
HST, 19-64 F
HF, 19-44 F	  	OB/GYN
	 Preventive Care for Children – Well-Child Visits
  
 Target: 80% of children receive expected number of
visits:
 Children who turn 15 mos. old; 6+ visits. Children who were 3-6 years old; 1+ visit. Children who were
12-21 years old; 1+ visit.
	  	HF/HST, <1 M&F
HF/HST, 1 M&F
HF/HST, 2-13 M&F
HF/HST, 14-18 M
HF/HST, 14-18 F	  	Physician
	 Use of Appropriate Medications for People with Asthma
  
 Target: 95% of eligible Asthma members receive prescribed
medications acceptable as primary therapy for long-term control of asthma.
	  	HF/HST, 2-13 M&F
HF/HST, 14-18 M
HF/HST, 14-18 F
HF, 19-44 M
HF, 19-44 F
HF, 45+ M&F
HST, 19-64 F	  	Pharmacy
	 Annual Dental Visits
  

Target: 60% of enrolled children age 4-21 receive 1 dental visit.
	  	HF/HST, 2-13 M&F
HF/HST, 14-18 M
HF/HST, 14-18 F	  	Dental
	 Lead Screening
  
 Target: 80% of children age 1-2 receive a blood lead
screening.
	  	HF/HST, 1 M&F
HF/HST, 2-13 M&F	  	Physician
	  	  
	  	  

 Voluntary Selection 
 As a result of the adverse selection adjustment that was applied in the FFS Data Summaries, the FFS data already reflects the risk of the entire Medicaid program (i.e., FFS and managed care individuals). To solely reflect the risk of the
managed care program, Mercer modified the FFS data based on the projected managed care penetration levels for CY 2007. This voluntary selection adjustment modifies the FFS data to reflect the risk to the MCPs (i.e., only those individuals who enroll
in a health plan). 
 For the encounter and cost report data, the original base data reflects the historical penetration levels in SFY 2004-SFY 2005 and CY
2004-CY 2005, respectively. Where projected managed 

  

 D - 3 

 

 
  

 
care penetration levels differ from the historical values, the data was brought back to reflect the risk of the entire Medicaid program, and then adjusted
forward (as the FFS data was) to reflect projected managed care levels. 
 Credibility by Data Source 
 For regions composed of only new and voluntary counties, 100% credibility was placed on the FFS data. For regions with available FFS and managed care data, the FFS data
was used for the new and voluntary counties within the region, while the encounter and cost report data were used for the mandatory and Preferred Option counties within the region. 
 C-Section/Vaginal Percent 
 Mercer received MCP cesarean and vaginal rates from CY 2005 encounter data. Based on the analysis
for all MCPs combined, Mercer determined C-section and vaginal rate assumptions. 
 MCP Administration/Contingencies 
 Based on a review of MCP reported administration expenses, the MCP administration/ contingencies allowance will remain at 12% of premium prior to the franchise fee. For
existing health plans, 1% of the pre-franchise fee capitation rate will be put at risk, contingent upon MCPs meeting performance requirements for counties with managed care enrollment as of January 1, 2006. The at-risk amount for counties
entering managed care after January 1, 2006 will be 0% for the first two plan years. 
 For plans new to managed care in Ohio, the administration
schedule will be as follows. 
  

							
	 	  	Admin	 	 	At-Risk	 
	 Plan Year 1 (months 1-12)
	  	13	%	 	0	%
	 Plan Year 2 (months 13-24)
	  	12	%	 	0	%
	 Plan Year 3 (months 25-36)
	  	12	%	 	1	%

 For plans entering Ohio through the acquisition of another Ohio health plan’s membership, the administration
schedule will continue as outlined above based on the plan year of the acquired health plan membership. The administration schedule will not revert back to the Plan Year 1 schedule due to the membership acquisition. 
 In addition, the total capitation rate was adjusted to incorporate the 4.5% MCP franchise fee requirement. 
  

 D - 4 

 APPENDIX G 
 COVERAGE AND SERVICES 
 CFC ELIGIBLE POPULATION 
  

	1.	Basic Benefit Package 

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

	 	•	 	 Inpatient hospital services 

  

	 	•	 	 Outpatient hospital services 

  

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

  

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

  

	 	•	 	 Laboratory and x-ray services 

  

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

  

	 	•	 	 Family planning services and supplies 

  

	 	•	 	 Home health services 

  

	 	•	 	 Podiatry 

  

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

  

	 	•	 	 Physical therapy, occupational therapy, and speech therapy 

  

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

  

	 	•	 	 Prescription drugs 

  

	 	•	 	 Ambulance and ambulette services 

  

	 	•	 	 Dental services 

  

	 	•	 	 Durable medical equipment and medical supplies 

  

	 	•	 	 Vision care services, including eyeglasses 

 Appendix G 
 Page 2

  

	 	•	 	 Short-term rehabilitative stays in a nursing facility 

  

	 	•	 	 Hospice care 

  

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

  

	2.	Exclusions, Limitations and Clarifications 

  

	 	a.	Exclusions 

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

	 	•	 	 Services or supplies that are not medically necessary 

  

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

  

	 	•	 	 Organ transplants that are not covered by Medicaid 

  

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

  

	 	•	 	 Infertility services for males or females 

  

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

  

	 	•	 	 Reversal of voluntary sterilization procedures 

  

	 	•	 	 Plastic or cosmetic surgery that is not medically necessary* 

  

	 	•	 	 Immunizations for travel outside of the United States 

  

	 	•	 	 Services for the treatment of obesity unless medically necessary* 

  

	 	•	 	 Custodial or supportive care 

  

	 	•	 	 Sex change surgery and related services 

  

	 	•	 	 Sexual or marriage counseling 

 Appendix G 
 Page 3

  

	 	•	 	 Court ordered testing 

  

	 	•	 	 Acupuncture and biofeedback services 

  

	 	•	 	 Services to find cause of death (autopsy) 

  

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

  

	 	•	 	 Paternity testing 

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

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

  

	 	b.	Limitations & Clarifications 

  

	 	i.	Member Cost-Sharing 

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

 Appendix G 
 Page 4

  

	 	ii.	Abortion and Sterilization 

 The use of federal
funds to pay for abortion and sterilization services is prohibited unless the specific criteria found in 42 CFR 441 and OAC rules 5101:3-17-01 and 5101:3-21-01 are met. MCPs must verify that all of the information on the required forms (JFS 03197,
03198, and 03199) is provided and that the service meets the required criteria before any such claim is paid. 
 Additionally, payment must
not be made for associated services such as anesthesia, laboratory tests, or hospital services if the abortion or sterilization itself does not qualify for payment. MCPs are responsible for educating their providers on the requirements; implementing
internal procedures including systems edits to ensure that claims are only paid once the MCP has determined if the applicable forms are completed and the required criteria are met, as confirmed by the appropriate certification/consent forms; and for
maintaining documentation to justify any such claim payments. 
  

	 	iii.	Behavioral Health Services 

 Coordination of
Services: MCPs must have a process to coordinate benefits of and referrals to the publicly funded community behavioral health system. MCPs must ensure that members have access to all medically-necessary behavioral health services covered by the
Ohio Medicaid FFS program and are responsible for coordinating those services with other medical and support services. MCPs must notify members via the member handbook and provider directory of where and how to access behavioral health services,
including the ability to self-refer to mental health services offered through community mental health centers (CMHCs) as well as substance abuse services offered through Ohio Department of Alcohol and Drug Addiction Services (ODADAS)-certified
Medicaid providers. Pursuant to ORC Section 5111.16, alcohol, drug addiction and mental health services covered by Medicaid are not to be paid by the managed care program when the nonfederal share of the cost of those services is provided by a
board of alcohol, drug addiction, and mental health services or a state agency other than ODJFS. 
 MCPs must provide behavioral health
services for members who are unable to timely access services or are unwilling to access services through community providers. 
 Mental
Health Services: There are a number of various Medicaid-covered mental health (MH) services available through the CMHCs. 

 Appendix G 
 Page 5

  

 Where an MCP is responsible for providing MH services for their members, the MCP is responsible for
ensuring access to counseling and psychotherapy, physician/psychologist/psychiatrist services, outpatient clinic services, general hospital outpatient psychiatric services, pre-hospitalization screening, diagnostic assessment (clinical evaluation),
crisis intervention, psychiatric hospitalization in general hospitals (for all ages), and Medicaid-covered prescription drugs and laboratory services. MCPs are not required to cover partial hospitalization, or inpatient psychiatric care in a
free-standing psychiatric hospital. 
 Substance Abuse Services: There are a number of various Medicaid-covered substance abuse
services available through ODADAS-certified Medicaid providers. 
 Where an MCP is responsible for providing substance abuse services for
their members, the MCP is responsible for ensuring access to alcohol and other drug (AOD) urinalysis screening, assessment, counseling, physician/psychologist/psychiatrist AOD treatment services, outpatient clinic AOD treatment services, general
hospital outpatient AOD treatment services, crisis intervention, inpatient detoxification services in a general hospital, and Medicaid-covered prescription drugs and laboratory services. MCPs are not required to cover outpatient detoxification and
methadone maintenance. 
 Financial Responsibility: MCPs are responsible for the payment of Medicaid-covered prescription drugs
prescribed by a CMHC or ODADAS-certified provider when obtained through an MCP’s panel pharmacy. MCPs are also responsible for the payment of Medicaid-covered services provided by an MCP’s panel laboratory when referred by a CMHC or
ODADAS-certified provider. Additionally, MCPs are responsible for the payment of all other behavioral health services obtained through providers other than those who are CMHC or ODADAS-certified providers when arranged/authorized by the MCP. MCPs
are not responsible for paying for behavioral health services provided through CMHCs and ODADAS-certified Medicaid providers. MCPs are also not required to cover the payment of partial hospitalization (mental health), inpatient psychiatric care in a
free-standing inpatient psychiatric hospital, outpatient detoxification, or methadone maintenance. 
  

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

 Appendix G 
 Page 6

  

 MCPs may establish a preferred drug list for members and providers which includes a listing of the
drugs that they prefer to have prescribed. Preferred drugs requiring prior authorization approval must be clearly indicated as such. Pursuant to ORC §5111.72, ODJFS may approve MCP-specific pharmacy program utilization management strategies
(see appendix G.3.a). 
  

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

  

	3.	Care Coordination 

  

	 	a.	Utilization Management (Modification) Programs 

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

 Appendix G 
 Page 7

  

 Pharmacy Programs - Pursuant to ORC Sec. 5111.172 and OAC rule 5101:3-26-03(A) and (B), MCPs
subject to ODJFS prior-approval, may implement strategies, including prior authorization and limitations on the type of provider and locations where certain medications may be administered, for the management of pharmacy utilization. 
 Prior Authorizations: MCPs must receive prior approval from ODJFS on the types of medication that they wish to cover through prior authorizations.
MCPs must establish their prior authorization system so that it does not unnecessarily impede member access to medically-necessary Medicaid-covered services. 
 MCPs must comply with the provisions of 1927(d)(5) of the Social Security Act, 42 USC 1396r-8(k)(3), and OAC rule 5101:3-26-03.1 regarding the timeframes for prior authorization of covered outpatient drugs.

 MCPs may also, with ODJFS prior approval, implement pharmacy utilization modification programs designed to address members demonstrating
high or inappropriate utilization of specific prescription drugs. 
 Emergency Department Diversion (EDD) – MCPs must provide
access to services in a way that assures access to primary, specialist and urgent care in the most appropriate settings and that minimizes frequent, preventable utilization of emergency department (ED) services. OAC rule 5101:3-26-03.1(A)(7)(d)
requires MCPs to implement the ODJFS-required emergency department diversion (EDD) program for frequent utilizers. 
 Each MCP must establish
an ED diversion (EDD) program with the goal of minimizing frequent ED utilization. The MCP’s EDD program must include the monitoring of ED utilization, identification of frequent ED utilizers, and targeted approaches designed to reduce
avoidable ED utilization. MCP EDD programs must, at a minimum, address those ED visits which could have been prevented through improved education, access, quality or care management approaches. 
 Although there is often an assumption that frequent ED visits are solely the result of a preference on the part of the member and education is therefore
the standard remedy, it is also important to ensure that a member’s frequent ED utilization is not due to problems such as their PCP’s lack of accessibility or failure to make appropriate specialist referrals. The MCP’s EDD program
must therefore also include the identification of providers who serve as PCPs for a substantial number of frequent ED utilizers and the implementation of corrective action with these providers as so indicated. 

 Appendix G 
 Page 8

  

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

	 	b.	Case Management 

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

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

  

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

  

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

  

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

  

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

  

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

 Appendix G 
 Page 9

  

	 	 
periodic review of the member’s need for case management and updating of the care treatment plan; 

  

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

  

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

  

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

  

	 	c.	Children with Special Health Care Needs 

 Children
with special health care needs (CSHCN) are a particularly vulnerable population which often have chronic and complex medical health care conditions. In order to ensure state compliance with the provisions of 42 CFR 438.208, ODJFS has implemented
program requirements for the identification, assessment, and case management of CSHCN. 
 Each MCP must establish a CSHCN program with the
goal of conducting timely identification and screening, assuring a thorough and comprehensive assessment, and providing appropriate and targeted case management services for any CSHCN. 

 Appendix G 
 Page 10

  

	 	i.	Definition of CSHCN 

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

	 	-	 	 Asthma 

  

	 	-	 	 HIV/AIDS 

  

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

  

	 	-	 	 Supplemental security income (SSI) for a health-related condition 

  

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

  

	 	ii.	Identification of CSHCN 

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

	 	iii.	Assessment of CSHCN 

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

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

 Appendix G 
 Page 11

  

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

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

  

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

  

	 	iv.	Case Management of CSHCN 

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

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

  

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

  

	 	v.	Access to Specialists for CSHCN 

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

 Appendix G 
 Page 12

  

	 	vi.	Submission of Data on CSHCN 

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

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

  

	 	d.	Care Coordination with ODJFS-Designated Providers 

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

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

  

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

  

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

  

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

  

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

  

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

 Appendix G 
 Page 13

  

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

  

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

  

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

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

	 	e.	Care coordination with Non-Contracting Providers 

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

 APPENDIX H 
 PROVIDER PANEL SPECIFICATIONS 
 CFC ELIGIBLE POPULATION 
  

	1.	GENERAL PROVISIONS 

 MCPs must provide or arrange for the
delivery of all medically necessary, Medicaid-covered health services, as well as assure that they meet all applicable provider panel requirements for their entire designated service area. The ODJFS provider panel requirements are specified in the
charts included with this appendix and must be met prior to the MCP receiving a provider agreement with ODJFS. The MCP must remain in compliance with these requirements for the duration of the provider agreement. 
 If an MCP is unable to provide the medically necessary, Medicaid-covered services through their contracted provider panel, the MCP must ensure access to these services
on an as needed basis. For example, if an MCP meets the pediatrician requirement but a member is unable to obtain a timely appointment from a pediatrician on the MCP’s provider panel, the MCP will be required to secure an appointment from a
panel pediatrician or arrange for an out-of-panel referral to a pediatrician. 
 MCPs are required to make transportation available to any
member that must travel 30 miles or more from their home to receive a medically-necessary Medicaid-covered service. If the MCP offers transportation to their members as an additional benefit and this transportation benefit only covers
a limited number of trips, the required transportation listed above may not be counted toward this trip limit (as specified in Appendix C). 
 In
developing the provider panel requirements, ODJFS considered, on a county-by-county basis, the population size and utilization patterns of the Covered Families and Children (CFC) consumers, as well as the potential availability of the designated
provider types. ODJFS has integrated existing utilization patterns into the provider network requirements to avoid disruption of care. Most provider panel requirements are county-specific but in certain circumstances, ODJFS requires providers to be
located anywhere in the region. Although all provider types listed in this appendix are required provider types, only those listed on the attached charts must be submitted for ODJFS prior approval. 
  

	2.	PROVIDER SUBCONTRACTING 

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

 Appendix H 
 Page 2

  

 ODJFS must prior approve all MCP providers in the ODJFS- required provider type categories before they can begin to
provide services to that MCP’s members. MCPs may not employ or contract with providers excluded from participation in Federal health care programs under either section 1128 or section 1128A of the Social Security Act. As part of the prior
approval process, MCPs must submit documentation verifying that all necessary contract documents have been appropriately completed. ODJFS will verify the approvability of the submission and process this information using the ODJFS Provider
Verification System (PVS). The PVS is a centralized database system that maintains information on the status of all MCP-submitted providers. 
 Only those
providers who meet the applicable criteria specified in this document, as determined by ODJFS, will be approved by ODJFS. MCPs must credential/recredential providers in accordance with the standards specified by the National Committee for Quality
Assurance (or receive approval from ODJFS to use an alternate industry standard) and must have completed the credentialing review before submitting any provider to ODJFS for approval. Regardless of whether ODJFS has approved a provider, the MCP must
ensure that the provider has met all applicable credentialing criteria before the provider can render services to the MCP’s members. 
 MCPs must notify
ODJFS of the addition and deletion of their contracting providers as specified in OAC rule 5101:3-26-05, and must notify ODJFS within one working day in instances where the MCP has identified that they are not in compliance with the provider panel
requirements specified in this appendix. 
  

	3.	PROVIDER PANEL REQUIREMENTS 

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

	a.	Primary Care Physicians (PCPs) 

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

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

 Appendix H 
 Page 3

  

 
ODJFS reviews the capacity totals for each PCP to determine if they appear excessive. ODJFS reserves the right to request clarification from an MCP for any
PCP whose total stated capacity for all MCP networks added together exceeds 2000 Medicaid members (i.e., 1 FTE). ODJFS may also compare a PCP’s capacity against the number of members assigned to that PCP, and/or the number of patient encounters
attributed to that PCP to determine if the reported capacity number reasonably reflects a PCP’s expected caseload for a specific MCP. Where indicated, ODJFS may set a cap on the maximum amount of capacity that we will recognize for a specific
PCP. ODJFS may allow up to an additional 750 member capacity for each nurse practitioner or physician’s assistant that is used to provide clinical support for a PCP. 
 For PCPs contracting with more than one MCP, the MCP must ensure that the capacity figure stated by the PCP in their subcontract reflects only the capacity the PCP intends to provide for that one MCP. ODJFS utilizes
each approved PCP’s capacity figure to determine if an MCP meets the provider panel requirements and this stated capacity figure does not prohibit a PCP from actually having a caseload that exceeds the capacity figure indicated in their
subcontract. 
 ODJFS recognizes that MCPs will need to utilize specialty physicians to serve as PCPs for some special needs members. Also, in some
situations (e.g., continuity of care) a PCP may only want to serve a very small number of members for an MCP. In these situations it will not be necessary for the MCP to submit these PCPs to ODJFS for prior approval. These PCPs will not be included
in the ODJFS PVS database and therefore may not appear as PCPs in the MCP’s provider directory. Also, no PCP capacity will be counted for these providers. These PCPs will, however, need to execute a subcontract with the MCP which includes the
appropriate Model Medicaid Addendum. 
 The PCP requirement is based on an MCP having sufficient PCP capacity to serve 55% of the eligibles in the region. At
a, each MCP must meet both the PCP FTE requirement for that region, and a ratio of one PCP FTE for each 2,000 of their Medicaid members in that region. MCPs must also satisfy a PCP geographic accessibility standard. ODJFS will match the PCP practice
sites and the stated PCP capacity with the geographic location of the eligible population in that region (on a county-specific basis) and perform analysis using Geographic Information Systems (GIS) software. The analysis will be used to determine if
at least 40% of the eligible population is located within 10 miles of PCP with available capacity in urban counties and 40% of the eligible population within 30 miles of a PCP with available capacity in rural counties. [Rural areas are defined
pursuant to 42 CFR 412.62(f)(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. 

 Appendix H 
 Page 4

  

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

 Appendix H 
 Page 5

  

 If an MCP-contracted hospital elects not to provide specific Medicaid-covered hospital services because of an
objection on moral or religious grounds, the MCP must ensure that these hospital services are available to its members through another MCP-contracted hospital in the specified county/region. 
 OB/GYNs - MCPs must contract with the specified number of OB/GYNs for each county/region, all of whom must maintain a full-time obstetrical practice at a site(s)
located in the specified county/region. All MCP-contracting OB/GYNs must have current hospital delivery privileges at a hospital under contract with the MCP in the region. 
 Certified Nurse Midwives (CNMs) and Certified Nurse Practitioners (CNPs) - MCPs must ensure access to CNM and CNP services in the region if such provider types are present within the region. The MCP may
contract directly with the CNM or CNP providers, or with a physician or other provider entity who is able to obligate the participation of a CNM or CNP. If an MCP does not contract for CNM or CNP services and such providers are present within the
region, the MCP will be required to allow members to receive CNM or CNP services outside of the MCP’s provider network. 
 Contracting CNMs must have
hospital delivery privileges at a hospital under contract to the MCP in the region. The MCP must ensure a member’s access to CNM and CNP services if such providers are practicing within the region. 
 Vision Care Providers - MCPs must contract with the specified number of ophthalmologists/optometrists for each specified county/region , all of whom must maintain
a full-time practice at a site(s) located in the specified county/region. All ODJFS-approved vision providers must regularly perform routine eye exams. (MCPs will be expected to contract with an adequate number of ophthalmologists as part of
their overall provider panel, but only ophthalmologists who regularly perform routine eye exams can be used to meet the vision care provider panel requirement.) If optical dispensing is not sufficiently available in a region through the MCP’s
contracting ophthalmologists/optometrists, the MCP must separately 
 contract with an adequate number of optical dispensers located in the region.

 Dental Care Providers - MCPs must contract with the specified number of dentists. In order to assure sufficient access to adult MCP members, no
more than two-thirds of the dentists used to meet the provider panel requirement may be pediatric dentists. 
 Federally Qualified Health Centers/Rural
Health Clinics (FQHCs/RHCs)—MCPs are required to ensure member access to any federally qualified health center or rural health clinic (FQHCs/RHCs), regardless of contracting status. Contracting FQHC/RHC providers must be submitted for ODJFS
approval via the PVS process. Even if no FQHC/RHC is available within the region, MCPs must have mechanisms in place to ensure coverage for FQHC/RHC services in the event that a member accesses these services outside of the region. 

 Appendix H 
 Page 6

  

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

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

  

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

  

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

 MCPs are required to educate their staff and providers on the need to assure member access to FQHC/RHC services. 
 Qualified Family Planning Providers (QFPPs) - All MCP members must be permitted to self-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. Although ODJFS is aware that certain outpatient substance abuse services may only be available
through Medicaid providers certified by the Ohio Department of Drug and Alcohol Addiction Services (ODADAS) in some areas, MCPs must maintain an adequate number of contracted mental health providers in the region to assure access for members who are
unable to timely access services or unwilling to access services through community mental health centers. MCPs are advised not to contract with community mental health centers as all services they provide to MCP members are to be billed to ODJFS.

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

 Appendix H 
 Page 7

  

	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. 

 Appendix H 
 Page 8

  

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

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

  

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

  

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

  

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

  

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

  

	•	 	 any PCP or specialist practice limitations. 

 Printed Provider Directory 
 Prior to receiving a provider agreement, all MCPs must develop a printed provider directory that shall be
prior-approved by ODJFS for each covered population. For example, an MCP who serves CFC and ABD in the Central Region would have two provider directories, one for CFC and one for ABD. Once approved, this directory may be regularly updated with
provider additions or deletions by the MCP without ODJFS prior-approval, however, copies of the revised directory (or inserts) must be submitted to ODJFS prior to distribution to members. 
 On a quarterly basis, MCPs must create an insert to each printed directory that lists those providers deleted from the MCP’s provider panel during the
previous three months. Although this insert does not need to be prior approved by ODJFS, copies of the insert must be submitted to ODJFS two weeks prior to distribution to members. 
 Internet Provider Directory 
 MCPs are required to have an internet-based provider directory available in the
same format as their ODJFS-approved printed directory. This internet directory must allow members to electronically search for MCP panel providers based on name, provider type, and geographic proximity, and population (e.g. CFC and/or ABD). If an
MCP has one internet-based directory for multiple populations, each provider must include a description of which population they serve. 
 The internet
directory may be updated at any time to include providers who are not one of the ODJFS-required provider types listed on the charts included with this appendix. ODJFS-required providers must be added to the internet directory within
one week of the MCP’s notification 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 provider to the MCP of the deletion. These deleted providers must be included in the
inserts to the MCP’s provider directory referenced above. 

 Appendix H 
 Page 9

  

	6.	FEDERAL ACCESS STANDARDS 

 MCPs must demonstrate that they
are in compliance with the following federally defined provider panel access standards as required by 42 CFR 438.206: 
 In establishing and maintaining their
provider panel, MCPs must consider the following: 
  

	•	 	 The anticipated Medicaid membership. 

  

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

  

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

  

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

  

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

 Contracting providers must offer hours of operation that are no less than the
hours of operation offered to commercial members or comparable to Medicaid fee-for-service, if the provider serves only Medicaid members. MCPs must ensure that services are available 24 hours a day, 7 days a week, when medically necessary. MCPs must
establish mechanisms to ensure that panel providers comply with timely access requirements, and must take corrective action if there is failure to comply. 
 In order to demonstrate adequate provider panel capacity and services, 42 CFR 438.206 and 438.207 stipulates that the MCP must submit documentation to ODJFS, in a format specified by ODJFS, that demonstrates it offers an appropriate range
of preventive, primary care and specialty services adequate for the anticipated number of members in the service area, while maintaining a provider panel that is sufficient in number, mix, and geographic distribution to meet the needs of the number
of members in the service area. 
 This documentation of assurance of adequate capacity and services must be submitted to ODJFS no less frequently than at
the time the MCP enters into a contract with ODJFS; at any time there is a significant change (as defined by ODJFS) in the MCP’s operations that would affect adequate capacity and services (including changes in services, benefits, geographic
service or payments); and at any time there is enrollment of a new population in the MCP. 

 Appendix H 
 Page 10

  

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

 North East Region - Hospitals 
  

																							
	Minimum Provider Panel Requirements
	 	  	Total
Required
Hospitals	 	 	Ashtabula	  	Cuyahoga	 	 	Erie	  	Geauga	  	Huron	  	Lake	  	Lorain	  	Medina	  	 Additional
 Required
 Hospitals:
 Out-of-
 Region

	 General Hospital3
	  	8 	4	 	1	  	1 	4	 	1	  	1	  	1	  	1	  	1	  	1	  	
											
	 Hospital System
	  	1	 	 		  	1	 	 		  		  		  		  		  		  	

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

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

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

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

 As of November 20, 2006 

 North East Central Region - Hospitals 
  

												
	Minimum Provider Panel Requirements
	 	  	Total
Required
Hospitals	  	Columbiana	  	Mahoning	 	 	Trumbull	  	 Additional
Required
 Hospitals:
Out-of-Region

	 General Hospital3
	  	3	  	1	  	1	4	 	1	  	
						
	 Hospital System
	  		  		  			 		  	

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

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

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

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

 East Central Region - Hospitals 
  

																								
	Minimum Provider Panel Requirements
	 	  	Total
Required
Hospitals	  	Ashland	  	Carroll	  	Holmes	  	Portage	  	Richland	  	Stark	  	Summit	 	 	Tuscarawas	  	Wayne	  	 Additional
Required
Hospitals:
Out-of-
 Region

	 General Hospital3
	  	8	  	1	  		  	1	  	1	  	1	  	1	  	1 	4	 	1	  	1	  	
												
	 Hospital System
	  	1	  		  		  		  		  		  		  	1	 	 		  		  	

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

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

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

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

 South East Region - Hospitals 
  

																																					
	Minimum Provider Panel Requirements
																			
	 	  	 Total
 Required
 Hospitals
	  	Athens	  	Belmont	  	Coshocton	  	Gallia	  	Guernsey	  	Harrison	  	Jackson	  	Jefferson	  	Lawrence	  	Meigs	  	Monroe	  	Morgon	  	Muskingum	  	Noble	  	Vinton	  	Washington	  	 Additional
Required
Hospitals: Out-
 of-Region

	 General Hospital3
	  	11	  	1	  	1	  	1	  	1	  	1	  		  		  	1	  		  		  		  		  	1	  		  		  	1	  	Cabell AND
King’s Daughter
AND Children’s
Hospital
Columbus
																			
	 Hospital System
	  		  		  		  		  		  		  		  		  		  		  		  		  		  		  		  		  		  	

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

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

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

 Central Region - Hospitals 
  

																																										
	Minimum Provider Panel Requirements
																					
	 	  	Total
Required
Hospitals	  	Crawford	  	Delaware	  	Fairfield	  	Fayette	  	Franklin	 	 	Hocking	  	Knox	  	Licking	  	Logan	  	Madison	  	Marion	  	Morrow	  	Perry	  	Pickaway	  	Pike	  	Ross	  	Scioto	  	Union	  	 Additional
 Required
Hospitals:
 Out-of-
 Region

	General Hospital3	  	14	  	1	  		  	1	  	1	  	1	 4	 		  	1	  	1	  	1	  	1	  	1	  		  		  	1	  		  	1	  	1	  	1	  	Genesis
Health
Care
System,
Inc.
																					
	Hospital System	  	2	  		  		  		  		  	2	 	 		  		  		  		  		  		  		  		  		  		  		  		  		  	

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

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

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

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

 South West Region - Hospitals 
  

																						
	Minimum Provider Panel Requirements
											
	 	  	Total
Required
Hospitals	  	Adams	  	Brown	  	Butler	  	Clermont	  	Clinton	  	Hamilton	 	 	Highland	  	Warren	  	 Additional
 Required
 Hospitals:
 Out-of-
 Region

	 General Hospital3
	  	6	  		  	1	  	1	  		  	1	  	1 	4	 	1	  		  	Grandview
or Miami
Valley
											
	 Hospital System
	  	2	  		  		  		  		  		  	2	 	 		  		  	

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

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

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

	 4
	 Must be a hospital that includes two-hundred (200) pediatric beds and thirty-five
(35) pediatric intensive care unit (PICU) beds. 

 West Central Region - Hospitals 
  

																						
	Minimum Provider Panel Requirements
											
	 	  	Total
Required
Hospitals	  	Champaign	  	Clark	  	Darke	  	Greene	  	Miami	  	Montgomery	 	 	Preble	  	Shelby	  	 Additional
 Required
Hospitals:
 Out-of-
 Region

	 General Hospital3
	  	6	  		  	1	  	1	  	1	  	1	  	1	 4	 		  	1	  	
											
	 Hospital System
	  	1	  		  		  		  		  		  	1	 	 		  		  	

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

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

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

	 4
	 Must be a hospital that includes seventy-five (75) pediatric beds and ten (10) pediatric intensive
care unit (PICU) beds. 

 North West Region - Hospitals 
  

																																										
	Minimum Provider Panel Requirements
																					
	 	  	Total
Required
Hospitals	  	Allen	  	Auglaize	  	Defiance	  	Fulton	  	Hancock	  	Hardin	  	Henry	  	Lucas	 	 	Mercer	  	Ottawa	  	Paulding	  	Putnam	  	Sandusky	  	Seneca	  	Van Wert	  	Williams	  	Wood	  	Wyandot	  	 Additional
 Required
Hospitals:
 Out-of-
 Region

	 General Hospital3
	  	10	  	1	  		  	1	  	1	  	1	  		  		  			 	1	  		  		  		  	1	  		  	1	  	1	  		  	1	  	Bellevue
Hospital
Association
																					
	 Hospital System
	  	1	  		  		  		  		  		  		  		  	1 	4	 		  		  		  		  		  		  		  		  		  		  	

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

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

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

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

 North East Region - PCP Capacity 
  

																					
	Minimum PCP Capacity Requirements
											
	 PCPs
	  	Total
Required	  	Ashtabula	  	Cuyahoga	  	Erie	  	Geauga	  	Huron	  	Lake	  	Lorain	  	Medina	  	 Additional
Required:
 In-Region *

	 Capacity 1
	  	146,000	  	6,560	  	111,520	  	3,680	  	2,080	  	3,960	  	3,680	  	11,320	  	3,200	  	
											
	 FTEs
	  	73.00	  	3.28	  	55.76	  	1.84	  	1.04	  	1.98	  	1.84	  	5.66	  	1.60	  	

	 1
	 Based on an FTE of 2000 members 

	*	Must be located within the region. 

 North East Central Region - PCP Capacity 
  

											
	Minimum PCP Capacity Requirements
						
	 PCPs
	  	Total
Required	  	Columbiana	  	Mahoning	  	Trumbull	  	Additional
Required:
In-Region *
	 Capacity 1
	  	39,140	  	6,440	  	16,340	  	11,360	  	5,000
						
	 FTEs
	  	19.57	  	3.22	  	8.17	  	5.68	  	2.50

	 1
	 Based on an FTE of 2000 members 

	*	Must be located within the region. 

 East Central Region - PCP Capacity 
  

																							
	Minimum PCP Capacity Requirements
												
	 PCPs
	  	Total
Required	  	Ashland	  	Carroll	  	Holmes	  	Portage	  	Richland	  	Stark	  	Summit	  	Tuscarawas	  	Wayne	  	Additional
Required:
In-Region *
	 Capacity 1
	  	84,000	  	2,940	  	2,000	  	2,000	  	4,520	  	7,400	  	22,660	  	33,560	  	4,360	  	4,560	  	
												
	 FTEs
	  	42.00	  	1.47	  	1.00	  	1.00	  	2.26	  	3.70	  	11.33	  	16.78	  	2.18	  	2.28	  	

	 1
	 Based on an FTE of 2000 members 

	*	Must be located within the region. 

 South East Region - PCP Capacity 
  

					
	 County
	  	Capacity 1	  	FTEs
	 Total Required
	  	53,000	  	26.50
	 Athens
	  	5,000	  	2.50
	 Belmont
	  	2,880	  	1.44
	 Coshocton
	  	2,400	  	1.20
	 Gallia
	  	7,220	  	3.61
	 Guernsey
	  	3,820	  	1.91
	 Harrison
	  	940	  	0.47
	 Jackson
	  	1,000	  	0.50
	 Jefferson
	  	4,340	  	2.17
	 Lawrence
	  	4,020	  	2.01
	 Meigs
	  	700	  	0.35
	 Monroe
	  	780	  	0.39
	 Morgon
	  	1,260	  	0.63
	 Muskingum
	  	7,400	  	3.70
	 Noble
	  	600	  	0.30
	 Vinton
	  	820	  	0.41
	 Washington
	  	2,820	  	1.41
			
	 Additional Required:
 In-Region *
	  	7,000	  	3.50

	 1
	 Based on an FTE of 2000 members 

	*	Must be located within the region. 

 Central Region - PCP Capacity 
  

					
	 County
	  	Capacity 1	  	FTEs
	 Total Required
	  	138,000	  	69.00
	 Crawford
	  	2,720	  	1.36
	 Delaware
	  	1,900	  	0.95
	 Fairfield
	  	5,660	  	2.83
	 Fayette
	  	1,320	  	0.66
	 Franklin
	  	84,200	  	42.10
	 Hocking
	  	1,860	  	0.93
	 Knox
	  	2,800	  	1.40
	 Licking
	  	6,740	  	3.37
	 Logan
	  	2,380	  	1.19
	 Madison
	  	980	  	0.49
	 Marion
	  	4,080	  	2.04
	 Morrow
	  	1,620	  	0.81
	 Perry
	  	2,200	  	1.10
	 Pickaway
	  	2,000	  	1.00
	 Pike
	  	2,400	  	1.20
	 Ross
	  	6,620	  	3.31
	 Scioto
	  	6,940	  	3.47
	 Union
	  	1,580	  	0.79
			
	 Additional Required:
 In-Region *
	  		  	

	 1
	 Based on an FTE of 2000 members

	*	Must be located within the region. 

 South West Region - PCP Capacity 
  

																					
	Minimum PCP Capacity Requirements
											
	 PCPs
	  	 Total
 Required
	  	Adams	  	Brown	  	Butler	  	Clermont	  	Clinton	  	Hamilton	  	Highland	  	Warren	  	Additional
Required: In
Region *
	 Capacity 1
	  	88,000	  	2,420	  	2,540	  	12,500	  	2,860	  	2,940	  	59,680	  	2,620	  	2,440	  	
											
	 FTEs
	  	44.00	  	1.21	  	1.27	  	6.25	  	1.43	  	1.47	  	29.84	  	1.31	  	1.22	  	

	 1
	 Based on an FTE of 2000 members

	*	Must be located within the region. 

 West Central Region - PCP Capacity 
  

																					
	Minimum PCP Capacity Requirements
											
	 PCPs
	  	Total
Required	  	Champaign	  	Clark	  	Darke	  	Greene	  	Miami	  	Montgomery	  	Preble	  	Shelby	  	 Additional
Required:
 In-Region *

	 Capacity 1
	  	59,600	  	1,140	  	9,360	  	1,320	  	4,700	  	4,020	  	35,660	  	1,400	  	2,000	  	
											
	 FTEs
	  	29.80	  	0.57	  	4.68	  	0.66	  	2.35	  	2.01	  	17.83	  	0.70	  	1.00	  	

	 1
	 Based on an FTE of 2000 members

	*	Must be located within the region. 

 North West Region - PCP Capacity 
  

					
	 County
	  	Capacity 1	  	FTEs
	 Total Required
	  	90,860	  	45.43
	 Allen
	  	7,780	  	3.89
	 Auglaize
	  	1,260	  	0.63
	 Defiance
	  	2,600	  	1.30
	 Fulton
	  	1,300	  	0.65
	 Hancock
	  	3,620	  	1.81
	 Hardin
	  	1,220	  	0.61
	 Henry
	  	1,200	  	0.60
	 Lucas
	  	38,620	  	19.31
	 Mercer
	  	1,080	  	0.54
	 Ottawa
	  	1,200	  	0.60
	 Paulding
	  	900	  	0.45
	 Putnam
	  	960	  	0.48
	 Sandusky
	  	2,700	  	1.35
	 Seneca
	  	2,340	  	1.17
	 Van Wert
	  	1,020	  	0.51
	 Williams
	  	1,900	  	0.95
	 Wood
	  	2,000	  	1.00
	 Wyandot
	  	960	  	0.48
			
	 Additional Required:
 In-Region *
	  	18,200	  	9.10

	 1
	 Based on an FTE of 2000 members

	*	Must be located within the region. 

 As of November 20, 2006

 North East Region - Practitioners 
  

																					
	Minimum Provider Panel Requirements
											
	 Provider Types
	  	Total
Required
Providers1	  	Ashtabula	  	Cuyahoga	  	Erie	  	Geauga	  	Huron	  	Lake	  	Lorain	  	Medina	  	 Additional
 Required
 Providers2

	 Pediatricians4
	  	90	  	1	  	66	  	2	  		  		  	3	  	8	  	3	  	7
											
	 OB/GYNs
	  	25	  	1	  	16	  	1	  		  	1	  	1	  	2	  	1	  	2
											
	 Vision
	  	33	  	1	  	25	  	1	  		  		  	1	  	2	  	1	  	2
											
	 General Surgeons
	  	20	  		  	12	  	1	  		  	1	  	1	  	2	  	1	  	2
											
	 Otolaryngologist
	  	6	  		  	2	  		  		  		  		  	1	  		  	3
											
	 Allergists
	  	5	  		  	2	  		  		  		  		  	1	  		  	2
											
	 Orthopedists
	  	16	  		  	8	  	1	  		  		  	1	  	2	  	1	  	3
											
	 Dentists5
	  	90	  	3	  	65	  	1	  	1	  	1	  	5	  	10	  	3	  	1

	 1
	 All required providers must be located within the region. 

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

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

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

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

 North East Central - Practitioners 
  

											
	Minimum Provider Panel Requirements
						
	 Provider Types
	  	Total
Required
Providers1	  	Columbiana	  	Mahoning	  	Trumbull	  	Additional
Required
Providers2
	 Pediatricians4
	  	23	  	2	  	10	  	6	  	5
						
	 OB/GYNs
	  	7	  	1	  	3	  	2	  	1
						
	 Vision
	  	7	  		  	3	  	2	  	2
						
	 General Surgeons
	  	6	  	1	  	3	  	1	  	1
						
	 Otolaryngologist
	  	2	  		  	1	  		  	1
						
	 Allergists
	  	1	  		  		  		  	1
						
	 Orthopedists
	  	4	  		  	2	  	1	  	1
						
	 Dentists5
	  	23	  	2	  	11	  	8	  	2

	 1
	 All required providers must be located within the region. 

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

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

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

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

 East Central - Practitioners 
  

																							
	Minimum Provider Panel Requirements
												
	 Provider Types
	  	Total
Required
Providers1	  	Ashland	  	Carroll	  	Holmes	  	Portage	  	Richland	  	Stark	  	Summit	  	Tuscarawas	  	Wayne	  	 Additional
Required
 Providers2

	 Pediatricians4
	  	49	  	1	  		  		  	2	  	3	  	14	  	20	  	2	  	2	  	5
												
	 OB/GYNs
	  	17	  		  		  		  		  	1	  	5	  	8	  		  	1	  	2
												
	 Vision
	  	18	  		  		  		  		  	1	  	5	  	8	  		  		  	4
												
	 General Surgeons
	  	13	  		  		  		  	1	  	2	  	3	  	4	  	1	  	1	  	1
												
	 Otolaryngologist
	  	7	  		  		  		  		  		  	2	  	2	  		  		  	3
												
	 Allergists
	  	3	  		  		  		  		  		  	1	  	1	  		  		  	1
												
	 Orthopedists
	  	9	  		  		  		  		  	1	  	2	  	2	  		  	1	  	3
												
	 Dentists5
	  	48	  	2	  		  		  	3	  	5	  	13	  	17	  	3	  	3	  	2

	 1
	 All required providers must be located within the region. 

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

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

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

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

 South East - Practitioners 
  

																																					
	Minimum Provider Panel Requirements
																			
	 Provider Types
	  	Total
Required
Providers1	  	Athens	  	Belmont	  	Coshocton	  	Gallia	  	Guernsey	  	Harrison	  	Jackson	  	Jefferson	  	Lawrence	  	Meigs	  	Monroe	  	Morgon	  	Muskingum	  	Noble	  	Vinton	  	Washington	  	 Additional
Required
 Providers2

	 Pediatricians4
	  	31	  	1	  	1	  		  	2	  	1	  		  		  	1	  		  		  		  		  	2	  		  		  	1	  	22
																			
	 OB/GYNs
	  	9	  	1	  		  		  		  	1	  		  		  	1	  		  		  		  		  	1	  		  		  	1	  	4
																			
	 Vision
	  	13	  	1	  	1	  		  	1	  	1	  		  	1	  	1	  	1	  		  		  		  	2	  		  		  	1	  	3
																			
	 General Surgeons
	  	8	  		  	1	  		  	1	  	1	  		  		  	1	  		  		  		  		  	1	  		  		  	1	  	2
																			
	 Otolaryngologist
	  	3	  		  		  		  	1	  		  		  		  		  		  		  		  		  	1	  		  		  		  	1
																			
	 Allergists
	  	1	  		  		  		  		  		  		  		  		  		  		  		  		  		  		  		  		  	1
																			
	 Orthopedists
	  	5	  		  		  		  	1	  		  		  		  		  		  		  		  		  	1	  		  		  	1	  	2
																			
	 Dentists5
	  	30	  	2	  	3	  	1	  	1	  	3	  		  	1	  	3	  	2	  		  		  		  	3	  		  		  	2	  	9

	 1
	 All required providers must be located within the region. 

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

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

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

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

 Central - Practitioners 
  

																																									
	Minimum Provider Panel Requirements
																					
	 Provider Types
	  	Total
Required
Providers1	  	Crawford	  	Delaware	  	Fairfield	  	Fayette	  	Franklin	  	Hocking	  	Knox	  	Licking	  	Logan	  	Madison	  	Marion	  	Morrow	  	Perry	  	Pickaway	  	Pike	  	Ross	  	Scioto	  	Union	  	 Additional
Required
 Providers2

	 Pediatricians4
	  	86	  		  	4	  	3	  		  	55	  		  	1	  	2	  	1	  	1	  	2	  		  		  	1	  		  	2	  	2	  	1	  	11
																					
	 OB/GYNs
	  	24	  		  	2	  	2	  		  	12	  		  	1	  	1	  		  		  	1	  		  		  		  		  	1	  	1	  		  	3
																					
	 Vision
	  	31	  	1	  	2	  	2	  		  	15	  		  	1	  	1	  	1	  		  	1	  		  		  	1	  		  	1	  	1	  	1	  	3
																					
	 General Surgeons
	  	22	  	1	  	1	  	1	  		  	10	  		  	1	  	1	  	1	  		  	1	  		  		  		  		  	1	  	1	  	1	  	2
																					
	 Otolaryngologist
	  	6	  		  	1	  		  		  	4	  		  		  		  		  		  		  		  		  		  		  		  		  		  	1
																					
	 Allergists
	  	4	  		  		  		  		  	2	  		  		  		  		  		  		  		  		  		  		  		  		  		  	2
																					
	 Orthopedists
	  	13	  		  		  	1	  		  	7	  		  		  	1	  		  		  	1	  		  		  		  		  	1	  		  		  	2
																					
	 Dentists5
	  	77	  	1	  	2	  	3	  	1	  	45	  	1	  	2	  	3	  	1	  	1	  	2	  	1	  	1	  	1	  	1	  	3	  	2	  	1	  	5

	 1
	 All required providers must be located within the region. 

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

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

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

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

 South West - Practitioners 
  

																					
	Minimum Provider Panel Requirements
											
	 Provider Types
	  	Total
Required
Providers1	  	Adams	  	Brown	  	Butler	  	Clermont	  	Clinton	  	Hamilton	  	Highland	  	Warren	  	 Additional
Required
 Providers2

	 Pediatricians4
	  	59	  		  		  	7	  	2	  	1	  	39	  		  		  	10
											
	 OB/GYNs
	  	16	  		  	1	  	2	  	1	  	1	  	9	  		  	1	  	1
											
	 Vision
	  	21	  		  		  	3	  	1	  	1	  	11	  	1	  	1	  	3
											
	 General Surgeons
	  	13	  		  		  	2	  	1	  	1	  	7	  		  	1	  	1
											
	 Otolaryngologist
	  	6	  		  		  	1	  		  		  	3	  		  	1	  	1
											
	 Allergists
	  	7	  		  		  		  		  		  	4	  		  		  	3
											
	 Orthopedists
	  	9	  		  		  	2	  		  		  	5	  		  		  	2
											
	 Dentists5
	  	50	  	1	  	1	  	10	  	4	  	1	  	26	  	2	  	2	  	3

	 1
	 All required providers must be located within the region. 

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

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

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

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

 West Central - Practitioners 
  

																					
	Minimum Provider Panel Requirements
											
	 Provider Types
	  	Total
Required
Providers1	  	Champaign	  	Clark	  	Darke	  	Greene	  	Miami	  	Montgomery	  	Preble	  	Shelby	  	 Additional
Required
 Providers2

	 Pediatricians4
	  	36	  		  	2	  		  	3	  	1	  	22	  		  		  	8
											
	 OB/GYNs
	  	12	  		  	2	  		  	1	  	1	  	6	  		  	1	  	1
											
	 Vision
	  	20	  		  	2	  	1	  	2	  	2	  	10	  		  	1	  	2
											
	 General Surgeons
	  	10	  		  	2	  		  	2	  	1	  	3	  		  		  	2
											
	 Otolaryngologist
	  	7	  		  	1	  		  		  		  	3	  		  		  	3
											
	 Allergists
	  	4	  		  		  		  		  		  	2	  		  		  	2
											
	 Orthopedists
	  	6	  		  		  		  	2	  		  	2	  		  		  	2
											
	 Dentists5
	  	39	  	1	  	5	  	1	  	3	  	3	  	20	  	1	  	1	  	4

	 1
	 All required providers must be located within the region. 

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

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

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

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

 North West - Practitioners 
  

																																									
	Minimum Provider Panel Requirements
																					
	 Provider Types
	  	Total
Required
Providers1	  	Allen	  	Auglaize	  	Defiance	  	Fulton	  	Hancock	  	Hardin	  	Henry	  	Lucas	  	Mercer	  	Ottawa	  	Paulding	  	Putnam	  	Sandusky	  	Seneca	  	Van Wert	  	Williams	  	Wood	  	Wyandot	  	Additional
Required
Providers2
	 Pediatricians4
	  	45	  	4	  		  		  		  	1	  		  		  	23	  		  		  		  		  	1	  		  		  	1	  	2	  		  	13
																					
	 OB/GYNs
	  	13	  	2	  		  		  		  	1	  		  		  	5	  		  		  		  		  	1	  	1	  		  		  	1	  		  	2
																					
	 Vision
	  	18	  	2	  	1	  	1	  		  	1	  		  		  	7	  	1	  		  		  		  	1	  		  		  	1	  	2	  		  	1
																					
	 General Surgeons
	  	13	  	2	  		  		  		  	1	  		  		  	4	  		  		  		  		  	1	  		  		  	1	  	2	  		  	2
																					
	 Otolaryngologist
	  	7	  	1	  		  		  		  	1	  		  		  	2	  		  		  		  		  		  		  		  		  		  		  	3
																					
	 Allergists
	  	3	  	1	  		  		  		  		  		  		  	1	  		  		  		  		  		  		  		  		  		  		  	1
																					
	 Orthopedists
	  	7	  	2	  		  		  		  	1	  		  		  	2	  		  		  		  		  	1	  		  		  		  	1	  		  	
																					
	 Dentists5
	  	45	  	4	  	1	  	1	  	1	  	2	  	1	  	1	  	20	  	1	  	1	  		  	1	  	2	  	2	  	1	  	1	  	2	  	1	  	2

	 1
	 All required providers must be located within the region. 

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

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

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

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

 As of November 20, 2006 

 APPENDIX I 
 PROGRAM INTEGRITY 
 CFC ELIGIBLE POPULATION 
 MCPs must comply with all applicable program integrity requirements, including those specified in 42 CFR 455 and Subpart H. 
  

	1.	Fraud and Abuse Program: 

 In addition to the
specific requirements of OAC rule 5101:3-26-06, MCPs must have a program that includes administrative and management arrangements or procedures, including a mandatory compliance plan to guard against fraud and abuse. The MCP’s compliance plan
must designate staff responsibility for administering the plan and include clear goals, milestones or objectives, measurements, key dates for achieving identified outcomes, and explain how the MCP will determine the compliance plan’s
effectiveness. 
 In addition to the requirements in OAC rule 5101:3-26-06, the MCP’s compliance program which safeguards against fraud
and abuse must, at a minimum, specifically address the following: 
  

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

  

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

  

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

  

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

  

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

  

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

 Appendix I 
 Page 2

  

	 	b.	Monitoring for fraud and abuse: The MCP’s program which safeguards against fraud and abuse must specifically address the MCP’s prevention, detection, investigation,
and reporting strategies in at least the following areas: 

  

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

  

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

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

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

  

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

  

	 	d.	Reporting fraud and abuse: MCPs are required to promptly report all instances of provider fraud and abuse to ODJFS and member fraud to the CDJFS. The MCP, at a minimum, must
report the following information on cases where the MCP’s investigation has revealed that an incident of fraud and/or abuse has occurred: 

  

	 	i.	provider’s name and Medicaid provider number or provider reporting number (PRN); 

 Appendix I 
 Page 3

  

	 	ii.	source of complaint; 

  

	 	iii.	type of provider; 

  

	 	iv.	nature of complaint; 

  

	 	v.	approximate range of dollars involved, if applicable; vi. results of MCP’s investigation and actions taken; 

  

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

  

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

  

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

  

	2.	Data Certification: 

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

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

 

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

  

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

  

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

  

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

  

	 	i.	The MCP’s Chief Executive Officer; 

  

	 	ii.	The MCP’s Chief Financial Officer, or 

 Appendix I 
 Page 4

  

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

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

 APPENDIX J 
 FINANCIAL PERFORMANCE 
 ABD ELIGIBLE POPULATION 
 MCP : Molina Healthcare of Ohio, Inc. 
  

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

  

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

  

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

 Appendix J 
 Page 2

  

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

  

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

  

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

  

	2.	FINANCIAL PERFORMANCE MEASURES AND STANDARDS 

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

					
	 a.
	  	Indicator:	 	Net Worth as measured by Net Worth Per Member 
			
		  	Definition:	 	Net Worth = Total Admitted Assets minus Total Liabilities divided by Total Members across all lines of business
			
		  	Standard:	 	For the financial report that covers calendar year 2007, a minimum net worth per member of $155.00, as determined from the annual Financial Statement submitted to ODI and the
ODJFS.
			
		  		 	The Net Worth Per Member (NWPM) standard is the Medicaid Managed Care Capitation amount paid to the MCP during the preceding calendar year, excluding the at-risk amount, expressed as a
per-member per-month figure, multiplied by the applicable proportion below:
			
		  		 	0.75 if the MCP had a total membership of 100,000 or more during that calendar year
			
		  		 	0.90 if the MCP had a total membership of less than 100,000 for that calendar year

 Appendix J 
 Page 3

  

					
			
		  		  	If the MCP did not receive Medicaid Managed Care Capitation payments during the preceding calendar year, then the NWPM standard for the MCP is the average Medicaid Managed Care capitation
amount paid to Medicaid-contracting MCPs during the preceding calendar year, excluding the at-risk amount, multiplied by the applicable proportion above.
			
	b.	  	Indicator:	  	Administrative Expense Ratio
			
		  	Definition:	  	Administrative Expense Ratio = Administrative Expenses minus Franchise Fees divided by Total Revenue minus Franchise Fees
			
		  	Standard:	  	Administrative Expense Ratio not to exceed 15%, as determined from the annual Financial Statement submitted to ODI and ODJFS.
			
	c.	  	Indicator:	  	Overall Expense Ratio
			
		  	Definition:	  	Overall Expense Ratio = The sum of the Administrative Expense Ratio and the Medical Expense Ratio
			
		  		  	Administrative Expense Ratio = Administrative Expenses minus Franchise Fees divided by Total Revenue minus Franchise Fees
			
		  		  	Medical Expense Ratio = Medical Expenses divided by Total Revenue minus Franchise Fees
			
		  	Standard:	  	Overall Expense Ratio not to exceed 100% as determined from the annual Financial Statement submitted to ODI and ODJFS.

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

 Appendix J 
 Page 4

  

 Failure to submit complete quarterly and annual Financial Statements on a timely basis will be deemed
a failure to meet the standards and will be subject to the noncompliance penalties listed for indicators 2.a., 2.b., and 2.c., including the imposition of a new membership freeze. The new membership freeze will take effect at the first of the month
following the month in which the determination was made that the MCP was non-compliant for failing to submit financial reports timely. 
 In
addition, ODJFS will review two liquidity indicators if a plan demonstrates potential problems in meeting related administrative requirements or the standards listed above. The two standards, 2.d and 2.e, reflect ODJFS’ expected level of
performance. At this time, ODJFS has not established penalties for noncompliance with these standards; however, ODJFS will consider the MCP’s performance regarding the liquidity measures, in addition to indicators 2.a., 2.b., and 2.c., in
determining whether to impose a new membership freeze, as outlined above, or to not issue or renew a contract with an MCP. The source for each indicator will be the NAIC Quarterly and annual Financial Statements. 
 Long-term investments that can be liquidated without significant penalty within 24 hours, which a plan would like to include in Cash and Short-Term
Investments in the next two measurements, must be disclosed in footnotes on the NAIC Reports. Descriptions and amounts should be disclosed. Please note that “significant penalty” for this purpose is any penalty greater than 20%. Also,
enter the amortized cost of the investment, the market value of the investment, and the amount of the penalty. 
  

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

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

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

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

  

	3.	REINSURANCE REQUIREMENTS 

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

 Appendix J 
 Page 5

  

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

 For transplant services, the reinsurance must cover, at a minimum, 50% of transplant related costs incurred by one member in one year, in
excess of $75,000.00. 
 An MCP may request a higher deductible amount and/or that the reinsurance cover less than 80% of inpatient costs in
excess of the deductible amount. If the MCP does not have more than 75,000 members in Ohio, but does have more than 75,000 members between Ohio and other states, ODJFS may consider alternate reinsurance arrangements. However, depending on the
corporate structures of the Medicaid MCP, other forms of security may be required in addition to reinsurance. These other security tools may include parental guarantees, letters of credit, or performance bonds. In determining whether or not the
request will be approved, the ODJFS may consider any or all of the following: 
  

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

  

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

  

	 	c.	the number of members covered by the MCP; 

  

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

  

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

  

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

 The MCP has been approved to have a reinsurance policy with a deductible amount of $150,000 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, 

 Appendix J 
 Page 6

  

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

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

	4.	PROMPT PAY REQUIREMENTS 

 In accordance with 42 CFR
447.46, MCPs must pay 90% of all submitted clean claims within 30 days of the date of receipt and 99% of such claims within 90 days of the date of receipt, unless the MCP and its contracted provider(s) have established an alternative payment
schedule that is mutually agreed upon and described in their contract. The prompt pay requirement applies to the processing of both electronic and paper claims for contracting and non-contracting providers by the MCP and delegated claims processing
entities. 
 The date of receipt is the date the MCP receives the claim, as indicated by its date stamp on the claim. The date of payment is
the date of the check or date of electronic payment transmission. A claim means a bill from a provider for health care services that is assigned a unique identifier. A claim does not include an encounter form. 
 A “claim” can include any of the following: (1) a bill for services; (2) a line item of services; or (3) all services for one
recipient within a bill. A “clean claim” is a claim that can be processed without obtaining additional information from the provider of a service or from a third party. 
 Clean claims do not include payments made to a provider of service or a third party where the timing of payment is not directly related to submission of a
completed claim by the provider of service or third party (e.g., capitation). A clean claim also does not include a claim from a provider who is under investigation for fraud or abuse, or a claim under review for medical necessity. 
 Penalty for noncompliance: Noncompliance with prompt pay requirements will result in progressive penalties to be assessed on a quarterly basis, as
outlined in Appendix N of the Provider Agreement. 
  

	5.	PHYSICIAN INCENTIVE PLAN DISCLOSURE REQUIREMENTS 

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

 Appendix J 
 Page 7

  

 If the physician incentive plan places a physician or physician group at substantial financial risk
[as determined under paragraph (d) of 42 CFR 422.208] for services that the physician or physician group does not furnish itself, the MCP must assure that all physicians and physician groups at substantial financial risk have either aggregate
or per-patient stop-loss protection in accordance with paragraph (f) of 42 CFR 422.208, and conduct periodic surveys in accordance with paragraph (h) of 42 CFR 422.208. 
 In accordance with 42 CFR 417.479 and 42 CFR 422.210, MCPs must maintain copies of the following required documentation and submit to ODJFS annually, no
later than 30 days after the close of the state fiscal year and upon any modification of the MCP’s physician incentive plan: 
  

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

  

	 	b.	A description of information/data feedback to a physician/group on their: 

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

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

  

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

 Upon request by a member or a potential member and no later than 14 calendar days after the
request, the MCP must provide the following information to the member: (1) whether the MCP uses a physician incentive plan that affects the use of referral services; (2) the type of incentive arrangement; (3) whether stop-loss
protection is provided; and 

 Appendix J 
 Page 8

  

 
(4) a summary of the survey results if the MCP was required to conduct a survey. The information provided by the MCP must adequately address the
member’s request. 
  

	6.	NOTIFICATION OF REGULATORY ACTION 

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

 APPENDIX K 
 QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM 
 AND 
 EXTERNAL QUALITY REVIEW 
 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. 
 In addition, as noted in Appendix M, if an MCP fails to meet the Minimum Performance Standard for selected Clinical Performance Measures, the MCP will be
required to complete a PIP. 
  

	 	b.	UNDER- AND OVER-UTILIZATION 

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

 Appendix K 
 Page 2

  

 It should also be noted that pursuant to the program integrity provisions outlined in Appendix I,
MCPs must monitor for the potential under-utilization of services by their members in order to assure that all Medicaid-covered services are being provided, as required. If any under-utilized services are identified, the MCP must immediately
investigate and correct the problem(s) which resulted in such under-utilization of services. 
 In addition, beginning in SFY 2005, the MCP
must conduct an ongoing review of service denials and must monitor utilization on an ongoing basis in order to identify services which may be under-utilized. 
  

	 	c.	SPECIAL HEALTH CARE NEEDS 

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

  

	 	ii.	Child Immunization Status 

  

	 	iii.	Adolescent Immunization Status 

 The measures must have
received a “report” designation from the HEDIS certified auditor and must be specific to the Medicaid population. Data must be submitted annually and in an electronic format. Data will be used for MCP clinical performance monitoring and
will be incorporated into comparative reports developed by the EQRO. 
 Initiation of submission of performance data will begin in the second
year of participation in the Medicaid managed care program. 
  

	2.	EXTERNAL QUALITY REVIEW 

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

 Appendix K 
 Page 3

  

	 	a.	EQRO ADMINISTRATIVE REVIEW AND NON-DUPLICATION OF MANDATORY ACTIVITIES 

 The EQRO will conduct administrative compliance assessments for each MCP every three (3) years. The review will include, but not be limited to, the following domains as specified by ODJFS: member rights and
services, QAPI program, access standards, provider network, grievance system, case management, coordination and continuity of care, and utilization management. In accordance with 42 CFR 438.360 and 438.362, MCPs with accreditation from a national
accrediting organization approved by the Centers for Medicare and Medicaid Services (CMS) may request a non-duplication exemption from certain specified components of the administrative review. Non-duplication exemptions may not be requested for SFY
07. 
  

	 	b.	ANNUAL REVIEW OF QAPI AND CASE MANAGEMENT PROGRAM 

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

 

	 	c.	EXTERNAL QUALITY REVIEW PERFORMANCE 

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

 APPENDIX L 
 DATA QUALITY 
 CFC ELIGIBLE POPULATION 
 A high level of performance on the data quality measures established in this appendix is crucial in order for the Ohio Department of Job and Family Services (ODJFS) to
determine the value of the Medicaid Managed Health Care Program and to evaluate Medicaid consumers’ access to and quality of services. Data collected from MCPs are used in key performance assessments such as the external quality review,
clinical performance measures, utilization review, care coordination and case management, and in determining incentives. The data will also be used in conjunction with the cost reports in setting the premium payment rates. 
 Data sets collected from MCPs with data quality standards include: encounter data; case management data; data used in the external quality review; members’ PCP
data; and appeal and grievance data. 
 1. ENCOUNTER DATA 
 For detailed descriptions of the encounter data quality measures below, see ODJFS Methods for Encounter Data Quality Measures for CFC and ABD. 
 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 1 below, is the rate of utilization (e.g., discharges, visits) per 1,000 member months (MM). 
 Report Period: The report periods for the SFY 2007 and SFY 2008 contract periods are listed in the table below. 

 Appendix L 
 Page 2

  

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

							
	 Quarterly Report Periods
	 	 Data Source:
 Estimated Encounter
 Data File Update
	 	 Quarterly Report
 Estimated Issue Date
	 	 Contract Period

	 Qtr 3 & Qtr 4 2003, 2004, 2005
 Qtr 1
2006
	 	July 2006	 	August 2006	 	SFY 2007
	  
 Qtr 3 & Qtr 4 2003, 2004, 2005
 Qtr 1, Qtr 2 2006
	 	October 2006	 	November 2006	 
	  
 Qtr 4 2003, 2004, 2005
 Qtr 1 thru Qtr 3 2006
	 	January 2007	 	February 2007	 
	  
 Qtr 1 thru Qtr 4: 2004, 2005, 2006
	 	April 2007	 	May 2007	 
	  
 Qtr 2 thru Qtr 4 2004,
 Qtr 1 thru Qtr4: 2005, 2006
 Qtr 1 2007
	 	July 2007	 	August 2007	 	SFY 2008
	  
 Qtr 3, Qtr 4: 2004,
 Qtr 1 thru Qtr 4: 2005, 2006
 Qtr 1, Qtr 2 2007
	 	October 2007	 	November 2007	 
	  
 Qtr 4: 2004,
 Qtr 1 thru Qtr 4: 2005, 2006
 Qtr 1 thru Qtr 3 2007
	 	January 2008	 	February 2008	 
	  
 Qtr 1 thru Qtr 4: 2005, 2006, 2007
	 	April 2008	 	May 2008	 

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

 Appendix L 
 Page 3

  

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

											
	 Category
	  	 Measure per
1,000/MM
	  	Standard for
Dates of Service
7/1/2003 thru
6/30/2004	  	Standard for
Dates of Service
7/1/2004 thru
6/30/2006	  	 Standard for
 Dates of
 Service on
or
after
7/1/2006
	  	 Description

	Inpatient Hospital	  	Discharges	  	5.4	  	5.0	  	5.4	  	General/acute care, excluding newborns and mental health and chemical dependency services
	  	  	  	  	  
	Emergency Department	  	Visits	  	51.6	  	51.4	  	50.7	  	Includes physician and hospital emergency department encounters
	Dental	  	  	38.2	  	41.7	  	50.9	  	Non-institutional and hospital dental visits
	Vision	  	  	11.6	  	11.6	  	10.6	  	Non-institutional and hospital outpatient optometry and ophthalmology visits
	Primary and Specialist Care	  	  	220.1	  	225.7	  	233.2	  	Physician/practitioner and hospital outpatient visits
	Ancillary Services	  	  	144.7	  	123.0	  	133.6	  	Ancillary visits
	Behavioral Health	  	Service	  	7.6	  	8.6	  	10.5	  	Inpatient and outpatient behavioral encounters
	Pharmacy	  	Prescriptions	  	388.5	  	457.6	  	492.2	  	Prescribed drugs

 County-Based Approach: All counties with managed care membership as of 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.] 
 Data Quality Standard, County-Based Approach: The standards in Table 2 apply to the MCP’s county-based results (see County-Based Approach above). The
utilization rate for all service categories listed in Table 2 must be equal to or greater than the standard established in Table 2 below. 

 Appendix L 
 Page 4

  

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

							
	 Category
	  	 Measure per
1,000/MM
	  	 Standard for
Dates of Service
 on or after
7/1/2006
	  	 Description

	Inpatient Hospital	  	Discharges	  	2.7	  	General/acute care, excluding newborns and mental health and chemical dependency services
	Emergency Department	  	Visits	  	25.3	  	Includes physician and hospital emergency department encounters
	Dental	  	  	25.5	  	Non-institutional and hospital dental visits
	Vision	  	  	5.3	  	Non-institutional and hospital outpatient optometry and ophthalmology visits
	Primary and Specialist Care	  	  	116.6	  	Physician/practitioner and hospital outpatient visits
	Ancillary Services	  	  	66.8	  	Ancillary visits
	Behavioral Health	  	Service	  	5.2	  	Inpatient and outpatient behavioral encounters
	Pharmacy	  	Prescriptions	  	246.1	  	Prescribed drugs

 Appendix L 
 Page 5

  

 Determination of Compliance: Performance is monitored once every quarter for the entire report period. If the
standard is not met for every service category in all quarters of the report period in either the county-based or interim regional-based approach, or both, then the MCP will be determined to be noncompliant for the report period. 
 Penalty for noncompliance: The first time an MCP is noncompliant with a standard for this measure, ODJFS will issue a Sanction Advisory informing the MCP that any
future noncompliance instances with the standard for this measure will result in ODJFS imposing a monetary sanction. Upon all subsequent measurements of performance, if an MCP is again determined to be noncompliant with the standard, ODJFS will
impose a monetary sanction (see Section 6.) of two percent of the current month’s premium payment. Monetary sanctions will not be levied for consecutive quarters that an MCP is determined to be noncompliant. If an MCP is noncompliant for
three consecutive quarters, membership will be frozen. Once the MCP is determined to be compliant with the standard and the violations/deficiencies are resolved to the satisfaction of ODJFS, the penalties will be lifted, if applicable, and monetary
sanctions will be returned. 
 Regional-Based Approach: Transition to the regional-based approach will occur by region, after the first four quarters
(i.e., full calendar year quarters) of regional membership. Encounter data volume will be evaluated by MCP, by region, after determination of the regional-based data quality standards. ODJFS will use the first four quarters of data (i.e., full
calendar year quarters) from all MCPs serving in an active region to determine minimum encounter volume data quality standards for that region. 
 1.a.ii.
Encounter Data Omissions 
 Omission studies will evaluate the completeness of the encounter data. 
 Measure: This study will compare the medical records of members during the time of membership to the encounters submitted. Omission rates will be calculated per
MCP (i.e., to include all counties serviced by the MCP). 
 The encounters documented in the medical record that do not appear in the encounter data will be
counted as omissions. 
 Report Period: In order to provide timely feedback on the omission rate of encounters, the report period will be the most
recent from when the measure is initiated. This measure is conducted annually. 
 Medical records retrieval from the provider and submittal to ODJFS or its
designee is an integral component of the omission measure. ODJFS has optimized the sampling to minimize the number of records required. This methodology requires a high record submittal rate. To aid MCPs in achieving a high submittal rate, ODJFS
will give at least an 8 week period to retrieve and submit medical records as a part of the validation process. A record submittal rate will be calculated as a percentage of all records requested for the study. 

 Appendix L 
 Page 6

  

 Data Quality Standard: The data quality standard is a maximum omission rate of 15% for studies with time
periods ending in the CY 2006 and CY 2007 contract periods. 
 Penalty for Noncompliance: The first time an MCP is noncompliant with a standard for
this measure, ODJFS will issue a Sanction Advisory informing the MCP that any future noncompliance instances with the standard for this measure will result in ODJFS imposing a monetary sanction. 
 Upon all subsequent measurements of performance, if an MCP is again determined to be noncompliant with the standard, ODJFS will impose a monetary sanction (see
Section 6) of one percent of the current month’s premium payment. Once the MCP is performing at standard levels and violations/deficiencies are resolved to the satisfaction of ODJFS, the money will be refunded. 
 1.a.iii. Incomplete Outpatient Hospital Data 
 Since July 1,
1997, MCPs have been required to provide both the revenue code and the HCPCS code on applicable outpatient hospital encounters. ODJFS will be monitoring, on a quarterly basis, the percentage of hospital encounters which contain a revenue code and
CPT/HCPCS code. A CPT/HCPCS code must accompany certain revenue center codes. These codes are listed in Appendix B of Ohio Administrative Code rule 5101:3-2-21 (fee-for-service outpatient hospital policies) and in the methods for calculating the
completeness measures. 
 Measure: The percentage of outpatient hospital line items with certain revenue center codes, as explained above, which had
an accompanying valid procedure (CPT/HCPCS) code. The measure will be calculated per MCP (i.e., to include all counties serviced by the MCP). 
 Report
Period: For the SFY 2007 and SFY 2008 contract periods, performance will be evaluated using the report periods listed in 1.a.i., Table 1. 
 Data
Quality Standard: The data quality standard is a minimum rate of 95%. 
 Determination of Compliance: Performance is monitored once every quarter for
all report periods. If the standard is not met in all report periods, then the MCP will be determined to be noncompliant. 
 Penalty for
noncompliance: The first time an MCP is noncompliant with a standard for this measure, ODJFS will issue a Sanction Advisory informing the MCP that any future noncompliance instances with the standard for this measure will result in ODJFS
imposing a monetary sanction. 
 Upon all subsequent quarterly measurements of performance, if an MCP is again determined to be noncompliant with the
standard, ODJFS will impose a monetary sanction (see Section 6) of one percent of the current month’s premium payment. Once the MCP is performing at standard levels and violations/deficiencies are resolved to the satisfaction of ODJFS, the
money will be refunded. 

 Appendix L 
 Page 7

  

 1.a.iv. Incomplete Data For Last Menstrual Period 
 As outlined in ODJFS Encounter Data Specifications, the last menstrual period (LMP) field is a required encounter data field. It is discussed in Item 14 of
the “HCFA 1500 Billing Instructions.” The date of the LMP is essential for calculating the clinical performance measures and allows the ODJFS to adjust performance expectations for the length of a pregnancy. 
 The occurrence code and date fields on the UB-92, which are “optional” fields, can also be used to submit the date of the LMP. These fields are described in
Items 32a & b, 33a & b, 34a & b, 35a & b of the “Inpatient Hospital” and “Outpatient Hospital UB-92 Claim Form Instructions.” 
 An occurrence code value of ‘10’ indicates that a LMP date was provided. The actual date of the LMP would be given in the ‘Occurrence Date’ field. 
 Measure: The percentage of recipients with a live birth during the report period where a “valid” LMP date was given on one or more of the
recipient’s perinatal claims. If the LMP date is before the date of birth and there is a difference of between 119 and 315 days between the date the recipient gave birth and the LMP date, then the LMP date will be considered a valid date. The
measure will be calculated per MCP (i.e., to include all counties in which the MCP has CFC membership). 
 Report Period: For the SFY 2007 contract
period, performance will be evaluated using the January—December 2006 report period. For the SFY 2008 contract period, performance will be evaluated using the January—December 2007 report period. 
 Data Quality Standard: The data quality standard is 80%. 
 Penalty
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.v. Rejected Encounters 
 Encounters submitted to ODJFS that are incomplete or inaccurate are rejected and reported back to the MCPs on
the Exception Report. If an MCP does not resubmit rejected encounters, ODJFS’ encounter data set will be incomplete. 
 Measure 1 only applies to
MCPs that have had Medicaid membership for more than one year. 
 Measure 1: The percentage of encounters submitted to ODJFS that are rejected. The
measure will be calculated per MCP (i.e., to include all counties serviced by the MCP). 

 Appendix L 
 Page 8

  

 Report Period: For the SFY 2007 contract period, performance will be evaluated using the following report
periods: April—June 2006; July—September 2006; October—December 2006 and January—March 2007. For the SFY 2008 contract period, performance will be evaluated using the following report periods: April—June 2007;
July—September 2007; October—December 2007 and January—March 2008. 
 Data Quality Standard 1: Data Quality Standard 1 is a maximum
encounter data rejection rate of 10% for each file in the ODJFS-specified medium per format for encounters submitted in SFY 2004 and thereafter. The measure will be calculated per MCP (i.e., to include all counties serviced by the MCP).

 Determination of Compliance: Performance is monitored once every quarter. Compliance determination with the standard applies only to the quarter
under consideration and does not include performance in previous quarters. 
 Penalty for noncompliance with Data Quality Standard 1: The first time
an MCP is noncompliant with a standard for this measure, ODJFS will issue a Sanction Advisory informing the MCP that any future noncompliance instances with the standard for this measure will result in ODJFS imposing a monetary sanction. Upon all
subsequent measurements of performance, if an MCP is again determined to be noncompliant with the standard, ODJFS will impose a monetary sanction (see Section 6.) of one percent of the current month’s premium payment. The monetary sanction
will be applied for each file in the ODJFS-specified medium per format that is determined to be out of compliance. 
 Once the MCP is performing at standard
levels and violations/deficiencies are resolved to the satisfaction of ODJFS, the money will be refunded. 
 Measure 2 only applies to MCPs that have had
Medicaid membership for one year or less. 
 Measure 2: The percentage of encounters submitted to ODJFS that are rejected. The measure will be
calculated per MCP (i.e., to include all counties serviced by the MCP). 
 Report Period: The report period for Measure 2 is monthly. Results are
calculated and performance is monitored monthly. The first reporting month begins with the third month of enrollment. 
 Data Quality Standard 2: The
data quality standard is a maximum encounter data rejection rate for each file in the ODJFS-specified medium per format as follows: 
  

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

 Appendix L 
 Page 9

  

 Files in the ODJFS-specified medium per format that are totally rejected will not be considered in the determination
of noncompliance. 
 Determination of Compliance: Performance is monitored once every month. Compliance determination with the standard applies only
to the month under consideration and does not include performance in previous quarters. 
 Penalty for Noncompliance with Data Quality Standard 2: If
the MCP is determined to be noncompliant for either standard, ODJFS will impose a monetary sanction of one percent of the MCP’s current month’s premium payment. The monetary sanction will be applied only once per measure per compliance
determination period and will not exceed a total of two percent of the MCP’s current month’s premium payment. Once the MCP is performing at standard levels and violations/deficiencies are resolved to the satisfaction of ODJFS, the money
will be refunded. Special consideration will be made for MCPs with less than 1,000 members. 
 1.a.vi. Acceptance Rate 
 This measure only applies to MCPs that have had Medicaid membership for one year or less. 
 Measure: The rate of encounters that are submitted to ODJFS and accepted (accepted encounters per 1,000 member months). The measure will be calculated per MCP (i.e., to include all counties serviced by the
MCP). 
 Report Period: The report period for this measure is monthly. Results are calculated and performance is monitored monthly. The first
reporting month begins with the third month of enrollment. 
 Data Quality Standard: The data quality standard is a monthly minimum accepted rate of
encounters for each file in the ODJFS-specified medium per format as follows: 
  

			
	Third through sixth month with membership:	 	50 encounters per 1,000 MM for NCPDP
		 	65 encounters per 1,000 MM for NSF
		 	20 encounters per 1,000 MM for UB-92
		
	Seventh through twelfth month of membership:	 	250 encounters per 1,000 MM for NCPDP
		 	350 encounters per 1,000 MM for NSF
		 	100 encounters per 1,000 MM for UB-92

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

 Appendix L 
 Page 10

  

 
payment. The monetary sanction will be applied only once per measure per compliance determination period and will not exceed a total of two percent of the
MCP’s current month’s premium payment. Once the MCP is performing at standard levels and violations/deficiencies are resolved to the satisfaction of ODJFS, the money will be refunded. 
 1.a.vii. Incomplete Birth Weight Data 
 Measure: The percentage
of newborn delivery inpatient encounters during the report period which contained a birth weight. If a value of “88” through “96” is found on any of the five condition code fields on the UB-92 inpatient claim format, then the
encounter will be considered to have a birth weight. The condition code fields are described in Items 24-30 of the “Inpatient Hospital, UB-92 Claim Form Instructions.” The measure will be calculated per MCP (i.e., to include all counties
in which the MCP has CFC membership). 
 Report Period: For the SFY 2007 contract period, performance will be evaluated using the
January—December 2006 report period. For the SFY 2008 contract period, performance will be evaluated using the January—December 2007 report period. 
 Data Quality Standard: The data quality standard is 90%. 
 Penalty for noncompliance: If an MCP is determined to be noncompliant with
the standard, ODJFS will impose a monetary sanction (see Section 6.) of one percent of the current month’s premium payment. Once the MCP is performing at standard levels and violations/deficiencies are resolved to the satisfaction of
ODJFS, the money will be refunded. 
 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 all counties serviced by the
MCP). 
 Report Period: In order to provide timely feedback on the accuracy rate of encounters, the report period will be the most recent from when
the measure is initiated. This measure is conducted annually. 

 Appendix L 
 Page 11

  

 Medical records retrieval from the provider and submittal to ODJFS or its designee is an integral component of the
validation process. ODJFS has optimized the sampling to minimize the number of records required. This methodology requires a high record submittal rate. To aid MCPs in achieving 
 a high submittal rate, ODJFS will give at least an 8 week period to retrieve and submit medical records as a part of the validation process. A record submittal rate will be calculated as a percentage of all records
requested for the study. 
 Data Quality Standard 1: For results that are finalized during the contract year, the accuracy rate for encounters
generating delivery payments is 100%.  
 Penalty for noncompliance: The MCP must participate in a detailed review of delivery payments made
for deliveries during the report period. Any duplicate or unvalidated delivery payments must be returned to ODJFS. 
 Data Quality Standard for Measure 2:
A minimum record submittal rate of 85%. 
 Penalty 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 (i.e., to include all
counties serviced by the MCP). 
 Payment information found in MCPs’ claims systems for paid claims that does not match payment information found on a
corresponding encounter will be counted as omissions. 
 Report Period: In order to provide timely feedback on the omission rate of encounters, the
report period will be the most recent from when the measure is initiated. This measure is conducted annually. 
 Data Quality Standard for Measure 2: TBD
for SFY 2008 based on study conducted in SFY 2007 
 Penalty for Noncompliance: Does not apply for SFY 2006 or SFY 2007. The first time an MCP is
noncompliant with a standard for this measure, ODJFS will issue a Sanction Advisory informing the MCP that any future noncompliance instances with the standard for this measure will result in ODJFS imposing a monetary sanction. 

 Appendix L 
 Page 12

  

 Upon all subsequent measurements of performance, if an MCP is again determined to be noncompliant with the standard,
ODJFS will impose a monetary sanction (see Section 6) of one percent of the current month’s premium payment. Once the MCP is performing at standard levels and violations/deficiencies are resolved to the satisfaction of ODJFS, the money
will be refunded. 
 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 (i.e., to include all counties serviced by the MCP). 
 All other encounters are required to have the MMIS
provider number of the servicing provider. The report period for this measure is quarterly. 
 Report Period: For the SFY 2007 and SFY 2008 contract
periods, performance will be evaluated using the report periods listed in 1.a.i., Table 1. 
 Data Quality Standard: A maximum generic provider usage
rate of 10%. 
 Determination of Compliance: Performance is monitored once every quarter for all report periods. If the standard is not met in all report
periods, then the MCP will be determined to be noncompliant. 
 Penalty for noncompliance: The first time an MCP is noncompliant with a standard
for this measure, ODJFS will issue a Sanction Advisory informing the MCP that any future noncompliance instances with the standard for this measure will result in ODJFS imposing a monetary sanction. Upon all subsequent measurements of performance,
if an MCP is again determined to be noncompliant with the standard, ODJFS will impose a monetary sanction (see Section 6.) of three percent of the current month’s premium payment. Once the MCP is performing at standard levels and
violations/deficiencies are resolved to the satisfaction of ODJFS, the money will be refunded. 
 1.c. Timely Submission of Encounter Data 

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 

 MCP submissions of encounter data files in the ODJFS-specified medium per format to ODJFS are limited to two per format per month. Should an MCP wish
to send additional files in the ODJFS-specified medium per format, permission to do so must be obtained by contacting BMHC. 

 Appendix L 
 Page 13

  

 Information concerning the proper submission of encounter data may be obtained from the ODJFS Encounter Data File
and Submission Specifications document. The MCP must submit a letter of certification, using the form required by ODJFS, with each encounter data file in the ODJFS-specified medium per format. 
 The letter of certification must be signed by the MCP’s Chief Executive Officer (CEO), Chief Financial Officer (CFO), or an individual who has delegated authority
to sign for, and who reports directly to, the MCP’s CEO or CFO. 
 2. CASE MANAGEMENT DATA 
 ODJFS designed a case management system (CAMS) in order to monitor MCP compliance with program requirements specified in Appendix G, Coverage and Services. Each
MCP’s case management data submissions will be assessed for completeness and accuracy. The MCP is responsible for submitting a case management file every month. Failure to do so jeopardizes the MCP’s ability to demonstrate compliance with
CSHCN requirements. For detailed descriptions of the case management measures below, see ODJFS Methods for Case Management Data Quality Measures. 
 2.a. Case Management System Data Accuracy 
 2.a.i. Open Case Management Spans for Disenrolled Members 
 Measure: The percentage of the MCP’s adult and children case management records in the Screening, Assessment, and Case Management System that have open case
management date spans for members who have disenrolled from the MCP. 
 Report Period: For the SFY 2007 contract period, July – September
2006, October – December 2006, January – March 2007, and April – June 2007 report periods. For the SFY 2008 contract period, July – September 2007, October – December 2007, January – March 2008, and
April – June 2008 report periods. 
 Data Quality Standard: A rate of open case management spans for disenrolled members of no more than 1.0%.

 For an MCP which had membership as of February 1, 2006: Performance will be evaluated using: 1) region-based results for any active region
in which all selected MCPs had at least 10,000 members during each month of the entire report period; and/or 2) the statewide result for all counties that were not included in the region-based results, but in which the MCP had managed care
membership as of February 1, 2006.  

 Appendix L 
 Page 14

  

 For any MCP which did not have membership as 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 the clinical studies, quality must be sufficient to ensure valid sampling. 
 An adequate number of medical records must then be retrieved from providers and submitted to ODJFS or its designee in order to generalize results to all applicable
members. To aid MCPs in achieving the required medical record submittal rate, ODJFS will give at least an eight week period to retrieve and submit medical records. 
 If an MCP does not complete a study because either their encounter data is of insufficient quality or too few medical records are submitted, accurate evaluation of clinical quality in the study area cannot be determined for the individual
MCP and the assurance of adequate clinical quality for the program as a whole is jeopardized. 

 Appendix L 
 Page 15

  

 3.a. Independent External Quality Review 
 Measure: The independent external quality review covers both administrative and clinical focus areas of study. 
 Report Period: The report period is one year. Results are calculated and performance is monitored annually. Performance is measured with each review. 
 Data Quality Standard 1: Sufficient encounter data quality in each study area to draw a sample as determined by the external quality review organization 
 Penalty for noncompliance with Data Quality Standard 1: For each study that is completed during this contract period, if an MCP is noncompliant with the standard,
ODJFS will impose a non-refundable $10,000 monetary sanction. 
 Data Quality Standard 2: A minimum record submittal rate of 85% for each clinical
measure. 
 Penalty for noncompliance for Data Quality Standard 2: For each study that is completed during this contract period, if an MCP is
noncompliant with the standard, ODJFS will impose a non-refundable $10,000 monetary sanction. 
 4. MEMBERS’ PCP DATA 
 The designated PCP is the physician who will manage and coordinate the overall care for CFC members, including those who have case management needs. The MCP must submit a
Members’ Designated PCP file every month. Specialists may and should be identified as the PCP as appropriate for the member’s condition; however, no CFC member may have more than one PCP identified. 
 4.a. Timely submission of Member’s PCP Data 
 Data Quality
Submission Requirement: The MCP must submit a Members’ Designated PCP Data file on a monthly basis according to the specifications established in ODJFS Member’s PCP Data File and Submission Specifications. 
 Penalty for noncompliance: See Appendix N, Compliance Assessment System, for the penalty for noncompliance with this requirement. 
 4.b. Designated PCP for newly enrolled members 
 Measure: The
percentage of MCP’s newly enrolled members who were designated a PCP by their effective date of enrollment. 
 Report Periods: For the SFY 2007
contract period, performance will be evaluated quarterly using the January – March 2007 and April – June 2007 report periods. For the SFY 2008 contract period, performance will be evaluated quarterly using the July-September
2007, October – December 2007, January – March 2008 and April – June 2008 report periods. 

 Appendix L 
 Page 16

  

 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 1 and quarter 2 of SFY 2008. A minimum rate of 85% of new members with PCP designation by their effective date of enrollment for quarter 3 and quarter 4 of SFY 2008. 
 Statewide Approach: MCPs will be evaluated using a statewide result, including all regions in which an MCP has CFC membership. 
 Penalty for noncompliance: If an MCP is noncompliant with the standard, ODJFS will impose a monetary sanction of one-half of one percent the current month’s
premium payment. Once the MCP is performing at standard levels and violations/deficiencies are resolved to the satisfaction of ODJFS, the money will be refunded. As stipulated in OAC rule 5101:3-26-08.2, each new member must have a designated
primary care physician (PCP) prior to their effective date of coverage. Therefore, MCPs are subject to additional corrective action measures under Appendix N, Compliance Assessment System, for failure to meet this requirement. 
 5. APPEALS AND GRIEVANCES DATA 
 Pursuant to OAC rule 5101:3-26-08.4,
MCPs are required to submit information at least monthly to ODJFS regarding appeal and grievance activity. ODJFS requires these submissions to be in an electronic data file format pursuant to the Appeal File and Submission Specifications and
Grievance File and Submission Specifications. 
 The appeal data file and the grievance data file must include all appeal and grievance activity,
respectively, for the previous month, and must be submitted by the ODJFS-specified due date. These data 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.v., and 1.a.vi., 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 

 Appendix L 
 Page 17

  

 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. The Ohio Medicaid managed care
program will transition to a regional-based system as managed care expands statewide, beginning in SFY 2007. Evaluation of performance will transition to a regional-based approach after completion of the statewide expansion. If statewide expansion
is not complete by December 31, 2006, ODJFS may adjust performance measure reporting periods based on the number of months an MCP has had regional membership. Due to differences in data and reporting requirements, transition to the
regional-based approach will vary by performance measure. Unless otherwise noted, performance measures and standards (see Sections 1, 2, 3 and 4) will be applicable for all counties in which the MCP has membership as of February 1, 2006, until
the regional-based approach is developed. 
 Selected measures in this appendix will be used to determine pay-for-performance (P4P) as specified in
Appendix O, Pay for Performance. 
 1. QUALITY OF CARE 
 1.a.i Independent External Quality Review [Only use in SFY2006 Incentive System; only applicable for MCPs with membership as of February 1, 2006] 
 In accordance with federal law and regulations state Medicaid agencies must annually provide for an external review of the quality outcomes and timeliness of, and access to, services provided by Medicaid-contracting
MCPs [(42 CFR 438.204(d)]. The external review assists the state in assuring MCP compliance with program requirements and facilitates the collection of accurate and reliable information concerning MCP performance. 
 Measure: The independent external quality review covers both an administrative component and clinical focus areas of study. The overall score is weighted to
emphasize clinical performance. 
 Report Period: For the SFY 2006 contract period, performance will be evaluated using the reviews that are finalized
during SFY 2006. 
 Minimum Performance Standard 1: A minimum score of 75% for each clinical study and the administrative component. 
 Action Required for Noncompliance with the Minimum Performance Standard 1: For all studies that are finalized during this contract period, if an MCP is
noncompliant with the standard, then the MCP is required to complete a Performance Improvement Project, as described in Appendix K, 

 Appendix M 
 Page 2

  

 Quality Assessment and Performance Improvement Program, to address the area(s) of noncompliance. 

Minimum Performance Standard 2: Each MCP must achieve an overall score of at least 75%. 
 Penalty for Noncompliance with the Minimum Performance Standard 2: A serious deficiency may result in immediate termination or nonrenewal of the provider agreement. (Examples of an external quality review
serious deficiency are a score of less than 75 percent for each clinical study or a score of less than 75 percent for the administrative component with a score of less than 75 percent on the preponderance of clinical studies). 
 1.a.ii Independent External Quality Review [Effective SFY 2007] 
 In
accordance with federal law and regulations, state Medicaid agencies must annually provide for an external quality review of the quality outcomes and timeliness of, and access to, services provided by Medicaid-contracting MCPs [(42 CFR 438.204(d)].
The external review assists the state in assuring MCP compliance with program requirements and facilitates the collection of accurate and reliable information concerning MCP performance. 
 Measure: The independent external quality review covers both an administrative review and focused quality of care studies as outlined in Appendix K. 
 Report Period: Performance will be evaluated using the reviews conducted during SFY 2007. 
 Action Required for
Deficiencies: For all reviews conducted during the contract period, if the EQRO cites a deficiency in the administrative review or quality of care studies, the MCP will be required to complete a Corrective Action Plan, Quality Improvement Directive,
or Performance Improvement Project as outlined in Appendix K. Serious deficiencies may result in immediate termination or non-renewal of the provider agreement. 
 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 (Use in SFY2006
Incentive System; only applicable for MCPs with membership as of January 1, 2006) 
 Measure: The average monthly case
management rate for children 6 months and over and under 21 years of age. 

 Appendix M 
 Page 3

  

 Report Period: For the SFY 2006 contract period, performance will be evaluated using the January - June 2005
and July - December 2005 report periods. For the SFY 2007 contract period, performance will be evaluated using the January - June 2006 report period. 
 Performance Target: A minimum case management rate of 5.0%. 
 Minimum Performance Standard: For results that are below the
performance target the performance standard is an improvement level that results in a 20% decrease between the target and the previous reporting period’s results. For MCPs that reach or surpass the performance target, then the standard is to
keep the results at or above the performance target. 
 Penalty for Noncompliance: The first time an MCP is noncompliant with the standard for this
measure, ODJFS will issue a Sanction Advisory informing the MCP that any future noncompliance instances with the standard for this measure will result in ODJFS imposing a monetary sanction. Upon all subsequent semi-annual measurements of
performance, if an MCP is again determined to be noncompliant with the standard for this measure. ODJFS will impose a monetary sanction (see Section 5) of one half of one percent of the current month’s premium payment. Once the MCP is
performing at standard levels and the violations/deficiencies are resolved to the satisfaction of ODJFS, the money will be refunded. 
 1.b.ii. Case
Management of Children 
 Measure: The average monthly case management rate for children under 21 years of age. 
 Report Period: For the SFY 2007 contract period, July - September 2006, October - December 2006, January - March 2007, and April - June 2007 report
periods. For the SFY 2008 contract period, July - September 2007, October - December 2007, January - March 2008, and April - June 2008 report periods. 
 County-Based Approach: MCPs with managed care membership as of February 1, 2006 will be evaluated using their county-based statewide result until regional evaluation is implemented for the county’s applicable region. The
county-based statewide result will include data for all counties in which the MCP had membership as of February 1, 2006 that are not included in any regional-based result. Regional-based results will not be used for evaluation until all
selected MCPs in an active region have at least 10,000 members during each month of the entire report period. Upon implementation of regional-based evaluation for a particular county’s region, the county will be included in the MCP’s
regional-based result and will no longer be included in the MCP’s county-based statewide result. [Example: The county-based statewide result for MCP AAA, which has contracts in the Central and West Central regions, 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.] 

 Appendix M 
 Page 4

  

 Regional-Based Approach: MCPs will be evaluated by region, using results for all counties included in the
region. Performance will begin to be evaluated using regional-based results for any active region in which all selected MCPs had at least 10,000 members during each month of the entire report period. 
 Minimum Performance Standard: For the first and second quarters of SFY 2007, a case management rate of 4.5%. For the third and fourth quarters of SFY 2007, a case
management rate of 5.0%. For SFY 2008, a case management rate of 6.0%. 
 Penalty for Noncompliance: The first time an MCP is noncompliant with the
standard for this measure, ODJFS will issue a Sanction Advisory informing the MCP that any future noncompliance instances with the standard for this measure will result in new member selection freezes or a reduction of assignments will occur as
outlined in Appendix N of the Provider Agreement. Once the MCP is performing at standard levels and the violations/deficiencies are resolved to the satisfaction of ODJFS, the new member selection freeze/reduction of assignments will be lifted.

 1.b.iii. Case Management of Children with an ODJFS-Mandated Condition (only applicable for MCPs with membership as of
January 1, 2006) 
 Measure 1: The percent of children 6 months and over and under 21 years of age with a positive identification through
an ODJFS administrative review of data for the ODJFS-mandated case management condition of asthma that are case managed. 
 Report Period: For
the SFY 2006 contract period, performance will be evaluated using the July - September 2005 and 
 January - March 2006 report periods. 
 Measure 2: The percent of children age 17 and under with a positive identification through an ODJFS administrative review of data for the ODJFS-mandated case
management condition of teenage pregnancy that are case managed. 
 Report Period: For the SFY 2006 contract period, performance will be
evaluated using the - January - June 2005 and July - December 2005 report periods. For the SFY 2007 contract period, performance will be evaluated using the January - June 2006 report period. 
 Measure 3: The percent of children 6 months and over and under 21 years of age with a positive identification through an ODJFS administrative review of data for
the ODJFS-mandated case management condition of HIV/AIDS that are case managed. 
 Report Period: For the SFY 2006 contract period, performance
will be evaluated using the July - September 2005 and 
 January - March 2006 report periods. 
 Performance Target for Measures 1, 2, and 3: A minimum case management rate of 80%. 
 Minimum Performance Standard
for Measures 1, 2, and 3: For results that are below the performance target the performance standard is an improvement level that results in a 20% decrease between the target and the previous reporting period’s results. For MCPs that reach
or surpass the performance target, then the standard is to keep the results at or above the performance target. 

 Appendix M 
 Page 5

  

 Penalty for Noncompliance for Measures 1 and 2: The first time an MCP is noncompliant with the standard for
this measure, ODJFS will issue a Sanction Advisory informing the MCP that any future noncompliance instances with the standard for this measure will result in ODJFS imposing a monetary sanction . Upon all subsequent semi-annual measurements of
performance, if an MCP is again determined to be noncompliant with the standard (see Section 5) for measures 1 or 2, ODJFS will impose a monetary sanction of one half of one percent of the current month’s premium payment. Once the MCP is
performing at standard levels and the violations/deficiencies are resolved to the satisfaction of ODJFS, the money will be refunded. Note: For SFY 2006, measure 3 is a reporting-only measure. 
 1.b.iv. Case Management of Children with an ODJFS-Mandated Condition 
 Measure 1: The percent of children under 21 years of age with a positive identification through an ODJFS administrative review of data for the ODJFS-mandated case management condition of asthma that are case managed.

 Measure 2: The percent of children age 17 and under with a positive identification through an ODJFS administrative review of data for the
ODJFS-mandated case management condition of teenage pregnancy that are case managed. 
 Measure 3: The percent of children under 21 years of
age with a positive identification through an ODJFS administrative review of data for the ODJFS-mandated case management condition of HIV/AIDS that are case managed. 
 Report Periods for Measures 1, 2, and 3: For the SFY 2007 contract period, July – September 2006, October – December 2006, January – March 2007, and April – June 2007 report
periods. For the SFY 2008 contract period, July – September 2007, October – December 2007, January – March 2008, and April – June 2008 report periods. 
 County-Based Approach: MCPs with managed care membership as of February 1, 2006 will be evaluated using their county-based statewide result until regional evaluation is implemented for the county’s
applicable region. The county-based statewide result will include data for all counties in which the MCP had membership as of February 1, 2006 that are not included in any regional-based result. Regional-based results will not be used for
evaluation until all selected MCPs in an active region have at least 10,000 members during each month of the entire report period. Upon implementation of regional-based evaluation for a particular county’s region, the county will be included in
the MCP’s regional-based result and will no longer be included in the MCP’s county-based statewide result. [Example: The county-based statewide result for MCP AAA, which has contracts in the Central and West Central regions, 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.] 

 Appendix M 
 Page 6

  

 Regional-Based Approach: MCPs will be evaluated by region, using results for all counties included in the
region. Performance will begin to be evaluated using regional-based results for any active region in which all selected MCPs had at least 10,000 members during each month of the entire report period. 
 Minimum Performance Standard for Measures 1 and 3: For the first and second quarters of SFY 2007, a case management rate of 65%. For the third and fourth quarters
of SFY 2007, a case management rate of 70%. For SFY 2008, a case management rate of 80%. 
 Minimum Performance Standard for Measure 2: For the first
and second quarters of SFY 2007, a case management rate of 55%. For the third and fourth quarters of SFY 2007, a case management rate of 60%. For SFY 2008, a case management rate of 70%. 
 Penalty for Noncompliance for Measures 1 and 2: The first time an MCP is noncompliant with the standard for this measure, ODJFS will issue a Sanction Advisory informing the MCP that any future noncompliance
instances with the standard for this measure will result in new member selection freezes or a reduction of assignments will occur as outlined in Appendix N of the Provider Agreement. Once the MCP is performing at standard levels and the
violations/deficiencies are resolved to the satisfaction of ODJFS the new member selection freeze/reduction of assignments will be lifted. Note: For the first reporting period during which regional results are used to evaluate performance, measures
1, 2, and 3 are reporting-only measures. For both SFY 2007 and 2008, measure 3 is a reporting-only measure. 
 1.c. Clinical Performance Measures

 MCP performance will be assessed based on the analysis of submitted encounter data for each year. For certain measures, standards are established; the
identification of these standards is not intended to limit the assessment of other indicators for performance improvement activities. Performance on multiple measures will be assessed and reported to the MCPs and others, including Medicaid
consumers. 
 The clinical performance measures described below closely follow the National Committee for Quality Assurance’s Health Plan
Employer Data and Information Set (HEDIS). Minor adjustments to HEDIS measures were required to account for the differences between the commercial population and the Medicaid population such as shorter and interrupted enrollment periods. NCQA may
annually change its method for calculating a measure. These changes can make it difficult to evaluate whether improvement occurred from a prior year. For this reason, ODJFS will use the same methods to calculate the baseline results and the results
for the period in which the MCP is being held accountable. For example, the same methods were being used to calculate calendar year 2003 results (the baseline period) and calendar year 2004 results. The methods will be updated and a new baseline
will be created during 2005 for calendar year 2004 results. These results will then serve as the baseline to evaluate whether improvement occurred from calendar year 2004 to calendar year 2005. Clinical performance measure results will be calculated
after a sufficient amount of time has passed after the end of the report period in order to allow for claims runout. For a comprehensive description of the clinical performance measures below, see ODJFS Methods for 

 Appendix M 
 Page 7

  

 
Clinical Performance Measures for the Medicaid 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: Prior to the
transition to the regional-based approach, MCP performance will be evaluated using an MCP’s statewide result for the counties in which the MCP had membership as of February 1, 2006. For reporting periods CY 2007 and CY 2008, targets and
performance standards for Clinical Performance Measures in this Appendix (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 approach for any active region in which the MCP had membership. 
 Regional-Based Approach:
MCPs will be evaluated by region, using results for all counties included in the region. CY 2008 will be the first reporting year that MCPs will be held accountable to the performance standards for an active region, and penalties will be applied
for noncompliance. CY 2007 will be the first baseline reporting year for an active region. 
 ODJFS will use a sufficient amount of data needed per
performance measure from all MCPs serving an active region to determine performance standards and targets for that region. For example, should a measure call for one calendar year of baseline data, first full calendar year data will be used. CY 2008
will be the first reporting year for measures that call for one year of baseline data. Should a measure call for two calendar years of baseline data, the first two full calendar years of data will be used. CY 2009 will be the first reporting year
for measures that call for two years of baseline data. 
 Report Period: In order to adhere to the statewide expansion timeline, reporting periods may
be adjusted based on the number of months of managed care membership. For the SFY 2006 contract period, performance will be evaluated using the January - December 2005 report period. For the SFY 2007 contract period, performance will be evaluated
using the January - December 2006 report period. For the SFY 2008 contract period, performance will be evaluated using the January - December 2007 report period. 
 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. 
 Target: 80% of the eligible population must receive 81% or more of the expected number of prenatal visits. 

 Appendix M 
 Page 8

  

 Minimum Performance Standard: The level of improvement must result in at least a 10% decrease in the
difference between the target and the previous report period’s results. (For example, if last year’s results were 20%, then the difference between the target and last year’s results is 60%. In this example, the standard is an
improvement in performance of 10% of this difference or 6%. In this example, results of 26% or better would be compliant with the standard.) 
 Action
Required for Noncompliance: If the standard is not met and the results are below 42%, then the MCP is required to complete a Performance Improvement Project, as described in Appendix K, Quality Assessment and Performance Improvement
Program, to address the area of noncompliance. 
 If the standard is not met and the results are at or above 42%, then ODJFS will issue a Quality
Improvement Directive which will notify the MCP of noncompliance and may outline the steps that the MCP must take to improve the results. 
 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. 
 Target: 90% of the eligible population initiate prenatal care within the specified time. 
 Minimum Performance Standard: The level of
improvement must result in at least a 10% decrease in the difference between the target and the previous year’s results. 
 Action Required for
Noncompliance: If the standard is not met and the results are below 71%, then the MCP is required to complete a Performance Improvement Project, as described in Appendix K, Quality Assessment and Performance Improvement Program, to
address the area of noncompliance. If the standard is not met and the results are at or above 71%, then ODJFS will issue a Quality Improvement Directive which will notify the MCP of noncompliance and may outline the steps that the MCP must take to
improve the results. 
 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. 
 Target: At least 80% of the eligible population must receive a postpartum visit. 
 Minimum Performance Standard: The level of
improvement must result in at least a 5% decrease in the difference between the target and the previous year’s results. 
 Action Required for
Noncompliance: If the standard is not met and the results are below 48%, then the MCP is required to complete a Performance Improvement Project, as described in Appendix K, Quality Assessment and Performance Improvement Program, to
address the area of noncompliance. If the standard is not met and the results are at or above 48%, then ODJFS will issue a Quality Improvement Directive which will notify the MCP of noncompliance and may outline the steps that the MCP must take to
improve the results. 

 Appendix M 
 Page 9

  

 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. 
 Target: At least 80% of the eligible children receive the expected number of well-child visits. 
 Minimum Performance Standard for Each of the Age Groups: The level of improvement must result in at least a 10% decrease in the difference between the target and
the previous year’s results. 
 Action Required for Noncompliance (15 month old age group): If the standard is not met and the results are below
34%, then the MCP is required to complete a Performance Improvement Project, as described in Appendix K, Quality Assessment and Performance Improvement Program, to address the area of noncompliance. If the standard is not met and the results
are at or above 34%, then ODJFS will issue a Quality Improvement Directive which will notify the MCP of noncompliance and may outline the steps that the MCP must take to improve the results. 
 Action Required for Noncompliance (3-6 year old age group): If the standard is not met and the results are below 50%, then the MCP is required to complete a
Performance Improvement Project, as described in Appendix K, Quality Assessment and Performance Improvement Program, to address the area of noncompliance. If the standard is not met and the results are at or above 50%, then ODJFS will issue a
Quality Improvement Directive which will notify the MCP of noncompliance and may outline the steps that the MCP must take to improve the results. 
 Action Required for Noncompliance (12-21 year old age group): If the standard is not met and the results are below 30%, then the MCP is required to complete a Performance Improvement Project, as described in Appendix K, Quality
Assessment and Performance Improvement Program, to address the area of noncompliance. If the standard is not met and the results are at or above 30%, then ODJFS will issue a Quality Improvement Directive which will notify the MCP of
noncompliance and may outline the steps that the MCP must take to improve the results. 
 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. 

 Appendix M 
 Page 10

  

 Target: 95% of the eligible population must receive the recommended medications. 
 Minimum Performance Standard: The level of improvement must result in at least a 10% decrease in the difference between the target and the previous year’s
results. 
 Action Required for Noncompliance: If the standard is not met and the results are below 83%, then the MCP is required to complete a
Performance Improvement Project, as described in Appendix K, Quality Assessment and Performance Improvement Program, to address the area of noncompliance. If the standard is not met and the results are at or above 83%, then ODJFS will issue a
Quality Improvement Directive which will notify the MCP of noncompliance and may outline the steps that the MCP must take to improve the results. 
 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. 
 Target: At least 60% of the eligible population receive a
dental visit. 
 Minimum Performance Standard: The level of improvement must result in at least a 10% decrease in the difference between the target and
the previous year’s results. 
 Action Required for Noncompliance: If the standard is not met and the results are below 40%, then the MCP is
required to complete a Performance Improvement Project, as described in Appendix K, Quality Assessment and Performance Improvement Program, to address the area of noncompliance. If the standard is not met and the results are at or above 40%,
then ODJFS will issue a Quality Improvement Directive which will notify the MCP of noncompliance and may outline the steps that the MCP must take to improve the results. 
 1.c.vii. Lead Screening 
 Measure: The percentage of one and two year olds who received a blood lead screening
by age group. 
 Target: At least 80% of the eligible population receive a blood lead screening. 
 Minimum Performance Standard for Each of the Age Groups: The level of improvement must result in at least a 10% decrease in the difference between the target and
the previous year’s results. 
 Action Required for Noncompliance (1 year olds): If the standard is not met and the results are below 45% then
the MCP is required to complete a Performance Improvement Project, as described in Appendix K, Quality Assessment and Performance Improvement Program, to address the area of noncompliance. If the standard is not met and the results are at or
above 45%, then ODJFS will issue a Quality Improvement Directive which will notify the MCP of noncompliance and may outline the steps that the MCP must take to improve the results. 

 Appendix M 
 Page 11

  

 Action Required for Noncompliance (2 year olds): If the standard is not met and the results are below 28% then
the MCP is required to complete a Performance Improvement Project, as described in Appendix K, Quality Assessment and Performance Improvement Program, to address the area of noncompliance. 
 If the standard is not met and the results are at or above 28%, then ODJFS will issue a Quality Improvement Directive which will notify the MCP of noncompliance and may
outline the steps that the MCP must take to improve the results. 
 2. ACCESS 
 Performance in the Access category will be determined by the following measures: Primary Care Physician (PCP) Turnover, Children’s Access to Primary Care, and Adults’ Access to Preventive/Ambulatory Health
Services. For a comprehensive description of the access performance measures below, see ODJFS Methods for Access Performance Measures for the Medicaid CFC Managed Care Program. 
 2.a. PCP Turnover 
 A high PCP turnover rate may affect continuity of care and may signal poor management of
providers. However, some turnover may be expected when MCPs end contracts with physicians who are not adhering to the MCP’s standard of care. Therefore, this measure is used in conjunction with the children and adult access measures to assess
performance in the access category. 
 Measure: The percentage of primary care physicians affiliated with the MCP as of the beginning of the
measurement year who were not affiliated with the MCP as of the end of the year. 
 For an MCP which had membership as of February 1, 2006: Prior
to the transition to the regional-based approach, MCP performance will be evaluated using an MCP’s statewide result for the counties in which the MCP had membership as of February 1, 2006. The minimum performance standard in the
Appendix (2.a) will be applicable to the MCP’s statewide result for the counties in which the MCP had membership as of February 1, 2006. The last reporting year using the MCP’s statewide result for the counties in which
the MCP had membership as of February 1, 2006 for performance evaluation is CY 2007; the last reporting year using the MCP’s statewide result for the counties in which the MCP had membership as of February 1, 2006 for
P4P(Appendix 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 approach for any active region in which the MCP had membership. 
 Regional-Based Approach: MCPs will be evaluated by region, using
results for all counties included in the region. ODJFS will use the first full calendar year of data (which may be adjusted based on the number of months of managed care membership). from all MCPs serving an active region to determine a minimum
performance standard for that region. CY 2008 will be the first reporting year that MCPs will be held accountable to the performance standards for an active region, and penalties will be applied for noncompliance. 

 Appendix M 
 Page 12

  

 Report Period: In order to adhere to the statewide expansion timeline, reporting periods may be adjusted based
on the number of months of managed care membership. For the SFY 2006 contract period, performance will be evaluated using the January - December 2005 report period. For the SFY 2007 contract period, performance will be evaluated using the January -
December 2006 report period. For the SFY 2008 contract period, performance will be evaluated using the January - December 2007 report period. 
 Minimum
Performance Standard: A maximum PCP Turnover rate of 18%. 
 Action Required for Noncompliance: MCPs are required to perform a causal analysis of
the high PCP turnover rate and assess the impact on timely access to health services, including continuity of care. If access has been reduced or coordination of care affected, then the MCP must develop and implement an action plan to address the
findings. 
 2.b. Children’s Access to Primary Care 
 This measure indicates whether children aged 12 months to 11 years are accessing PCPs for sick or well-child visits. 
 Measure: The
percentage of members age 12 months to 11 years who had a visit with an MCP PCP-type provider. 
 For an MCP which had membership as of February 1,
2006: Prior to the transition to the regional-based approach, MCP performance will be evaluated using an MCP’s statewide result for the counties in which the MCP had membership as of February 1, 2006. The minimum performance standard
in the Appendix (2.b) will be applicable to the MCP’s statewide result for the counties in which the MCP had membership as of February 1, 2006. The last reporting year using the MCP’s statewide result for the counties in
which the MCP had membership as of February 1, 2006 is CY 2008. 
 For any MCP which did not have membership as of February 1, 2006:
Performance will be evaluated using a regional-based approach for any active region in which the MCP had membership. 
 Regional-Based Approach: MCPs
will be evaluated by region, using results for all counties included in the region. ODJFS will use the first two full calendar years of data (which may be adjusted based on the number of months of managed care membership) from all MCPs serving an
active region to determine a minimum performance standard for that region. CY 2009 will be the first reporting year that MCPs will be held accountable to the performance standards for an active region, and penalties will be applied for
noncompliance. Performance measure results for that region 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 2006 contract period, performance will be evaluated using the January-December 2005 report period. For the 

 Appendix M 
 Page 13

  

 
SFY 2007 contract period, performance will be evaluated using the January - December 2006 report period. For the SFY 2008 contract period, performance will
be evaluated using the January - December 2007 report period. 
 Minimum Performance Standards: 
 CY 2005 report period – 70% of the children must receive a visit. 
 CY
2006 report period – 70% of the children must receive a visit. 
 CY 2007 report period – 71% of the children must receive a visit. 
 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 February 1, 2006: Prior to the transition
to the regional-based approach, MCP performance will be evaluated using an MCP’s statewide result for the counties in which the MCP had membership as of February1, 2006. The minimum performance standard in the Appendix (2.c) will be
applicable to the MCP’s statewide result for the counties in which the MCP had membership as of February 1, 2006. The last reporting year using the MCP’s statewide result for the counties in which the MCP had membership as of
February 1, 2006 for performance evaluation is CY2007; the last reporting year using the MCP’s statewide result for the counties in which the MCP had membership as of February 1, 2006 for P4P (Appendix 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 approach for any active
region in which the MCP had membership. 
 Regional-Based Approach: MCPs will be evaluated by region, using results for all counties included in the
region. ODJFS will use the first full calendar year of data (which may be adjusted based on the number of months of managed care membership) from all MCPs serving an active region to determine a minimum performance standard for that region. CY 2008
will be the first reporting year that MCPs will be held accountable to the performance standards for an active region, and penalties will be applied for noncompliance. Performance measure results for that region will be calculated after a sufficient
amount of time has passed after the end of the report period in order to allow for claims runout. 
 Report Period: In order to adhere to the
statewide expansion timeline, reporting periods may be adjusted based on the number of months of managed care membership. For the SFY 2006 contract period, performance will be evaluated using the January - December 2005 report period. For the 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. 

 Appendix M 
 Page 14

  

 Minimum Performance Standards: 63% of the adults must receive a visit. 
 Penalty for Noncompliance: If an MCP is noncompliant with the Minimum Performance Standard, then the MCP must develop and implement a corrective action plan.

 2.d. Adults’ Access to Designated PCP (new measure pending review) 
 The MCP must encourage and assist CFC members without a designated primary care physician (PCP) to establish such a relationship, so that a designated PCP can coordinate and manage a member’s health care needs.
This measure is to be used to assess MCPs’ performance in the access category. 
 Measure: The percentage of members who had a visit through
members’ designated PCPs. 
 Regional-Based Approach: MCPs will be evaluated by region, using results for all counties included in the region.
ODJFS will use the first full calendar year of data as a baseline from all MCPs serving CFC membership to determine a minimum performance standard for that region. CY 2008 will be the first reporting year that MCPs will be held accountable to the
performance standards for an active region and penalties will be applied for noncompliance. Performance measure results for that region will be calculated after a sufficient amount of time has passed after the end of the report period in order to
allow for claims runout. 
 Report Period: For the SFY 2009 contract period, performance will be evaluated using the January - December 2008 report
period. 
 Minimum Performance Standards: TBD 
 Penalty
for Noncompliance: If an MCP is noncompliant with the Minimum Performance Standard, then the MCP must develop and implement a corrective action plan. 
 3. CONSUMER SATISFACTION 
 The regional approach for this measure is to be determined for SFY 2008. The county-based approach remains
effective in SFY 2007; the county-based approach is only applicable for MCPs with membership as of February1, 2006 and for the counties in which the MCPs had membership as of February1, 2006. 
 In accordance with federal requirements and in the interest of assessing enrollee satisfaction with MCP performance, ODJFS periodically conducts independent consumer
satisfaction surveys. Results are used to assist in identifying and correcting MCP performance overall and in the areas of access, quality of care, and member services. Performance in this category will be determined by the overall satisfaction
score. For a comprehensive description of the Consumer Satisfaction performance measure below, see ODJFS Methods for Consumer Satisfaction Performance Measures for the Medicaid CFC Managed Care Program. 

 Appendix M 
 Page 15

  

 Measure: Overall Satisfaction with MCP: The average rating of the respondents to the Consumer Satisfaction
Survey who were asked to rate their overall satisfaction with their MCP. The results of this measure are reported annually. 
 Report Period: For the
SFY 2006 contract period, performance will be evaluated using the results from the most recent consumer satisfaction survey completed prior to the end of the SFY 2006. For the SFY 2007 contract period, performance will be evaluated using the results
from the most recent consumer satisfaction survey completed prior to the end of the SFY 2007. For the SFY 2008 contract period, the measure is under review and the report period has not been determined. 
 Minimum Performance Standard: An average score of no less than 7.0. 
 Penalty for noncompliance: If an MCP is determined noncompliant with the Minimum Performance Standard, then the MCP must develop a corrective action plan and provider agreement renewals may be affected. 
 4. ADMINISTRATIVE CAPACITY 
 The ability of an MCP to meet
administrative requirements has been found to be both an indicator of current plan performance and a predictor of future performance. Deficiencies in administrative capacity make the accurate assessment of performance in other categories difficult,
with findings uncertain. Performance in this category will be determined by the Compliance Assessment System, and the emergency department diversion program. For a comprehensive description of the Administrative Capacity performance measures below,
see ODJFS Methods for Administrative Capacity Performance Measures for the Medicaid CFC Managed Care Program. 
 4.a. Compliance Assessment System

 Measure: The number of points accumulated for one contract year (one state fiscal year) through the Compliance Assessment System. 
 Report Period: For the SFY 2005 contract period, performance will be evaluated using the July 2004 - June 2005 report period. For the SFY 2006 contract period,
performance will be evaluated using the July 2005 - June 2006 report period. 
 Minimum Performance Standard: No more than 25 points 
 Penalty for Noncompliance: Penalties for points are established in Appendix N, Compliance Assessment System. 

 Appendix M 
 Page 16

  

 4.b. Emergency Department Diversion 
 Managed care plans must provide access to services in a way that assures access to primary and urgent care in the most effective settings and minimizes inappropriate utilization of emergency department (ED) services.
MCPs are required to identify high utilizers of ED services and implement action plans designed to minimize inappropriate ED utilization. 
 Measure:
The percentage of members who had four or more ED visits during the six month reporting period. 
 For an MCP which had membership as of February 1,
2006: Prior to the transition to the regional-based approach, MCP performance will be evaluated using an MCP’s statewide result for the counties in which the MCP had membership as of February1, 2006. The minimum performance standard and the
target in the Appendix (4.b) will be applicable to the MCP’s statewide result for the counties in which the MCP had membership as of February 1, 2006. The last reporting period using the MCP’s statewide result for the
counties in which the MCP had membership as of February 1, 2006 for performance evaluation is July-December 2007; the last reporting period using the MCP’s statewide result for the counties in which the MCP had membership as of
February 1, 2006 for P4P (Appendix O) is July-December 2008. 
 For any MCP which did not have membership as of February 1, 2006:
Performance will be evaluated using a regional-based approach for any active region in which the MCP had membership. 
 Regional-Based Approach: MCPs
will be evaluated by region, using results for all counties included in the region. The reporting period will be a full calendar year. ODJFS will use the first full calendar year of data, which may be adjusted based on the number of months of
managed care membership, as a baseline from all MCPs serving an active region to determine a minimum performance standard and a target for that region. CY 2008 will be the first reporting year that MCPs will be held accountable to the performance
standards for an active region, and penalties will be applied for noncompliance. Performance measure results for that region will be calculated after a sufficient amount of time has passed after the end of the report period in order to allow for
claims runout. 
 Regional-Based Measure: The percentage of members who had TBD or more ED visits during the 12 month reporting period. 
 Report Period: In order to adhere to the statewide expansion timeline, reporting periods may be adjusted based on the number of months of managed care membership.
For the SFY 2006 contract period, a baseline level of performance will be set using the 
 January - June 2005 report period. Results will be calculated for
the reporting period of July-December 2005 and compared to the baseline results to determine if the minimum performance standard is met. For the SFY 2007 contract period, a baseline level of performance will be set using the January - June 2006
report period. Results will be calculated for the reporting period of July - December 2006 and compared to the baseline results to determine if the minimum performance standard is met. For the SFY 2008 contract period, a baseline level of
performance will be set using the January - June 2007 report period (which may be adjusted based on the number of months of managed care membership). Results will be calculated for the reporting period of July - December 2007 and compared to the
baseline results to determine if the minimum performance standard is met. SFY 2008 is also the first year for regional based reporting, using January - December 2007 as a baseline. 

 Appendix M 
 Page 17

  

 Target: A maximum of 0.70% of the eligible population will have four or more ED visits during the reporting
period. 
 Minimum Performance Standard: The level of improvement must result in at least a 10% decrease in the difference between the target and the
baseline period results. 
 Penalty for Noncompliance: If the standard is not met and the results are above 1.1%, then the MCP must develop a
corrective action plan, for which ODJFS may direct the MCP to develop the components of their EDD program as specified by ODJFS. If the standard is not met and the results are at or below 1.1%, then the MCP must develop a Quality Improvement
Directive. 
 5. NOTES 
 5.a. Report Periods

 Unless otherwise noted, the most recent report or study finalized prior to the end of the contract period will be used in determining the MCP’s
performance level for that contract period. 
 5.b. Monetary Sanctions 
 Penalties for noncompliance with individual standards in this appendix will be imposed as the results are finalized. Penalties for noncompliance with individual standards for each period compliance is determined in
this appendix will not exceed $250,000. 
 Refundable monetary sanctions will be based on the capitation payment in the month of the cited deficiency and due
within 30 days of notification by ODJFS to the MCP of the amount. Any monies collected through the imposition of such a sanction would be returned to the MCP (minus any applicable collection fees owed to the Attorney General’s Office, if the
MCP has been delinquent in submitting payment) after they have demonstrated improved performance in accordance with this appendix. If an MCP does not comply within two years of the date of notification of noncompliance, then the monies will not be
refunded. 
 5.c. Combined Remedies 
 If ODJFS determines
that one systemic problem is responsible for multiple deficiencies, ODJFS may impose a combined remedy which will address all areas of deficient performance. The total fines assessed in any one month will not exceed 15% of the MCP’s monthly
capitation. 
 5.d. Enrollment Freezes 
 MCPs found to
have a pattern of repeated or ongoing noncompliance may be subject to an enrollment freeze. 

 Appendix M 
 Page 18

  

 5.e. Reconsideration 
 Requests for reconsideration of monetary sanctions and enrollment freezes may be submitted as provided in Appendix N, Compliance Assessment System. 
 5.f. Contract Termination, Nonrenewals or Denials 
 Upon termination, nonrenewal or denial of an MCP contact, all monetary sanctions
collected under this appendix will be retained by ODJFS. The at-risk amount paid to the MCP under the current provider agreement will be returned to ODJFS in accordance with Appendix P, Terminations, of the provider agreement. 

 APPENDIX N 
 COMPLIANCE ASSESSMENT SYSTEM (CAS) 
 CFC ELIGIBLE POPULATION 
 The Compliance Assessment System (CAS) is designed to improve the quality of each MCP’s performance through actions taken by ODJFS to address identified failures to
meet certain program requirements. The CAS assesses progressive remedies with specified values (occurrences or points) assigned for certain documented failures to satisfy the deliverables required by the Agreement. Remedies are progressive based
upon the severity of the violation, or a repeated pattern of violations. The CAS does not include categories which require subjective assessments or which are not within the MCPs control. CAS allows the accumulated point total to reflect both
patterns of less serious violations as well as less frequent, more serious violations. 
 The CAS focuses on clearly identifiable deliverables and
occurrences/points are only assessed in documented and verified instances of noncompliance. The CAS does not replace ODJFS’ ability to require corrective action plans (CAPs) and program improvements, or to impose any of the sanctions specified
in Ohio Administrative Code (OAC) rule 5101:3-26-10, including the proposed termination, amendment, or nonrenewal of the MCP’s provider agreement. 
 As
stipulated in OAC rule 5101:3-26-10(F), regardless of whether ODJFS imposes a sanction, MCPs are required to initiate corrective action for any MCP program violations or deficiencies as soon as they are identified by the MCP or ODJFS. 
 Corrective Action Plans (CAPs) - MCPs may be required to develop CAPs for any instance of noncompliance, and CAPs are not limited to actions taken under the CAS.
All CAPs requiring ongoing activity on the part of an MCP to ensure their compliance with a program requirement remain in effect for the next provider agreement period. In situations where ODJFS has already determined the specific action which must
be implemented by the MCP or if the MCP has failed to submit an ODJFS-approvable CAP, ODJFS may require the MCP to comply with an ODJFS-developed or “directed” CAP. 

 Appendix N 
 Page 2

  

 Occurrences and Points - Occurrences and points are defined and applied as follows: 
 Occurrences — Failures to meet program requirements, including but not limited to, noncompliance with administrative requirements. 
  

			
	Examples include:	 	-         Use of unapproved marketing materials.
		
		 	-         Failure to attend a required meeting.
		
		 	-         Second failure to meet a call center standard.

 5 Points — Failures to meet program requirements, including but not limited to, actions which could impair
the member’s ability to access information regarding services in a timely manner or which could impair a member’s rights. 
  

			
	Examples include:	 	-         24-hour call-in system is not staffed by medical personnel.
		
		 	-         Failure to notify a member of their right to a state hearing when the MCP proposes to
          deny, reduce, suspend or terminate a Medicaid-covered service.
		
		 	-         Failure to appropriately notify ODJFS of provider panel terminations.

 10 Points — Failures to meet program requirements, including but not limited to, actions which could affect
the ability of the MCP to deliver or the member to access covered services. 
  

			
	Examples include:	 	-         Failure to comply with the minimum provider panel requirements specified in
          Appendix H of the Agreement.
		
		 	-         Failure to provide medically-necessary Medicaid covered services to members.
		
		 	-         Failure to meet the electronic claims adjudication requirements.

 Failure to submit or comply with CAPs will result in the assessment of occurrences or points based on the nature
of the violation under correction. 

 Appendix N 
 Page 3

  

 Notwithstanding the assessment of occurrences and/or points as a result of individual events, the following
cumulative actions will be imposed for repeated violations. 
 After accumulating a total of three occurrences within a contract term, all
subsequent occurrences during the period will be assessed as 5-point violations, regardless of the number of 5-point violations which have been accrued by the MCP. 
 After accumulating a total of three 5-point violations within a contract term, all subsequent 5-point violations during the period will be assessed as 8-point violations, except as specified above. 
 After accumulating a total of two 10-point violations within a contract term, all subsequent 10-point violations during the period will be assessed as
15-point violations. 
 Occurrences and points will accumulate over the contract term of the Agreement. Upon the beginning of a new Agreement, the MCP will
begin the new contract term with a score of zero unless the MCP has accrued a total of 55 points or more during the prior provider agreement period. Those MCPs who have accrued a total of 55 points or more during the contract term of a prior
provider agreement will carry these points over for the first three (3) months of their next provider agreement. If the MCP does not accrue any additional points during this three (3) month period the MCP will then have their point total
reduced to zero and continue on in the new contract term. If the MCP does accrue additional points during this three-month period, the MCP will continue to carry the points accrued from the prior provider agreement plus any additional points accrued
during the new provider agreement contract term. 
 For purposes of the CAS, the date that ODJFS first becomes aware of an MCP’s program violation is
considered the date on which the violation occurred. Therefore, program violations that technically reflect noncompliance from the previous provider agreement period will be subject to remedial action under CAS at the time that ODJFS first becomes
aware of this noncompliance. 
 In cases where an MCP subcontracting provider is found to have violated a program requirement (e.g., failing to provide
adequate contract termination notice, marketing to potential members, unapprovable billing of members, etc.), ODJFS will not assess occurrences or points if: (1) the MCP can document that they provided sufficient notification/education to
providers of applicable program requirements and prohibited activities; and (2) the MCP takes immediate and appropriate action to correct the problem and to ensure that it does not happen again to the satisfaction of ODJFS. Repeated incidents
will be reviewed to determine if the MCP has a systemic problem in this area, and if so, occurrences or points may be assessed, as determined by ODJFS. 
 All required submissions to be received by their specified deadline. Unless otherwise specified, late submissions will initially be addressed through CAPs, with repeated instances of untimely submissions resulting in escalating penalties,
as may be determined by ODJFS. 

 Appendix N 
 Page 4

  

 If an MCP determines that they will be unable to meet a program deadline, the MCP must verbally inform the designated
ODJFS contact person (or their supervisor) of such and submit a written request (by facsimile transmission) for an extension of the deadline, as soon as possible, but no later than 3 PM EST on the date of the deadline in question. Extension requests
should only be submitted in situations where unforeseeable circumstances have arisen which make it impossible for the MCP to meet an ODJFS-stipulated deadline and all such requests will be evaluated upon the basis and with that in mind. Only written
approval as may be granted by ODJFS of a deadline extension will preclude the assessment of a CAP, occurrence or points for untimely submissions. 
 No
points or occurrences will be assigned for any violation where an MCP is able to document that the precipitating circumstances were completely beyond their control and could not have been foreseen (e.g., a construction crew severs a phone line, a
lightning strike blows a computer system, etc.). 
 REMEDIES 
 Progressive remedies will be based on the number of points accumulated at the time of the most recent incident. Unless specifically otherwise indicated in this appendix, all fines issued under the CAS are nonrefundable. 
 1-9 Points Corrective Action Plan (CAP) 
 10-19 Points CAP + $5,000 fine 
 20-29 Points CAP + $10,000 fine 
 30-39 Points CAP + $20,000 fine 
 40-69 Points
CAP + $30,000 fine 
 70+ Points Proposed Contract Termination 

 Appendix N 
 Page 5

  

 New Member Selection Freezes: 
 Notwithstanding any other penalty, occurrence or point assessment that ODJFS may impose on MCP under this Appendix, ODJFS may prohibit an MCP from receiving new membership through consumer initiated selection or the
assignment process (selection freeze) in one or more counties if : (1) the MCP has accumulated a total of 20 or more points during a contract term; (2) or the MCP fails to fully implement a CAP within the designated time frame; or
(3) circumstances exist which potentially jeopardize the MCP’s members’ access to care. 
 [Examples of circumstances that ODJFS may consider
as jeopardizing member access to care include: 
  

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

  

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

  

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

  

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

 Payments provided for under the Agreement will be denied for new enrollees, when and for so long as, payments for those enrollees is denied by CMS in accordance with the
requirements in 42 CFR 438.730. 
 Reduction of Assignments 
 ODJFS may reduce the number of assignments an MCP receives if ODJFS, in its sole discretion, determines that the MCP lacks sufficient administrative capacity to meet the needs of the increased volume in membership. Examples of circumstances
which ODJFS may determine demonstrate a lack of sufficient administrative capacity include, but are not limited to an MCP’s failure to: repeatedly provide new member materials by the member’s effective date; meet the minimum call center
requirements; meet the minimum performance standards for identifying and assessing children with special health care needs and members needing case management services; and/or provide complete and accurate appeal/grievance, member’s PCP and
CAMS data files. 
 Noncompliance with Claims Adjudication Requirements: 
 If ODJFS finds that an MCP is unable to (1) electronically accept and adjudicate claims to final status and/or (2) notify providers of the status of their submitted claims, as stipulated in 

 Appendix N 
 Page 6

  

 
Appendix C of the Agreement, ODJFS will assess the MCP with a 10-point penalty and a monetary sanction of $20,000 per day for the period of noncompliance.
ODJFS may assess additional penalty points based on the length of noncompliance, as it may determine in its sole discretion. 
 If ODJFS has identified
specific instances where an MCP has failed to take the necessary steps to comply with the requirements specified in Appendix C of the Agreement for (1) failing to notify non-contracting providers of procedures for claims submissions when
requested and/or (2) failing to notify contracting and non-contracting providers of the status of their submitted claims, the MCP will be assessed 5 points per incident of noncompliance. 
 Noncompliance with Prompt Payment: 
 Noncompliance with the prompt pay
requirements as specified in Appendix J of the Agreement will result in progressive penalties. The first violation during the contract term will result in the assessment of 5 points, quarterly prompt pay reporting, and submission of monthly status
reports to ODJFS until the next quarterly report is due. The second and any subsequent violation during the contract term will result in the submission of monthly status reports, assessment of 10 points and a refundable fine equal to 5% of the
MCP’s monthly premium payment or $300,000, whichever is less. The refundable fine will be applied in lieu of a nonrefundable fine and the money will be refunded by ODJFS only after the MCP complies with the required standards for two
(2) consecutive quarters. 
 If an MCP is found to have not been in compliance with the prompt pay requirements for any time period for which a report
and signed attestation have been submitted representing the MCP as being in compliance, the MCP will be subject to a selection freeze of not less than three (3) months duration. 
 Noncompliance with Franchise Fee Assessment Requirements 
 In accordance with ORC
Section 5111.176, and in addition to the imposition of any other penalty, occurrence or points under this Appendix, an MCP that does not pay the franchise permit fee in full by the due date is subject to any or all of the following. :

  

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

  

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

  

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

 Appendix N 
 Page 7

  

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

  

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

  

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

  

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

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

Submission of unpaid encounters (except for immunization services as specified in Appendix L) will result in the assessment of a nonrefundable $1,000 fine for each
violation. 
 Noncompliance with Abortion and Sterilization Payment 
 Noncompliance with abortion and sterilization requirements as specified by ODJFS will result in the assessment of a nonrefundable $1,000 fine for each documented violation. Additionally, MCPs must take all appropriate
action to correct each such ODJFS-documented violation. 
 Negligent Breach of Protected Health Information (PHI) Standards 
 Non-compliance with the HIPAA Privacy Regulations and negligent breach of protected health information (PHI) standards will be assessed in accordance with Appendix C.27.
Therefore, the progressive remedies specified under Appendix N, Compliance Assessment System will not be utilized for assessing non-compliance with the HIPAA Privacy Regulations and negligent breach of PHI. 
 Refusal to Comply with Program Requirements 
 If ODJFS has instructed
an MCP that they must comply with a specific program requirement and the MCP refuses, such refusal constitutes documentation that the MCP is no longer operating in the best interests of the MCP’s members or the state of Ohio and ODJFS will move
to terminate or nonrenew the MCP’s provider agreement. 
 General Provisions: 
 All notifications of the imposition by ODJFS of a fine or freeze will be made via certified or overnight mail to the identified MCP Medicaid Coordinator. 

 Appendix N 
 Page 8

  

 Pursuant to procedures as established by ODJFS, refundable and nonrefundable monetary sanctions/assurances must be
remitted to ODJFS within thirty (30) days of receipt of the invoice by the MCP. In addition, per Ohio Revised Code Section 131.02, payments not received within forty-five (45) days will be certified to the Attorney General’s
(AG’s) office. MCP payments certified to the AG’s office will be assessed the appropriate collection fee by the AG’s office. 
 Refundable
monetary sanctions/assurances applied by ODJFS will be based on the premium payment for the month in which the MCP was cited for the deficiency. Any monies collected through the imposition of such a fine will be returned to the MCP (minus any
applicable collection fees owed to the Attorney General’s Office if the MCP has been delinquent in submitting payment) after they have demonstrated full compliance, as determined by ODJFS, with the particular program requirement. 
 If an MCP does not comply within one (1) year of the date of notification of noncompliance involving issues of case management and two (2) years of the date of
notification of noncompliance in issues involving encounter data, then the monies will not be refunded. MCPs are required to submit a written request for refund to ODJFS at the time they believe is appropriate before a refund of monies will be
considered. 
 Notwithstanding any other action ODJFS may take under this Appendix, ODJFS may impose a combined remedy which will address all areas of
noncompliance if ODJFS determines, in its sole discretion, that (1) one systemic problem is responsible for multiple areas of noncompliance and/or (2) that there are a number of repeated instances of noncompliance with the same program
requirement. 
 In addition, ODJFS can at any time move to terminate, amend or deny renewal of a provider agreement. 
 Upon such termination, nonrenewal or denial of an MCP provider agreement, all previously collected monetary sanctions will be retained by ODJFS. 
 In addition to the remedies imposed under the CAS, remedies related to areas of data quality and financial performance may also be imposed pursuant to Appendices J, L,
and M respectively, of the Agreement. 
 If ODJFS determines that an MCP has violated any of the requirements of sections 1903(m) or 1932 of the Social
Security Act which are not specifically identified within the CAS, the ODJFS may, pursuant to the provisions of OAC rule 5101:3-26-10(A): (1) notify the MCP’s members that they may terminate from the MCP without cause; and/or
(2) suspend any further new member selections. 

 Appendix N 
 Page 9

  

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

	 	•	 	 MCPs notified of ODJFS’ imposition of remedial action taken under the CAS (i.e., occurrences, points, fines, assignment reductions and selection freezes), will
have five (5) working days from the date of receipt to request reconsideration, although ODJFS will impose selection freezes based on an access to care concern concurrent with initiating notification to the MCP. (All notifications of the
imposition of a fine or a freeze will be made via certified or overnight mail to the identified MCP Contact.) Any information that the MCP would like reviewed as part of the reconsideration request must be submitted at the time of submission of the
reconsideration request, unless ODJFS extends the time frame in writing. 

  

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

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

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

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

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

 Appendix N 
 Page 10

  

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

	 	•	 	 Unapproved use of marketing/member materials. 

  

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

  

	 	•	 	 Failure to maintain ODJFS-required documentation. 

  

	 	•	 	 Use of unapproved subcontracting providers where prior approval is required by ODJFS. 

  

	 	•	 	 Use of unapprovable subcontractors (e.g., not in good standing with Medicaid and/or Medicare programs, provider listed in directory but no current contract, etc.)
where prior-approval is not required by ODJFS. 

  

	 	•	 	 Failure to provide timely notification to members, as required by ODJFS (e.g., notice of PCP or hospital termination from provider panel).

  

	 	•	 	 Participation in a prohibited or unapproved marketing activity. 

  

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

  

	 	•	 	 Failure to submit and/or comply with a Corrective Action Plan (CAP) requested by ODJFS as the result of an occurrence, or when no occurrence was designated for the
precipitating violation of OAC rules or provider agreement 

  

	 	•	 	 Failure to comply with the physician incentive plan requirements, except for noncompliance where member rights are violated (i.e, failure to complete required
patient satisfaction surveys or to provide members with requested physician incentive information) or where false, misleading or inaccurate information is provided to ODJFS. 

 Appendix N 
 Page 11

  

 5 POINTS: Failures to meet program requirements, including but not limited to, actions which could impair the
member’s ability to access information regarding services in a timely manner or which could impair a consumer’s or member’s rights, as determined by ODJFS. Examples include, but are not limited to, the following: 
  

	 	•	 	 Violations which result in selection or termination counter to the recipient’s preference (e.g., a recipient makes a selection decision based on inaccurate
provider panel information from the MCP). 

  

	 	•	 	 Any violation of a member’s rights. 

  

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

  

	 	•	 	 Failure to comply with appeal, grievance, or state hearing requirements, including timely submission to ODJFS. 

  

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

  

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

  

	 	•	 	 Failure to submit and/or comply with a CAP as a result of a 5-point violation. 

  

	 	•	 	 Failure to meet the prompt payment requirements (first violation). 

  

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

  

	 	•	 	 Failure to submit a required monthly CAMS file (as specified in Appendix L of the Agreement) by the end of the month the submission was required.

  

	 	•	 	 Failure to submit a required monthly Members’ Designated PCP file (as specified in Appendix L of the Agreement) by the end of the month the submission was
required. 

 Appendix N 
 Page 12

  

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

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

  

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

  

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

  

	 	•	 	 Failure to process prior authorization requests within prescribed time frame. 

  

	 	•	 	 Failure to remit any ODJFS-required payments within the specified time frame. 

  

	 	•	 	 Failure to meet the electronic claims adjudication requirements. 

  

	 	•	 	 Failure to submit and/or comply with a CAP as a result of a 10-point violation. 

  

	 	•	 	 Failure to meet the prompt payment requirements (second and subsequent violations). 

  

	 	•	 	 Fourth and any subsequent failure to meet the monthly call-center requirements for either the member services or the 24-hour call-in system lines.

  

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

  

	 	•	 	 Failure to submit a required monthly appeal or grievance file (as specified in Appendix L of the Agreement) by the end of the month the submission was required.

  

	 	•	 	 Misrepresentation or falsification of information that the MCP furnishes to the ODJFS or to the Centers for Medicare and Medicaid Services.

 APPENDIX 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 Evaluation on selected
measures, and achieve P4P standards established for the Emergency Department Diversion and selected Clinical Performance Measures. For qualifying MCPs, higher performance standards for three measures must be 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 P4P system (SFY 2006 through SFY 2009), the county-based P4P system (sections 1 and 2 of this Appendix) will apply to MCPs with membership as of February 1, 2006. Only counties with membership as of February 1, 2006 will be
used to calculate performance levels for the county-based P4P system. 
 1. SFY 2006 P4P 
 1.a. Qualifying Performance Levels 
 To qualify for consideration of the SFY 2006 P4P, an MCP’s performance level
must: 
 1) Meet the minimum performance standards set in Appendix M, Performance Evaluation, for the measures listed below; and

 2) Meet the P4P standards established for the Emergency Department Diversion and Clinical Performance Measures below. 
 A detailed description of the methodologies for each measure can be found on the BMHC page of the ODJFS website. 
 Measures for which the minimum performance standard for SFY 2006 established in Appendix M, Performance Evaluation, must be met to qualify for consideration of
P4P are as follows: 
 1. Independent External Quality Review (Appendix M, Section 1.a.i. – Minimum Performance Standard 2)  

 Appendix O 
 Page 2

  

 Report Period: The most recent Independent External Quality Review completed prior to the end
of the SFY 2006 contract period. 
 2. PCP Turnover (Appendix M, Section 2.a.) 
 Report Period: CY 2005 
 3. Children’s Access to
Primary Care (Appendix M, Section 2.b.) 
 Report Period: CY 2005 
 4. Adults’ Access to Preventive/Ambulatory Health Services (Appendix M, Section 2.c.)  
 Report Period: CY 2005 
 5. Overall Satisfaction with MCP (Appendix M, Section 3.) 
 Report Period: The most recent consumer satisfaction survey completed prior to the end of the SFY 2006 contract period. 
 For the EDD performance measure, the MCP must meet the P4P standard for the report period of July - December, 2005 to be considered for SFY 2006 P4P. The MCP meets the
P4P standard if one of two criteria are met. The P4P standard is a performance level of either: 
 1) The minimum performance standard established in Appendix
M, Section 4.b.; or 
 2) The Medicaid benchmark of a performance level at or below 1.1%. 
 For each clinical performance measure listed below, the MCP must meet the P4P standard to be considered for SFY 2006 P4P. The MCP meets the P4P standard if one of two criteria are met. The P4P standard is a
performance level of either: 
 1) The minimum performance standard established in Appendix M, Performance Evaluation, for seven of the nine clinical
performance measures listed below; or 
 2) The Medicaid benchmarks for seven of the nine clinical performance measures listed below. 
  

				
	 Clinical Performance Measure
	  	Medicaid
Benchmark	 
	 1. Perinatal Care - Frequency of Ongoing Prenatal Care
	  	42	%
	 2. Perinatal Care - Initiation of Prenatal Care
	  	71	%
	 3. Perinatal Care - Postpartum Care
	  	48	%
	 4. Well-Child Visits - Children who turn 15 months old
	  	34	%
	 5. Well-Child Visits - 3, 4, 5, or 6, years old
	  	50	%
	 6. Well-Child Visits - 12 through 21 years old
	  	30	%
	7. Use of Appropriate Medications for People with Asthma	  	59	%
	8. Annual Dental Visits	  	40	%
	9. Blood Lead - 1 year olds	  	45	%

 Appendix 0 
 Page 3

  

 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. 
 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: July - December 2005 
 Excellent Standard: 2.5%  
 Superior Standard: 3.8% 
 2. Use of Appropriate Medications for People with Asthma (Appendix M, Section 1.c.vi.)  
 Report Period: CY 2005  
 Excellent Standard: 59%  
 Superior Standard: 68% 
 3. Adults’ Access to Preventive/Ambulatory Health Services (Appendix M, Section 2.c.)  
 Report Period: CY 2005  
 Excellent Standard: 76%  
 Superior Standard: 83% 
 1.c. Determining SFY 2006 P4P 
 MCP’s reaching the minimum
performance standards described in Section 2.a. will be considered for P4P including retention of the at-risk amount and any additional P4P. For each Excellent standard established in Section 2.b. that an MCP meets, one-third of the
at-risk amount may be retained. For MCPs meeting all of the Excellent and Superior standards established in Section 2.b., additional P4P may be awarded. For MCPs receiving additional P4P, the amount in the P4P fund (see section 3.) will be
divided equally, up to the maximum amount, among all MCPs’ Aged, Blind or Disabled (ABD) and/or Covered Families and Children (CFC) receiving additional P4P. The maximum amount to be awarded to a single plan P4P additional to the at- risk
amount is $250,000 per contract year. An MCP may receive up to $500,000 should both of the MCP’s ABD and CFC programs achieve the Superior Performance levels. 

 Appendix O 
 Page 4

  

 2. SFY 2007 P4P 
 2.a. Qualifying Performance Levels 
 To qualify for consideration of the SFY 2007 P4P, an MCP’s performance level must: 
 1) Meet the minimum performance standards set in Appendix M, Performance Evaluation, for the measures listed below; and 
 2) Meet the P4P standards established for the Emergency Department Diversion and Clinical Performance Measures below. 
 A detailed description of the methodologies for each measure can be found on the BMHC page of the 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%. 

 Appendix O 
 Page 5

  

 For each clinical performance measure listed below, the MCP must meet the P4P standard to be considered for SFY 2007
P4P. The MCP meets the P4P standard if one of two criteria are met. The P4P standard is a performance level of either: 
 1) The minimum performance standard
established in Appendix M, Performance Evaluation, for seven of the nine clinical performance measures listed below; or 
 2) The Medicaid benchmarks
for seven of the nine clinical performance measures listed below. The Medicaid benchmarks are subject to change based on the revision or update of applicable national standards, methods or benchmarks. 
  

				
	 Clinical Performance Measure
	  	Medicaid
Benchmark	 
	 1. Perinatal Care - Frequency of Ongoing Prenatal Care
	  	42	%
	 2. Perinatal Care - Initiation of Prenatal Care
	  	71	%
	 3. Perinatal Care - Postpartum Care
	  	48	%
	 4. Well-Child Visits - Children who turn 15 months old
	  	34	%
	 5. Well-Child Visits - 3, 4, 5, or 6, years old
	  	50	%
	 6. Well-Child Visits - 12 through 21 years old
	  	30	%
	 7. Use of Appropriate Medications for People with Asthma
	  	83	%
	 8. Annual Dental Visits
	  	40	%
	9. Blood Lead - 1 year olds	  	45	%

 2.b. Excellent and Superior Performance Levels 
 For qualifying MCPs as determined by Section 2.a., performance will be evaluated on the measures below to determine the status of the at-risk amount or any
additional P4P that may be awarded. Excellent and Superior standards are set for the three measures described below. The standards are subject to change based on the revision or update of applicable national standards, methods or benchmarks.

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

 Appendix O 
 Page 6

  

 Excellent Standard: 86% 
 Superior Standard: 88% 
 3. Adults’ Access to
Preventive/Ambulatory Health Services (Appendix M, Section 2.c.) 
 Report Period: CY 2006  
 Excellent Standard: 76%  
 Superior Standard: 83% 
 2.c. Determining SFY 2007 P4P 
 MCP’s reaching the minimum performance standards described in Section 2.a. will be considered for P4P including retention of the at-risk amount and any additional P4P. For each Excellent standard established
in Section 2.b. that an MCP meets, one-third of the at-risk amount may be retained. For MCPs meeting all of the Excellent and Superior standards established in Section 2.b., additional P4P may be awarded. For MCPs receiving additional P4P,
the amount in the P4P fund (see section 3.) will be divided equally, up to the maximum amount, among all MCPs’ Aged, Blind or Disabled (ABD) and/or Covered Families and Children (CFC) receiving additional P4P. The maximum amount to be awarded
to a single plan P4P additional to the at-risk amount is $250,000 per contract year. An MCP may receive up to $500,000 should both of the MCP’s ABD and CFC programs achieve the Superior Performance levels. 
 3. NOTES 
 3.a. Initiation of the P4P System 
 For MCPs in their first twenty-four months of Ohio Medicaid Managed Care Program participation, the status of the at-risk amount will not be determined because compliance
with many of the standards cannot be determined in an MCP’s first two contract years (see Appendix F., Rate Chart). In addition, MCPs in their first two contract years are not eligible for the additional P4P amount 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. 

 Appendix O 
 Page 7

  

 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. Transition from a county-based to a regional-based P4P system. 
 The current county-based P4P system will transition to a regional-based system as managed care expands statewide. The regional-approach will be fully phased in no later than SFY 2010. The regional-based P4P system
will be modeled after the county-based system with adjustments to performance standards where appropriate to account for regional differences. 
 3.c.i.
County-based P4P system 
 During the transition to a regional-based system (SFY 2006 through SFY 2009), MCPs with membership as of February 1, 2006
will continue in the county-based P4P system until the transition is complete. These MCPs will be put at-risk for a portion of the premiums received for members in counties they are serving as of February 1, 2006. 
 3.c.ii. Regional-based P4P system 
 All MCPs will be included in the
regional-based P4P system. The at-risk amount will be determined separately for each region an MCP serves. 
 The status of the at-risk amount for counties
not included in the county-based P4P system will not be determined for the first twenty-four months of regional membership. Starting with the twenty-fifth month of regional membership, the MCP’s at-risk amount will be included in the P4P
system. The determination of the status of this at-risk amount will be after at least three full calendar years of regional membership as many of the performance standards require three full calendar years to determine an MCP’s performance
level. If statewide expansion is 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 P4P system for the SFY 2009 P4P determination, will be excluded from the at-risk dollars included in the first regional P4P determination. 
 3.d. Contract Termination, Nonrenewals, or Denials 
 Upon termination, nonrenewal or denial of an MCP contract, the
at-risk amount paid to the MCP under the current provider agreement will be returned to ODJFS in accordance with Appendix P., Terminations/Nonrenewals/Amendments, of the provider agreement. 

 Appendix O 
 Page 8

  

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

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

 APPENDIX P 
 MCP TERMINATIONS/NONRENEWALS/AMENDMENTS 
 CFC ELIGIBLE POPULATION 
 Upon termination either by the MCP or ODJFS, nonrenewal or denial of an MCP’s provider agreement, all previously collected refundable monetary sanctions will be
retained by ODJFS. 
 MCP-INITIATED TERMINATIONS/NONRENEWALS 
 If an MCP provides notice of the termination/nonrenewal of their provider agreement to ODJFS, pursuant to Article VIII of the agreement, the MCP will be required to submit a refundable monetary assurance. This monetary assurance will be
held by ODJFS until such time that the MCP has submitted all outstanding monies owed and reports, including, but not limited to, grievance, appeal, encounter and cost report data related to time periods through the final date of service under the
MCP=s provider agreement. The monetary assurance must be in an amount of either $50,000 or 5 % of the capitation amount paid by ODJFS in the month the termination/nonrenewal notice is issued, whichever is greater. 
 The MCP must also return to ODJFS the at-risk amount paid to the MCP under the current provider agreement. The amount to be returned will be based on actual MCP
membership for preceding months and estimated MCP membership through the end date of the contract. MCP membership for each month between the month the termination/nonrenewal is issued and the end date of the provider agreement will be estimated as
the MCP membership for the month the termination/nonrenewal is issued. Any over payment will be determined by comparing actual to estimated MCP membership and will be returned to the MCP following the end date of the provider agreement. 

The MCP must remit the monetary assurance and the at-risk amount in the specified amounts via separate electronic fund transfers (EFT) payable to Treasurer of
State, State of Ohio (ODJFS). The MCP should contact their Contract Administrator to verify the correct amounts required for the monetary assurance and the at-risk amount and obtain an invoice number prior to submitting the monetary assurance
and the at-risk amount. Information from the invoices must be included with each EFT to ensure monies are deposited in the appropriate ODJFS Fund account. In addition, the MCP must send copies of the EFT bank confirmations and copies of the invoices
to their Contract Administrator. 
 If the monetary assurance and the at-risk amount are not received as specified above, ODJFS will withhold the MCP’s
next month’s capitation payment until such time that ODJFS receives documentation that the monetary assurance and the at-risk amount are received by the Treasurer of State. If within one year of the date of issuance of the invoice, an MCP does
not submit all outstanding monies owed and required submissions, including, but not limited to, grievance, appeal, encounter and cost report data related to time periods through the final date of service under the MCP’s provider agreement, the
monetary assurance will not be refunded to the MCP. 

 Appendix P 
 Page 2

  

 ODJFS-INITIATED TERMINATIONS 
 If ODJFS initiates the proposed termination, nonrenewal or amendment of an MCP=s provider agreement pursuant to OAC rule 5101:3-26-10 and the MCP appeals that proposed action, the MCP’s provider agreement
will be extended through the duration of the appeals process. 
 During this time, the MCP will continue to accrue points and be assessed penalties for each
subsequent compliance assessment occurrence/violation under Appendix N of the provider agreement. If the MCP exceeds 69 points, each subsequent point accrual will result in a $15,000 nonrefundable fine. 
 Pursuant to OAC rule 5101:3-26-10(H), if ODJFS has proposed the termination, nonrenewal, denial or amendment of a provider agreement, ODJFS may notify the MCP’s
members of this proposed action and inform the members of their right to immediately terminate their membership with that MCP without cause. If ODJFS has proposed the termination, nonrenewal, denial or amendment of a provider agreement and access to
medically-necessary covered services is jeopardized, ODJFS may propose to terminate the membership of all of the MCP’s members. The appeal process for reconsideration of either of these proposed actions is as follows: 
  

	 	•	 	 All notifications of such a proposed MCP membership termination will be made by ODJFS via certified or overnight mail to the identified MCP Contact.

  

	 	•	 	 MCPs notified by ODJFS of such a proposed MCP membership termination will have three working days from the date of receipt to request reconsideration.

  

	 	•	 	 All reconsideration requests must be submitted by either facsimile transmission or overnight mail to the Deputy Director, Office of Ohio Health Plans, and received
by 3PM on the third working day following receipt of the ODJFS notification of termination. The address and fax number to be used in making these requests will be specified in the ODJFS notification of termination document.

  

	 	•	 	 The MCP will be responsible for verifying timely receipt of all reconsideration requests. All requests must explain in detail why the proposed MCP membership
termination is not justified. The MCP’s justification for reconsideration will be limited to a review of the written material submitted by the MCP. 

 Appendix P 
 Page 3

  

	 	•	 	 A final decision or request for additional information will be made by the Deputy Director within three working days of receipt of the request for
reconsideration. Should the Deputy Director require additional time in rendering the final reconsideration decision, the MCP will be notified of such in writing. 

  

	 	•	 	 The proposed MCP membership termination will not occur while an appeal is under review and pending the Deputy Director’s decision. If the Deputy
Director denies the appeal, the MCP membership termination will proceed at the first possible effective date. The date may be retroactive if the ODJFS determines that it would be in the best interest of the members.Ohio Medicaid Medical Assistance Provider Agreement  for Aged, Blind & Disabled

 Exhibit 10.22 
 Aged, Blind or Disabled (ABD) Population 
 OHIO DEPARTMENT OF JOB AND FAMILY SERVICES 
 OHIO MEDICAL ASSISTANCE PROVIDER AGREEMENT 
 FOR MANAGED CARE PLAN 
 ABD ELIGIBLE POPULATION 
 This provider agreement is entered into this first day of January, 2007, at Columbus, Franklin County, Ohio, between the State of Ohio, Department of Job
and Family Services, (hereinafter referred to as ODJFS) whose principal offices are located in the City of Columbus, County of Franklin, State of Ohio, and Molina Healthcare of Ohio, Inc., Managed Care Plan (hereinafter referred to as MCP), an Ohio
for-profit corporation, whose principal office is located in the city of Columbus, County of Franklin, State of Ohio. 
 MCP is licensed as a
Health Insuring Corporation by the State of Ohio, Department of Insurance (hereinafter referred to as ODI), pursuant to Chapter 1751. of the Ohio Revised Code and is organized and agrees to operate as prescribed by Chapter 5101:3-26 of the Ohio
Administrative Code (hereinafter referred to as OAC), and other applicable portions of the OAC as amended from time to time. 
 MCP is an
entity eligible to enter into a provider agreement in accordance with 42 CFR 438.6 and is engaged in the business of providing prepaid comprehensive health care services as defined in 42 CFR 438.2 through the managed care program for the Aged, Blind
or Disabled (ABD) eligible population described in OAC rule 5101:3-26-02 (B). 
 ODJFS, as the single state agency designated to administer
the Medicaid program under Section 5111.02 of the Ohio Revised Code and Title XIX of the Social Security Act, desires to obtain MCP services for the benefit of certain Medicaid recipients. In so doing, MCP has provided and will continue to
provide proof of MCP’s capability to provide quality services, efficiently, effectively and economically during the term of this agreement. 

 Aged, Blind or Disabled (ABD) Population 
  Page
 2
 of 10 
  

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

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

  

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

  

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

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

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

 ARTICLE
III—REIMBURSEMENT 
  

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

 Aged, Blind or Disabled (ABD) Population 
  Page
 3
 of 10 
  

 ARTICLE IV—MCP INDEPENDENCE 
  

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

 ARTICLE V—CONFLICT OF INTEREST; ETHICS LAWS 
  

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

  

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

  

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

 Aged, Blind or Disabled (ABD) Population 
  Page
 4
 of 10 
  

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

  

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

 ARTICLE
VI—EQUAL EMPLOYMENT OPPORTUNITY 
  

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

  

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

  

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

 ARTICLE
VII—RECORDS, DOCUMENTS AND INFORMATION 
  

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

  

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

 Aged, Blind or Disabled (ABD) Population 
  Page
 5
 of 10 
  

	 	 
confidential by ODJFS. Proprietary information is information which, if made public, would put MCP at a disadvantage in the market place and trade of which
MCP is a part [see Ohio Revised Code Section 1333.61(D)]. MCP is responsible for notifying ODJFS of the nature of the information prior to its release to ODJFS. ODJFS reserves the right to require reasonable evidence of MCP’s assertion of
the proprietary nature of any information to be provided and ODJFS will make the final determination of whether this assertion is supported. The provisions of this Article are not self-executing. 

  

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

 ARTICLE VIII—SUSPENSION AND TERMINATION 
  

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

  

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

  

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

  

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

 Aged, Blind or Disabled (ABD) Population 
  Page
 6
 of 10 
  

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

 ARTICLE
IX—AMENDMENT AND RENEWAL 
  

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

  

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

 

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

 ARTICLE X—LIMITATION OF LIABILITY 
  

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

  

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

  

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

 Aged, Blind or Disabled (ABD) Population 
  Page
 7
 of 10 
  

 ARTICLE XI—ASSIGNMENT 
  

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

  

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

 ARTICLE XII—CERTIFICATION MADE BY MCP 
  

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

  

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

 

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

 Aged, Blind or Disabled (ABD) Population 
  Page
 8
 of 10 
  

	 	 
other arrangement with any such debarred or suspended person for the provision of items or services or services that are significant and material to the
MCP’s contractual obligation with ODJFS. This certification is a material representation of fact upon which reliance was placed when this provider agreement was entered into. If it is ever determined that MCP knowingly executed this
certification erroneously, then in addition to any other remedies, this provider agreement shall be terminated pursuant to Article VII, and ODJFS must advise the Secretary of the appropriate Federal agency of the knowingly erroneous certification.

  

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

  

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

  

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

 

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

  

	H.	By executing this agreement, MCP certifies and affirms that, as applicable to MCP, no party listed in Division (I) or (J) of Section 3517.13 of the Ohio Revised Code
or spouse of such party has made, as an individual, within the two previous calendar years, one or more contributions in excess of $1,000.00 to the Governor or to his campaign committees. This certification is a material representation of fact upon
which reliance was placed when this provider agreement was entered into. If it is ever determined that MCP’s certification of this requirement is false or misleading, and not withstanding any criminal or civil liabilities imposed by law, MCP
shall return to ODJFS all monies paid to MCP under this provider agreement. The provisions of this section shall survive the expiration or termination of this provider agreement. 

  

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

  

	J.	By executing this agreement, MCP agrees to comply with the false claims recovery requirements of Section 6032 of The Deficit Reduction Act of 2005 (also see Section 5111.101 of
the Revised Code). 

 Aged, Blind or Disabled (ABD) Population 
  Page
 9
 of 10 
  

 ARTICLE XIII—CONSTRUCTION 
  

	A.	This provider agreement shall be governed, construed and enforced in accordance with the laws and regulations of the State of Ohio and appropriate federal statutes and regulations.
If any portion of this provider agreement is found unenforceable by operation of statute or by administrative or judicial decision, the operation of the balance of this provider agreement shall not be affected thereby; provided, however, the absence
of the illegal provision does not render the performance of the remainder of the provider agreement impossible. 

 ARTICLE
XIV—INCORPORATION BY REFERENCE 
  

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

  

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

  

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

 Aged, Blind or Disabled (ABD) Population 
 The parties have executed this agreement the date first written above. The agreement is hereby accepted and considered binding in accordance with the terms and conditions set forth in the preceding statements.

  

									
	MOLINA HEALTHCARE OF OHIO, INC.:	 		 		 	
					
	 BY:
	 	  
	 		 	DATE:	 	  

		 	JESSE THOMAS, PRESIDENT & CEO	 		 		 	
				
	 OHIO DEPARTMENT OF JOB AND FAMILY SERVICES:
	 		 		 	
					
	 BY:
	 	  
	 		 	DATE:	 	  

		 	BARBARA E. RILEY, DIRECTOR	 		 		 	

 ABD PROVIDER AGREEMENT INDEX 
 December 1, 2006 
  

			
	APPENDIX	    	 TITLE

	APPENDIX A	    	OAC RULES 5101:3-26
		
	APPENDIX B	    	SERVICE AREA SPECIFICATIONS - ABD ELIGIBLE POPULATION
		
	APPENDIX C	    	MCP RESPONSIBILITIES – ABD ELIGIBLE POPULATION
		
	APPENDIX D	    	ODJFS RESPONSIBILITIES - ABD ELIGIBLE POPULATION
		
	APPENDIX E	    	RATE METHODOLOGY - ABD ELIGIBLE POPULATION
		
	APPENDIX F	    	REGIONAL RATES - ABD ELIGIBLE POPULATION
		
	APPENDIX G	    	COVERAGE AND SERVICES - ABD ELIGIBLE POPULATION
		
	APPENDIX H	    	PROVIDER PANEL SPECIFICATIONS - ABD ELIGIBLE POPULATION
		
	APPENDIX I	    	PROGRAM INTEGRITY - ABD ELIGIBLE POPULATION
		
	APPENDIX J	    	FINANCIAL PERFORMANCE - ABD ELIGIBLE POPULATION
		
	APPENDIX K	    	QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM AND EXTERNAL QUALITY REVIEW - ABD ELIGIBLE POPULATION
		
	APPENDIX L	    	DATA QUALITY - ABD ELIGIBLE POPULATION
		
	APPENDIX M	    	PERFORMANCE EVALUATION - ABD ELIGIBLE POPULATION
		
	APPENDIX N	    	COMPLIANCE ASSESSMENT SYSTEM - ABD ELIGIBLE POPULATION
		
	APPENDIX O	    	PAY-FOR-PERFORMANCE (P4P) - ABD ELIGIBLE POPULATION
		
	APPENDIX P	    	MCP TERMINATIONS/NONRENEWALS/AMENDMENTS – ABD ELIGIBLE POPULATION

 APPENDIX A 
 OAC RULES 5101:3-26 
 The managed care program rules can be accessed electronically through the BMHC page of the
ODJFS website. 

 APPENDIX B 
 SERVICE AREA SPECIFICATIONS 
 ABD ELIGIBLE POPULATION 
 MCP : Molina Healthcare of Ohio, Inc. 
 The MCP
agrees to provide services to Aged, Blind or Disabled (ABD) members residing in the following service area(s): 
  

	Service	Area: Southwest Region: Adams, Brown, Butler, Clermont, Clinton, Hamilton, Highland, and Warren counties. 

  

	Service	Area: West Central Region: Champaign, Clark, Darke, Greene, Miami, Montgomery, Preble, and Shelby counties. 

  

	Service	Area: Southeast Region : Athens, Belmont, Coshocton, Gallia, Guernsey, Harrison, Jackson, Jefferson, Lawrence, Meigs, Monroe, Morgan, Muskingum, Noble, Vinton, and Washington
counties. 

  

	Service	Area: Central Region—Crawford, Delaware, Fairfield, Fayette, Franklin, Hocking, Knox, Licking, Logan, Madison, Marion, Montgomery, Morrow, Perry, Pickaway, Pike, Ross,
and Scioto counties. 

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

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

  

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

  

	3	The MCP must designate the following: 

 a. A primary
contact person (the Medicaid Coordinator) who will dedicate a majority of their time to the Medicaid product line and coordinate overall communication between ODJFS and the MCP. ODJFS may also require the MCP to designate contact staff for specific
program areas. The Medicaid Coordinator will be responsible for ensuring the timeliness, accuracy, completeness and responsiveness of all MCP submissions to ODJFS. 
 b. A provider relations representative for each service area included in their ODJFS provider agreement. This provider relations representative can serve in this capacity for only one service area (as specified in
Appendix H). 
 If an MCP serves both the CFC and ABD populations, they are not required to designate a separate provider relations
representative or Medicaid Coordinator for each population group. 
  

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

  

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

  

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

 Appendix C 
 Page 2 
  

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

  

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

  

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

  

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

  

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

  

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

  

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

  

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

  

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

 Appendix C 
 Page 3 
  

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

  

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

  

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

  

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

  

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

  

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

  

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

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

 Appendix C 
 Page 4

  

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

  

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

  

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

 Appendix C 
 Page 5

  

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

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

  

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

  

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

  

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

  

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

  

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

  

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

  

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

  

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

 Appendix C 
 Page 6 
  

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

  

	 	i.	Provides written information to all adult members concerning: 

  

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

  

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

  

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

  

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

  

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

  

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

  

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

  

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

 Appendix C 
 Page 7 
  

	24.	New Member Materials 

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

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

  

	 	b.	The ID card and new member letter must be mailed together to the member via a method that will ensure its receipt prior to the member’s effective date of coverage. No other
materials may be included with this mailing. 

  

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

  

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

  

	25.	Call Center Standards 

 The MCP must provide
assistance to members through a member services toll-free call-in system pursuant to OAC rule 5101:3-26-08.2(A)(1). MCP member services staff must be available nationwide to provide assistance to members through the toll-free call-in system every
Monday through Friday, at 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 

 Appendix C     
 Page 8 
  

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

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

	26.	Notification of Optional MCP Membership 

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

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

 Appendix C 
 Page 9 
  

	27.	HIPAA Privacy Compliance Requirements 

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

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

  

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

  

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

  

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

  

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

  

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

  

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

  

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

  

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

  

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

 Appendix C 
 Page 10

  

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

  

	29.	MCP Membership acceptance, documentation and reconciliation 

  

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

  

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

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

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

  

	 	d.	 Hospital Deferment Requests: When the MCP learns of a new member’s hospitalization that is eligible for deferment prior to that member’s discharge,
the MCP shall notify the hospital and treating providers of the potential that the MCP may not be the payer. The MCP shall work with hospitals, providers and ODJFS to assure that discharge planning assures continuity of care and accurate payment.
Notwithstanding the MCP’s right to request a hospital deferment up to six (6) months following the member’s effective date, when the MCP learns of a 

 Appendix C 
 Page 11

  

	 	 
deferment-eligible hospitalization, the MCP shall make every effort to notify ODJFS and request the deferment as soon as possible. When the MCP is notified
by ODJFS of a potential hospital deferment, the MCP must make every effort to respond to ODJFS within ten (10) business days of the receipt of the deferment information. 

  

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

  

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

  

	 	g.	Pending Member 

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

	 	h.	Transition of Fee-For-Service Members 

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

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

 Appendix C 
 Page 12

  

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

  

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

  

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

  

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

  

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

  

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

  

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

  

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

 Appendix C 
 Page 13 
  

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

  

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

  

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

  

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

  

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

  

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

  

	 	vi.	Document the provision of transition services as follows: 

  

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

  

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

  

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

  

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

 Appendix C 
 Page 14 
  

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

  

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

  

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

  

	30.	Health Information System Requirements 

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

	 	a.	Health Information System 

  

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

  

	 	ii.	As required by 42 CFR 438.242(b)(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. 

 Appendix C 
 Page 15

  

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

  

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

  

	 	a.	Before an MCP may submit production files 

  

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

  

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

 MCPs that change or modify information systems that are involved in producing any type of electronically submitted files, either internally or by
changing vendors, are required to submit to ODJFS for review and approval a transition plan including the submission of test files in the ODJFS-specified formats. Once an acceptable test file is submitted to ODJFS, as determined solely by ODJFS, the
MCP can return to submitting production files. ODJFS will inform MCPs in writing when a test file is acceptable. Once an MCP’s new or modified information system is operational, that MCP will have up to ninety (90) days to submit an
acceptable test file and an acceptable production file. 
 Submission of test files can start before the new or modified information system
is in production. ODJFS reserves the right to verify any MCP’s capability to report elements in the minimum data set prior to executing the provider agreement for the next contract period. Penalties for noncompliance with this requirement are
specified in Appendix N, Compliance Assessment System of the Provider Agreement. 
  

	 	b.	Electronic Data Interchange and Claims Adjudication Requirements 

 Claims Adjudication 
 The MCP must have the capacity to electronically accept and adjudicate all claims to final status
(payment or denial). Information on claims submission procedures 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, 

 Appendix C 
 Page 16

  

 
denied, pended (suspended)] within one month of receipt. Such notification may be in the form of a claim payment/remittance advice produced on a routine
monthly, or more frequent, basis. 
 Electronic Data Interchange 
 The MCP shall comply with all applicable provisions of HIPAA including electronic data interchange (EDI) standards for code sets and the following
electronic transactions: 
 Health care claims; 
 Health care claim status request and response; 
 Health care payment and remittance status; and 

Standard code sets. 
 Each EDI transaction
processed by the MCP shall be implemented in conformance with the appropriate version of the transaction implementation guide, as specified by applicable federal rule or regulation. 
 The MCP must have the capacity to accept the following transactions from the Ohio Department of Job and Family services consistent with EDI processing
specifications in the transaction implementation guides and in conformance with the 820 and 834 Transaction Companion Guides issued by ODJFS: 
 ASC 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 submit
written verification to ODJFS for transaction standards and 
  

 Appendix C 
 Page 17 
  

 
code sets specified in 45 CFR Part 162 – Health Insurance Reform: Standards for Electronic Transactions (HIPAA regulations), that the MCP has
established the capability of sending and receiving applicable transactions in compliance with the HIPAA regulations. The written verification shall specify the date that the MCP has: 1) achieved capability for sending and/or receiving the following
transactions, 2) entered into the appropriate trading partner agreements, and 3) implemented standard code sets. If the MCP has obtained third-party certification of HIPAA compliance for any of the items listed below, that certification may be
submitted in lieu of the MCP’s written verification for the applicable item(s). 
  

	 	i.	Trading Partner Agreements 

  

	 	ii.	Code Sets 

  

	 	iii.	Transactions 

  

	 	a.	Health Care Claims or Equivalent Encounter Information (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 

 Appendix C 
 Page 18 
  

	 	•	 	 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. 

 Appendix C 
 Page 19 
  

 Acceptance testing of encounter data is required as specified in Section 29(a)(v) of this
Appendix. 
 Encounter Data File Submission Procedures 
 A certification letter must accompany the submission of an encounter data file in the ODJFS-specified medium. The certification letter must be signed by the MCP’s Chief Executive Officer (CEO), Chief Financial
Officer (CFO), or an individual who has delegated authority to sign for, and who reports directly to, the MCP’s CEO or CFO. 
 No more
than two production files in the ODJFS-specified medium per format (e.g., NSF) should be submitted each month. If it is necessary for an MCP to submit more than two production files in the ODJFS-specified medium for a particular format in a month,
they must request and receive permission to do so from their designated Contract Administrator. 
 Timing of Encounter Data
Submissions 
 ODJFS recommends that MCPs submit encounters no more than thirty-five (35) days after the end of the month in which
they were paid. (For example, claims paid in January are due March 5.) ODJFS recommends that MCPs submit files in the ODJFS-specified medium by the 5th of each month. This will help to ensure that the encounters are included in the ODJFS master
file in the same month in which they were submitted. 
  

	 	d.	Information Systems Review 

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

  

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

 Appendix C 
 Page 20

  

	 	ii.	Review the completed ISCA and accompanying documents; 

  

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

  

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

  

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

  

	 	vi.	Examine MCP processes for data transfers; 

  

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

  

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

  

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

 As noted above, the information system review may be performed every two years. However, if ODJFS or its designee identifies significant information system problems, then ODJFS or its designee may conduct, and the MCP
must participate in, a review the following year, or in such a timeframe as ODJFS, in their sole discretion, deems appropriate to ensure accuracy and efficiency of the MCP health information system. 
 If an MCP had an assessment performed of its information system through a private sector accreditation body or other independent entity within the two
years preceding the time when ODJFS or its designee will be conducting its review, and has not made significant changes to its information system since that time, and the information gathered is the same as or consistent with the ODJFS or its
designee’s proposed review, as determined by the ODJFS, then the MCP will not required to undergo the IS review. The MCP must provide ODJFS or its designee with a copy of the review that was performed so that ODJFS can determine whether or not
the MCP will be required to participate in the IS review. MCPs who are determined to be exempt from the IS review must participate in subsequent information system reviews, as determined by ODJFS. 

 Appendix C 
 Page 21

  

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

  

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

  

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

  

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

  

	35.	Franchise Fee Assessment Requirements 

  

	 	 a.
	 Each MCP is required to pay a franchise permit fee to ODJFS for each calendar quarter as required by ORC
Section 5111.176. The current fee to be paid is an amount equal to 4 1/2 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 

 Appendix C 
 Page 22

  

	 	 
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 providers where they will be able to confirm a consumer’s MCP enrollment and through
this website (or through e-mail process) allow providers to electronically submit and receive responses to prior authorization requests. This website must also include: (1) a list of the counties that are covered in their service area;
(2) the MCP’s provider manual;(3) MCP contact information; (4) a link to the MCP’s on- line provider directory as referenced in section 36(a) of this appendix; (5) the MCP’s current PDL list, including an explanation of
the list, which drugs require PA, and the PA process; and (6) the MCP’s current list of drugs covered only with PA, the PA process, and the MCP’s policy for covering generic for brand- name drugs. MCPs must ensure that all provider
materials designated specifically for CFC and/or ABD consumers (i.e. The MCP’s provider manual) are clearly labeled as such. ODJFS may require MCPs to include additional information on the provider website, as needed. 

 Appendix C 
 Page 23 
  

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

  

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

  

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

 APPENDIX D 
 ODJFS RESPONSIBILITIES 
 ABD ELIGIBLE POPULATION 
 The following are ODJFS responsibilities or clarifications that are not otherwise specifically stated in OAC Chapter 5101: 3-26 or elsewhere in the ODJFS-MCP provider
agreement. 
 General Provisions 
  

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

  

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

 

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

  

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

  

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

  

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

  

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

  

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

  

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

  

	10.	On a monthly basis, ODJFS will provide MCPs with an electronic Master Provider File containing all the Ohio Medicaid fee-for-service providers, which includes their Medicaid

 Appendix D 
 Page 2 
  

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

  

	11.	It is the intent of ODJFS to utilize electronic commerce for many processes and procedures that are now limited by 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 will provide MCP eligible individuals, including current MCP members, with a Consumer Guide. The Consumer Guide will describe the managed care program and include information on the MCP
options in the service area and other information regarding the managed care program as specified in 42 CFR 438.10. 

  

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

  

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

 Appendix D 
 Page 3 
  

	15.	Membership Selection and Premium Payment 

  

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

 The SSC shall distribute the most current Consumer Guide that includes the managed care program information as specified in 42 CFR 438.10, as well as
ODJFS prior-approved MCP materials, such as solicitation brochures and provider directories, to consumers who request additional materials. 
  

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

  

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

  

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

  

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

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

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

  

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

 Appendix D 
 Page 4 
  

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

  

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

  

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

  

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

  

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

  

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

  

	19.	Communications 

  

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

  

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

  

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

 Appendix D 
 Page 5 
  

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

 APPENDIX E 
 RATE METHODOLOGY 
 ABD ELIGIBLE POPULATION 

 Appendix G 
 Page 1

  

 APPENDIX G 
 COVERAGE AND SERVICES 
 ABD ELIGIBLE POPULATION 
  

	1.	Basic Benefit Package 

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

	 	•	 	 Inpatient hospital services 

  

	 	•	 	 Outpatient hospital services 

  

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

  

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

  

	 	•	 	 Laboratory and x-ray services 

  

	 	•	 	 Family planning services and supplies 

  

	 	•	 	 Home health services 

  

	 	•	 	 Podiatry 

  

	 	•	 	 Physical therapy, occupational therapy, and speech therapy 

  

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

  

	 	•	 	 Prescription drugs 

  

	 	•	 	 Ambulance and ambulette services 

  

	 	•	 	 Dental services 

  

	 	•	 	 Durable medical equipment and medical supplies 

  

	 	•	 	 Vision care services, including eyeglasses 

  

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

 Appendix G 
 Page 2

  

	 	•	 	 Hospice care 

  

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

  

	2.	Exclusions, Limitations and Clarifications 

  

	 	a.	Exclusions 

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

	 	•	 	 Services or supplies that are not medically necessary 

  

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

  

	 	•	 	 Organ transplants that are not covered by Medicaid 

  

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

  

	 	•	 	 Infertility services for males or females 

  

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

  

	 	•	 	 Reversal of voluntary sterilization procedures 

  

	 	•	 	 Plastic or cosmetic surgery that is not medically necessary* 

  

	 	•	 	 Immunizations for travel outside of the United States 

  

	 	•	 	 Services for the treatment of obesity unless medically necessary* 

  

	 	•	 	 Custodial or supportive care 

  

	 	•	 	 Sex change surgery and related services 

  

	 	•	 	 Sexual or marriage counseling 

 Appendix G 
 Page 3

  

	 	•	 	 Court ordered testing 

  

	 	•	 	 Acupuncture and biofeedback services 

  

	 	•	 	 Services to find cause of death (autopsy) 

  

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

  

	 	•	 	 Paternity testing 

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

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

  

	 	b.	Limitations & Clarifications 

  

	 	i.	Member Cost-Sharing 

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

 Appendix G 
 Page 4

  

	 	ii.	Abortion and Sterilization 

 The use of federal
funds to pay for abortion and sterilization services is prohibited unless the specific criteria found in 42 CFR 441 and OAC rules 5101:3-17-01 and 5101:3-21-01 are met. MCPs must verify that all of the information on the required forms (JFS 03197,
03198, and 03199) is provided and that the service meets the required criteria before any such claim is paid. 
 Additionally, payment must
not be made for associated services such as anesthesia, laboratory tests, or hospital services if the abortion or sterilization itself does not qualify for payment. MCPs are responsible for educating their providers on the requirements; implementing
internal procedures including systems edits to ensure that claims are only paid once the MCP has determined if the applicable forms are completed and the required criteria are met, as confirmed by the appropriate certification/consent forms; and for
maintaining documentation to justify any such claim payments. 
  

	 	iii.	Behavioral Health Services 

 Coordination of
Services: MCPs must have a process to coordinate benefits of and referrals to the publicly funded community behavioral health system. MCPs must ensure that members have access to all medically-necessary behavioral health services covered by the
Ohio Medicaid FFS program and are responsible for coordinating those services with other medical and support services. MCPs must notify members via the member handbook and provider directory of where and how to access behavioral health services,
including the ability to self-refer to mental health services offered through community mental health centers (CMHCs) as well as substance abuse services offered through Ohio Department of Alcohol and Drug Addiction Services (ODADAS)-certified
Medicaid providers. Pursuant to ORC Section 5111.16, alcohol, drug addiction and mental health services covered by Medicaid are not to be paid by the managed care program when the nonfederal share of the cost of those services is provided by a
board of alcohol, drug addiction, and mental health services or a state agency other than ODJFS. 
 MCPs must provide behavioral health
services for members who are unable to timely access services or unwilling to access services through community providers. 
 Mental
Health Services: There are a number of various Medicaid-covered mental health (MH) services available through the CMHCs. 

 Appendix G 
 Page 5

  

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

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

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

 Appendix G 
 Page 6

  

 MCPs may establish a preferred drug list for members and providers which includes a listing of the
drugs that they prefer to have prescribed. Preferred drugs requiring prior authorization approval must be clearly indicated as such. Pursuant to ORC §5111.72, ODJFS may approve MCP-specific pharmacy program utilization management strategies
(see appendix G.3.a). 
  

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

  

	3.	Care Coordination 

  

	 	a.	Utilization Management (Modification) Programs 

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

 Appendix G 
 Page 7

  

 
department diversion (EDD) program for frequent users. In that ODJFS has developed the parameters for an MCP’s EDD program, it therefore does not
require ODJFS approval. 
 Pharmacy Programs - Pursuant to ORC Sec. 5111.172 and OAC rule 5101:3-26-03(A) and (B), MCPs subject to
ODJFS prior-approval, may implement strategies, including prior authorization and limitations on the type of provider and locations where certain medications may be administered, for the management of pharmacy utilization. 
 MCPs must receive prior approval from ODJFS on the types of medication that they wish to cover through prior authorizations. MCPs must establish their
prior authorization system so that it does not unnecessarily impede member access to medically-necessary Medicaid-covered services. As outlined in paragraph 29(i) of Appendix C, MCPs must adhere to specific prior-authorization limitations to assist
with the transition of new ABD members from FFS Medicaid. 
 MCPs must comply with the provisions of 1927(d)(5) of the Social Security Act,
42 USC 1396r-8(k)(3), and OAC rule 5101:3-26-03.1 regarding the timeframes for prior authorization of covered outpatient drugs. 
 MCPs may
also, with ODJFS prior approval, implement pharmacy utilization modification programs designed to address members demonstrating high or inappropriate utilization of specific prescription drugs. 
 Emergency Department Diversion (EDD) – MCPs must provide access to services in a way that assures access to primary, specialist and urgent
care in the most appropriate settings and that minimizes frequent, preventable utilization of emergency department (ED) services. OAC rule 5101:3-26-03.1(A)(7)(d) requires MCPs to implement the ODJFS-required emergency department diversion (EDD)
program for frequent utilizers. 
 Each MCP must establish an ED diversion (EDD) program with the goal of minimizing frequent ED utilization.
The MCP’s EDD program must include the monitoring of ED utilization, identification of frequent ED utilizers, and targeted approaches designed to reduce avoidable ED utilization. MCP EDD programs must, at a minimum, address those ED visits
which could have been prevented through improved education, access, quality or care management approaches. 
 Although there is often an
assumption that frequent ED visits are solely the result of a preference on the part of the member and education is therefore the standard remedy, it is also important to ensure that a member’s frequent ED utilization is not due to problems
such as their 

 Appendix G 
 Page 8 
  

 
PCP’s lack of accessibility or failure to make appropriate specialist referrals. The MCP’s EDD program must therefore also include the
identification of providers who serve as PCPs for a substantial number of frequent ED utilizers and the implementation of corrective action with these providers as so indicated. 
 This requirement does not replace the MCP’s responsibility to inform and educate all members regarding the appropriate use of the ED. 
  

	4.	Case Management 

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

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

  

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

  

	 	i.	Identification – 

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

	 	ii.	Assessment – 

 The MCP must arrange for or conduct a
comprehensive assessment of the member’s physical and/or behavioral health condition(s) to confirm the results of a positive identification, and to determine the need for case management services. The goals of the assessment are to identify the
member’s existing and/or potential health care needs and assess the member’s need for case management services. 
 The assessment
must be completed by a physician, physician assistant, RN, LPN, licensed social worker, or a graduate of a two or four year allied health program. If the assessment is completed by another medical professional, there should be oversight and
monitoring by either a registered nurse or a physician. 
 The MCP must have a process to inform members and their PCPs that they have been
identified as meeting the criteria for case management, including their enrollment into case management services. 
  

	 	iii.	Case Management – 

 Risk Stratification/Levels of
Care 
 The MCP must develop a strategy to assign members to risk stratification levels, based on the member’s comprehensive needs
assessment. Once the member’s 

 Appendix G 
 Page 9

  

 
risk level has been determined, the MCP must, at a minimum: -develop a care treatment plan (as described below); 
  

	 	•	 	 implement member-level interventions; 

  

	 	•	 	 continuously monitor the progress of the member; 

  

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

  

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

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

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

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

 Appendix G 
 Page 10

  

	 	iv.	ODJFS Targeted Case Management Conditions 

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

	 	•	 	 Congestive Heart Failure 

  

	 	•	 	 Coronary Artery Disease 

  

	 	•	 	 Non-Mild Hypertension 

  

	 	•	 	 Diabetes 

  

	 	•	 	 Chronic Obstructive Pulmonary Disease 

  

	 	•	 	 Asthma 

  

	 	•	 	 Severe mental illness 

  

	 	•	 	 High risk or high cost substance abuse disorders 

  

	 	•	 	 Severe cognitive and/or developmental limitation 

 The MCP should also focus on all members whose health conditions warrant case management services and should not limit these services only to members with these conditions (e.g., cystic fibrosis, cerebral palsy and
sickle cell anemia). 
 Refer to Appendix M for the performance measures and standards related to case management. 
  

	 	v.	Case Management Program Staffing 

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

	 	vi.	Case Management Strategies 

 The MCP must follow
best-practice and/or evidence based clinical guidelines when devising a member’s care treatment plan and coordinating the case management needs. If an MCP uses a disease management methodology to identify and/or stratify members in need of case
management services, the methods must be validated by scientific research and/or nationally accepted in the health care industry. 
 The MCP
must develop and implement mechanisms to educate and equip physicians and case managers with evidence-based clinical guidelines or best practice approaches to assist in providing a high level of quality of care to members. 
  

	 	vii.	Information Technology System for Case Management 

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

 Appendix G 
 Page 11

  

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

	 	viii.	Data Submission 

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

	 	c.	All MCPs must have an ODJFS-approved case management system which includes the items in Section 4(a) and (b) of Appendix G. Each MCP must implement an evaluation process
to review, revise and/or update the case management program. The MCP must annually submit its case management program for review and approval by ODJFS. Any subsequent changes to an approved case management system description must be submitted to
ODJFS in writing for review and approval prior to implementation. Refer to Appendix K for the requirements regarding the annual review of the case management program. 

  

	 	d.	Care Coordination with ODJFS-Designated Providers 

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

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

 Appendix G 
 Page 12

  

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

  

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

  

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

  

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

  

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

  

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

  

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

  

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

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

	 	e.	Care coordination with Non-Contracting Providers 

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

 APPENDIX H 
 PROVIDER PANEL SPECIFICATIONS 
 ABD ELIGIBLE POPULATION 
  

	1.	GENERAL PROVISIONS 

 MCPs must provide or arrange for the
delivery of all medically necessary, Medicaid-covered health services, as well as assure that they meet all applicable provider panel requirements for their entire designated service area. The ODJFS provider panel requirements are specified in the
charts included with this appendix and must be met prior to the MCP receiving a provider agreement with ODJFS. The MCP must remain in compliance with these requirements for the duration of the provider agreement. 
 If an MCP is unable to provide the medically necessary, Medicaid-covered services through their contracted provider panel, the MCP must ensure access to these services
on an as needed basis. For example, if an MCP meets the gastroenterologist requirement but a member is unable to obtain a timely appointment from a gastroenterologist on the MCP’s provider panel, the MCP will be required to secure an
appointment from a panel gastroenterologist or arrange for an out-of-panel referral to a gastroenterologist. 
 MCPs are required to make
transportation available to any member that must travel 30 miles or more from their home to receive a medically-necessary Medicaid-covered service. If the MCP offers transportation to their members as an additional benefit and this
transportation benefit only covers a limited number of trips, the required transportation listed above may not be counted toward this trip limit (as specified in Appendix C). 
 In developing the provider panel requirements, ODJFS considered, on a county-by-county basis, the population size and utilization patterns of the Aged, Blind or Disabled
(ABD) consumers, as well as the potential availability of the designated provider types. ODJFS has integrated existing utilization patterns into the provider network requirements to avoid disruption of care. Most provider panel requirements are
county-specific but in certain circumstances, ODJFS requires providers to be located anywhere in the region. Although all provider types listed in this appendix are required provider types, only those listed on the attached charts must be submitted
for ODJFS prior approval. 
  

	2.	PROVIDER SUBCONTRACTING 

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

 ODJFS must prior approve all MCP providers in the ODJFS- required provider type categories before they can begin to provide services to that MCP’s
members. MCPs may not employ or 

 Appendix H 
 Page 2

  

 
contract with providers excluded from participation in Federal health care programs under either section 1128 or section 1128A of the Social Security Act. As
part of the prior approval process, MCPs must submit documentation verifying that all necessary contract documents have been appropriately completed. ODJFS will verify the approvability of the submission and process this information using the ODJFS
Provider Verification System (PVS). The PVS is a centralized database system that maintains information on the status of all MCP-submitted providers. 
 Only
those providers who meet the applicable criteria specified in this document, and as determined by ODJFS, will be approved by ODJFS. MCPs must credential/recredential providers in accordance with the standards specified by the National Committee for
Quality Assurance (or receive approval from ODJFS to use an alternate industry standard) and must have completed the credentialing review before submitting any provider to ODJFS for approval. Regardless of whether ODJFS has approved a provider, the
MCP must ensure that the provider has met all applicable credentialing criteria before the provider can render services to the MCP’s members. 
 MCPs
must notify ODJFS of the addition and deletion of their contracting providers as specified in OAC rule 5101:3-26-05, and must notify ODJFS within one working day in instances where the MCP has identified that they are not in compliance with the
provider panel requirements specified in this appendix. 
  

	3.	PROVIDER PANEL REQUIREMENTS 

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

	a.	Primary Care Physicians (PCPs) 

 Primary Care Physicians (PCPs) may
be individuals or group practices/clinics [Primary Care Clinics (PCCs)]. Acceptable specialty types for PCPs are family/general practice, and internal medicine. Acceptable PCCs include FQHCs, RHCs and the acceptable group practices/clinics specified
by ODJFS. As part of their subcontract with an MCP, PCPs must stipulate the total Medicaid member capacity that they can ensure for that individual MCP. Each PCP must have the capacity and agree to serve at least 50 Medicaid members at each practice
site in order to be approved by ODJFS as a PCP, and to be included in the MCP’s total PCP capacity calculation. The capacity-by-site requirement must be met for all ODJFS-approved PCPs. 
 ODJFS reviews the capacity totals for each PCP to determine if they appear excessive. ODJFS reserves the right to request clarification from an MCP for any PCP whose
total stated capacity for all MCP networks added together exceeds 2000 Medicaid members (i.e., 1 FTE). ODJFS may also compare a PCP’s capacity against the number of members assigned to that PCP, and/or the number of patient encounters
attributed to that PCP to determine if the reported capacity number reasonably reflects a PCP’s expected caseload for a specific MCP. Where indicated, ODJFS may set a cap on the maximum amount of capacity that we will recognize for a specific
PCP. ODJFS may allow up to an additional 750 member capacity for each nurse practitioner or physician’s assistant that is used to provide clinical support for a PCP. 

 Appendix H 
 Page 3

  

 For PCPs contracting with more than one MCP, the MCP must ensure that the capacity figure stated by the PCP in their
subcontract reflects only the capacity the PCP intends to provide for that one MCP. ODJFS utilizes each approved PCP’s capacity figure to determine if an MCP meets the provider panel requirements and this stated capacity figure does not
prohibit a PCP from actually having a caseload that exceeds the capacity figure indicated in their subcontract. 
 ODJFS expects that MCPs will need to
utilize specialty physicians to serve as PCPs for some special needs members. In these situations it will not be necessary for the MCP to submit these specialists to the PVS database as PCPs, however, they must be submitted to PVS as the appropriate
required provider type. Also, in some situations (e.g., continuity of care) a PCP may only want to serve a very small number of members for an MCP. In these situations it will not be necessary for the MCP to submit these PCPs to ODJFS for prior
approval. These PCPs will not be included in the ODJFS PVS database and therefore may not appear as PCPs in the MCP’s provider directory. Also, no PCP capacity will be counted for these providers. These PCPs will, however, need to execute a
subcontract with the MCP which includes the appropriate Model Medicaid Addendum. 
 The PCP requirement is based on an MCP having sufficient PCP capacity to
serve 55% of the eligibles in the region. Each MCP must meet the PCP minimum FTE requirement for that region. MCPs must also satisfy a PCP geographic accessibility standard. ODJFS will match the PCP practice sites and the stated PCP capacity with
the geographic location of the eligible population in that region (on a county-specific basis) and perform analysis using Geographic Information Systems (GIS) software. The analysis will be used to determine if at least 40% of the eligible
population is located within 10 miles of a PCP with available capacity in urban counties and 40% of the eligible population within 30 miles of a PCP with available capacity in rural counties. [Rural areas are defined pursuant to 42 CFR
412.62(f)(1)(iii).] 
  

	b.	Non-PCP Provider Network 

 In addition to the PCP capacity
requirements, each MCP is also required to maintain adequate capacity in the remainder of its provider network within the following categories: hospitals, cardiovascular, dentists, gastroenterology, nephrology, neurology, oncology, physical
medicine, podiatry, psychiatry, urology, vision care providers, obstetricians/gynecologists (OB/GYNs), allergists, general surgeons, otolaryngologists, orthopedists, federally qualified health centers (FQHCs)/rural health centers (RHCs) and
qualified family planning providers (QFPPs). CNMs, CNPs, FQHCs/RHCs and QFPPs are federally-required provider types. 
 All Medicaid-contracting MCPs must
provide all medically-necessary Medicaid-covered services to their members and therefore their complete provider network will include many other additional specialists and provider types. MCPs must ensure that all non-PCP network providers
follow community standards in the scheduling of routine appointments (i.e., the amount of time members must wait from the time of their request to the first available time when the visit can occur). 

 Appendix H 
 Page 4

  

 Although there are currently no capacity requirements for the non-PCP required provider types, MCPs are required to
ensure that adequate access is available to members for all required provider types. Additionally, for certain non-PCP required provider types, MCPs must ensure that these providers maintain a full-time practice at a site(s) located in the specified
county/region (i.e., the ODJFS-specified county within the region or anywhere within the region if no particular county is specified). A full-time practice is defined as one where the provider is available to patients at their practice site(s) in
the specified county/region for at least 25 hours a week. ODJFS will monitor access to services through a variety of data sources, including: consumer satisfaction surveys; member appeals/grievances/complaints and state hearing
notifications/requests; clinical quality studies; encounter data volume; provider complaints, and clinical performance measures. 
 Hospitals -MCPs
must contract with the number and type of hospitals specified by ODJFS for each county/region. In developing these hospital requirements, ODJFS considered, on a county-by-county basis, the population size and utilization patterns of the Aged, Blind
or Disabled (ABD) consumers and integrated the existing utilization patterns into the hospital network requirements to avoid disruption of care. For this reason, ODJFS may require that MCPs contract with out-of-state hospitals (i.e. Kentucky, West
Virginia, etc.). 
 For each Ohio hospital, ODJFS utilizes the hospital’s most current Annual Hospital Registration and Planning Report, as filed with
the Ohio Department of Health, in verifying types of services that hospital provides. Although ODJFS has the authority, under certain situations, to obligate a non-contracting hospital to provide non-emergency hospital services to an MCP’s
members, MCPs must still contract with the specified number and type of hospitals unless ODJFS approves a provider panel exception (see Section 4 of this appendix – Provider Panel Exceptions). 
 If an MCP-contracted hospital elects not to provide specific Medicaid-covered hospital services because of an objection on moral or religious grounds, the MCP must
ensure that these hospital services are available to its members through another MCP-contracted hospital in the specified county/region. 
 OB/GYNs - MCPs must contract with the specified number of OB/GYNs for each county/region, all of whom must maintain a full-time obstetrical practice at a site(s) located in the specified county/region. All MCP-contracting OB/GYNs
must have current hospital delivery privileges at a hospital under contract with the MCP in the region. 
 Certified Nurse Midwives (CNMs) and Certified
Nurse Practitioners (CNPs) - MCPs must ensure access to CNM and CNP services in the region if such provider types are present within the region. The MCP may contract directly with the CNM or CNP providers, or with a physician or other provider
entity who is able to obligate the participation of a CNM or CNP. If an MCP does not contract for CNM or CNP services and such providers are present within the region, the MCP will be required to allow members to receive CNM or CNP services outside
of the MCP’s provider network. 
 Contracting CNMs must have hospital delivery privileges at a hospital under contract to the MCP in the region. The MCP
must ensure a member’s access to CNM and CNP services if such providers are practicing within the region. 

 Appendix H 
 Page 5

  

 Vision Care Providers - MCPs must contract with the specified number of ophthalmologists/optometrists for each
specified county/region, all of whom must maintain a full-time practice at a site(s) located in the specified county/region. All ODJFS-approved vision providers must regularly perform routine eye exams. (MCPs will be expected to contract with
an adequate number of ophthalmologists as part of their overall provider panel, but only ophthalmologists who regularly perform routine eye exams can be used to meet the vision care provider panel requirement.) If optical dispensing is not
sufficiently available in a region through the MCP’s contracting ophthalmologists/optometrists, the MCP must separately contract with an adequate number of optical dispensers located in the region. 
 Dental Care Providers - MCPs must contract with the specified number of dentists.  
 Federally Qualified Health Centers/Rural Health Clinics (FQHCs/RHCs) - MCPs are required to ensure member access to any federally qualified health center or rural health clinic (FQHCs/RHCs), regardless of
contracting status. Contracting FQHC/RHC providers must be submitted for ODJFS approval via the PVS process. Even if no FQHC/RHC is available within the region, MCPs must have mechanisms in place to ensure coverage for FQHC/RHC services in the event
that a member accesses these services outside of the region. 
 In order to ensure that any FQHC/RHC has the ability to submit a claim to ODJFS for the
state’s supplemental payment, MCPs must offer FQHCs/RHCs reimbursement pursuant to the following: 
  

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

  

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

  

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

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

 Appendix H 
 Page 6

  

 
must reimburse all medically-necessary Medicaid-covered family planning services provided to eligible members by a QFPP provider (including on-site pharmacy
and diagnostic services) on a patient self-referral basis, regardless of the provider’s status as a panel or non-panel provider. MCPs will be required to work with QFPPs in the region to develop mutually-agreeable HIPAA compliant policies and
procedures to preserve patient/provider confidentiality, and convey pertinent information to the member’s PCP and/or MCP. 
 Behavioral Health
Providers – MCPs must assure member access to all Medicaid-covered behavioral health services for members as specified in Appendix G.b.ii. herein. Although ODJFS is aware that certain outpatient substance abuse services may only be
available through Medicaid providers certified by the Ohio Department of Drug and Alcohol Addiction Services (ODADAS) in some areas, MCPs must maintain an adequate number of contracted mental health providers in the region to assure access for
members who are unable to timely access services or unwilling to access services through community mental health centers. MCPs are advised not to contract with community mental health centers as all services they provide to MCP members are to be
billed to ODJFS. 
 Other Specialty Types (general surgeons, otolaryngologists, orthopedists, cardiologists, gastroenterologists, nephrologists,
neurologists, oncologists, podiatrists, 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. Contracting general surgeons, orthopedists, otolaryngologists, cardiologists, gastroenterologists, nephrologists,
neurologists, oncologists, podiatrists, physiatrists, psychiatrists, and urologists must have admitting privileges at a hospital under contract with the MCP in the region. 
  

	4.	PROVIDER PANEL EXCEPTIONS 

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

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

  

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

 

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

 Appendix H 
 Page 7

  

 If an MCP is unable to contract with or maintain a sufficient number of providers to meet the ODJFS-specified
provider panel criteria, the MCP may request an exception to these criteria by submitting a provider panel exception request as specified by ODJFS. ODJFS will review the exception request and determine whether the MCP has sufficiently demonstrated
that all reasonable efforts were made to obtain contracts with providers of the type in question and that they will be able to provide access to the services in question. 
 ODJFS will aggressively monitor access to all services related to the approval of a provider panel exception request through a variety of data sources, including: consumer satisfaction surveys; member
appeals/grievances/complaints and state hearing notifications/requests; member just-cause for termination requests; clinical quality studies; encounter data volume; provider complaints, and clinical performance measures. ODJFS approval of a provider
panel exception request does not exempt the MCP from assuring access to the services in question. If ODJFS determines that an MCP has not provided sufficient access to these services, the MCP may be subject to sanctions. 
  

	5.	PROVIDER DIRECTORIES 

 MCP provider directories must include
all MCP-contracted providers [except as specified by ODJFS] as well as certain non-contracted providers. At the time of ODJFS’ review, the information listed in the MCP’s provider directory for all ODJFS-required provider types specified
on the attached charts must exactly match the data currently on file in the ODJFS PVS. 
 MCP provider directories must utilize a format specified by ODJFS.
Directories may be region-specific or include multiple regions, however, the providers within the directory must be divided by region, county, and provider type, in that order. 
 The directory must also specify: 
  

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

  

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

  

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

  

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

  

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

  

	 	•	 	 any PCP or specialist practice limitations. 

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

 Appendix H 
 Page 8

  

 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. 

 Appendix H 
 Page 9

  

 Contracting providers must offer hours of operation that are no less than the hours of operation offered to
commercial members or comparable to Medicaid fee-for-service, if the provider serves only Medicaid members. MCPs must ensure that services are available 24 hours a day, 7 days a week, when medically necessary. MCPs must establish mechanisms to
ensure that panel providers comply with timely access requirements, and must take corrective action if there is failure to comply. 
 In order to demonstrate
adequate provider panel capacity and services, 42 CFR 438.206 and 438.207 stipulates that the MCP must submit documentation to ODJFS, in a format specified by ODJFS, that demonstrates it offers an appropriate range of preventive, primary care and
specialty services adequate for the anticipated number of members in the service area, while maintaining a provider panel that is sufficient in number, mix, and geographic distribution to meet the needs of the number of members in the service area.

 This documentation of assurance of adequate capacity and services must be submitted to ODJFS no less frequently than at the time the MCP enters into a
contract with ODJFS; at any time there is a significant change (as defined by ODJFS) in the MCP’s operations that would affect adequate capacity and services (including changes in services, benefits, geographic service or payments); and at any
time there is enrollment of a new population in the MCP. 
 MCPs are to follow the procedures specified in the current MCP PVS Instructional Manual,
posted on the ODJFS website, in order to comply with these federal access requirements. 

 North East Region - Hospitals 
  

																					
	 Minimum Provider Panel
Requirements

	 	  	Total
Required
Hospitals	  	Ashtabula	  	Cuyahoga	  	Erie	  	Geauga	  	Huron	  	Lake	  	Lorain	  	Medina	  	Additional
Required
Hospitals:
In-Region
	 General Hospital
	  		  	1	  		  		  	1	  	1	  	1	  	1	  	1	  	
	 Hospital System1
	  	1	  		  	1	  		  		  		  		  		  		  	1

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

 North East Central Region - Hospitals 
  

											
	 Minimum Provider Panel
Requirements

	 	  	Total
Required
Hospitals	  	Columbiana	  	Mahoning	  	Trumbull	  	Additional
Required
Hospitals:
In-Region
	 General Hospital
	  	3	  	1	  	1	  		  	1
	 Hospital System
	  		  		  		  		  	

 East Central Region - Hospitals 
  

																							
	 Minimum Provider Panel
Requirements

	 	  	Total
Required
Hospitals	  	Ashland	  	Carroll	  	Holmes	  	Portage	  	Richland	  	Stark	  	Summit	  	Tuscarawas	  	Wayne	  	Additional
Required
Hospitals:
In- Region
	General Hospital	  	7	  		  		  		  	1	  	1	  	1	  		  	1	  	1	  	2
	Hospital System1	  	1	  		  		  		  		  		  		  	1	  		  		  	

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

 South East Region - Hospitals 
  

																																					
	 Minimum Provider Panel
Requirements

	 	  	Total
Required
Hospitals	  	Athens	  	Belmont	  	Coshocton	  	Gallia	  	Guernsey	  	Harrison	  	Jackson	  	Jefferson	  	Lawrence	  	Meigs	  	Monroe	  	Morgon	  	Muskingum	  	Noble	  	Vinton	  	Washington	  	Additional
Required
Hospitals:
In-Region
	General Hospital	  	8	  	1	  	1	  	1	  	1	  	1	  		  		  	1	  		  		  		  		  	1	  		  		  	1	  	
	Hospital System	  		  		  		  		  		  		  		  		  		  		  		  		  		  		  		  		  		  	

 Central Region - Hospitals 
  

																																									
	 Minimum Provider Panel
Requirements
	 	 
	 	 	Total
Required
Hospitals	 	Crawford	 	Delaware	 	Fairfield	 	Fayette	 	Franklin	 	Hocking	 	Knox	 	Licking	 	Logan	 	Madison	 	Marion	 	Morrow	 	Perry	 	Pickaway	 	Pike	 	Ross	 	Scioto	 	Union	 	Additional
Required
Hospitals:
In-Region
	 General Hospital
	 	10	 		 		 	1	 	1	 		 		 		 	1	 		 		 	1	 		 		 	1	 		 	1	 	1	 		 	3
	 Hospital System1
	 	2	 		 		 		 		 	2	 		 		 		 		 		 		 		 		 		 		 		 		 		 	

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

 South West Region - Hospitals 
  

																					
	 Minimum Provider Panel
Requirements

	 	 	Total
Required
Hospitals	 	Adams	 	Brown	 	Butler	 	Clermont	 	Clinton	 	Hamilton	 	Highland	 	Warren	 	Additional
Required
Hospitals:
In-Region
	 General Hospital
	 	6	 		 	1	 	1	 		 	1	 	1	 	1	 		 	1
	 Hospital System1
	 	2	 		 		 		 		 		 	2	 		 		 	

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

 West Central Region - Hospitals 
  

																					
	 Minimum Provider Panel
Requirements

	 	  	Total
Required
Hospitals	  	Champaign	  	Clark	  	Darke	  	Greene	  	Miami	  	Montgomery	  	Preble	  	Shelby	  	Additional
Required
Hospitals:
In-Region
	 General Hospital
	  	5	  		  	1	  		  	1	  	1	  		  		  		  	2
	 Hospital System2
	  	1	  		  		  		  		  		  	1	  		  		  	

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

 North West Region - Hospitals 
  

																																									
	 Minimum Provider Panel
Requirements

	 	 	Total
Required
Hospitals	 	Allen	 	Auglaize	 	Defiance	 	Fulton	 	Hancock	 	Hardin	 	Henry	 	Lucas	 	Mercer	 	Ottawa	 	Paulding	 	Putnam	 	Sandusky	 	Seneca	 	Van Wert	 	Williams	 	Wood	 	Wyandot	 	 Additional
Required
Hospitals:
 In- Region

	 General Hospital
	 	7	 	1	 		 	1	 		 	1	 		 		 		 		 		 		 		 	1	 		 		 		 		 		 	3
	 Hospital System1
	 	1	 		 		 		 		 		 		 		 	1	 		 		 		 		 		 		 		 		 		 		 	

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

 Last Revised May 25, 2006 
 North East Region - PCP Capacity 
  

																					
	 Minimum PCP Capacity Requirements -
ABD

	 PCPs
	  	Total
Required	  	Ashtabula	  	Cuyahoga	  	Erie	  	Geauga	  	Huron	  	Lake	  	Lorain	  	Medina	  	Additional
Required:
In-Region *
	 Capacity
	  	14,196	  	799	  	10,587	  	283	  	117	  	228	  	541	  	1,372	  	269	  	
	 PCPs1
	  	31	  	4	  	16	  	2	  	1	  	1	  	2	  	4	  	1	  	
	 Number of Eligibles
	  	25,810	  	1453	  	19249	  	514	  	212	  	415	  	983	  	2495	  	489	  	

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

 Last Revised May 25,2006 
 North East Central Region - PCP Capacity 
  

											
	 Minimum PCP Capacity Requirements -
ABD

	 PCPs
	  	Total
Required	  	Columbiana	  	Mahoning	  	Trumbull	  	Additional
Required:
In- Region *
	 Capacity
	  	4,230	  	798	  	2,028	  	1,405	  	
	 PCPs1
	  	11	  	3	  	4	  	4	  	
	 Number of Eligibles
	  	7,691.00	  	1,450	  	3,687	  	2,554	  	

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

 Last Revised May 25, 2006 
 East Central Region - PCP Capacity 
  

																							
	 Minimum PCP Capacity Requirements -
ABD

	 PCPs
	  	Total
Required	  	Ashland	  	Carroll	  	Holmes	  	Portage	  	Richland	  	Stark	  	Summit	  	Tuscarawas	  	Wayne	  	Additional
Required:
In-Region *
	 Capacity
	  	7,415	  	152	  	134	  	83	  	479	  	710	  	1,870	  	3,051	  	458	  	480	  	
	 PCPs1
	  	21	  	1	  	1	  	1	  	2	  	3	  	4	  	5	  	2	  	2	  	
	 Number of Eligbles
	  	13,482	  	276	  	243	  	150	  	871	  	1,290	  	3,400	  	5,547	  	833	  	872	  	

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

 Last Revised May 25, 2006 
 South East Region - PCP Capacity 
  

							
	 Minimum PC8P Capacity Requirements -
ABD

	 County
	  	Capacity	  	PCPs1	  	Number of
Eligbles
	 Total Required
	  	7,434	  	30	  	13,516
	Athens	  	724	  	2	  	1,317
	Belmont	  	654	  	2	  	1,189
	Coshocton	  	234	  	1	  	426
	Gallia	  	457	  	2	  	830
	Guernsey	  	395	  	2	  	718
	Harrison	  	172	  	1	  	313
	Jackson	  	483	  	2	  	879
	Jefferson	  	795	  	3	  	1,445
	Lawrence	  	1,154	  	4	  	2,098
	Meigs	  	393	  	2	  	714
	Monroe	  	134	  	1	  	244
	Morgon	  	175	  	1	  	319
	Muskingum	  	889	  	3	  	1,617
	Noble	  	86	  	1	  	157
	Vinton	  	197	  	1	  	359
	Washington	  	490	  	2	  	891
	Additional Required: In-Region *	  		  		  	

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

 Last Revised May 25, 2006 
 Central Region - PCP Capacity 
  

							
	 Minimum PCP Capacity Requirements -
ABD

	 County
	  	Capacity	  	PCPs1	  	Number of
Eligibles
	 Total Required
	  	13,660	  	59	  	24,837
	Crawford	  	258	  	2	  	469
	Delaware	  	226	  	2	  	410
	Fairfield	  	528	  	3	  	960
	Fayette	  	207	  	2	  	377
	Franklin	  	6,592	  	17	  	11,985
	Hocking	  	237	  	2	  	431
	Knox	  	282	  	2	  	512
	Licking	  	682	  	4	  	1,240
	Logan	  	168	  	2	  	305
	Madison	  	149	  	1	  	270
	Marion	  	496	  	3	  	902
	Morrow	  	133	  	1	  	241
	Perry	  	334	  	3	  	608
	Pickaway	  	306	  	2	  	557
	Pike	  	524	  	3	  	952
	Ross	  	741	  	4	  	1,348
	Scioto	  	1,687	  	5	  	3,068
	Union	  	111	  	1	  	202
	Additional Required: In-Region	  		  		  	

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

 Last Revised May 25, 2006 
 West Central Region - PCP Capacity 
  

																					
	 Minimum PCP Capacity Requirements -
ABD

	 PCPs
	  	Total
Required	  	Champaign	  	Clark	  	Darke	  	Greene	  	Miami	  	Montgomery	  	Preble	  	Shelby	  	 Additional
Required:
 In-Region *

	 Capacity
	  	5,965	  	138	  	986	  	171	  	498	  	316	  	3,537	  	147	  	174	  	
	 PCPs1
	  	17	  	1	  	4	  	1	  	2	  	2	  	6	  	1	  	1	  	
	 Number of Eligibles
	  	10,846	  	250	  	1,793	  	311	  	905	  	574	  	6,430	  	267	  	316	  	

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

 Last Revised May 25, 2006 
 South West Region - PCP Capacity 
  

																					
	 Minimum PCP Capacity Requirements -
ABD

	 PCPs
	  	Total
Required	  	Adams	  	Brown	  	Butler	  	Clermont	  	Clinton	  	Hamilton	  	Highland	  	Warren	  	Additional
Required:
In-Region *
	 Capacity
	  	8,615	  	502	  	248	  	1,581	  	717	  	212	  	4,696	  	315	  	344	  	
	 PCPs1
	  	22	  	3	  	1	  	4	  	3	  	1	  	6	  	2	  	2	  	
	 Number of Eligibles
	  	15,663	  	912	  	451	  	2,875	  	1,303	  	386	  	8,539	  	572	  	625	  	

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

 Last Revised October 14, 2005 
 North West Region - PCP Capacity 
  

							
	 Minimum PCP Capacity Requirements -
ABD

	 County
	  	Capacity	  	PCPs1	  	Number of
Eligibles
	 Total Required
	  	6,748	  	33	  	12,269
	Allen	  	591	  	3	  	1,075
	Auglaize	  	105	  	1	  	190
	Defiance	  	150	  	1	  	272
	Fulton	  	93	  	1	  	169
	Hancock	  	212	  	2	  	385
	Hardin	  	182	  	2	  	330
	Henry	  	54	  	1	  	99
	Lucas	  	3,963	  	9	  	7,206
	Mercer	  	102	  	1	  	185
	Ottawa	  	103	  	1	  	188
	Paulding	  	90	  	1	  	163
	Putnam	  	72	  	1	  	130
	Sandusky	  	240	  	2	  	436
	Seneca	  	243	  	2	  	442
	Van Wert	  	111	  	1	  	202
	Williams	  	128	  	1	  	233
	Wood	  	253	  	2	  	460
	Wyandot	  	57	  	1	  	104
	Additional Required: In- Region *	  		  		  	

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

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

 Last Revised May 25, 2006 
 North East Region - Practitioners 
  

																					
	 ABD Provider Panel
Requirements

	 Provider Types
	  	Total
Required
Providers1	  	Ashtabula	  	Cuyahoga	  	Erie	  	Geauga	  	Huron	  	Lake	  	Lorain	  	Medina	  	Additional
Required
Providers2
	 Cardiovascular
	  	6	  		  	3	  		  		  		  		  	1	  		  	2
	 Dentists
	  	28	  	1	  	20	  		  		  		  	2	  	3	  	1	  	1
	 Gastroenterology
	  	3	  		  	2	  		  		  		  		  		  		  	1
	 General Surgeons
	  	11	  		  	6	  	1	  		  	1	  	1	  	1	  	1	  	
	 Nephrology
	  	2	  		  	1	  		  		  		  		  		  		  	1
	 Neurology
	  	3	  		  	2	  		  		  		  		  		  		  	1
	 OB/GYNs
	  	12	  		  	8	  	1	  		  		  		  	1	  		  	2
	 Oncology
	  	1	  		  		  		  		  		  		  		  		  	1
	 Orthopedists
	  	7	  		  	4	  		  		  		  		  	1	  		  	2
	 Otolaryngologist
	  	3	  		  	1	  		  		  		  		  	1	  		  	1
	 Physical Med Rehab
	  	3	  		  	2	  		  		  		  		  		  		  	1
	 Podiatry
	  	8	  		  	4	  		  		  		  		  	2	  		  	2
	 Psychiatry
	  	11	  		  	5	  		  		  		  		  	3	  		  	3
	 Urology
	  	4	  		  	2	  		  		  		  		  		  		  	2
	 Vision
	  	14	  	1	  	7	  	1	  		  		  	1	  	1	  		  	3

	 1
	 All required providers must be located within the region. 

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

 Last Revised May 25, 2006 
 North East Central - Practitioners 
  

											
	 ABD Provider Panel
Requirements

	 Provider Types
	  	Total
Required
Providers1	  	Columbiana	  	Mahoning	  	Trumbull	  	Additional
Required
Providers 2
	 Cardiovascular
	  	2	  		  	1	  		  	1
	 Dentists
	  	7	  	1	  	3	  	3	  	
	 Gastroenterology
	  	1	  		  		  		  	1
	 General Surgeons
	  	3	  	1	  	1	  	1	  	
	 Nephrology
	  	1	  		  		  		  	1
	 Neurology
	  	1	  		  		  		  	1
	 OB/GYNs
	  	4	  	1	  	1	  	1	  	1
	 Oncology
	  	1	  		  		  		  	1
	 Orthopedists
	  	2	  		  	1	  		  	1
	 Otolaryngologist
	  	1	  		  	1	  		  	
	 Physical Med Rehab
	  	1	  		  		  		  	1
	 Podiatry
	  	1	  		  		  		  	1
	 Psychiatry
	  	6	  		  	3	  	2	  	1
	 Urology
	  	1	  		  		  		  	1
	 Vision
	  	5	  		  	2	  	2	  	1

	 1
	 All required providers must be located within the region. 

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

 Last Revised May 25, 2006 
 East Central - Practitioners 
  

																							
	 ABD Provider Panel
Requirements

	 Provider Types
	  	Total
Required
Providers1	  	Ashland	  	Carroll	  	Holmes	  	Portage	  	Richland	  	Stark	  	Summit	  	Tuscarawas	  	Wayne	  	 Additional
Required
 Providers 2

	 Cardiovascular
	  	3	  		  		  		  		  		  	1	  	1	  		  		  	1
	 Dentists
	  	14	  	1	  		  		  		  	2	  	4	  	6	  	1	  		  	
	 Gastroenterology
	  	2	  		  		  		  		  		  		  		  		  		  	2
	 General Surgeons
	  	7	  		  		  		  		  	1	  	1	  	2	  		  	1	  	2
	 Nephrology
	  	1	  		  		  		  		  		  		  		  		  		  	1
	 Neurology
	  	2	  		  		  		  		  		  		  		  		  		  	2
	 OB/GYNs
	  	6	  		  		  		  		  		  	2	  	4	  		  		  	
	 Oncology
	  	1	  		  		  		  		  		  		  		  		  		  	1
	 Orthopedists
	  	4	  		  		  		  		  		  	1	  	1	  		  		  	2
	 Otolaryngologist
	  	2	  		  		  		  		  		  	1	  	1	  		  		  	
	 Physical Med Rehab
	  	2	  		  		  		  		  		  		  		  		  		  	2
	 Podiatry
	  	4	  		  		  		  		  		  	1	  	2	  		  		  	1
	 Psychiatry
	  	6	  		  		  		  		  		  	2	  	3	  		  		  	1
	 Urology
	  	2	  		  		  		  		  		  		  		  		  		  	2
	 Vision
	  	8	  		  		  		  		  	1	  	2	  	3	  		  		  	2

	 1
	 All required providers must be located within the region. 

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

 Last Revised May 25, 2006 
 South East - Practitioners 
  

																																					
	 ABD Provider Panel
Requirements

	 Provider Types
	  	Total
Required
Providers1	  	Athens	  	Belmont	  	Coshocton	  	Gallia	  	Guernsey	  	Harrison	  	Jackson	  	Jefferson	  	Lawrence	  	Meigs	  	Monroe	  	Morgon	  	Muskingum	  	Noble	  	Vinton	  	Washington	  	 Additional
 Required
 Providers 2

	 Cardiovascular
	  	3	  		  		  		  	1	  		  		  		  		  		  		  		  		  	1	  		  		  		  	1
	 Dentists
	  	8	  	1	  	1	  		  		  	1	  		  		  		  	1	  		  		  		  	1	  		  		  	1	  	2
	 Gastroenterology
	  	2	  		  		  		  		  		  		  		  		  		  		  		  		  		  		  		  		  	2
	 General Surgeons
	  	5	  		  	1	  		  	1	  	1	  		  		  	1	  		  		  		  		  	1	  		  		  		  	
	 Nephrology
	  	1	  		  		  		  		  		  		  		  		  		  		  		  		  		  		  		  		  	1
	 Neurology
	  	2	  		  		  		  		  		  		  		  		  		  		  		  		  		  		  		  		  	2
	 OB/GYNs
	  	6	  	1	  		  		  		  	1	  		  		  	1	  		  		  		  		  	1	  		  		  	1	  	1
	 Oncology
	  	1	  		  		  		  		  		  		  		  		  		  		  		  		  		  		  		  		  	1
	 Orthopedists
	  	4	  		  		  		  	1	  		  		  		  		  		  		  		  		  	1	  		  		  	1	  	1
	 Otolaryngologist
	  	2	  		  		  		  	1	  		  		  		  		  		  		  		  		  	1	  		  		  		  	
	 Physical Med Rehab
	  	2	  		  		  		  		  		  		  		  		  		  		  		  		  		  		  		  		  	2
	 Podiatry
	  	4	  		  	1	  		  		  		  		  		  		  		  		  		  		  	1	  		  		  		  	2
	 Psychiatry
	  	6	  	2	  	1	  		  		  		  		  		  		  		  		  		  		  	1	  		  		  		  	2
	 Urology
	  	2	  		  		  		  		  		  		  		  		  		  		  		  		  		  		  		  		  	2
	 Vision
	  	8	  	1	  	1	  		  	1	  	1	  		  	1	  		  	1	  		  		  		  	1	  		  		  	1	  	

	 1
	 All required providers must be located within the region. 

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

 Last Revised May 25, 2006 
 Central - Practitioners 
  

																																									
	 ABD Provider Panel
Requirements

	 Provider Types
	  	Total
Required
Providers1	  	Crawford	  	Delaware	  	Fairfield	  	Fayette	  	Franklin	  	Hocking	  	Knox	  	Licking	  	Logan	  	Madison	  	Marion	  	Morrow	  	Perry	  	Pickaway	  	Pike	  	Ross	  	Scioto	  	Union	  	 Additional
 Required
 Providers 2

	 Cardiovascular
	  	5	  		  		  		  		  	2	  		  		  		  		  		  		  		  		  		  		  		  		  		  	3
	 Dentists
	  	21	  		  	1	  	1	  		  	15	  		  	1	  	1	  		  		  	1	  		  		  		  		  	1	  		  		  	
	 Gastroenterology
	  	3	  		  		  		  		  	1	  		  		  		  		  		  		  		  		  		  		  		  		  		  	2
	 General Surgeons
	  	10	  		  	1	  	1	  		  	5	  		  		  		  		  		  		  		  		  		  		  	1	  	1	  		  	1
	 Nephrology
	  	2	  		  		  		  		  	1	  		  		  		  		  		  		  		  		  		  		  		  		  		  	1
	 Neurology
	  	3	  		  		  		  		  	1	  		  		  		  		  		  		  		  		  		  		  		  		  		  	2
	 OB/GYNs
	  	10	  		  	1	  	1	  		  	6	  		  		  		  		  		  		  		  		  		  		  		  		  		  	2
	 Oncology
	  	1	  		  		  		  		  		  		  		  		  		  		  		  		  		  		  		  		  		  		  	1
	 Orthopedists
	  	7	  		  		  	1	  		  	3	  		  		  	1	  		  		  	1	  		  		  		  		  	1	  		  		  	
	 Otolaryngologist
	  	3	  		  	1	  		  		  	2	  		  		  		  		  		  		  		  		  		  		  		  		  		  	
	 Physical Med Rehab
	  	3	  		  		  		  		  	1	  		  		  		  		  		  		  		  		  		  		  		  		  		  	2
	 Podiatry
	  	7	  		  	1	  		  		  	3	  		  		  		  		  		  		  		  		  		  		  		  		  		  	3
	 Psychiatry
	  	11	  		  	1	  	1	  		  	5	  		  		  		  		  		  		  		  		  		  		  		  		  		  	4
	 Urology
	  	4	  		  		  		  		  		  		  		  		  		  		  		  		  		  		  		  		  		  		  	
	 Vision
	  	14	  	1	  	1	  	1	  		  	5	  		  	1	  	1	  	1	  		  	1	  		  		  		  		  	1	  	1	  		  	

	 1
	 All required providers must be located within the region. 

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

 Last Revised May 25, 2006 
 South West - Practitioners 
  

																					
	 ABD Provider Panel
Requirements

	 Provider Types
	  	Total
Required
Providers1	  	Adams	  	Brown	  	Butler	  	Clermont	  	Clinton	  	Hamilton	  	Highland	  	Warren	  	 Additional
Required
 Providers2

	 Cardiovascular
	  	4	  		  		  		  		  		  	1	  		  	1	  	2
	 Dentists
	  	15	  		  		  	3	  	1	  		  	8	  	1	  	1	  	1
	 Gastroenterology
	  	2	  		  		  		  		  		  		  		  		  	2
	 General Surgeons
	  	9	  		  		  	1	  	1	  	1	  	3	  	2	  	1	  	
	 Nephrology
	  	1	  		  		  		  		  		  		  		  		  	1
	 Neurology
	  	2	  		  		  		  		  		  		  		  		  	2
	 OB/GYNs
	  	7	  		  	1	  	1	  		  		  	4	  		  	1	  	
	 Oncology
	  	1	  		  		  		  		  		  		  		  		  	1
	 Orthopedists
	  	5	  		  		  	1	  		  		  	2	  		  		  	2
	 Otolaryngologist
	  	2	  		  		  		  		  		  	1	  		  		  	1
	 Physical Med Rehab
	  	2	  		  		  		  		  		  		  		  		  	2
	 Podiatry
	  	5	  		  		  	1	  		  		  	2	  		  		  	2
	 Psychiatry
	  	7	  		  		  		  		  		  	3	  		  		  	4
	 Urology
	  	3	  		  		  		  		  		  		  		  		  	3
	 Vision
	  	8	  		  		  	1	  		  	1	  	3	  	1	  	1	  	1

	 1
	 All required providers must be located within the region. 

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

 Last Revised May 25, 2006 
 West Central - Practitioners 
  

																					
	 ABD Provider Panel
Requirements

	 Provider Types
	  	Total
Required
Providers1	  	Champaign	  	Clark	  	Darke	  	Greene	  	Miami	  	Montgomery	  	Preble	  	Shelby	  	 Additional
Required
 Providers 2

	 Cardiovascular
	  	3	  		  		  		  		  		  	1	  		  		  	2
	 Dentists
	  	5	  		  	1	  		  		  		  	3	  		  		  	1
	 Gastroenterology
	  	1	  		  		  		  		  		  		  		  		  	1
	 General Surgeons
	  	5	  		  	1	  		  	1	  		  	1	  		  		  	2
	 Nephrology
	  	1	  		  		  		  		  		  		  		  		  	1
	 Neurology
	  	2	  		  		  		  		  		  		  		  		  	2
	 OB/GYNs
	  	5	  		  	1	  		  	1	  		  	3	  		  		  	
	 Oncology
	  	1	  		  		  		  		  		  		  		  		  	1
	 Orthopedists
	  	3	  		  		  		  	1	  		  	1	  		  		  	1
	 Otolaryngologist
	  	2	  		  		  		  		  		  	1	  		  		  	1
	 Physical Med Rehab
	  	2	  		  		  		  		  		  		  		  		  	2
	 Podiatry
	  	4	  		  		  		  		  		  	2	  		  		  	2
	 Psychiatry
	  	5	  		  		  		  	1	  		  	2	  		  		  	2
	 Urology
	  	2	  		  		  		  		  		  		  		  		  	2
	 Vision
	  	7	  		  	1	  		  	1	  		  	3	  		  		  	2

	 1
	 All required providers must be located within the region. 

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

 Last Revised May 25, 2006 
 North West - Practitioners 
  

																																									
	 ABD Provider Panel
Requirements

	 Provider Types
	  	Total
Required
Providers1	  	Allen	  	Auglaize	  	Defiance	  	Fulton	  	Hancock	  	Hardin	  	Henry	  	Lucas	  	Mercer	  	Ottawa	  	Paulding	  	Putnam	  	Sandusky	  	Seneca	  	Van Wert	  	Williams	  	Wood	  	Wyandot	  	 Additional
 Required
 Providers 2

	 Cardiovascular
	  	3	  		  		  		  		  		  		  		  	1	  		  		  		  		  		  		  		  		  		  		  	2
	 Dentists
	  	11	  	1	  		  		  	1	  		  		  		  	6	  		  		  		  	1	  	1	  		  		  	1	  		  		  	
	 Gastroenterology
	  	2	  		  		  		  		  		  		  		  	1	  		  		  		  		  		  		  		  		  		  		  	1
	 General Surgeons
	  	5	  	1	  		  		  		  		  		  		  	2	  		  		  		  		  		  		  		  		  	1	  		  	1
	 Nephrology
	  	1	  		  		  		  		  		  		  		  		  		  		  		  		  		  		  		  		  		  		  	1
	 Neurology
	  	2	  		  		  		  		  		  		  		  	1	  		  		  		  		  		  		  		  		  		  		  	1
	 OB/GYNs
	  	6	  	1	  		  		  		  		  		  		  	2	  		  		  		  		  	1	  	1	  		  		  	1	  		  	
	 Oncology
	  	1	  		  		  		  		  		  		  		  		  		  		  		  		  		  		  		  		  		  		  	1
	 Orthopedists
	  	4	  	1	  		  		  		  	1	  		  		  	1	  		  		  		  		  		  		  		  		  	1	  		  	
	 Otolaryngologist
	  	2	  		  		  		  		  		  		  		  	1	  		  		  		  		  		  		  		  		  		  		  	1
	 Physical Med Rehab
	  	2	  		  		  		  		  		  		  		  	1	  		  		  		  		  		  		  		  		  		  		  	1
	 Podiatry
	  	4	  		  		  		  		  		  		  		  	2	  		  		  		  		  		  		  		  		  	1	  		  	1
	 Psychiatry
	  	6	  	1	  		  		  		  		  		  		  	3	  		  		  		  		  		  		  		  		  	1	  		  	1
	 Urology
	  	2	  		  		  		  		  		  		  		  	1	  		  		  		  		  		  		  		  		  		  		  	1
	 Vision
	  	7	  	1	  		  	1	  		  		  		  		  	2	  	1	  		  		  		  	1	  		  	1	  		  		  		  	

	 1
	 All required providers must be located within the region. 

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

 APPENDIX I 
 PROGRAM INTEGRITY 
 ABD ELIGIBLE POPULATION 
 MCPs must comply with all applicable program integrity requirements, including those specified in 42 CFR 455 and Subpart H. 
  

	1.	Fraud and Abuse Program: 

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

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

  

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

  

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

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

 Appendix I 
 Page 2

  

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

  

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

  

	 	c.	Reporting fraud and abuse: MCPs are required to promptly report all instances of provider fraud and abuse to ODJFS and member fraud to the CDJFS. The MCP, at a minimum, must
report the following information on cases where the MCP’s investigation has revealed that an incident of fraud and/or abuse has occurred: 

  

	 	i.	provider’s name and Medicaid provider number or provider reporting number (PRN); 

  

	 	ii.	source of complaint; 

  

	 	iii.	type of provider; 

  

	 	iv.	nature of complaint; 

  

	 	v.	approximate range of dollars involved, if applicable; vi. results of MCP’s investigation and actions taken; 

  

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

  

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

  

	2.	Data Certification: 

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

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

 

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

 Appendix I 
 Page 3 
  

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

  

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

  

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

  

	 	i.	The MCP’s Chief Executive Officer; 

  

	 	ii.	The MCP’s Chief Financial Officer, or 

  

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

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

	3.	Prohibited Affiliations: 

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

 APPENDIX J 
 FINANCIAL PERFORMANCE 
 ABD ELIGIBLE POPULATION 
  

	1.	SUBMISSION OF FINANCIAL STATEMENTS AND REPORTS 

 MCPs must submit the following financial reports to ODJFS: 
  

	 	a.	The National Association of Insurance Commissioners (NAIC) quarterly and annual Health Statements (hereafter referred to as the “Financial Statements”), as outlined in
Ohio Administrative Code (OAC) rule 5101:3-26-09(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.	Annual physician incentive plan disclosure statements and disclosure of and changes to the MCP’s physician incentive plans, as outlined in OAC rule 5101:3-26-09(B);

  

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

  

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

 Appendix J 
 Page 2 
  

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

  

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

  

	 	j.	In accordance with ORC Section 5111.76 and Appendix C, MCP 

 Responsibilities, MCPs must submit ODJFS-specified franchise fee reports in hard copy and electronic formats pursuant to ODJFS specifications. 
  

	2.	FINANCIAL PERFORMANCE MEASURES AND STANDARDS 

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

			
	 a.      Indicator:
	  	Net Worth as measured by Net Worth Per Member
		
	     Definition:
	  	Net Worth = Total Admitted Assets minus Total Liabilities divided by Total Members across all lines of business
		
	     Standard:
	  	For the financial report that covers calendar year 2007, a minimum net worth per member of $155.00, as determined from the annual Financial Statement submitted to ODI and the
ODJFS.
		
		  	The Net Worth Per Member (NWPM) standard is the Medicaid Managed Care Capitation amount paid to the MCP during the preceding calendar year, excluding the at-risk amount, expressed as a
per-member per-month figure, multiplied by the applicable proportion below:
		
		  	0.75 if the MCP had a total membership of 100,000 or more during that calendar year
		
		  	0.90 if the MCP had a total membership of less than 100,000 for that calendar year

 Appendix J 
 Page 3 
  

			
		  	If the MCP did not receive Medicaid Managed Care Capitation payments during the preceding calendar year, then the NWPM standard for the MCP is the average Medicaid Managed Care capitation amount
paid to Medicaid-contracting MCPs during the preceding calendar year, excluding the at-risk amount, multiplied by the applicable proportion above.
	 b.      Indicator:
	  	Administrative Expense Ratio
		
	     Definition:
	  	Administrative Expense Ratio = Administrative Expenses minus Franchise Fees divided by Total Revenue minus Franchise Fees
		
	     Standard:
	  	Administrative Expense Ratio not to exceed 15%, as determined from the annual Financial Statement submitted to ODI and ODJFS.
		
	 c.      Indicator:
	  	Overall Expense Ratio
		
	     Definition:
	  	Overall Expense Ratio = The sum of the Administrative Expense Ratio and the Medical Expense Ratio
		
		  	Administrative Expense Ratio = Administrative Expenses minus Franchise Fees divided by Total Revenue minus Franchise Fees
		
		  	Medical Expense Ratio = Medical Expenses minus Franchise Fees divided by Total Revenue minus Franchise Fees
		
	     Standard:
	  	Overall Expense Ratio not to exceed 100% as determined from the annual Financial Statement submitted to ODI and ODJFS.

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

 Appendix J 
 Page 4 
  

 Failure to submit complete quarterly and annual Financial Statements on a timely basis will be deemed
a failure to meet the standards and will be subject to the noncompliance penalties listed for indicators 2.a., 2.b., and 2.c., including the imposition of a new membership freeze. The new membership freeze will take effect at the first of the month
following the month in which the determination was made that the MCP was non-compliant for failing to submit financial reports timely. 
 In
addition, ODJFS will review two liquidity indicators if a plan demonstrates potential problems in meeting related administrative requirements or the standards listed above. The two standards, 2.d and 2.e, reflect ODJFS’ expected level of
performance. At this time, ODJFS has not established penalties for noncompliance with these standards; however, ODJFS will consider the MCP’s performance regarding the liquidity measures, in addition to indicators 2.a., 2.b., and 2.c., in
determining whether to impose a new membership freeze, as outlined above, or to not issue or renew a contract with an MCP. The source for each indicator will be the NAIC Quarterly and annual Financial Statements. 
 Long-term investments that can be liquidated without significant penalty within 24 hours, which a plan would like to include in Cash and Short-Term
Investments in the next two measurements, must be disclosed in footnotes on the NAIC Reports. Descriptions and amounts should be disclosed. Please note that “significant penalty” for this purpose is any penalty greater than 20%. Also,
enter the amortized cost of the investment, the market value of the investment, and the amount of the penalty. 
  

			
	d.      Indicator:	  	Days Cash on Hand 
		
	     Definition:
	  	Days Cash on Hand = Cash and Short-Term Investments divided by (Total Hospital and Medical Expenses plus Total Administrative Expenses) divided by 365.
		
	     Standard:
	  	Greater than 25 days as determined from the annual Financial Statement submitted to ODI and ODJFS.
		
	 e.      Indicator:
	  	Ratio of Cash to Claims Payable 
		
	     Definition:
	  	Ratio of Cash to Claims Payable = Cash and Short-Term Investments divided by claims Payable (reported and unreported).
		
	     Standard:
	  	Greater than 0.83 as determined from the annual Financial Statement submitted to ODI and ODJFS.
		  	

  

	3.	REINSURANCE REQUIREMENTS 

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

 Appendix J 
 Page 5 
  

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

 For transplant services, the reinsurance must cover, at a minimum, 50% of transplant related costs incurred by one member in one year, in
excess of $75,000.00. 
 An MCP may request a higher deductible amount and/or that the reinsurance cover less than 80% of inpatient costs in
excess of the deductible amount. If the MCP does not have more than 75,000 members in Ohio, but does have more than 75,000 members between Ohio and other states, ODJFS may consider alternate reinsurance arrangements. However, depending on the
corporate structures of the Medicaid MCP, other forms of security may be required in addition to reinsurance. These other security tools may include parental guarantees, letters of credit, or performance bonds. In determining whether or not the
request will be approved, the ODJFS may consider any or all of the following: 
  

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

  

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

  

	 	c.	the number of members covered by the MCP; 

  

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

  

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

  

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

 The MCP has been approved to have a reinsurance policy with a deductible amount of $150,000 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, 

 Appendix J 
 Page 6 
  

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

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

	4.	PROMPT PAY REQUIREMENTS 

 In accordance with 42 CFR
447.46, MCPs must pay 90% of all submitted clean claims within 30 days of the date of receipt and 99% of such claims within 90 days of the date of receipt, unless the MCP and its contracted provider(s) have established an alternative payment
schedule that is mutually agreed upon and described in their contract. The prompt pay requirement applies to the processing of both electronic and paper claims for contracting and non-contracting providers by the MCP and delegated claims processing
entities. 
 The date of receipt is the date the MCP receives the claim, as indicated by its date stamp on the claim. The date of payment is
the date of the check or date of electronic payment transmission. A claim means a bill from a provider for health care services that is assigned a unique identifier. A claim does not include an encounter form. 
 A “claim” can include any of the following: (1) a bill for services; (2) a line item of services; or (3) all services for one
recipient within a bill. A “clean claim” is a claim that can be processed without obtaining additional information from the provider of a service or from a third party. 
 Clean claims do not include payments made to a provider of service or a third party where the timing of payment is not directly related to submission of
a completed claim by the provider of service or third party (e.g., capitation). A clean claim also does not include a claim from a provider who is under investigation for fraud or abuse, or a claim under review for medical necessity. 
 Penalty for noncompliance: Noncompliance with prompt pay requirements will result in progressive penalties to be assessed on a quarterly basis, as
outlined in Appendix N of the Provider Agreement. 
  

	5.	PHYSICIAN INCENTIVE PLAN DISCLOSURE REQUIREMENTS 

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

 If the physician incentive plan places a physician or physician group at substantial financial risk [as
determined under paragraph (d) of 42 CFR 422.208] for services that the physician or physician group does not furnish itself, the MCP must assure that all physicians and physician groups at substantial financial risk have either aggregate or
per-patient stop-loss protection in accordance with paragraph (f) of 42 CFR 422.208, and conduct periodic surveys in accordance with paragraph (h) of 42 CFR 422.208. 
 In accordance with 42 CFR 417.479 and 42 CFR 422.210, MCPs must maintain copies of the following required documentation and submit to ODJFS annually, no
later than 30 days after the close of the state fiscal year and upon any modification of the MCP’s physician incentive plan: 
  

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

  

	 	b.	A description of information/data feedback to a physician/group on their: 

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

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

  

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

 Upon request by a member or a potential member and no later than 14 calendar days after the
request, the MCP must provide the following information to the member: (1) whether the MCP uses a physician incentive plan that affects the use of referral services; (2) the type of incentive arrangement; (3) whether stop-loss
protection is provided; and 

 Appendix J 
 Page 8 
  

 (4) a summary of the survey results if the MCP was required to conduct a survey. The information
provided by the MCP must adequately address the member’s request. 
  

	6.	NOTIFICATION OF REGULATORY ACTION 

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

 APPENDIX K 
 QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM 
 AND 
 EXTERNAL QUALITY REVIEW 
 ABD ELIGIBLE
POPULATION 
 1. As required by federal regulation, 42 CFR 438.240, each managed care plan (MCP) must have an ongoing Quality Assessment and Performance
Improvement Program (QAPI) that is annually prior-approved by the Ohio Department of Job and Family Services (ODJFS). The program must include the following elements: 
 a. PERFORMANCE IMPROVEMENT PROJECTS 
 Each MCP must conduct performance improvement projects (PIPs),
including those specified by ODJFS. PIPs must achieve, through periodic measurements and intervention, significant and sustained improvement in clinical and non-clinical areas which are expected to have a favorable effect on health outcomes and
satisfaction. MCPs must adhere to ODJFS PIP content and format specifications. 
 All ODJFS-specified PIPs must be prior-approved by ODJFS.
As part of the external quality review organization (EQRO) process, the EQRO will assist MCPs with conducting PIPs by providing technical assistance and will annually validate the PIPs. In addition, the MCP must annually submit to ODJFS the status
and results of each PIP. 
 ODJFS will identify the clinical and/or non-clinical study topics for the SFY 2008 Provider Agreement. Initiation
of the PIPs will begin in the second year of participation in the ABD Medicaid managed care program. 
 In addition, as noted in Appendix M,
if an MCP fails to meet the Minimum Performance Standard for selected Clinical Performance Measures, the MCP will be required to complete a PIP. 
 b. UNDER- AND OVER-UTILIZATION 
 Each MCP must have mechanisms in place to detect under- and over-utilization of health care
services. The MCP must specify the mechanisms used to monitor utilization in its annual submission of the QAPI program to ODJFS. 
 It should
also be noted that pursuant to the program integrity provisions outlined in Appendix I, MCPs must monitor for the potential under-utilization of services by their members in order to assure that all Medicaid-covered services are being provided, as
required. If any under-utilized services are identified, the MCP must immediately investigate and correct the problem(s) which resulted in such under-utilization of services. 

 Appendix K 
 Page 2

  

 In addition, beginning in SFY 2005, the MCP must conduct an ongoing review of service denials and
must monitor utilization on an ongoing basis in order to identify services which may be under-utilized. 
 c. SPECIAL HEALTH CARE
NEEDS 
 Each MCP must have mechanisms in place to assess the quality and appropriateness of care furnished to members with special
health care needs. The MCP must specify the mechanisms used in its annual submission of the 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 2008 Provider Agreement. 
 The measures must have received a
“report” designation from the HEDIS certified auditor and must be specific to the Medicaid population. Data must be submitted annually and in an electronic format. Data will be used for MCP clinical performance monitoring and will be
incorporated into comparative reports developed by the EQRO. 
 Initiation of submission of performance data will begin in the second year of
participation in the Medicaid managed care program. 
  

	2.	EXTERNAL QUALITY REVIEW 

 In addition to the following
requirements, MCPs must participate in external quality review activities as outlined in OAC 5101:3-26-07. 
 a. EQRO ADMINISTRATIVE
REVIEW AND NON-DUPLICATION OF MANDATORY ACTIVITIES 
 The EQRO will conduct administrative compliance assessments for each MCP every
three (3) years. The review will include, but not be limited to, the following domains as specified by ODJFS: member rights and services, QAPI program, access standards, provider network, grievance system, case management, coordination and
continuity of care, and utilization management. In accordance with 42 CFR 438.360 and 438.362, MCPs with accreditation from a national accrediting organization approved by the Centers for Medicare and Medicaid Services (CMS) may request a
non-duplication exemption from certain specified components of the administrative review. Non-duplication exemptions may not be requested for SFY 07. 

 b. ANNUAL REVIEW OF QAPI AND CASE MANAGEMENT PROGRAM 
 Each MCP must implement an evaluation process to review, revise, and/or update the QAPI program. The MCP must annually submit its QAPI program for review
and approval by ODJFS. 
 The annual QAPI and case management (refer to Appendix G) program submissions are subject to an administrative
review by the EQRO. If the EQRO identifies deficiencies during its review, the MCP must develop and implement Corrective Action Plan(s) that are prior approved by ODJFS. Serious deficiencies may result in immediate termination or non-renewal of the
provider agreement. 
 c. EXTERNAL QUALITY REVIEW PERFORMANCE 
 In accordance with OAC rule 5101:3-26-07, each MCP must participate in clinical or non-clinical focused quality of care studies as part of the annual
external quality review survey. If the EQRO cites a deficiency in clinical or non-clinical performance, the MCP will be required to complete a Corrective Action Plan (e.g., ODJFS technical assistance session), Quality Improvement Directives or
Performance Improvement Projects depending on the severity of the deficiency. (An example of a deficiency is if an MCP fails to meet certain clinical or administrative standards as supported by national evidence-based guidelines or best practices.)
Serious deficiencies may result in immediate termination or non-renewal of the provider agreement. These quality improvement measures recognize the importance of ongoing MCP performance improvement related to clinical care and service delivery.

 APPENDIX L 
 DATA QUALITY 
 ABD ELIGIBLE POPULATION 
 A high level of performance on the data quality measures established in this appendix is crucial in order for the Ohio Department of Job and Family Services (ODJFS) to
determine the value of the Aged, Blinded or Disabled (ABD) Medicaid Managed Health Care program and to evaluate Medicaid consumers’ access to and quality of services. Data collected from MCPs are used in key performance assessments such as the
external quality review, clinical performance measures, utilization review, care coordination and case management, and in determining incentives. The data will also be used in conjunction with the cost reports in setting the premium payment rates.
The following measures, as specified in this appendix, will be calculated per MCP and include all Ohio Medicaid members receiving services from the MCP (i.e., Covered Families and Children (CFC) and ABD membership, if applicable): Encounter Data
Omissions, Incomplete Outpatient Hospital Data,, Rejected Encounters, Acceptance Rate, Encounter Data Accuracy, and Generic Provider Number Usage. 
 Data
sets collected from MCPs with data quality standards include: encounter data; case management data; data used in the external quality review; members’ PCP data; and appeal and grievance data. 
 1. ENCOUNTER DATA 
 For detailed descriptions of the encounter data
quality measures below, see ODJFS Methods for the ABD and CFC Medicaid Managed Care Programs Data Quality Measures. 
 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 (i.e., to include all counties with
ABD memberships served by the MCP). 
 Report Period: The report periods for the SFY 2007 and SFY 2008 contract periods are listed in the table below.

 Appendix L 
 Page 2

  

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

							
	Report Period	 	 Data Source:
 Estimated Encounter
 Data File
Update
	 	 Quarterly Report
 Estimated Issue Date
	 	Contract Period
	Qtr 1 2007	 	July 2007	 	August 2007	 	SFY 2007
	Qtr 1, Qtr 2 2007	 	October 2007	 	November 2007	 
				
	Qtr 1 thru Qtr 3 2007	 	January 2008	 	February 2008	 	
				
	Qtr 1 thru Qtr 4 2007	 	April 2007	 	May 2007	 	SFY 2008
	Qtr 1 thru Qtr 4 2007, Qtr 1 2008	 	July 2008	 	August 2008	 
				
	Qtr 1 thru Qtr 4 2007, Qtr 1, Qtr 2 2008	 	October 2008	 	November 2008	 	

  

							
	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 (see below, Table 2 – Encounter Data Volume Standards). 
 Statewide Approach: Prior
to establishment of statewide minimum performance standards, ODJFS will evaluate MCP performance using the interim standards for Encounter data volume. ODJFS will use the first four quarters of data (i.e., full calendar year quarters) from all MCPs
serving ABD program membership to determine statewide minimum encounter volume data quality standards. 

 Appendix L 
 Page 3 
  

 Table 2. Interim Standards – Encounter Data Volume 
  

							
	Category	  	Measure per
1,000/MM	  	Standard for
Dates of
Service
on or after
1/1/2007	  	Description
	Inpatient Hospital	  	Discharges	  	2.7	  	General/acute care,
excluding newborns and
mental health and
chemical dependency
services
				
	Emergency Department	  		  	25.3	  	Includes physician and
hospital emergency
department encounters
	Dental	  	  	25.5	  	Non-institutional and
hospital dental visits
				
	Vision	  	Visits	  	5.3	  	Non-institutional and
hospital outpatient
optometry and
ophthalmology visits
				
	Primary and Specialist Care	  		  	116.6	  	Physician/practitioner and
hospital outpatient visits
	Ancillary Services	  	  	66.8	  	Ancillary visits
				
	Behavioral Health	  	Service	  	5.2	  	Inpatient and outpatient
behavioral encounters
				
	Pharmacy	  	Prescriptions	  	246.1	  	Prescribed drugs

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

 Appendix L 
 Page 4

  

 1.a.ii. Encounter Data Omissions 
 Omission studies will evaluate the completeness of the encounter data. 
 Measure: This study will compare the medical
records of members during the time of membership to the encounters submitted. Omission rates will be calculated per MCP (i.e., to include all counties serviced by the MCP). 
 The encounters documented in the medical record that do not appear in the encounter data will be counted as omissions. 
 Report Period: In order to provide timely feedback on the omission rate of encounters, the report period will be the most recent from when the measure is initiated. This measure is conducted annually. 
 Medical records retrieval from the provider and submittal to ODJFS or its designee is an integral component of the omission measure. ODJFS has optimized the sampling to
minimize the number of records required. This methodology requires a high record submittal rate. To aid MCPs in achieving a high submittal rate, ODJFS will give at least an 8 week period to retrieve and submit medical records as a part of the
validation process. A record submittal rate will be calculated as a percentage of all records requested for the study. 
 Data Quality Standard: The
data quality standard is a maximum omission rate of 15% for studies with time periods ending in CY 2008. 
 Penalty for Noncompliance: The first time
an MCP is noncompliant with a standard for this measure, ODJFS will issue a Sanction Advisory informing the MCP that any future noncompliance instances with the standard for this measure will result in ODJFS imposing a monetary sanction. 

Upon all subsequent measurements of performance, if an MCP is again determined to be noncompliant with the standard, ODJFS will impose a monetary sanction (see
Section 6) of one percent of the current month’s premium payment. Once the MCP is performing at standard levels and violations/deficiencies are resolved to the satisfaction of ODJFS, the money will be refunded. 
 1.a.iii. Incomplete Outpatient Hospital Data 
 ODJFS will be
monitoring, on a quarterly basis, the percentage of hospital encounters which contain a revenue code and CPT/HCPCS code. A CPT/HCPCS code must accompany certain revenue center codes. These codes are listed in Appendix B of Ohio Administrative Code
rule 5101:3-2-21 (fee-for-service outpatient hospital policies) and in the methods for calculating the completeness measures. 
 Measure: The
percentage of outpatient hospital line items with certain revenue center codes, as explained above, which had an accompanying valid procedure (CPT/HCPCS) code. The measure will be calculated per MCP (i.e., to include all counties serviced by the
MCP). 

 Appendix L 
 Page 5 
  

 Report Period: For the SFY 2007 contract period, perf ormance will be evaluated using the following report
periods: January – March 2007; April – June 2007. For the SFY 2008 contract period, performance will be evaluated using the following report periods: January - March 2007; April – June 2007; July-September 2007; October
– December 2007; January – March 2008; April – June 2008. 
 Data Quality Standard: The data quality standard is a minimum
rate of 95%. 
 Determination of Compliance: Performance is monitored once every quarter. If the standard is not met in all report periods, then the
MCP will be determined to be noncompliant. 
 Penalty for noncompliance: The first time an MCP is noncompliant with a standard for this measure, ODJFS
will issue a Sanction Advisory informing the MCP that any future noncompliance instances with the standard for this measure will result in ODJFS imposing a monetary sanction. 
 Upon all subsequent quarterly measurements of performance, if an MCP is again determined to be noncompliant with the standard, ODJFS will impose a monetary sanction (see Section 6) of one percent of the current
month’s premium payment. Once the MCP is performing at standard levels and violations/deficiencies are resolved to the satisfaction of ODJFS, the money will be refunded. 
 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 (i.e., to include all counties serviced by the MCP). 
 Report Period:
For the SFY 2007 contract period, performance will be evaluated using the following report periods: January – March 2007; April – June 2007. For the SFY 2008 contract period, performance will be evaluated using the following report
periods July – September 2007; October – December 2007; January – March 2008; April – June 2008. 
 Data Quality Standard 1:
Data Quality Standard 1 is a maximum encounter data rejection rate of 10% for each file in the ODJFS-specified medium per format. The measure will be calculated per MCP (i.e., to include all counties serviced by the MCP). 
 Determination of Compliance: Performance is monitored once every quarter. Compliance determination with the standard applies only to the quarter under
consideration and does not include performance in previous quarters. 

 Appendix L 
 Page 6 
  

 Penalty for noncompliance with Data Quality Standard 1: The first time an MCP is noncompliant with a standard
for this measure, ODJFS will issue a Sanction Advisory informing the MCP that any future noncompliance instances with the standard for this measure will result in ODJFS imposing a monetary sanction. Upon all subsequent measurements of performance,
if an MCP is again determined to be noncompliant with the standard, ODJFS will impose a monetary sanction (see Section 6.) of one percent of the current month’s premium payment. The monetary sanction will be applied for each file in the
ODJFS-specified medium per format that is determined to be out of compliance. 
 Once the MCP is performing at standard levels and violations/deficiencies
are resolved to the satisfaction of ODJFS, the money will be refunded. 
 Measure 2 only applies to MCPs that have had Medicaid membership for one year or
less. 
 Measure 2: The percentage of encounters submitted to ODJFS that are rejected. The measure will be calculated per MCP (i.e., to include
all counties serviced by the MCP). 
 Report Period: The report period for Measure 2 is monthly. Results are calculated and performance is monitored
monthly. The first reporting month begins with the third month of enrollment. 
 Data Quality Standard 2: The data quality standard is a maximum
encounter data rejection rate for each file in the ODJFS-specified medium per format as follows: 
 Third through sixth months with
membership: 50% 
 Seventh through twelfth month with membership: 25% 
 Files in the ODJFS-specified medium per format that are totally rejected will not be considered in the determination of noncompliance. 
 Determination of Compliance: Performance is monitored once every month. Compliance determination with the standard applies only to the month under consideration and does not include performance in previous
quarters. 
 Penalty for Noncompliance with Data Quality Standard 2: If the MCP is determined to be noncompliant for either standard, ODJFS will
impose a monetary sanction of one percent of the MCP’s current month’s premium payment. The monetary sanction will be applied only once per measure per compliance determination period and will not exceed a total of two percent of the
MCP’s current month’s premium payment. Once the MCP is performing at standard levels and violations/deficiencies are resolved to the satisfaction of ODJFS, the money will be refunded. Special consideration will be made for MCPs with less
than 1,000 members. 

 Appendix L 
 Page 7 
  

 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 ODJFS and accepted (i.e. accepted encounters per 1,000 member months). The measure will be calculated per MCP (i.e., to include all counties serviced by the MCP). 
 Report Period: The report period for this measure is monthly. Results are calculated and performance is monitored monthly. The first reporting month begins with the third month of enrollment. 
 Data Quality Standard: The data quality standard is a monthly minimum accepted rate of encounters for each file in the ODJFS-specified medium per format as
follows: 
  

			
	Third through sixth month with membership:	  	 
		  	50 encounters per 1,000 MM for NCPDP
		  	65 encounters per 1,000 MM 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 only once per measure per compliance determination
period and will not exceed a total of two percent of the MCP’s current month’s premium payment. Once the MCP is performing at standard levels and violations/deficiencies are resolved to the satisfaction of ODJFS, the money will be
refunded. 

 Appendix L 
 Page 8 
  

 1.a.vi. Informational Encounter Data Completeness Measures 
 The encounter data quality measures listed below (section 1.a.vi. (1) –(2)) are informational only for the ABD population. Although there are no minimum
performance standards for these measures, results will be reported and used as one component in monitoring the quality of data submitted to ODJFS by the MCPs. 
 (1) Incomplete Data For Last Menstrual Period 
 (2) Incomplete Birth Weight Data 
 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 (i.e., to include all counties
serviced by the MCP). 
 Payment information found in MCPs’ claims systems for paid claims that does not match payment information found on a
corresponding encounter will be counted as omissions. 
 Report Period: In order to provide timely feedback on the omission rate of encounters, the
report period will be the most recent from when the measure is initiated. This measure is conducted annually. 
 Data Quality Standard for Measure:
TBD for SFY 2008. 
 Penalty for Noncompliance: The first time an MCP is noncompliant with a standard for this measure, ODJFS will issue a
Sanction Advisory informing the MCP that any future noncompliance instances with the standard for this measure will result in ODJFS imposing a monetary sanction. 
 Upon all subsequent measurements of performance, if an MCP is again determined to be noncompliant with the standard, ODJFS will impose a monetary sanction (see Section 6) of one percent of the current month’s premium payment. Once
the MCP is performing at standard levels and violations/deficiencies are resolved to the satisfaction of ODJFS, the money will be refunded. 
 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 (i.e., to include all counties serviced by the MCP). 

 Appendix L 
 Page 9 
  

 All other encounters are required to have the MMIS provider number of the servicing provider. The report period for
this measure is quarterly. 
 Report Period: For the SFY 2007 contract period, performance will be evaluated using the following report periods:
January – March 2007; April – June 2007. For the SFY 2008 contract period, performance will be evaluated using the following report periods: January – March 2007; April – June 2007; July-September 2007; October
– December 2007; January – March 2008; April – June 2008. 
 Data Quality Standard: A maximum generic provider usage rate of
10%. 
 Determination of Compliance: Performance is monitored once every quarter. If the standard is not met in all report periods, then the MCP will
be determined to be noncompliant. 
 Penalty for noncompliance: The first time an MCP is noncompliant with a standard for this measure, ODJFS will
issue a Sanction Advisory informing the MCP that any future noncompliance instances with the standard for this measure will result in ODJFS imposing a monetary sanction. Upon all subsequent measurements of performance, if an MCP is again determined
to be noncompliant with the standard, ODJFS will impose a monetary sanction (see Section 6.) of three percent of the current month’s premium payment. Once the MCP is performing at standard levels and violations/deficiencies are resolved to
the satisfaction of ODJFS, the money will be refunded. 
 1.c. Timely Submission of Encounter Data 
 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 

 MCP submissions of encounter data files in the ODJFS-specified medium per format to ODJFS are limited to two per format per month. Should an MCP wish
to send additional files in the ODJFS-specified medium per format, permission to do so must be obtained by contacting BMHC. Information concerning the proper submission of encounter data may be obtained from the ODJFS Encounter Data File and
Submission Specifications document. The MCP must submit a letter of certification, using the form required by ODJFS, with each encounter data file in the ODJFS-specified medium per format. 

 Appendix L 
 Page 10

  

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

 ODJFS designed a case management system (CAMS) in order to monitor MCP compliance with program requirements specified in Appendix G, Coverage and
Services. Each MCP’s case management data submissions will be assessed for completeness and accuracy. The MCP is responsible for submitting a case management file every month. Failure to do so jeopardizes the MCP’s ability to
demonstrate compliance with case management requirements. For detailed descriptions of the case management measures below, see ODJFS Methods for 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 
 Measure: The percentage of the MCP’s case management records in CAMS for the ABD program that have
open case management date spans for members who have disenrolled from the MCP. 
 Report Period: January – March 2007, and April – June 2007
report periods. For the SFY 2008 contract period, July – September 2007, October – December 2007, January – March 2008, and April – June 2008 report periods. 
 Data Quality Standard: A rate of open case management spans for disenrolled members of no more than 1.0%. 
 Statewide Approach: MCPs will be evaluated using a statewide result specific for the ABD program, including all regions in which an MCP has ABD membership. An MCP
will not be evaluated until the MCP has at least 3,000 ABD members statewide who have had at least three months of continuous enrollment during each month of the entire report period. As the ABD Medicaid managed care program expands statewide and
regions become active in different months, statewide results will include every region in which an MCP has membership [Example: MCP AAA has: 6,000 members in the South West region beginning in January 2007; 7,000 members in the West Central region
beginning in February 2007; and 8,000 members in the South East region beginning in March 2007. MCP AAA’s statewide results for the April-June 2007 report period will include data for the South West, West Central, and South East regions.]

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

 Appendix L 
 Page 11

  

 Once the MCP is performing at standard levels and violations/deficiencies are resolved to the satisfaction 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 the clinical studies, quality must be sufficient to ensure valid sampling. 
 An adequate number of medical
records must then be retrieved from providers and submitted to ODJFS or its designee in order to generalize results to all applicable members. To aid MCPs in achieving the required medical record submittal rate, ODJFS will give at least an eight
week period to retrieve and submit medical records. 
 If an MCP does not complete a study because either their encounter data is of insufficient quality or
too few medical records are submitted, accurate evaluation of clinical quality in the study area cannot be determined for the individual MCP and the assurance of adequate clinical quality for the program as a whole is jeopardized. 
 3.a. Independent External Quality Review 
 Measure: The
independent external quality review covers both administrative and clinical focus areas of study. 
 Report Period: The report period is one year.
Results are calculated and performance is monitored annually. Performance is measured with each review. 
 Data Quality Standard 1: Sufficient
encounter data quality in each study area to draw a sample as determined by the external quality review organization 

 Appendix L 
 Page 12 
  

 Penalty for noncompliance with Data Quality Standard 1: For each study that is completed during this contract
period, if an MCP is noncompliant with the standard, ODJFS will impose a non-refundable $10,000 monetary sanction. 
 Data Quality Standard 2: A
minimum record submittal rate of 85% for each clinical measure. 
 Penalty for noncompliance for Data Quality Standard 2: For each study that is
completed during this contract period, if an MCP is noncompliant with the standard, ODJFS will impose a non-refundable $10,000 monetary sanction. 
 4.
MEMBERS’ PCP DATA 
 The designated PCP is the physician who will manage and coordinate the overall care for ABD members including those who have
case management needs. The MCP must submit a Members’ Designated PCP file every month. Specialists may and should be identified as the PCP as appropriate for the member’s condition; however, no ABD member may have more than one PCP
identified. 
 4.a. Timely submission of Member’s PCP Data 
 Data Quality Submission Requirement: The MCP must submit a Members’ Designated PCP Data files on a monthly basis according to the specifications established in ODJFS Member’s PCP Data File and Submission
Specifications. 
 Penalty for noncompliance: See Appendix N, Compliance Assessment System, for the penalty for noncompliance with this
requirement. 
 4.b. Designated PCP for newly enrolled members 
 Measure: The percentage of MCP’s newly enrolled members who were designated a PCP by their effective date of enrollment. 
 Report
Periods: For the SFY 2007 contract period, performance will be evaluated quarterly using the January – March 2007 and April – June 2007 report periods. For the SFY 2008 contract period, performance will be evaluated quarterly using the
July-September 2007, October – December 2007, January – March 2008 and April – June 2008 report periods. 
 Data Quality
Standard: A minimum rate of 65% of new members with PCP designation by their effective date of enrollment for quarter 3 and quarter 4 of SFY 2007. A minimum rate of 75% of new members with PCP designation by their effective date of enrollment
for quarter 1 and quarter 2 of SFY 2008. A minimum rate of 85% of new members with PCP designation by their effective date of enrollment for quarter 3 and quarter 4 of SFY 2008. 
 Statewide Approach: MCPs will be evaluated using a statewide result, including all regions in which an MCP has ABD membership. An MCP will not be evaluated until the MCP has at least 3,000 ABD members statewide
who have had at least three months of continuous enrollment during each month of the entire report period. 

 Appendix L 
 Page 13 
  

 Penalty for noncompliance: If an MCP is noncompliant with the standard, ODJFS will impose a monetary sanction
of one-half of one percent the current month’s premium payment. Once the MCP is performing at standard levels and violations/deficiencies are resolved to the satisfaction of ODJFS, the money will be refunded. As stipulated in OAC rule
5101:3-26-08.2, each new member must have a designated primary care physician (PCP) prior to their effective date of coverage. Therefore, MCPs are subject to additional corrective action measures under Appendix N, Compliance Assessment System, for
failure to meet this requirement. 
 5. APPEALS AND GRIEVANCES DATA 
 Pursuant to OAC rule 5101:3-26-08.4, MCPs are required to submit information at least monthly to ODJFS regarding appeal and grievance activity. ODJFS requires these submissions to be in an electronic data file format
pursuant to the Appeal File and Submission Specifications and Grievance File and Submission Specifications. 
 The appeal data file and the
grievance data file must include all appeal and grievance activity, respectively, for the previous month, and must be submitted by the ODJFS-specified due date. These data files must be submitted in the ODJFS-specified format and with the
ODJFS-specified filename in order to be successfully processed. 
 Penalty for noncompliance: MCPs who fail to submit their monthly electronic data
files to the ODJFS by the specified due date or who fail to resubmit, by no later than the end of that month, a file which meets the data quality requirements will be subject to penalty as stipulated under the Compliance Assessment System (Appendix
N). 
 6. NOTES 
  

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

 Penalties for noncompliance with standards outlined in this appendix, including monetary sanctions, will be imposed as the results are finalized. With the exception of Sections 1.a.i., 1.a.v., and 1.a.v.i., 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. 

 Appendix L 
 Page 14

  

 Any monies collected through the imposition of such a sanction will be returned to the MCP (minus any applicable
collection fees owed to the Attorney General’s Office, if the MCP has been delinquent in submitting payment) after the MCP has demonstrated full compliance with the particular program requirement and the violations/deficiencies are resolved to
the satisfaction of ODJFS. If an MCP does not comply within two years of the date of notification 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 review covers both an administrative review and focused quality of care studies as outlined in Appendix K. 
 Report Period: Performance will be evaluated using the reviews conducted during SFY 2008. 
 Action Required for Deficiencies: For all reviews
conducted during the contract period, if the EQRO cites a deficiency in the administrative review or quality of care studies, the MCP will be required to complete a Corrective Action Plan, Quality Improvement Directive, or Performance Improvement
Project as outlined in Appendix K of the Agreement. Serious deficiencies may result in immediate termination or non-renewal of the Agreement. 
  

	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 

 Appendix M 
 Page 2 
  

 
these measures is to provide appropriate and targeted case management services to MSHCN who have specific diagnoses and/or who require high-cost or extensive
services. Given the expedited schedule for implementing the ABD Medicaid managed care program, coupled with the challenges facing a new Medicaid program in the State of Ohio, the minimum performance standards for the case management requirements for
MSHCN are phased in throughout SFY 2007 and SFY 2008. The minimum standards for these performance measures will be fully phased in by no later than 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.ii.	Case Management of Members 

 Measure: The average monthly
case management rate for members who have at least three months of consecutive enrollment in one MCP. 
 Report Period: For the SFY 2007 contract
period, April – June 2007 report period. For the SFY 2008 contract period, July – September 2007, October – December 2007, January – March 2008, and April – June 2008 report periods. 
 Statewide Approach: MCPs will be evaluated using a statewide result, including all regions in which an MCP has membership. An MCP will not be evaluated until the
MCP has at least 3,000 members statewide who have had at least three months of continuous enrollment during each month of the entire report period. As the ABD Medicaid managed care program expands statewide and regions become active in different
months, statewide results will include every region in which an MCP has membership [Example: MCP AAA has: 6,000 members in the South West region beginning in January 2007; 7,000 members in the West Central region beginning in February 2007; and
8,000 members in the South East region beginning in March 2007. MCP AAA’s statewide results for the April – June 2007 report period will include case management rates for all members who meet minimum continuous enrollment criteria for this
measure in: the South West region for April 2007’s monthly rate calculation; the South West and West Central regions for May 2007’s monthly rate calculation; and the South West, West Central, and South East regions for June 2007’s
monthly rate calculation.] 
 Minimum Performance Standard: For the fourth quarters of SFY 2007, a case management rate of 30%. For the first and
second quarters of SFY 2008, a case management rate of 35%. For the third and fourth quarters of SFY 2008, a case management rate of 40%. ODJFS expects the minimum standard for this measure to increase to 50% by the fourth quarter of SFY 2009.

 Penalty for Noncompliance: The first time an MCP is noncompliant with the standard for this measure, ODJFS will issue a Sanction Advisory informing
the MCP that any future noncompliance instances with the standard for this measure will result in new member selection freezes or a reduction of assignments will occur as outlined in Appendix N of the Provider Agreement. Once the MCP is performing
at standard levels and the violations/deficiencies are resolved to the satisfaction of ODJFS, the new member selection freeze/reduction of assignments will be lifted. 

 Appendix M 
 Page 3 
  

	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 severe mental illness who have had at least three consecutive months of enrollment in one MCP
that are case managed. 
 Measure 5: The percent of members with a positive identification through an ODJFS administrative review of data for the
ODJFS-mandated case management condition of high risk or high cost substance abuse disorders who have had at least three consecutive months of enrollment in one MCP that are case managed. 
 Measure 6: The percent of members with a positive identification through an ODJFS administrative review of data for the ODJFS-mandated case management condition
of severe cognitive and/or developmental limitation who have had at least three consecutive months of enrollment in one MCP that are case managed. 
 Measure 7: The percent of members with a positive identification through an ODJFS administrative review of data for the ODJFS-mandated case management condition of diabetes who have had at least three consecutive months of
enrollment in one MCP that are case managed. 
 Measure 8: The percent of members with a positive identification through an ODJFS administrative
review of data for the ODJFS-mandated case management condition of non-mild hypertension who have had at least three consecutive months of enrollment in one MCP that are case managed. 
 Measure 9: The percent of members with a positive identification through an ODJFS administrative review of data for the ODJFS-mandated case management condition
of coronary arterial disease who have had at least three consecutive months of enrollment in one MCP that are case managed. 
 Report Periods for
Measures 1-9: For the SFY 2007 contract period April – June 2007 report periods. For the SFY 2008 contract period, July – September 2007, October – December 2007, January – March 2008, and April – June 2008
report periods. 

 Appendix M 
 Page 4

  

 Statewide Approach: MCPs will be evaluated using a statewide result, including all regions in which an MCP has
membership. An MCP will not be evaluated until the MCP has at least 3,000 members statewide who have had at least three months of continuous enrollment during each month of the entire report period. As the ABD Medicaid managed care programs expands
statewide and regions become active in different months, statewide results will include every region in which an MCP has membership [Example: MCP AAA has: 6,000 members in the South West region beginning in January 2007; 7,000 members in the West
Central region beginning in February 2007; and 8,000 members in the South East region beginning in March 2007. MCP AAA’s statewide results for the April-June 2007 report period will include case management rates for all members in the South
West, West Central, and South East regions who are identified through the administrative data review as having a mandated condition and are continuously enrolled for at least three consecutive months in one MCP.] 
 Minimum Performance Standard for Measures 1-9: For the fourth quarter of SFY 2007, a case management rate of 60%. For the first and second quarters of SFY 2008, a
case management rate of 65%. For the third and fourth quarters of SFY 2008, a case management rate of 70%. ODJFS expects the minimum standard for this measure to increase to 80% by the fourth quarter of SFY 2009. 
 Penalty for Noncompliance for Measures 1-9: The first time an MCP is noncompliant with the standard for this measure, ODJFS will issue a Sanction Advisory
informing the MCP that any future noncompliance instances with the standard for this measure will result in new member selection freezes or a reduction of assignments will occur as outlined in Appendix N of the Provider Agreement. Once the MCP is
performing at standard levels and the violations/deficiencies are resolved to the satisfaction of ODJFS the new member selection freeze/reduction of assignments will be lifted. 
  

	1.c.	Clinical Performance Measures 

 MCP performance will be assessed
based on the analysis of submitted encounter data for each year. For certain measures, standards are established; the identification of these standards is not intended to limit the assessment of other indicators for performance improvement
activities. Performance on multiple measures will be assessed and reported to the MCPs and others, including Medicaid consumers. 
 The clinical performance
measures described below closely follow the National Committee for Quality Assurance’s (NCQA) Health Plan Employer Data and Information Set (HEDIS). NCQA may annually change its method for calculating a measure. These changes can make it
difficult to evaluate whether improvement occurred from a prior year. For this reason, ODJFS will use the same methods to calculate the baseline results and the results for the period in which the MCP is being held accountable. For example, the same
methods are used to calculate calendar year 2008 results (the baseline period) and calendar year 2009 results. The methods will be updated and a new baseline will be created during 2009 for calendar year 2010 results. These results will then serve
as the baseline to evaluate whether improvement occurred from calendar year 2009 to calendar year 2010. Clinical performance measure results will be calculated after a sufficient amount of time has passed after the end of the report period in order
to allow for claims runout. For a 

 AppendixM 
 Page 5

  

 
comprehensive description of the clinical performance measures below, see ODJFS Methods for Clinical Performance Measures, ABD Medicaid Managed
Care Program. Performance standards are subject to change, based on the revision or update of NCQA methods or other national standards, methods or benchmarks. 
 MCPs will be evaluated using a statewide result, including all regions in which an MCP has membership. ODJFS will use the first calendar year of an MCP’s ABD managed care program membership as the baseline year (i.e., CY2007). The
baseline year will be used to determine performance standards and targets; baseline data will come from a combination of FFS claims data and MCP encounter data. For those performance measures that require two calendar years of baseline data, the
additional calendar year (i.e., the calendar year prior to the first calendar year of ABD managed care program membership, i.e., CY2006) data will come from FFS claims data. 
 An MCP’s second calendar year of ABD managed care program membership (i.e., CY2008) will be the initial report period of evaluation for performance measures that require one calendar year of baseline data (i.e.,
CY2007), and for performance measures that require two calendar years of baseline data (i.e., CY2006 and CY2007). 
 Report Period: For the SFY 2008
contract period, performance will be evaluated using the January – December 2007 report period and may be adjusted based on the number of months of ABD managed care membership. For the SFY 2009 contract period, performance will be evaluated
using the January – December 2008 report period. 
  

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

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

 Target: TBD 
 Minimum Performance Standard: The
level of improvement must result in at least a TBD% decrease in the difference between the target and the previous report period’s results. (For example, if last year’s results were TBD%, then the difference between the target and last
year’s results is TBD%. In this example, the standard is an improvement in performance of TBD% of this difference or TBD%. In this example, results of TBD% or better would be compliant with the standard.) 
 Action Required for Noncompliance: If the standard is not met and the results are below TBD%, then the MCP is required to complete a Performance Improvement
Project, as described in Appendix K, Quality Assessment and Performance Improvement Program, to address the area of noncompliance. If the standard is not met and the results are at or above TBD%, then ODJFS will issue a Quality Improvement
Directive which will notify the MCP of noncompliance and may outline the steps that the MCP must take to improve the results. 

 AppendixM 
 Page 6

  

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

 Measure: The number of emergency department visits in the reporting year where the primary diagnosis was CHF, per thousand member months, for members who had a diagnosis of CHF in the year prior to the
reporting year. 
 Target: TBD 
 Minimum Performance
Standard: The level of improvement must result in at least a TBD% decrease in the difference between the target and the previous report period’s results. 
 Action Required for Noncompliance: If the standard is not met and the results are below TBD%, then the MCP is required to complete a Performance Improvement Project, as described in Appendix K, Quality Assessment and Performance
Improvement Program, to address the area of noncompliance. If the standard is not met and the results are at or above TBD%, then ODJFS will issue a Quality Improvement Directive which will notify the MCP of noncompliance and may outline the
steps that the MCP must take to improve the results. 
  

	1.c.iii.	Congestive Heart Failure (CHF) – ACE Inhibitor/Angiotensin Receptor Blocker 

 Measure: The percentage of members who had a diagnosis of CHF in the year prior to the reporting year, who were enrolled for six or more months in the reporting year, who received one or more prescriptions for
an ACE Inhibitor or Angiotensin Receptor Blocker during the reporting year. 
 Target: TBD. 
 Minimum Performance Standard: The level of improvement must result in at least a TBD% decrease in the difference between the target and the previous year’s
results. 
 Action Required for Noncompliance: If the standard is not met and the results are below TBD%, then the MCP is required to complete a
Performance Improvement Project, as described in Appendix K, Quality Assessment and Performance Improvement Program, to address the area of noncompliance. If the standard is not met and the results are at or above TBD%, then ODJFS will issue
a Quality Improvement Directive which will notify the MCP of noncompliance and may outline the steps that the MCP must take to improve the results. 
  

	1.c.iv.	Congestive Heart Failure (CHF) – Cardiac Related Hospital Readmission 

 Measure: The rate of cardiac related readmissions during the reporting period for members who had a diagnosis of CHF in the year prior to the reporting period. A readmission is defined as a cardiac related admission that occurs
within 30 days of a prior cardiac related admission. 
 Target: TBD. 
 Minimum Performance Standard: The level of improvement must result in at least a TBD% decrease in the difference between the target and the previous year’s results. 
 Action Required for Noncompliance: If the standard is not met and the results are below TBD%, then the MCP is required to complete a Performance Improvement
Project, as described in 

 Appendix M 
 Page 7 
  

 
Appendix K, Quality Assessment and Performance Improvement Program, to address the area of noncompliance. If the standard is not met and the results
are at or above TBD%, then ODJFS will issue a Quality Improvement Directive which 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) – Inpatient Hospital Discharge Rate 

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

 Target: TBD 
 Minimum Performance Standard: The
level of improvement must result in at least a TBD% decrease in the difference between the target and the previous report period’s results. 
 Action
Required for Noncompliance: If the standard is not met and the results are below TBD%, then the MCP is required to complete a Performance Improvement Project, as described in Appendix K, Quality Assessment and Performance Improvement
Program, to address the area of noncompliance. If the standard is not met and the results are at or above TBD%, then ODJFS will issue a Quality Improvement Directive which will notify the MCP of noncompliance and may outline the steps that the
MCP must take to improve the results. 
  

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

 Measure: The number of emergency department visits in the reporting year where the principal diagnosis was CAD, per thousand member months, for members who had a diagnosis of CAD in the year prior to the
reporting year. 
 Target: TBD 
 Minimum Performance
Standard: The level of improvement must result in at least a TBD% decrease in the difference between the target and the previous report period’s results. 
 Action Required for Noncompliance: If the standard is not met and the results are below TBD%, then the MCP is required to complete a Performance Improvement Project, as described in Appendix K, Quality Assessment and Performance
Improvement Program, to address the area of noncompliance. If the standard is not met and the results are at or above TBD%, then ODJFS will issue a Quality Improvement Directive which will notify the MCP of noncompliance and may outline the
steps that the MCP must take to improve the results. 
  

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

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

 Appendix M 
 Page 8 
  

 Target: TBD. 
 Minimum Performance Standard: The level of improvement must result in at least a TBD% decrease in the difference between the target and the previous year’s results. 
 Action Required for Noncompliance: If the standard is not met and the results are below TBD%, then the MCP is required to complete a Performance Improvement Project, as described in Appendix K, Quality
Assessment and Performance Improvement Program, to address the area of noncompliance. If the standard is not met and the results are at or above TBD%, then ODJFS will issue a Quality Improvement Directive which will notify the MCP of
noncompliance and may outline the steps that the MCP must take to improve the results.  
  

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

 Measure: The percentage of members 35 years and older as of December 31st of the reporting year who were hospitalized from January 1 – December 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%, then the MCP is required to complete a Performance Improvement Project, as described in Appendix K, Quality Assessment and Performance Improvement Program, to address the area of noncompliance. If the standard is not met and the results
are at or above TBD%, then ODJFS will issue a Quality Improvement Directive which will notify the MCP of noncompliance and may outline the steps that the MCP must take to improve the results. 
  

	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%, then the MCP is required to complete a Performance Improvement
Project, as described in Appendix K, Quality Assessment and Performance Improvement Program, to address the area of 

 Appendix M 
 Page 9 
  

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

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

 Measure:
The number of acute inpatient hospital discharges in the reporting year where the primary diagnosis was non-mild hypertension, per thousand member months, for members who had a diagnosis of non-mild hypertension in the year prior to the
reporting year. 
 Target: TBD 
 Minimum Performance
Standard: The level of improvement must result in at least a TBD% decrease in the difference between the target and the previous report period’s results. 
 Action Required for Noncompliance: If the standard is not met and the results are below TBD%, then the MCP is required to complete a Performance Improvement Project, as described in Appendix K, Quality Assessment and Performance
Improvement Program, to address the area of noncompliance. If the standard is not met and the results are at or above TBD%, then ODJFS will issue a Quality Improvement Directive which will notify the MCP of noncompliance and may outline the
steps that the MCP must take to improve the results. 
  

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

 Measure: The number of emergency department visits in the reporting year where the principal diagnosis was non-mild hypertension, per thousand member months, for members who had a diagnosis of non-mild hypertension in the year prior
to the reporting year. 
 Target: TBD 
 Minimum
Performance Standard: The level of improvement must result in at least a TBD% decrease in the difference between the target and the previous report period’s results. 
 Action Required for Noncompliance: If the standard is not met and the results are below TBD%, then the MCP is required to complete a Performance Improvement Project, as described in Appendix K, Quality
Assessment and Performance Improvement Program, to address the area of noncompliance. If the standard is not met and the results are at or above TBD%, then ODJFS will issue a Quality Improvement Directive which will notify the MCP of
noncompliance and may outline the steps that the MCP must take to improve the results. 
  

	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 

 Appendix M 
 Page 10 
  

 Minimum Performance Standard: The level of improvement must result in at least a TBD% decrease in the
difference between the target and the previous report period’s results. 
 Action Required for Noncompliance: If the standard is not met and the
results are below TBD%, then the MCP is required to complete a Performance Improvement Project, as described in Appendix K, Quality Assessment and Performance Improvement Program, to address the area of noncompliance. If the standard is not
met and the results are at or above TBD%, then ODJFS will issue a Quality Improvement Directive which will notify the MCP of noncompliance and may outline the steps that the MCP must take to improve the results. 
  

	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%, then the MCP is required to complete a Performance Improvement Project, as described in Appendix K, Quality Assessment and Performance Improvement Program, to
address the area of noncompliance. If the standard is not met and the results are at or above TBD%, then ODJFS will issue a Quality Improvement Directive which will notify the MCP of noncompliance and may outline the steps that the MCP must take to
improve the results. 
  

	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%, then the MCP is required to complete a Performance Improvement Project, as described in Appendix K, Quality Assessment and Performance Improvement Program, to
address the area of noncompliance. If the standard is not met and the results are at or above TBD%, then ODJFS will issue a Quality Improvement Directive which will notify the MCP of noncompliance and may outline the steps that the MCP must take to
improve the results. 

 Appendix M 
 Page 11 
  

	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%, then the MCP is required to complete a Performance Improvement Project, as described in Appendix K, Quality
Assessment and Performance Improvement Program, to address the area of noncompliance. If the standard is not met and the results are at or above TBD%, then ODJFS will issue a Quality Improvement Directive which will notify the MCP of
noncompliance and may outline the steps that the MCP must take to improve the results. 
  

	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%, then the MCP is required to complete a Performance Improvement Project, as described in Appendix K, Quality Assessment and Performance
Improvement Program, to address the area of noncompliance. If the standard is not met and the results are at or above TBD%, then ODJFS will issue a Quality Improvement Directive which will notify the MCP of noncompliance and may outline the
steps that the MCP must take to improve the results. 
  

	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 

 Appendix M 
 Page 12 
  

 Minimum Performance Standard: The level of improvement must result in at least a TBD% decrease in the
difference between the target and the previous report period’s results. 
 Action Required for Noncompliance: If the standard is not met and the
results are below TBD%, then the MCP is required to complete a Performance Improvement Project, as described in Appendix K, Quality Assessment and Performance Improvement Program, to address the area of noncompliance. 
 If the standard is not met and the results are at or above TBD%, then ODJFS will issue a Quality Improvement Directive which will notify the MCP of noncompliance and may
outline the steps that the MCP must take to improve the results. 
  

	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%, then the MCP is required to complete a Performance Improvement Project, as described in Appendix K, Quality Assessment and Performance Improvement Program, to
address the area of noncompliance. If the standard is not met and the results are at or above TBD%, then ODJFS will issue a Quality Improvement Directive which will notify the MCP of noncompliance and may outline the steps that the MCP must take to
improve the results. 
  

	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%, then the MCP is required to complete a Performance Improvement Project, as described in Appendix K, Quality Assessment and Performance Improvement Program, to address the area of noncompliance. If the standard
is not met and the results are at or above TBD%, then ODJFS will issue a Quality Improvement Directive which will notify the MCP of noncompliance and may outline the steps that the MCP must take to improve the results. 

 Appendix M 
 Page 13 
  

	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%, then the MCP is required to complete a Performance Improvement Project, as described in Appendix K, Quality
Assessment and Performance Improvement Program, to address the area of noncompliance. If the standard is not met and the results are at or above TBD%, then ODJFS will issue a Quality Improvement Directive which will notify the MCP of
noncompliance and may outline the steps that the MCP must take to improve the results. 
  

	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%, then the MCP is required to complete a Performance Improvement Project, as described in Appendix K, Quality
Assessment and Performance Improvement Program, to address the area of noncompliance. If the standard is not met and the results are at or above TBD%, then ODJFS will issue a Quality Improvement Directive which will notify the MCP of
noncompliance and may outline the steps that the MCP must take to improve the results. 
  

	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.

 Appendix M 
 Page 14

  

 Minimum Performance Standard For Each Measure: The level of improvement must result in at least a TBD%
decrease in the difference between the target and the previous year’s results. 
 Action Required for Noncompliance (Follow-up visits within 30 days
of discharge): If the standard is not met and the results are below TBD%, then the MCP is required to complete a Performance Improvement Project, as described in Appendix K, Quality Assessment and Performance Improvement Program, to
address the area of noncompliance. If the standard is not met and the results are at or above TBD%, then ODJFS will issue a Quality Improvement Directive which will notify the MCP of noncompliance and may outline the steps that the MCP must take to
improve the results. 
 Action Required for Noncompliance (Follow-up visits within 7 days of discharge): If the standard is not met and the results
are below TBD%, then the MCP is required to complete a Performance Improvement Project, as described in Appendix K, Quality Assessment and Performance Improvement Program, to address the area of noncompliance. If the standard is not met and
the results are at or above TBD%, then ODJFS will issue a Quality Improvement Directive which will notify the MCP of noncompliance and may outline the steps that the MCP must take to improve the results. 
 1.c.xxiii. Mental Health, Severely Mentally Disabled (SMD) – SMD Related Hospital Readmission 
 Measure: The number of SMD related readmissions for members for members who had a diagnosis of SMD in the year prior to the reporting year. A readmission is defined as a SMD related admission that occurs
within 30 days of a prior SMD related admission.  
 Target: TBD. 
 Minimum Performance Standard: The level of improvement must result in at least a TBD% decrease in the difference between the target and the previous year’s results. 
 Action Required for Noncompliance: If the standard is not met and the results are below TBD%, then the MCP is required to complete a Performance Improvement
Project, as described in Appendix K, Quality Assessment and Performance Improvement Program, to address the area of noncompliance. If the standard is not met and the results are at or above TBD%, then ODJFS will issue a Quality Improvement
Directive which will notify the MCP of noncompliance and may outline the steps that the MCP must take to improve the results. 
 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. 

 Appendix M 
 Page 15

  

 Target: TBD 
 Minimum Performance Standard: The level of improvement must result in at least a TBD% decrease in the difference between the target and the previous report period’s results. 
 Action Required for Noncompliance: If the standard is not met and the results are below TBD%, then the MCP is required to complete a Performance Improvement
Project, as described in Appendix K, Quality Assessment and Performance Improvement Program, to address the area of noncompliance. If the standard is not met and the results are at or above TBD%, then ODJFS will issue a Quality Improvement
Directive which will notify the MCP of noncompliance and may outline the steps that the MCP must take to improve the results. 
 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%, then the MCP is required to complete a Performance Improvement Project, as described in Appendix K, Quality Assessment and Performance Improvement
Program, to address the area of noncompliance. If the standard is not met and the results are at or above TBD%, then ODJFS will issue a Quality Improvement Directive which will notify the MCP of noncompliance and may outline the steps that the
MCP must take to improve the results. 
 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%, then the MCP is required to complete a Performance Improvement Project, as described in 

 Appendix M 
 Page 16

  

 
Appendix K, Quality Assessment and Performance Improvement Program, to address the area of noncompliance. If the standard is not met and the results
are at or above TBD%, then ODJFS will issue a Quality Improvement Directive which will notify the MCP of noncompliance and may outline the steps that the MCP must take to improve the results. 
 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 Physician (PCP) Turnover, Adults’ Access to Preventive/Ambulatory Health Services, and Adults’ Access to Designated PCP. For a
comprehensive description of the access performance measures below, see ODJFS Methods 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 physicians who are not adhering to the MCP’s standard of care. Therefore, this measure is used in conjunction with the adult access and designated PCP measures to assess performance in the
access category. 

 Appendix M 
 Page 17

  

 Measure: The percentage of primary care physicians affiliated with the MCP as of the beginning of the
measurement year who were not affiliated with the MCP as of the end of the year. 
 Statewide Approach: MCPs will be evaluated using a statewide
result, including all regions in which an MCP has membership. ODJFS will use the first calendar year 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 in itial report period of evaluation, and penalties will be applied for noncompliance. 
 Report Period: For the SFY 2008 contract period, a baseline level of performance will be established using the CY2007 report period (and may be adjusted based on
the number of months of ABD managed care membership). For the SFY 2009 contract period, performance will be evaluated using the January – December 2008 report period. The first reporting period in which MCPs will be held accountable to the
performance standards will be the CY2008 reporting period. 
 Minimum Performance Standard: A maximum PCP Turnover rate of 18%. 
 Action Required for Noncompliance: MCPs are required to perform a causal analysis of the high PCP turnover rate and assess the impact on timely access to health
services, including continuity of care. If access has been reduced or coordination of care affected, then the MCP must develop and implement an action plan to address the findings. 
 2.b. Adults’ Access to Designated PCP 
 The MCP must encourage and assist ABD members without a designated
primary care physician (PCP) to establish such a relationship, so that a designated PCP can coordinate and manage member’s health care needs. This measure is used to assess MCPs’ performance in the access category. 
 Measure: The percentage of members who had a visit through member’s designated PCPs. 
 Statewide Approach: MCPs will be evaluated using a statewide result, including all regions in which an MCP has membership. ODJFS will use the first calendar year 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. 

 Appendix M 
 Page 18

  

 Minimum Performance Standards: TBD 
 Penalty for Noncompliance: If an MCP is noncompliant with the Minimum Performance Standard, then the MCP must develop and implement a corrective action plan. 
 2.c. Adults’ Access to Preventive/Ambulatory Health Services 
 This measure indicates whether adult members are accessing health services. 
 Measure: The percentage of members age 21 and older who had an
ambulatory or preventive-care visit. 
 Statewide Approach: MCPs will be evaluated using a statewide result, including all regions in which an MCP has
membership. ODJFS will use the first calendar year 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 CY2008 reporting period. 
 Minimum Performance Standards: TBD 
 Penalty for
Noncompliance: If an MCP is noncompliant with the Minimum Performance Standard, then the MCP must develop and implement a corrective action plan. 
 3. CONSUMER SATISFACTION 
 MCPs will be evaluated using a statewide result, including all regions in which an MCP has membership. 

In accordance with federal requirements and in the interest of assessing enrollee satisfaction with MCP performance, ODJFS periodically conducts independent consumer
satisfaction surveys. Results are used to assist in identifying and correcting MCP performance overall and in the areas of access, quality of care, and member services. Performance in this category will be determined by the overall satisfaction
score. For a comprehensive description of the Consumer Satisfaction performance measure below, see ODJFS Methods for ABD Medicaid Managed Care Program Consumer Satisfaction Performance Measures, which are incorporated in this Appendix.

 Appendix M 
 Page 19

  

 Measure: Overall Satisfaction with MCP: The average rating of the respondents to the Consumer Satisfaction
Survey who were asked to rate their overall satisfaction with their MCP. The results of this measure are reported annually. 
 Report Period: For the
SFY 2008 contract period, the measure is under review and the report period has not been determined. 
 Minimum Performance Standard: An average score
of no less than 7.0. 
 Penalty 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 ABD Medicaid Managed Care Program Administrative Capacity Performance Measures, which are
incorporated in this Appendix. 
 4.b. Emergency Department Diversion 
 Managed care plans must provide access to services in a way that assures access to primary and urgent care in the most effective settings and minimizes inappropriate utilization of emergency department (ED) services.
MCPs are required to identify high utilizers of ED services and implement action plans designed to minimize inappropriate ED utilization. 
 Measure:
The percentage of members who had TBD ED visits during a twelve month reporting period. 
 Statewide Approach: MCPs will be evaluated using a
statewide result, including all regions in which an MCP has membership. ODJFS will use the first calendar year of ABD managed care membership as the baseline year (i.e., CY2007). The baseline year will be used to determine a minimum statewide
performance standard and a target. The number of members with an ED visit used to calculate the measure for the baseline year will be adjusted based on the number of months of ABD managed care membership in the baseline year. An MCP’s second
calendar year of ABD managed care program membership (i.e., CY2008) will be the initial report period of evaluation, and penalties will be applied for noncompliance. 
 Report Period: For the SFY 2008 contract period, a baseline level of performance will be established using the CY2007 report period (and may be adjusted based on the number of months of ABD managed care
membership). For the SFY 2009 contract period, results will be calculated for the reporting period of CY2008 and compared to the CY2007 baseline results to determine if the minimum performance standard is met. 

 Appendix M 
 Page 20

  

 Target: TBD 
 Minimum Performance Standard: TBD 
 Penalty for Noncompliance: If the standard is not met and the results are above TBD%, then the
MCP must develop a corrective action plan, for which ODJFS may direct the MCP to develop the components of their EDD program as specified by ODJFS. If the standard is not met and the results are at or below TBD%, then the MCP must develop a Quality
Improvement Directive. 
 5. Notes 
 Given that unforeseen
circumstances (e.g., revision or update of applicable national standards, methods or benchmarks, or issues related to program implementation) may impact performance assessment as specified in Sections 1 through 4, ODJFS reserves the right to apply
the most appropriate penalty to the area of deficiency identified with any individual measure, notwithstanding the penalties specified in this Appendix. 

 APPENDIX N 
 COMPLIANCE ASSESSMENT SYSTEM (CAS) 
 ABD ELIGIBLE POPULATION 
 The Compliance Assessment System (CAS) is designed to improve the quality of each MCP’s performance through actions taken by ODJFS to address identified failures to
meet certain program requirements. The CAS assesses progressive remedies with specified values (occurrences or points) assigned for certain documented failures to satisfy the deliverables required by the Agreement. Remedies are progressive based
upon the severity of the violation, or a repeated pattern of violations. The CAS does not include categories which require subjective assessments or which are not within the MCPs’ control. CAS allows the accumulated point total to reflect both
patterns of less serious violations as well as less frequent, more serious violations. 
 The CAS focuses on clearly identifiable deliverables, and
occurrences/points are only assessed in documented and verified instances of noncompliance. The CAS does not replace ODJFS’ ability to require corrective action plans (CAPs) and program improvements, or to impose any of the sanctions specified
in Ohio Administrative Code (OAC) rule 5101:3-26-10, including the proposed termination, amendment, or nonrenewal of the MCP’s provider agreement. 
 As
stipulated in OAC rule 5101:3-26-10(F), regardless of whether ODJFS imposes a sanction, MCPs are required to initiate corrective action for any MCP program violations or deficiencies as soon as they are identified by the MCP or ODJFS. 
 Corrective Action Plans (CAPs) – MCPs may be required to develop CAPs for any instance of noncompliance, and CAPs are not limited to actions taken under the CAS.
All CAPs requiring ongoing activity on the part of an MCP to ensure their compliance with a program requirement remain in effect for the next provider agreement period. In situations where ODJFS has already determined the specific action which must
be implemented by the MCP or if the MCP has failed to submit an ODJFS-approvable CAP, ODJFS may require the MCP to comply with an ODJFS-developed or “directed” CAP. 

 Appendix N 
 Page 2 
  

 Occurrences and Points – Occurrences and points are defined and applied as follows: 
 Occurrences – Failures to meet program requirements, including but not limited to, noncompliance with administrative requirements. 
  

					
	 Examples include:
	  	–	    	Use of unapproved marketing materials.
			
		  	–	    	Failure to attend a required meeting.
			
		  	–	    	Second failure to meet a call center standard.

 5 Points – Failures to meet program requirements, including but not limited to, actions which could impair
the member’s ability to access information regarding services in a timely manner or which could impair a member’s rights. 
  

					
	 Examples include:
	  	–	    	24-hour call-in system is not staffed by medical personnel.
			
		  	–	    	Failure to notify a member of their right to a state hearing when the MCP proposes to deny, reduce, suspend or terminate a Medicaid-covered service.
			
		  	–	    	Failure to appropriately notify ODJFS of provider panel terminations.

 10 Points – Failures to meet program requirements, including but not limited to, actions which could affect
the ability of the MCP to deliver or the member to access covered services. 
  

					
	 Examples include:
	  	–	    	Failure to comply with the minimum provider panel requirements specified in Appendix H of the Agreement.
			
		  	–	    	Failure to provide medically-necessary Medicaid covered services to members.
			
		  	–	    	Failure to meet the electronic claims adjudication requirements.

 Failure to submit or comply with CAPs will result in the assessment of occurrences or points based on the nature
of the violation under correction. 

 Appendix N 
 Page 3 
  

 Notwithstanding the assessment of occurrences and/or points as a result of individual events, the following
cumulative actions will be imposed for repeated violations. 
  

	 	•	 	 After accumulating a total of three occurrences within a contract term, all subsequent occurrences during the period will be assessed as 5-point violations,
regardless of the number of 5-point violations which have been accrued by the MCP. 

  

	 	•	 	 After accumulating a total of three 5-point violations within a contract term, all subsequent 5-point violations during the period will be assessed as 8-point
violations, except as specified above. 

  

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

 Occurrences and points will accumulate over the contract term of the Agreement. Upon the beginning of a new Agreement, the
MCP will begin a new contract term with a score of zero unless the MCP has accrued a total of 55 points or more during the prior provider agreement period. Those MCPs who have accrued a total of 55 points or more during the contract term of a prior
provider agreement will carry these points over for the first three (3) months of their next provider agreement. If the MCP does not accrue any additional points during this three (3) month period the MCP will then have their point total
reduced to zero and continue on in the new contract term. If the MCP does accrue additional points during this three-month period, the MCP will continue to carry the points accrued from the prior provider agreement plus any additional points accrued
during the new provider agreement contract term. 
 For purposes of the CAS, the date that ODJFS first becomes aware of an MCP’s program violation is
considered the date on which the violation occurred. Therefore, program violations that technically reflect noncompliance from the previous provider agreement period will be subject to remedial action under CAS at the time that ODJFS first becomes
aware of this noncompliance. 
 In cases where an MCP subcontracting provider is found to have violated a program requirement (e.g., failing to provide
adequate contract termination notice, marketing to potential members, unapprovable billing of members, etc.), ODJFS will not assess occurrences or points if: (1) the MCP can document that they provided sufficient notification/education to
providers of applicable program requirements and prohibited activities; and (2) the MCP takes immediate and appropriate action to correct the problem and to ensure that it does not happen again to the satisfaction of ODJFS. Repeated incidents
will be reviewed to determine if the MCP has a systemic problem in this area, and if so, occurrences or points may be assessed, as determined by ODJFS. 

 Appendix N 
 Page 4

  

 All required submissions are to be received by their specified deadline. Unless otherwise specified, late submissions
will initially be addressed through CAPs, with repeated instances of untimely submissions resulting in escalating penalties, as may be determined by ODJFS. 
 If an MCP determines that they will be unable to meet a program deadline, the MCP must verbally inform the designated ODJFS contact person (or their supervisor) of such and submit a written request (by facsimile transmission) for an
extension of the deadline as soon as possible, but no later than 3 PM Eastern Time (ET) on the date of the deadline in question. Extension requests should only be submitted in situations where unforeseeable circumstances have arisen which make it
impossible for the MCP to meet an ODJFS-stipulated deadline and all such requests will be evaluated upon that basis and with that in mind. Only written approval as may be granted by ODJFS of a deadline extension will preclude the assessment of a
CAP, occurrence or points for untimely submissions. 
 No points or occurrences will be assigned for any violation where an MCP is able to document that the
precipitating circumstances were completely beyond their control and could not have been foreseen (e.g., a construction crew severs a phone line, a lightning strike blows a computer system, etc.). 
 REMEDIES 
 Progressive remedies will be based on the number of points
accumulated at the time of the most recent incident. Unless specifically otherwise indicated in this appendix, all fines issued under the CAS are nonrefundable. 
  

			
	1-9 Points	  	Corrective Action Plan (CAP)
		
	10-19 Points	  	CAP + $5,000 fine
		
	20-29 Points	  	CAP + $10,000 fine
		
	30-39 Points	  	CAP + $20,000 fine
		
	40-69 Points	  	CAP + $30,000 fine
		
	70+ Points	  	Proposed Contract Termination

 Appendix N 
 Page 5

  

 New Member Selection Freezes: 
 Notwithstanding any other penalty, occurrence or point assessment that ODJFS may impose on an MCP under this Appendix, ODJFS may prohibit an MCP from receiving new membership through consumer initiated selection or
the assignment process (selection freeze) in one or more counties if : (1) the MCP has accumulated a total of 20 or more points during a contract term; (2) or the MCP fails to fully implement a CAP within the designated time frame; or
(3) circumstances exist which potentially jeopardize the MCP’s members’ access to care. [Examples of circumstances that ODJFS may consider as jeopardizing member access to care include: 
  

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

  

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

  

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

  

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

 Payments provided for under the Agreement will be denied for new enrollees, when and for so long as, payments for those enrollees is denied by CMS in accordance with the
requirements in 42 CFR 438.730. 
 Reduction of Assignments 
 ODJFS may reduce the number of assignments an MCP receives if ODJFS, in its sole discretion, determines that the MCP lacks sufficient administrative capacity to meet the needs of the increased volume in membership. Examples of circumstances
which ODJFS may determine demonstrate a lack of sufficient administrative capacity include, but are not limited to, an MCP’s failure to: repeatedly provide new member materials by the member’s effective date; meet the minimum call center
requirements; meet the minimum performance standards for identifying and assessing children with special health care needs and members needing case management services; and/or provide complete and accurate appeal/grievance, member’s PCP and
CAMS data files. 
 Noncompliance with Claims Adjudication Requirements: 
 If ODJFS finds that an MCP is unable to (1) electronically accept and adjudicate claims to final status and/or (2) notify providers of the status of their submitted claims, as stipulated in 

 Appendix N 
 Page 6

  

 
Appendix C of the Agreement, ODJFS will assess the MCP with a 10-point penalty and a monetary sanction of $20,000 per day for the period of noncompliance.
ODJFS may assess additional penalty points based on the length of noncompliance, as it may determine in its sole discretion. 
 If ODJFS has identified
specific instances where an MCP has failed to take the necessary steps to comply with the requirements specified in Appendix C of the Agreement, for (1) failing to notify non-contracting providers of procedures for claims submissions when
requested and/or (2) failing to notify contracting and non-contracting providers of the status of their submitted claims, the MCP will be assessed 5 points per incident of noncompliance. 
 Noncompliance with Prompt Payment: 
 Noncompliance with the prompt pay
requirements as specified in Appendix J of the Agreement, will result in progressive penalties. The first violation during the contract term will result in the assessment of 5 points, quarterly prompt pay reporting, and submission of monthly status
reports to ODJFS until the next quarterly report is due. The second and any subsequent violation during the contract term will result in the submission of monthly status reports, assessment of 10 points and a refundable fine equal to 5% of the
MCP’s monthly premium payment or $300,000, whichever is less. The refundable fine will be applied in lieu of a nonrefundable fine and the money will be refunded by ODJFS only after the MCP complies with the required standards for two
(2) consecutive quarters. 
 If an MCP is found to have not been in compliance with the prompt pay requirements for any time period for which a report
and signed attestation have been submitted representing the MCP as being in compliance, the MCP will be subject to a selection freeze of not less than three (3) months duration. 
 Noncompliance with Franchise Fee Assessment Requirements 
 In accordance with ORC
Section 5111.176, and in addition to the imposition of any other penalty, occurrence or points under this Appendix, an MCP that does not pay the franchise permit fee in full by the due date is subject to any or all of the following. :

  

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

  

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

  

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

 Appendix N 
 Page 7

  

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

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

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

Noncompliance with Encounter Data Submissions: 
 Submission of
unpaid encounters (except for immunization services as specified in Appendix L) will result in the assessment of a nonrefundable $1,000 fine for each violation. 
 Noncompliance with Abortion and Sterilization Payment 
 Noncompliance with abortion and sterilization requirements as specified by ODJFS will
result in the assessment of a nonrefundable $1,000 fine for each documented violation. Additionally, MCPs must take all appropriate action to correct each such ODJFS-documented violation. 
 Negligent Breach of Protected Health Information (PHI) Standards 
 Non-compliance with the HIPAA Privacy Regulations and negligent breach of protected health information (PHI) standards will be assessed in accordance with Appendix C. Therefore, the progressive remedies specified under Appendix N,
Compliance Assessment System will not be utilized for assessing non-compliance with the HIPAA Privacy Regulations and negligent breach of PHI. 
 Refusal
to Comply with Program Requirements 
 If ODJFS has instructed an MCP that they must comply with a specific program requirement and the MCP refuses, such
refusal constitutes documentation that the MCP is no longer operating in the best interests of the MCP’s members or the state of Ohio and ODJFS will move to terminate or nonrenew the MCP’s provider agreement. 
 General Provisions: 
 All notifications of the imposition by ODJFS of
a fine or freeze will be made via certified or overnight mail to the identified MCP Medicaid Coordinator. 

 Appendix N 
 Page 8

  

 Pursuant to procedures as may be established by ODJFS, refundable and nonrefundable monetary sanctions/assurances
must be remitted to ODJFS within thirty (30) days of receipt of the invoice by the MCP. In addition, per Ohio Revised Code Section 131.02, payments not received within forty-five (45) days will be certified to the Attorney
General’s (AG’s) office. MCP payments certified to the AG’s office will be assessed the appropriate collection fee by the AG’s office. 
 Refundable monetary sanctions/assurances applied by ODJFS will be based on the premium payment for the month in which the MCP was cited for the deficiency. Any monies collected through the imposition of such a fine will be returned to the
MCP (minus any applicable collection fees owed to the Attorney General’s Office if the MCP has been delinquent in submitting payment) after they have demonstrated full compliance, as determined by ODJFS, with the particular program requirement.

 If an MCP does not comply within one (1) year of the date of notification of noncompliance involving issues of case management and two (2) years
of the date of notification of noncompliance in issues involving encounter data, then the monies will not be refunded. MCPs are required to submit a written request for refund to ODJFS at the time they believe is appropriate before a refund of
monies will be considered. 
 Notwithstanding any other action ODJFS may take under this Appendix, ODJFS may impose a combined remedy which will address
multiple areas of noncompliance if ODJFS determines, in its sole discretion, that (1) one systemic problem is responsible for multiple areas of noncompliance and/or (2) that there are a number of repeated instances of noncompliance with
the same program requirement. 
 In addition, ODJFS can at any time move to terminate, amend or deny renewal of a provider agreement. 
 Upon such termination, nonrenewal or denial of an MCP provider agreement, all previously collected monetary sanctions will be retained by ODJFS. 
 In addition to the remedies imposed under the CAS, remedies related to areas of data quality and financial performance may also be imposed pursuant to Appendices J, L,
and M respectively, of the Agreement. 
 If ODJFS determines that an MCP has violated any of the requirements of sections 1903(m) or 1932 of the Social
Security Act which are not specifically identified within the CAS, the ODJFS may, pursuant to the provisions of OAC rule 5101:3-26-10(A): (1) notify the MCP’s members that they may terminate from the MCP without cause; and/or
(2) suspend any further new member selections. 

 Appendix N 
 Page 9

  

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

	 	•	 	 MCPs notified of ODJFS’ imposition of remedial action taken under the CAS (i.e., occurrences, points, fines, assignment reductions and selection freezes), will
have five (5) working days from the date of receipt to request reconsideration, although ODJFS will impose selection freezes based on an access to care concern concurrent with initiating notification to the MCP. (All notifications of the
imposition of a fine or a freeze will be made via certified or overnight mail to the identified MCP Contact.) Any information that the MCP would like reviewed as part of the reconsideration request must be submitted at the time of submission of the
reconsideration request, unless ODJFS extends the timeframe in writing. 

  

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

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

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

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

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

 Appendix N 
 Page 10 
  

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

	 	•	 	 Unapproved use of marketing/member materials. 

  

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

  

	 	•	 	 Failure to maintain ODJFS-required documentation. 

  

	 	•	 	 Use of unapproved subcontracting providers where prior approval is required by ODJFS. 

  

	 	•	 	 Use of unapprovable subcontractors (e.g., not in good standing with Medicaid and/or Medicare programs, provider listed in directory but no current contract, etc.)
where prior-approval is not required by ODJFS. 

  

	 	•	 	 Failure to provide timely notification to members, as required by ODJFS (e.g., notice of PCP or hospital termination from provider panel).

  

	 	•	 	 Participation in a prohibited or unapproved marketing activity. 

  

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

  

	 	•	 	 Failure to submit and/or comply with a Corrective Action Plan (CAP) requested by ODJFS as the result of an occurrence, or when no occurrence was designated for the
precipitating violation of OAC rules or provider agreement 

  

	 	•	 	 Failure to comply with the physician incentive plan requirements, except for noncompliance where member rights are violated (i.e., failure to complete required
patient satisfaction surveys or to provide members with requested physician incentive information) or where false, misleading or inaccurate information is provided to ODJFS. 

 Appendix N 
 Page 11 
  

 5 POINTS: Failures to meet program requirements, including but not limited to, actions which could
impair the member’s ability to access information regarding services in a timely manner or which could impair a consumer’s or member’s rights, as determined by ODJFS. Examples include, but are not limited to, the following:

  

	 	•	 	 Violations which result in selection or termination counter to the recipient’s preference (e.g., a recipient makes a selection decision based on inaccurate
provider panel information from the MCP). 

  

	 	•	 	 Any violation of a member’s rights. 

  

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

  

	 	•	 	 Failure to comply with appeal, grievance, or state hearing requirements, including timely submission to ODJFS. 

  

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

  

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

  

	 	•	 	 Failure to submit and/or comply with a CAP as a result of a 5-point violation. 

  

	 	•	 	 Failure to meet the prompt payment requirements (first violation). 

  

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

  

	 	•	 	 Failure to submit a required monthly CAMS file (as specified in Appendix L of the Agreement) by the end of the month the submission was required.

  

	 	•	 	 Failure to submit a required monthly Members’ Designated PCP file (as specified in Appendix L of the Agreement) by the end of the month the submission was
required. 

 Appendix N 
 Page 12 
  

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

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

  

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

  

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

  

	 	•	 	 Failure to process prior authorization requests within prescribed time frame. 

  

	 	•	 	 Failure to remit any ODJFS-required payments within the specified time frame. 

  

	 	•	 	 Failure to meet the electronic claims adjudication requirements. 

  

	 	•	 	 Failure to submit and/or comply with a CAP as a result of a 10-point violation. 

  

	 	•	 	 Failure to meet the prompt payment requirements (second and subsequent violations). 

  

	 	•	 	 Fourth and any subsequent failure to meet the monthly call-center requirements for either the member services or the 24-hour call-in system lines.

  

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

  

	 	•	 	 Failure to submit a required monthly appeal or grievance file (as specified in Appendix L of the Agreement) by the end of the month the submission was required.

  

	 	•	 	 Misrepresentation or falsification of information that the MCP furnishes to the ODJFS or to the Centers for Medicare and Medicaid Services.

 APPENDIX 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. SFY2009 will become the first year, an MCP’s performance level for P4P can be determined. 
 1. SFY 2009 P4P

 1.a. Qualifying Performance Levels 
 To qualify for
consideration of the SFY 2009 P4P, an MCP’s performance level must: 
 1) Meet the minimum performance standards set in Appendix M,
Performance Evaluation, for the measures listed below; and 
 2) Meet the P4P standards established for the Clinical Performance
Measures below. 

 Appendix O 
 Page 2

  

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

 Measures for which the minimum performance standard for SFY 2009 established in Appendix M, Performance Evaluation, must be met to qualify for consideration of
incentives are as follows: 
 1. PCP Turnover (Appendix M, Section 2.a.) 
 Report Period: CY 2008 
 2. Adults’ Access to Preventive/Ambulatory Health Services (Appendix M,
Section 2.c.) 
 Report Period: CY 2008 
 3. Satisfaction with MCP Customer Service (Appendix M, Section 3.) 
 Report Period: The most recent consumer
satisfaction survey completed prior to the end of the SFY 2009 contract period. 
 For each clinical performance measure listed below, the MCP must meet the
P4P standard to be considered for SFY 2009 P4P. The MCP meets the P4P standard if one of two criteria is met. The P4P standard is a performance level of either: 
 1) The minimum performance standard established in Appendix M, Performance Evaluation, for five of eight clinical performance measures listed below; or 
 2) The Medicaid benchmarks for five of eight clinical performance measures listed below. The Medicaid benchmarks are subject to change based on the revision or update of applicable national standards, methods or
benchmarks. 
  

					
	 	 	 Clinical Performance Measure
	  	Medicaid
Benchmark
			
	1.	 	CHF: ACE Inhibitor/Angiotensin Receptor Blocker	  	TBD
			
	2.	 	CAD: Beta-Blocker Treatment after Heart Attack (AMI -related admission)	  	TBD
			
	3.	 	CAD: Cholesterol Management for Patients with Cardiovascular Conditions/LDL-C screening performed	  	TBD
			
	4.	 	Hypertension: Inpatient Hospital Discharge Rate	  	TBD
			
	5.	 	Diabetes: Comprehensive Diabetes Care (CDC)/Eye exam	  	TBD
			
	6.	 	COPD: Inpatient Hospital Discharge Rate	  	TBD
			
	7.	 	Asthma: Use of Appropriate Medications for People with Asthma	  	TBD
			
	8.	 	Mental Health: Follow-up After Hospitalization for Mental Illness	  	TBD

  

 Appendix O 
 Page 3

  

 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 2008 
 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 
 MCP’s 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 as determined by ODJFS. For MCPs receiving additional P4P, the amount in the P4P fund (see section 2.) will be divided equally, up to the maximum amount, among all MCPs’ABD and/or CFC programs receiving
additional P4P. The maximum amount to be awarded to a single plan in P4P additional to the at-risk amount is $250,000 per contract year. An MCP may receive up to $500,000 should both of the MCP’s ABD and CFC programs achieve the Superior
Performance Levels. 

 Appendix O 
 Page 4

  

 2. NOTES 
 2.a.
Initiation of the P4P System 
 For MCPs in their first twenty-four (24) months of Ohio Medicaid ABD Managed Care Program participation, the status
of the at-risk amount will not be determined because compliance with many of the standards in the ABD program cannot be determined in an MCP’s first two contract years (see Appendix F., Rate Chart). In addition, MCPs in their first two
(2) contract years in the ABD program are not eligible for the additional P4P amount awarded for superior performance. 
 Starting with the twenty-fifth (25th) month of participation in the ABD
program, the MCP’s at-risk amount will be included in the P4P system. The determination of the status of this at-risk amount will occur after two (2) calendar years of ABD membership as compliance with many performance standards requires
two (2) calendar years to determine. Because of this requirement, the number of months of at-risk dollars to be included in an MCP’s first at-risk status determination may vary depending on when an MCP starts with the ABD program relative
to the calendar year. 
 2.b. Determination of at-risk amounts and additional P4P payments 
 For MCPs that have participated in the Ohio Medicaid ABD Managed Care Program long enough to calculate performance levels for all of the performance measures included in
the P4P system, determination of the status of an MCP’s at-risk amount will occur within six (6) months of the end of the contract period. Determination of additional P4P payments will be made at the same time the status of an MCP’s
at-risk amount is determined. 
 2.c. Statewide P4P system 
 All MCPs will be included in a statewide P4P system for the ABD program. The at-risk amount will be determined using a statewide result for all regions in which an MCP serves ABD membership. 
 2.d. Contract Termination, Nonrenewals, or Denials 
 Upon termination,
nonrenewal or denial of an MCP contract, the at-risk amount paid to the MCP under the current provider agreement will be returned to ODJFS in accordance with Appendix P., Terminations/Nonrenewals/Amendments, of the provider agreement.

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

 Appendix O 
 Page 5

  

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

 APPENDIX P 
 MCP TERMINATIONS/NONRENEWALS/AMENDMENTS 
 ABD ELIGIBLE POPULATION 
 Upon termination either by the MCP or ODJFS, nonrenewal or denial of an MCP’s provider agreement, all previously collected refundable monetary sanctions will be
retained by ODJFS. 
 MCP-INITIATED TERMINATIONS/NONRENEWALS 
 If an MCP provides notice of the termination/nonrenewal of their provider agreement to ODJFS, pursuant to Article VIII of the agreement, the MCP will be required to submit a refundable monetary assurance. This monetary assurance will be
held by ODJFS until such time that the MCP has submitted all outstanding monies owed and reports, including, but not limited to, grievance, appeal, encounter and cost report data related to time periods through the final date of service under the
MCP=s provider agreement. The monetary assurance must be in an amount of either $50,000 or 5 % of the capitation amount paid by ODJFS in the month the termination/nonrenewal notice is issued, whichever is greater. 
 The MCP must also return to ODJFS the at-risk amount paid to the MCP under the current provider agreement. The amount to be returned will be based on actual MCP
membership for preceding months and estimated MCP membership through the end date of the contract. MCP membership for each month between the month the termination/nonrenewal is issued and the end date of the provider agreement will be estimated as
the MCP membership for the month the termination/nonrenewal is issued. Any over payment will be determined by comparing actual to estimated MCP membership and will be returned to the MCP following the end date of the provider agreement. 

The MCP must remit the monetary assurance and the at-risk amount in the specified amounts via separate electronic fund transfers (EFT) payable to Treasurer of
State, State of Ohio (ODJFS). The MCP should contact their Contract Administrator to verify the correct amounts required for the monetary assurance and the at-risk amount and obtain an invoice number prior to submitting the monetary assurance
and the at-risk amount. Information from the invoices must be included with each EFT to ensure monies are deposited in the appropriate ODJFS Fund account. In addition, the MCP must send copies of the EFT bank confirmations and copies of the invoices
to their Contract Administrator. 
 If the monetary assurance and the at-risk amount are not received as specified above, ODJFS will withhold the MCP’s
next month’s capitation payment until such time that ODJFS receives documentation that the monetary assurance and the at-risk amount are received by the Treasurer of State. If within one year of the date of issuance of the invoice, an MCP does
not submit all outstanding monies owed and required submissions, including, but not limited to, grievance, appeal, encounter and cost report data related to time periods through the final date of service under the MCP’s provider agreement, the
monetary assurance will not be refunded to the MCP. 

 Appendix P 
 Page 2

  

 ODJFS-INITIATED TERMINATIONS 
 If ODJFS initiates the proposed termination, nonrenewal or amendment of an MCP=s provider agreement pursuant to OAC rule 5101:3-26-10 and the MCP appeals that proposed action, the MCP’s provider agreement
will be extended through the duration of the appeals process. 
 During this time, the MCP will continue to accrue points and be assessed penalties for each
subsequent compliance assessment occurrence/violation under Appendix N of the provider agreement. If the MCP exceeds 69 points, each subsequent point accrual will result in a $15,000 nonrefundable fine. 
 Pursuant to OAC rule 5101:3-26-10(H), if ODJFS has proposed the termination, nonrenewal, denial or amendment of a provider agreement, ODJFS may notify the MCP’s
members of this proposed action and inform the members of their right to immediately terminate their membership with that MCP without cause. If ODJFS has proposed the termination, nonrenewal, denial or amendment of a provider agreement and access to
medically-necessary covered services is jeopardized, ODJFS may propose to terminate the membership of all of the MCP’s members. The appeal process for reconsideration of either of these proposed actions is as follows: 
  

	 	•	 	 All notifications of such a proposed MCP membership termination will be made by ODJFS via certified or overnight mail to the identified MCP Contact.

  

	 	•	 	 MCPs notified by ODJFS of such a proposed MCP membership termination will have three working days from the date of receipt to request reconsideration.

  

	 	•	 	 All reconsideration requests must be submitted by either facsimile transmission or overnight mail to the Deputy Director, Office of Ohio Health Plans, and received
by 3PM Eastern Time (ET) on the third working day following receipt of the ODJFS notification of termination. The address and fax number to be used in making these requests will be specified in the ODJFS notification of termination document.

  

	 	•	 	 The MCP will be responsible for verifying timely receipt of all reconsideration requests. All requests must explain in detail why the proposed MCP membership
termination is not justified. The MCP’s justification for reconsideration will be limited to a review of the written material submitted by the MCP. 

  

	 	•	 	 A final decision or request for additional information will be made by the Deputy Director within three working days of receipt of the request for reconsideration.
Should the Deputy Director require additional time in rendering the final reconsideration decision, the MCP will be notified of such in writing. 

  

	 	•	 	 The proposed MCP membership termination will not occur while an appeal is under review and pending the Deputy Director’s decision. If the Deputy Director
denies the appeal, the MCP membership termination will proceed at the first possible effective date. The date may be retroactive if the ODJFS determines that it would be in the best interest of the members.

Source: [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00119-of-00352.parquet"}, [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00119-of-00352.parquet"}]]