Document:

Amendments to contract included as Exhibit 10.34 to Form 10-K

 OHIO DEPARTMENT OF JOB AND FAMILY SERVICES 
  
 OHIO MEDICAL ASSISTANCE PROVIDER AGREEMENT 
 FOR MANAGED CARE PLAN 
  
 This provider agreement is entered into this first day of July, 2004, 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 Buckeye Community Health Plan, 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 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. 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. 
  
 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. 
  

 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 in which the MCP agrees to provide comprehensive medical services 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. 

  
 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, 2005, unless this provider agreement is suspended or
terminated pursuant to Article VIII prior to the termination date, or otherwise amended pursuant to Article IX. 

  
 ARTICLE III - REIMBURSEMENT 
  

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

  

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 ARTICLE IV - MCP INDEPENDENCE 
  

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

  
 ARTICLE V - CONFLICT OF INTEREST; ETHICS LAWS 
  

	A.	In accordance with the safeguards specified in section 27 of the Office of Federal Procurement Policy Act (41 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. 

  

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

  

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

  
 ARTICLE VI - EQUAL EMPLOYMENT OPPORTUNITY 
  

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

  

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

  

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

  
 ARTICLE VII - RECORDS, DOCUMENTS AND INFORMATION 
  

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

  

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

  

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

  
 ARTICLE VIII - SUSPENSION AND TERMINATION 
  

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

  

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

  

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

  

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

  

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	E.	When initiated by MCP, termination of or failure to renew the provider agreement requires written notice to be received by ODJFS at least 75 days in advance of the termination or
renewal date, provided, however, that termination or non-renewal must be effective at the end of the last day of a calendar month. In the event of non-renewal of the provider agreement with ODJFS, if MCP is unable to provide notice to ODJFS 75 days
prior to the date when the provider agreement expires, and if, as a result of said lack of notice, ODJFS is unable to disenroll Medicaid enrollees prior to the expiration date, then the provider agreement shall be deemed extended for up to two
calendar months beyond the expiration date and both parties shall, for that time, continue to fulfill their duties and obligations as set forth herein. 

  
 ARTICLE IX - AMENDMENT AND RENEWAL 
  

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

  

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

 

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

  
 ARTICLE X - LIMITATION OF
LIABILITY 
  

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

  

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

  

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

  

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 ARTICLE XI - ASSIGNMENT 
  

	A.	MCP shall not assign any interest in this provider agreement and shall not transfer any interest in the same (whether by assignment or novation) without the prior written approval
of ODJFS and subject to such conditions and provisions as ODJFS may deem necessary. Any such assignments shall be submitted for ODJFS’ review 120 days prior to the desired effective date. No such approval by ODJFS of any assignment shall be
deemed in any event or in any manner to provide for the incurrence of any obligation by ODJFS in addition to the total agreed-upon reimbursement in accordance with this agreement. 

  

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

  
 ARTICLE XII - CERTIFICATION MADE BY MCP 
  

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

  

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

  

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

  

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 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 certifies compliance with section 4141.044 of the Ohio Revised Code which requires MCP to provide a listing of all available job vacancies to the
ODJFS. This requirement does not apply when MCP is filling the vacancy from within the organization or pursuant to a customary and traditional employer-union hiring arrangement. 

  

	H.	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. 

  

	I.	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. 

  

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

  

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 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. 

  

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 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. 
  

									
	 BUCKEYE COMMUNITY HEALTH PLAN, INC.:
	 	 	 	 
				
	BY:	 	/S/    MICHAEL F.
NEIDORFF        	 	 	 	 DATE: 6/16/04

	 	 	MICHAEL F. NEIDORFF, PRESIDENT	 	 	 	 	 	 

  

									
	 OHIO DEPARTMENT OF JOB AND FAMILY SERVICES:
	 	 	 	 
				
	BY:	 	/s/    THOMAS J. HAYES        	 	 	 	 DATE: 6/30/04

	 	 	THOMAS J. HAYES, DIRECTOR	 	 	 	 	 	 

  

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	 Bob Taft
 Governor
	  	[GRAPHIC]	  	 Tom Hayes
 Director

			
	 	  	 30 East Broad Street $
Columbus, Ohio 43215-3414
 http://jfs.ohio.gov
	  	 

  
 To Medicaid-Contracting
Managed Care Plans 
  

							
	 TO:
	 	 MCP Medicaid Coordinators
	 	 	  	 
				
	 FROM:    / S /
	 	 Deborah MacDonald, Acting Chief
 Bureau of Managed Health Care
	 	 	  	 
				
	 SUBJECT:
	 	 SFY05 MCP Provider Agreement
	 	 	  	 
				
	 DATE:
	 	 June 14, 2004
	 	 	  	 

  
 Attached you will find for signature
the new managed care plan (MCP) provider agreement for July 1, 2004, through June 30, 2005. A draft copy of the proposed revisions to this agreement and a summary of changes were sent to you for review on May 5, 2004, and your responses were due
back to the Bureau of Managed Health Care (BMHC) on May 25, 2004. We held a conference call on June 2, 2004, to discuss several key issues. A separate document is attached which includes all of the comments we received and our responses. 

 
 As we indicated to you, we continued to make minor edits during the last few weeks to
correct wording, format, clarity, and consistency issues and so you will see some additional non-substantive changes in the final provider agreement document. 
  

Based on omissions that we discovered, comments we received from the MCPs, and our follow-up discussions, several notable changes were made to the provider agreement
as originally proposed: 
  
 Appendix C -
Primary Language Information 
  
 The section regarding advance directives was
deleted in error and has been re-inserted; gifts of nominal value are now defined as items worth no more than $15.00; and language has been added to further clarify that the submission of delivery payments that are over one year old may require the
use of a manual process to pay such claims. 
  
 An Equal
Opportunity Employer 
  

 SFY 2005 MCP Provider Agreement 
 Page 2 
 June 14, 2004 
  

 As discussed in the June 2, 2004, the word “system” has been changed to “database” to more
clearly convey the ODJFS’ expectation regarding the MCP’s data management of their listing of members identified with limited English proficiency. 
  
 Additionally, in our first draft we neglected to add language to explain that major holiday closures could also be specified in the MCP’s member newsletter or other
such general issuances to the MCP’s members and this oversight has now been corrected. 
  
 Appendix G - Coverage and Services 
  
 The due date for submission of the MCP’s Emergency Department Diversion (EDD) program has been deleted and that section was revised to state that MCPs must have
approved EDD programs which, if changed, require ODJFS approval. This correction was erroneously omitted from the draft document you originally received. As a result of the June 2, 2004, conference call, we have accentuated the need for MCPs to
refer to the provider e-manuals on the ODJFS website as the definitive information source for the Medicaid covered-services specifications. The BMHC will also arrange for an upcoming technical assistance session on how to access and utilize the
electronic provider manuals. 
  
 Appendix H -
Provider Panel Specifications 
  
 In response to the comments we received,
the language in the hospital section of the Non-PCP Minimum Provider Network section has been revised to further clarify that MCPs must ensure that Medicaid-covered “hospital” services are available to their members from another hospital
when the MCP’s contracted hospital elects not to provide a particular Medicaid-covered hospital service due to a moral or religious objection. 
  
 Also, in reviewing the comments we received on the “full-time practice” revision we realized that the OB/GYN and vision provider sections of this appendix were
not as clear as they should have been and we have further revised these sections to improve their clarity. 
  
 Appendix K - Quality Assessment and Performance Improvement Program 
  
 As a result of the comments received and the discussion in our June 2, 2004, conference call, further clarification was added regarding
exemptions from the non-duplication of mandatory activities as part of the administrative review portion of the external quality review activities. 
  

 SFY 2005 MCP Provider Agreement 
 Page 3 
 June 14, 2004 
  

 Appendix L - Data Quality 
  
 The language in the paragraph describing ODJFS’ discretion to apply the most
appropriate penalty has been clarified to clearly indicate that the $300,000 monetary cap applies to all data quality penalties. 
  
 Appendix M - Performance Evaluation 
  
 The penalty for noncompliance with EDD performance was modified so as to not unduly penalize high-performing MCPs that experience a slight decrease in their performance
level. Additionally, for consistency purposes, the language “17 years of age and under” has been corrected to “children 17 and under.” 
  
 Appendix O - Performance Incentives 
  
 The minimum performance standard for the Emergency Department Diversion (EDD) performance measure was modified. With the added language, the minimum level of performance
needed to qualify MCPs for the SFY 2005 performance incentive is either the standard level of improvement or the breakpoint established in appendix M. Additionally, for SFY 2005, the ODJFS will be using the updated HEDIS 2004 methods for the
“Use of Appropriate Medication for People with Asthma” measure. NCQA is including fewer drugs in the HEDIS 2004 methods than in the HEDIS 2003 methods and we expect this to slightly lower results. To account for this change in methodology,
the ODJFS has reduced the excellent standard from 54% to 53% and the superior standard from 62% to 61% for the SFY 2005 incentive system. The term “national” benchmarks has also been changed to “Medicaid” benchmarks. 

 
 Future Provider Agreement Revisions 
  
 The request was made that in the future the MCPs have an opportunity to discuss proposed
provider agreement revisions with the BMHC prior to the issuance of the draft written document for the MCPs’ review and comment, and that additional written detail be provided on each of the proposed revisions. Whenever major provider agreement
revisions have been proposed in the past (e.g. rate changes, development of the new grievance and appeal process, selection of clinical study topics, the introduction of the Performance Evaluation and Incentive System, etc.), the BMHC has engaged in
considerable conversation with the MCPs before the draft rule or provider agreement revisions were distributed for review and we will certainly continue this practice. 
  

 SFY 2005 MCP Provider Agreement 
 Page 4 
 June 14, 2004 
  

 We do recognize that it would also be beneficial for the BMHC to routinely plan in advance for either an in-person
meeting or telephone conference for the discussion of issues which are identified as significant concerns by a substantial number of the MCPs and this will be added to our future timelines. Also, we remind the MCPs that when draft revisions are
distributed for their review and comment, the accompanying cover letter always encourages the MCPs to contact the BMHC for immediate clarification on any proposed revision at any time during the comment period. Often, what is an issue for one MCP,
is not of similar concern to another, and our experience has been that these issues are most productively addressed in direct discussions between the BMHC and that MCP where plan-specific information can be more openly shared. 
  
 In response to the request for more detailed written explanations of the proposed changes,
the BMHC does recognize that when revisions are so pervasive that it is not possible to use the strike-out/bold typeface approach, it is certainly more challenging to determine what specific changes have been made. This was the case with the 1997
Balance Budget Act revisions that were incorporated into the provider agreement for SFY 2004. Fortunately, the SFY 2005 revisions were primarily time period adjustments and clarifications of existing program requirements rather than substantive
changes to the Medicaid managed care program and we were therefore able to easily identify all proposed changes through the strike-out/bold typeface approach. The comments we received, and the June 2, 2004, conference call, however, did help us
appreciate the value in providing specific examples with technical revisions such as the calculation for a specific performance standard (i.e., the new EDD target measure), and we will try and include such examples in the future. 
  
 Please ensure that the appropriate party at your MCP signs the provider agreement
signature page (the last page of the baseline section of the document) and returns it to the attention of Kimberly Blaz by no later than 3 PM on June 18, 2004. We must receive an original copy of the signed agreement as we are unable to accept a
facsimile or photocopy of the signature page for the execution of this agreement. Please be sure to use the correct address for the Bureau of Managed Health Care. 
  

					
	If mailed:	  	30 East Broad Street	  	If hand-delivered or by courier:
	 	  	31st Floor	  	255 East Main Street
	 	  	Columbus, OH 43215-3414	  	2nd Floor
	 	  	 	  	Columbus, OH 43215-5222

  
 Copies of the fully executed signature
page will be forwarded to you for your files. The new provider agreements are for an effective date of July 1, 2004. 
  

 SFY 2005 MCP Provider Agreement 
 Page 5 
 June 14, 2004 
  

 If you have any questions or concerns regarding this memorandum, please contact me at 614-466-4693. 
  
 Thank you. 
  

	c:	BMHC Chiefs 

	    	CAs and Supervisors 

	    	Suzie Garcia, HMA 

	    	Kelly McGivern, OAHP 

	    	Matthew Moore, Three Rivers Health Plan 

	    	Kelly Johnson, Molina Health Plan 

	    	Tom Samol, The Health Plan 

	    	Debbie Bahnsen, AmeriGroup 

  

 RESPONSES TO MCP COMMENTS 
 ON 07/01/04 PROVIDER AGREEMENT 
  
 Appendix A 
  
 MCPs would like
to request the implementation of a process whereby MCPs are notified of all web address changes as well as any time information is posted on the web if information already on the web is revised. Frequently throughout the previous year, MCPs found
out web sites had changed, methodologies were revised and added to the website, etc. The letters that accompany the information say that the information is available on the web but they do not state whether it is revised information. 

 
 Response: When methods for data quality and performance measures are updated, the Bureau
of Managed Health Care (BMHC) notifies managed care plans (MCPs) via memo. For the MCP’s convenience, these methods are also posted on our website. Some of the confusion cited here may be referring to the instance where all ODJFS websites
changed with little or no notice to the users, including ODJFS staff. Maintenance of the Ohio Department of Job and Family Services ‘(ODJFS) websites is not under the control of the BMHC, but we will keep the MCPs apprised of any changes to
addresses as soon as we are made aware of them. 
  
 Appendix B

  
 Appendix B, Page 4 - MCP Provider Agreement Amendments 

 
 New language has been inserted addressing those MCPs interested in amending their
provider agreement to serve eligible Medicaid individuals in additional counties. It would be helpful to the MCPs and other MCP providers in the Medicaid system if a regional plan were outlined for this amendment with a timetable attached.

  
 To appropriately consider future expansion possibilities, what counties
does ODJFS consider clusters? Or service areas? Does ODJFS have a proposed expansion timeline? 
  
 Outlining the steps necessary for service area expansion filing, separate from the initial procurement process, makes very good sense. While we understand the Bureau’s desire to save cost and not prepare
appendices E & H for the entire state, we would appreciate a definition of the expected timeline for the ODJFS to develop those requirements for counties not currently defined. 
  

 1 

 In addition, for planning purposes, it would be extremely helpful for MCPs to know which counties will only be
considered as part of a larger group or cluster of counties. The “regional” approach might lend itself nicely to future expansions by building upon already established access patterns into more major urban areas. 
  
 Response: The development of minimum provider panel requirements for each county is a
considerably complex and time-consuming process. The county-specific requirements are developed using a provider to resident ratio which is applied to the number of Medicaid managed care eligibles in each county for each provider type. In order to
determine if an alternate provider area is indicated for a county, ODJFS must consider the out-of-county utilization patterns depicted in both fee-for-service (FFS) and MCP encounter data claims. In instances where out-of-county utilization for a
specific neighboring county is significant, a minimum provider requirement may be established for the neighboring county. In Ohio’s more rural counties, this out-of-county utilization may include any number of counties. ODJFS may determine that
if a MCP wishes to provide Medicaid managed care services in a county that has high out-of-county utilization in more than one neighboring county, then the MCP must first establish adequate provider panels for the out-of-county areas most utilized
by the Medicaid population. In some cases, ODJFS may determine that the MCP must serve a “region” or “cluster” of counties in light of utilization patterns and/or provider availability. ODJFS is unable to specify which counties
might be required to be served as “regions” or “clusters” until we perform our complete analysis of these counties. Due to the extensive work this involves, we will not begin this process until an MCP has indicated a serious
interest in serving this county(ies). Depending on other priorities, ODJFS anticipates that it will take at least four to six weeks after an MCP has submitted a letter of intent to provide Medicaid managed care services in a new county, to develop
provider panel requirements for any county currently not included in appendix H. 
  
 In terms of rate development, on March 5, 2004, the ODJFS requested that MCPs and all currently-identified prospective MCPs identify any new counties they might wish to serve in 2005-2006. Our actuary, Mercer Government Human Services
Consulting Firm (Mercer), is preparing rates for all the new counties submitted. If additional expansion counties are submitted in the future, we will ask Mercer to prepare these rates as soon as possible but the exact time frame will be dependent
on the other work priorities they have at that time. 
  

 2 

 Appendix C 
  
 Appendix C, Page 2, Section 11 – MCP Responsibilities 
  
 Although no changes is yet proposed, MCPs would like to request that a qualifier be added to the item stating, “ . . .ODJFS retains the right to make the final
determination on medical necessity in specific member situations, unless the benefit is specifically excluded from coverage.” This will help clarify that services like adult chiropractic,
although potentially “medically necessary,” will not be arbitrarily added to a plan’s financial responsibility. 
  
 Response: The purpose of this provision is to clarify that the MCP, and not its providers, are ultimately responsible for determining the medical necessity for services
and supplies requested for their members. In the past we have had state hearing disputes where the provider has asserted that if they prescribe a service or supply, then that service or supply is inherently medically necessary or it would not have
been prescribed. ODJFS, however, must retain the right, however, to make final determinations on medical necessity in member-specific situations. We do not believe that it is necessary to add the proposed qualifier to this section as MCPs are not
required to cover excluded benefits (see appendix G.2.a.). 
  
 Appendix C, Page
3, Section 19, subsection b – Primary Language 
  
 MCPs agree that an
MCP member primary language information (PLI) system is advantageous to the MCP and the member. MCPs agree this system should be readily available to MCP staff. However, it is impossible to guarantee MCP staff fluent in every language globally, when
there may exist only one MCP member using this as their primary language, speaking fluently in a secondary language designation of a more common language. Additionally, MCPs question the need to share all PLI with providers, except on an
“as requested” basis. Sharing PLI information with PCPs, PBMs, and TPAs would required expensive system enhancements across all of their systems, with very little return for their investment. Members will self-select those providers who
are accommodating to their respective culture. As such, MCPs recommend deleting the last two sentences on the paragraph at the top of page 4. 
  
 The last two sentences should be removed. An extensive data sharing process with PBMs, TPAs, providers, etc, would be unreasonably expensive. No requirement beyond
verbal communication when requested, of the Primary Language Indicator (PLI), should be mandated. To be competitive, an MCP will naturally work toward contracting with providers who are capable of communicating effectively with significant
subpopulations. However, placing the requirement globally for any language, and the loose requirement as it now stands that a provider’s system must accommodate a data feed from us, creates a whole new process and provider systems enhancement
that is cost prohibitive. 
  

 3 

 Response: As we indicated during our conference call on June 2, 2004, we understand that the use of the term
“system” was confusing and are therefore revising this provision to instead specify that the MCPs are to utilize a centralized “database.” This clarification makes the language consistent with the interpreter services discussions
we had with the MCPs last fall and with Julie Davis’ memo of December 5, 2003. We also clarified during our conference call that if an MCP has identified one of their members as requiring interpreter services, we expect the MCP to notify the
member’s primary care physician (PCP) (or use this information in assigning the member to the most appropriate PCP) and the MCP’s pharmacy benefit manger (PBM) so that these providers can take whatever steps may be needed to address the
member’s language needs (e.g., having an interpreter available for that member’s appointments or adding an edit to the pharmacy system to alert the pharmacist to this situation). This information exchange can take whatever form the MCP
deems most appropriate. 
  
 We are confused by the assertions that this provision
would require all MCP staff to be fluent in all languages. MCPs are required to provide interpreter services to members who require such assistance and this requirement applies to the MCP’s providers and the MCP’s staff members that
interact with the MCP’s members. As in the past, we expect the MCPs to use services such as the Language Line or locally-available interpreters when these services are needed. There is no requirement or expectation that all MCP staff must be
fluent in all languages. 
  
 Appendix C, Page 4-5, Section 21 – Advance
Directives 
  
 MCPs would like to know the reason for deletion of the
Advance Directives language and verification that it is not necessary for inclusion in the Medicaid member kits. 
  
 Why was the reference to Advance Directives was removed from the Provider Agreement when Ohio Administrative Code (OAC) still has requirements? 
  
 Response: This section was deleted in error during the renumbering within this appendix. This
section has been reinserted into the provider agreement as #22 and the wording is the same as it was when it appeared in the SFY 2003 provider agreement. The ODJFS apologizes for any confusion this inadvertent deletion may have caused. 

 
 Appendix C, Page 4, Section 22 – Call Center Standards 
  
 Please be more specific on definition of a major holiday. Do closure days normally
observed by banks, government offices, or many businesses include Christmas Eve, New Year’s Eve, Martin Luther King Jr. Day, President’s Day, etc.? Do we have discretion over what we term to be a major holiday as long as we list it in the
Member Handbook? 
  

 4 

 Response: Because the MCP member services staff perform such a critical function in assisting MCP members in receiving
their health care benefit, ODJFS expects the member services staff to be available when members would reasonably expect them to be available. For that reason we do not permit the MCP member services toll-free hotline to be closed during business
hours for any reason other than major holidays. Since there are some regional differences in terms of the “importance” of how certain holidays/events are recognized, we have not developed a definitive list of acceptable holiday closures
but believe the criteria we have stipulated should guide the MCPs in determining what holiday closures will be acceptable to ODJFS. In that ODJFS must prior approve all MCP member materials, including the MCP member handbook, ODJFS would determine
if the holiday closures proposed by the MCP were appropriate as part of that member material review process. (Note: During our final review of the revised provider agreement we identified an omission in this section. We neglected to add that major
holiday closures could also be specified in the MCP’s member newsletter or other such general issuances to the MCP’s members. This omission has now been corrected.) 
  
 Appendix C, Page 5, Section 21, subsection a – Marketing Materials 
  
 This section defines marketing materials, including gifts of nominal value (i.e., items
worth no more than $10.00). We suggest the amount be updated to $15.00, the amount currently cited by CMS. 
  
 Response: The ODJFS wants to thank the Ohio Association of Health Plans (OAHP) for providing the Center for Medicare and Medicaid Services (CMS) citation referenced in this comment. Although this is a Medicare
provision, there is comparability on this specific issue and after further internal review and discussion, ODJFS has revised the provider agreement to state that gifts of nominal value are items worth no more than $15.00. 
  
 Appendix C, Page 15, Section 26 – Timing of Delivery Payments 
  
 New language in this section outlining delivery payments states that the delivery payment
will not cover encounters that occurred over one year ago. MCPs suggest exception language be added to this section for those cases where the HMO is the secondary payor. This is a current requirement in the Ohio Revised Code 3901.384 for the
commercial market. 
  
 Considering the time involved in coordination of
benefits (COB) cases, we requests that ODJFS consider removing the proposed limitation for timing of delivery payments in cases where COB efforts can be documented. Briefly, a delivery can be considered an emergency service requiring MCPs to work
with non-contracting providers. Some MCPs allow non-contracting providers 365 days for billing. When considering COB activities this limitation appears disadvantageous. 
  

 5 

 Response: Language was added to this section to clarify that delivery payments that were over one year old may require
payment through a manual process as described in the June 2002 memo which notified the MCPs of this process. In some cases, MCPs have submitted delivery encounters more than two years after the delivery occurred. ODJFS implemented this change to
assure that ODJFS does not make duplicate payments for the same delivery. The June 2002 memo explained that, if an MCP is denied payment through the department’s 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 the ODJFS to receive payment. Payment will be made for the delivery if a payment had not previously been made for the same delivery. The language in this section of the
provider agreement has been modified to reflect this policy for delivery encounters submitted more than one year after the delivery occurred. 
  
 Appendix G 
  
 Appendix G, Page 1, Section 1 – Coverage and Services 
  
 MCPs request an explanation for changes to the list of coverage items including the deletion of certain services and language changes in others. MCPs feel an overall understanding of changes from the SFY 2004
agreement would be helpful. Although the ODJFS website is cited, for contract purposes a clear explanation is needed. 
  
 A full definition of subsection f., family planning services and supplies, is requested. MCPs are uncertain whether this new language is a change in what must
be covered under family planning services. If new services are provided, MCPs would anticipate a corresponding change in rates. 
  
 MCPs would like clarification on the need for changing the word prescribed to prescription. Does this change the services that are already being provided and if so the
MCPs would anticipate a corresponding change in rates. 
  
 We request an
explanation on why some of the changes were made; for example why was “obstetrical services” lined out? Why were the references to FQHC and RHC lined out? How does ODJFS define short term in regards to rehabilitative care? 

 
 We find it difficult to reference a “list” of basic benefit explanations in
the Provider Agreement to then be referred to the web site that contains electronic manuals. We were unable to directly tie the provided list back to the website. 
  

 6 

 Could this list become more static? As changes occur year after year, the MCPs try to determine whether the benefits
are really changing. An example is adding “and supplies” to Family Planning Services. Is that change just a clarification, or are other “supplies” now being covered that weren’t historically. The ODJFS should indicate such
on each change within Appendix G, as well as indicate the actuarial impact if benefits are changing. 
  
 We assume the change “Prescription drugs” is simply a clarification, but please confirm. 
  
 There are concerns about appendix G. Obstetrical services, Clinical services (including federal health centers and rural health clinics), Emergency services and speech
and hearing services, among others, have been crossed out. This is a bit confusing. Why are they crossed out? Are they now considered to be lumped under “physician services”? Speech and hearing services (formerly O) is now J and grouped
with physical therapy. Is this the same situation for the others? Please verify. 
  
 We would like clarification of the following points in Appendix G: 
  

	*	1i—Clinic Services (including federally qualified health centers and rural health clinics). 

  

	*	1m—Emergency Services 

  

	*	2 a Education testing and diagnosis 

  
 Response: As discussed in our June 2, 2004, conference call, the Bureau of Health Plan Policy (BHPP) has requested that all bureaus in the Office of Ohio Health Plans
(OHP) utilize this standardized list when providing general information regarding the services covered by the Medicaid program. The development of a standardized list was necessary because the various OHP bureaus were using different lists and some
of the lists had become archaic and potentially confusing. For example, the list currently included in the MCPs’ provider agreement reflects obstetrical services separately from all other physician services for no apparent reason. Therefore,
the changes in the list of covered services is not meant to signify any changes in the Medicaid benefit package but simply the utilization of the standardized list. Medicaid offers a complex set of health care benefits and there is no complete list
of covered services available to include in the provider agreement. The ODJFS reiterated during the conference call the limitations of a “summary” list and asked the MCPs if they would prefer to have the summary list removed from the
provider agreement. The MCPs indicated that they did see value in continuing to include the summary list in the provider agreement and, therefore, the ODJFS continues to include the summary list, as revised, in the provider agreement. For the
complete list of Medicaid-covered services, MCPs must refer to the e-manuals on the OHP website included in Appendix G of the provider agreement. 
  

 7 

 Appendix G, Page 1 – Coverage and Services 
  
 As rates move to a calendar year basis while the contract stays on a fiscal year, there should be a provision for rate adjustments in the
event the contract changes benefits off-cycle from the rate setting process. The change protects both sides; ODJFS when benefits are re moved from coverage, as well as MCPs when benefits are added. 
  
 Response: The rate schedule was moved to a calendar year to make provisions for rate
adjustments for potential program changes that might be approved by the legislature as part of the department’s budget for that year. This budget approval information is not available until July which is the beginning of a fiscal year. If we go
by SFY rate schedule to match the MCP contract year we have to revise the rates after the budget is finalized. We have done that in the past and it proved to be burdensome for the MCPs and the ODJFS. 
  
 Appendix G, Page 6 – Emergency Department Diversion 
  
 Regarding EDD, page seven, please explain why the reference to the EDD program still says
it must be submitted by a date in the past when other date references have been dealt with by saying “must have approved”.....program. 
  
 Response: The deletion of the previous due date for the MCP’s Emergency Department Diversion (EDD) program was inadvertently overlooked by the ODJFS during the
revision process. Please note that this section has been revised to read as follows: 
  
 “In accordance with Appendix C, MCP Responsibilities, MCPs must have an ODJFS-approved EDD program. Any subsequent changes to an approved EDD program must be submitted to ODJFS in writing for review and approval prior to
implementation.” 
  
 Appendix H 
  
 Appendix H, Page 5, Section 1 b – Minimum Non-PCP Network 
  
 This section requires non-PCP provider types maintain a fulltime practice, defined as
being available to patients at a “practice site” for at least 25 hours a week. Several questions have been raised. First, does this apply to all non-PCP provider types? Next, Does the term “practice site” include office, surgical
and clinical sites? For instance, surgeons and orthopedists may have some office hours but many more surgical hours that are divided between one or more facilities. It would be unrealistic to require the 25 hours be spent in only on site for certain
providers. Finally, this requirement could incite another reason for providers to refuse to contract with an MCP. 
  

 8 

 Regarding the requirement to have non-PCP type physician’s full time practice defined as 25 hours per week at a
practice location, we do not think this is a realistic requirement specifically for general surgeons and orthopedists. These two specialty types are in surgery and making hospital rounds a significant portion of every day. 
  
 We do not feel that 25 hours is appropriate for all specialties. For example, a general
surgeon may have a practice site but spend most of his or her time performing surgeries at the hospital. Under the guidelines would the surgeon need to have 25 hours a week at the office site? 
  
 Response: As discussed in our June 2, 2004, conference call, the ODJFS does accept the
inclusion of inpatient/outpatient surgical hours for general surgeons, otolaryngologists, and orthopedists, and hospital delivery hours for obstetricians/gynecologists in addition to regular office hours to fulfill the fulltime practice requirement.
The “full-time” practice requirement (without a specific definition in terms of “hours”) was first added to the provider agreement in July 2002. After the ODJFS determined that there appeared to be some confusion in terms of how
the MCPs were supposed to submit the practice designations and, at the request of the MCPs to establish a specific definition of the “full-time” term, clarification was provided through Appendix L of the ODJFS’s October 15, 2003,
Medicaid Managed Care Plan Provider Verification System Instructional Manual and the BMHC’s October 17, 2003, memorandum to MCP Coordinators. Both of these earlier issuances specifically stipulated that in order for certain specialty providers
to be counted toward the minimum provider panel requirements, they must routinely be available to patients at their practice site(s) in that county at least 25 hours per week which includes the clarifications explained earlier in this response.

  
 Appendix H, Page 5, Section 1 b. – Non-PCP Minimum Provider Network
– Hospitals 
  
 Currently, the addition reads: “If an
MCP-contracted hospital elects not to provide specific Medicaid-covered services because of an objection on moral or religious grounds, then the MCP must ensure that these services are available to its members through another MCP-contracted hospital
in the contract service area.” There are services often available at non-hospital providers that may also be part of the contracted network. MCPs should be given the flexibility to have those Medicaid-covered services provided at alternative
“MCP-contracted providers”, instead of just “MCP-contracted hospitals.” This would mirror the FFS program and how Medicaid consumers typically access those services. The current revision holds MCPs to a different and higher
standard, and could prohibit an entrance into a more rural county where a limited number of hospitals exist. 
  

 9 

 Response: When a hospital elects to contract with an MCP, that hospital (or the larger entity representing that hospital)
must complete the ODJFS- specified model contract addendum which includes a Hospital Services Form. Hospitals use this form to specify what types of hospital services they are agreeing to provide for the MCP, as well as to indicate if there are
certain services they will not provide due to an objection on moral or religious grounds. While some hospital services might also be provided by a non-hospital provider, the appropriate setting would be driven by the specific case in question.
Obviously, in the vast majority of situations, hospital services need to be provided by a hospital. In order to better clarify this requirement we will revise this language to indicate that this is only applicable if the hospital elects not to
provide specific Medicaid-covered “hospital” services. 
  
 Appendix
H, Page 8 – Provider Panel Exceptions 
  
 Regarding the proposed
language for Provider Panel Exceptions, while understanding the intent of the language, we find the language broad with no defined terms. For example what is “sufficient documentation”? This questions the fairness of the language and
leaves us wondering how ODJFS would administer in a way that would not be arbitrary. Perhaps adding more definition around the terms would be helpful. The most notable issue however is how this language erodes one of the most important managed care
concepts, that being contracted access to care. 
  
 Response: This
provision has been part of the MCP provider agreement since 1999. It was added when we identified the need to be able to deviate from the specified minimum provider panel requirements in situations where the MCP has made all reasonable efforts to
obtain a critical provider contract and the provider has refused. Since the time that this provision went into effect we have approved only one provider panel exception and that approval was rendered moot when the originally-required provider soon
thereafter signed a contract with the MCP. ODJFS of course believes that contractual provider relationships are critical to assuring a member’s access to care but we are also cognizant that some services are only available from a minimal number
of providers which may place them in an unfair bargaining position. ODJFS would prefer to never exercise the option of approving a provider panel exception request but we believe this provision is essential to ensure the current stability and future
expansion of the Medicaid managed care program. Since these requests are so infrequent and situation-specific, ODJFS believes it is sufficient to stress the general principles that we will use in making such determinations. 
  

 10 

 Appendix H, Page 11-28 – Minimum Provider Panel Charts 
  
 We are concerned that minimum requirements have increased in some counties. ODJFS does
publish methodology for how PCP requirements are determined. Methodology is not known for non-PCP providers and as such we is concerned that requirements for dental providers have increased. Difficulties regarding dental providers for Medicaid
recipients for both FFS and MCP are known. 
  
 Will ODJFS share the
calculations and methodology for minimum standards? 
  
 Response: Minimum
provider requirements for non-PCPs are calculated on a county-by-county basis and are based on a ratio of the number of providers (by type) per the number of residents. Ratios are calculated for the following provider types: dentists, pediatricians,
OB/GYNs, general surgeons, otolaryngologosts, allergists / immunologists, orthopedists, opthalmologists / optometrists, and pharmacies. This ratio is applied to the number of Medicaid managed care eligibles in each county for each provider type. The
pediatrician and OB/GYN provider ratios are applied only to children and women of child-bearing age, respectively, and therefore, the number of children and women are calculated for each county based on statewide percentages of managed care
eligibles in each category. The total managed care eligibles in each county is adjusted based on the number of eligibles and their enrollment status. For mandatory and voluntary counties, if the total number of eligibles is greater than 100,000, the
MCP’s provider panel must include enough providers to cover at least 40% of the total eligibles. If the total number of eligibles is less than or equal to 100,000, the MCP’s provider panel must cover at least 50% of the total eligibles. In
order to ensure that MCPs in preferred option counties can provide access to an adequate number of non-PCP specialists that takes into account the “default” assignment of additional Medicaid eligibles, a 1.5 multiplier is applied to the
calculation to determine the minimum specialist provider requirement. A change (increase or decrease) in the population of either providers, residents, or eligibles in the state directly affects the calculation of the provider to resident ratio.
This change, in turn, is reflected by an increase or decrease in the number of required providers for a county when the ratio is applied to the county-specific Medicaid managed care eligibles. 
  
 The 2004 dental provider numbers increased because the number of dental providers in the
state increased. This increase in the actual number of statewide dental providers affected the provider to resident ratio described above and therefore, led to an increase in the recommended number of dental providers for each county. If the
MCP is able to adequately provide their members with access to all Medicaid-covered dental services, then ODJFS will not consider the MCP to be out of compliance with the dental panel requirement even if the MCP’s dental provider panel does not
meet the recommendations as specified in Appendix H. 
  

 11 

 Appendix I 
  
 Appendix I – Program Integrity 
  
 Although there are no proposed changes to this appendix we would like to offer some comments. Considering PCP turnover rate has such significant incentive outcomes, we
request that providers who are termed from the MCP for fraud and abuse issues, including those providers terminated after receiving notification from ODJFS, be excluded from the PCP turnover rate calculation. 
  
 Response: The PCP turnover rate is based on the HEDIS practitioner turnover measure which
specifies that there are no exclusions from the denominator. All providers are to be included regardless of whether they died, retired, relocated, or were terminated. The HEDIS methodology does not define ‘terminated’ providers.
Therefore, all terminated providers are to be included in the measure regardless of the reason for their termination. 
  
 Appendix K 
  
 Appendix K, Page 1, Section 1 – Performance Improvement Projects 
  
 There is no further discussion of the requirements for PIPs. Was this an oversight? 
  
 Response: Additional discussion on the requirements for Performance Improvements Projects (PIPs) was not included in the SFY 2005 provider agreement because the SFY 2004
PIP process, as currently described in the provider agreement, will continue through SFY 2005. The protocols for the PIPs were developed by the ODJFS in accordance with guidelines established by the CMS. The PIP process includes 10 steps to design
and implement the quality improvement studies. For SFY 2004, ODJFS selected one clinical and non-clinical study and defined the study topic questions (Steps 1-2). The MCPs were required to develop the study topic indicators, identify the study
population, and define the sampling methods and the data collection procedures (Steps 3-6). Upon ODJFS approval of the MCPs’ PIP submission, the MCPs were expected to implement their PIPs in SFY 2004. 
  
 The remaining steps (7-10) in the PIP process will be completed during SFY 2005. MCPs will
submit PIP findings for ODJFS to review the data, analyze the results, and assess any progress made due to the implementation of the PIP. Additionally, the external quality review (EQR) vendor will review each MCP’s PIP submissions and submit
recommendations to ODJFS about the extent to which the findings of the MCPs’ PIPs are valid and reliable. A detailed letter instructing the MCPs of the requirements for the final phase and timeline of the PIP process will be distributed in the
near future. 
  

 12 

 Appendix K, Page 3, Section 5 – Non-Duplication Exemptions 
  
 MCPs believe the language contained in this section is overly restrictive.
Non-duplication exemptions could include use of HEDIS data in lieu of duplicating efforts in compiling clinical data. This exemption can also be used as an exemption for administrative reviews. MCPs oppose language that would prohibit either option
from going forward in SFY ’05. We strongly encourage the state to go forward in accepting HEDIS data for the next round of EQR clinical studies in SFY ’05 and, where possible, exempt eligible plans from portions of the administrative
review. 
  
 It was also our understanding that some of these revised
requirements were still under negotiation between the MCPs and the Bureau, such as issues in the Quality Assessment and Performance Improvement Program, Appendix K. MCPs and BMHC held a conference call meeting on this issue as late as Monday, May
24, 1:00 - 3:00 PM, for further discussion. With submission of comments on the provider agreement due Tuesday, May 25, including comments on Appendix K, it is extremely disappointing to see the SFY 05 Proposed Provider Agreement reflect an ODJFS
position without the results and discussion of the May 24 conference call. 
  
 Response: The language in the provider agreement was revised to reflect the revisions to 42 CFR 438.360 and 438.362 that became effective in October 2003. In reviewing the MCP and OAHP comments, it appears as though there was confusion
around the interpretation of the terms “exemption from the non-duplication of mandatory activities” and/or “deeming.” We believed that this distinction had been fully addressed during the March 24, 2004, monthly MCP meeting
(followed by the clarifying question and answer document) and the subsequent May 24, 2004, conference call. As discussed in our June 2, 2004, conference call and as outlined in the above-referenced CFR citations, MCPs that meet the specified
eligibility requirement(s) may be able to apply for an exemption only from portions of the administrative review conducted during the EQR. An exemption from the non-duplication of mandatory activities would not include the acceptance of HEDIS
data in lieu of the clinical quality of care studies. Additional language will be incorporated into Appendix K to clearly state that the exemption from the non-duplication of mandatory activities is only applicable to the administrative review.

  
 As discussed during the conference call, ODJFS’ EQR administrative review
is not scheduled to begin until Fall of 2004. ODJFS will work over the next few months to establish the components of the administrative review pursuant to 42 CFR 438.360 and 438.362. Once the components have been established, a detailed comparison
must then be made between ODJFS’ administrative review components and the National Committee for Quality Assurance’s (NCQA) standards. If ODJFS determines that elements of the administrative review are comparable to the NCQA standards,
then ODJFS can propose a process by which MCPs may apply for an exemption from the non-duplication of mandatory activities. ODJFS would then submit this proposal to CMS for review and approval. 
  

 13 

 Upon approval from CMS, the MCPs may be eligible to apply for exemption from portions of the administrative review during
SFY 2006. ODJFS recognizes that MCPs are concerned with the timeframe for this activity, however, it is anticipated that the planning and approval process for this written plan will take at least six to 12 months. Given this, the language in the
provider agreement identifying this timeframe must remain as originally proposed so as not to raise false expectations about the possibility of exemptions being awarded prior to SFY 2006 although we have attempted to further clarify the limitation
of what activities may be exempted. 
  
 ODJFS staff are committed to participating
in an on-going dialogue with the MCPs to explore proposed recommendations to the EQR process. 
  
 Appendix L 
  
 Appendix L, Page
1, Section 1 – Encounter Data 
  
 Encounter data volume minimums have
increased in most categories. We request the volumes be measured six (6) months after the report period to allow for adequate claims lag. 
  
 Response: The claims lag was shortened in SFY 2004 to give the MCPs feedback in a more timely manner after analysis showed that the data needed to set the standard was
significantly complete (i.e. the data had a high completion factor) after four months. ODJFS believes that more timely feedback will aid the MCPs in more quickly addressing poor quality encounter data submissions. The claims lag used to set the
standard and the claims lag used to calculate the results for the encounter data volume measure must match. If a longer claims lag is used in calculating the results than was used in setting the standard, then a completion factor would have to be
incorporated into the methods and the feedback would be delayed. The ODJFS believes it is more appropriate to use a calculation method that is more direct and timely than what was proposed. 
  
 Appendix L, Page 15, Section 6a – Penalties for Noncompliance 
  
 MCPs are concerned with language that provides ODJFS with unlimited discretion to apply
unconstrained penalties to an area of deficiency identified when an MCP is determined to be noncompliant with a standard. Caps on penalties are the norm in both the Ohio Revised Code and Administrative rules and serve as a protection and assurance
of a limit on consequences. This language should be removed and the cap of $300,000 should remain as written. 
  
 Encounter data volume minimums have increased in most categories. We request that the volumes be measured six (6) months after the report period to allow for adequate
claims lag. 
  

 14 

 Additionally, we request that the penalty for noncompliance with volume issues be revised to incorporate a rolling
year of quarters. A membership freeze would be inappropriate for this data quality measure when it was documented the issue was a variation in utilization of this service. The current methodology does not allow the noncompliant period to roll off.

  
 Response: The importance of accurate encounter data submitted by MCPs is
emphasized by ODJFS’ policy of conducting standard compliance evaluations on a quarterly basis. Encounter data is increasingly being used by ODJFS for a variety of reasons and accurate data is important to both ODJFS and the MCPs. Quarterly
evaluations are beneficial to the MCPs because it allows them to more easily and quickly correct errors that may arise which would be more difficult to accomplish if evaluations were only conducted annually. 
  
 The intent of the encounter data volume measure is to periodically assess the data quality of
encounter data submissions and provide an incentive for MCPs to evaluate and resolve instances where a particular measure indicates poor quality data. The expectation is that a particular deficiency will be resolved and therefore,
subsequent compliance for the deficient quarter and service category will not be an issue. In order to ensure the maintenance of accurate and complete historical data, encounter data volume will be monitored over time. A single year’s worth of
data is not considered sufficient for historical purposes. Considering that program evaluations and rate setting both require trending over a minimum of three years of encounter data and MCPs have the ability to add or delete encounters over any
time period, measuring the volume on a one year rolling basis would not be sufficient to ensure the data used meets minimum data quality standards. 
  
 ODJFS considers the penalty system in place to be a graduated system and not duplicative. Instead of starting with a new member selection freeze, MCPs who are
noncompliant with this measure for the first time are issued a sanction advisory. If noncompliance continues for the next quarter, a refundable financial penalty is imposed. The financial penalty is not repeated for consecutive quarters of
noncompliance. If noncompliance continues for three consecutive quarters, then a selection freeze is imposed. This system gives the MCP three quarters to resolve a data quality problem before enrollment is frozen. Penalties remain in place until
compliance with the standard(s) is achieved. Notwithstanding other provisions of this appendix and once an MCP comes into compliance with the standard(s), any financial penalties assessed against the MCP are returned and the MCP’s enrollment is
unfrozen. We believe that this graduated penalty system gives MCPs sufficient time to address and resolve data quality problems and underscores the importance ODJFS places on the submission of high quality encounter data. 
  

 15 

 Table 1 Standards. MCPs need to understand the basis for changes in the expectations. Please share the calculations
and methodology. 
  
 Response: 
  
 Calculating the Standards 
  
 Changes in the methods for calculating the standards reflect changes due to HIPAA and two
new considerations: county variances and seasonality (i.e., fluctuations in utilization from quarter to quarter). HIPAA required the elimination of local codes. The primary effect on this measures was the grouping of encounters in the ancillary and
primary/specialists categories of service. With the updated methods, all antepartum and postpartum visits are reported in one category of service (i.e., primary/specialist) versus a split across these two categories of service. To account for county
variances, results were calculated for each MCP by county (MCP/county) by quarter. An MCP/county average (across all MCPs) was then calculated for each quarter. The high outlier MCP/counties (e.g., counties with a significantly high result primarily
due to low enrollment) was excluded from the calculation of the average. In order to allow for seasonality in the data, the quarter with the lowest average was used to establish the standard. As in previous years, once the average for a category of
service was established the standard was set at 1.5 standard deviations below the average. 
  
 Changes in Methodology 
  
 It should be noted that the SFY 2005 methods were calculated using CY 2003 encounter data. The SFY 2004 methods used CY 2002 data. 
  
 Inpatient: There were no changes in methodology for this service category. The change in the
standard (from 5.4 to 5.0) reflects the seasonality effect described above. 
  
 Emergency Department: The methodology was revised to exclude any ED encounters with a behavioral health diagnosis or procedure code in order to be more consistent with HEDIS methodology. However, the actual standard increased because the
encounter data for CY 2003 reflects a higher number of ED encounters submitted per member per month. 
  
 Dental: There was no change to the dental methodology. The increase in the standard reflects improvements in data quality. 
  
 Vision: The vision methodology was changed to exclude the “supply of materials” current procedural terminology (CPT) codes 93290-92396. These codes represented
a small number of encounters and did not significantly affect the calculation of the standard. This measure is not intended to include frames and lenses and therefore should not include the “supply of materials” codes. In addition, the
county variance added to the drop in the standard for this measure. 
  
 Primary
and Specialist Care: This measure was revised to include all antepartum and postpartum visits reported with CPT codes 59420, 59425, 59426, 59430 (which were previously included in the ancillary category). 
  

 16 

 Ancillary Services: This measure was revised to exclude the antepartum and postpartum visits referred to above under
primary and specialist care. 
  
 Behavioral Health: There was no change to the
methodology for this service category. 
  
 Pharmacy: There was no change to the
methodology for this service category. However, pharmacy encounters for one MCP were under-reported in the past. The issue was resolved, the MCP’s pharmacy encounter data has been corrected, and the SFY 2005 standard reflects this correction.

  
 Appendix L, Page 15, section 6.a. – Penalties, Including Monetary
Sanctions, for Noncompliance 
  
 Regarding the language added on page 15,
6.a., we request that the following statement be added “The appropriate penalty would not exceed the penalty described in each section and sub-section”. 
  
 The quarterly evaluation table has the propensity to penalize an MCP quarter after quarter if they have one bad quarter. The table
instead should be based upon a rolling annual basis, evaluating no more than 1 year at a time. A bad quarter in 2003 continues to affect reporting through May of 2006! 
  
 Please specify “.....ODJFS reserves the right to apply the most appropriate penalty.....” This would seem to have the potential to for a MCP to be subject to a more severe penalty than what is stated in the appendix. 

 
 Response: The second sentence of this paragraph that states, “[p]enalties for
noncompliance on an individual measure for each period compliance is determined in this appendix will not exceed $300,000,” has been moved to the end of the paragraph to clarify that this monetary cap applies to all provisions of the paragraph.

  
 Appendix M 
  
 Appendix M, Page 15, Section 4.b – Emergency Department Diversion 
  
 Language in this section designates the SFY 2005 contract reporting period for a baseline
level for more a restrictive performance standard for EDD using the January – June, 2004 report period. The next reporting period cited, July – December 2004, would be used for comparison to determine if the minimum performance standard is
met. Because of this proposed change in the EDD target, it is virtually impossible to have this significant of an impact during this reporting period. MCPs recommend maintaining the 1.0% minimum performance standard. 
  

 17 

 Impacting EDD requires extensive resources and interventions on behalf of MCP staff. The lack of necessary incentives
such as co-payments and the existence of prudent layperson requirements leave little room in trying to successfully impact the use of emergency rooms to the level being proposed. To demonstrate the impact, the OAHP commercial plans reported a 45%
increase in ER utilization since the passage of prudent layperson into Ohio law. 
  
 This appendix establishes a target of 0.7% for the Emergency Department Diversion measure. This contradicts the SFY 2004 provider agreement that states “for report period of contract period SFY 2005 (July-December, 2004) the minimum
performance standard is 1.0%.” Is there a national benchmark to indicate this is an achievable target? 
  
 While we understand the minimum standard includes a 10% gap decrease, not requiring us to achieve the 0.7% rate, our concerns remain; the continuing decrease in the
performance standard of a measure with such significant financial implications and a measure in which MCPs are limited by legislation to impose known utilization reducing processes. 
  
 4.b. Changing a target from 1% to 0.7% of the eligible population having four or more ED visits during the reporting period is
unrealistic in a one-year period of time. While we fully support improving quality results year over year, a target of 30% improvement from a program already experiencing good results isn’t appropriate. Even the minimum performance standard of
a 10% improvement in the difference between the target and baseline results is unrealistic for a State program already performing strongly. Incremental change at that high level of performance can become cost prohibitive, particularly in a program
where there’s no opportunity to help drive compliance levels by member cost sharing techniques. ODJFS should set targets upon a more realistic basis. 
  

We would like clarification of the following points in Appendix M: The reduction of the ED Diversion Target to 0.7%. 
  
 Response: The change in methods reduces the expected level of improvement for all MCPs
performing at a rate above 1.0%. For an MCP with a rate of 1.5%, the existing standard expects a reduction of 0.5% or 33%. By changing the standard to account for the expectation that the difference between last year’s result and 0.70% would be
reduced by 10%, the same MCP would be expected to reduce their result by 0.08% or 5.3%. 
  
 For MCPs that are already performing at or below the previously established 1.0% standard, the change in method required them to maintain their performance versus allowing the level of their performance to drop below the 1.0% standard. In
recognition of the increase in the expected level of performance, a change was made to the proposed standard to lower the expected level of performance for MCPs in the above situation. 
  

 18 

 Similar to what was done regarding the clinical performance measures, a breakpoint was established where MCPs that are
performing better than average (i.e., at or below 1.1%) but do not meet the standard level of performance will be issued a quality improvement directive. 1.1% was chosen because it is the current program average. 
  
 MCPs not meeting the standard level of improvement and are above the average, must develop a
corrective action plan and ODJFS may direct the MCP to develop the components of their EDD program as specified by ODJFS. 
  
 ODJFS recognizes that this measure is integral to the incentive system. As you know, ODJFS’ actuary calculates actuarially sound capitation rates and ODJFS adds 1%
as an incentive to improve performance in specific areas important to the Medicaid MCPs’ members. MCPs receive the extra 1% with their monthly premium payments. To retain the extra amount, MCPs must achieve a minimum level of performance on
selected measures and improve performance by meeting higher standard levels for three selected measures. MCPs that do not qualify for or meet the higher performance standards must return the extra 1% because the MCP did not complete this deliverable
as specified in the provider agreement. 
  
 With the changes to the standard in
appendix M for the EDD measure, accompanying changes were made to the EDD minimum performance expectation in the incentive system in appendix O. As with the clinical performance measures, MCPs that meet the breakpoint established in appendix M are
considered to have met the minimum performance level needed to qualify for the retention of incentive payments made in accordance with the incentive system. 
  
 Appendix M – Case Management of ODJFS-Mandated Conditions 
  
 Regarding Measure 2, Case Management of ODJFS-Mandated Conditions, please clarify the correct verbiage. In the methodology documents the verbiage is “17 years of
age and under” while the verbiage in the Provider Agreement, SFY2004 and SFY2005, states “under 17 years of age”. We believe the verbiage should be identical in the two documents. 
  
 Response: The correct language is, ‘children 17 and under’ and the provider
agreement has been corrected to reflect this. 
  

 19 

 Appendix O 
  
 Appendix O – Performance Incentives 
  
 This section indicates that the methodologies for 2005 measures can be found on the website listed. However, this information is not updated for 2005 as noted. The
MCPS request a hard copy or electronic version of the 2005 methodologies be sent before final acceptance of the SFY ‘05 provider agreement. 
  
 The website listing the “detailed description of the methodologies of each measure” www.jfs.ohio.gov/ohp/ODJFS/managed.stm contains information from SFY
2004. We would like a chance to review the draft methodologies. When can we expect updated information to appear? 
  
 Response: The updated methods were finalized and sent to all MCPs during the second week of June. 
  
 Additionally, this section makes reference to “national benchmarks”. MCPs request a citation on the source of the national
benchmarks used for these measures. 
  
 The ODJFS should share the
methodology used to calculate the standards, and define where the National Benchmarks are obtained. 
  
 Response: The figures were established based upon national Medicaid results, as obtained from NCQA at: 
  
 http://www.ncqa.org/Programs/HEDIS/02medicaid.htm 
  
 National results were available for all of the measures except for the lead screening measure. To avoid confusion, the term “National Benchmark” will be changed
to “Medicaid Benchmark.” 
  
 Although not specifically addressed in
the proposed revisions to the Provider Agreement, we would like to take this opportunity to request ODJFS allow all claims be submitted through the encounter data process. ODJFS and HSAG cite HEDIS as benchmarks, however, MCPs are allowed to submit
denied claims only for immunizations. As you know HEDIS accepts all submitted claims regardless of final adjudication status. We believe ODJFS should adopt the same practice and allow MCPs to submit all claims, regardless of final status.

  
 Response: ODJFS will be modifying the encounter data specifications in the
future. ODJFS cannot allow denied encounters to be submitted at this time because we would not be able to differentiate between the denied and paid claims. Rate setting requires the use of only paid claims. Once we are able to differentiate between
these two claim types, we will include them in the specifications. 
  

 20 

 APPENDIX A 
  

OAC RULES 5101:3-26 
  
 The managed care program rules can be accessed electronically through the following website: 
  
 http://emanuals.odjfs.state.oh.us/emanuals/medicaid/MHC/@Generic_BookView;cs=default;ts=default 
  

 APPENDIX B 
  

MCP PROCUREMENT AND PRE-CONTRACTING REQUIREMENTS 
  
 The Ohio Department of Job and Family Services (ODJFS) has an open procurement process (pursuant to 45 CFR 92.36 whereby any qualifying entity may request consideration
to receive a Managed Care Plan (MCP) provider agreement from ODJFS. Prospective MCPs interested in participating in Ohio’s Medicaid managed care program must submit a formal letter of intent to the Chief of the Bureau of Managed Health Care
(BMHC) which specifically states that the prospective MCP wishes to actively pursue a provider agreement with ODJFS. Upon receipt of this letter, BMHC staff will schedule a meeting with the prospective MCP, following which ODJFS will provide the
prospective MCP with a follow-up letter further outlining the pre-contracting requirements specified in this Appendix and the projected timetable required for the MCP to receive a provider agreement. The projected timetable to receive a provider
agreement to serve Medicaid eligibles in counties currently not included in Appendix E (Rate Methodology) and/or Appendix H (Provider Panel Specifications) may need to incorporate sufficient time for ODJFS to determine the appropriate capitation
rates and/or provider panel requirements for these service areas. ODJFS may require that some counties may only be included in a provider agreement if they are part of a larger group or cluster of counties which would constitute one combined service
area. 
  
 ODJFS may at its discretion allow a prospective MCP to begin the
pre-contracting process prior to the receipt of their certificate of authority (COA) from the Ohio Department of Insurance. However, the MCP must have a valid COA prior to entering into a provider agreement with ODJFS. A prospective MCP that
previously had a provider agreement with ODJFS must comply with all procurement and pre-contracting requirements prior to receiving a new provider agreement. If the prior provider agreement terminated more than two years prior to the effective date
of any new provider agreement, such MCP will be considered a plan new to Ohio Medicaid Managed Care and in its first year of operation. 
  
 Prior to ODJFS’ issuance of a provider agreement, a prospective MCP must demonstrate the capability to meet all applicable program requirements specified in Chapter
5101:3-26 of the Ohio Administrative Code (OAC) and the ODJFS - MCP Provider Agreement. This demonstration will include a review of documentation and data submitted by the prospective MCP, and may also include an on-site review of the prospective
MCP’s administrative operations. The ODJFS’ review and approval of submissions from the prospective MCP includes, but is not limited to the following: 
  

	1.	Administrative submissions: 

  

	 	a.	a listing of the counties the prospective MCP initially proposes to serve; 

  

	 	b.	an Ohio Medicaid Provider Number Application, including a request for Taxpayer Identification Number and Certification (W-9) authorization agreement for state Medicaid payments and
an electronic funds transfer (EFT) application; 

  

 Appendix B 
 Page 2

  

	 	c.	the designation of an individual who will serve as the primary point of contact between the prospective MCP and ODJFS. A different individual may be designated as the contact person
for the prospective MCP’s management information systems; 

  

	 	d.	a statement confirming the organization’s willingness to accommodate on-site visits to their administrative offices, its participating provider facilities, and its
subcontractors by ODJFS representatives and/or designees; 

  

	 	e.	a description of the prospective MCP in terms of practice model type (e.g., group model, staff model, individual practice association, etc.); 

  

	 	f.	a table of organization; 

  

	 	g.	a statement of affirmative action that the prospective MCP does not discriminate in its employment practices with regard to race, color, religion, sex, sexual orientation, age,
disability, national origin, veteran’s status, ancestry, health status or need for health services; 

  

	 	h.	information including name, address, and association of any individual/ group/entity that will be assisting the prospective MCP with the submission of documentation to ODJFS;

  

	 	i.	a signed copy of the ODJFS-required form guaranteeing compliance with noncompetitive bid provisions; and 

  

	 	j.	notification if the MCP elects not to provide, reimburse for, or provide coverage of, a counseling or referral service because of an objection on moral or religious grounds.

  

	2.	Completed personalized Model Medicaid Addendums as described in OAC rule 5101:3-26-05 and Appendix H of this provider agreement which incorporate all applicable Ohio Administrative
Code rule requirements specific to provider subcontracting. 

  

	3.	Completed MCP Delegation of Services form(s), as applicable. 

  

	4.	Provider panel and subcontracting requirements: Prospective MCPs must submit documentation to verify compliance with provider panel and subcontracting requirements specified
in OAC rule 5101:3-26-05 and Appendix H of this provider agreement. 

  

	5.	MIS Requirements: Prospective MCPs must meet the Health Information Systems requirements and formats specified in Appendix C of this provider agreement and may be required to
complete an information systems questionnaire. MCPs must allow adequate time to meet encounter data requirements (on average it has taken most MCPs approximately four months to successfully complete encounter data testing). ODJFS will not accept
encounter data test tapes from the prospective MCP or their ODJFS-approved delegated entity(ies) until the prospective MCP has received an Ohio Medicaid Provider Number. Before ODJFS enters into a provider agreement, ODJFS or designee may review the
information system capabilities of each prospective MCP as described in Appendix C of this provider agreement. 

  

 Appendix B 
 Page 3

  

 In addition to encounter data testing, the prospective MCP will be required to demonstrate to ODJFS
their capability to successfully provide the following required electronic file submissions in the specified formats: Screening Assessment and Case Management System (SACMS), appeals and grievances, newborn notification and member-designated primary
care physician (PCP) files. 
  

	6.	Verification of operational program requirements specified by ODJFS, including but not limited to, the following areas: 

  

	 	a.	Care coordination with non-contracting providers requirements specified in OAC rule 5101:3-26-03.1; 

  

	 	b.	Call Center requirements specified in Appendix C of this provider agreement; 

  

	 	c.	Case Management requirements specified in OAC rule 5101:3-26-03.1 and Appendix G of this provider agreement; 

  

	 	d.	Children with Special Health Care needs requirements specified in Appendix G of this provider agreement; 

  

	 	e.	Program Integrity requirements specified in OAC rule 5101:3-26-06 and Appendix I of this provider agreement; 

  

	 	f.	Appeal, Grievance and State Hearings requirements specified in OAC rules 5101:3-26-08.3, 08.4, and 08.5. 

  

	 	g.	Interpreter Services requirements specified in OAC rules 5101:3-26-03.1(A)(7)(c), 5101:3-26-05(D)(26), 5101:3-26-08,5101:3-26-08.2, and Appendix C of this provider agreement;

  

	 	h.	Requirements for marketing materials including marketing staff training (if applicable), solicitation brochure, and marketing plan as specified in OAC rule 5101:3-26-08.2;

  

	 	i.	New member material requirements including Member Identification (ID) Card, Member Handbook, Provider Directory and Advance Directives Notification as specified in OAC rule
5101:3-26-08.2; 

  

	 	j.	Utilization Management and Prior Authorization requirements specified in OAC rule 5101:3-26-03.1 and Appendix G of this provider agreement; and 

  

	 	k.	Quality Assessment and Performance Improvement (QAPI) requirements specified in OAC rule 5101:3-26-07.1 and Appendix K of this provider agreement. 

  

	7.	Prospective MCPs must attend and participate in mandatory technical assistance sessions provided by ODJFS. 

  

	8.	Financial submissions: Prospective MCPs must submit the following documentation to verify compliance with the financial requirements specified in OAC rule 5101:3-26-09 and Appendix
J of this provider agreement. 

  

 Appendix B 
 Page 4

  

	 	a.	Evidence of reinsurance coverage from a licensed commercial carrier to protect against catastrophic inpatient-related medical expenses incurred by Medicaid members;

  
 Quarterly, Annual and Independently Audited
Annual National Association of Insurance Commissioners (NAIC) Financial Statements for the past three years for all lines of business. If the MCP has been operating for fewer than three years, then MCP should provide the referenced NAIC financial
statements for the available years. 
  

	9.	Membership Data and Reconciliation: Prospective MCPs must complete the Membership Data Maintenance and Reconciliation questionnaire and demonstrate the following membership
data and reconciliation requirements: 

  

	 	a.	Capability to accept and utilize consumer contact record (CCR) data; 

  

	 	b.	Capability to accept and maintain membership data contained on the monthly member roster (MMR); 

  

	 	c.	Capability to accept and reconcile premium and delivery payments with the monthly remittance advice; 

  

	 	d.	Capability to reconcile membership data with remittance advice; 

  

	 	e.	Capability to accept and maintain pending member-provided information, such as PCP choice, hospitalization reporting, etc., prior to receiving and reconciling the CCR and MMR; and

  

	 	f.	Identification of new members hospitalized prior to and remaining hospitalized on the effective date of MCP membership. 

  
 MCP Provider Agreement Amendments 
  
 MCPs currently participating in Ohio’s Medicaid managed care program that are
interested in amending their provider agreement to serve eligible Medicaid individuals in additional counties, must submit a formal letter of intent to the Chief of the Bureau of Managed Health Care (BMHC) that specifically states the additional
counties the MCP wishes to actively pursue. MCPs that identify counties currently not included in Appendix E (Rate Methodology) and/or Appendix H (Provider Panel Specifications) must be advised that ODJFS will require sufficient time to determine
the appropriate capitation rates and/or provider panel requirements for these service areas. ODJFS may require that some counties may only be included in a provider agreement if they are part of a larger group or cluster of counties which would
constitute one combined service area. 
  

 Appendix B 
 Page 5

  

 ODJFS’ review and approval of submissions from the MCP to amend their provider agreement to include additional
counties includes, but is not limited to the following: 
  

	 	i.	An Ohio Medicaid Provider Number Application, including a request for Taxpayer Identification Number and Certification (W-9) authorization agreement for state Medicaid payments and
an electronic funds transfer (EFT) application; 

  

	 	ii.	A copy of the MCP’s currently approved Model Medicaid Addendums that are revised to include the additional counties, if applicable; 

  

	 	iii.	Completed MCP Delegation of Services form(s), as applicable; 

  

	 	iv.	Documentation to verify compliance with provider panel and subcontracting requirements specified in OAC rule 5101:3-26-05 and Appendix H of this provider agreement;

  

	 	v.	Verification of operational program requirements specified by ODJFS for each additional service area, including but not limited to the following areas: 

  

	 	a.	Coordination with non-contracting provider requirements specified in OAC rule 5101:3-26-03.1; 

  

	 	b.	Requirements for marketing materials including marketing staff training (if applicable), solicitation brochure, and marketing plan as specified in OAC rule 5101:3-26-08;

  

	 	c.	New member material requirements including member handbook and provider directory as specified in OAC rule 5101:3-26-08.2; 

  

	 	vi.	Evidence that the MCP’s reinsurance policy from a licensed commercial carrier to protect against catastrophic inpatient-related medical expenses incurred by Medicaid members
covers members in the additional counties; 

  

	 	vii.	Revisions to previously submitted county-specific information/materials/ procedures to include the new service areas; 

  

	 	viii.	Documentation of the ability to meet all program requirements, in consideration of the potential additional membership, as requested by ODJFS. 

  

 APPENDIX C 
  

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

	1.	The MCP agrees to implement program modifications in response to changes in applicable state and federal laws and regulations. 

  

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

  

	3.	The MCP must designate 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. 

  

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

  

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

  

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

  

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

  

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

  

 Appendix C 
 Page 2

  

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

  

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

  

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

  

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

  

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

  

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

  

	15.	MCPs must comply with any applicable Federal and State laws that pertain to member rights and ensure that its staff and affiliated providers take those rights into account when
furnishing services to members. 

  

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

  

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

  

 Appendix C 
 Page 3

  

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

  
 All MCPs must
comply with the requirements specified in OAC rules 5101:3-26-03.1, 5101:3-26-05(D), 5101:3-26-08 and 5101:3-26-08.2 for providing assistance to LEP members and eligible individuals. In addition, MCPs must: 
  

	 	a.	Provide written translations of certain MCP materials in the prevalent non-English languages of members and eligible individuals in accordance with the following:

  

	 	i.	When 10% or more of the eligible individuals in the MCP’s service area have a common primary language other than English, the MCP must translate all ODJFS-approved marketing
materials into the primary language of that group. The MCP must monitor, on an ongoing basis, changes in the eligible population in the service area to determine which, if any, primary language groups meet the 10% threshold; and

  

	 	ii.	When 10% or more of an MCP’s 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, on an ongoing basis, changes in their membership to determine which, if any, primary language groups meet the 10% threshold. 

  

	 	b.	Utilize a centralized database which records all MCP member primary language information (PLI) when identified by the following sources, including but not limited to: MCP staff
(e.g., member services and case management staff), the MCP’s providers, members, or member representatives; ODJFS; and the ODJFS selection services entity. This centralized database must be readily available to MCP staff and be used in
coordinating communication and services to LEP members, including the selection of a PCP who speaks the member’s primary language, when available. MCPs must share PLI with their providers [e.g., PCPs, Pharmacy Benefit Managers (PBMs), and Third
Party Administrators (TPAs)], as applicable. ODJFS may periodically request a summary of the MCP’s LEP members. 

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

 Appendix C 
 Page 4

  

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

  

	21.	Pursuant to OAC rule 5101:3-26-08 and 5101:3-26-08.2, the MCP is responsible for ensuring that all MCP marketing and member materials are prior approved by ODJFS. Marketing and
member materials are defined as follows: 

  

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

  

	 	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. 

  

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

  

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

  

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

  

	 	i.	Provides written information to all adult members concerning: 

  

	 	a.	the member’s rights under state law to make decisions concerning their medical care, including the right to accept or refuse medical or surgical treatment and the right to
formulate advance directives. 

  

 Appendix C 
 Page 5

  

	 	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 90 days after the proposed effective date of the change; and 

  

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

  

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

  

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

  

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

  

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

  

	23.	Call Center Standards 

  
 The MCP must provide assistance to enrollees 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 at all times to provide assistance to members through the toll-free call-in system every Monday through Friday, 8:30 a.m. to 4:30 p.m., except for major holidays as specified in the MCP’s member handbook, member
newsletter, or other general issuance to the MCP’s members. ODJFS defines a major holiday as a day when much of the workforce is exempt from work to commemorate an event (i.e., holiday closure days normally observed by banks, government
offices, or many businesses). 
  
 The MCP must also provide
access to medical advice and direction through a centralized twenty-four-hour toll-free call-in system pursuant to OAC rule 5101:3-26-03.1(A)(6). 
  

 Appendix C 
 Page 6

  

 The twenty-four hour call-in system must be staffed by appropriately trained medical personnel. For
the purposes of meeting this requirement, trained medical professionals are defined as physicians, physician assistants, licensed practical nurses, and registered nurses. 
  
 MCPs must meet the current American Accreditation HealthCare Commission/URAC-designed Health Call Center Standards (HCC) for
call center abandonment rate, blockage rate and average speed of answer. By the 10th of each month, MCPs must
self-report their prior month performance in these three areas for their member services and twenty-four-hour toll-free call-in systems to ODJFS. ODJFS will inform the MCPs of any changes/updates to these URAC call center standards. 
  

	24.	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. 

  

	 	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. 

  

 Appendix C 
 Page 7

  

	 	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. 

  

	25.	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 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 8

  

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

  

	 	e.	Just Cause and Continuity of Care Deferment 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: Effective December 1, 2003, the MCP is required to submit newborn notifications to ODJFS in accordance with the ODJFS Newborn Notification File and
Submissions Specifications. 

  

	 	g.	Pending Member 

  

	 	(i)	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 and ensure that any care coordination (e.g., PCP selection, continuity of care) information provided by the member is forwarded to the appropriate MCP staff for processing. Such communication does not constitute
confirmation of membership. 

  

	 	(ii)	Upon receipt of the CCR, the MCP may contact pending members to confirm information provided on the CCR that is unrelated to health status and to inquire if the pending member has
any membership questions. In the case of pending members who have actively selected membership (as opposed to assigned members), the MCP may also confirm any health status information provided on the CCR. 

  

 Appendix C 
 Page 9

  

	26.	Health Information System Requirements 

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

	 	a.	Health Information System 

  

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

  

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

  

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

  

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

  

	 	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 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, suspended) within one month of submission. Such notification may be in the form of a claim payment/remittance advice produced on a routine monthly, or more frequent,
basis. 
  

 Appendix C 
 Page 10

  

 Electronic Data Interchange 
  
 The MCP shall comply with all applicable provisions of HIPAA including electronic data interchange (EDI) standards for code
sets and the following electronic transactions: 
  
 Health care
claims; 
  
 Health care claim status request and response;

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

 Appendix C 
 Page 11

  

 Verification of Compliance with HIPAA (Health Insurance Portability and Accountability Act of
1995) 
  
 MCPs shall submit written verification, prior to
the compliance dates for transaction standards and code sets specified in 42 CFR Part 162 – Health Insurance Reform: Standards for Electronic Transactions (HIPAA regulations), that the MCP has established the capability of sending and receiving
applicable transactions in compliance with the HIPAA regulations. The written verification shall specify the date that the MCP has: 1) achieved capability for sending and/or receiving the following transactions, 2) entered into the appropriate
trading partner agreements, and 3) implemented standard code sets. If the MCP has obtained third-party certification of HIPAA compliance for any of the items listed below, that certification may be submitted in lieu of the MCP’s written
verification for the applicable item(s). 
  

	 	1.	Trading Partner Agreements 

  

	 	2.	Code Sets 

  

	 	3.	Transactions 

  

	 	a.	Health Care Claims or Equivalent Encounter Information (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 the provider agreement may be waived at the discretion of ODJFS; if submission prior to entering into the provider agreement is waived, the trading partner agreement must be submitted at a subsequent date determined by ODJFS.

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

 Appendix C 
 Page 12

  

	 	c.	Encounter Data Submission Requirements 

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

	 	•	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 help set MCP capitation rates. For these reasons, it is important that encounter data is timely, accurate, and complete. Data quality and performance measures and standards are described
in the MCP Provider Agreement. 
  
 An encounter represents all of
the services, including medical supplies and medications, provided to a member of the MCP by a particular provider, regardless of the payment arrangement 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). 
  

 Appendix C 
 Page 13

  

 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. 
  
 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 tape in the required formats prior to contracting or prior to an information systems replacement or update. 
  
 Acceptance testing of encounter data is required: 
  

	 	(i)	Before an MCP may submit “production” encounter tapes; and/or 

  

	 	(ii)	Whenever an MCP changes the method or preparer of the electronic media; and/or 

  

	 	(iii)	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 encounter data 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 tapes. Once an acceptable test file is submitted to ODJFS, the MCP can return to submitting production files. ODJFS will
inform MCPs in writing when a test file is acceptable. Once an MCP’s new or modified information systems are operational, that MCP will have up to 90 days to submit an acceptable test file and an acceptable production file. Submission of test
files can start before the new or modified information systems are 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. 
  
 Encounter Data Tape Submission Procedures 
  
 A certification letter must accompany the submission of an encounter data tape. 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. 
  

 Appendix C 
 Page 14

  

 No more than two production tapes per format (e.g., NSF) should be submitted each month. If it is
necessary for an MCP to submit more than two production tapes for a particular format in a month, they must request permission to do so through their Contract Administrator. 
  
 Timing of Encounter Data Submissions 
  
 ODJFS recommends that MCPs submit encounters no more than thirty-five days after the end of the month in which they were
paid. For example, claims paid in January are due March 5. ODJFS recommends that MCPs submit tapes by the 5th of each month. This will help to ensure that the encounters are included in the ODJFS master file in the same month in which they were
submitted. 
  

	 	d.	Information Systems Review 

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

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

  

	 	(ii)	Review the completed ISCA and accompanying documents; 

  

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

  

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

  

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

  

	 	(vi)	Examine MCP processes for data transfers; 

  

 Appendix C 
 Page 15

  

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

  

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

  

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

  
 As noted above, the information system review may be performed every two years. However, if ODJFS or its designee identifies significant information
system problems, then ODJFS or its designee may conduct, and the MCP must participate in, a review the following year. 
  
 If an MCP had an assessment performed of its information system through a private sector accreditation body or other independent entity within the two
years preceding when the ODJFS or its designee will be conducting its review, and has not made significant changes to its information system since that time, and the information gathered is the same as or consistent 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. 
  

	27.	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. 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. 
  

 Appendix C 
 Page 16

  

 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 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 tape. Tracking, correcting and resubmitting all rejected encounters is the responsibility of the MCP and is required by
ODJFS. 
  
 Timing of Delivery Payments 
  
 MCPs will be paid monthly for deliveries. For example, payment for a
delivery encounter submitted with the required encounter data submission in March, will be reimbursed in March. The delivery payment will cover any encounters submitted with the monthly encounter data submission regardless of the date of the
encounter, but will not cover encounters that occurred over one year ago. This payment will be a part of the weekly update (adjustment payment) that is in place currently. The third weekly update of the month will include the delivery payment. The
remittance advice is in the same format as the capitation remittance advice. A delivery payment will be indicated by the code >MC00W= in the >Proc-Mod / Revenue-Proc / Drug Code= field. All other information will be the same as a capitation payment. 
  

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). 
  

 Appendix C 
 Page 17

  

 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.

  

	28.	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. 

  

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

  

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

  

	31.	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 D 
  

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

  

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

  

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

 

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

  

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

  

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

  

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

  

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

  

	8.	ODJFS will recalculate the geographic accessibility standards, using the geographic information systems (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.

  

 Appendix D 
 Page 2

  

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

  

	11.	County Designation (Voluntary/Mandatory /Preferred Option Designation) 

  

Membership in a service area is voluntary unless ODJFS approves membership in the service area for Preferred Option or mandatory status. It is
ODJFS’ intention to implement mandatory managed care programs in service areas wherever choice and capacity allow and the criteria in 42 CFR 438.50(a) are met. An MCP in a voluntary county that believes it exceeds minimum capacity requirements
and possesses an exemplary performance history may request that ODJFS designate the county as Preferred Option and the plan as the Preferred Option MCP. 
  

	12.	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.

  

	13.	Membership Selection and Premium Payment 

  

	 	a.	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. 

  

 Appendix D 
 Page 3

  

 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.	Assignments: ODJFS or the SSC shall assign to an MCP those eligible individuals in mandatory and Preferred Option counties who fail to make a health plan selection following
receipt of notice to do so. Assignments shall be based on previous MCP membership history or previous Medicaid FFS primary care relationships when possible. 

  

	 	c.	Consumer Contact Record (CCR): ODJFS or their designated entity shall forward CCRs to MCPs on no less than a weekly basis. 

  

	 	d.	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.

  

	 	e.	Remittance Advice: ODJFS will confirm all premium payments and delivery payments to the MCP during the month via a monthly remittance advice (RA), which is sent to the MCP
the week following state cut-off. 

  

	 	f.	MCP Reconciliation Assistance: ODJFS will work with an MCP-designated contact(s) to resolve the MCP’s member and newborn eligibility and premium payment inquiries and
discrepancies and hospital deferment request determinations. 

  

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

  

	15.	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. 

  

 APPENDIX E 
  

RATE METHODOLOGY 
  

 MERCER 

			
	 Government Human Services Consulting
	 	 800 LaSalle Avenue, Suite 2100
 Minneapolis, MN 55402-2012
 612 642 8892 Fax 612 642 8911
 angela.wasdyke@mercer.com
 www.mercerHR.com

  
 November 11, 2003 
  
 Ms. Mitali Ghatak 
 Office of Health Plan Policy 
 Ohio Department of Job and Family Services 
 30 East Broad Street, 27th Floor 
 Columbus, Ohio 43215-3414 
  
 Subject: 
  
 July 1, 2003 - December 31, 2004 Capitation Rate Final Certification 
  
 Dear Mitali: 
  
 The Ohio Department of Job and Family Services (State) contracted with Mercer Government Human Services Consulting (Mercer) to develop actuarially sound capitation rates
for use during July 1, 2003 through December 31, 2004. Six (6)-month rates were developed for the period July 1, 2003 through December 31, 2003 and twelve (12) - month rates were developed for the period January 1, 2004 through December 31, 2004. As
part of the rate-setting process, Mercer developed a Data Book summarizing Ohio’s historical Medicaid fee-for-service (FFS) cost and utilization experience. This letter, together with the Data Book, details the methodology used to determine the
fee-for-service equivalents (FFSEs) and capitation rates for the Healthy Families (HF) and Healthy Start (HST) populations. 
  
 Overview 
  

	I.	Data Book 

  

	II.	Develop FFSEs 

  

	III.	Develop Capitation Rates 

  

	IV.	Certification of Final Rates 

  

	I.	Data Book 

  
 The rate-setting process began with summarizing the FFS data from calendar years (CY) 1998-2000, which is contained in the Data Book dated March 29, 2002. This data was validated by the State as outlined in the
Centers for Medicare and Medicaid Services’ (CMS) Rate Checklist. 
  
 During
the time period of this base data, three significant expansions took place in Ohio that have an effect upon the 6-month and 12-month rates. These expansions increased eligibility 

  

 [GRAPHIC] Marsh & McLennan Companies 

 MERCER 
 Government Human Services Consulting 
  
 Page 2 
 November 11, 2003 
 Ms. Mitali Ghatak 
 Ohio Department of Job and Family Services 
  

 
definitions for covered populations and included populations previously ineligible. These expansion populations are listed below: 
  

	 	•	January 1998 Child Expansion: Healthy Start – children < age 19 up to 150% federal poverty level (FPL), 

  

	 	•	January 2000: Pregnant women up to 150% FPL, 

  

	 	•	July 2000 Child Expansion: CHIP II – children < age 19 up to 200% FPL, and 

  

	 	•	July 2000 Parent Expansion: Parent Expansion up to 100% FPL. 

  
 For July 1, 2003 through December 31, 2004 rate-setting purposes, historical experience was available in sufficient quantity only for the first expansion occurring in
January 1998. Although the experience for the January and July 2000 expansions was reviewed, it was not used in rate setting since it was determined insufficiently credible. Instead, non-expansion and credible expansion data were blended together to
account for the new populations. 
  
 The FFS data are categorized by rate cohort.
The basis of these rate cohorts is the demographics of the population and the treatment patterns and risks associated with each group. For this reason, newborns are isolated, males and females are separated where differences exist, maternity is
separated from non-maternity, and ages are split into groupings based on levels of expenses. More detail regarding these breakdowns, services covered, and any adjustments made to this data are outlined in the Data Book. Some of the adjustments
applied to the FFS data are: 
  

	 	•	Incurred claims completion factors, 

  

	 	•	Gross adjustments for payments not processed through MMIS, 

  

	 	•	Third party liability, 

  

	 	•	Hospital settlements, 

  

	 	•	Pharmacy rebates, 

  

	 	•	Third trimester enrollment, 

  

	 	•	Retrospective eligibility costs, and 

  

	 	•	Fraud and abuse. 

  
 The data and corresponding adjustments are described in further detail in Sections 1 through 9 of the Data Book. 
  

 MERCER 
 Government Human Services Consulting 
  
 Page 3 
 November 11, 2003 
 Ms. Mitali Ghatak 
 Ohio Department of Job and Family Services 
  

	II.	Develop FFSEs 

  
 The FFSEs represent the corresponding claims experience expressed on a per member per month (PMPM) basis for a population that is actuarially equivalent to the population that will be enrolled in the managed care
program during the 6-month and 12-month periods. 
  
 The FFSEs are derived from
further adjusting the data contained in the Data Book. These further adjustments are described in the following sections: 
  

	A.	Historical Trend 

  
 After the Data Book adjustments were applied, the data was trended to a common year. The CY 1998 data was trended forward two years, while the CY 1999 data was trended forward one year. This resulted in a base period
with the midpoint of July 1, 2000. Historical trends are based on Ohio FFS data for the HF and HST populations. Trends were developed by categories of service (COS): inpatient, outpatient, physician, pharmacy, and other. 
  

	B.	Data Credibility 

  
 Since the FFS data has eroded due to the increase in managed care membership, some of the remaining FFS data may not be meaningful, and should not be used to set capitation rates. The increase in managed care
enrollment is due to the Preferred Option program and higher enrollment in some voluntary counties. Mercer did not rely on historical data for time periods with managed care penetration in excess of 60%. As a result, area factors were used in
several counties1. Data was used in two counties2 with managed care penetration exceeding 60% in one of the three base years; however, less credibility was given to the year in question. All remaining counties
received equal credibility between the three trended base years. 
  
 Area factors
were developed for most counties using a blend of historical FFS data from state fiscal year (SFY) 1995 and SFY 1996. Because managed care penetration was below 60% in all but Hamilton and Montgomery counties, the data from SFY 1995-SFY 1996 was
deemed credible. Historical FFS data from these years was summarized for each area factor county and the Base Region3. Each area factor county’s FFS cost and utilization data was compared with the 

	1	Butler, Cuyahoga, Franklin, Hamilton, Lucas,
Montgomery, and Summit counties 

  

	2	Stark and Wood counties

  

	3	Allen, Belmont, Clark, Clermont, Columbiana, Crawford, Defiance, Delaware, Fairfield, Fulton, Greene, Henry, Huron,
Jefferson, Licking, Lorain, Madison, Mahoning, Monroe, Muskingum, Ottawa, Portage, Pickaway, Richland, Sandusky, Trumbull, Warren, and Washington counties. 

  

 MERCER 
 Government Human Services Consulting 
  
 Page 4 
 November 11, 2003 
 Ms. Mitali Ghatak 
 Ohio Department of Job and Family Services 
  

 Base Region FFS data from the same time period. This was done on a COS and rate cohort level of detail. Developing
the area factors by rate cohort removes the impact of shifting demographics from year to year. 
  
 Since the managed care penetration level for Hamilton and Montgomery counties was greater than 60% in SFY 1995 and SFY 1996, the FFS data for these counties and this time period were deemed not credible. Therefore,
the area factor approach as outlined above could not be used. The rates for these counties were developed based on Cuyahoga county data and adjusted for inpatient services reflective of each county. This is the same approach used in the CY 2002
rate-setting process. 
  
 Furthermore, adequate membership size was necessary to
develop individual county capitation rates. The FFS data from a number of smaller, more rural counties expected to enter managed care during the 12-month rating period were combined to develop the capitation rates. These counties included
Belmont/Monroe, Clark/Madison, Defiance/Fulton/Henry, and Ottawa/Sandusky. 
  

	C.	Blending with CY 2002 FFSEs 

  
 In order to smooth data fluctuations year over year and develop a more reliable base for the capitation rates, Mercer recommended the 6-month and 12-month FFSEs (FFS base period: CY 1998, CY 1999, and CY 2000) be
blended together with CY 2002 FFSEs (FFS base period: SFY 1997, SFY 1998, and SFY 1999). Prior to blending, the CY 2002 FFSEs were trended forward to the midpoint of each of the rating periods. For counties new to managed care, Mercer blended the
6-month and 12-month FFSEs with trended statewide CY 2002 FFSEs. The resulting blended FFSEs were compared with other historical FFS data sources for reasonability. 
  

	III.	Develop Capitation Rates 

  
 The capitation rates that are developed cover only services provided in the State plan. In addition, the data used to develop capitation rates reflects all medical
expenses and is not reduced for reinsurance premiums or stop loss. The State currently requires the managed care plans (MCPs) to purchase reinsurance to cover, at a minimum, 80% of inpatient costs incurred by one member in one year, in excess of
$75,000. No risk sharing arrangements between the MCPs and the State are used, except as noted below for MCP administration. 
  

 MERCER 
 Government Human Services Consulting 
  
 Page 5 
 November 11, 2003 
 Ms. Mitali Ghatak 
 Ohio Department of Job and Family Services 
  

	A.	Prospective Trend 

  
 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 in whole or in part upon expenses incurred in prior years. CMS requires the FFSEs be trended forward from the base period to the contract period, and actual trend experience is used to the fullest extent possible. 

 
 Cost and utilization trend factors were developed by category of service using monthly
Ohio historical experience, with some consideration of national trends and indices. The base data was trended forward 39 months from the midpoint of the base period (July 1, 2000) to the midpoint of the contract period (October 1, 2003) for the
6-month rates. For the 12-month rates, the base data was trended forward 48 months from the midpoint of the base period (July 1, 2000) to the midpoint of the contract period (July 1, 2004). 
  

	B.	Programmatic Changes 

  
 CMS requires the rate-setting methodology used to determine capitation rates incorporate the impact of any programmatic changes that have taken place or are anticipated to take place between the base period and the
contract period. 
  
 The State provided Mercer with a detailed list of program
changes that will have a material impact upon 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. For those adjustments not
incorporated through trend, Mercer adjusted the FFS experience for the following changes: 
  

	 	•	Psychologist and chiropractic services were eliminated for adults 21 years of age and older and pregnant women, effective January 1, 2004. These program changes only affect the
12-month rates. 

  

	 	•	The legislature removed the inpatient fee schedule freezes for children’s hospitals effective January 1, 2003 and January 1, 2004. The January 1, 2003 adjustment of 2.9% was
applied to the 6-month rates. For the 12-month rates, the 2.9% was applied along with the additional adjustment of 3.6% effective January 1, 2004. 

  

 MERCER 
 Government Human Services Consulting 
  
 Page 6 
 November 11, 2003 
 Ms. Mitali Ghatak 
 Ohio Department of Job and Family Services 
  

	 	•	The legislature also increased the outpatient rates for general hospitals effective July 1, 2003. Mercer applied a unit cost adjustment to both the 6-month and 12-month rates for
this program change. 

  

	 	•	Mercer reviewed more recent cesarean rate data provided by the State that showed an increase in caesarean rates year over year. As a result, Mercer updated the caesarean rate from
16% to 17% for the 6-month and 12-month rates. 

  

	C.	Voluntary Selection 

  
 As a result of the adverse selection adjustment that was applied in the Data Book, the FFSEs already reflect the risk of the entire Medicaid program, i.e., FFS and managed care individuals. To reflect solely the risk
of the managed care program, Mercer modified the FFSEs based on the projected managed care penetration levels for the 6-month and 12-month rates4. This voluntary selection adjustment modifies the FFSEs to reflect the risk to the MCPs, i.e., only those individuals who enroll in a health plan. This adjustment is based on data from other states as
well as the actuarial principle that costs associated with enrolled managed care members are generally lower. This adjustment varied by county based on the projected MCP penetration level for the contract period. 
  

	D.	Clinical Measures 

  
 As part of the MCPs contract, the State requires each MCP reach a minimum performance standard in certain areas including dental, maternity, and well-child services. Mercer has reviewed the impact on the managed care
rates based on these standards and incentives and has developed a set of adjustments based upon the State’s expected improvement rate. These utilization targets were built into the capitation rates. 
  

	E.	Managed Care Savings 

  
 In developing managed care savings assumptions, Mercer applied generally accepted actuarial principles that attempt to reflect the impact on FFS experience of MCP programs. Cost Report (MCP reported Medicaid
utilization, cost, and PMPM experience) data from CY 2000 and CY 2001 and CY 2002 data were used to assist Mercer with determining how services and costs may have shifted under managed care by COS. The CY 2000 and CY 2001 cost reports were reviewed
by an independent auditor, as required by the State. In addition, the State performed a 

	4	Please see revised penetration chart shown in Exhibit A. 

  

 MERCER 
 Government Human Services Consulting 
  
 Page 7 
 November 11, 2003 
 Ms. Mitali Ghatak 
 Ohio Department of Job and Family Services 
  

 desk audit to validate the Cost Report data. The resulting assumptions are consistent with an economic and
efficiently operated Medicaid managed care plan. These managed care savings assumptions vary by county, cohort, and COS. Mercer further assumed a mix of Cesarean deliveries of 17% under managed care, based on review of historical MCP data.

  

	F.	MCP Administrative Load 

  
 In return for providing more efficient care to enrollees, there are additional administrative costs the MCPs incur. In addition to these administrative costs, the State allows the MCPs a load for risk charges and
profit. The final capitation rate is the result of netting out the savings achieved through case management and adding the MCP administrative/profit load. Mercer reviewed the MCP reported administrative experience and overall financial results to
determine an amount for administration of 12% of premium for existing plans with 1% of this administrative load contingent upon MCPs meeting administrative requirements. For plans new to managed care in Ohio, the administrative load and at-risk
amounts will be set as follows: 
  

	 	•	First Plan Year 

  

	 	•	Administration of 13% of premium 

  

	 	•	0% at risk 

  

	 	•	Second Plan Year 

  

	 	•	Administration of 12% of premium 

  

	 	•	0% percent at risk 

  

	 	•	Third Plan Year 

  

	 	•	Administration of 12% of premium 

  

	 	•	1% at risk 

  

	IV.	Certification of Final Rates 

  
 The following capitation rates were developed for each participating county for the 6-month (July 1, 2003 through December 31, 2003) and the 12-month contract period
(January 1, 2004 through December 31, 2004): 
  

	 	•	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, 

  

 MERCER 
 Government Human Services Consulting 
  
 Page 8 
 November 11, 2003 
 Ms. Mitali Ghatak 
 Ohio Department of Job and Family Services 
  

	 	•	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. 

  
 Summaries of the 6-month and 12-month rates by county and by rate cohort may be found in Exhibit B. 
  
 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 has developed these rates on behalf of the State to demonstrate compliance with the CMS requirements under 42 CFR 438.6(c) and 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 that stated may not be appropriate. 
  
 Sincerely, 
  

	
	
	/s/    ANGELA L.
WASDYKE        
	Angela L. WasDyke, A.S.A., M.A.A.A.

  
 AW/SJ/KC/kb 
  
 Copy: 
 Stephanie Davis, Shereen Jensen, Kristin Coyle 
  

					
	 State of Ohio
	  	Exhibit A	  	Final
	 	  	Penetration Chart	  	 

  

							
	 County

	  	 Projected
 7/03-12/03

	 	 	 Projected
 CY04

	 
	  	 
	 Allen
	  	 	 	 	15	%
	 Belmont/Monroe
	  	 	 	 	5	%
	 Butler
	  	65	%	 	75	%
	 Clark
	  	40	%	 	 	 
	 Clark/Madison
	  	 	 	 	60	%
	 Clermont
	  	5	%	 	5	%
	 Columbiana
	  	 	 	 	15	%
	 Crawford
	  	 	 	 	5	%
	 Cuyahoga
	  	90	%	 	90	%
	 Defiance/Fulton/Henry
	  	 	 	 	5	%
	 Delaware
	  	 	 	 	5	%
	 Fairfield
	  	 	 	 	5	%
	 Franklin
	  	65	%	 	75	%
	 Greene
	  	40	%	 	45	%
	 Hamilton
	  	65	%	 	70	%
	 Huron
	  	 	 	 	5	%
	 Jefferson
	  	 	 	 	5	%
	 Licking
	  	 	 	 	15	%
	 Lorain
	  	60	%	 	65	%
	 Lucas
	  	90	%	 	90	%
	 Mahoning
	  	5	%	 	40	%
	 Montgomery
	  	60	%	 	75	%
	 Muskingum
	  	 	 	 	5	%
	 Ottawa/Sandusky
	  	 	 	 	5	%
	 Pickaway
	  	5	%	 	5	%
	 Portage
	  	 	 	 	15	%
	 Richland
	  	 	 	 	5	%
	 Stark
	  	75	%	 	90	%
	 Summit
	  	90	%	 	90	%
	 Trumbull
	  	5	%	 	40	%
	 Warren
	  	5	%	 	5	%
	 Washington
	  	 	 	 	5	%
	 Wood
	  	15	%	 	15	%

  

					
	 Mercer Government Human Services Consulting
	  	 	  	 

					
	 State of Ohio
	  	Exhibit B	  	Final
	 	  	Six Month Rates	  	 
	 	  	2nd Half 2003	  	 

  

																							
	 County

	  	 Rate Cohort

	  	 Annualized
 Dec 2002
 Managed Care
 MM/Delv

	  	% of MM

	 	 	 CY 2002
 Rate w/
 Admin

	  	 7/1/2003 -
 12/31/2003
 Guaranteed
 Rate

	  	 7/1/2003 -
12/31/2003
 Rate At Risk

	  	 7/1/2003 -
 12/31/2003
 Rate w/
 Admin

	  	 Percent
 Increase

	 
	 Butler
	  	HF/HST, Age 0, M & F	  	7,908	  	6.1	%	 	$	527.77	  	$	428.03	  	$	4.32	  	$	432.36	  	-18.1	%
	 Butler
	  	HF/HST, Age 1, M & F	  	7,752	  	6.0	%	 	$	110.32	  	$	119.95	  	$	1.21	  	$	121.16	  	9.8	%
	 Butler
	  	HF/HST, Age 2-13, M & F	  	66,072	  	50.7	%	 	$	70.25	  	$	78.13	  	$	0.79	  	$	78.92	  	12.3	%
	 Butler
	  	HF/HST, Age 14-18, M	  	7,452	  	5.7	%	 	$	94.50	  	$	101.30	  	$	1.02	  	$	102.32	  	8.3	%
	 Butler
	  	HF/HST, Age 14-18, F	  	8,184	  	6.3	%	 	$	123.11	  	$	137.87	  	$	1.39	  	$	139.27	  	13.1	%
	 Butler
	  	HF, Age 19-44, M	  	6,564	  	5.0	%	 	$	221.82	  	$	220.97	  	$	2.23	  	$	223.20	  	0.6	%
	 Butler
	  	HF, Age 19-44, F	  	23,040	  	17.7	%	 	$	187.85	  	$	211.60	  	$	2.14	  	$	213.74	  	13.8	%
	 Butler
	  	HF, Age 45+, M & F	  	1,608	  	1.2	%	 	$	490.36	  	$	488.26	  	$	4.93	  	$	493.19	  	0.6	%
	 Butler
	  	HST, Age 19-64, F	  	1,668	  	1.3	%	 	$	304.21	  	$	341.42	  	$	3.45	  	$	344.87	  	13.4	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Butler
	  	Subtotal	  	130,248	  	100.0	%	 	$	141.75	  	$	146.19	  	$	1.48	  	$	147.66	  	4.2	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Butler
	  	Delivery Payment	  	269	  	0.2	%	 	$	3,417.97	  	$	3,873.73	  	$	39.13	  	$	3,912.86	  	14.5	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Butler
	  	Total	  	130,248	  	100.0	%	 	$	148.81	  	$	154.19	  	$	1.56	  	$	155.75	  	4.7	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Clark
	  	HF/HST, Age 0, M & F	  	1,116	  	6.0	%	 	$	578.29	  	$	444.83	  	$	4.49	  	$	449.32	  	-22.3	%
	 Clark
	  	HF/HST, Age 1, M & F	  	1,044	  	5.6	%	 	$	116.69	  	$	122.08	  	$	1.23	  	$	123.31	  	5.7	%
	 Clark
	  	HF/HST, Age 2-13, M & F	  	9,036	  	48.8	%	 	$	70.44	  	$	76.92	  	$	0.78	  	$	77.70	  	10.3	%
	 Clark
	  	HF/HST, Age 14-18, M	  	924	  	5.0	%	 	$	88.36	  	$	93.27	  	$	0.94	  	$	94.21	  	6.6	%
	 Clark
	  	HF/HST, Age 14-18, F	  	924	  	5.0	%	 	$	126.73	  	$	139.13	  	$	1.41	  	$	140.53	  	10.9	%
	 Clark
	  	HF, Age 19-44, M	  	1,188	  	6.4	%	 	$	192.54	  	$	190.61	  	$	1.93	  	$	192.53	  	0.0	%
	 Clark
	  	HF, Age 19-44, F	  	3,936	  	21.3	%	 	$	200.69	  	$	224.96	  	$	2.27	  	$	227.24	  	13.2	%
	 Clark
	  	HF, Age 45+, M & F	  	252	  	1.4	%	 	$	383.27	  	$	408.24	  	$	4.12	  	$	412.36	  	7.6	%
	 Clark
	  	HST, Age 19-64, F	  	96	  	0.5	%	 	$	281.21	  	$	308.43	  	$	3.12	  	$	311.55	  	10.8	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Clark
	  	Subtotal	  	18,516	  	100.0	%	 	$	148.23	  	$	150.04	  	$	1.52	  	$	151.55	  	2.2	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Clark
	  	Delivery Payment	  	45	  	0.2	%	 	$	3,388.96	  	$	3,762.72	  	$	38.01	  	$	3,800.73	  	12.2	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Clark
	  	Total	  	18,516	  	100.0	%	 	$	156.47	  	$	159.18	  	$	1.61	  	$	160.79	  	2.8	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Clermont
	  	HF/HST, Age 0, M & F	  	427	  	5.5	%	 	$	546.23	  	$	417.91	  	$	4.22	  	$	422.14	  	-22.7	%
	 Clermont
	  	HF/HST, Age 1, M & F	  	430	  	5.5	%	 	$	141.76	  	$	140.79	  	$	1.42	  	$	142.21	  	0.3	%
	 Clermont
	  	HF/HST, Age 2-13, M & F	  	3,975	  	51.2	%	 	$	73.20	  	$	82.80	  	$	0.84	  	$	83.64	  	14.3	%
	 Clermont
	  	HF/HST, Age 14-18, M	  	456	  	5.9	%	 	$	81.01	  	$	90.95	  	$	0.92	  	$	91.87	  	13.4	%
	 Clermont
	  	HF/HST, Age 14-18, F	  	522	  	6.7	%	 	$	139.84	  	$	156.97	  	$	1.59	  	$	158.56	  	13.4	%
	 Clermont
	  	HF, Age 19-44, M	  	268	  	3.5	%	 	$	197.25	  	$	193.51	  	$	1.95	  	$	195.47	  	-0.9	%
	 Clermont
	  	HF, Age 19-44, F	  	1,513	  	19.5	%	 	$	212.15	  	$	238.48	  	$	2.41	  	$	240.89	  	13.5	%
	 Clermont
	  	HF, Age 45+, M & F	  	96	  	1.2	%	 	$	472.01	  	$	497.78	  	$	5.03	  	$	502.81	  	6.5	%
	 Clermont
	  	HST, Age 19-64, F	  	79	  	1.0	%	 	$	362.51	  	$	371.10	  	$	3.75	  	$	374.85	  	3.4	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Clermont
	  	Subtotal	  	7,766	  	100.0	%	 	$	147.17	  	$	152.12	  	$	1.54	  	$	153.65	  	4.4	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Clermont
	  	Delivery Payment	  	26	  	0.3	%	 	$	4,043.64	  	$	3,893.41	  	$	39.33	  	$	3,932.74	  	-2.7	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Clermont
	  	Total	  	7,766	  	100.0	%	 	$	160.71	  	$	165.15	  	$	1.67	  	$	166.82	  	3.8	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Cuyahoga
	  	HF/HST, Age 0, M & F	  	80,520	  	4.5	%	 	$	584.96	  	$	475.39	  	$	4.80	  	$	480.19	  	-17.9	%
	 Cuyahoga
	  	HF/HST, Age 1, M & F	  	86,280	  	4.8	%	 	$	124.16	  	$	135.90	  	$	1.37	  	$	137.28	  	10.6	%
	 Cuyahoga
	  	HF/HST, Age 2-13, M & F	  	891,084	  	50.0	%	 	$	65.37	  	$	73.31	  	$	0.74	  	$	74.05	  	13.3	%
	 Cuyahoga
	  	HF/HST, Age 14-18, M	  	119,844	  	6.7	%	 	$	73.86	  	$	79.26	  	$	0.80	  	$	80.06	  	8.4	%
	 Cuyahoga
	  	HF/HST, Age 14-18, F	  	127,620	  	7.2	%	 	$	113.20	  	$	128.73	  	$	1.30	  	$	130.03	  	14.9	%
	 Cuyahoga
	  	HF, Age 19-44, M	  	61,008	  	3.4	%	 	$	174.98	  	$	170.34	  	$	1.72	  	$	172.06	  	-1.7	%
	 Cuyahoga
	  	HF, Age 19-44, F	  	360,012	  	20.2	%	 	$	196.51	  	$	223.69	  	$	2.26	  	$	225.94	  	15.0	%
	 Cuyahoga
	  	HF, Age 45+, M & F	  	36,600	  	2.1	%	 	$	386.19	  	$	380.57	  	$	3.84	  	$	384.42	  	-0.5	%
	 Cuyahoga
	  	HST, Age 19-64, F	  	17,808	  	1.0	%	 	$	343.12	  	$	388.93	  	$	3.93	  	$	392.86	  	14.5	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Cuyahoga
	  	Subtotal	  	1,780,776	  	100.0	%	 	$	135.35	  	$	142.09	  	$	1.44	  	$	143.53	  	6.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Cuyahoga
	  	Delivery Payment	  	6,847	  	0.4	%	 	$	3,975.41	  	$	4,634.00	  	$	46.81	  	$	4,680.81	  	17.7	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Cuyahoga
	  	Total	  	1,780,776	  	100.0	%	 	$	150.63	  	$	159.91	  	$	1.62	  	$	161.52	  	7.2	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Franklin
	  	HF/HST, Age 0, M & F	  	41,412	  	4.9	%	 	$	503.34	  	$	408.34	  	$	4.12	  	$	412.47	  	-18.1	%
	 Franklin
	  	HF/HST, Age 1, M & F	  	45,912	  	5.5	%	 	$	107.80	  	$	116.70	  	$	1.18	  	$	117.88	  	9.3	%
	 Franklin
	  	HF/HST, Age 2-13, M & F	  	432,048	  	51.6	%	 	$	63.12	  	$	70.60	  	$	0.71	  	$	71.32	  	13.0	%
	 Franklin
	  	HF/HST, Age 14-18, M	  	47,880	  	5.7	%	 	$	75.42	  	$	80.51	  	$	0.81	  	$	81.33	  	7.8	%
	 Franklin
	  	HF/HST, Age 14-18, F	  	54,540	  	6.5	%	 	$	112.59	  	$	127.29	  	$	1.29	  	$	128.57	  	14.2	%
	 Franklin
	  	HF, Age 19-44, M	  	29,256	  	3.5	%	 	$	195.37	  	$	193.10	  	$	1.95	  	$	195.05	  	-0.2	%
	 Franklin
	  	HF, Age 19-44, F	  	168,024	  	20.1	%	 	$	217.48	  	$	247.09	  	$	2.50	  	$	249.58	  	14.8	%
	 Franklin
	  	HF, Age 45+, M & F	  	10,668	  	1.3	%	 	$	413.63	  	$	412.66	  	$	4.17	  	$	416.83	  	0.8	%
	 Franklin
	  	HST, Age 19-64, F	  	7,488	  	0.9	%	 	$	264.53	  	$	300.16	  	$	3.03	  	$	303.19	  	14.6	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Franklin
	  	Subtotal	  	837,228	  	100.0	%	 	$	133.14	  	$	140.21	  	$	1.42	  	$	141.62	  	6.4	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Franklin
	  	Delivery Payment	  	2,999	  	0.4	%	 	$	3,305.57	  	$	3,828.57	  	$	38.67	  	$	3,867.24	  	17.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Franklin
	  	Total	  	837,228	  	100.0	%	 	$	144.98	  	$	153.92	  	$	1.55	  	$	155.48	  	7.2	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

  

					
	 Mercer Government Human Services Consulting
	  	 Page 1 of 4
	  	 

					
	 State of Ohio
	  	Exhibit B	  	Final
	 	  	Six Month Rates	  	 
	 	  	2nd Half 2003	  	 

  

																							
	 County

	  	 Rate Cohort

	  	 Annualized
 Dec 2002
 Managed Care
 MM/Delv

	  	% of MM

	 	 	 CY 2002
 Rate w/
 Admin

	  	 7/1/2003 -
12/31/2003
 Guaranteed
 Rate

	  	 7/1/2003 -
12/31/2003
 Rate At Risk

	  	 7/1/2003 -
12/31/2003
 Rate w/
Admin

	  	 Percent
 Increase

	 
	 Greene
	  	HF/HST, Age 0, M & F	  	2,543	  	5.5	%	 	$	578.29	  	$	452.62	  	$	4.57	  	$	457.20	  	-20.9	%
	 Greene
	  	HF/HST, Age 1, M & F	  	2,561	  	5.5	%	 	$	116.69	  	$	124.30	  	$	1.26	  	$	125.56	  	7.6	%
	 Greene
	  	HF/HST, Age 2-13, M & F	  	23,654	  	51.2	%	 	$	70.44	  	$	82.15	  	$	0.83	  	$	82.98	  	17.8	%
	 Greene
	  	HF/HST, Age 14-18, M	  	2,716	  	5.9	%	 	$	88.36	  	$	96.89	  	$	0.98	  	$	97.87	  	10.8	%
	 Greene
	  	HF/HST, Age 14-18, F	  	3,108	  	6.7	%	 	$	126.73	  	$	142.41	  	$	1.44	  	$	143.84	  	13.5	%
	 Greene
	  	HF, Age 19-44, M	  	1,596	  	3.5	%	 	$	192.54	  	$	191.25	  	$	1.93	  	$	193.18	  	0.3	%
	 Greene
	  	HF, Age 19-44, F	  	9,006	  	19.5	%	 	$	200.69	  	$	228.01	  	$	2.30	  	$	230.32	  	14.8	%
	 Greene
	  	HF, Age 45+, M & F	  	570	  	1.2	%	 	$	383.27	  	$	381.51	  	$	3.85	  	$	385.37	  	0.5	%
	 Greene
	  	HST, Age 19-64, F	  	470	  	1.0	%	 	$	281.21	  	$	321.33	  	$	3.25	  	$	324.57	  	15.4	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Greene
	  	Subtotal	  	46,224	  	100.0	%	 	$	141.37	  	$	148.10	  	$	1.50	  	$	149.59	  	5.8	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Greene
	  	Delivery Payment	  	156	  	0.3	%	 	$	3,388.96	  	$	3,902.69	  	$	39.42	  	$	3,942.11	  	16.3	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Greene
	  	Total	  	46,224	  	100.0	%	 	$	152.81	  	$	161.27	  	$	1.63	  	$	162.90	  	6.6	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Hamilton
	  	HF/HST, Age 0, M & F	  	24,540	  	5.9	%	 	$	629.79	  	$	510.07	  	$	5 .15	  	$	515.22	  	-18.2	%
	 Hamilton
	  	HF/HST, Age 1, M & F	  	22,860	  	5.5	%	 	$	125.83	  	$	137.00	  	$	1.38	  	$	138.39	  	10.0	%
	 Hamilton
	  	HF/HST, Age 2-13, M & F	  	213,888	  	51.8	%	 	$	65.52	  	$	72.73	  	$	0.73	  	$	73.47	  	12.1	%
	 Hamilton
	  	HF/HST, Age 14-18, M	  	26,520	  	6.4	%	 	$	75.82	  	$	80.75	  	$	0.82	  	$	81.56	  	7.6	%
	 Hamilton
	  	HF/HST, Age 14-18, F	  	31,944	  	7.7	%	 	$	112.60	  	$	127.50	  	$	1.29	  	$	128.79	  	14.4	%
	 Hamilton
	  	HF, Age 19-44, M	  	8,688	  	2.1	%	 	$	180.67	  	$	175.04	  	$	1.77	  	$	176.81	  	-2.1	%
	 Hamilton
	  	HF, Age 19-44, F	  	74,136	  	18.0	%	 	$	197.19	  	$	222.26	  	$	2.25	  	$	224.50	  	13.9	%
	 Hamilton
	  	HF, Age 45+, M & F	  	4,752	  	1.2	%	 	$	392.89	  	$	382.85	  	$	3.87	  	$	386.72	  	-1.6	%
	 Hamilton
	  	HST, Age 19-64, F	  	5,316	  	1.3	%	 	$	344.27	  	$	386.60	  	$	3.91	  	$	390.50	  	13.4	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Hamilton
	  	Subtotal	  	412,644	  	100.0	%	 	$	140.16	  	$	143.69	  	$	1.45	  	$	145.14	  	3.5	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Hamilton
	  	Delivery Payment	  	1,267	  	0.3	%	 	$	4,319.39	  	$	5,026.48	  	$	50.77	  	$	5,077.26	  	17.5	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Hamilton
	  	Total	  	412,644	  	100.0	%	 	$	153.43	  	$	159.12	  	$	1.61	  	$	160.73	  	4.8	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Lorain
	  	HF/HST, Age 0, M & F	  	7,236	  	5.0	%	 	$	422.96	  	$	345.40	  	$	3.49	  	$	348.89	  	-17.5	%
	 Lorain
	  	HF/HST, Age 1, M & F	  	8,100	  	5.6	%	 	$	88.61	  	$	92.40	  	$	0.93	  	$	93.33	  	5.3	%
	 Lorain
	  	HF/HST, Age 2-13, M & F	  	72,528	  	49.9	%	 	$	57.69	  	$	62.36	  	$	0.63	  	$	62.99	  	9.2	%
	 Lorain
	  	HF/HST, Age 14-18, M	  	8,496	  	5.8	%	 	$	57.46	  	$	61.51	  	$	0.62	  	$	62.13	  	8.1	%
	 Lorain
	  	HF/HST, Age 14-18, F	  	8,844	  	6.1	%	 	$	108.81	  	$	122.36	  	$	1.24	  	$	123.59	  	13.6	%
	 Lorain
	  	HF, Age 19-44, M	  	7,428	  	5.1	%	 	$	160.70	  	$	162.14	  	$	1.64	  	$	163.78	  	1.9	%
	 Lorain
	  	HF, Age 19-44, F	  	29,268	  	20.1	%	 	$	179.46	  	$	199.03	  	$	2.01	  	$	201.04	  	12.0	%
	 Lorain
	  	HF, Age 45+, M & F	  	2,040	  	1.4	%	 	$	299.67	  	$	299.69	  	$	3.03	  	$	302.72	  	1.0	%
	 Lorain
	  	HST, Age 19-64, F	  	1,416	  	1.0	%	 	$	309.72	  	$	343.68	  	$	3.47	  	$	347.16	  	12.1	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Lorain
	  	Subtotal	  	145,356	  	100.0	%	 	$	116.33	  	$	120.42	  	$	1.22	  	$	121.63	  	4.6	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Lorain
	  	Delivery Payment	  	494	  	0.3	%	 	$	3,289.08	  	$	3,534.17	  	$	35.70	  	$	3,569.87	  	8.5	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Lorain
	  	Total	  	145,356	  	100.0	%	 	$	127.50	  	$	132.43	  	$	1.34	  	$	133.76	  	4.9	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Lucas
	  	HF/HST, Age 0, M & F	  	32,076	  	5.4	%	 	$	647.45	  	$	533.45	  	$	5.39	  	$	538.84	  	-16.8	%
	 Lucas
	  	HF/HST, Age 1, M & F	  	33,228	  	5.6	%	 	$	100.36	  	$	109.64	  	$	1.11	  	$	110.75	  	10.4	%
	 Lucas
	  	HF/HST, Age 2-13, M & F	  	294,060	  	49.3	%	 	$	62.88	  	$	70.64	  	$	0.71	  	$	71.35	  	13.5	%
	 Lucas
	  	HF/HST, Age 14-18, M	  	37,416	  	6.3	%	 	$	71.47	  	$	78.97	  	$	0.80	  	$	79.77	  	11.6	%
	 Lucas
	  	HF/HST, Age 14-18, F	  	40,872	  	6.9	%	 	$	116.85	  	$	131.41	  	$	1.33	  	$	132.74	  	13.6	%
	 Lucas
	  	HF, Age 19-44, M	  	24,528	  	4.1	%	 	$	187.36	  	$	183.95	  	$	1.86	  	$	185.81	  	-0.8	%
	 Lucas
	  	HF, Age 19-44, F	  	115,356	  	19.4	%	 	$	199.19	  	$	224.58	  	$	2.27	  	$	226.85	  	13.9	%
	 Lucas
	  	HF, Age 45+, M & F	  	9,048	  	1.5	%	 	$	415.02	  	$	407.68	  	$	4.12	  	$	411.80	  	-0.8	%
	 Lucas
	  	HST, Age 19-64, F	  	9,516	  	1.6	%	 	$	340.77	  	$	385.01	  	$	3.89	  	$	388.90	  	14.1	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Lucas
	  	Subtotal	  	596,100	  	100.0	%	 	$	141.95	  	$	146.99	  	$	1.48	  	$	148.48	  	4.6	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Lucas
	  	Delivery Payment	  	2,712	  	0.5	%	 	$	3,844.21	  	$	4,320.87	  	$	43.65	  	$	4,364.52	  	13.5	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Lucas
	  	Total	  	596,100	  	100.0	%	 	$	159.44	  	$	166.65	  	$	1.68	  	$	168.33	  	5.6	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Mahoning
	  	HF/HST, Age 0, M & F	  	953	  	5.5	%	 	$	512.84	  	$	395.11	  	$	3.99	  	$	399.10	  	-22.2	%
	 Mahoning
	  	HF/HST, Age 1, M & F	  	959	  	5.5	%	 	$	109.61	  	$	117.08	  	$	1.18	  	$	118.26	  	7.9	%
	 Mahoning
	  	HF/HST, Age 2-13, M & F	  	8,862	  	51.2	%	 	$	71.58	  	$	74.18	  	$	0.75	  	$	74.93	  	4.7	%
	 Mahoning
	  	HF/HST, Age 14-18, M	  	1,017	  	5.9	%	 	$	101.19	  	$	104.99	  	$	1.06	  	$	106.05	  	4.8	%
	 Mahoning
	  	HF/HST, Age 14-18, F	  	1,165	  	6.7	%	 	$	121.54	  	$	131.29	  	$	1.33	  	$	132.62	  	9.1	%
	 Mahoning
	  	HF, Age 19-44, M	  	598	  	3.5	%	 	$	203.35	  	$	179.71	  	$	1.82	  	$	181.53	  	-10.7	%
	 Mahoning
	  	HF, Age 19-44, F	  	3,374	  	19.5	%	 	$	211.29	  	$	228.23	  	$	2.31	  	$	230.53	  	9.1	%
	 Mahoning
	  	HF, Age 45+, M & F	  	214	  	1.2	%	 	$	400.10	  	$	383.32	  	$	3.87	  	$	387.19	  	-3.2	%
	 Mahoning
	  	HST, Age 19-64, F	  	176	  	1.0	%	 	$	346.92	  	$	343.88	  	$	3.47	  	$	347.35	  	0.1	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Mahoning
	  	Subtotal	  	17,318	  	100.0	%	 	$	141.70	  	$	140.08	  	$	1.41	  	$	141.50	  	-0.1	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Mahoning
	  	Delivery Payment	  	58	  	0.3	%	 	$	3,509.06	  	$	3,818.98	  	$	38.58	  	$	3,857.56	  	9.9	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Mahoning
	  	Total	  	17,318	  	100.0	%	 	$	153.45	  	$	152.87	  	$	1.54	  	$	154.42	  	0.6	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

  

					
	 Mercer Government Human Services Consulting
	  	 Page 2 of 4
	  	 

					
	State of Ohio	  	 Exhibit B
 Six Month Rates
 2nd Half 2003
	  	Final

  

																							
	 County

	  	 Rate Cohort

	  	Annualized
Dec 2002
Managed
Care
MM/Delv

	  	% of MM

	 	 	CY 2002
Rate w/
Admin

	  	7/1/2003-
12/31/2003
Guaranteed
Rate

	  	7/1/2003-
12/31/2003
Rate At Risk

	  	7/1/2003-
12/31/2003
Rate w/
Admin

	  	Percent
Increase

	 
	 Montgomery
	  	 HF/HST, Age 0, M & F
	  	22,200	  	6.3	%	 	$	602.39	  	$	481.06	  	$	4.86	  	$	485.92	  	-19.3	%
	 Montgomery
	  	 HF/HST, Age 1, M & F
	  	19,524	  	5.5	%	 	$	123.80	  	$	133.49	  	$	1.35	  	$	134.84	  	8.9	%
	 Montgomery
	  	 HF/HST, Age 2-13, M & F
	  	177,480	  	50.2	%	 	$	64.80	  	$	71.63	  	$	0.72	  	$	72.35	  	11.6	%
	 Montgomery
	  	 HF/HST, Age 14-18, M
	  	20,316	  	5.7	%	 	$	74.10	  	$	77.90	  	$	0.79	  	$	78.69	  	6.2	%
	 Montgomery
	  	 HF/HST, Age 14-18, F
	  	23,388	  	6.6	%	 	$	111.83	  	$	125.38	  	$	1.27	  	$	126.64	  	13.3	%
	 Montgomery
	  	 HF, Age 19-44, M
	  	11,952	  	3.4	%	 	$	176.03	  	$	169.42	  	$	1.71	  	$	171.13	  	-2.8	%
	 Montgomery
	  	 HF, Age 19-44, F
	  	71,304	  	20.2	%	 	$	194.95	  	$	218.71	  	$	2.21	  	$	220.92	  	13.3	%
	 Montgomery
	  	 HF, Age 45+, M & F
	  	4,020	  	1.1	%	 	$	385.54	  	$	375.66	  	$	3.79	  	$	379.45	  	-1.6	%
	 Montgomery
	  	 HST, Age 19-64, F
	  	3,312	  	0.9	%	 	$	340.60	  	$	382.39	  	$	3.86	  	$	386.25	  	13.4	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Montgomery
	  	 Subtotal
	  	353,496	  	100.0	%	 	$	141.71	  	$	144.02	  	$	1.45	  	$	145.47	  	2.7	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Montgomery
	  	 Delivery Payment
	  	935	  	0.3	%	 	$	4,146.90	  	$	4,751.44	  	$	47.99	  	$	4,799.44	  	15.7	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Montgomery
	  	 Total
	  	353,496	  	100.0	%	 	$	152.68	  	$	156.59	  	$	1.58	  	$	158.17	  	3.6	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Pickaway
	  	 HF/HST, Age 0, M & F
	  	148	  	5.5	%	 	$	501.13	  	$	403.29	  	$	4.07	  	$	407.37	  	-18.7	%
	 Pickaway
	  	 HF/HST, Age 1, M & F
	  	149	  	5.5	%	 	$	123.14	  	$	122.25	  	$	1.23	  	$	123.48	  	0.3	%
	 Pickaway
	  	 HF/HST, Age 2-13, M & F
	  	1,378	  	51.2	%	 	$	70.44	  	$	73.24	  	$	0.74	  	$	73.98	  	5.0	%
	 Pickaway
	  	 HF/HST, Age 14-18, M
	  	158	  	5.9	%	 	$	87.67	  	$	90.86	  	$	0.92	  	$	91.78	  	4.7	%
	 Pickaway
	  	 HF/HST, Age 14-18, F
	  	181	  	6.7	%	 	$	122.78	  	$	130.76	  	$	1.32	  	$	132.08	  	7.6	%
	 Pickaway
	  	 HF, Age 19-44, M
	  	93	  	3.5	%	 	$	219.16	  	$	210.10	  	$	2.12	  	$	212.22	  	-3.2	%
	 Pickaway
	  	 HF, Age 19-44, F
	  	525	  	19.5	%	 	$	214.34	  	$	241.07	  	$	2.44	  	$	243.50	  	13.6	%
	 Pickaway
	  	 HF, Age 45+, M & F
	  	33	  	1.2	%	 	$	416.49	  	$	430.49	  	$	4.35	  	$	434.84	  	4.4	%
	 Pickaway
	  	 HST, Age 19-64, F
	  	27	  	1.0	%	 	$	346.07	  	$	361.94	  	$	3.66	  	$	365.60	  	5.6	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Pickaway
	  	 Subtotal
	  	2,692	  	100.0	%	 	$	141.78	  	$	143.73	  	$	1.45	  	$	145.19	  	2.4	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Pickaway
	  	 Delivery Payment
	  	9	  	0.3	%	 	$	3,384.09	  	$	3,508.09	  	$	35.44	  	$	3,543.52	  	4.7	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Pickaway
	  	 Total
	  	2,692	  	100.0	%	 	$	153.09	  	$	155.46	  	$	1.57	  	$	157.03	  	2.6	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Richland
	  	 HF/HST, Age 0, M & F
	  	417	  	5.5	%	 	$	435.57	  	$	362.45	  	$	3.66	  	$	366.11	  	-15.9	%
	 Richland
	  	 HF/HST, Age 1, M & F
	  	420	  	5.5	%	 	$	119.58	  	$	125.70	  	$	1.27	  	$	126.97	  	6.2	%
	 Richland
	  	 HF/HST, Age 2-13, M & F
	  	3,882	  	51.2	%	 	$	65.11	  	$	74.16	  	$	0.75	  	$	74.91	  	15.1	%
	 Richland
	  	 HF/HST, Age 14-18, M
	  	446	  	5.9	%	 	$	73.40	  	$	84.99	  	$	0.86	  	$	85.84	  	16.9	%
	 Richland
	  	 HF/HST, Age 14-18, F
	  	510	  	6.7	%	 	$	130.13	  	$	142.23	  	$	1.44	  	$	143.67	  	10.4	%
	 Richland
	  	 HF, Age 19-44, M
	  	262	  	3.5	%	 	$	163.01	  	$	160.46	  	$	1.62	  	$	162.08	  	-0.6	%
	 Richland
	  	 HF, Age 19-44, F
	  	1,478	  	19.5	%	 	$	176.92	  	$	$202.52	  	$	2.05	  	$	204.56	  	15.6	%
	 Richland
	  	 HF, Age 45+, M & F
	  	94	  	1.2	%	 	$	323.07	  	$	336.51	  	$	3.40	  	$	339.91	  	5.2	%
	 Richland
	  	 HST, Age 19-64, F
	  	77	  	1.0	%	 	$	266.88	  	$	300.05	  	$	3.03	  	$	303.09	  	13.6	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Richland
	  	 Subtotal
	  	7,586	  	100.0	%	 	$	123.76	  	$	131.61	  	$	1.33	  	$	132.94	  	7.4	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Richland
	  	 Delivery Payment
	  	26	  	0.3	%	 	$	2,900.54	  	$	3,365.72	  	$	34.00	  	$	3,399.71	  	17.2	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Richland
	  	 Total
	  	7,586	  	100.0	%	 	$	133.70	  	$	143.14	  	$	1.45	  	$	144.59	  	8.1	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Stark
	  	 HF/HST, Age 0, M & F
	  	348	  	4.2	%	 	$	433.74	  	$	340.28	  	$	3.44	  	$	343.72	  	-20.8	%
	 Stark
	  	 HF/HST, Age 1, M & F
	  	372	  	4.5	%	 	$	98.56	  	$	108.09	  	$	1.09	  	$	109.18	  	10.8	%
	 Stark
	  	 HF/HST, Age 2-13, M & F
	  	4,392	  	53.4	%	 	$	62.03	  	$	68.02	  	$	0.69	  	$	68.71	  	10.8	%
	 Stark
	  	 HF/HST, Age 14-18, M
	  	552	  	6.7	%	 	$	68.52	  	$	75.71	  	$	0.76	  	$	76.47	  	11.6	%
	 Stark
	  	 HF/HST, Age 14-18, F
	  	576	  	7.0	%	 	$	116.83	  	$	129.05	  	$	1.30	  	$	130.36	  	11.6	%
	 Stark
	  	 HF, Age 19-44, M
	  	300	  	3.6	%	 	$	152.83	  	$	154.63	  	$	1.56	  	$	156.19	  	2.2	%
	 Stark
	  	 HF, Age 19-44, F
	  	1,440	  	17.5	%	 	$	185.77	  	$	211.52	  	$	2.14	  	$	213.65	  	15.0	%
	 Stark
	  	 HF, Age 45+, M & F
	  	144	  	1.8	%	 	$	383.72	  	$	385.12	  	$	3.89	  	$	389.01	  	1.4	%
	 Stark
	  	 HST, Age 19-64, F
	  	96	  	1.2	%	 	$	277.06	  	$	315.24	  	$	3.18	  	$	318.42	  	14.9	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Stark
	  	 Subtotal
	  	8,220	  	100.0	%	 	$	116.83	  	$	122.89	  	$	1.24	  	$	124.14	  	6.3	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Stark
	  	 Delivery Payment
	  	23	  	0.3	%	 	$	3,036.07	  	$	3,464.84	  	$	35.00	  	$	3,499.84	  	15.3	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Stark
	  	 Total
	  	8,220	  	100.0	%	 	$	125.33	  	$	132.59	  	$	1.34	  	$	133.93	  	6.9	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Summit
	  	 HF/HST, Age 0, M & F
	  	27,504	  	5.0	%	 	$	544.75	  	$	442.59	  	$	4.47	  	$	447.06	  	-17.9	%
	 Summit
	  	 HF/HST, Age 1, M & F
	  	27,600	  	5.0	%	 	$	106.04	  	$	116.01	  	$	1.17	  	$	117.18	  	10.5	%
	 Summit
	  	 HF/HST, Age 2-13, M & F
	  	268,860	  	49.0	%	 	$	63.11	  	$	70.76	  	$	0.71	  	$	71.47	  	13.2	%
	 Summit
	  	 HF/HST, Age 14-18, M
	  	32,988	  	6.0	%	 	$	85.66	  	$	92.28	  	$	0.93	  	$	93.21	  	8.8	%
	 Summit
	  	 HF/HST, Age 14-18, F
	  	37,812	  	6.9	%	 	$	122.35	  	$	138.62	  	$	1.40	  	$	140.02	  	14.4	%
	 Summit
	  	 HF, Age 19-44, M
	  	24,096	  	4.4	%	 	$	171.17	  	$	170.65	  	$	1.72	  	$	172.37	  	0.7	%
	 Summit
	  	 HF, Age 19-44, F
	  	114,744	  	20.9	%	 	$	202.85	  	$	230.77	  	$	233	  	$	233.10	  	14.9	%
	 Summit
	  	 HF, Age 45+, M & F
	  	10,764	  	2.0	%	 	$	401.55	  	$	399.71	  	$	4.04	  	$	403.75	  	0.5	%
	 Summit
	  	 HST, Age 19-64, F
	  	4,884	  	0.9	%	 	$	324.03	  	$	367.39	  	$	3.71	  	$	371.10	  	14.5	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Summit
	  	 Subtotal
	  	549,252	  	100.0	%	 	$	137.71	  	$	144.51	  	$	1.46	  	$	145.97	  	6.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Summit
	  	 Delivery Payment
	  	2,475	  	0.5	%	 	$	4,091.24	  	$	4,688.78	  	$	47.36	  	$	4,736.14	  	15.8	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Summit
	  	 Total
	  	549,252	  	100.0	%	 	$	156.14	  	$	165.64	  	$	1.67	  	$	167.31	  	7.2	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

  

					
	 Mercer Government Human Services Consulting
	  	 Page 3 of 4
	  	 

					
	State of Ohio	  	 Exhibit B
 Six Month Rates
 2nd Half 2003
	  	Final

  

																							
	 County

	  	 Rate Cohort

	  	Annualized
Dec 2002
Managed Care
MM/Delv

	  	% of MM

	 	 	CY 2002
Rate w/
Admin

	  	7/1/2003-
12/31/2003
Guaranteed
Rate

	  	7/1/2003-
12/31/2003
Rate At Risk

	  	7/1/2003-
12/31/2003
Rate w/
Admin

	  	Percent
Increase

	 
	 Trumbull
	  	 HF/HST, Age 0, M & F
	  	775	  	5.5	%	 	$	512.84	  	$	389.00	  	$	3.93	  	$	392.93	  	-23.4	%
	 Trumbull
	  	 HF/HST, Age 1, M & F
	  	781	  	5.5	%	 	$	109.61	  	$	119.54	  	$	1.21	  	$	120.75	  	10.2	%
	 Trumbull
	  	 HF/HST, Age 2-13, M & F
	  	7,211	  	51.2	%	 	$	71.58	  	$	78.25	  	$	0.79	  	$	79.04	  	10.4	%
	 Trumbull
	  	 HF/HST, Age 14-18, M
	  	828	  	5.9	%	 	$	101.19	  	$	97.81	  	$	0.99	  	$	98.80	  	-2.4	%
	 Trumbull
	  	 HF/HST, Age 14-18, F
	  	948	  	6.7	%	 	$	121.54	  	$	133.68	  	$	1.35	  	$	135.03	  	11.1	%
	 Trumbull
	  	 HF, Age 19-44, M
	  	487	  	3.5	%	 	$	203.35	  	$	201.54	  	$	2.04	  	$	203.58	  	0.1	%
	 Trumbull
	  	 HF, Age 19-44, F
	  	2,745	  	19.5	%	 	$	211.29	  	$	233.98	  	$	2.36	  	$	236.35	  	11.9	%
	 Trumbull
	  	 HF, Age 45+, M & F
	  	174	  	1.2	%	 	$	400.10	  	$	380.23	  	$	3.84	  	$	384.07	  	-4.0	%
	 Trumbull
	  	 HST, Age 19-64, F
	  	143	  	1.0	%	 	$	346.92	  	$	363.68	  	$	3.67	  	$	367.36	  	5.9	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Trumbull
	  	 Subtotal
	  	14,092	  	100.0	%	 	$	141.68	  	$	143.73	  	$	1.45	  	$	145.18	  	2.5	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Trumbull
	  	 Delivery Payment
	  	48	  	0.3	%	 	$	3,509.06	  	$	3,693.19	  	$	37.30	  	$	3,730.49	  	6.3	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Trumbull
	  	 Total
	  	14,092	  	100.0	%	 	$	153.63	  	$	156.31	  	$	1.58	  	$	157.89	  	2.8	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Warren
	  	 HF/HST, Age 0, M & F
	  	204	  	5.5	%	 	$	459.45	  	$	371.75	  	$	3.76	  	$	375.51	  	-18.3	%
	 Warren
	  	 HF/HST, Age 1, M & F
	  	206	  	5.6	%	 	$	95.81	  	$	104.78	  	$	1.06	  	$	105.84	  	10.5	%
	 Warren
	  	 HF/HST, Age 2-13, M & F
	  	1,898	  	51.2	%	 	$	64.76	  	$	70.08	  	$	0.71	  	$	70.79	  	9.3	%
	 Warren
	  	 HF/HST, Age 14-18, M
	  	218	  	5.9	%	 	$	65.83	  	$	74.57	  	$	0.75	  	$	75.32	  	14.4	%
	 Warren
	  	 HF/HST, Age 14-18, F
	  	249	  	6.7	%	 	$	109.91	  	$	126.09	  	$	1.27	  	$	127.37	  	15.9	%
	 Warren
	  	 HF, Age 19-44, M
	  	128	  	3.5	%	 	$	182.03	  	$	182.47	  	$	1.84	  	$	184.32	  	1.3	%
	 Warren
	  	 HF, Age 19-44, F
	  	723	  	19.5	%	 	$	209.88	  	$	230.34	  	$	2.33	  	$	232.66	  	10.9	%
	 Warren
	  	 HF, Age 45+, M & F
	  	46	  	1.2	%	 	$	458.20	  	$	470.19	  	$	4.75	  	$	474.94	  	3.7	%
	 Warren
	  	 HST, Age 19-64, F
	  	38	  	1.0	%	 	$	276.50	  	$	315.66	  	$	3.19	  	$	318.84	  	15.3	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Warren
	  	 Subtotal
	  	3,710	  	100.0	%	 	$	130.65	  	$	135.20	  	$	1.37	  	$	136.57	  	4.5	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Warren
	  	 Delivery Payment
	  	13	  	0.4	%	 	$	3,211.66	  	$	3,427.75	  	$	34.62	  	$	3,462.37	  	7.8	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Warren
	  	 Total
	  	3,710	  	100.0	%	 	$	141.91	  	$	147.21	  	$	1.49	  	$	148.70	  	4.8	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Wood
	  	 HF/HST, Age 0, M & F
	  	516	  	5.5	%	 	$	436.52	  	$	337.53	  	$	3.41	  	$	340.94	  	-21.9	%
	 Wood
	  	 HF/HST, Age 1, M & F
	  	432	  	4.6	%	 	$	115.67	  	$	152.85	  	$	1.54	  	$	154.39	  	33.5	%
	 Wood
	  	 HF/HST, Age 2-13, M & F
	  	4,848	  	51.9	%	 	$	68.00	  	$	74.08	  	$	0.75	  	$	74.83	  	10.0	%
	 Wood
	  	 HF/HST, Age 14-18, M
	  	564	  	6.0	%	 	$	69.03	  	$	67.82	  	$	0.69	  	$	68.50	  	-0.8	%
	 Wood
	  	 HF/HST, Age 14-18, F
	  	600	  	6.4	%	 	$	125.18	  	$	131.43	  	$	1.33	  	$	132.76	  	6.1	%
	 Wood
	  	 HF, Age 19-44, M
	  	564	  	6.0	%	 	$	159.33	  	$	151.43	  	$	1.53	  	$	152.96	  	4.0	%
	 Wood
	  	 HF, Age 19-44, F
	  	1,608	  	17.2	%	 	$	188.12	  	$	208.99	  	$	2.11	  	$	211.10	  	12.2	%
	 Wood
	  	 HF, Age 45+, M & F
	  	132	  	1.4	%	 	$	387.37	  	$	381.42	  	$	3.85	  	$	385.28	  	-0.5	%
	 Wood
	  	 HST, Age 19-64, F
	  	72	  	0.8	%	 	$	350.29	  	$	344.89	  	$	3.48	  	$	348.37	  	-0.5	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Wood
	  	 Subtotal
	  	9,336	  	100.0	%	 	$	127.21	  	$	129.94	  	$	1.31	  	$	131.25	  	3.2	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Wood
	  	 Delivery Payment
	  	70	  	0.7	%	 	$	2,858.71	  	$	3,123.56	  	$	31.55	  	$	3,155.11	  	10.4	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Wood
	  	 Total
	  	9,336	  	100.0	%	 	$	148.65	  	$	153.36	  	$	1.55	  	$	154.90	  	4.2	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Total Managed Care
	  	 HF/HST, Age 0, M & F
	  	250,843	  	5.1	%	 	$	572.95	  	$	464.98	  	$	4.70	  	$	469.68	  	-18.0	%
	 Total Managed Care
	  	 HF/HST, Age 1, M & F
	  	258,610	  	5.2	%	 	$	114.60	  	$	124.73	  	$	1.26	  	$	125.99	  	9.9	%
	 Total Managed Care
	  	 HF/HST, Age 2-13, M & F
	  	2,485,156	  	50.3	%	 	$	64.44	  	$	72.01	  	$	0.73	  	$	72.73	  	12.9	%
	 Total Managed Care
	  	 HF/HST, Age 14-18, M
	  	308,791	  	6.3	%	 	$	75.63	  	$	81.22	  	$	0.82	  	$	82.04	  	8.5	%
	 Total Managed Care
	  	 HF/HST, Age 14-18, F
	  	341,987	  	6.9	%	 	$	114.83	  	$	129.87	  	$	1.31	  	$	131.18	  	14.2	%
	 Total Managed Care
	  	 HF, Age 19-44, M
	  	179,004	  	3.6	%	 	$	181.37	  	$	178.05	  	$	1.80	  	$	179.85	  	-0.8	%
	 Total Managed Care
	  	 HF, Age 19-44, F
	  	982,232	  	19.9	%	 	$	200.51	  	$	227.19	  	$	2.29	  	$	229.48	  	14.4	%
	 Total Managed Care
	  	 HF, Age 45+, M & F
	  	81,255	  	1.6	%	 	$	395.40	  	$	390.60	  	$	3.95	  	$	394.54	  	-0.2	%
	 Total Managed Care
	  	 HST, Age 19-64, F
	  	52,682	  	1.1	%	 	$	326.70	  	$	368.85	  	$	3.73	  	$	372.58	  	14.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Total Managed Care
	  	 Subtotal
	  	4,940,560	  	100.0	%	 	$	136.60	  	$	142.40	  	$	1.44	  	$	143.84	  	5.3	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Total Managed Care
	  	 Delivery Payment
	  	18,472	  	0.4	%	 	$	3,852.02	  	$	4,432.28	  	$	44.77	  	$	4,477.05	  	16.2	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Total Managed Care
	  	 Total
	  	4,940,560	  	100.0	%	 	$	151.00	  	$	158.97	  	$	1.61	  	$	160.57	  	6.3	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

  

					
	 Mercer Government Human Services Consulting
	  	 Page 4 of 4
	  	 

					
	State of Ohio	  	 Exhibit B
 Twelve Month Rates
 CY 2004
	  	Final

  

																							
	 County

	  	 Rate Cohort

	  	 Annualized
 Dec 2002
 Managed Care
 MM/Delv

	  	% of
MM

	 	 	 CY 2002
 Rate w/
Admin

	  	 1/1/2004-
12/31/2004
 Guaranteed
 Rate

	  	 1/1/2004-
12/31/2004
 Rate At Risk

	  	 1/1/2004-
12/31/2004
 Rate w/
 Admin

	  	 Percent
 Increase

	 
	 Allen
	  	HF/HST, Age 0, M & F	  	941	  	5.5	%	 	$	—  	  	$	379.21	  	$	3.83	  	$	383.04	  	0.0	%
	 Allen
	  	HF/HST, Age 1, M & F	  	948	  	5.5	%	 	$	—  	  	$	116.84	  	$	1.18	  	$	118.02	  	0.0	%
	 Allen
	  	HF/HST, Age 2-13, M & F	  	8,757	  	51.2	%	 	$	—  	  	$	69.97	  	$	0.71	  	$	70.68	  	0.0	%
	 Allen
	  	HF/HST, Age 14-18, M	  	1,005	  	5.9	%	 	$	—  	  	$	76.56	  	$	0.77	  	$	77.33	  	0.0	%
	 Allen
	  	HF/HST, Age 14-18, F	  	1,151	  	6.7	%	 	$	—  	  	$	129.12	  	$	1.30	  	$	130.42	  	0.0	%
	 Allen
	  	HF, Age 19-44, M	  	591	  	3.5	%	 	$	—  	  	$	163.19	  	$	1.65	  	$	164.84	  	0.0	%
	 Allen
	  	HF, Age 19-44, F	  	3,334	  	19.5	%	 	$	—  	  	$	214.59	  	$	2.17	  	$	216.76	  	0.0	%
	 Allen
	  	HF, Age 45+, M&F	  	211	  	1.2	%	 	$	—  	  	$	372.45	  	$	3.76	  	$	376.21	  	0.0	%
	 Allen
	  	HST, Age 19-64, F	  	174	  	1.0	%	 	$	—  	  	$	350.32	  	$	3.54	  	$	353.86	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Allen
	  	Subtotal	  	17,112	  	100.0	%	 	$	—  	  	$	131.92	  	$	1.33	  	$	133.25	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Allen
	  	Delivery Payment	  	58	  	0.3	%	 	$	—  	  	$	3,620.88	  	$	36.57	  	$	3,657.45	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Allen
	  	Total	  	17,112	  	100.0	%	 	$	—  	  	$	144.19	  	$	1.46	  	$	145.65	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Belmont/Monroe
	  	HF/HST, Age 0, M & F	  	335	  	5.5	%	 	$	—  	  	$	361.21	  	$	3.65	  	$	364.86	  	0.0	%
	 Belmont/Monroe
	  	HF/HST, Age 1, M & F	  	337	  	5.5	%	 	$	—  	  	$	112.61	  	$	1.14	  	$	113.75	  	0.0	%
	 Belmont/Monroe
	  	HF/HST, Age 2-13, M & F	  	3,114	  	51.2	%	 	$	—  	  	$	68.47	  	$	0.69	  	$	69.16	  	0.0	%
	 Belmont/Monroe
	  	HF/HST, Age 14-18, M	  	358	  	5.9	%	 	$	—  	  	$	75.95	  	$	0.77	  	$	76.72	  	0.0	%
	 Belmont/Monroe
	  	HF/HST, Age 14-18, F	  	409	  	6.7	%	 	$	—  	  	$	123.95	  	$	1.25	  	$	125.21	  	0.0	%
	 Belmont/Monroe
	  	HF, Age 19-44, M	  	210	  	3.5	%	 	$	—  	  	$	157.82	  	$	1.59	  	$	159.42	  	0.0	%
	 Belmont/Monroe
	  	HF, Age 19-44, F	  	1,185	  	19.5	%	 	$	—  	  	$	210.26	  	$	2.12	  	$	212.39	  	0.0	%
	 Belmont/Monroe
	  	HF, Age 45+, M& F	  	75	  	1.2	%	 	$	—  	  	$	361.96	  	$	3.66	  	$	365.61	  	0.0	%
	 Belmont/Monroe
	  	HST, Age 19-64, F	  	62	  	1.0	%	 	$	—  	  	$	338.13	  	$	 3.42	  	$	341.55	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Belmont/Monroe
	  	Subtotal	  	6,085	  	100.0	%	 	$	—  	  	$	128.26	  	$	1.30	  	$	129.56	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Belmont/Monroe
	  	Delivery Payment	  	21	  	0.3	%	 	$	—  	  	$	3,535.77	  	$	35.71	  	$	3,571.49	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Belmont/Monroe
	  	Total	  	6,085	  	100.0	%	 	$	—  	  	$	140.47	  	$	1.42	  	$	141.88	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Butler
	  	HF/HST, Age 0, M & F	  	7,908	  	6.1	%	 	$	527.77	  	$	437.98	  	$	4.42	  	$	442.40	  	-16.2	%
	 Butler
	  	HF/HST, Age 1, M & F	  	7,752	  	6.0	%	 	$	110.32	  	$	123.62	  	$	1.25	  	$	124.87	  	13.2	%
	 Butler
	  	HF/HST, Age 2-13, M & F	  	66,072	  	50.7	%	 	$	70.25	  	$	81.05	  	$	0.82	  	$	81.87	  	16.5	%
	 Butler
	  	HF/HST, Age 14-18, M	  	7,452	  	5.7	%	 	$	94.50	  	$	104.49	  	$	1.06	  	$	105.54	  	11.7	%
	 Butler
	  	HF/HST, Age 14-18, F	  	8,184	  	6.3	%	 	$	123.11	  	$	142.24	  	$	1.44	  	$	143.68	  	16.7	%
	 Butler
	  	HF, Age 19-44, M	  	6,564	  	5.0	%	 	$	221.82	  	$	229.95	  	$	2.32	  	$	232.28	  	4.7	%
	 Butler
	  	HF, Age 19-44, F	  	23,040	  	17.7	%	 	$	187.85	  	$	220.57	  	$	2.23	  	$	222.80	  	18.6	%
	 Butler
	  	HF, Age 45+, M & F	  	1,608	  	1.2	%	 	$	490.36	  	$	512.08	  	$	5.17	  	$	517.26	  	5.5	%
	 Butler
	  	HST, Age 19-64, F	  	1,668	  	1.3	%	 	$	304.21	  	$	352.41	  	$	3.56	  	$	355.97	  	17.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Butler
	  	Subtotal	  	130,248	  	100.0	%	 	$	141.75	  	$	151.42	  	$	1.53	  	$	152.95	  	7.9	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Butler
	  	Delivery Payment	  	269	  	0.2	%	 	$	3,417.97	  	$	3,935.67	  	$	39.75	  	$	3,975.42	  	16.3	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Butler
	  	Total	  	130,248	  	100.0	%	 	$	148.81	  	$	159.55	  	$	1.61	  	$	161.16	  	8.3	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Clark/Madison
	  	HF/HST, Age 0, M & F	  	1,203	  	6.0	%	 	$	578.29	  	$	464.46	  	$	4.69	  	$	469.15	  	-18.9	%
	 Clark/Madison
	  	HF/HST, Age 1, M & F	  	1,132	  	5.6	%	 	$	116.69	  	$	128.58	  	$	1.30	  	$	129.88	  	11.3	%
	 Clark/Madison
	  	HF/HST, Age 2-13, M & F	  	9,845	  	49.0	%	 	$	70.44	  	$	81.77	  	$	0.83	  	$	82.59	  	17.2	%
	 Clark/Madison
	  	HF/HST, Age 14-18, M	  	1,017	  	5.1	%	 	$	88.36	  	$	99.65	  	$	1.01	  	$	100.66	  	13.9	%
	 Clark/Madison
	  	HF/HST, Age 14-18, F	  	1,030	  	5.1	%	 	$	126.73	  	$	147.40	  	$	1.49	  	$	148.89	  	17.5	%
	 Clark/Madison
	  	HF, Age 19-44, M	  	1,243	  	6.2	%	 	$	192.54	  	$	201.57	  	$	2.04	  	$	203.60	  	5.7	%
	 Clark/Madison
	  	HF, Age 19-44, F	  	4,244	  	21.1	%	 	$	200.69	  	$	238.60	  	$	2.41	  	$	241.01	  	20.1	%
	 Clark/Madison
	  	HF, Age 45+, M & F	  	272	  	1.4	%	 	$	383.27	  	$	435.40	  	$	4.40	  	$	439.80	  	14.8	%
	 Clark/Madison
	  	HST, Age 19-64, F	  	112	  	0.6	%	 	$	281.21	  	$	325.27	  	$	3.29	  	$	328.55	  	16.8	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Clark/Madison
	  	Subtotal	  	20,098	  	100.0	%	 	$	147.70	  	$	158.25	  	$	1.60	  	$	159.85	  	8.2	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Clark/Madison
	  	Delivery Payment	  	50	  	0.2	%	 	$	3,388.96	  	$	3,869.97	  	$	39.09	  	$	3,909.06	  	15.3	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Clark/Madison
	  	Total	  	20,098	  	100.0	%	 	$	156.13	  	$	167.88	  	$	1.70	  	$	169.57	  	8.6	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Clermont
	  	HF/HST, Age 0, M & F	  	427	  	5.5	%	 	$	546.23	  	$	428.41	  	$	4.33	  	$	432.74	  	-20.8	%
	 Clermont
	  	HF/HST, Age 1, M & F	  	430	  	5.5	%	 	$	141.76	  	$	145.43	  	$	1.47	  	$	146.90	  	3.6	%
	 Clermont
	  	HF/HST, Age 2-13, M & F	  	3,975	  	51.2	%	 	$	73.20	  	$	85.93	  	$	0.87	  	$	86.80	  	18.6	%
	 Clermont
	  	HF/HST, Age 14-18, M	  	456	  	5.9	%	 	$	81.01	  	$	94.66	  	$	0.96	  	$	95.61	  	18.0	%
	 Clermont
	  	HF/HST, Age 14-18, F	  	522	  	6.7	%	 	$	139.84	  	$	162.72	  	$	1.64	  	$	164.36	  	17.5	%
	 Clermont
	  	HF, Age 19-44, M	  	268	  	3.5	%	 	$	197.25	  	$	199.87	  	$	2.02	  	$	201.89	  	2.3	%
	 Clermont
	  	HF, Age 19-44, F	  	1,513	  	19.5	%	 	$	212.15	  	$	247.49	  	$	2.50	  	$	249.99	  	17.8	%
	 Clermont
	  	HF, Age 45+, M & F	  	96	  	1.2	%	 	$	472.01	  	$	518.18	  	$	5.23	  	$	523.41	  	10.9	%
	 Clermont
	  	HST, Age 19-64, F	  	79	  	1.0	%	 	$	362.51	  	$	380.75	  	$	3.85	  	$	384.59	  	6.1	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Clermont
	  	Subtotal	  	7,766	  	100.0	%	 	$	147.17	  	$	157.48	  	$	1.59	  	$	159.07	  	8.1	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Clermont
	  	Delivery Payment	  	26	  	0.3	%	 	$	4,043.64	  	$	3,933.34	  	$	39.73	  	$	3,973.07	  	-1.7	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Clermont
	  	Total	  	7,766	  	100.0	%	 	$	160.71	  	$	170.65	  	$	1.72	  	$	172.37	  	7.3	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

  

					
	 Mercer Government Human Services Consulting
	  	 Page 1 of 7
	  	 

					
	State of Ohio	  	 Exhibit B
 Twelve Month Rates
 CY 2004
	  	Final

  

																							
	 County

	  	 Rate Cohort

	  	 Annualized
 Dec 2002
 Managed Care
 MM/Delv

	  	% of
MM

	 	 	 CY 2002
 Rate w/
Admin

	  	 1/1/2004-
12/31/2004
 Guaranteed
 Rate

	  	 1/1/2004-
12/31/2004
 Rate At Risk

	  	 1/1/2004-
12/31/2004
 Rate w/
 Admin

	  	 Percent
 Increase

	 
	 Columbiana
	  	HF/HST, Age 0, M & F	  	1,346	  	5.5	%	 	$	—  	  	$	379.02	  	$	3.83	  	$	382.85	  	0.0	%
	 Columbiana
	  	HF/HST, Age 1, M & F	  	1,356	  	5.5	%	 	$	—  	  	$	118.38	  	$	1.20	  	$	119.58	  	0.0	%
	 Columbiana
	  	HF/HST, Age 2-13, M & F	  	12,526	  	51.2	%	 	$	—  	  	$	72.28	  	$	0.73	  	$	73.01	  	0.0	%
	 Columbiana
	  	HF/HST, Age 14-18, M	  	1,438	  	5.9	%	 	$	—  	  	$	79.58	  	$	0.80	  	$	80.38	  	0.0	%
	 Columbiana
	  	HF/HST, Age 14-18, F	  	1,646	  	6.7	%	 	$	—  	  	$	128.35	  	$	1.30	  	$	129.64	  	0.0	%
	 Columbiana
	  	HF, Age 19-44, M	  	845	  	3.5	%	 	$	—  	  	$	166.09	  	$	1.68	  	$	167.77	  	0.0	%
	 Columbiana
	  	HF, Age 19-44, F	  	4,769	  	19.5	%	 	$	—  	  	$	218.03	  	$	2.20	  	$	220.23	  	0.0	%
	 Columbiana
	  	HF, Age 45+, M & F	  	302	  	1.2	%	 	$	—  	  	$	369.40	  	$	3.73	  	$	373.13	  	0.0	%
	 Columbiana
	  	HST, Age 19-64, F	  	249	  	1.0	%	 	$	—  	  	$	350.76	  	$	3.54	  	$	354.30	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Columbiana
	  	Subtotal	  	24,477	  	100.0	%	 	$	—  	  	$	134.04	  	$	1.35	  	$	135.39	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Columbiana
	  	Delivery Payment	  	83	  	0.3	%	 	$	—  	  	$	3,646.17	  	$	36.83	  	$	3,683.00	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Columbiana
	  	Total	  	24,477	  	100.0	%	 	$	—  	  	$	146.40	  	$	1.48	  	$	147.88	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Crawford
	  	HF/HST, Age 0, M & F	  	166	  	5.5	%	 	$	—  	  	$	362.10	  	$	3.66	  	$	365.76	  	0.0	%
	 Crawford
	  	HF/HST, Age 1, M & F	  	167	  	5.5	%	 	$	—  	  	$	110.18	  	$	1.11	  	$	111.30	  	0.0	%
	 Crawford
	  	HF/HST, Age 2-13, M & F	  	1,542	  	51.2	%	 	$	—  	  	$	66.94	  	$	0.68	  	$	67.61	  	0.0	%
	 Crawford
	  	HF/HST, Age 14-18, M	  	177	  	5.9	%	 	$	—  	  	$	75.08	  	$	0.76	  	$	75.84	  	0.0	%
	 Crawford
	  	HF/HST, Age 14-18, F	  	203	  	6.7	%	 	$	—  	  	$	125.55	  	$	1.27	  	$	126.82	  	0.0	%
	 Crawford
	  	HF, Age 19-44, M	  	104	  	3.5	%	 	$	—  	  	$	160.35	  	$	1.62	  	$	161.97	  	0.0	%
	 Crawford
	  	HF, Age 19-44, F	  	587	  	19.5	%	 	$	—  	  	$	208.24	  	$	2.10	  	$	210.34	  	0.0	%
	 Crawford
	  	HF, Age 45+, M & F	  	37	  	1.2	%	 	$	—  	  	$	347.17	  	$	3.51	  	$	350.68	  	0.0	%
	 Crawford
	  	HST, Age 19-64, F	  	31	  	1.0	%	 	$	—  	  	$	332.53	  	$	3.36	  	$	335.89	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Crawford
	  	Subtotal	  	3,014	  	100.0	%	 	$	—  	  	$	126.93	  	$	1.28	  	$	128.21	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Crawford
	  	Delivery Payment	  	10	  	0.3	%	 	$	—  	  	$	3,501.94	  	$	35.37	  	$	3,537.32	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Crawford
	  	Total	  	3,014	  	100.0	%	 	$	—  	  	$	138.55	  	$	1.40	  	$	139.95	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Cuyahoga
	  	HF/HST, Age 0, M & F	  	80,520	  	4.5	%	 	$	584.96	  	$	486.83	  	$	4.92	  	$	491.75	  	-15.9	%
	 Cuyahoga
	  	HF/HST, Age 1, M & F	  	86,280	  	4.8	%	 	$	124.16	  	$	140.22	  	$	1.42	  	$	141.63	  	14.1	%
	 Cuyahoga
	  	HF/HST, Age 2-13, M & F	  	891,084	  	50.0	%	 	$	65.37	  	$	75.98	  	$	0.77	  	$	76.75	  	17.4	%
	 Cuyahoga
	  	HF/HST, Age 14-18, M	  	119,844	  	6.7	%	 	$	73.86	  	$	81.89	  	$	0.83	  	$	82.71	  	12.0	%
	 Cuyahoga
	  	HF/HST, Age 14-18, F	  	127,620	  	7.2	%	 	$	113.20	  	$	133.38	  	$	1.35	  	$	134.73	  	19.0	%
	 Cuyahoga
	  	HF, Age 19-44, M	  	61,008	  	3.4	%	 	$	174.98	  	$	175.09	  	$	1.77	  	$	176.86	  	1.1	%
	 Cuyahoga
	  	HF, Age 19-44, F	  	360,012	  	20.2	%	 	$	196.51	  	$	231.15	  	$	2.33	  	$	233.49	  	18.8	%
	 Cuyahoga
	  	HF, Age 45+, M & F	  	36,600	  	2.1	%	 	$	386.19	  	$	395.37	  	$	3.99	  	$	399.37	  	3.4	%
	 Cuyahoga
	  	HST, Age 19-64, F	  	17,808	  	1.0	%	 	$	343.12	  	$	398.42	  	$	4.02	  	$	402.44	  	17.3	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Cuyahoga
	  	Subtotal	  	1,780,776	  	100.0	%	 	$	135.35	  	$	146.74	  	$	1.48	  	$	148.22	  	9.5	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Cuyahoga
	  	Delivery Payment	  	6,847	  	0.4	%	 	$	3,975.41	  	$	4,675.13	  	$	47.22	  	$	4,722.35	  	18.8	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Cuyahoga
	  	Total	  	1,780,776	  	100.0	%	 	$	150.63	  	$	164.71	  	$	1.66	  	$	166.38	  	10.5	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Defiance/Fulton/Henry
	  	HF/HST, Age 0, M & F	  	253	  	5.5	%	 	$	—  	  	$	367.98	  	$	3.72	  	$	371.70	  	0.0	%
	 Defiance/Fulton/Henry
	  	HF/HST, Age 1, M & F	  	255	  	5.5	%	 	$	—  	  	$	111.52	  	$	1.13	  	$	112.65	  	0.0	%
	 Defiance/Fulton/Henry
	  	HF/HST, Age 2-13, M & F	  	2,357	  	51.2	%	 	$	—  	  	$	67.86	  	$	0.69	  	$	68.54	  	0.0	%
	 Defiance/Fulton/Henry
	  	HF/HST, Age 14-18, M	  	271	  	5.9	%	 	$	—  	  	$	75.18	  	$	0.76	  	$	75.94	  	0.0	%
	 Defiance/Fulton/Henry
	  	HF/HST, Age 14-18, F	  	310	  	6.7	%	 	$	—  	  	$	125.25	  	$	1.27	  	$	126.51	  	0.0	%
	 Defiance/Fulton/Henry
	  	HF, Age 19-44, M	  	159	  	3.5	%	 	$	—  	  	$	157.10	  	$	1.59	  	$	158.69	  	0.0	%
	 Defiance/Fulton/Henry
	  	HF, Age 19-44, F	  	897	  	19.5	%	 	$	—  	  	$	208.16	  	$	2.10	  	$	210.26	  	0.0	%
	 Defiance/Fulton/Henry
	  	HF, Age 45+, M & F	  	57	  	1.2	%	 	$	—  	  	$	337.45	  	$	3.41	  	$	340.86	  	0.0	%
	 Defiance/Fulton/Henry
	  	HST, Age 19-64, F	  	47	  	1.0	%	 	$	—  	  	$	334.79	  	$	3.38	  	$	338.17	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Defiance/Fulton/Henry
	  	Subtotal	  	4,606	  	100.0	%	 	$	—  	  	$	127.52	  	$	1.29	  	$	128.81	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Defiance/Fulton/Henry
	  	Delivery Payment	  	16	  	0.3	%	 	$	—  	  	$	3,522.15	  	$	35.58	  	$	3,557.72	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Defiance/Fulton/Henry
	  	Total	  	4,606	  	100.0	%	 	$	—  	  	$	139.75	  	$	1.41	  	$	141.16	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Delaware
	  	HF/HST, Age 0, M & F	  	159	  	5.5	%	 	$	—  	  	$	367.06	  	$	3.71	  	$	370.77	  	0.0	%
	 Delaware
	  	HF/HST, Age 1, M & F	  	160	  	5.5	%	 	$	—  	  	$	110.49	  	$	1.12	  	$	111.61	  	0.0	%
	 Delaware
	  	HF/HST, Age 2-13, M & F	  	1,477	  	51.2	%	 	$	—  	  	$	67.56	  	$	0.68	  	$	68.24	  	0.0	%
	 Delaware
	  	HF/HST, Age 14-18, M	  	170	  	5.9	%	 	$	—  	  	$	75.68	  	$	0.76	  	$	76.44	  	0.0	%
	 Delaware
	  	HF/HST, Age 14-18, F	  	194	  	6.7	%	 	$	—  	  	$	124.25	  	$	1.26	  	$	125.50	  	0.0	%
	 Delaware
	  	HF, Age 19-44, M	  	100	  	3.5	%	 	$	—  	  	$	159.50	  	$	1.61	  	$	161.11	  	0.0	%
	 Delaware
	  	HF, Age 19-44, F	  	562	  	19.5	%	 	$	—  	  	$	210.63	  	$	2.13	  	$	212.75	  	0.0	%
	 Delaware
	  	HF, Age 45+, M & F	  	36	  	1.2	%	 	$	—  	  	$	360.43	  	$	3.64	  	$	364.07	  	0.0	%
	 Delaware
	  	HST, Age 19-64, F	  	29	  	1.0	%	 	$	—  	  	$	337.90	  	$	3.41	  	$	341.31	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Delaware
	  	Subtotal	  	2,887	  	100.0	%	 	$	—  	  	$	128.12	  	$	1.29	  	$	129.42	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Delaware
	  	Delivery Payment	  	10	  	0.3	%	 	$	—  	  	$	3,527.06	  	$	35.63	  	$	3,562.68	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Delaware
	  	Total	  	2,887	  	100.0	%	 	$	—  	  	$	140.34	  	$	1.42	  	$	141.76	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

  

					
	 Mercer Government Human Services Consulting
	  	 Page 2 of 7
	  	 

					
	 State of Ohio
	 	Exhibit B	 	Final
	 	 	Twelve Month Rates	 	 
	 	 	CY 2004	 	 

  

																							
	 County

	  	 Rate Cohort

	  	 Annualized
 Dec 2002
 Managed Care
 MM/Delv

	  	% of
MM

	 	 	CY 2002
Rate w/
Admin

	  	1/1/2004-
12/31/2004
Guaranteed
Rate

	  	1/1/2004-
12/31/2004
Rate At Risk

	  	1/1/2004-
12/31/2004
Rate w/
Admin

	  	Percent
Increase

	 
	 Fairfield
	  	HF/HST, Age 0, M & F	  	287	  	5.5	%	 	$	—  	  	$	365.44	  	$	3.69	  	$	369.13	  	0.0	%
	 Fairfield
	  	HF/HST, Age 1, M & F	  	289	  	5.5	%	 	$	—  	  	$	112.58	  	$	1.14	  	$	113.72	  	0.0	%
	 Fairfield
	  	HF/HST, Age 2-13, M & F	  	2,666	  	51.2	%	 	$	—  	  	$	68.98	  	$	0.70	  	$	69.68	  	0.0	%
	 Fairfield
	  	HF/HST, Age 14-18, M	  	306	  	5.9	%	 	$	—  	  	$	93.93	  	$	0.95	  	$	94.88	  	0.0	%
	 Fairfield
	  	HF/HST, Age 14-18, F	  	350	  	6.7	%	 	$	—  	  	$	129.66	  	$	1.31	  	$	130.97	  	0.0	%
	 Fairfield
	  	HF, Age 19-44, M	  	180	  	3.5	%	 	$	—  	  	$	163.00	  	$	1.65	  	$	164.64	  	0.0	%
	 Fairfield
	  	HF, Age 19-44, F	  	1,015	  	19.5	%	 	$	—  	  	$	217.09	  	$	2.19	  	$	219.28	  	0.0	%
	 Fairfield
	  	HF, Age 45+, M & F	  	64	  	1.2	%	 	$	—  	  	$	357.49	  	$	3.61	  	$	361.10	  	0.0	%
	 Fairfield
	  	HST, Age 19-64, F	  	53	  	1.0	%	 	$	—  	  	$	347.11	  	$	3.51	  	$	350.61	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Fairfield
	  	Subtotal	  	5,210	  	100.0	%	 	$	—  	  	$	131.75	  	$	1.33	  	$	133.08	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Fairfield
	  	Delivery Payment	  	18	  	0.3	%	 	$	—  	  	$	3,528.59	  	$	35.64	  	$	3,564.23	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Fairfield
	  	Total	  	5,210	  	100.0	%	 	$	—  	  	$	143.94	  	$	1.45	  	$	145.39	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Franklin
	  	HF/HST, Age 0, M & F	  	41,412	  	4.9	%	 	$	503.34	  	$	420.76	  	$	4.25	  	$	425.01	  	-15.6	%
	 Franklin
	  	HF/HST, Age 1, M & F	  	45,912	  	5.5	%	 	$	107.80	  	$	120.19	  	$	1.21	  	$	121.41	  	12.6	%
	 Franklin
	  	HF/HST, Age 2-13, M & F	  	432,048	  	51.6	%	 	$	63.12	  	$	73.22	  	$	0.74	  	$	73.96	  	17.2	%
	 Franklin
	  	HF/HST, Age 14-18, M	  	47,880	  	5.7	%	 	$	75.42	  	$	83.12	  	$	0.84	  	$	83.96	  	11.3	%
	 Franklin
	  	HF/HST, Age 14-18, F	  	54,540	  	6.5	%	 	$	112.59	  	$	131.71	  	$	1.33	  	$	133.04	  	18.2	%
	 Franklin
	  	HF, Age 19-44, M	  	29,256	  	3.5	%	 	$	195.37	  	$	201.08	  	$	2.03	  	$	203.11	  	4.0	%
	 Franklin
	  	HF, Age 19-44, F	  	168,024	  	20.1	%	 	$	217.48	  	$	258.89	  	$	2.62	  	$	261.51	  	20.2	%
	 Franklin
	  	HF, Age 45+, M & F	  	10,668	  	1.3	%	 	$	413.63	  	$	434.56	  	$	4.39	  	$	438.95	  	6.1	%
	 Franklin
	  	HST, Age 19-64, F	  	7,488	  	0.9	%	 	$	264.53	  	$	309.72	  	$	3.13	  	$	312.85	  	18.3	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Franklin
	  	Subtotal	  	837,228	  	100.0	%	 	$	133.14	  	$	145.81	  	$	1.47	  	$	147.28	  	10.6	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Franklin
	  	Delivery Payment	  	2,999	  	0.4	%	 	$	3,305.57	  	$	3,887.49	  	$	39.27	  	$	3,926.76	  	18.8	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Franklin
	  	Total	  	837,228	  	100.0	%	 	$	144.98	  	$	159.74	  	$	1.61	  	$	161.35	  	11.3	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Greene
	  	HF/HST, Age 0, M & F	  	2,860	  	5.5	%	 	$	578.29	  	$	459.93	  	$	4.65	  	$	464.58	  	-19.7	%
	 Greene
	  	HF/HST, Age 1, M & F	  	2,881	  	5.5	%	 	$	116.69	  	$	127.60	  	$	1.29	  	$	128.89	  	10.5	%
	 Greene
	  	HF/HST, Age 2-13, M & F	  	26,611	  	51.2	%	 	$	70.44	  	$	84.98	  	$	0.86	  	$	85.83	  	21.9	%
	 Greene
	  	HF/HST, Age 14-18, M	  	3,055	  	5.9	%	 	$	88.36	  	$	100.04	  	$	1.01	  	$	101.05	  	14.4	%
	 Greene
	  	HF/HST, Age 14-18, F	  	3,497	  	6.7	%	 	$	126.73	  	$	146.50	  	$	1.48	  	$	147.98	  	16.8	%
	 Greene
	  	HF, Age 19-44, M	  	1,796	  	3.5	%	 	$	192.54	  	$	199.30	  	$	2.01	  	$	201.31	  	4.6	%
	 Greene
	  	HF, Age 19-44, F	  	10,131	  	19.5	%	 	$	200.69	  	$	237.82	  	$	2.40	  	$	240.22	  	19.7	%
	 Greene
	  	HF, Age 45+, M & F	  	641	  	1.2	%	 	$	383.27	  	$	397.53	  	$	4.02	  	$	401.54	  	4.8	%
	 Greene
	  	HST, Age 19-64, F	  	529	  	1.0	%	 	$	281.21	  	$	331.53	  	$	3.35	  	$	334.88	  	19.1	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Greene
	  	Subtotal	  	52,001	  	100.0	%	 	$	141.37	  	$	153.07	  	$	1.55	  	$	154.62	  	9.4	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Greene
	  	Delivery Payment	  	176	  	0.3	%	 	$	3,388.96	  	$	4,021.19	  	$	40.62	  	$	4,061.81	  	19.9	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Greene
	  	Total	  	52,001	  	100.0	%	 	$	152.84	  	$	166.88	  	$	1.68	  	$	168.36	  	10.2	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Hamilton
	  	HF/HST, Age 0, M & F	  	24,540	  	5.9	%	 	$	629.79	  	$	523.73	  	$	5.29	  	$	529.02	  	-16.0	%
	 Hamilton
	  	HF/HST, Age 1, M & F	  	22,860	  	5.5	%	 	$	125.83	  	$	141.71	  	$	1.43	  	$	143.14	  	13.8	%
	 Hamilton
	  	HF/HST, Age 2-13, M & F	  	213,888	  	51.8	%	 	$	65.52	  	$	75.58	  	$	0.76	  	$	76.35	  	16.5	%
	 Hamilton
	  	HF/HST, Age 14-18, M	  	26,520	  	6.4	%	 	$	75.82	  	$	83.63	  	$	0.84	  	$	84.47	  	11.4	%
	 Hamilton
	  	HF/HST, Age 14-18, F	  	31,944	  	7.7	%	 	$	112.60	  	$	132.46	  	$	1.34	  	$	133.80	  	18.8	%
	 Hamilton
	  	HF, Age 19-44, M	  	8,688	  	2.1	%	 	$	180.67	  	$	180.26	  	$	1.82	  	$	182.09	  	0.8	%
	 Hamilton
	  	HF, Age 19-44, F	  	74,136	  	18.0	%	 	$	197.19	  	$	230.20	  	$	2.33	  	$	232.52	  	17.9	%
	 Hamilton
	  	HF, Age 45+, M & F	  	4,752	  	1.2	%	 	$	392.89	  	$	398.50	  	$	4.03	  	 	402.53	  	2.5	%
	 Hamilton
	  	HST, Age 19-64, F	  	5,316	  	1.3	%	 	$	344.27	  	$	396.96	  	$	4.01	  	$	400.97	  	16.5	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Hamilton
	  	Subtotal	  	412,644	  	100.0	%	 	$	140.16	  	$	148.66	  	$	1.50	  	$	150.16	  	7.1	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Hamilton
	  	Delivery Payment	  	1,267	  	0.3	%	 	$	4,319.39	  	$	5,084.77	  	$	51.36	  	$	5,136.13	  	18.9	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Hamilton
	  	Total	  	412,644	  	100.0	%	 	$	153.43	  	$	164.27	  	$	1.66	  	$	165.93	  	8.2	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Huron
	  	HF/HST, Age 0, M & F	  	192	  	5.5	%	 	$	—  	  	$	370.32	  	$	3.74	  	$	374.07	  	0.0	%
	 Huron
	  	HF/HST, Age 1, M & F	  	193	  	5.5	%	 	$	—  	  	$	112.66	  	$	1.14	  	$	113.80	  	0.0	%
	 Huron
	  	HF/HST, Age 2-13, M & F	  	1,786	  	51.2	%	 	$	—  	  	$	67.46	  	$	0.68	  	$	68.14	  	0.0	%
	 Huron
	  	HF/HST, Age 14-18, M	  	205	  	5.9	%	 	$	—  	  	$	75.48	  	$	0.76	  	$	76.25	  	0.0	%
	 Huron
	  	HF/HST, Age 14-18, F	  	235	  	6.7	%	 	$	—  	  	$	123.99	  	$	1.25	  	$	125.25	  	0.0	%
	 Huron
	  	HF, Age 19-44, M	  	121	  	3.5	%	 	$	—  	  	$	153.16	  	$	1.55	  	$	154.71	  	0.0	%
	 Huron
	  	HF, Age 19-44, F	  	680	  	19.5	%	 	$	—  	  	$	211.18	  	$	2.13	  	$	213.31	  	0.0	%
	 Huron
	  	HF, Age 45+, M & F	  	43	  	1.2	%	 	$	—  	  	$	349.39	  	$	3.53	  	$	352.92	  	0.0	%
	 Huron
	  	HST, Age 19-64, F	  	35	  	1.0	%	 	$	—  	  	$	336.47	  	$	3.40	  	$	339.87	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Huron
	  	Subtotal	  	3,490	  	100.0	%	 	$	—  	  	$	128.04	  	$	1.29	  	$	129.34	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Huron
	  	Delivery Payment	  	12	  	0.3	%	 	$	—  	  	$	3,514.27	  	$	35.50	  	$	3,549.77	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Huron
	  	Total	  	3,490	  	100.0	%	 	$	—  	  	$	140.13	  	$	1.42	  	$	141.54	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

  

					
	 Mercer Government Human Services Consulting
	  	 Page 3 of 7
	  	 

					
	 State of Ohio
	 	Exhibit B	 	Final
	 	 	Twelve Month Rates	 	 
	 	 	CY 2004	 	 

  

																							
	 County

	  	 Rate Cohort

	  	 Annualized
Dec 2002
Managed Care
 MM/Delv

	  	% of MM

	 	 	CY 2002
Rate w/
Admin

	  	1/1/2004 -
12/31/2004
Guaranteed
Rate

	  	1/1/2004 -
12/31/2004
Rate At Risk

	  	1/1/2004 -
12/31/2004
Rate w/
Admin

	  	Percent
Increase

	 
	 Jefferson
	  	HF/HST, Age 0, M & F	  	274	  	5.5	%	 	$	—  	  	$	366.23	  	$	3.70	  	$	369.92	  	0.0	%
	 Jefferson
	  	HF/HST, Age 1, M & F	  	276	  	5.5	%	 	$	—  	  	$	112.58	  	$	1.14	  	$	113.71	  	0.0	%
	 Jefferson
	  	HF/HST, Age 2-13, M & F	  	2,545	  	51.2	%	 	$	—  	  	$	68.05	  	$	0.69	  	$	68.74	  	0.0	%
	 Jefferson
	  	HF/HST, Age 14-18, M	  	292	  	5.9	%	 	$	—  	  	$	75.67	  	$	0.76	  	$	76.43	  	0.0	%
	 Jefferson
	  	HF/HST, Age 14-18, F	  	334	  	6.7	%	 	$	—  	  	$	123.13	  	$	1.24	  	$	124.37	  	0.0	%
	 Jefferson
	  	HF, Age 19-44, M	  	172	  	3.5	%	 	$	—  	  	$	158.45	  	$	1.60	  	$	160.05	  	0.0	%
	 Jefferson
	  	HF, Age 19-44, F	  	969	  	19.5	%	 	$	—  	  	$	209.68	  	$	2.12	  	$	211.80	  	0.0	%
	 Jefferson
	  	HF, Age 45+, M & F	  	61	  	1.2	%	 	$	—  	  	$	357.74	  	$	3.61	  	$	361.35	  	0.0	%
	 Jefferson
	  	HST, Age 19-64, F	  	51	  	1.0	%	 	$	—  	  	$	344.49	  	$	3.48	  	$	347.96	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Jefferson
	  	Subtotal	  	4,974	  	100.0	%	 	$	—  	  	$	128.20	  	$	1.29	  	$	129.49	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Jefferson
	  	Delivery Payment	  	17	  	0.3	%	 	$	—  	  	$	3,537.71	  	$	35.73	  	$	3,573.44	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Jefferson
	  	Total	  	4,974	  	100.0	%	 	$	—  	  	$	140.29	  	$	1.42	  	$	141.71	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Licking
	  	HF/HST, Age 0, M & F	  	1,199	  	5.5	%	 	$	—  	  	$	376.04	  	$	3.80	  	$	379.84	  	0.0	%
	 Licking
	  	HF/HST, Age 1, M & F	  	1,207	  	5.5	%	 	$	—  	  	$	115.17	  	$	1.16	  	$	116.34	  	0.0	%
	 Licking
	  	HF/HST, Age 2-13, M & F	  	11,152	  	51.2	%	 	$	—  	  	$	70.07	  	$	0.71	  	$	70.78	  	0.0	%
	 Licking
	  	HF/HST, Age 14-18, M	  	1,280	  	5.9	%	 	$	—  	  	$	79.58	  	$	0.80	  	$	80.39	  	0.0	%
	 Licking
	  	HF/HST, Age 14-18, F	  	1,465	  	6.7	%	 	$	—  	  	$	128.46	  	$	1.30	  	$	129.76	  	0.0	%
	 Licking
	  	HF, Age 19-44, M	  	753	  	3.5	%	 	$	—  	  	$	158.46	  	$	1.60	  	$	160.06	  	0.0	%
	 Licking
	  	HF, Age 19-44, F	  	4,246	  	19.5	%	 	$	—  	  	$	214.86	  	$	2.17	  	$	217.03	  	0.0	%
	 Licking
	  	HF, Age 45+, M & F	  	269	  	1.2	%	 	$	—  	  	$	368.17	  	$	3.72	  	$	371.89	  	0.0	%
	 Licking
	  	HST, Age 19-64, F	  	222	  	1.0	%	 	$	—  	  	$	347.73	  	$	3.51	  	$	351.25	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Licking
	  	Subtotal	  	21,793	  	100.0	%	 	$	—  	  	$	131.66	  	$	1.33	  	$	132.99	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Licking
	  	Delivery Payment	  	74	  	0.3	%	 	$	—  	  	$	3633.70	  	$	36.70	  	$	3,670.41	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Licking
	  	Total	  	21,793	  	100.0	%	 	$	—  	  	$	144.00	  	$	1.45	  	$	145.45	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Lorain
	  	HF/HST, Age 0, M & F	  	7,236	  	5.0	%	 	$	422.96	  	$	356.94	  	$	3.61	  	$	360.54	  	-14.8	%
	 Lorain
	  	HF/HST, Age 1, M & F	  	8,100	  	5.6	%	 	$	88.61	  	$	96.46	  	$	0.97	  	$	97.44	  	10.0	%
	 Lorain
	  	HF/HST, Age 2-13, M & F	  	72,528	  	49.9	%	 	$	57.69	  	$	65.26	  	$	0.66	  	$	65.91	  	14.3	%
	 Lorain
	  	HF/HST, Age 14-18, M	  	8,496	  	5.8	%	 	$	57.46	  	$	64.67	  	$	0.65	  	$	65.32	  	13.7	%
	 Lorain
	  	HF/HST, Age 14-18, F	  	8,844	  	6.1	%	 	$	108.81	  	$	127.66	  	$	1.29	  	$	128.95	  	18.5	%
	 Lorain
	  	HF, Age 19-44, M	  	7,428	  	5.1	%	 	$	160.70	  	$	169.02	  	$	1.71	  	$	170.73	  	6.2	%
	 Lorain
	  	HF, Age 19-44, F	  	29,268	  	20.1	%	 	$	179.46	  	$	207.63	  	$	2.10	  	$	209.73	  	16.9	%
	 Lorain
	  	HF, Age 45+, M & F	  	2,040	  	1.4	%	 	$	299.67	  	$	316.05	  	$	3.19	  	$	319.24	  	6.5	%
	 Lorain
	  	HST, Age 19-64, F	  	1,416	  	1.0	%	 	$	309.72	  	$	355.46	  	$	3.59	  	$	359.05	  	15.9	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Lorain
	  	Subtotal	  	145,356	  	100.0	%	 	$	116.33	  	$	125.59	  	$	1.27	  	$	126.86	  	9.1	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Lorain
	  	Delivery Payment	  	494	  	0.3	%	 	$	3,289.08	  	$	3,597.03	  	$	36.33	  	$	3,633.37	  	10.5	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Lorain
	  	Total	  	145,356	  	100.0	%	 	$	127.50	  	$	137.82	  	$	1.39	  	$	139.21	  	9.2	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Lucas
	  	HF/HST, Age 0, M & F	  	32,076	  	5.4	%	 	$	647.45	  	$	542.31	  	$	5.48	  	$	547.79	  	-15.4	%
	 Lucas
	  	HF/HST, Age 1, M & F	  	33,228	  	5.6	%	 	$	100.36	  	$	112.27	  	$	1.13	  	$	113.40	  	13.0	%
	 Lucas
	  	HF/HST, Age 2-13, M & F	  	294,060	  	49.3	%	 	$	62.88	  	$	72.76	  	$	0.73	  	$	73.50	  	16.9	%
	 Lucas
	  	HF/HST, Age 14-18, M	  	37,416	  	6.3	%	 	$	71.47	  	$	81.13	  	$	0.82	  	$	81.95	  	14.7	%
	 Lucas
	  	HF/HST, Age 14-18, F	  	40,872	  	6.9	%	 	$	116.85	  	$	134.90	  	$	1.36	  	$	136.26	  	16.6	%
	 Lucas
	  	HF, Age 19-44, M	  	24,528	  	4.1	%	 	$	187.36	  	$	187.38	  	$	1.89	  	$	189.28	  	1.0	%
	 Lucas
	  	HF, Age 19-44, F	  	115,356	  	19.4	%	 	$	199.19	  	$	231.26	  	$	2.34	  	$	233.60	  	17.3	%
	 Lucas
	  	HF, Age 45+, M & F	  	9,048	  	1.5	%	 	$	415.02	  	$	421.13	  	$	4.25	  	$	425.38	  	2.5	%
	 Lucas
	  	HST, Age 19-64, F	  	9,516	  	1.6	%	 	$	340.77	  	$	392.90	  	$	3.97	  	$	396.87	  	16.5	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Lucas
	  	Subtotal	  	596,100	  	100.0	%	 	$	141.95	  	$	150.80	  	$	1.52	  	$	152.33	  	7.3	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Lucas
	  	Delivery Payment	  	2,712	  	0.5	%	 	$	3,844.21	  	$	4320.65	  	$	 43.64	  	$	4,364.29	  	13.5	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Lucas
	  	Total	  	596,100	  	100.0	%	 	$	159.44	  	$	170.46	  	$	1.72	  	$	172.18	  	8.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Mahoning
	  	HF/HST, Age 0, M & F	  	7,620	  	5.5	%	 	$	512.84	  	$	419.13	  	$	4.23	  	$	423.36	  	-17.4	%
	 Mahoning
	  	HF/HST, Age 1, M & F	  	7,676	  	5.5	%	 	$	109.61	  	$	123.78	  	$	1.25	  	$	125.03	  	14.1	%
	 Mahoning
	  	HF/HST, Age 2-13, M & F	  	70,893	  	51.2	%	 	$	71.58	  	$	78.77	  	$	0.80	  	$	79.56	  	11.2	%
	 Mahoning
	  	HF/HST, Age 14-18, M	  	8,140	  	5.9	%	 	$	101.19	  	$	111.09	  	$	1.12	  	$	112.21	  	10.9	%
	 Mahoning
	  	HF/HST, Age 14-18, F	  	9,316	  	6.7	%	 	$	121.54	  	$	139.44	  	$	1.41	  	$	140.85	  	15.9	%
	 Mahoning
	  	HF, Age 19-44, M	  	4,785	  	3.5	%	 	$	203.35	  	$	192.51	  	$	1.94	  	$	194.45	  	-4.4	%
	 Mahoning
	  	HF, Age 19-44, F	  	26,991	  	19.5	%	 	$	211.29	  	$	247.27	  	$	2.50	  	$	249.77	  	18.2	%
	 Mahoning
	  	HF, Age 45+, M & F	  	1,709	  	1.2	%	 	$	400.10	  	$	416.84	  	$	4.21	  	$	421.05	  	5.2	%
	 Mahoning
	  	HST, Age 19-64, F	  	1,408	  	1.0	%	 	$	346.92	  	$	368.43	  	$	3.72	  	$	372.16	  	7.3	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Mahoning
	  	Subtotal	  	138,538	  	100.0	%	 	$	141.68	  	$	149.83	  	$	1.51	  	$	151.35	  	6.8	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Mahoning
	  	Delivery Payment	  	468	  	0.3	%	 	$	3,509.06	  	$	3,980.19	  	$	40.20	  	$	4,020.39	  	14.6	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Mahoning
	  	Total	  	138,538	  	100.0	%	 	$	153.53	  	$	163.28	  	$	1.65	  	$	164.93	  	7.4	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

  

					
	 Mercer Government Human Services Consulting
	  	 Page 4 of 7
	  	 

					
	 State of Ohio
	 	Exhibit B	 	Final
	 	 	Twelve Month Rates	 	 
	 	 	CY 2004	 	 

  

																							
	 County

	  	 Rate Cohort

	  	Annualized
Dec 2002
Managed Care
MM/Delv

	  	% of MM

	 	 	CY 2002
Rate w/
Admin

	  	1/1/2004-
12/31/2004
Guaranteed
Rate

	  	1/1/2004 -
12/31/2004
Rate At Risk

	  	1/1/2004-
12/31/2004
Rate w/
Admin

	  	Percent
Increase

	 
	 Montgomery
	  	HF/HST, Age 0, M & F	  	22,200	  	6.3	%	 	$	602.39	  	$	499.26	  	$	5.04	  	$	504.30	  	-16.3	%
	 Montgomery
	  	HF/HST, Age 1, M & F	  	19,524	  	5.5	%	 	$	123.80	  	$	139.57	  	$	1.41	  	$	140.98	  	13.9	%
	 Montgomery
	  	HF/HST, Age 2-13, M & F	  	177,480	  	50.2	%	 	$	64.80	  	$	75.24	  	$	0.76	  	$	76.00	  	17.3	%
	 Montgomery
	  	HF/HST, Age 14-18, M	  	20,316	  	5.7	%	 	$	74.10	  	$	81.56	  	$	0.82	  	$	82.39	  	11.2	%
	 Montgomery
	  	HF/HST, Age 14-18, F	  	23,388	  	6.6	%	 	$	111.83	  	$	131.66	  	$	1.33	  	$	132.99	  	18.9	%
	 Montgomery
	  	HF, Age 19-44, M	  	11,952	  	3.4	%	 	$	176.03	  	$	176.43	  	$	1.78	  	$	178.21	  	1.2	%
	 Montgomery
	  	HF, Age 19-44, F	  	71,304	  	20.2	%	 	$	194.95	  	$	229.01	  	$	2.31	  	$	231.33	  	18.7	%
	 Montgomery
	  	HF, Age 45+, M & F	  	4,020	  	1.1	%	 	$	385.54	  	$	395.38	  	$	3.99	  	$	399.38	  	3.6	%
	 Montgomery
	  	HST, Age 19-64, F	  	3,312	  	0.9	%	 	$	340.60	  	$	396.93	  	$	4.01	  	$	400.94	  	17.7	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Montgomery
	  	Subtotal	  	353,496	  	100.0	%	 	$	141.71	  	$	150.61	  	$	1.52	  	$	152.14	  	7.4	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Montgomery
	  	Delivery Payment	  	935	  	0.3	%	 	$	4,146.90	  	$	4,858.52	  	$	49.08	  	$	4,907.60	  	18.3	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Montgomery
	  	Total	  	353,496	  	100.0	%	 	$	152.68	  	$	163.46	  	$	1.65	  	$	165.12	  	8.1	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Muskingum
	  	HF/HST, Age 0, M & F	  	384	  	5.5	%	 	$	—  	  	$	365.04	  	$	3.69	  	$	368.72	  	0.0	%
	 Muskingum
	  	HF/HST, Age 1, M & F	  	387	  	5.5	%	 	$	—  	  	$	114.05	  	$	1.15	  	$	115.20	  	0.0	%
	 Muskingum
	  	HF/HST, Age 2-13, M & F	  	3,574	  	51.2	%	 	$	—  	  	$	67.59	  	$	0.68	  	$	68.27	  	0.0	%
	 Muskingum
	  	HF/HST, Age 14-18, M	  	410	  	5.9	%	 	$	—  	  	$	76.34	  	$	0.77	  	$	77.11	  	0.0	%
	 Muskingum
	  	HF/HST, Age 14-18, F	  	470	  	6.7	%	 	$	—  	  	$	126.57	  	$	1.28	  	$	127.85	  	0.0	%
	 Muskingum
	  	HF, Age 19-44, M	  	241	  	3.5	%	 	$	—  	  	$	154.07	  	$	1.56	  	$	155.63	  	0.0	%
	 Muskingum
	  	HF, Age 19-44, F	  	1,361	  	19.5	%	 	$	—  	  	$	208.20	  	$	2.10	  	$	210.30	  	0.0	%
	 Muskingum
	  	HF, Age 45+, M & F	  	86	  	1.2	%	 	$	—  	  	$	350.23	  	$	3.54	  	$	353.77	  	0.0	%
	 Muskingum
	  	HST, Age 19-64, F	  	71	  	1.0	%	 	$	—  	  	$	345.81	  	$	3.49	  	$	349.30	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Muskingum
	  	Subtotal	  	6,984	  	100.0	%	 	$	—  	  	$	127.69	  	$	1.29	  	$	128.98	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Muskingum
	  	Delivery Payment	  	24	  	0.3	%	 	$	—  	  	$	3,527.02	  	$	35.63	  	$	3,562.64	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Muskingum
	  	Total	  	6,984	  	100.0	%	 	$	—  	  	$	139.81	  	$	1.41	  	$	141.23	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Ottawa/Sandusky
	  	HF/HST, Age 0, M & F	  	241	  	5.5	%	 	$	—  	  	$	363.41	  	$	3.67	  	$	367.08	  	0.0	%
	 Ottawa/Sandusky
	  	HF/HST, Age 1, M & F	  	243	  	5.5	%	 	$	—  	  	$	111.53	  	$	1.13	  	$	112.66	  	0.0	%
	 Ottawa/Sandusky
	  	HF/HST, Age 2-13, M & F	  	2,245	  	51.2	%	 	$	—  	  	$	66.67	  	$	0.67	  	$	67.34	  	0.0	%
	 Ottawa/Sandusky
	  	HF/HST, Age 14-18, M	  	258	  	5.9	%	 	$	—  	  	$	75.74	  	$	0.77	  	$	76.50	  	0.0	%
	 Ottawa/Sandusky
	  	HF/HST, Age 14-18, F	  	295	  	6.7	%	 	$	—  	  	$	123.82	  	$	1.25	  	$	125.07	  	0.0	%
	 Ottawa/Sandusky
	  	HF, Age 19-44, M	  	152	  	3.5	%	 	$	—  	  	$	151.96	  	$	1.53	  	$	153.50	  	0.0	%
	 Ottawa/Sandusky
	  	HF, Age 19-44, F	  	855	  	19.5	%	 	$	—  	  	$	205.63	  	$	2.08	  	$	207.70	  	0.0	%
	 Ottawa/Sandusky
	  	HF, Age 45+, M & F	  	54	  	1.2	%	 	$	—  	  	$	339.06	  	$	3.42	  	$	342.49	  	0.0	%
	 Ottawa/Sandusky
	  	HST, Age 19-64, F	  	45	  	1.0	%	 	$	—  	  	$	335.99	  	$	3.39	  	$	339.38	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Ottawa/Sandusky
	  	Subtotal	  	4,388	  	100.0	%	 	$	—  	  	$	125.27	  	$	1.27	  	$	127.24	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Ottawa/Sandusky
	  	Delivery Payment	  	15	  	0.3	%	 	$	—  	  	$	3,509.02	  	$	35.44	  	$	3,544.46	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Ottawa/Sandusky
	  	Total	  	4,388	  	100.0	%	 	$	—  	  	$	137.97	  	$	1.39	  	$	139.36	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Pickaway
	  	HF/HST, Age 0, M & F	  	148	  	5.5	%	 	$	501.13	  	$	413.50	  	$	4.18	  	$	417.68	  	-16.7	%
	 Pickaway
	  	HF/HST, Age 1, M & F	  	149	  	5.5	%	 	$	123.14	  	$	126.63	  	$	1.28	  	$	127.91	  	3.9	%
	 Pickaway
	  	HF/HST, Age 2-13, M & F	  	1,378	  	51.2	%	 	$	70.44	  	$	76.41	  	$	0.77	  	$	77.18	  	9.6	%
	 Pickaway
	  	HF/HST, Age 14-18, M	  	158	  	5.9	%	 	$	87.67	  	$	95.71	  	$	0.97	  	$	96.67	  	10.3	%
	 Pickaway
	  	HF/HST, Age 14-18, F	  	181	  	6.7	%	 	$	122.78	  	$	135.78	  	$	1.37	  	$	137.15	  	11.7	%
	 Pickaway
	  	HF, Age 19-44, M	  	93	  	3.5	%	 	$	219.16	  	$	216.64	  	$	2.19	  	$	218.82	  	-0.2	%
	 Pickaway
	  	HF, Age 19-44, F	  	525	  	19.5	%	 	$	214.34	  	$	250.24	  	$	2.53	  	$	252.77	  	17.9	%
	 Pickaway
	  	HF, Age 45+, M & F	  	33	  	1.2	%	 	$	416.49	  	$	451.35	  	$	4.56	  	$	455.91	  	9.5	%
	 Pickaway
	  	HST, Age 19-64, F	  	27	  	1.0	%	 	$	346.07	  	$	371.77	  	$	3.76	  	$	375.53	  	8.5	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Pickaway
	  	Subtotal	  	2,692	  	100.0	%	 	$	141.78	  	$	149.15	  	$	1.51	  	$	150.66	  	6.3	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Pickaway
	  	Delivery Payment	  	9	  	0.3	%	 	$	3,384.76	  	$	3,543.99	  	$	35.80	  	$	3,579.79	  	5.8	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Pickaway
	  	Total	  	2,692	  	100.0	%	 	$	153.09	  	$	161.00	  	$	1.63	  	$	162.63	  	6.2	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Portage
	  	HF/HST, Age 0, M & F	  	959	  	5.5	%	 	$	—  	  	$	377.92	  	$	3.82	  	$	381.74	  	0.0	%
	 Portage
	  	HF/HST, Age 1, M & F	  	965	  	5.5	%	 	$	—  	  	$	117.61	  	$	1.19	  	$	118.79	  	0.0	%
	 Portage
	  	HF/HST, Age 2-13, M & F	  	8,917	  	51.2	%	 	$	—  	  	$	70.54	  	$	0.71	  	$	71.25	  	0.0	%
	 Portage
	  	HF/HST, Age 14-18, M	  	1,024	  	5.9	%	 	$	—  	  	$	79.32	  	$	0.80	  	$	80.12	  	0.0	%
	 Portage
	  	HF/HST, Age 14-18, F	  	1,172	  	6.7	%	 	$	—  	  	$	128.32	  	$	1.30	  	$	129.62	  	0.0	%
	 Portage
	  	HF, Age 19-44, M	  	602	  	3.5	%	 	$	—  	  	$	163.70	  	$	1.65	  	$	165.35	  	0.0	%
	 Portage
	  	HF, Age 19-44, F	  	3,395	  	19.5	%	 	$	—  	  	$	216.54	  	$	2.19	  	$	218.73	  	0.0	%
	 Portage
	  	HF, Age 45+, M & F	  	215	  	1.2	%	 	$	—  	  	$	370.57	  	$	3.74	  	$	374.31	  	0.0	%
	 Portage
	  	HST, Age 19-64, F	  	177	  	1.0	%	 	$	—  	  	$	351.16	  	$	3.55	  	$	354.71	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Portage
	  	Subtotal	  	17,426	  	100.0	%	 	$	—  	  	$	132.68	  	$	1.34	  	$	134.02	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Portage
	  	Delivery Payment	  	59	  	0.3	%	 	$	—  	  	$	3,657.47	  	$	36.94	  	$	3,694.41	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Portage
	  	Total	  	17,426	  	100.0	%	 	$	—  	  	$	145.06	  	$	1.47	  	$	146.53	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

  

					
	 Mercer Government Human Services Consulting
	  	 Page 5 of 7
	  	 

					
	 State of Ohio
	 	Exhibit B	 	Final
	 	 	Twelve Month Rates	 	 
	 	 	CY 2004	 	 

  

																							
	 County

	  	 Rate Cohort

	  	 Annualized
Dec 2002
Managed Care
 MM/Delv

	  	% of MM

	 	 	CY 2002
Rate w/
Admin

	  	1/1/2004 -
12/31/2004
Guaranteed
Rate

	  	1/1/2004 -
12/31/2004
Rate At Risk

	  	1/1/2004 -
12/31/2004
Rate w/
Admin

	  	Percent
Increase

	 
	 Richland
	  	HF/HST, Age 0, M & F	  	417	  	5.5	%	 	$	435.57	  	$	350.76	  	$	3.54	  	$	354.30	  	-18.7	%
	 Richland
	  	HF/HST, Age 1, M & F	  	420	  	5.5	%	 	$	119.58	  	$	121.94	  	$	1.23	  	$	123.17	  	3.0	%
	 Richland
	  	HF/HST, Age 2-13, M & F	  	3,882	  	51.2	%	 	$	65.11	  	$	72.63	  	$	0.73	  	$	73.37	  	12.7	%
	 Richland
	  	HF/HST, Age 14-18, M	  	446	  	5.9	%	 	$	73.40	  	$	83.86	  	$	0.85	  	$	84.71	  	15.4	%
	 Richland
	  	HF/HST, Age 14-18, F	  	510	  	6.7	%	 	$	130.13	  	$	137.75	  	$	1.39	  	$	139.14	  	6.9	%
	 Richland
	  	HF, Age 19-44, M	  	262	  	3.5	%	 	$	163.01	  	$	154.69	  	$	1.56	  	$	156.25	  	-4.1	%
	 Richland
	  	HF, Age 19-44, F	  	1,478	  	19.5	%	 	$	176.92	  	$	200.11	  	$	2.02	  	$	202.13	  	14.2	%
	 Richland
	  	HF, Age 45+, M&F	  	94	  	1.2	%	 	$	323.07	  	$	335.58	  	$	3.39	  	$	338.97	  	4.9	%
	 Richland
	  	HST, Age 19-64, F	  	77	  	1.0	%	 	$	266.88	  	$	295.75	  	$	2.99	  	$	298.74	  	11.9	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Richland
	  	Subtotal	  	7,586	  	100.0	%	 	$	123.88	  	$	128.88	  	$	1.30	  	$	130.18	  	5.2	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Richland
	  	Delivery Payment	  	26	  	0.3	%	 	$	2,900.54	  	$	3,287.93	  	$	33.21	  	$	3,321.14	  	14.5	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Richland
	  	Total	  	7,586	  	100.0	%	 	$	133.70	  	$	140.15	  	$	1.42	  	$	141.57	  	5.9	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Stark
	  	HF/HST, Age 0, M & F	  	348	  	4.2	%	 	$	433.74	  	$	351.55	  	$	3.55	  	$	355.10	  	-18.1	%
	 Stark
	  	HF/HST, Age 1, M & F	  	372	  	4.5	%	 	$	98.56	  	$	112.15	  	$	1.13	  	$	113.28	  	14.9	%
	 Stark
	  	HF/HST, Age 2-13, M & F	  	4,392	  	53.4	%	 	$	62.03	  	$	70.56	  	$	0.71	  	$	71.28	  	14.9	%
	 Stark
	  	HF/HST, Age 14-18, M	  	552	  	6.7	%	 	$	68.52	  	$	78.60	  	$	0.79	  	$	79.39	  	15.9	%
	 Stark
	  	HF/HST, Age 14-18, F	  	576	  	7.0	%	 	$	116.83	  	$	133.38	  	$	1.35	  	$	134.73	  	15.3	%
	 Stark
	  	HF, Age 19-44, M	  	300	  	3.6	%	 	$	152.83	  	$	159.84	  	$	1.61	  	$	161.46	  	5.6	%
	 Stark
	  	HF, Age 19-44, F	  	1,440	  	17.5	%	 	$	185.77	  	$	219.63	  	$	2.22	  	$	221.85	  	19.4	%
	 Stark
	  	HF, Age 45+, M&F	  	144	  	1.8	%	 	$	383.72	  	$	402.26	  	$	4.06	  	$	406.32	  	5.9	%
	 Stark
	  	HST, Age 19-64, F	  	96	  	1.2	%	 	$	277.06	  	$	326.15	  	$	3.29	  	$	329.44	  	18.9	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Stark
	  	Subtotal	  	8,220	  	100.0	%	 	$	116.83	  	$	127.45	  	$	1.29	  	$	128.74	  	10.2	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Stark
	  	Delivery Payment	  	23	  	0.3	%	 	$	3,036.07	  	$	3,526.07	  	$	35.62	  	$	3,561.69	  	17.3	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Stark
	  	Total	  	8,220	  	100.0	%	 	$	125.33	  	$	137.32	  	$	1.39	  	$	138.70	  	10.7	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Summit
	  	HF/HST, Age 0, M & F	  	27,504	  	5.0	%	 	$	544.75	  	$	453.44	  	$	4.58	  	$	458.02	  	-15.9	%
	 Summit
	  	HF/HST, Age 1, M & F	  	27,600	  	5.0	%	 	$	106.04	  	$	119.86	  	$	1.21	  	$	121.07	  	14.2	%
	 Summit
	  	HF/HST, Age 2-13, M & F	  	268,860	  	49.0	%	 	$	63.11	  	$	73.62	  	$	0.74	  	$	74.36	  	17.8	%
	 Summit
	  	HF/HST, Age 14-18, M	  	32,988	  	6.0	%	 	$	85.66	  	$	95.66	  	$	0.97	  	$	96.63	  	12.8	%
	 Summit
	  	HF/HST, Age 14-18, F	  	37,812	  	6.9	%	 	$	122.35	  	$	143.79	  	$	1.45	  	$	145.24	  	18.7	%
	 Summit
	  	HF, Age 19-44, M	  	24,096	  	4.4	%	 	$	171.17	  	$	177.56	  	$	1.79	  	$	179.35	  	4.8	%
	 Summit
	  	HF, Age 19-44, F	  	114,744	  	20.9	%	 	$	202.85	  	$	240.56	  	$	2.43	  	$	242.99	  	19.8	%
	 Summit
	  	HF, Age 45+, M & F	  	10,764	  	2.0	%	 	$	401.55	  	$	419.44	  	$	4.24	  	$	423.68	  	5.5	%
	 Summit
	  	HST, Age 19-64, F	  	4,884	  	0.9	%	 	$	324.03	  	$	378.98	  	$	3.83	  	$	382.80	  	18.1	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Summit
	  	Subtotal	  	549,252	  	100.0	%	 	$	137.71	  	$	150.05	  	$	1.52	  	$	151.56	  	10.1	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Summit
	  	Delivery Payment	  	2,475	  	0.5	%	 	$	4,091.24	  	$	4,734.82	  	$	47.83	  	$	4,782.64	  	16.9	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Summit
	  	Total	  	549,252	  	100.0	%	 	$	156.14	  	$	171.38	  	$	1.73	  	$	173.11	  	10.9	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Trumbull
	  	HF/HST, Age 0, M & F	  	6,201	  	5.5	%	 	$	512.84	  	$	420.17	  	$	4.24	  	$	424.42	  	-17.2	%
	 Trumbull
	  	HF/HST, Age 1, M & F	  	6,246	  	5.5	%	 	$	109.61	  	$	127.40	  	$	1.29	  	$	128.69	  	17.4	%
	 Trumbull
	  	HF/HST, Age 2-13, M & F	  	57,685	  	51.2	%	 	$	71.58	  	$	84.74	  	$	0.86	  	$	85.60	  	19.6	%
	 Trumbull
	  	HF/HST, Age 14-18, M	  	6,623	  	5.9	%	 	$	101.19	  	$	104.08	  	$	1.05	  	$	105.13	  	3.9	%
	 Trumbull
	  	HF/HST, Age 14-18, F	  	7,581	  	6.7	%	 	$	121.54	  	$	143.03	  	$	1.44	  	$	144.48	  	18.9	%
	 Trumbull
	  	HF, Age 19-44, M	  	3,893	  	3.5	%	 	$	203.35	  	$	208.99	  	$	2.11	  	$	211.10	  	3.8	%
	 Trumbull
	  	HF, Age 19-44, F	  	21,962	  	19.5	%	 	$	211.29	  	$	248.24	  	$	2.51	  	$	250.74	  	18.7	%
	 Trumbull
	  	HF, Age 45+, M & F	  	1,390	  	1.2	%	 	$	400.10	  	$	403.15	  	$	4.07	  	$	407.23	  	1.8	%
	 Trumbull
	  	HST, Age 19-64, F	  	1,146	  	1.0	%	 	$	346.92	  	$	381.87	  	$	3.86	  	$	385.72	  	11.2	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Trumbull
	  	Subtotal	  	112,727	  	100.0	%	 	$	141.68	  	$	153.70	  	$	1.55	  	$	155.26	  	9.6	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Trumbull
	  	Delivery Payment	  	381	  	0.3	%	 	$	3,509.06	  	$	3,855.96	  	$	38.95	  	$	3,894.91	  	11.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Trumbull
	  	Total	  	112,727	  	100.0	%	 	$	153.54	  	$	166.74	  	$	1.68	  	$	168.42	  	9.7	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Warren
	  	HF/HST, Age 0, M & F	  	204	  	5.5	%	 	$	459.45	  	$	381.23	  	$	3.85	  	$	385.09	  	-16.2	%
	 Warren
	  	HF/HST, Age 1, M & F	  	206	  	5.6	%	 	$	95.81	  	$	107.52	  	$	1.09	  	$	108.60	  	13.4	%
	 Warren
	  	HF/HST, Age 2-13, M & F	  	1,898	  	51.2	%	 	$	64.76	  	$	72.19	  	$	0.73	  	$	72.92	  	12.6	%
	 Warren
	  	HF/HST, Age 14-18, M	  	218	  	5.9	%	 	$	65.83	  	$	76.94	  	$	0.78	  	$	77.72	  	18.1	%
	 Warren
	  	HF/HST, Age 14-18, F	  	249	  	6.7	%	 	$	109.91	  	$	129.53	  	$	1.31	  	$	130.84	  	19.0	%
	 Warren
	  	HF, Age 19-44, M	  	128	  	3.5	%	 	$	182.03	  	$	189.08	  	$	1.91	  	$	190.99	  	4.9	%
	 Warren
	  	HF, Age 19-44, F	  	723	  	19.5	%	 	$	209.88	  	$	241.88	  	$	2.44	  	$	244.32	  	16.4	%
	 Warren
	  	HF, Age 45+, M & F	  	46	  	1.2	%	 	$	458.20	  	$	491.59	  	$	4.97	  	$	496.55	  	8.4	%
	 Warren
	  	HST, Age 19-64, F	  	38	  	1.0	%	 	$	276.50	  	$	324.06	  	$	3.27	  	$	327.34	  	18.4	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Warren
	  	Subtotal	  	3,710	  	100.0	%	 	$	130.65	  	$	140.16	  	$	1.42	  	$	141.57	  	8.4	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Warren
	  	Delivery Payment	  	13	  	0.4	%	 	$	3,211.66	  	$	3,491.56	  	$	35.27	  	$	3,526.83	  	9.8	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Warren
	  	Total	  	3,710	  	100.0	%	 	$	141.91	  	$	152.39	  	$	1.54	  	$	153.93	  	8.5	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

  

					
	 Mercer Government Human Services Consulting
	  	 Page 6 of 7
	  	 

					
	 State of Ohio
	 	Exhibit B	 	Final
	 	 	Twelve Month Rates	 	 
	 	 	CY 2004	 	 

  

																							
	 County

	  	 Rate Cohort

	  	Annualized
Dec 2002
Managed Care
MM/Delv

	  	% of
MM

	 	 	CY 2002
Rate w/
Admin

	  	1/1/2004 -
12/31/2004
Guaranteed Rate

	  	1/1/2004 -
12/31/2004
Rate At Risk

	  	 1/1/2004 -
 12/31/2004
Rate w/
Admin

	  	Percent
Increase

	 
	 Washington
	  	 HF/HST, Age 0, M & F
	  	231	  	5.5	%	 	$	—  	  	$	363.21	  	$	3.67	  	$	366.88	  	0.0	%
	 Washington
	  	 HF/HST, Age 1, M & F
	  	233	  	5.5	%	 	$	—  	  	$	110.71	  	$	1.12	  	$	111.83	  	0.0	%
	 Washington
	  	 HF/HST, Age 2-13, M & F
	  	2,152	  	51.2	%	 	$	—  	  	$	69.09	  	$	0.70	  	$	69.79	  	0.0	%
	 Washington
	  	 HF/HST, Age 14-18, M
	  	247	  	5.9	%	 	$	—  	  	$	76.06	  	$	0.77	  	$	76.83	  	0.0	%
	 Washington
	  	 HF/HST, Age 14-18, F
	  	283	  	6.7	%	 	$	—  	  	$	123.98	  	$	1.25	  	$	125.23	  	0.0	%
	 Washington
	  	 HF, Age 19-44, M
	  	145	  	3.4	%	 	$	—  	  	$	158.26	  	$	1.60	  	$	159.86	  	0.0	%
	 Washington
	  	 HF, Age 19-44, F
	  	819	  	19.5	%	 	$	—  	  	$	213.95	  	$	2.16	  	$	216.11	  	0.0	%
	 Washington
	  	 HF, Age 45+, M & F
	  	52	  	1.2	%	 	$	—  	  	$	359.98	  	$	3.64	  	$	363.61	  	0.0	%
	 Washington
	  	 HST, Age 19-64, F
	  	43	  	1.0	%	 	$	—  	  	$	339.44	  	$	3.43	  	$	342.86	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Washington
	  	 Subtotal
	  	4,205	  	100.0	%	 	$	—  	  	$	129.31	  	$	1.31	  	$	130.61	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Washington
	  	 Delivery Payment
	  	14	  	0.3	%	 	$	—  	  	$	3,516.35	  	$	35.52	  	$	3,551.87	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Washington
	  	 Total
	  	4,205	  	100.0	%	 	$	—  	  	$	141.01	  	$	1.42	  	$	142.44	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Wood
	  	 HF/HST, Age 0, M & F
	  	516	  	5.5	%	 	$	436.52	  	$	343.33	  	$	3.47	  	$	346.80	  	-20.6	%
	 Wood
	  	 HF/HST, Age 1, M & F
	  	432	  	4.6	%	 	$	115.67	  	$	154.96	  	$	1.57	  	$	156.52	  	35.3	%
	 Wood
	  	 HF/HST, Age 2-13, M & F
	  	4,848	  	51.9	%	 	$	68.00	  	$	76.24	  	$	0.77	  	$	77.01	  	13.2	%
	 Wood
	  	 HF/HST, Age 14-18, M
	  	564	  	6.0	%	 	$	69.03	  	$	69.04	  	$	0.70	  	$	69.74	  	1.0	%
	 Wood
	  	 HF/HST, Age 14-18, F
	  	600	  	6.4	%	 	$	125.18	  	$	133.82	  	$	1.35	  	$	135.17	  	8.0	%
	 Wood
	  	 HF, Age 19-44, M
	  	564	  	6.0	%	 	$	159.33	  	$	149.05	  	$	1.51	  	$	150.55	  	-5.5	%
	 Wood
	  	 HF, Age 19-44, F
	  	1,608	  	17.2	%	 	$	188.12	  	$	211.65	  	$	2.14	  	$	213.78	  	13.6	%
	 Wood
	  	 HF, Age 45+, M & F
	  	132	  	1.4	%	 	$	387.37	  	$	384.43	  	$	3.88	  	$	388.31	  	0.2	%
	 Wood
	  	 HST, Age 19-64, F
	  	72	  	0.8	%	 	$	350.29	  	$	346.63	  	$	3.50	  	$	350.13	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Wood
	  	 Subtotal
	  	9,336	  	100.0	%	 	$	127.21	  	$	132.07	  	$	1.33	  	$	133.40	  	4.9	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Wood
	  	 Delivery Payment
	  	70	  	0.7	%	 	$	2,858.71	  	$	3,136.72	  	$	31.68	  	$	3,168.40	  	10.8	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Wood
	  	 Total
	  	9,336	  	100.0	%	 	$	148.65	  	$	155.59	  	$	1.57	  	$	157.16	  	5.7	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 New Counties
	  	 HF/HST, Age 0, M & F
	  	6,967	  	5.5	%	 	$	—  	  	$	373.31	  	$	3.77	  	$	377.08	  	0.0	%
	 New Counties
	  	 HF/HST, Age 1, M & F
	  	7,016	  	5.5	%	 	$	—  	  	$	115.26	  	$	1.16	  	$	116.42	  	0.0	%
	 New Counties
	  	 HF/HST, Age 2-13, M & F
	  	64,810	  	51.2	%	 	$	—  	  	$	69.78	  	$	0.70	  	$	70.48	  	0.0	%
	 New Counties
	  	 HF/HST, Age 14-18, M
	  	7,441	  	5.9	%	 	$	—  	  	$	78.50	  	$	0.79	  	$	79.29	  	0.0	%
	 New Counties
	  	 HF/HST, Age 14-18, F
	  	8,517	  	6.7	%	 	$	—  	  	$	127.31	  	$	1.29	  	$	128.60	  	0.0	%
	 New Counties
	  	 HF, Age 19-44, M
	  	4,375	  	3.5	%	 	$	—  	  	$	160.85	  	$	1.62	  	$	162.47	  	0.0	%
	 New Counties
	  	 HF, Age 19-44, F
	  	24,674	  	19.5	%	 	$	—  	  	$	214.02	  	$	2.16	  	$	216.18	  	0.0	%
	 New Counties
	  	 HF, Age 45+, M & F
	  	1,562	  	1.2	%	 	$	—  	  	$	363.59	  	$	3.67	  	$	367.26	  	0.0	%
	 New Counties
	  	 HST, Age 19-64, F
	  	1,289	  	1.0	%	 	$	—  	  	$	346.37	  	$	3.50	  	$	349.86	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 New Counties
	  	 Subtotal
	  	126,651	  	100.0	%	 	$	—  	  	$	131.06	  	$	1.32	  	$	132.38	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 New Counties
	  	 Delivery Payment
	  	431	  	0.3	%	 	$	—  	  	$	3,597.59	  	$	36.34	  	$	3,633.93	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 New Counties
	  	 Total
	  	126,651	  	100.0	%	 	$	—  	  	$	143.30	  	$	1.45	  	$	144.75	  	0.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Original Counties
	  	 HF/HST, Age 0, M & F
	  	263,340	  	5.1	%	 	$	570.19	  	$	474.34	  	$	4.79	  	$	479.14	  	-16.0	%
	 Original Counties
	  	 HF/HST, Age 1, M & F
	  	271,200	  	5.2	%	 	$	114.38	  	$	128.62	  	$	1.30	  	$	129.92	  	13.6	%
	 Original Counties
	  	 HF/HST, Age 2-13, M & F
	  	2,601,427	  	50.3	%	 	$	64.75	  	$	75.04	  	$	0.76	  	$	75.80	  	17.1	%
	 Original Counties
	  	 HF/HST, Age 14-18, M
	  	322,141	  	6.2	%	 	$	76.67	  	$	85.00	  	$	0.86	  	$	85.86	  	12.0	%
	 Original Counties
	  	 HF/HST, Age 14-18, F
	  	357,266	  	6.9	%	 	$	115.13	  	$	134.85	  	$	1.36	  	$	136.21	  	18.3	%
	 Original Counties
	  	 HF, Age 19-44, M
	  	186,852	  	3.6	%	 	$	182.28	  	$	184.60	  	$	1.86	  	$	186.46	  	2.3	%
	 Original Counties
	  	 HF, Age 19-44, F
	  	1,026,499	  	19.9	%	 	$	200.96	  	$	236.47	  	$	2.39	  	$	238.86	  	18.9	%
	 Original Counties
	  	 HF, Age 45+, M & F
	  	84,057	  	1.6	%	 	$	395.54	  	$	407.54	  	$	4.12	  	$	411.66	  	4.1	%
	 Original Counties
	  	 HST, Age 19-64, F
	  	54,992	  	1.1	%	 	$	327.46	  	$	378.59	  	$	3.82	  	$	382.42	  	16.8	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Original Counties
	  	 Subtotal
	  	5,167,774	  	100.0	%	 	$	136.82	  	$	147.62	  	$	1.49	  	$	149.11	  	9.0	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Original Counties
	  	 Delivery Payment
	  	19,240	  	0.4	%	 	$	3,838.17	  	$	4,455.56	  	$	45.01	  	$	4,500.57	  	17.3	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Original Counties
	  	 Total
	  	5,167,774	  	100.0	%	 	$	151.11	  	$	164.21	  	$	1.66	  	$	165.87	  	9.8	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Total Managed Care
	  	 HF/HST, Age 0, M & F
	  	270,307	  	5.1	%	 	$	570.19	  	$	471.74	  	$	4.77	  	$	476.51	  	-16.4	%
	 Total Managed Care
	  	 HF/HST, Age 1, M & F
	  	278,216	  	5.3	%	 	$	114.38	  	$	128.28	  	$	1.30	  	$	129.58	  	13.3	%
	 Total Managed Care
	  	 HF/HST, Age 2-13, M & F
	  	2,666,237	  	50.4	%	 	$	64.75	  	$	74.92	  	$	0.76	  	$	75.67	  	16.9	%
	 Total Managed Care
	  	 HF/HST, Age 14-18, M
	  	329,582	  	6.2	%	 	$	76.67	  	$	84.86	  	$	0.86	  	$	85.71	  	11.8	%
	 Total Managed Care
	  	 HF/HST, Age 14-18, F
	  	365,783	  	6.9	%	 	$	115.13	  	$	134.67	  	$	1.36	  	$	136.03	  	18.2	%
	 Total Managed Care
	  	 HF, Age 19-44, M
	  	191,227	  	3.6	%	 	$	182.28	  	$	184.06	  	$	1.86	  	$	185.91	  	2.0	%
	 Total Managed Care
	  	 HF, Age 19-44, F
	  	1,051,173	  	19.9	%	 	$	200.96	  	$	235.94	  	$	2.38	  	$	238.32	  	18.6	%
	 Total Managed Care
	  	 HF, Age 45+, M & F
	  	85,619	  	1.6	%	 	$	395.54	  	$	406.74	  	$	4.11	  	$	410.85	  	3.9	%
	 Total Managed Care
	  	 HST, Age 19-64, F
	  	56,281	  	1.1	%	 	$	327.46	  	$	377.86	  	$	3.82	  	$	381.67	  	16.6	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Total Managed Care
	  	 Subtotal
	  	5,294,425	  	100.0	%	 	$	136.82	  	$	147.23	  	$	1.49	  	$	148.71	  	8.7	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Total Managed Care
	  	 Delivery Payment
	  	19,671	  	0.4	%	 	$	3,836.17	  	$	4,436.76	  	$	44.82	  	$	4,481.58	  	16.8	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

	 Total Managed Care
	  	 Total
	  	5,294,425	  	100.0	%	 	$	 151.11	  	$	163.71	  	$	1.65	  	$	165.36	  	9.4	%
	 	  	 	  	
	  	
	
	 	
	
	  	
	
	  	
	
	  	
	
	  	
	

  

					
	 Mercer Government Human Services Consulting
	  	 Page 7 of 7
	  	 

 APPENDIX F 
 COUNTY SPECIFICATIONS 
  
 1. PREMIUM RATES WITHOUT THE AT-RISK PAYMENT AMOUNTS FOR 07/01/04, THROUGH 12/31/04, SHALL BE AS FOLLOWS*: 
  
 MCP: BUCKEYE COMMUNITY HEALTH PLAN, INC. 
  

																																	
	 SERVICE
ENROLLMENT
AREA

	  	 VOLUNTARY/
 MANDATORY/
 PREFERRED OPTION**

	  	HF/HST
Age < 1

	  	HF/HST
Age 1

	  	HF/HST
Age 2-13

	  	HF/HST
Age 14-18
Male

	  	 HF/HST
Age 14-18
 Female

	  	 HF
 Age 19-44
Male

	  	 HF
 Age 19-44
Female

	  	HF
Age 45
and over

	  	HST
Age 19-64
Female

	  	Delivery
Payment

	 Lucas
	  	Mandatory	  	$	554.09	  	$	114.71	  	$	74.34	  	$	82.89	  	$	137.83	  	$	191.45	  	$	236.29	  	$	430.27	  	$	401.44	  	$	4,414.48

  
 List of Eligible Assistance Groups
(AGs) 
  

					
	 Healthy Families:
	  	 -   MA-C Categorically eligible due to ADC cash
	  	 -   MA-V ADC; failed due to loss of dependent care

	 	  	 -   MA-H Cash assistance failed due to stepparent income
	  	 -   MA-W Cash Assistance failed due to loss of 30 or 1/3 disregard Medicaid

	 	  	 -   MA-S Cash assistance failed due to sibling income
	  	 -   MA-X Cash Assistance failed due to sibling income

	 	  	 -   MA-T Children under 21
	  	 -   MA-Y Transitional Medicaid

			
	 Healthy Start:
	  	 -   MA-P Pregnant Women and Children
	  	 

  

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

  

	*	Since Buckeye Community Health Plan, Inc. is in its first year of operation, per Appendix E, Rate Methodology, the rates reflect a new plan rate add-on, with zero percent of
the premium rates at-risk. 

  

	**	County status subject to change. 

  

 Page 1 of 3 

 APPENDIX F 
 COUNTY SPECIFICATIONS 
  
 2. AT-RISK AMOUNTS FOR 07/01/04, THROUGH 12/31/04, SHALL BE AS FOLLOWS: 
  
 MCP: BUCKEYE COMMUNITY HEALTH PLAN, INC. 
  
 AT-RISK AMOUNTS * 
  

																																	
	 SERVICE
ENROLLMENT
AREA

	  	VOLUNTARY/
MANDATORY/
PREFERRED OPTION**

	  	HF/HST
Age < 1

	  	HF/HST
Age 1

	  	HF/HST
Age 2-13

	  	 HF/HST
Age 14-18
 Male

	  	HF/HST
Age 14-18
Female

	  	 HF
 Age 19-44
 Male

	  	 HF
 Age 19-44
Female

	  	 HF
 Age 45
and over

	  	 HST
 Age 19-64
Female

	  	Delivery
Payment

	 Lucas
	  	Mandatory	  	$	0.00	  	$	0.00	  	$	0.00	  	$	0.00	  	$	0.00	  	$	0.00	  	$	0.00	  	$	0.00	  	$	0.00	  	$	0.00

  
 List of Eligible Assistance Groups
(AGs) 
  

									
	 Healthy Families:
	  	 - MA-C
	 	 Categorically eligible due to ADC cash
	 	 - MA-V ADC; failed due to loss of dependent care
	  	 
	 	  	 - MA-H
	 	 Cash assistance failed due to stepparent income
	 	 - MA-W Cash Assistance failed due to loss of 30 or 1/3 disregard Medicaid
	  	 
	 	  	 - MA-S
	 	 Cash assistance failed due to sibling income
	 	 - MA-X Cash Assistance failed due to sibling income
	  	 
	 	  	 - MA-T
	 	 Children under 21
	 	 - MA-Y Transitional Medicaid
	  	 
	 Healthy Start:
	  	 - MA-P
	 	 Pregnant Women and Children
	 	 	  	 

  

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

  

	*	Since Buckeye Community Health Plan, Inc. is in its first year of operation, per Appendix E, Rate Methodology, the rates reflect a new plan rate add-on, with zero percent of
the premium rates at-risk. 

  

	**	County status subject to change. 

  

 Page 2 of 3 

 APPENDIX F 
 COUNTY SPECIFICATIONS 
  
 3. PREMIUM RATES* FOR 07/01/04, THROUGH 12/31/04, SHALL BE AS FOLLOWS: 
  
 MCP: BUCKEYE COMMUNITY HEALTH PLAN, INC. 
  

																																	
	 SERVICE
ENROLLMENT
AREA

	  	VOLUNTARY/
MANDATORY/
PREFERRED OPTION**

	  	HF/HST
Age < 1

	  	HF/HST
Age 1

	  	HF/HST
Age 2-13

	  	HF/HST
Age 14-18
Male

	  	HF/HST
Age 14-18
Female

	  	 HF
 Age 19-44
Male

	  	 HF
 Age 19-44
Female

	  	 HF
 Age 45 and
over

	  	 HST
 Age 19-64
Female

	  	Delivery
Payment

	 Lucas
	  	Mandatory	  	$	554.09	  	$	114.71	  	$	74.34	  	$	82.89	  	$	137.83	  	$	191.45	  	$	236.29	  	$	430.27	  	$	401.44	  	$	4,414.48

  
 List of Eligible Assistance Groups
(AGs) 
  

									
	 Healthy Families:
	  	 - MA-C
	 	 Categorically eligible due to ADC cash
	 	 - MA-V ADC; failed due to loss of dependent care
	  	 
	 	  	 - MA-H
	 	 Cash assistance failed due to stepparent income
	 	 - MA-W Cash Assistance failed due to loss of 30 or 1/3 disregard Medicaid
	  	 
	 	  	 - MA-S
	 	 Cash assistance failed due to sibling income
	 	 - MA-X Cash Assistance failed due to sibling income
	  	 
	 	  	 - MA-T
	 	 Children under 21
	 	 - MA-Y Transitional Medicaid
	  	 
	 Healthy Start:
	  	 - MA-P
	 	 Pregnant Women and Children
	 	 	  	 

  

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

  

	*	Since Buckeye Community Health Plan, Inc. is in its first year of operation, per Appendix E, Rate Methodology, the rates reflect a new plan rate add-on, with zero percent of
the premium rates at-risk. 

  

	**	County status subject to change. 

  

 Page 3 of 3 

 APPENDIX G 
  

COVERAGE AND SERVICES 
  

	1.	Basic Benefit Package By Service Type 

  
 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 following ODJFS website:http://emanuals.odjfs.state.oh.us:80/emanuals/medicaid/. The
following is a general list of the services covered by the Ohio Medicaid fee-for-service program: 
  

	 	•	Inpatient hospital services 

  

	 	•	Outpatient hospital services 

  

	 	•	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 [no longer covered for adults age twenty-one (21) and older as of January 1,2004] 

  

	 	•	Physical therapy, occupational therapy, and speech therapy 

  

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

  

	 	•	Independent psychologist services [no longer covered for adults age twenty-one (21) and older as of January 1, 2004] 

  

	 	•	Prescription drugs 

  

 Appendix G 
 Page 2

  

	 	•	Ambulance and ambulette services 

  

	 	•	Dental services 

  

	 	•	Durable medical equipment and medical supplies 

  

	 	•	Vision care services, including eyeglasses 

  

	 	•	Short-term rehabilitative stays in a nursing facility 

  

	 	•	Hospice care 

  

	 	•	Behavioral health services (see section G.2.b.ii of this appendix) 

  

	2.	Exclusions, Limitations and Clarifications 

  

	 	a.	Exclusions 

  
 MCPs are not required to pay for Ohio Medicaid FFS program (Medicaid) non-covered services. For information regarding Medicaid noncovered services, MCPs
must refer to the following ODJFS website. http://emanuals.odjfs.state.oh.us:80/emanuals/medicaid/. 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 

  

 Appendix G 
 Page 3

  

	 	•	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 

  

	 	•	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 

  
 Notwithstanding any provision in the Medicaid fee-for-service program which permits cost-sharing by Medicaid consumers, including provisions specific to
the pharmacy benefit, MCPs must ensure compliance with OAC rule 5101:3-26-05(D)(10) which prohibits subcontracting providers from charging members any copayment, 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 the information on the required forms (JFS 03197,03198, and 03199) meets the required criteria for any such claims 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 paid only if the required criteria are met, as confirmed by the appropriate certification/consent forms; and for maintaining documentation to justify any such claim payments. 
  

	 	iii.	Behavioral Health Services 

  
 Coordination of Services: MCPs must ensure that members have access to all medically-necessary behavioral health services covered by the Ohio
Medicaid FFS program and are responsible for coordinating those services with other medical and support services. MCPs must notify members via the member handbook and provider directory of where and how to access behavioral health services,
including the ability to self-refer to mental health services offered through community mental health centers (CMHCs) as well as substance abuse services offered through Ohio Department of Alcohol and Drug Addiction Services (ODADAS)-certified
Medicaid providers. 
  
 MCPs must provide behavioral health
services for members who are unable to timely access services or unwilling to access services through community providers. 
  
 Mental Health Services: There are a number of various Medicaid-covered mental health (MH) services available through the CMHCs. 
  

 Appendix G 
 Page 5

  

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

 Appendix G 
 Page 6

  

	3.	Care Coordination 

  

	 	a.	Utilization Management (Modification) Programs 

  
 General Provisions - Pursuant to OAC rule 5101:3-26-03.1(A)(7)(e),MCPs must implement the ODJFS-required emergency department diversion program for
frequent users and may develop other such 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. 
  
 Pharmacy Programs - Pursuant to ORC Sec. 5111.172 and OAC rule 5101:3-26-03(A) and (B), but subject to ODJFS prior-approval, MCPs 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 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)(e) 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. 
  

 Appendix G 
 Page 7

  

 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’s 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 diversion 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. 
  
 In accordance with Appendix C, MCP Responsibilities, MCPs must have an ODJFS-approved EDD program. Any subsequent changes to an approved EDD
program must be submitted to ODJFS in writing for review and approval prior to implementation. 
  

	 	(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.	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 the specification of specific diagnosis, cost threshold
and amount of service utilization; 

  

	 	b.	identification of the methodology or process (e.g.; administrative data, provider referrals, self-referrals) by which the MCP identifies members meeting the criteria in section (a);

  

	 	c.	a process to inform members and their PCPs in writing that they have been identified as meeting the criteria for case management and any applicable procedures for further health
needs assessment to confirm the provision of case management services; and 

  

 Appendix G 
 Page 8

  

	 	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 the opportunity to participate in the treatment plan’s development; and provide for the periodic review of the member’s need for case management and updating of the care treatment plan; 

  

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

  

	 	iii.	MCPs must submit a monthly electronic report to the Screening, Assessment, and Case Management System (SACMS) for all members who are case managed. 

  

	 	iv.	MCP’s 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. 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 and minimum standards 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 CSHCN. 
  

	 	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 

  

 Appendix G 
 Page 9

  

	 	•	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. These identification mechanisms must include, at a minimum: 
  

	 	•	For all newly-enrolled members who were not screened at the time of membership selection by the Selection Services Contractor (SSC) and are not identified as a CSHCN through an
administrative review, MCPs are required to use the ODJFS CSHCN Screening Questions to identify potential CSHCN. See ODJFS CSHCN Program Requirements for a description of the ODJFS CSHCN Screening Questions.

  

	 	•	For all newly-enrolled members who were screened at the time of membership selection by the SSC, MCPs may choose to re-screen a child. However, if unable to complete a screen, the
MCP must submit the screening result from the Consumer Contact Record (CCR) in the screening and assessment file required to be submitted to ODJFS on a monthly basis. 

  
 MCPs are expected to use other identification criteria, such as MCP administrative review, PCP referrals, or outreach, in
order to identify children that meet the definition of CSHCN and are in need of a follow-up assessment. 
  

 Appendix G 
 Page 10

  

	 	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 based on the CSHCN Screening Questions as a
CSHCN. 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 criteria used by the MCP in assessing members with a positive identification as a CSHCN, through a mechanism other than the ODJFS CSHCN Screening Questions.

  

	 	•	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 or a positive identification through
administrative data for an ODJFS mandated condition. The ODJFS mandated conditions for case management are HIV/AIDS, 
 asthma, and pregnant
teens as specified by the ODJFS methods for Screening, Assessment and Case Management Performance Measures. This case management mechanism must include, at a minimum: 
  

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

  

 Appendix G 
 Page 11

  

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

	 	vi.	Submission of Data on CSHCN 

  
 MCPs must submit to ODJFS all screening and assessment results (except as provided in Appendix M, Performance Evaluation, Section 1. b.) and all
case management records as specified by the ODJFS Screening, Assessment, and 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. Any subsequent changes to an approved CSHCN system
description must be submitted to ODJFS in writing for review and approval prior to implementation. 

  

 APPENDIX H 
  

PROVIDER PANEL SPECIFICATIONS 
  

	1.	GENERAL PROVISIONS 

  
 MCPs must demonstrate that they have an appropriate provider network with an adequate network capacity for each ODJFS-designated service area they wish to serve. A
service area may be either one county or multiple counties grouped as a region. 
  
 MCPs must meet all applicable provider panel requirements prior to receiving a provider agreement with ODJFS and must remain in compliance with these requirements for the duration of the provider agreement. 
  
 In addition to achieving and maintaining compliance with the minimum provider panel
requirements, an MCP must ensure access to appropriate provider types on an as needed basis. For example, if an MCP meets the minimum pediatrician requirement but a member is unable to obtain a timely appointment from a pediatrician on the
MCP’s provider panel in that service area, the MCP will be required to secure an appointment from a panel pediatrician or arrange for an out-of-panel referral to a pediatrician. If such a provider were located outside the service area, the
alternate provider area travel requirements would apply. [See section (8) of this appendix, Transportation Requirements for Alternate Provider Areas, for additional clarification.] For service areas without a designated alternate provider area, 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. 
  
 Many of the service areas included in this provider agreement have historically had substantial numbers of the eligible population seek
certain types of services outside of the county boundaries. ODJFS has therefore tried to integrate these utilization patterns into the minimum provider network requirements to recognize this practice and to avoid disruption of care. The charts found
in this appendix indicate the minimum provider panel requirements for each service area, and in some cases, the ODJFS-designated alternate provider area(s). Alternate provider areas are designated on the basis of demonstrated out-of-county
utilization of medical services by the Medicaid population eligible for MCP enrollment. 
  
 Provider panel requirements listed as “discretionary” refer only to where the provider may be located. Discretionary provider panel requirements may be met in an alternate provider area or in the actual service area. Where an MCP
exercises the option to meet a minimum provider panel requirement by contracting with a provider in an alternate provider area, it will be necessary for the MCP to provide transportation to members on an as needed basis if such providers are located
30 miles or more from the major eligible population center in the service area. 
  

 Appendix H 
 Page 2

  

 Although ODJFS does offer some latitude in where the minimum required provider panel members may be located, MCPs are
strongly urged to consider the importance of geographic accessibility (i.e., within the county/service area or consistent with existing utilization patterns) in developing their entire provider panel. Available and accessible providers have been
found to be the essential element in attracting and retaining members. 
  

	2.	PROVIDER SUBCONTRACTING 

  
 Unless otherwise specified in this appendix or OAC rule 5101:3-26-05, all MCPs will be required to enter into fully-executed subcontracts with their providers. These
subcontracts must include a baseline contractual agreement, as well as the appropriate Model Medicaid Addendum. The Model Medicaid Addendums incorporate all applicable Ohio Administrative Code rule requirements specific to provider subcontracting
and therefore cannot be modified except to add personalizing information such as the MCP’s name. 
  
 ODJFS must prior approve all MCP providers in the required provider type categories before they can begin to provide services to that MCP’s members. MCPs may not employ or contract with providers excluded from
participation in Federal health care programs under either section 1128 or section 1128A of the Social Security Act. As part of the prior approval process, MCPs must submit documentation verifying that all necessary contract documents have been
appropriately completed. ODJFS will verify the approvability of the submission and process this information using the ODJFS Provider Verification System (PVS). The PVS is a database system that maintains information on the status of all
MCP-submitted providers. Unless otherwise specified by ODJFS, MCPs are to submit provider panel information to ODJFS in accordance with the processes and timelines specified in the current MCP PVS Instructional Manual in order to
comply with the provider subcontracting requirements. 
  
 Only those providers who
have been approved through the MCP’s credentialing process (where applicable) and who meet the applicable criteria specified in this appendix will be approved by ODJFS. MCPs must credential/recredential providers in accordance with the
standards specified by the National Committee for Quality Assurance, or the MCP may request that ODJFS allow the use of an alternate industry standard for provider credentialing/recredentialing. 
  
 MCPs must notify ODJFS of the addition and deletion of their 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. 
  

 Appendix H 
 Page 3

  

	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. Generally acceptable specialty types for PCPs are family/general practice, internal
medicine, pediatrics and obstetrics/gynecology. (ODJFS reserves the right to request verification of a physician’s specialty type.) 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 included in the MCP’s total PCP capacity calculation. The
capacity by site requirement must be met for all ODJFS-approved PCPs. 
  
 A
PCP’s total capacity number may reflect the support the provider receives from residents, nurse practitioners, physician assistants, etc. For example, a PCP in private practice with no assistants might state that they have the capacity to serve
1000 members for an MCP. A PCP with assistants, however, might state that they are able to see up to 2500 members for an MCP. 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 full-time equivalent (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 will be approved for a specific PCP. 
  
 For PCPs
contracting with more than one MCP, the MCP must ensure that the capacity figure stated by the PCP in their subcontract reflects only the capacity the PCP intends to provide for that one MCP. ODJFS utilizes each approved PCP’s capacity figure
to determine if an MCP meets the minimum provider panel requirements and this stated capacity figure does not prohibit a PCP from actually having a caseload that exceeds the capacity figure indicated in their subcontract. 
  
 ODJFS expects, however, 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. 
  

 Appendix H 
 Page 4

  

 In order to determine if adequate PCP FTE capacity exists for each service area, ODJFS will total each MCP’s
approvable PCP FTEs for each service area (this would include both PCPs with practice sites located within that service area and PCP practice sites located in nearby counties which have been designated as alternate provider areas by ODJFS) and apply
the following criteria: 
  

				
	 Number of Eligibles/County

	  	Minimum PCP Capacity (% Eligibles)

	 
	 >100,000
	  	40	%*
	 <100,000
	  	50	%*

  

	*	the minimum PCP capacity requirement is higher for Preferred Option counties 

  
 (For example, WeCare MCP has a PCP FTE capacity of 19.5 for Service Area X. Service Area X has a population of 75,000 eligible recipients.
50% of 75,000 equals 37,500. 37,500 divided by 2000 equals 18.75. In that WeCare has a minimum PCP capacity of 19.5 FTEs for Service Area X and only is required to have a PCP capacity of 18.75 FTEs, ODJFS would find that WeCare MCP has sufficient
PCP capacity to serve Service Area X.) 
  
 At a minimum, each MCP must meet both
the PCP minimum FTE requirement for that service area, as well as a minimum ratio of one PCP FTE for each 2,000 of their Medicaid members in that service area. When alternate provider areas are designated, there continues to be a minimum PCP
capacity requirement which must be met by the MCP’s PCPs within the service area itself. The discretionary PCP FTE figure represents the maximum amount of PCP capacity that may be met in a designated alternate provider area. The minimum PCP
provider panel requirements are specified in the charts in Section H of this appendix. 
  
 Except in voluntary enrollment counties, all MCPs meeting the minimum PCP provider panel requirement must also satisfy a PCP geographic accessibility standard before they will receive a provider agreement for a specific service area. This
standard must be maintained in each service area for the duration of the contract. ODJFS will match the PCP practice sites with the geographic location of the eligible population in that service area and perform analysis using Geographic Information
Systems (GIS) software. The analysis will be used to determine if at least 40% of the eligible population are located within 10 miles of an MCP’s in-area or alternate provider area PCP provider site with PCP capacity taken into consideration.

  
 In addition to the PCP FTE capacity requirement, MCPs must also contract with
the specified number of pediatric PCPs for each service area. 
  
 These
must be pediatricians who 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 service area or
an alternate provider area, and be listed as a pediatrician with the Ohio State Medical Board. In addition, a designated number of these physicians must also be certified by the American Board of Pediatrics. 
  

 Appendix H 
 Page 5

  

 The minimum provider panel requirements for pediatricians are included in specialty provider charts in Section H of
this appendix. 
  

	b.	Non-PCP Minimum Provider Network 

  
 In addition to the PCP capacity requirements, each MCP is also required to maintain adequate capacity in the remainder of its provider network within the following
categories: hospitals, dentists, pharmacies, vision care providers, obstetricians/gynecologists (OB/GYNs), allergists, general surgeons, otolaryngologists, orthopedists, certified nurse midwives (CNMs), certified nurse practitioners (CNPs),
federally qualified health centers (FQHCs)/rural health centers (RHCs) and qualified family planning providers (QFPPs), CNMs, CNPs, FQHCs/RHCs and QFPPs are federally-required provider types. 
  
 All Medicaid-contracting MCPs must provide all medically-necessary Medicaid-covered services
to their members and therefore their complete provider network will include many other additional specialists and provider types. MCPs must ensure that all non-PCP network providers follow community standards in the scheduling of routine
appointments (i.e., the amount of time members must wait from the time of their request to the first available time when the visit can occur). 
  
 Although there are currently no FTE capacity requirements for any of the non-PCP required provider types, MCPs are required to ensure that adequate access is available to
members for all required provider types. Additionally, for certain non-PCP required provider types, MCPs must ensure that these providers maintain a full-time practice at a site(s) located in the contract service area. A full-time practice is
defined as one where the provider is available to patients at their practice site(s) in the contract service area 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 at least one hospital in the service area or an
alternate provider area, and this hospital, alone or in combination with other contracted hospitals within the service area or the alternate provider area, must be capable and agree to provide all of the following services during the contract
period: general medical/surgical services for both the adult and pediatric population; obstetrical services; nursery services; adult, pediatric and neonatal (Levels I and II) intensive care; cardiac care; outpatient surgery; and emergency room
services. ODJFS utilizes each hospital’s most current Annual Hospital Registration and Planning Report, as filed with the Ohio Department of Health, in determining what types of services that hospital provides. 
  

 Appendix H 
 Page 6

  

 If an MCP-contracted hospital elects not to provide specific Medicaid-covered hospital services because of an
objection on moral or religious grounds, then the MCP must ensure that these hospital services are available to its members through another MCP-contracted hospital in the contract service area. 
  
 It will be possible to meet the hospital requirement for some service areas by contracting
only with one full-service general hospital outside the service area, however, MCPs are required to contract with at least one hospital in the service area if at least two general hospitals (which are not both members of the same hospital system)
are located in that service area. Failing to contract with a local hospital may make such a provider network less attractive to potential members. 
  
 OB/GYNs - MCPs must contract with the specified number of OB/GYNs for each service area, all of whom must maintain a full-time obstetrical practice at a site(s)
located in the service area or alternate provider area. All MCP-contracting OB/GYNs must have current hospital delivery privileges at a hospital under contract with the MCP in the service area or an alternate provider area. 
  
 Certified Nurse Midwives (CNMs) and Certified Nurse Practitioners (CNPs) - MCPs must
ensure access to at least one CNM and one CNP in the service area or alternate provider area, if such provider types are present. Access to additional CNMs and CNPs must be added on an as needed basis to ensure that no member is denied access to
such services. For this provider panel requirement, the MCP may contract directly with the CNM or CNP, or with a physician or other provider entity who is able to obligate the participation of the CNM or CNP. If an MCP does not contract with a CNM
or CNP and such providers are present within a service area or alternate provider area, 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 service area or an alternate provider area. The MCP must always ensure a member’s access to CNM and CNP services if such providers are present within the service area. 
  
 Vision Care Providers - MCPs must contract with the specified number of ophthalmologists/optometrists for each service area, all of
whom must maintain a full-time practice at a site(s) located in the service area or alternate provider area. All ODJFS-approved vision providers must regularly perform routine eye exams. If optical dispensing is not available in a particular service
area or alternate provider area through the MCP’s contracting ophthalmologists/optometrists, the MCP must separately contract with an optical dispenser located in the service area or alternate provider area. 
  
 Dental Care Providers - MCPs must assure access to dental services. MCPs will be
required to provide access to all Medicaid-covered dental services regardless of the number of dentists under contract and/or the number of contracting dentists accepting new patients. 
  

 Appendix H 
 Page 7

  

 The charts in Section H of this appendix reflect the number of dental providers which ODJFS will use as a guideline
in assessing the MCP’s capacity to assure access to dental services. 
  
 ODJFS will aggressively monitor access to dental services through a variety of data sources, including: consumer satisfaction surveys; member appeals/grievances/complaints and state hearing notifications/requests; member just-cause for
disenrollment requests; dental quality studies; dental encounter data volume; provider complaints, and dental performance measures. 
  
 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. Even if no FQHC/RHC is available within the service area, 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 service area. In order to assure FQHC/RHC access to members, MCPs must make provisions for the following: 
  

	 	•	Non-contracting FQHC/RHC providers serving as a PCP for an MCP’s member must be allowed to refer that member to another provider in the MCP’s provider panel.

  

	 	•	MCPs may require that their members request a referral from their PCP in order to access FQHC/RHC providers; however, such referral requests must be approved.

  
 In order to ensure that any FQHCs/RHCs 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. 
  

 Appendix H 
 Page 8

  

 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 on a patient self-referral basis, irrespective of the provider’s status as a panel or non-panel
provider. MCPs will be required to work with QFPPs in their service area to develop mutually-agreeable 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 ODADAS-certified Medicaid providers in some areas, MCPs
must maintain an adequate number of contracted mental health providers in the contract service area to assure access for members who are unable to timely access services or unwilling to access services through community mental health centers.

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

	4.	PROVIDER PANEL EXCEPTIONS 

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

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

  

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

  

 Appendix H 
 Page 9

  

	5.	PROVIDER PANEL DIRECTORIES 

  
 All MCPs must produce a printed ODJFS-approved provider directory by July 1 of each year. MCPs’ provider directories must include all MCP-contracted providers
approved by ODJFS, as well as providers available to the MCP’s members on a self-referral basis. At the time of ODJFS’ review, the information listed in the MCP’s provider directory for all ODJFS-required provider types must exactly
match with the data currently on file in the ODJFS PVS. 
  
 MCP provider
directories must utilize a format specified by ODJFS and include a county-specific listing of the providers who will serve the MCP’s members, including at a minimum, all providers of those types specified in this appendix. The directory must
also specify: 
  

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

  

	•	which of these providers will be available to members on a self-referral basis and practice limitations for these self-referred providers; 

  

	•	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. 

  
 MCPs must annually revise their directory and this will be the only ODJFS-allowable revision to the actual directory document. MCPs may supplement their directory on an
ongoing basis with inserts detailing recent changes to the MCP’s provider panel. Such inserts must be prior approved by ODJFS. If an MCP wants to include a provider panel directory on their website, this directory must include all information
required for their printed directory and the MCP must receive prior approval from ODJFS before adding this directory to their website. 
  

	6.	FEDERAL ACCESS STANDARDS 

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

  

	•	The anticipated Medicaid membership. 

  

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

  

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

  

 Appendix H 
 Page 10

  

	•	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
panel providers must offer hours of operation that are no less than the hours of operation offered to commercial members or comparable to Medicaid fee-for-service, if the provider serves only Medicaid members. MCPs must ensure that services are
available 24 hours a day, 7 days a week, when medically necessary. MCPs must establish mechanisms to ensure that panel providers comply with these timely access requirements. MCPs are required to regularly monitor their provider panels to determine
compliance and if necessary take corrective action if there is failure to comply. 
  
 In order to demonstrate adequate provider panel capacity and services, 42 CFR 437.207 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 in order to comply with these federal access requirements. 
  

 Appendix H 
 Page 11

  

	7.	MINIMUM PROVIDER PANEL CHARTS 

  
 MINIMUM SPECIALIST PROVIDER PANEL REQUIREMENTS 
 July 1, 2004 
  
 Service Area: Butler 

 

									
	 Specialty
 Provider Type

	  	 Total
 Providers

	  	 Minimum Providers
 in
 Contract County

	  	 Discretionary
 Providers1

	  	 Alternate
 County

	 Pediatricians
	  	7(4)2	  	5	  	2	  	Hamilton or Montgomery
	 OB/GYNs
	  	2	  	1	  	1	  	Hamilton or Montgomery
	 Dentists3
	  	7(4)4	  	4	  	2	  	Hamilton
	 Vision
	  	3	  	2	  	1	  	Hamilton
	 Gen. Surgeons
	  	2	  	1	  	1	  	Hamilton or Montgomery
	 Otolaryngologist
	  	1	  	1	  	X	  	X
	 Allergists
	  	1	  	X	  	1	  	Hamilton or Montgomery
	 Orthopedists
	  	1	  	1	  	X	  	X
	 Pharmacies
	  	2	  	2	  	X	  	X
	 Cert. Nurse Midwife
	  	1	  	X	  	1	  	Hamilton
	 Cert. Nurse Practitioner
	  	1	  	X	  	1	  	Hamilton

  

	1.	If it is not possible to contract with providers in the contract county, discretionary
providers located in the alternate provider areas can be used to fulfill the minimum provider panel requirement. 

  

	2.	Indicates the minimum number of pediatricians (i.e., 50%) who must be certified by the
American Board of Pediatrics. 

  

	3.	The dental numbers are not minimum provider panel requirements but rather reflect guidelines
to assist in measuring the MCP’s capacity to assure access to dental services. MCPs will be required to provide access to all Medicaid-covered dental services regardless of the number of dentists under contract and/or the number of contracting
dentists accepting new patients. 

  

	4.	Indicates the maximum number of pediatric dentists (i.e., two-thirds) that could be used to
meet the minimumdentist provider guideline. 

  

 Appendix H 
 Page 12

  

 MINIMUM SPECIALIST PROVIDER PANEL REQUIREMENTS 
 July 1, 2004 
  
 Service Area: Hamilton 
  

									
	 Specialty
 Provider Type

	  	 Total
 Providers

	  	 Minimum Providers
 in
 Contract County

	  	 Discretionary
 Providers1

	  	 Alternate
 County

	 Pediatricians
	  	21(11)2	  	21	  	X	  	X
	 OB/GYNs
	  	7	  	7	  	X	  	X
	 Dentists3
	  	21(14)2	  	21	  	X	  	X
	 Vision
	  	8	  	8	  	X	  	X
	 Gen. Surgeons
	  	5	  	5	  	X	  	X
	 Otolaryngologist
	  	2	  	2	  	X	  	X
	 Allergists
	  	1	  	1	  	X	  	X
	 Orthopedists
	  	3	  	3	  	X	  	X
	 Pharmacies
	  	7	  	7	  	X	  	X
	 Cert. Nurse Midwife
	  	1	  	1	  	X	  	X
	 Cert. Nurse Practitioner
	  	1	  	1	  	X	  	X

  

	1.	If it is not possible to contract with providers in the contract county, discretionary
providers located in the alternate provider areas can be used to fulfill the minimum provider panel requirement. 

  

	2.	Indicates the minimum number of pediatricians (i.e., 50%) who must be certified by the
American Board of Pediatrics. 

  

	3.	The dental numbers are not minimum provider panel requirements but rather reflect guidelines to assist in measuring the MCP’s capacity to assure access to
dental services. MCPs will be required to provide access to all Medicaid-covered dental services regardless of the number of dentists under contract and/or the number of contracting dentists accepting new patients. 

  

	4.	Indicates the maximum number of pediatric dentists (i.e., two-thirds) that could be used to
meet the minimum dentist provider guideline. 

  

 Appendix H 
 Page 13

  

 MINIMUM SPECIALIST PROVIDER PANEL REQUIREMENTS 
 July 1, 2004 
  
 Service Area: Warren 
  

									
	 Specialty
 Provider Type

	  	 Total
 Providers

	  	 Minimum Providers
 in
 Contract County

	  	 Discretionary
 Providers1

	  	 Alternate
 County

	 Pediatricians
	  	2(1)2	  	X	  	2	  	Hamilton or Montgomery5
	 OB/GYNs
	  	2	  	X	  	2	  	Hamilton or Montgomery5
	 Dentists3
	  	2(1)4	  	1	  	1	  	Butler or Hamilton
	 Vision
	  	2	  	1	  	1	  	Hamilton
	 Gen. Surgeons
	  	2	  	X	  	2	  	Hamilton or Montgomery5
	 Otolaryngologist
	  	2	  	X	  	2	  	Hamilton or Montgomery5
	 Allergists
	  	1	  	X	  	1	  	Hamilton or Montgomery
	 Orthopedists
	  	2	  	X	  	2	  	Hamilton or Montgomery5
	 Pharmacies
	  	1	  	1	  	X	  	X
	 Cert. Nurse Midwife
	  	1	  	X	  	1	  	Hamilton
	 Cert. Nurse Practitioner
	  	1	  	X	  	1	  	Hamilton

  

	1.	If it is not possible to contract with providers in the contract county, discretionary
providers located in the alternate provider areas can be used to fulfill the minimum provider panel requirement. 

  

	2.	Indicates the minimum number of pediatricians (i.e., 50%) who must be certified by the American Board of Pediatrics. 

  

	3.	The dental numbers are not minimum provider panel requirements but rather reflect guidelines
to assist in measuring the MCP’s capacity to assure access to dental services. MCPs will be required to provide access to all Medicaid-covered dental services regardless of the number of dentists under contract and/or the number of contracting
dentists accepting new patients. 

  

	4.	Indicates the maximum number of pediatric dentists (i.e., two-thirds) that could be used to
meet the minimum dentist provider guideline. 

  

	5.	If more than one alternate county is listed, all the discretionary providers may be located
in one of the alternate counties or they may be located in multiple alternate counties in any combination (e.g., if there are 2 discretionary providers and the alternate counties are Hamilton and Montgomery, both providers could be located in
Hamilton or both located in Montgomery or one located in Hamilton and one located in Montgomery). 

  

 Appendix H 
 Page 14

  

 MINIMUM SPECIALIST PROVIDER PANEL REQUIREMENTS 
 July 1, 2004 
  
 Service Area: Clermont 
  

									
	 Specialty
 Provider Type

	  	 Total
 Providers

	  	 Minimum Providers
 in
 Contract County

	  	 Discretionary
 Providers1

	  	 Alternate
 County

	 Pediatricians
	  	4(2)2	  	1	  	3	  	Hamilton
	 OB/GYNs
	  	1	  	x	  	1	  	Hamilton
	 Dentists3
	  	4(2)4	  	2	  	2	  	Hamilton
	 Vision
	  	2	  	1	  	1	  	Hamilton
	 Gen. Surgeons
	  	1	  	x	  	1	  	Hamilton
	 Otolaryngologist
	  	1	  	x	  	1	  	Hamilton
	 Allergists
	  	1	  	x	  	1	  	Hamilton
	 Orthopedists
	  	1	  	x	  	1	  	Hamilton
	 Pharmacies
	  	1	  	1	  	x	  	x
	 Cert. Nurse Midwife
	  	1	  	x	  	1	  	Hamilton
	 Cert. Nurse Practitioner
	  	1	  	x	  	1	  	Hamilton

  

	1.	If it is not possible to contract with providers in the contract county, discretionary
providers located in the alternate provider areas can be used to fulfill the minimum provider panel requirement. 

  

	2.	Indicates the minimum number of pediatricians (i.e., 50%) who must be certified by the
American Board of Pediatrics. 

  

	3.	The dental numbers are not minimum provider panel requirements but rather reflect guidelines
to assist in measuring the MCP’s capacity to assure access to dental services. MCPs will be required to provide access to all Medicaid-covered dental services regardless of the number of dentists under contract and/or the number of contracting
dentists accepting new patients. 

  

	4.	Indicates the maximum number of pediatric dentists (i.e., two-thirds) that could be used to
meet the minimum dentist provider guideline. 

  

 Appendix H 
 Page 15

  

 MINIMUM SPECIALIST PROVIDER PANEL REQUIREMENTS 
 July 1, 2004 
  
 Service Area: Montgomery 
  

									
	 Specialty
 Provider Type

	  	 Total
 Providers

	  	 Minimum Providers
 in
 Contract County

	  	 Discretionary
 Providers1

	  	 Alternate
 County

	 Pediatricians
	  	15(8)2	  	15	  	x	  	x
	 OB/GYNs
	  	5	  	5	  	x	  	x
	 Dentists3
	  	14(9)4	  	14	  	x	  	x
	 Vision
	  	5	  	5	  	x	  	x
	 Gen. Surgeons
	  	4	  	4	  	x	  	x
	 Otolaryngologist
	  	1	  	1	  	x	  	x
	 Allergists
	  	1	  	1	  	x	  	x
	 Orthopedists
	  	2	  	2	  	x	  	x
	 Pharmacies
	  	5	  	5	  	x	  	x
	 Cert. Nurse Midwife
	  	1	  	1	  	x	  	x
	 Cert. Nurse Practitioner
	  	1	  	1	  	x	  	x

  

	1.	If it is not possible to contract with providers in the contract county, discretionary
providers located in the alternate provider areas can be used to fulfill the minimum provider panel requirement. 

  

	2.	Indicates the minimum number of pediatricians (i.e., 50%) who must be certified by the
American Board of Pediatrics. 

  

	3.	The dental numbers are not minimum provider panel requirements but rather reflect guidelines
to assist in measuring the MCP’s capacity to assure access to dental services. MCPs will be required to provide access to all Medicaid-covered dental services regardless of the number of dentists under contract and/or the number of contracting
dentists accepting new patients. 

  

	4.	Indicates the maximum number of pediatric dentists (i.e., two-thirds) that could be used to
meet the minimum dentist provider guideline. 

  

 Appendix H 
 Page 16

  

 MINIMUM SPECIALIST PROVIDER PANEL REQUIREMENTS 
 July 1, 2004 
  
 Service Area: Clark 
  

									
	 Specialty
 Provider Type

	  	 Total
 Providers

	  	 Minimum Providers
 in
 Contract County

	  	 Discretionary
 Providers1

	  	 Alternate
 County

	 Pediatricians
	  	5(3)2	  	3	  	2	  	Montgomery
	 OB/GYNs
	  	2	  	1	  	1	  	Montgomery
	 Dentists3
	  	5(3)4	  	3	  	2	  	Montgomery
	 Vision
	  	2	  	2	  	x	  	x
	 Gen. Surgeons
	  	1	  	x	  	1	  	Montgomery
	 Otolaryngologist
	  	1	  	x	  	1	  	Montgomery
	 Allergists
	  	1	  	x	  	1	  	Montgomery
	 Orthopedists
	  	1	  	x	  	1	  	Montgomery
	 Pharmacies
	  	2	  	2	  	x	  	x
	 Cert. Nurse Midwife
	  	1	  	x	  	1	  	Montgomery
	 Cert. Nurse Practitioner
	  	1	  	x	  	1	  	Montgomery

  

	1.	If it is not possible to contract with providers in the contract county, discretionary
providers located in the alternate provider areas can be used to fulfill the minimum provider panel requirement. 

  

	2.	Indicates the minimum number of pediatricians (i.e., 50%) who must be certified by the
American Board of Pediatrics. 

  

	3.	The dental numbers are not minimum provider panel requirements but rather reflect guidelines
to assist in measuring the MCP’s capacity to assure access to dental services. MCPs will be required to provide access to all Medicaid-covered dental services regardless of the number of dentists under contract and/or the number of contracting
dentists accepting new patients. 

  

	4.	Indicates the maximum number of pediatric dentists (i.e., two-thirds) that could be used to
meet the minimum dentist provider guideline. 

  

 Appendix H 
 Page 17

  

 MINIMUM SPECIALIST PROVIDER PANEL REQUIREMENTS 
 July 1, 2004 
  
 Service Area: Greene 
  

									
	 Specialty
 Provider Type

	  	 Total
 Providers

	  	 Minimum Providers
in
Contract County

	  	 Discretionary
 Providers1

	  	 Alternate
 County

	 Pediatricians
	  	3(2)2	  	2	  	1	  	Montgomery
	 OB/GYNs
	  	2	  	1	  	1	  	Montgomery
	 Dentists3
	  	3(2)4	  	2	  	1	  	Montgomery
	 Vision
	  	2	  	1	  	1	  	Montgomery
	 Gen. Surgeons
	  	2	  	1	  	1	  	Montgomery
	 Otolaryngologist
	  	1	  	x	  	1	  	Montgomery
	 Allergists
	  	1	  	x	  	1	  	Montgomery
	 Orthopedists
	  	1	  	x	  	1	  	Montgomery
	 Pharmacies
	  	1	  	1	  	x	  	x
	 Cert. Nurse Midwife
	  	1	  	x	  	1	  	Montgomery
	 Cert. Nurse Practitioner
	  	1	  	x	  	1	  	Montgomery

  

	1.	If it is not possible to contract with providers in the contract county, discretionary providers located in the alternate provider areas can be used to fulfill the
minimum provider panel requirement. 

  

	2.	Indicates the minimum number of pediatricians (i.e., 50%) who must be certified by the American Board of Pediatrics. 

  

	3.	The dental numbers are not minimum provider panel requirements but rather reflect guidelines to assist in measuring the MCP’s capacity to assure access to
dental services. MCPs will be required to provide access to all Medicaid-covered dental services regardless of the number of dentists under contract and/or the number of contracting dentists accepting new patients. 

  

	4.	Indicates the maximum number of pediatric dentists (i.e., two-thirds) that could be used to meet the minimum dentist provider guideline. 

  

 Appendix H 
 Page 18

  

 MINIMUM SPECIALIST PROVIDER PANEL REQUIREMENTS 
 July 1, 2004 
  
 Service Area: Franklin 
  

									
	 Specialty
 Provider Type

	  	 Total
 Providers

	  	 Minimum Providers
in
Contract County

	  	 Discretionary
 Providers1

	  	 Alternate
 County

	 Pediatricians
	  	27(14)2	  	27	  	x	  	x
	 OB/GYNs
	  	9	  	9	  	x	  	x
	 Dentists3
	  	27(18)3	  	27	  	x	  	x
	 Vision
	  	10	  	10	  	x	  	x
	 Gen. Surgeons
	  	7	  	7	  	x	  	x
	 Otolaryngologist
	  	2	  	2	  	x	  	x
	 Allergists
	  	1	  	1	  	x	  	x
	 Orthopedists
	  	4	  	4	  	x	  	x
	 Pharmacies
	  	9	  	9	  	x	  	x
	 Cert. Nurse Midwife
	  	1	  	1	  	x	  	x
	 Cert. Nurse Practitioner
	  	1	  	1	  	x	  	x

  

	1.	If it is not possible to contract with providers in the contract county, discretionary providers located in the alternate provider areas can be used to fulfill the
minimum provider panel requirement. 

  

	2.	Indicates the minimum number of pediatricians (i.e., 50%) who must be certified by the American Board of Pediatrics. 

  

	3.	The dental numbers are not minimum provider panel requirements but rather reflect guidelines to assist in measuring the MCP’s capacity to assure access to
dental services. MCPs will be required to provide access to all Medicaid-covered dental services regardless of the number of dentists under contract and/or the number of contracting dentists accepting new patients. 

  

	4.	Indicates the maximum number of pediatric dentists (i.e., two-thirds) that could be used to meet the minimum dentist provider guideline. 

  

 Appendix H 
 Page 19

  

 MINIMUM SPECIALIST PROVIDER PANEL REQUIREMENTS 
 July 1, 2004 
  
 Service Area: Pickaway 
  

									
	 Specialty
 Provider Type

	  	 Total
 Providers

	  	 Minimum Providers
in
Contract County

	  	 Discretionary
 Providers1

	  	 Alternate
 County

	 Pediatricians
	  	1(1)2	  	x	  	1	  	Franklin
	 OB/GYNs
	  	l	  	x	  	1	  	Franklin
	 Dentists3
	  	2(1)4	  	x	  	2	  	Franklin or Ross
	 Vision
	  	1	  	1	  	x	  	x
	 Gen. Surgeons
	  	1	  	x	  	1	  	Franklin
	 Otolaryngologist
	  	1	  	x	  	1	  	Franklin
	 Allergists
	  	1	  	x	  	1	  	Franklin
	 Orthopedists
	  	1	  	x	  	1	  	Franklin
	 Pharmacies
	  	2	  	1	  	1	  	Franklin
	 Cert. Nurse Midwife
	  	1	  	x	  	1	  	Franklin
	 Cert. Nurse Practitioner
	  	1	  	x	  	1	  	Franklin

  

	1.	If it is not possible to contract with providers in the contract county, discretionary providers located in the alternate provider areas can be used to fulfill the
minimum provider panel requirement. 

  

	2.	Indicates the minimum number of pediatricians (i.e., 50%) who must be certified by the American Board of Pediatrics. 

  

	3.	The dental numbers are not minimum provider panel requirements but rather reflect guidelines to assist in measuring the MCP’s capacity to assure access to
dental services. MCPs will be required to provide access to all Medicaid-covered dental services regardless of the number of dentists under contract and/or the number of contracting dentists accepting new patients. 

  

	4.	Indicates the maximum number of pediatric dentists (i.e., two-thirds) that could be used to meet the minimum dentist provider guideline. 

  

 Appendix H 
 Page 20

  

 MINIMUM SPECIALIST PROVIDER PANEL REQUIREMENTS 
 July 1, 2004 
  
 Service Area: Cuyahoga 
  

									
	 Specialty
 Provider Type

	  	 Total
 Providers

	  	 Minimum Providers in
Contract County

	  	 Discretionary
 Providers1

	  	 Alternate
 County

	 Pediatricians
	  	39(20)2	  	39	  	x	  	x
	 OB/GYNs
	  	13	  	13	  	x	  	x
	 Dentists3
	  	38(25)4	  	38	  	x	  	x
	 Vision
	  	14	  	14	  	x	  	x
	 Gen. Surgeons
	  	9	  	9	  	x	  	x
	 Otolaryngologist
	  	2	  	2	  	x	  	x
	 Allergists
	  	1	  	1	  	x	  	x
	 Orthopedists
	  	6	  	6	  	x	  	x
	 Pharmacies
	  	13	  	13	  	x	  	x
	 Cert. Nurse Midwife
	  	1	  	1	  	x	  	x
	 Cert. Nurse Practitioner
	  	1	  	1	  	x	  	x

  

	1.	If it is not possible to contract with providers in the contract county, discretionary providers located in the alternate provider areas can be used to fulfill the
minimum provider panel requirement. 

  

	2.	Indicates the minimum number of pediatricians (i.e., 50%) who must be certified by the American Board of Pediatrics. 

  

	3.	The dental numbers are not minimum provider panel requirements but rather reflect guidelines to assist in measuring the MCP’s capacity to assure access to
dental services. MCPs will be required to provide access to all Medicaid-covered dental services regardless of the number of dentists under contract and/or the number of contracting dentists accepting new patients. 

  

	4.	Indicates the maximum number of pediatric dentists (i.e., two-thirds) that could be used to meet the minimum dentist provider guideline. 

  

 Appendix H 
 Page 21

  

 MINIMUM SPECIALIST PROVIDER PANEL REQUIREMENTS 
 July 1, 2004 
  
 Service Area: Lorain 
  

									
	 Specialty
 Provider Type

	  	 Total
 Providers

	  	 Minimum Providers in
Contract County

	  	 Discretionary
 Providers1

	  	 Alternate
 County

	 Pediatricians
	  	8(4)2	  	5	  	3	  	Cuyahoga
	 OB/GYNs
	  	3	  	2	  	1	  	Cuyahoga
	 Dentists3
	  	8(5)4	  	8	  	x	  	x
	 Vision
	  	3	  	3	  	x	  	x
	 Gen. Surgeons
	  	2	  	1	  	1	  	Cuyahoga
	 Otolaryngologist
	  	1	  	x	  	1	  	Cuyahoga
	 Allergists
	  	1	  	x	  	1	  	Cuyahoga
	 Orthopedists
	  	2	  	1	  	1	  	Cuyahoga
	 Pharmacies
	  	3	  	3	  	x	  	x
	 Cert. Nurse Midwife
	  	1	  	x	  	1	  	Cuyahoga
	 Cert. Nurse Practitioner
	  	1	  	x	  	1	  	Cuyahoga

  

	1.	If it is not possible to contract with providers in the contract county, discretionary providers located in the alternate provider areas can be used to fulfill the
minimum provider panel requirement. 

  

	2.	Indicates the minimum number of pediatricians (i.e., 50%) who must be certified by the American Board of Pediatrics. 

  

	3.	The dental numbers are not minimum provider panel requirements but rather reflect guidelines to assist in measuring the MCP’s capacity to assure access to
dental services. MCPs will be required to provide access to all Medicaid-covered dental services regardless of the number of dentists under contract and/or the number of contracting dentists accepting new patients. 

  

	4.	Indicates the maximum number of pediatric dentists (i.e., two-thirds) that could be used to meet the minimum dentist provider guideline. 

  

 Appendix H 
 Page 22

  

 MINIMUM SPECIALIST PROVIDER PANEL REQUIREMENTS 
 July 1, 2004 
  
 Service Area: Summit 
  

									
	 Specialty
 Provider Type

	  	 Total
 Providers

	  	 Minimum Providers in
Contract County

	  	 Discretionary
 Providers1

	  	 Alternate
 County

	 Pediatricians
	  	15(8)2	  	15	  	x	  	x
	 OB/GYNs
	  	5	  	5	  	x	  	x
	 Dentists3
	  	14(9)4	  	14	  	x	  	x
	 Vision
	  	9	  	5	  	x	  	x
	 Gen. Surgeons
	  	4	  	4	  	x	  	x
	 Otolaryngologist
	  	1	  	1	  	x	  	x
	 Allergists
	  	1	  	1	  	x	  	x
	 Orthopedists
	  	2	  	2	  	x	  	x
	 Pharmacies
	  	5	  	5	  	x	  	x
	 Cert. Nurse Midwife
	  	1	  	1	  	x	  	x
	 Cert. Nurse Practitioner
	  	1	  	1	  	x	  	x

  

	1.	If it is not possible to contract with providers in the contract county, discretionary providers located in the alternate provider areas can be used to fulfill the
minimum provider panel requirement. 

  

	2.	Indicates the minimum number of pediatricians (i.e., 50%) who must be certified by the American Board of Pediatrics. 

  

	3.	The dental numbers are not minimum provider panel requirements but rather reflect guidelines to assist in measuring the MCP’s capacity to assure access to
dental services. MCPs will be required to provide access to all Medicaid-covered dental services regardless of the number of dentists under contract and/or the number of contracting dentists accepting new patients. 

  

	4.	Indicates the maximum number of pediatric dentists (i.e., two-thirds) that could be used to meet the minimum dentist provider guideline. 

  

 Appendix H 
 Page 23

  

 MINIMUM SPECIALIST PROVIDER PANEL REQUIREMENTS 
 July 1, 2004 
  
 Service Area: Stark 
  

									
	 Specialty
 Provider Type

	  	 Total
 Providers

	  	 Minimum Providers
 in
 Contract County

	  	 Discretionary
 Providers1

	  	 Alternate
 County

	 Pediatricians
	  	10(5)2	  	10	  	x	  	x
	 OB/GYNs
	  	3	  	3	  	x	  	x
	 Dentists3
	  	10(7)4	  	10	  	x	  	x
	 Vision
	  	4	  	4	  	x	  	x
	 Gen. Surgeons
	  	2	  	2	  	x	  	x
	 Otolaryngologist
	  	1	  	1	  	x	  	x
	 Allergists
	  	1	  	x	  	1	  	Summit
	 Orthopedists
	  	2	  	2	  	x	  	x
	 Pharmacies
	  	3	  	3	  	x	  	x
	 Cert. Nurse Midwife
	  	1	  	x	  	1	  	Cuyahoga
	 Cert. Nurse Practitioner
	  	1	  	x	  	1	  	Cuyahoga

  

	1.	If it is not possible to contract with providers in the contract county, discretionary
providers located in the alternate provider areas can be used to fulfill the minimum provider panel requirement. 

  

	2.	Indicates the minimum number of pediatricians (i.e., 50%) who must be certified by the
American Board of Pediatrics. 

  

	3.	The dental numbers are not minimum provider panel requirements but rather reflect guidelines
to assist in measuring the MCP’s capacity to assure access to dental services. MCPs will be required to provide access to all Medicaid-covered dental services regardless of the number of dentists under contract and/or the number of contracting
dentists accepting new patients. 

  

	4.	Indicates the maximum number of pediatric dentists (i.e., two-thirds) that could be used to
meet the minimum dentist provider guideline. 

  

 Appendix H 
 Page 24

  

 MINIMUM SPECIALIST PROVIDER PANEL REQUIREMENTS 
 July 1, 2004 
  
 Service Area: Lucas 
  

									
	 Specialty
 Provider Type

	  	 Total
 Providers

	  	 Minimum Providers
 in
 Contract County

	  	 Discretionary
 Providers1

	  	 Alternate
 County

	 Pediatricians
	  	16(8)2	  	16	  	x	  	x
	 OB/GYNs
	  	5	  	5	  	x	  	x
	 Dentists3
	  	16(11)4	  	16	  	x	  	x
	 Vision
	  	6	  	6	  	x	  	x
	 Gen. Surgeons
	  	4	  	4	  	x	  	x
	 Otolaryngologist
	  	1	  	1	  	x	  	x
	 Allergists
	  	1	  	1	  	x	  	x
	 Orthopedists
	  	2	  	2	  	x	  	x
	 Pharmacies
	  	5	  	5	  	x	  	x
	 Cert. Nurse Midwife
	  	1	  	1	  	x	  	x
	 Cert. Nurse Practitioner
	  	1	  	1	  	x	  	x

  

	1.	If it is not possible to contract with providers in the contract county, discretionary
providers located in the alternate provider areas can be used to fulfill the minimum provider panel requirement. 

  

	2.	Indicates the minimum number of pediatricians (i.e., 50%) who must be certified by the
American Board of Pediatrics. 

  

	3.	The dental numbers are not minimum provider panel requirements but rather reflect guidelines
to assist in measuring the MCP’s capacity to assure access to dental services. MCPs will be required to provide access to all Medicaid-covered dental services regardless of the number of dentists under contract and/or the number of contracting
dentists accepting new patients. 

  

	4.	Indicates the maximum number of pediatric dentists (i.e., two-thirds) that could be used to
meet the minimum dentist provider guideline. 

  

 Appendix H 
 Page 25

  

 MINIMUM SPECIALIST PROVIDER PANEL REQUIREMENTS 
 July 1, 2004 
  
 Service Area: Wood 
  

									
	 Specialty
 Provider Type

	  	 Total
 Providers

	  	 Minimum Providers
 in
 Contract County

	  	 Discretionary
 Providers1

	  	 Alternate
 County

	 Pediatricians
	  	2(1)2	  	1	  	1	  	Lucas
	 OB/GYNs
	  	2	  	1	  	1	  	Lucas
	 Dentists3
	  	2(1)4	  	1	  	1	  	Lucas
	 Vision
	  	2	  	1	  	1	  	Lucas
	 Gen. Surgeons
	  	1	  	x	  	1	  	Lucas
	 Otolaryngologist
	  	1	  	x	  	1	  	Lucas
	 Allergists
	  	1	  	x	  	1	  	Lucas
	 Orthopedists
	  	1	  	x	  	1	  	Lucas
	 Pharmacies
	  	2	  	1	  	1	  	Lucas
	 Cert. Nurse Midwife
	  	1	  	x	  	1	  	Lucas
	 Cert. Nurse Practitioner
	  	1	  	x	  	1	  	Lucas

  

	1.	If it is not possible to contract with providers in the contract county, discretionary
providers located in the alternate provider areas can be used to fulfill the minimum provider panel requirement. 

  

	2.	Indicates the minimum number of pediatricians (i.e., 50%) who must be certified by the
American Board of Pediatrics. 

  

	3.	The dental numbers are not minimum provider panel requirements but rather reflect guidelines
to assist in measuring the MCP’s capacity to assure access to dental services. MCPs will be required to provide access to all Medicaid-covered dental services regardless of the number of dentists under contract and/or the number of contracting
dentists accepting new patients. 

  

	4.	Indicates the maximum number of pediatric dentists (i.e., two-thirds) that could be used to
meet the minimum dentist provider guideline. 

  

 Appendix H 
 Page 26

  

 MINIMUM SPECIALIST PROVIDER PANEL REQUIREMENTS 
 July 1, 2004 
  
 Service Area: Mahoning 
  

									
	 Specialty
 Provider Type

	  	 Total
 Providers

	  	 Minimum Providers
 in
 Contract County

	  	 Discretionary
 Providers1

	  	 Alternate
 County

	 Pediatricians
	  	9(4)2	  	9	  	x	  	x
	 OB/GYNs
	  	3	  	3	  	x	  	x
	 Dentists3
	  	8(5)4	  	8	  	x	  	x
	 Vision
	  	3	  	2	  	1	  	Trumbull
	 Gen. Surgeons
	  	2	  	2	  	x	  	x
	 Otolaryngologist
	  	1	  	1	  	x	  	x
	 Allergists
	  	1	  	x	  	1	  	Cuyahoga
	 Orthopedists
	  	1	  	1	  	x	  	x
	 Pharmacies
	  	3	  	3	  	x	  	x
	 Cert. Nurse Midwife
	  	1	  	x	  	1	  	Cuyahoga
	 Cert. Nurse Practitioner
	  	1	  	x	  	1	  	Cuyahoga

  

	1.	If it is not possible to contract with providers in the contract county, discretionary
providers located in the alternate provider areas can be used to fulfill the minimum provider panel requirement. 

  

	2.	Indicates the minimum number of pediatricians (i.e., 50%) who must be certified by the
American Board of Pediatrics. 

  

	3.	The dental numbers are not minimum provider panel requirements but rather reflect guidelines
to assist in measuring the MCP’s capacity to assure access to dental services. MCPs will be required to provide access to all Medicaid-covered dental services regardless of the number of dentists under contract and/or the number of contracting
dentists accepting new patients. 

  

	4.	Indicates the maximum number of pediatric dentists (i.e., two-thirds) that could be used to
meet the minimum dentist provider guideline. 

  

 Appendix H 
 Page 27

  

 MINIMUM SPECIALIST PROVIDER PANEL REQUIREMENTS 
 July 1, 2004 
  
 Service Area: Trumbull 
  

									
	 Specialty
 Provider Type

	  	 Total
 Providers

	  	 Minimum Providers
 in
 Contract County

	  	 Discretionary
 Providers1

	  	 Alternate
 County

	 Pediatricians
	  	7(4)2	  	5	  	2	  	Mahoning
	 OB/GYNs
	  	2	  	1	  	1	  	Mahoning
	 Dentists3
	  	7(4)4	  	7	  	x	  	x
	 Vision
	  	2	  	2	  	1	  	Mahoning
	 Gen. Surgeons
	  	2	  	1	  	1	  	Mahoning
	 Otolaryngologist
	  	1	  	x	  	1	  	Mahoning
	 Allergists
	  	1	  	x	  	1	  	Cuyahoga
	 Orthopedists
	  	1	  	1	  	x	  	x
	 Pharmacies
	  	2	  	2	  	x	  	x
	 Cert. Nurse Midwife
	  	1	  	x	  	1	  	Cuyahoga
	 Cert. Nurse Practitioner
	  	1	  	x	  	1	  	Cuyahoga

  

	1.	If it is not possible to contract with providers in the contract county, discretionary
providers located in the alternate provider areas can be used to fulfill the minimum provider panel requirement. 

  

	2.	Indicates the minimum number of pediatricians (i.e., 50%) who must be certified by the
American Board of Pediatrics. 

  

	3.	The dental numbers are not minimum provider panel requirements but rather reflect guidelines
to assist in measuring the MCP’s capacity to assure access to dental services. MCPs will be required to provide access to all Medicaid-covered dental services regardless of the number of dentists under contract and/or the number of contracting
dentists accepting new patients. 

  

	4.	Indicates the maximum number of pediatric dentists (i.e., two-thirds) that could be used to
meet the minimum dentist provider guideline. 

  

 Appendix H 
 Page 28

  

 MINIMUM PCP FTE REQUIREMENTS1 
 July 1, 2004 
  

									
	 County

	  	 Total FTE

	  	 Minimum
 Contract
 County
 FTE

	  	 Discretionary FTE1

	  	 Alternate
 County

	 Butler
	  	6.50	  	4.63	  	1.86	  	Hamilton
	 Clark
	  	4.25	  	3.40	  	0.85	  	Montgomery
	 Clermont
	  	3.41	  	0.92	  	2.49	  	Hamilton
	 Cuyahoga
	  	34.57	  	34.57	  	x	  	x
	 Franklin
	  	24.69	  	24.69	  	x	  	x
	 Greene
	  	2.63	  	1.35	  	1.28	  	Montgomery
	 Hamilton
	  	18.96	  	18.96	  	x	  	x
	 Lorain
	  	7.21	  	4.15	  	3.06	  	Cuyahoga
	 Lucas
	  	14.31	  	14.31	  	x	  	x
	 Mahoning
	  	7.55	  	7.55	  	x	  	x
	 Montgomery
	  	13.16	  	13.16	  	x	  	x
	 Pickaway
	  	1.26	  	0.75	  	0.51	  	Franklin
	 Stark
	  	8.72	  	8.72	  	x	  	x
	 Summit
	  	12.87	  	12.87	  	x	  	x
	 Trumbull
	  	6.00	  	4.61	  	1.38	  	Mahoning
	 Warren
	  	1.78	  	0.47	  	0.71	  	Hamilton
	 	  	 	  	 	  	0.36	  	Montgomery
	 	  	 	  	 	  	0.24	  	Butler
	 Wood
	  	1.50	  	0.73	  	0.77	  	Lucas

  

	1.	If it is not possible to contract with providers in the contract county, discretionary
providers located in the alternate counties can be used to fulfill the minimum provider panel requirement. 

  

 Appendix H 
 Page 29

  

 MINIMUM HOSPITAL REQUIREMENTS1 
  
 JULY 1, 2004 
  

					
	 COUNTY

	  	 IN-COUNTY
 HOSPITAL CONTRACTING
 REQUIREMENT

	  	 ALTERNATE COUNTY
 HOSPITAL SERVICE
 OPTION(S)2

	 Butler
	  	1	  	Hamilton (D)
	 Clark
	  	1	  	Montgomery (A, B, C, D)
	 Clermont
	  	0	  	Hamilton
	 Cuyahoga
	  	1	  	None
	 Franklin
	  	1	  	None
	 Greene
	  	0	  	Montgomery
	 Hamilton
	  	1	  	None
	 Lorain
	  	1	  	Cuyahoga (C, D)
	 Lucas
	  	1	  	None
	 Mahoning
	  	1	  	None
	 Montgomery
	  	1	  	None
	 Pickaway
	  	0	  	Franklin
	 Stark
	  	1	  	Summit (D)
	 Summit
	  	1	  	None
	 Trumbull
	  	1	  	Mahoning (A, B, C, D)
	 Warren
	  	0	  	Hamilton AND Montgomery AND Butler
	 Wood
	  	0	  	Lucas

  

	1.	Refer to section (3)(b) of this appendix for a description of required hospital services.

  

	2.	Hospital Service; A = OB, B = NICU, C = PED GEN, D = PED ICU

  

 Appendix H 
 Page 30

  

	8.	TRANSPORTATION REQUIREMENTS FOR ALTERNATE PROVIDER AREAS 

  

					
	 County

	  	Mandatory
Alternate
Provider
Area*

	  	 Mandatory Alternate Provider Area
 Transportation Requirement **

	 Butler
	  	Hamilton	  	Alternate provider area transportation is not required for the entire area of Hamilton County.
			
	 Clark
	  	Montgomery	  	Alternate provider area transportation is required for the area South or West of a line formed by starting at the eastern border of Montgomery County on Route 35, then going West on Route 35
to I-75, then North in I-75 to Route 40, then North on Route 40 to the northern border of Montgomery County.
	 Clermont
	  	Hamilton	  	Alternate provider area transportation is not required for the entire area of Hamilton County.
			
	 Cuyahoga
	  	None	  	N/A***
	 Franklin
	  	None	  	N/A***
	 Greene
	  	Montgomery	  	Alternate provider area transportation is not required for the entire area of Montgomery County.
	 Hamilton
	  	None	  	N/A***
	 Lorain
	  	Cuyahoga	  	Alternate provider area transportation is required for the area East of a line formed by starting at Lake Erie at Route I-90, then going South on Route I-90 to I-77, then South on Route I-77
to the southern border of Cuyahoga County.
	 Lucas
	  	None	  	N/A***
	 Mahoning
	  	Cuyahoga	  	Alternate provider area transportation is required for the entire area of Cuyahoga County.
	 	  	Trumbull	  	Alternate provider area transportation is not required for the entire area of Trumbull County.
	 Montgomery
	  	None	  	N/A***
	 Pickaway
	  	Franklin	  	Alternate provider area transportation is required for the area North of a line formed by starting at the western Franklin County line on Route I-70, and then going East on Route I-70 to the
eastern border of Franklin county.
	 Stark
	  	Cuyahoga	  	Alternate provider area transportation is required for the entire area of Cuyahoga County.
			
	 	  	Summit	  	Alternate provider area transportation is required for the area North of a line formed by starting at the western Summit County line at Route 18, then going Northeast through Fairlawn and
Cuyahoga Falls and through Stow to the eastern Summit County line.
	 Summit
	  	None	  	N/A***
	 Trumbull
	  	Cuyahoga	  	Alternate provider area transportation is required for the entire area of Cuyahoga County.
	 	  	Mahoning	  	Alternate provider area transportation is not required for the entire area of Mahoning County.
	 Warren
	  	Butler	  	Alternate provider area transportation is not required for the entire area of Butler County.
	 	  	Hamilton	  	Alternate provider area transportation is not required for the entire area of Hamilton County.
	 	  	Montgomery	  	Alternate provider area transportation is required for the area North of a line formed by starting at the western border of Montgomery County on Route 35, then going East on Route 35 to the
eastern border of Montgomery County.
	 Wood
	  	Lucas	  	Alternate provider area transportation is not required for the entire area of Lucas County.

  

	*	Please refer to county-specific charts in Appendix H for the specific provider types designated for alternate provider areas. 

  

	**	It will be necessary for the MCP to provide transportation to members on an as needed basis if such providers are located 30 miles or more from the major eligible population center
in the service area. 

  

	***	For service areas without a designated alternate provider area, MCPs are required to make transportation available to any member that must travel 30 miles or more from
their home to receive medically-necessary Medicaid-covered services. 

  

 APPENDIX I 
  

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

	1.	Fraud and Abuse Program: 

  
 In order to comply with OAC rule 5101:3-26-06, MCPs must have a program that includes administrative and management arrangements or procedures, including
a mandatory compliance plan, to guard against fraud and abuse. The MCP’s compliance plan must designate staff responsibility for administering the plan and include a clear goal, 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: For SFY 2004, the MCP must review their prior authorization procedures to determine that they do not unreasonably limit a member’s access to Medicaid-covered services. The MCP must also review 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. 
  
 Beginning July 1, 2004, in addition to the MCP’s annual review of prior authorization procedures and their provider
appeal procedures, the MCP must also monitor service denials and utilization on an ongoing basis in order to identify services which may be underutilized. 
  

 Appendix I 
 Page 2

  

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

  

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

  

	 	c.	Reporting fraud and abuse: MCPs are required to promptly report all instances of provider fraud and abuse to ODJFS and member fraud to the CDJFS. 

  

	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 

  

	 	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 I 
 Page 3

  

	3.	Prohibited Affiliations: 

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

 APPENDIX J 
  

FINANCIAL PERFORMANCE 
  

	1.	SUBMISSION OF FINANCIAL STATEMENTS AND REPORTS 

  
 MCPs must submit the following financial reports to ODJFS: 
  

	 	a.	The National Association of Insurance Commissioners (NAIC) quarterly and annual Health Statements (hereafter referred to as the “Financial Statements”), as outlined in
Ohio Administrative Code (OAC) rule 5101:3-26-09(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)(3). A hard copy and an electronic copy of the reports must be provided to ODJFS; 

  

	 	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;

  

 Appendix J 
 Page 2

  

	 	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); 

  

	2.	FINANCIAL PERFORMANCE MEASURES AND STANDARDS 

  
 This Appendix establishes specific expectations concerning the financial performance of MCPs. In the interest of administrative simplicity, nonduplication
of areas of the ODI authority and its emphasis 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. 
  

					
	a.	  	Indicator:	  	Net Worth as measured by New 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 2004, a minimum net worth per member of $115.00, as determined from the annual Financial Statement submitted to ODI and the
ODJFS.
			
	 	  	 	  	The Net Worth Per Member (NWPM) standard is the Medicaid Managed Care Capitation amount paid to the MCP during the preceding calendar year, including delivery payments, but excluding the
at-risk amount, expressed as a per-member per-month figure, multiplied by the applicable proportion below:
			
	 	  	 	  	0.75 if the MCP had a total membership of 100,000 or more during that calendar year
			
	 	  	 	  	0.90 if the MCP had a total membership of less than 100,000 for that calendar year
			
	 	  	 	  	If the MCP did not receive Medicaid Managed Care Capitation payments during the preceding calendar year, then the NWPM standard for the MCP is the average Medicaid Managed Care capitation
amount paid to Medicaid-contracting MCPs during the preceding calendar year, including delivery payments, but excluding the at-risk amount, multiplied by the applicable proportion above.

  

 Appendix J 
 Page 3

  

					
	b.	  	Indicator:	  	Administrative Expense Ratio
			
	 	  	Definition:	  	Administrative Expense Ratio = Administrative Expenses divided by Total Revenue
			
	 	  	Standard:	  	Administrative Expense Ratio less than or equal to 15%, as determined from the annual Financial Statement submitted to ODI and ODJFS.
			
	 c.
	  	Indicator:	  	Overall Expense Ratio
			
	 	  	Definition:	  	Overall Expense Ratio = The sum of the Administrative Expense Ratio and the Medical Expense Ratio
			
	 	  	 	  	Administrative Expense Ratio = Administrative Expenses divided by Total Revenue
			
	 	  	 	  	Medical Expense Ratio = Medical Expenses divided by Total Revenue
			
	 	  	Standard:	  	Overall Expense Ration not to exceed 100% as determined from the annual Financial Statement submitted to ODI and ODJFS.

  
 Report Period:
Compliance will be determined based on the annual Financial Statement. 
  
 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). 
  
 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 listed below 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.d., 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. 
  

 Appendix J 
 Page 4

  

 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.

  
 If the financial
statement is not submitted to ODI by the due date, the MCP continues to be obligated to submit the report to ODJFS by ODI’s originally specified due date unless the MCP requests and is granted an extension by ODJFS. 
  
 Failure to submit complete quarterly and annual Financial Statements on a
timely basis will be deemed a failure to meet the standards and will be subject to the noncompliance penalties listed for indicators 2.a., 2.b., and 2.c., including the imposition of a new membership freeze. The new membership freeze will take
effect at the first of the month following the month in which the determination was made that the MCP was non-compliant for failing to submit financial reports timely. 
  

	3.	REINSURANCE REQUIREMENTS 

  
 Pursuant to the provisions of OAC rule 5101:3-26-09 (C), each MCP must carry reinsurance coverage from a licensed commercial carrier to protect against
inpatient-related medical expenses incurred by Medicaid members. The annual deductible or retention amount for such insurance must be specified in the reinsurance agreement and must not exceed $75,000.00, except as provided below. Except for
transplant services, and as provided below, this reinsurance must cover, at a minimum, 80% of inpatient costs incurred by one member in one year, in excess of $75,000.00. 
  

 Appendix J 
 Page 5

  

 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. In determining whether or not the request will be approved, the ODJFS may consider any or
all of the following: 
  

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

  

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

  

	 	c.	the number of members covered by the MCP; 

  

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

  
 The MCP has been approved to have a reinsurance policy with a deductible amount of $75,000.00 that covers 80% of inpatient
costs in excess of the deductible amount for non-transplant services. 
  
 Penalty for noncompliance: If it is determined that an MCP failed to have reinsurance coverage, that an MCP’s deductible exceeds $75,000.00 without approval from ODJFS, or that the MCP’s reinsurance for non-transplant
services covers less than 80% of inpatient costs in excess of the deductible incurred by one member for one year without approval from ODJFS, then the MCP will be required to pay a monetary penalty to ODJFS. The amount of the penalty will be the
difference between the estimated amount, as determined by ODJFS, of what the MCP would have paid in premiums for the reinsurance policy if it had been in compliance and what the MCP did actually pay while it was out of compliance plus 5%. For
example, if the MCP paid $3,000,000.00 in premiums during the period of non-compliance and would have paid $5,000,000.00 if the requirements had been met, then the penalty would be $2,100,000.00. 
  
 If it is determined that an MCP’s reinsurance for transplant services
covers less than 50% of inpatient costs incurred by one member for one year, the MCP will be required to develop a corrective action plan (CAP). 
  

	4.	PROMPT PAY REQUIREMENTS 

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

 Appendix J 
 Page 6

  

 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 make this information available to ODJFS upon request: 
  

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

  

 Appendix J 
 Page 7

  

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

  

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

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

  

	6.	NOTIFICATION OF REGULATORY ACTION 

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

 APPENDIX K 
  

QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM 
  

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: 
  

	1.	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. 
  
 Starting in State Fiscal Year (SFY) 2004, MCPs must
initiate the following two (2) PIPs: 
  

	 	a.	Non-clinical Topic: Identifying children with special health care needs. 

  

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

  

Starting in SFY 2005, MCPs must initiate an additional PIP which will be specified by ODJFS. In addition, as noted in Appendix M, several of the
Clinical Performance Measures, if a MCP fails to meet the Minimum Performance Standard, the MCP will be required to complete a PIP. 
  

	2.	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. 
  

	3.	SPECIAL HEALTH CARE NEEDS 

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

	4.	SUBMISSION OF 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: 
  

	 	a.	Comprehensive Diabetes Care 

  

	 	b.	Child Immunization Status 

  

	 	c.	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. 
  
 This requirement will be phased in over a two-year period. MCPs that do not have HEDIS-audited measures during calendar year
(CY) 2004 will have the data collected and audited as part of the EQRO process. All MCPs will be required to submit the HEDIS-audited measures for the contract period beginning July 1, 2004. 
  

	5.	EQRO EVALUATION AND NON-DUPLICATION OF MANDATORY ACTIVITIES 

  
 The EQRO will conduct administrative compliance assessments and QAPI program reviews for each MCP every three (3) years. The review will cover all aspects
of the QAPI program and other quality and care coordinator areas as specified by ODJFS. In accordance with 42 CFR 438, 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 SFY05. 
  

 Appendix K 
 Page 3

  

	6.	MCP AND ODJFS ANNUAL EVALUATION 

  
 Each MCP must annually submit an evaluation of the effectiveness and impact of their QAPI program. ODJFS will review the effectiveness of each MCP’s
QAPI by reviewing the MCP’s self-evaluation, submission of required data, report on the status of each PIP provided by the MCP, the validation of the PIPs as conducted by the EQRO, and the EQRO’s review of the MCP’s QAPI functions.

  

	7.	EXTERNAL QUALITY REVIEW MINIMUM SCORE 

  
 As outlined in Appendix M, each MCP must achieve a minimum score of seventy-five percent (75%) for each clinical study and the administrative component.
In addition, each MCP must achieve an overall score of at least seventy-five percent (75%). 
  
 For all studies that are finalized during the contract period, if an MCP is noncompliant with the clinical study and administrative scoring requirements, a corrective action plan (CAP) must be developed by the MCP.
Serious deficiencies in the overall score may result in immediate termination or non-renewal of the provider agreement (Examples of an external quality review serious deficiency is a score of less than seventy-five percent (75%) for each clinical
study or a score of less than seventy-five percent (75%) for the administrative component with a score of less than seventy-five percent (75%) on the preponderance of clinical studies). Refer to Appendix M “Performance Evaluation” for a
more comprehensive description of minimum performance standards. 
  

 APPENDIX L 
  

DATA QUALITY 
  
 A high level of performance on the data quality measures established in this appendix is crucial in order for the Ohio Department of Job and Family Services (ODJFS) to
determine the value of the Medicaid Managed Health Care Program and to evaluate Medicaid consumers’ access to and quality of services. Data collected from MCPs are used in key performance assessments such as the external quality review,
clinical performance measures, utilization review, care coordination and case management, and in determining incentives. The data will also be used in conjunction with the cost reports in setting the 2005 premium payment rates. 
  
 Data sets collected from MCPs with data quality standards include: encounter data; screening,
assessment, and 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. 
  

	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 2005 and SFY 2006
contract periods are listed in the table below. 
  

 Appendix L 
 Page 2

  

	Table	1. Report Periods for the SFY 2005 and 2006 Contract Periods 

  

							
	 Quarterly Report Periods

	  	 Data Source:
 Estimated Encounter
 Data File Update

	  	 Quarterly Report
 Estimated Issue Date

	  	Contract Period

	 Qtr1 thru Qtr 4 2003 &
 Qtr 1 2004
	  	July 2004	  	August 2004	  	SFY 2005
	 Qtr1 thru Qtr 4 2003 &
 Qtr 1, Qtr 2 2004
	  	October 2004	  	November 2004	  
	 Qtr 1 thru Qtr 4 2003 &
 Qtr 1 thru Qtr 3 2004
	  	January 2005	  	February 2005	  
	 Qtr 1 thru Qtr 4 2003 &
 Qtr 1 thru Qtr 4 2004
	  	April 2005	  	May 2005	  
	 Qtr 1 thru Qtr 4 2003 &
 Qtr 1 thru Qtr 4 2004, &
 Qtr 1 2005
	  	July 2005	  	August 2005	  	SFY 2006
	 Qtr 1 thru Qtr 4 2003,
 Qtr 1 thru Qtr 4 2004, &
 Qtr 1, Qtr 2 2005
	  	October 2005	  	November 2005	  
	 Qtr 1 thru Qtr 4 2003,
 Qtr 1 thru Qtr 4 2004, &
 Qtr 1 thru Qtr 3 2005
	  	January 2006	  	February 2006	  
	 Qtr 1 thru Qtr 4 2003,
 Qtr 1 thru Qtr 4 2004, &
 Qtr 1 thru Qtr 4 2005
	  	April 2006	  	May 2006	  

  

							
	 Qtr1 = January to March
	  	Qtr2 = April to June	  	Qtr3 = July to September	  	Qtr4 = 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 standard established in Table 2 below. 
  

 Appendix L 
 Page 3

  

	Table	2. Standards – Encounter Data Volume 

  

									
	 Category

	  	 Measure per
 1,000/MM

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

	  	 Standard for
 Dates of Service
 on or after 7/1/2004

	  	 Description

	  	  	SFY ’04 Methods

	  	SFY ‘05 Methods

	  
	 Inpatient Hospital
	  	Discharges	  	5.4	  	5.0	  	General/acute care, excluding newborns and mental health and chemical dependency services
	 Emergency
 Department
	  	Visits	  	51.6	  	52.7	  	Includes physician and hospital emergency department encounters
	 Dental
	  	  	38.2	  	41.7	  	Non-institutional and hospital dental visits
	 Vision
	  	  	11.6	  	11.6	  	Non-institutional and hospital outpatient optometry and ophthalmology visits
	 Primary and
 Specialist Care
	  	  	220.1	  	225.7	  	Physician/practitioner and hospital outpatient visits
	 Ancillary Services
	  	  	144.7	  	123.0	  	Ancillary visits
	 Behavioral Health
	  	Service	  	7.6	  	8.6	  	Inpatient and outpatient behavioral encounters
	 Pharmacy
	  	Prescriptions	  	388.5	  	457.6	  	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. Special consideration will be made for MCPs with less than 1,000 members. 
  

 Appendix L 
 Page 4

  

 1.a.ii. Encounter Data Omissions 
  
 Measure: Omission studies will evaluate the completeness of the encounter data. This study will compare the medical records of
members during the time of membership to the encounters submitted. 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 35% for the study that will be finalized during contract period 2005,15% for the study finalized during contract period 2006, and 5% for the study finalized during contract period 2007 and for
subsequent studies. 
  
 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. 
  

 Appendix L 
 Page 5

  

 Report Period: For the SFY 2005 contract period, performance will be evaluated using the following report
periods: January - March 2004; April - June 2004; July - September 2004; October - December 2004. For the SFY 2006 contract period, performance will be evaluated using the following report periods: January - March 2005; April – June 2005; July
- September 2005; October - December 2005. 
  
 Data Quality Standard: The
data quality standard is a minimum rate of 95%. 
  
 Penalty for noncompliance:
The first time an MCP is noncompliant with a standard for this measure, ODJFS will issue a Sanction Advisory informing the MCP that any future noncompliance instances with the standard for this measure will result in ODJFS imposing a monetary
sanction. 
  
 Upon all subsequent quarterly measurements of performance, if an MCP
is again determined to be noncompliant with the standard, ODJFS will impose a monetary sanction (see Section 6) of one percent of the current month’s premium payment. Once the MCP is performing at standard levels and violations/deficiencies are resolved to the satisfaction of ODJFS, the money will be refunded. 
  
 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 SFY 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. 
  
 Report Period: For the SFY 2005 contract period, performance will be evaluated using the January - December 2004 report period. For the SFY 2006 contract period, performance will be evaluated using the January - December 2005 report
period. 
  

 Appendix L 
 Page 6

  

 Data Quality Standard: The data quality standard is 70% for encounters with dates of service in C Y 2003 and
80% for CY 2004 and thereafter. 
  
 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. 
  
 Report Period: For the SFY 2005 contract period, performance will be evaluated using
the following report periods: April - June 2004; July - September 2004; October - December 2004; and January - March 2005. For the SFY 2006 contract period, performance will be evaluated using the following report periods: April - June 2005; July -
September 2005; October - December 2005 and January - March 2006. 
  
 Data
Quality Standard 1: Data Quality Standard 1 is a maximum encounter data rejection rate of 10% for each tape format for encounters submitted in SFY 2004 and thereafter. 
  
 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 tape
format that is determined to be out of compliance. 
  

 Appendix L 
 Page 7

  

 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. 
  
 Report
Period: The report period for Measure 2 is three months. Results are calculated and performance is monitored quarterly. The first quarter begins with the first three months of enrollment. 
  
 Data Quality Standard 2: The data quality standard is a maximum encounter data
rejection rate for each tape format as follows: 
  

			
	 First & second quarters with membership:
	  	50%
	 Third & fourth quarters with membership:
	  	25%

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

 Appendix L 
 Page 8

  

 Data Quality Standard: The data quality standard is a monthly minimum accepted rate of encounters for each
tape format as follows: 
  

			
	 First and second quarters 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

		
	 Third and fourth quarters with 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 quarter. Compliance determination with the standard applies only to the quarter under consideration and does not include performance in previous quarters. 
  
 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. Special consideration will be made for
MCPs with less than 1,000 members. 
  
 1.a.vii. Incomplete Birth Weight Data

  
 Measure: The percentage of newborn delivery inpatient encounters
during the state fiscal year 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.” 
  
 Report Period: For the SFY 2005 contract period, performance will be evaluated using the January - December 2004 report period. For the SFY 2006 contract period,
performance will be evaluated using the January - December 2005 report period. 
  
 Data Quality Standard: The data quality standard is 50% for encounters with dates of service in CY 2003, 70% in CY 2004, and 90% in CY 2005 and thereafter. 
  
 Penalty for noncompliance: For report period SFY 2004 and thereafter, 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. 
  

 Appendix L 
 Page 9

  

 1.a.viii. Clinical Performance Measures 
  
 Results that reflect clinical services rendered for the Clinical Performance Measures as described in Appendix M, Performance Evaluation,
depend on complete encounter data. The completeness of the encounter data is assessed for all Clinical Performance Measures by calculating a composite score. 
  
 Report Period: For the SFY 2005 contract period, performance will be evaluated using the January - December 2004 report period. For
the SFY 2006 contract period, performance will be evaluated using the January - December 2005 report period. 
  
 For the SFY 2005 contract period, the results of the following CY 2004 Clinical Performance Measures will be used to calculated the composite score: 
  
 1. Perinatal Care – Frequency of Ongoing Prenatal Care 
  
 2. Perinatal Care – Initiation of Prenatal Care 
  
 3. Perinatal Care – Postpartum Care 
  
 4. Preventive Care for Children – Well-Child Visits 
  
 5. Use of Appropriate Medication for People with Asthma 
  
 6. Annual Dental Visits 
  
 7. Lead Screening 
  
 The composite score will be
determined by considering whether or not the MCP’ s results for each measure are within 70% of the results of the best performing MCP. Points will be awarded for each measure and summed to calculate the composite score. Points for each measure
will be awarded as follows: 
  

			
	 MCP’s results below 70% of the results of the best performing MCP:
	  	0 points
	 MCP’s results equal to or above 70% of the results of the best performing MCP:
	  	1 point

  
 The maximum composite score attainable
is seven. For measures with multiple components, each component will contribute equally to the score for the whole measure, e.g., the results for each of the three age ranges will contribute to one-third of the score of the well-child visit measure.

  

 Appendix L 
 Page 10

  

 Monetary sanctions between 0% and 5% of the current month’s premium payment will be determined according to the
following table: 
  

			
	 Composite Score

	 	 Monetary Sanction

	 7
	 	0%
	 6
	 	0%
	 5
	 	0%
	 4
	 	1%
	 3
	 	2%
	 2
	 	3%
	 1
	 	4%
	 0
	 	5%

  
 In order to transition to the new
method of calculating the clinical performance measures composite score for contract period SFY 2004, a one-time revision will be made in determining the method of refunding fines applied to the SFY 2002 results. 
  
 For MCPs that were sanctioned for low performance for SFY 2002 results, fines will be
refunded only if an MCP’s CY 2003 or CY 2004 composite score is high enough (5,6, or 7) to result in no additional fine being applied. 
  
 For the SFY 2005 contract period and later, when each year’s results for the Clinical Performance Measures are finalized, a new composite score will be determined
and ODJFS will impose new monetary sanctions, if applicable. At this time, if the composite score is higher than the prior year, then the prior year’s monetary sanctions related to this data quality measure will be refunded, if applicable. If a
higher composite score is not achieved within two years of a monetary sanction imposed under this data quality measure, then the monetary sanction will not be refunded. 
  
 1.b. Encounter Data Accuracy 
  
 As with data completeness, the MCPs are responsible for assuring the collection and submission of accurate data to ODJFS. Failure to do so jeopardizes the MCP’s
performance credibility and, if not corrected, will be assumed to indicate a failure in actual performance. 
  
 1.b.i. Encounter Data Accuracy Study 
  
 Measure: ODJFS validates the encounter data by measuring the rate of agreement between encounters and the corresponding medical records. The focus of the 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. 
  

 Appendix L 
 Page 11

  

 Report Period: In order to provide timely feedback on the accuracy rate of encounters, the report period will
be the most recent from when the measure is initiated. This measure is conducted annually. 
  
 Medical records retrieval from the provider and submittal to ODJFS or its designee is an integral component of the validation process. ODJFS has optimized the sampling to minimize the number of records required. This
methodology requires a high record submittal rate. To aid MCPs in achieving a high submittal rate, ODJFS will give at least an 8 week period to retrieve and submit medical records as a part of the validation process. A record submittal rate will be
calculated as a percentage of all records requested for the study. 
  
 Data
Quality Standard 1: For results that are finalized during the contract year, the accuracy rate for encounters generating delivery payments is 100%. 
  
 Penalty for noncompliance: The MCP must participate in a detailed review of delivery payments made for deliveries during the report period. Any duplicate or
unvalidated delivery payments must be returned to ODJFS. 
  
 Data Quality
Standard 2: 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. 
  
 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. 
  
 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 2005 contract period, performance will be evaluated using
the following report periods: January - March 2004; April - June 2004; July - September, 2004; October - December 2004. For the SFY 2006 contract period, performance will be evaluated using the following periods: January - March 2005; April - June
2005; July - September 2005; October - December 2005. 
  
 Data Quality
Standard: A maximum generic provider usage rate of 10%. 
  

 Appendix L 
 Page 12

  

 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 Tapes 
  
 MCP submissions of encounter data tapes to ODJFS are limited to two per format per month.
Should an MCP wish to send additional tapes, 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 tape. 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. SCREENING, ASSESSMENT,
AND CASE MANAGEMENT DATA 
  
 ODJFS designed a screening, assessment, and case
management system (SACMS) in order to monitor MCP compliance with program requirements specified in Appendix G, Coverage and Services. Each MCP’s screening, assessment, and case management data submissions will be assessed for
completeness and accuracy. The MCP is responsible for submitting a screening and assessment file (see Section 1 .b. of Appendix M, Performance Evaluation, for exceptions to this requirement) and 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 screening, assessment, and case management measures below, see ODJFS Methods for Screening, Assessment, and Case
Management Data Quality Measures. 
  

 Appendix L 
 Page 13

  

 2.a. Screening, Assessment, and 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 2005 contract period, performance will be evaluated using the January - June 2004 and July - December 2004 report periods. For the SFY
2006 contract period, performance will be evaluated using the January - June 2005 and July - December 2005 report periods. 
  
 Data Quality Standard: A rate of open case management spans for disenrolled members of no more than 1.0%. 
  
 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 Screening
and Assessment Files and Case Management Files 
  
 Data Quality Submission
Requirement: The MCP must submit Screening and Assessment and Case Management files on a monthly basis according to the specifications established in ODJFS Screening, Assessment, and 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. 
  

 Appendix L 
 Page 14

  

 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 
  
 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 percent 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=PCPDATA 
  
 Data Quality
Submission Requirement: The MCP must submit a Members’ Designated PCP Data files on a monthly basis according to the specifications established in ODJFS Members’ PCP Data File and Submission Specifications. 
  
 Penalty for noncompliance: See Appendix N, Compliance Assessment System, for
the penalty for noncompliance with this requirement. 
  

 Appendix L 
 Page 15

  

 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 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. and 1.a.v., no monetary sanctions described in this appendix will be imposed if the MCP is in its first contract year of Medicaid program participation.
Notwithstanding the penalties specified in this Appendix, ODJFS reserves the right to apply the most appropriate penalty to the area of deficiency identified when an MCP is determined to be noncompliant with a standard. Monetary penalties for
noncompliance on an individual measure for each period compliance is determined in this appendix will not exceed $300,000. 
  
 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. 
  

 Appendix L 
 Page 16

  

 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 
  
 This appendix establishes minimum performance standards for managed care plans (MCPs) in key program areas. The intent is to maintain accountability for contract
requirements. 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. Selected measures in this appendix will be used to determine incentives as specified in Appendix O, Performance Incentives. 
  
 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 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 assist 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 2004 contract period, performance will be evaluated using the reviews that are finalized during SFY 2004. For the SFY 2005 contract
period, performance will be evaluated using the reviews that are finalized during SFY 2005. 
  
 Minimum Performance Standard 1: A minimum score of 75% for each clinical study and the administrative component. 
  
 Action Required for Noncompliance with the Minimum Performance Standard 1: For all studies that are finalized during this contract period, if an MCP is
noncompliant with the standard, then the MCP is required to complete a Performance Improvement Project, as described in Appendix K, Quality Assessment and Performance Improvement Program, to address the area(s) of noncompliance.

  
 Minimum Performance Standard 2: Each MCP must achieve an overall
score of at least 75%. 
  

 Appendix M 
 Page 2

  

 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 a external quality review serious deficiency is 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.b. Children with Special Health Care Needs (CSHCN) 
  
 In order
to ensure state compliance with federal requirements under the 1915(b) Medicaid managed care waiver program authority, as well as 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 improve identification and screening, assure a thorough and
comprehensive assessment, and provide appropriate and targeted case management services to CSHCN. For a comprehensive description of the CSHCN measures below, see ODJFS Methods for Children with Special Health Care Needs Performance Measures.

  
 Data Submission Requirement and Performance Measures Exceptions:
Screening and assessment files are not required to be submitted to ODJFS as described in Appendix G, Coverage and Services, and measures pertaining to the screening and assessment of newly-enrolled children as described in this Appendix,
Sections 1.b.i. and ii do not apply if an MCP meets one of the two following criteria: 
  

	 	•	An MCP meets the performance target of 5.0% for the Case Management of Newly-Enrolled Children measure as described in Section 1.b.iii.; or 

 

	 	•	An MCP meets the 60% minimum performance standard for the Identification of Newly-Enrolled Children with Special Health Care Needs measure as described in Section
1.b.i, and during the same evaluation period meet the 85% minimum performance standard for the Assessment of Newly-Enrolled Children measure as described in Section 1.b.ii. 

  
 The frequency of measurement to determine this reporting and performance measures exception
is monthly and is based on a six month rolling period. 
  
 1.b.i Identification
of Newly-Enrolled Children with Special Health Care Needs 
  
 Measure:
The adjusted percentage of newly-enrolled children 6 months and over and under 21 years of age that are identified within 60 days of the effective date of enrollment, of those children expected to be screened. 
  

 Appendix M 
 Page 3

  

 Note: See Appendix G.ii., for identification methods. For all newly-enrolled members who were not screened at the
time of enrollment by the Selection Services Contractor (SSC) and are not identified as CSHCN through an administrative review, MCPs must use the ODJFS CSHCN Screening Questions to identify potential CSHCN. 
  
 Report Period: For the SFY 2005 contract period, performance will be evaluated using
the January - June 2004 and July - December 2004 report periods. For the SFY 2006 contract period, performance will be evaluated using the January - June 2005 and July - December 2005 report periods. 
  
 Minimum Performance Standard: A minimum adjusted screening rate of 60%. 
  
 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 semi-annual measurements of
performance, if an MCP is again determined to be noncompliant with the standard, ODJFS will impose a monetary sanction (see Section 5) of 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. Assessment of Newly-Enrolled Children 
  
 Measure: The adjusted percentage of newly-enrolled children 6 months and over and under 21 years of age with a positive identification that are assessed within 120 days of the effective date of enrollment, of those members expected
to be assessed. 
  
 Report Period: For the SFY 2005 contract period,
performance will be evaluated using the January - June 2004 and July - December 2004 report periods. For the SFY 2006 contract period, performance will be evaluated using the January - June 2005 and July - December 2005 report periods.

  
 Minimum Performance Standard: A minimum adjusted assessment rate of
85%. 
  
 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 semiannual
measurements of performance, if an MCP is again determined to be noncompliant with the standard, ODJFS will impose a monetary sanction (see Section 5) of one half of one percent of the current months 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. 
  

 Appendix M 
 Page 4

  

 1.b.iii. Case Management of Newly-Enrolled Children 
  
 Measure: The percent of newly-enrolled children 6 months and over and under 21 years
of age that receive case management services. 
  
 Report Period: Rolling
semiannual periods will be used to determine screening and assessment reporting exemptions. 
  
 Minimum Performance Standard: A minimum case management rate of 5.0%. 
  
 Note: There is not a performance standard or penalty for noncompliance for this measure. This measure will be used to determine whether MCPs are required to submit screening and assessment files and if measures
pertaining to the screening and assessment of new members will be applied (see Section 1. b.). 
  
 1.b.iv. Case Management of Children 
  
 Measure: The average monthly case management rate for children 6 months and over and under 21 years of age. 
  
 Report Period: The July - December 2003 report period will set the baseline level of performance for the January - June 2004 report period. For the SFY 2005
contract period, performance will be evaluated using the January - June 2004 and July - December 2004 report periods. For the SFY 2006 contract period, performance will be evaluated using the January - June 2005, and July - December 2005 report
periods. 
  
 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 periods 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 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 semiannual measurements of
performance, if an MCP is again determined to be noncompliant with the standard, ODJFS will impose a monetary sanction (see Section 5) of one half of one percent of the current months 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. 
  

 Appendix M 
 Page 5

  

 1.b.v. Case Management of Children with an ODJFS-Mandated Condition 
  
 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: The January - March 2004 report period will set the baseline level of performance for the July - September 2004 report period. For the SFY 2005
contract period, performance will be evaluated using the July - September 2004 and January - March 2005 report periods. For the SFY 2006 contract period, performance will be evaluated using the July - September 2005 and January - March 2006
reporting 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 teen pregnancy that are case managed. 
  
 Report Period: The January - June, 2004 report period will set the baseline level of performance for the July - December 2004 report
period. For the SFY 2005 contract period, performance will be evaluated using the July - December 2004 report period. For the SFY 2006 contract period, performance will be evaluated using the January - June 2005 and July - December 2005 reporting
periods. 
  
 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: The January - March, 2004 report period will set the baseline level of performance for the July - September 2004
report period. For the SFY 2005 contract period, performance will be evaluated using the July - September, 2004 and January - March 2005 report periods. For 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 periods 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 6

  

 Penalty for Noncompliance: The first time an MCP is noncompliant with the standard for measures 1 or 2, 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 measures 1 or 2, ODJFS will impose a monetary sanction (see Section 5) of one half of one percent of the current months 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 both SFY 2005 and 2006, 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 2002 results (the baseline period) and calendar year 2003 results. The methods will be updated and a new baseline will be created during 2004 for
calendar year 2003 results. These results will then serve as the baseline to evaluate whether improvement occurred from calendar year 2003 to calendar year 2004. For a comprehensive description of the clinical performance measures below, see
ODJFS Methods for Clinical Performance Measures. 
  
 Report Period:
For the SFY 2004 contract period, performance will be evaluated using the January - December 2003 report period for the clinical performance measures. For the SFY 2005 contract period, performance will be evaluated using the January - December
2004 report period. For the SFY 2006 contract period, performance will be evaluated using the January - December 2005 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 7

  

 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. 
  

 Appendix M 
 Page 8

  

 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. 
  
 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. 
  

 Appendix M 
 Page 9

  

 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. 
  
 Target: 80% 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 53%, 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 53%, 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. 
  

 Appendix M 
 Page 10

  

 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. 
  
 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. 
  
 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. 
  
 Report Period: For the SFY 2004 contract period, performance will be evaluated using the January - December 2003 report period For the SFY 2005 contract period, performance will be evaluated using the January -
December 2004 report period. For the SFY 2006 contract period, performance will be evaluated using the January - December 2005 report period. 
  
 Minimum Performance Standard: A maximum PCP Turnover rate of 18 percent. 
  

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. 
  

 Appendix M 
 Page 11

  

 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. 
  
 Report Period: For the SFY 2004 contract period,
performance will be evaluated using the January - December 2003 report period. For the SFY 2005 contract period, performance will be evaluated using the January - December 2004 report period. For the SFY 2006 contract period, performance will be
evaluated using the January - December 2005 report period. 
  
 Minimum
Performance Standards: 
  
 SFY 2004 contract period - 70% of the children
must receive a visit. 
 SFY 2005 contract period - 70% 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. 
  
 Report Period:
For the SFY 2004 contract period, performance will be evaluated using the January - December 2003 report period. For the SFY 2005 contract period, performance will be evaluated using the January - December 2004 report period. For the SFY 2006
contract period, performance will be evaluated using the January - December 2005 report period. 
  
 Mininum Performance Standards: 
  
 SFY
2004 contract period - 65% of the adults must receive a visit. 
 SFY 2005 contract period - 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. 
  

 Appendix M 
 Page 12

  

 3. CONSUMER SATISFACTION 
  
 In accordance with federal requirements and in the interest of assessing enrollee satisfaction with MCP performance, ODJFS periodically
conducts independent consumer satisfaction surveys. Results are used to assist in identifying and correcting MCP performance overall and in the areas of access, quality of care, and member services. Performance in this category will be determined by
the overall satisfaction score. For a comprehensive description of the Consumer Satisfaction performance measure below, see ODJFS Methods for Consumer Satisfaction Performance Measures. 
  
 Measure: Overall Satisfaction with MCP: The average rating of the respondents to the
Consumer Satisfaction Survey who were asked to rate their overall satisfaction with their MCP. The results of this measure are reported annually. 
  
 Report Period: For the SFY 2005 contract period, performance will be evaluated using the results from the most recent consumer satisfaction survey completed prior
to the end of the SFY 2005. 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. 
  
 Minimum Performance Standard: An average score of no less than 7.0. 
  
 Penalty for noncompliance: If an MCP is determined noncompliant with the Minimum
Performance Standard, then the MCP must develop a corrective action plan and provider agreement renewals may be affected. 
  
 4. ADMINISTRATIVE CAPACITY 
  
 The ability of an MCP to meet administrative requirements has been found to be both an indicator of current plan performance and a predictor of future performance.
Deficiencies in administrative capacity make the accurate assessment of performance in other categories difficult, with findings uncertain. Performance in this category will be determined by the Compliance Assessment System, and the emergency
department diversion program. For a comprehensive description of the Administrative Capacity performance measures below, see ODJFS Methods for Administrative Capacity Performance Measures. 
  
 4.a. Compliance Assessment System 
  
 Measure: The number of points accumulated for one contract year (one state fiscal
year) through the Compliance Assessment System. 
  
 Report Period: For the
SFY 2004 contract period, performance will be evaluated using the July 2003 - June 2004 report period. For the SFY 2005 contract period, performance will be evaluated using the July 2004 - June 2005 report period. 
  
 Minimum Performance Standard: No more than 25 points 
  

 Appendix M 
 Page 13

  

 Penalty for Noncompliance: Penalties for points are established in Appendix N, Compliance Assessment
System. 
  
 4.b. Emergency Department Diversion 
  
 Managed care plans must provide access to services in a way that assures access to primary
and urgent care in the most effective settings and minimizes inappropriate utilization of emergency department (ED) services. MCPs are required to identify high utilizers of 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. 
  
 Report Period: For the
SFY 2005 contract period, a baseline level of performance will be set using the January - June 2004 report period. Results will be calculated for the reporting period of July-December 2004 and compared to the baseline results to determine if the
minimum performance standard is met. 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. 
  
 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. 
  

 Appendix M 
 Page 14

  

 Refundable monetary sanctions will be based on the capitation payment in the month of the cited deficiency and due
within 30 days of notification by ODJFS to the MCP of the amount. Any monies collected through the imposition of such a sanction would be returned to the MCP (minus any applicable collection fees owed to the Attorney General=s Office, if the MCP has been delinquent in submitting payment) after they have demonstrated improved performance in accordance
with this appendix. If an MCP does not comply within two years of the date of notification of noncompliance, then the monies will not be refunded. 
  
 5.c. Combined Remedies 
  
 If ODJFS determines that one systemic problem is responsible for multiple deficiencies, ODJFS may impose a combined remedy which will address all areas of deficient performance. The total fines assessed in any one
month will not exceed 15% of the MCP=s monthly capitation. 
  
 5.d. Enrollment Freezes 
  
 MCPs found to have a pattern of repeated or ongoing noncompliance may be subject to an enrollment freeze. 
  
 5.e. Reconsideration 
  
 Requests for reconsideration of monetary sanctions and enrollment freezes may be submitted as provided in Appendix N, Compliance
Assessment System. 
  
 5.f. Contract Termination, Nonrenewals or Denials

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

  

 APPENDIX N 
  

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

 Appendix N 
 Page 2

  

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

					
	 Examples:
	  	–	  	 Use of unapproved/unapprovable marketing materials.

	 	  	–	  	 Failure to attend a required meeting.

	 	  	–	  	 Second failure to meet a call center standard.

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

					
	 Examples:
	  	–	  	 24-hour call-in system is not staffed by medical personnel.

	 	  	–	  	Failure to notify a member of their right to a state hearing when the MCP proposes to deny, reduce, suspend or terminate a Medicaid-covered service.
	 	  	–	  	 Failure to appropriately notify ODJFS of provider panel terminations.

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

					
	 Examples:
	  	–	  	 Failure to comply with the minimum provider panel requirements specified in Appendix H.

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

	 	  	–	  	 Failure to meet the electronic claims adjudication requirements.

  
 Failure to submit or comply with CAPs
will be assessed occurrences or points based on the nature of the violation under correction. 
  

 Appendix N 
 Page 3

  

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

 Appendix N 
 Page 4

  

 If an MCP determines that they will be unable to meet a program deadline, the MCP must verbally inform the designated
ODJFS contact person (or their supervisor) of such and submit a written request (by facsimile transmission) for an extension of the deadline by no later than 3 PM on the date of the deadline in question. Extension requests should only be submitted
in situations where unforeseeable circumstances have arisen which make it impossible for the MCP to meet an ODJFS-stipulated deadline. Only written approval by ODJFS of a deadline extension will preclude the assessment of a CAP, occurrence or points
for untimely submissions. 
  
 No points or occurrences will be assigned for any
violation where an MCP is able to document that the precipitating circumstances were completely beyond their control and could not have been foreseen (e.g., a construction crew severs a phone line, a lightning strike blows a computer system, etc.).

  
 ODJFS will not issue a 10-point violation for failure to meet minimum provider
panel requirements if the MCP notifies ODJFS that they will voluntarily amend their provider agreement to cease providing services to Medicaid eligibles in the county in question. 
  
 REMEDIES 
  

Progressive remedies will be based on the number of points accumulated at the time of the most recent incident. Unless otherwise indicated in this appendix, all fines
issued under the CAS are nonrefundable. 
  

			
		
	 1-9 Points
	 	 Corrective Action Plan (CAP)

		
	 10-19 Points
	 	 CAP + $2500 fine

		
	 20-29 Points
	 	 CAP + $5000 fine

		
	 30-39 Points
	 	 CAP + $10,000 fine

		
	 40-69 Points
	 	 CAP + $15,000 fine

		
	 70+ Points
	 	 Proposed Contract Termination

  

 Appendix N 
 Page 5

  

 New Member Selection Freezes: 
  
 ODJFS may prohibit an MCP from receiving new membership through voluntary selections or the
assignment process (selection freeze) in one or more counties if : (1) the MCP has accumulated a total of 20 or more points during the accrual period; (2) the MCP fails to fully implement a CAP within the designated time frame; or (3) circumstances
exist which potentially jeopardize the MCP’s members’ access to care. Examples of circumstances that ODJFS may consider as jeopardizing member access to care include: 
  

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

  

	 	•	the MCP has been found by ODJFS to be out of compliance with the provider panel requirements specified in Appendix H; 

  

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

  

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

  
 Reduction of Assignments 
  
 ODJFS may reduce the number of assignments an MCP receives if ODJFS determines that the MCP
lacks sufficient administrative capacity to meet the needs of the increased volume in membership. Examples of circumstances which ODJFS may determine demonstrate a lack of sufficient administrative capacity include, but are not limited to an
MCP’s failing to: repeatedly provide new member materials by the member’s effective date; meet the minimum call center requirements; meet the minimum performance standards for identifying and assessing children with special health care
needs and members needing case management services; and/or provide complete and accurate appeal/grievance, designated PCP and SACMS data files. 
  
 Noncompliance with Claims Adjudication Requirements: 
  
 In lieu of a nonrefundable fine, ODJFS will instead impose 10 points and a refundable fine equal to 5% of an MCP’s monthly premium
payment or $300,000, whichever is less, if ODJFS finds the MCP to be out of compliance with any of the claims adjudication requirements specified in Appendix C. 
  

 Appendix N 
 Page 6

  

 Noncompliance with Prompt Payment: 
  
 Noncompliance with prompt pay requirements as specified by ODJFS will result in progressive
penalties with penalties to be assessed on a quarterly basis. The first violation during the contract term will result in the assessment of 5 points and submission of monthly status reports to ODJFS until the next quarterly report is due. The second
and any subsequent violation during the contract term will result in the submission of monthly status reports, assessment of 10 points and a refundable fine equal to 5% of the MCP’s monthly premium payment or $300,000, whichever is less. The
refundable fine will be applied in lieu of a nonrefundable fine and the money will be refunded by ODJFS only after the MCP complies with the required standards for two consecutive quarters. 
  
 If an MCP is found to have not been in compliance with the prompt pay requirements for any
time period for which a report and signed attestation have been submitted representing the MCP as being in compliance, the MCP will be subject to a selection freeze of not less than three months duration. 
  
 Noncompliance with Clinical Laboratory Improvement
Amendments: 
  
 Noncompliance with CLIA requirements as specified by ODJFS
will result in the assessment of a nonrefundable $1,000 fine for each documented violation. 
  
 Noncompliance with Encounter Data Submissions: 
  
 Submission of unpaid encounters (except for immunization services as specified in Appendix L) will result in the assessment of a
nonrefundable $1,000 fine for each documented violation. 
  
 Noncompliance with Abortion and Sterilization Payment 
  
 Noncompliance with abortion and sterilization requirements as specified by ODJFS will result in the assessment of a nonrefundable $1,000 fine for each documented violation. Additionally, MCPs must take all appropriate
action to correct each such ODJFS-documented violation. 
  
 Refusal to Comply with Program Requirements 
  
 If ODJFS has instructed an MCP that they must comply with a specific program requirement and the MCP refuses, ODJFS will consider this to mean that the MCP is no longer operating in the best interests of the MCP’s members or the state
of Ohio and will move to terminate or nonrenew the MCP’s provider agreement pursuant to OAC rule 5101:3-26-10(G). 
  

 Appendix N 
 Page 7

  

 General Provisions: 
  
 All notifications of the imposition of a fine or freeze will be made via certified or
overnight mail to the identified MCP Medicaid Coordinator. 
  
 Pursuant to
procedures specified by ODJFS, refundable and nonrefundable monetary sanctions/assurances must be remitted to ODJFS within thirty days of receipt of the invoice by the MCP. In addition, per Ohio Revised Code Section 131.02, payments not received
within forty-five days will be certified to the Attorney General’s (AG’s) office. MCP payments certified to the AG’s office will be assessed the appropriate collection fee by the AG’s office. 
  
 Refundable monetary sanctions/assurances applied by ODJFS will be based on the premium
payment for the month in which the MCP was cited for the deficiency. Any monies collected through the imposition of such a fine would be returned to the MCP (minus any applicable collection fees owed to the Attorney General’s Office if the MCP
has been delinquent in submitting payment) after they have demonstrated full compliance with the particular program requirement. 
  
 If an MCP does not comply within two years of the date of notification of noncompliance, then the monies will not be refunded. 
  
 If ODJFS determines that one systemic problem is responsible for multiple areas of
noncompliance, ODJFS may impose a combined remedy which will address all areas of noncompliance. 
  
 Again, ODJFS can at any time move to terminate, amend or deny renewal of a provider agreement pursuant to the provisions of OAC rule 5101:3-26-10. 
  
 Upon termination, nonrenewal or denial of an MCP provider agreement, all previously collected monetary sanctions will be retained by ODJFS.

  
 In addition to the remedies imposed under the CAS, remedies related to areas
of data quality and financial performance may also be imposed pursuant to Appendices J, L, and M respectively. 
  
 If ODJFS determines that an MCP has violated any of the requirements of sections 1903(m) or 1932 of the Social Security Act which are not specifically identified within the CAS, the ODJFS may, pursuant to the
provisions of OAC rule 5101:3-26-10(A): (1) notify the MCP’s members that they may terminate from the MCP without cause; and/or (2) suspend any further new member selections. 
  

 Appendix N 
 Page 8

  

 RECONSIDERATIONS 
  
 Requests for reconsiderations of remedial action taken under the CAS may be submitted as
follows: 
  

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

  

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

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

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

  

 Appendix N 
 Page 9

  

 POINT COMPLIANCE SYSTEM - POINT VALUES 
  
 OCCURRENCES: Failures to meet program requirements, including but not limited
to, noncompliance with administrative requirements. Examples are: 
  

	•	Unapproved use of marketing/member materials. 

  

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

  

	•	Failure to maintain ODJFS-required documentation. 

  

	•	Use 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 the OAC rules or provider agreement 

  

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

  

 Appendix N 
 Page 10

  

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

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

  

	•	Any violation of an member’s rights. 

  

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

  

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

  

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

  

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

  

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

  

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

  

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

  

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

  

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

  

 Appendix N 
 Page 11

  

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

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

  

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

  

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

  

	•	Failure to process prior authorization requests 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) 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 
  

PERFORMANCE INCENTIVES 
  
 This Appendix establishes incentives for managed care plans (MCPs) to improve performance in specific areas important to the Medicaid MCP members. Incentives include the
at-risk amount included with the monthly premium payments (see Appendix F, Rate Chart), and possible additional monetary rewards up to $250,000. To qualify for consideration of any incentives, MCPs must meet minimum performance standards
established in Appendix M, Performance Evaluation on selected measures, and achieve a minimum level of performance on the Clinical Performance Measures. For qualifying MCPs, higher performance standards for selected measures must be reached
to be awarded a portion of the at-risk amount or additional incentives (see Sections 1 and 2). 
  
 The amount of incentives will be based on an MCP’s performance on three measures. An excellent and superior standard is set in this Appendix for each of the three measures. If an MCP qualifies for incentives,
they will be awarded a portion of the at-risk amount for each excellent standard met. If an MCP meets all three excellent and superior standards, they may be awarded additional incentives (see Section 3). Incentives will be determined within six
months after the end of the contract period. 
  
 1. SFY 2004 Incentives

  
 1.a. Qualifying Performance Levels 
  
 To qualify for consideration of the SFY 2004 incentives, an MCP’s performance level
must 
  

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

  

	 	2)	meet the incentive standards established for the Clinical Performance Measures below. A detailed description of the methodologies of each measure can be found on the internet at
www.jfs.ohio.gov/ohp/bmhc/managed.stm 

  
 Measures for which
the minimum performance standard for SFY 2004 established in Appendix M, Performance Evaluation, must be met to qualify for consideration of incentives are the following: 
  
 1. Independent External Quality Review (Appendix M, Section 1.a. - Minimum Performance Standard 2) 
  
 Report Period: The most recent Independent External Quality Review
completed prior to the end of the SFY 2004 contract period. 
  

 Appendix O 
 Page 2

  

 2. PCP Turnover (Appendix M, Section 2.a.) 
  
 Report Period: CY 2003 
  
 3. Children’s Access to Primary Care (Appendix M, Section 2.b.) 
  
 Report Period: CY 2003 
  
 4. Adults’ Access to Preventive/Ambulatory Health Services (Appendix M, Section 2.c.) 
  
 Report Period: CY 2003 
  
 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 2005 contract period. 
  
 6. Emergency
Department Diversion Program (Appendix M, Section 4.b.) 
  
 Report Period: July - December 2003 
  
 For each clinical
performance measure listed below, the MCP must meet the incentive standard to be considered for SFY 2005 incentives. The MCP meets the incentive standard if one of two criteria are met. The incentive standard is a performance level of either:

  
 1) The minimum performance standard established in Appendix M, Performance
Evaluation, for seven of the nine clinical performance measures listed below; OR 
  
 2) The Medicaid benchmarks for seven of the nine clinical performance measures are 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 - Low Birth Weight
	  	7.6	%
	 4. Perinatal Care - Postpartum Care
	  	48	%
	 5. Well-Child Visits - Children who turn 15 months old
	  	34	%
	 6. Well-Child Visits - 3, 4, 5, or 6, years old
	  	50	%
	 7. Well-Child Visits - 12 through 21 years old
	  	30	%
	 8. Use of Appropriate Medications for People with Asthma
	  	54	%
	 9. Annual Dental Visits
	  	40	%

  

 Appendix O 
 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 incentives that may be awarded. Excellent and Superior standards are set for the three measures described below. A brief description of these measures are described in Appendix M, Performance Evaluation.
A detailed description of the methodologies of each measure can be found on the internet at www.jfs.ohio.gov/ohp/bmhc/managed.stm. 
  
 1. Case Management of Children (Appendix M, Section 1.b.iv.) 
  
 Report Period: January – June, 2004 
  
 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 2003 
  
 Excellent Standard: 54% 
  
 Superior Standard: 62% 
  
 3. Adults’ Access to Preventive/Ambulatory Health Services (Appendix M, Section 2.c.) 
  
 Report Period: CY 2003 
  
 Excellent Standard: 72.8% 
  
 Superior Standard: 81.9% 
  
 1.c. Determining SFY 2004 Incentives 
  
 MCP’s reaching the minimum performance standards described in Section 1.a will be considered for incentives including retention of the at-risk amount and any
additional incentives. For each Excellent standard established in Section 1.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 1.b. of this
Appendix, additional incentives may be awarded. For MCPs receiving additional incentives, the amount in the incentive fund (see Section 3) will be divided equally, up to the maximum amount, among all MCPs receiving additional incentives. 

 
 The maximum amount to be awarded to a single plan in incentives additional to the at-risk
amount is $250,000 per contract year. 
  

 Appendix O 
 Page 4

  

 2. SFY 2005 Incentives 
  
 2.a. Qualifying Performance Levels 
  
 To qualify for consideration of the SFY 2005 incentives, an MCP’ s performance level must: 
  
 1.) meet the minimum performance standards set in Appendix M, Performance Evaluation, for the measures listed below;
and 
  
 2.) meet the incentive standards established for
the Emergency Department Diversion and Clinical Performance Measures below. 
  
 A
detailed description of the methodologies of each measure can be found on the internet at www.jfs.ohio.gov/ohp/bmhc/managed.stm 
  
 Measures for which the minimum performance standard for SFY 2005 established in Appendix M, Performance Evaluation, must be met to qualify for consideration of
incentives are the following: 
  
 1. Independent External Quality Review (Appendix
M. Section 1.a.–Minimum Performance Standard 2) 
  
 Report Period: The most recent Independent External Quality Review completed prior to the end of the SFY 2005 contract period. 
  
 2. PCP Turnover (Appendix M, Section 2.a.) 
  
 Report Period: CY 2004 
  
 3. Children’s Access to Primary Care (Appendix M. Section 2.b) 
  
 Report Period: CY 2004 
  
 4. Adults’ Access to Preventive/Ambulatory Health Services (Appendix M, Section 2.c.) 
  
 Report Period: CY2004 
  
 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 2005 contract period. 
  

 Appendix O 
 Page 5

  

 For the EDD performance measure, the MCP must meet the incentive standard for the report period of
July—December, 2004 to be considered for SFY 2005 incentives. The MCP meets the incentive standard if one of two criteria are met. The incentive standard is a performance level of either: 
  
 1) The minimum performance standard established in Appendix M, Section 4.b.; OR 

 
 2) The Medicaid benchmark of a performance level at or below 1.1%. 
  
 For each clinical performance measure listed below, the MCP must meet the incentive standard
to be considered for SFY 2005 incentives. The MCP meets the incentive standard if one of two criteria are met. The incentive standard is a performance level of either: 
  
 1) The minimum performance standard established in Appendix M, Performance Evaluation, for seven of the nine clinical performance
measures listed below; OR 
  
 2) The Medicaid benchmarks for seven of the nine
clinical performance measures are 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
	  	53	%
	 8. Annual Dental Visits
	  	40	%
	 9. Blood Lead – 1 year olds
	  	45	%

  
 2.b. Excellent and Superior
Performance Levels 
  
 For qualifying MCPs as determined by Section 2.a.,
performance will be evaluated on the measures below to determine the status of the at-risk amount or any additional incentives that may be awarded. Excellent and Superior standards are set for the three measures described below. 
  
 A brief description of these measures are described in Appendix M, Performance Evaluation.
A detailed description of the methodologies of each measure can be found on the internet at www.jfs.ohio.gov/ohp/bmhc/managed.stm 
  
 1. Case Management of Children (Appendix M, Section 1.b.iv.)  
  
 Report Period: July - December 2004  
  
 Excellent Standard: 2.5%  
  
 Superior Standard: 3.8% 
  

 Appendix O 
 Page 6

  

 2. Use of Appropriate Medications for People with Asthma (Appendix M, Section 1.c.vi.) 
  
 Report Period: CY 2004 
  
 Excellent Standard: 53% 
  
 Superior Standard: 61% 
  
 3. Adults’ Access to Preventive/Ambulatory Health Services (Appendix M, Section 2.c.)

  
 Report Period: CY 2004 
  
 Excellent Standard: 76% 
  
 Superior Standard: 83% 
  
 2.c. Determining SFY 2005 Incentives 
  
 MCP’s reaching the minimum performance standards described in Section 2.a. will be
considered for incentives including retention of the at-risk amount and any additional incentives. For each Excellent standard established in Section 2.b. that an MCP meets, one-third of the at-risk amount may be retained. For MCPs meeting all of
the Excellent and Superior standards established in Section 2.b. of this Appendix, additional incentives may be awarded. For MCPs receiving additional incentives, the amount in the incentive fund (see section 3) will be divided equally, up to the
maximum amount, among all MCPs receiving additional incentives. The maximum amount to be awarded to a single plan in incentives additional to the at-risk amount is $250,000 per contract year. 
  
 3. NOTES 
  
 3.a. Status Determination of the At-Risk Amount and Additional Incentive Payments 
  
 Determination of the status of each MCP’s at-risk amount will occur within six months
of the end of the contract period. For MCPs in their first two years of Ohio Medicaid 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 contract year (see Appendix F, Rate Chart). However, MCPs in their first contract year are not eligible for the additional incentive amount awarded for superior performance. 
  
 Incentive payments are issued from a specific account funded by monetary sanctions imposed on MCPs and the return of the at-risk amount. If
this fund is not accessed because overall performance levels are not at the superior level for any one MCP, then it may roll over to the next year’s fund. Determination of additional incentive payments will be made within six months of the end
of the contract period. 
  

 Appendix O 
 Page 7

  

 3.b. 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. 
  
 3.c. 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 
  
 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. 
  
 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 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 5 PM on the
third working day following receipt of the ODJFS notification. (For example, if ODJFS notification is received on August 6 the MCP’s request for reconsideration must be delivered to the Deputy Director by no later than 5 PM on August 9.) The address and fax number to be used in making these requests will be specified in the ODJFS notification document.

  

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

  

 Appendix P 
 Page 3

  

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

  

	$	The proposed MCP membership termination will not occur while an appeal is under review and pending the Deputy Director’s decision. If the Deputy Director denies the appeal, the MCP membership termination will proceed at the first possible effective date. The date may be
retroactive if the ODJFS determines that it would be in the best interest of the members.Contract for Medicaid and Badger Care HMO Services

 MAY 2004 – DECEMBER 2005 
  
 Contract for Medicaid and BadgerCare HMO Services 
  
 Between 
  
 HMO 
  
 And 
  
 Wisconsin Department of 
 Health and Family Services 
  
 [GRAPHIC] 
  

 TABLE OF CONTENTS 
  

									
	 	 	 	 	 	 	 	  	Page No.

	 ARTICLE I – DEFINITIONS
	  	1
		
	 ARTICLE II – DELEGATIONS OF AUTHORITY
	  	8
		
	 ARTICLE III – FUNCTIONS AND DUTIES OF THE HMO
	  	8
			
	 A.
	 	Statutory Requirement	  	8
			
	 B.
	 	Compliance with Applicable Law	  	8
			
	 C.
	 	Organizational Responsibilities and Duties	  	9
	 	 	 1.
	 	 Ineligible Organizations
	  	9
	 	 	 2.
	 	 Contract Representative
	  	11
	 	 	 3.
	 	 Attestation
	  	11
	 	 	 4.
	 	 Affirmative Action (AA), Equal Opportunity, Civil Rights Compliance (CRC) and Language Access
	  	11
	 	 	 5.
	 	 Non-Discrimination in Employment
	  	15
	 	 	 6.
	 	 Provision of Services to all HMO Members
	  	16
	 	 	 7.
	 	 Access to Premises
	  	16
	 	 	 8.
	 	 Liability for the Provision of Care
	  	17
	 	 	 9.
	 	 Subcontracts
	  	17
	 	 	 10.
	 	 Coordination with:
	  	17
	 	 	 	 	 a.
	 	 Community-Based Health Organizations
	  	17
	 	 	 	 	 b.
	 	 Local Health Departments
	  	18
	 	 	 	 	 c.
	 	 Bureau of Milwaukee Child Welfare
	  	18
	 	 	 	 	 d.
	 	 Prenatal Care Coordination (PNCC) Agencies
	  	19
	 	 	 	 	 e.
	 	 School-Based Services (SBS) Providers
	  	19
	 	 	 	 	 f.
	 	 Targeted Case Management (TMC) Agencies
	  	19
	 	 	 11.
	 	 Clinical Laboratory Improvement Amendments (CLIA)
	  	19
			
	 D.
	 	Payment Requirements/Procedures	  	20
	 	 	 1.
	 	 Claims Retrieval
	  	20
	 	 	 2.
	 	 Thirty Day Payment Requirement
	  	20
	 	 	 3.
	 	 Payment to a Non-HMO Provider for Services Provided to a Disabled Participant Less Than Three or for Services Ordered by the
Courts
	  	21
	 	 	 4.
	 	 Payment of HMO Referrals to Out-of-Area or Non-Affiliated Providers
	  	21
	 	 	 5.
	 	 Health Professional Shortage Area (HPSA) Payment Provision
	  	21
	 	 	 6.
	 	 Payment of Physician Services to Pregnant Women and Children Under Age 19
	  	22
	 	 	 7.
	 	 Federally Qualified Health Centers (FQHC) and Rural Health Centers (RHC)
	  	22

  

 -i- 

									
	 	 	 	 	 	 	 	  	Page No.

	 	 	 8.
	 	 Immunization Program
	  	22
	 	 	 9.
	 	 Transplants
	  	22
	 	 	 10.
	 	 Hospitalization at the Time of Enrollment or Disenrollment
	  	23
	 	 	 11.
	 	 Enrollees living in a public institution
	  	24
			
	 E.
	 	 Covered Medicaid Services
	  	24
	 	 	 1.
	 	 Provision of Contract Services
	  	24
	 	 	 2.
	 	 Medical Necessity
	  	25
	 	 	 3.
	 	 Required Services Under Wis. Stats., and Wis. Adm. Code
	  	25
	 	 	 4.
	 	 Pre-Existing Medical Conditions
	  	25
	 	 	 5.
	 	 Ambulance Services
	  	26
	 	 	 6.
	 	 Chiropractic Services
	  	26
	 	 	 7.
	 	 Common Carrier Transportation
	  	26
	 	 	 8.
	 	 Dental Services
	  	27
	 	 	 9.
	 	 Emergency and Post-Stabilization Services
	  	30
	 	 	 	 	 a.
	 	 24-Hour Coverage
	  	30
	 	 	 	 	 b.
	 	 Provision/Payment Requirements
	  	31
	 	 	 	 	 c.
	 	 Memoranda of Understanding (MOU) or Contract with Hospitals/Urgent Care Centers for the Provision of Emergency Services
	  	31
	 	 	 10.
	 	 Family Planning Services and Confidentiality of Family Planning Information
	  	32
	 	 	 11.
	 	 Fertility Drugs
	  	32
	 	 	 12.
	 	 Prenatal Care Coordination (PNCC) Agencies
	  	32
	 	 	 13.
	 	 School-Based Services (SBS)
	  	33
	 	 	 14.
	 	 Targeted Case Management (TCM) Services
	  	33
			
	 F.
	 	 Mental Health and Substance Abuse Coverage Requirements/Coordination of Services with Community Agencies
	  	33
	 	 	 1.
	 	 Conditions on Coverage of Mental Health/Substance Abuse Treatment
	  	33
	 	 	 2.
	 	 Mental Health/Substance Abuse Assessment Requirements
	  	34
	 	 	 3.
	 	 Assurance of Expertise for Child Abuse, Child Neglect and Domestic Violence
	  	35
	 	 	 4.
	 	 Court-Related Children’s Services
	  	35
	 	 	 5.
	 	 Court-Related Substance Abuse Services
	  	36
	 	 	 6.
	 	 Crisis Intervention Benefit
 Emergency Detention and Court-Related Mental Health Services
	  	36
	 	 	 7.
	 	  	36
	 	 	 8.
	 	 Institutionalized Individuals
	  	38
	 	 	 9.
	 	 Transportation Following Emergency Detention
	  	38
	 	 	 10.
	 	 Mental Health and/or Substance Abuse Exemptions
	  	38
	 	 	 11.
	 	 Memoranda of Understanding (MOU)/Contract Requirement and Relations with other Human Service Agencies
	  	39
			
	 G.
	 	 Provider Appeals
	  	39
			
	 H.
	 	 Provider Network and Access Requirements
	  	41
	 	 	 1.
	 	 Use of Medicaid Certified Providers
	  	41

  

 -ii- 

									
	 	 	 	 	 	 	 	  	Page No.

	 	 	 2.
	 	 Protocols/Standards to Ensure Access
	  	41
	 	 	 3.
	 	 Written Standards for Accessibility of Care
	  	41
	 	 	 4.
	 	 Access to Selected Medicaid Providers and/or Covered Services
	  	42
	 	 	 	 	 a.
	 	 Dental Providers
	  	42
	 	 	 	 	 b.
	 	 Mental Health or Substance Abuse Providers
	  	42
	 	 	 	 	c.	 	 High Risk Prenatal Care Services
	  	42
	 	 	 	 	d.	 	 HMO Referrals to Out-of-Network Providers for Services
	  	42
	 	 	 	 	e.	 	 Primary Care Providers
	  	42
	 	 	 	 	f.	 	 Second Medical Opinions
	  	43
	 	 	 	 	g.	 	 Women’s Health Specialists
	  	43
	 	 	 5.
	 	 Network Adequacy Requirements
	  	43
			
	 I.
	 	 Responsibilities to Enrollees
	  	44
	 	 	 1.
	 	 Advocate Requirements
	  	44
	 	 	 2.
	 	 Advance Directives
	  	47
	 	 	 3.
	 	 Choice of Health Care Professional
	  	48
	 	 	 4.
	 	 Coordination and Continuation of Care
	  	48
	 	 	 5.
	 	 Conversion Privileges
	  	49
	 	 	 6.
	 	 Cultural Competency
	  	49
	 	 	 7.
	 	 Enrollee Handbook, Education and Outreach for Newly Enrolled Recipients
	  	49
	 	 	 8.
	 	 Health Education and Disease Prevention
	  	51
	 	 	 9.
	 	 Interpreter Services
	  	53
			
	 J.
	 	 Prohibitions to Billing Enrollees
	  	54
			
	 K.
	 	 HealthCheck
	  	54
			
	 L.
	 	 Marketing Plans and Informing Materials
	  	56
	 	 	 1.
	 	 Approval of Marketing and Informing Materials
	  	57
	 	 	 2.
	 	 Prohibited Practices
	  	58
	 	 	 3.
	 	 HMOs Agreement to Abide by Marketing/Informing Criteria
	  	58
			
	 M.
	 	 Reproduction/Distribution of Materials
	  	58
			
	 N.
	 	 HMO ID Cards
	  	59
			
	 O.
	 	 Open Enrollment
	  	59
			
	 P.
	 	 Selective Reporting Requirements
	  	59
	 	 	 1.
	 	 Communicable Disease Reporting
	  	59
	 	 	 2.
	 	 Fraud and Abuse Investigations
	  	59
	 	 	 3.
	 	 Physician Incentive Plans
	  	60
		
	 ARTICLE IV – QUALITY ASSESSMENT/PERFORMANCE IMPROVEMENT (QAPI)
	  	60
			
	 A.
	 	 QAPI Program
	  	60
			
	 B.
	 	 Monitoring and Evaluation
	  	63
			
	 C.
	 	 Health Promotion and Disease Prevention Services
	  	64

  

 -iii- 

									
	 	 	 	 	 	 	 	  	Page No.

			
	 D.
	 	 Provider Selection (Credentialing) and Periodic Evaluation (Recredentialing)
	  	64
			
	 E.
	 	 Enrollee Feedback on Quality Improvement
	  	66
			
	 F.
	 	 Medical Records
	  	66
			
	 G.
	 	 Utilization Management (UM)
	  	68
			
	 H.
	 	 External Quality Review Contractor
	  	70
			
	 I.
	 	 Dental Services Quality Improvement (Applies only to HMOs Covering Dental Services)
	  	71
			
	 J.
	 	 Accreditation
	  	71
			
	 K.
	 	 Performance Improvement Priority Areas and Projects
	  	72
		
	 ARTICLE V – FUNCTIONS AND DUTIES OF THE DEPARTMENT
	  	77
			
	 A.
	 	 Eligibility Determination
	  	77
			
	 B.
	 	 Enrollment
	  	78
			
	 C.
	 	 Disenrollment
	  	78
			
	 D.
	 	 Enrollment Errors
	  	78
			
	 E.
	 	 HMO Enrollment Reports
	  	79
			
	 F.
	 	 Utilization Review and Control
	  	79
			
	 G.
	 	 HMO Review
	  	79
			
	 H.
	 	 Department Audit Schedule
	  	79
			
	 I.
	 	 HMO Review of Study or Audit Results
	  	80
			
	 J.
	 	 Vaccines
	  	80
			
	 K.
	 	 Coordination of Benefits
	  	80
			
	 L.
	 	 Wisconsin Medicaid Provider Reports
	  	80
			
	 M.
	 	 Enrollee Health Status and Primary Language Report
	  	80
			
	 N.
	 	 Fraud and Abuse Training
	  	80
			
	 O.
	 	 Provision of Data to HMOs
	  	80
			
	 P.
	 	 Special Procedures for Retroactive Payment Adjustments for Pregnant BadgerCare Enrollees
	  	81
		
	 ARTICLE VI – PAYMENT TO THE HMO
	  	81
			
	 A.
	 	 Capitation Rates
	  	81
			
	 B.
	 	 Actuarial Basis
	  	81
			
	 C.
	 	 Annual Negotiation of Capitation Rates
	  	81
			
	 D.
	 	 Reinsurance
	  	82
			
	 E.
	 	 Payment Schedule
	  	82

  

 -iv- 

									
	 	 	 	 	 	 	 	  	Page No.

			
	 F.
	 	 Capitation Payments For Newborns
	  	82
			
	 G.
	 	 Coordination of Benefits (COB)
	  	83
			
	 H.
	 	 Recoupments
	  	85
			
	 I.
	 	 Neonatal Intensive Care Unit (NICU) Risk-Sharing Payment(s)
	  	86
	 	 	 1.
	 	 Coverage Criteria
	  	86
	 	 	 2.
	 	 Reimbursement Criteria
	  	87
	 	 	 3.
	 	 Reporting Requirements
	  	88
			
	 J.
	 	 Payment(s) for AIDS/HIV and Ventilator Dependent Enrollees
	  	89
	 	 	 1.
	 	 Reimbursement Criteria.
	  	89
	 	 	 2.
	 	 Adjustments to Final Payment
	  	90
	 	 	 3.
	 	 Reporting Requirements.
	  	90
	 	 	 4.
	 	 Documentation Requirements
	  	91
	 	 	 5.
	 	 Dispute Resolution
	  	91
		
	 ARTICLE VII – COMPUTER/DATA REPORTING SYSTEM, DATA, RECORDS AND REPORTS
	  	92
			
	 A.
	 	 Access to and/or Disclosure of Financial Records
	  	92
			
	 B.
	 	 Access to and Audit of Contract Records
	  	92
			
	 C.
	 	 Abortions, Hysterectomies and Sterilization Reporting Requirements
	  	92
			
	 D.
	 	 Computer Data Reporting System
	  	93
			
	 E.
	 	 Coordination of Benefits (COB), Encounter Record, Formal Grievances and Birth Cost Reporting Requirements
	  	94
			
	 F.
	 	 Encounter Data Reporting Requirements
	  	95
	 	 	 1.
	 	 Reporting Requirement
	  	95
	 	 	 2.
	 	 Testing Encounter Data
	  	95
	 	 	 3.
	 	 Primary HMO Contact Person
	  	95
	 	 	 4.
	 	 HMO Encounter Technical Workgroup Requirement
	  	96
	 	 	 5.
	 	 Encounter Data Completeness and Accuracy
	  	96
	 	 	 6.
	 	 Analysis of Encounter Data
	  	96
			
	 G.
	 	 Records Retention
	  	96
			
	 H.
	 	 Reporting of Corporate and Other Changes
	  	97
			
	 I.
	 	 Provider List Requirement
	  	97
			
	 J.
	 	 Contract Specified Reports and Due Dates
	  	98
		
	 ARTICLE VIII – ENROLLMENT AND DISENROLLMENTS
	  	103
			
	 A.
	 	 Enrollment
	  	103
			
	 B.
	 	 Enrollment/Disenrollment Practices
	  	104
			
	 C.
	 	 Disenrollment/Exemption Requests
	  	104
	 	 	 1.
	 	 AIDS or HIV-Positive Exemption
	  	105

  

 -v- 

									
	 	 	 	 	 	 	 	  	Page No.

	 	 	 2.
	 	 Developmental Disability or Admission to a Birth to Three Program Exemption
	  	105
	 	 	 3.
	 	 Certified Nurse Midwives or Nurse Practitioners Exemption
	  	105
	 	 	 4.
	 	 Commercial HMO Insurance Exemption
	  	106
	 	 	 5.
	 	 Federally Qualified Health Centers Exemption
	  	106
	 	 	 6.
	 	 Just Cause Disenrollment
	  	106
	 	 	 7.
	 	 Inmates of a Public Institution Disenrollment
	  	107
	 	 	 8.
	 	 Medicare Beneficiaries
	  	107
	 	 	 9.
	 	 Mental Health and/or Substance Abuse Exemption
	  	107
	 	 	 10.
	 	 Native American Disenrollment
	  	108
	 	 	 11.
	 	 Ninth Month Pregnancy Exemption
	  	108
	 	 	 12.
	 	 SSI Exemption and/or Disenrollment
	  	108
	 	 	 13.
	 	 Third Trimester Pregnancy Exemption
	  	109
	 	 	 14.
	 	 Transplant Exemption
	  	109
		
	 ARTICLE IX – GRIEVANCE PROCEDURES
	  	110
			
	 A.
	 	 Procedures
	  	110
			
	 B.
	 	 Formal Grievance Process
	  	112
			
	 C.
	 	 Denial, Termination, Suspension, or Reduction of Benefit Notifications to Enrollees
	  	112
			
	 D.
	 	 Denial of New Benefit Notifications to Enrollees
	  	115
			
	 E.
	 	 Reporting of Grievances to the Department
	  	115
		
	 ARTICLE X – REMEDIES FOR VIOLATION, BREACH, OR NON-PERFORMANCE OF CONTRACT
	  	116
			
	 A.
	 	 Suspension of New Enrollment
	  	116
			
	 B.
	 	 Department-Initiated Enrollment Reductions
	  	116
			
	 C.
	 	 Other Enrollment Reductions
	  	116
			
	 D.
	 	 Withholding of Capitation Payments and Orders to Provide Services
	  	117
			
	 E.
	 	 Inappropriate Payment Denials
	  	120
			
	 F.
	 	 Sanctions
	  	120
			
	 G.
	 	 Sanctions and Remedial Actions
	  	120
		
	 ARTICLE XI – TERMINATION AND MODIFICATION OF CONTRACT
	  	120
			
	 A.
	 	 Termination by Mutual Consent
	  	120
			
	 B.
	 	 Unilateral Termination
	  	121
			
	 C.
	 	 Obligations of Contracting Parties Upon Termination
	  	122
			
	 D.
	 	 Modification
	  	123
		
	 ARTICLE XII – INTERPRETATION OF CONTRACT LANGUAGE
	  	123

  

 -vi- 

									
					
	 	 	 	 	 	 	 	  	Page No.

		
	 ARTICLE XIII – CONFIDENTIALITY OF RECORDS AND HIPAA REQUIREMENTS
	  	123
		
	 ARTICLE XIV – DOCUMENTS CONSTITUTING CONTRACT
	  	126
			
	 A.
	 	 Current Documents
	  	126
			
	 B.
	 	 Future Documents
	  	127
		
	 ARTICLE XV – MISCELLANEOUS
	  	127
			
	 A.
	 	 Indemnification
	  	127
			
	 B.
	 	 Independent Capacity of Contractor
	  	127
			
	 C.
	 	 Omissions
	  	127
			
	 D.
	 	 Choice of Law
	  	127
			
	 E.
	 	 Waiver
	  	128
			
	 F.
	 	 Severability
	  	128
			
	 G.
	 	 Survival
	  	128
			
	 H.
	 	 Force Majeure
	  	128
			
	 I.
	 	 Headings
	  	128
			
	 J.
	 	 Assignability
	  	128
			
	 K.
	 	 Right to Publish
	  	128
		
	 ARTICLE XVI – HMO SPECIFIC CONTRACT TERMS
	  	129
			
	 A.
	 	 Initial Contract Period
	  	129
			
	 B.
	 	 Renewals
	  	129
			
	 C.
	 	 Specific Terms of the Contract
	  	129
		
	 ADDENDUM I – SUBCONTRACTS AND MEMORANDA OF UNDERSTANDING
	  	131
		
	 Part A – Subcontracts
	  	131
			
	 I.
	 	 Subcontracts
	  	131
			
	 II.
	 	 Management Subcontracts
	  	135
			
	 III.
	 	 Disclosure Statements
	  	136
			
	 IV.
	 	 Business Transactions
	  	138
		
	 Part B – Memorandum of Understanding (MOU)
	  	139
			
	 I.
	 	 MOU Submission Requirements
	  	139
			
	 II.
	 	 Emergency Services MOU or Contract
	  	139

  

 -vii- 

									
	 	 	 	 	 	 	 	  	Page No.

			
	 III.
	 	 County and Other Human Service Agencies MOU or Contract Requirements for Services Ordered by the Courts
	  	140
			
	 IV.
	 	 Required MOUs or Contracts
	  	141
		
	 ADDENDUM II – STANDARD ENROLLEE HANDBOOK LANGUAGE
	  	148
		
	 ADDENDUM III – ACTUARIAL BASIS
	  	159
		
	 ADDENDUM IV – GUIDELINES FOR THE COORDINATION OF SERVICES BETWEEN HMOs AND THE BUREAU OF MILWAUKEE CHILD
WELFARE
	  	160
		
	 ADDENDUM V – GUIDELINES FOR THE COORDINATION OF SERVICES BETWEEN MEDICAID HMOS AND COUNTY BIRTH TO THREE
AGENCIES
	  	163
		
	 ADDENDUM VI – LOCAL HEALTH DEPARTMENTS AND COMMUNITY–BASED HEALTH ORGANIZATIONS A RESOURCE FOR
HMOs
	  	168
		
	 ADDENDUM VII – GUIDELINES FOR THE COORDINATION OF SERVICES BETWEEN HMOS, TARGETED CASE MANAGEMENT (TCM) AGENCIES, AND
CHILD WELFARE AGENCIES
	  	171
		
	 ADDENDUM VIII – REPORT FORMS AND WORKSHEETS
	  	173
			
	 A.
	 	 AIDS and Ventilator Dependent Quarterly Report Form and Detail Report Format
	  	173
			
	 B.
	 	 Coordination of Benefits Quarterly Report Form and Instructions for Completing the Form
	  	175
			
	 C.
	 	 Medicaid and BadgerCare HMO Newborn Report
	  	177
			
	 D.
	 	 HealthCheck Worksheet
	  	179
			
	 E.
	 	 Neonatal Intensive Care Unit (NICU) Risk-Sharing Report Format and Detail Data Requirements
	  	180
			
	 F.
	 	 Court Ordered Birth Cost Requests
	  	184
			
	 G.
	 	 Formal and Informal Grievance Reporting Forms
	  	188
			
	 H.
	 	 Attestation Form
	  	190
		
	 ADDENDUM IX – GENERAL INFORMATION ABOUT THE WIC PROGRAM AND SAMPLE HMO-TO-WIC REFERRAL FORMS
	  	191
		
	 ADDENDUM X – HMO SPECIFIC SERVICE AREA AND ENROLLMENT MAXIMUM
	  	194

  

 -viii- 

 CONTRACT FOR SERVICES 
  
 Between 
  
 The Wisconsin Department of Health and Family Services 
  
 and 
  
 HMO 
  
 The Wisconsin
Department of Health and Family Services (the Department) and the HMO, an insurer with a certificate of authority to do business in Wisconsin, and an organization that makes available to enrolled participants, in consideration of periodic fixed
payments, comprehensive health care services provided by providers selected by the organization and who are employees or partners of the organization or who have entered into a referral or contractual arrangement with the organization, for the
purpose of providing and paying for Medicaid and BadgerCare contract services to recipients enrolled in the HMO under the State of Wisconsin Medicaid Plan approved by the Secretary of the United States Department of Health and Human Services
pursuant to the provisions of the Social Security Act and for the further specific purpose of promoting coordination and continuity of preventive health services and other medical care including prenatal care, emergency care, and HealthCheck
services, do herewith agree: 
  
 ARTICLE I 
  

	I.	DEFINITIONS 

  
 Abuse means provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to
Medicaid/BadgerCare, in reimbursement for services that are not medically necessary, or services that fail to meet professionally recognized standards for health. Abuse also includes client or member practices that result in unnecessary costs to
Medicaid. 
  
 Action means the denial or limited
authorization of a requested service, including the type or level of service; the reduction, suspension or termination of a previously authorized service; the denial, in whole or in part, of payment for a service. 
  
 Appeal means a request for review of an action. 
  
 BadgerCare means part of the Wisconsin Medical Assistance Program
operated by the Wisconsin Department of Health and Family Services under Title XIX and Title XXI of the Federal Social Security Act, s. 49.655, Wis. Stats., and related state and federal rules and regulations. This term is used throughout this
contract. 
  

 -1- 

 Balanced workforce means an equitable representation of persons with disabilities, minorities and
women available for jobs at each job category from the relevant labor market from which the recipient recruits job applicants. 
  
 Business Associate means a person (or company) that provides a service to a Covered Program that requires their use of individually identifiable
health information. 
  
 CESA (Cooperative Educational
Service Agencies) means cooperatives that include multiple school districts that work together for purchasing and other coordinated functions. There are twelve (12) CESAs in Wisconsin. 
  
 CFR means Code of Federal Regulations. 
  
 Children With Special Health Care Needs means children with or at increased risk for chronic physical, developmental,
behavioral, or emotional conditions who also require health and related services of a type or amount beyond that required by children generally and who are enrolled in a Children with Special Health Care Needs program operated by a Local Health
Department or a local Title V funded Maternal and Child Health Program. 
  
 Clean claim means a truthful, complete and accurate claim that does not have to be returned for additional information. 
  

Community Based Health Organizations means non-profit agencies providing community based health services. These organizations provide important
health care services such as HealthCheck screenings, nutritional support, and family planning, targeting such services to high-risk populations. 
  
 Continuing Care Provider means as stated in 42 CFR 441.60(a), a provider who has an agreement with the Medicaid agency to provide: 
  

	 	A.	Any reports that the Department may reasonably require, and 

  

	 	B.	At least the following services to eligible HealthCheck recipients formally enrolled with the provider as enumerated in 42 CFR 441.60(a)(1)-(5): 

  

	 	1.	Screening, diagnosis, treatment, and referrals for follow-up services, 

  

	 	2.	Maintenance of the recipient’s consolidated health history, including information received from other providers, 

  

	 	3.	Physician’s services as needed by the recipient for acute, episodic or chronic illnesses or conditions, 

  

	 	4.	Provision or referral for dental services, and 

  

	 	5.	Transportation and scheduling assistance. 

  

 -2- 

 Contract means the agreement executed between the HMO and the Department to accomplish the duties
and functions, in accordance with the rules and arrangements specified in this document. The contract includes the base agreement and documents specified in Article XIV, Sections A and B. 
  
 Contract Services means services that the HMO is required to provide
under this contract. 
  
 Contractor means the HMO(s)
awarded a contract resulting from the HMO certification process to provide capitated managed care in accordance with the contract. 
  
 Covered Entity means a health plan, a health care clearinghouse, or a health care provider or HMO that transmits any health information in
electronic form in connection with a transaction covered by 45 CFR Parts 160 and 162. 
  
 Cultural Competency means a set of congruent behaviors, attitudes, practices and policies that are formed within an agency, and among professionals that enable the system, agency, and professionals to work
respectfully, effectively and responsibly in diverse situations. Essential elements of cultural competence include understanding diversity issues at work, understanding the dynamic of difference, institutionalizing cultural knowledge, and adapting
to and encouraging organizational diversity. 
  
 Department
means the Wisconsin Department of Health and Family Services.  
  
 Emergency Medical Condition means: 
  

	 	A.	A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health
and medicine, could reasonably expect the absence of immediate medical attention to result in: 

  

	 	1.	Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, 

  

	 	2.	Serious impairment of bodily functions, or 

  

	 	3.	Serious dysfunction of any bodily organ or part; or 

  

	 	B.	With respect to a pregnant woman who is in active labor: 

  

	 	1.	Where there is inadequate time to effect a safe transfer to another hospital before delivery; or 

  

	 	2.	Where transfer may pose a threat to the health or safety of the woman or the unborn child. 

  

	 	C.	A psychiatric emergency involving a significant risk of serious harm to oneself or others. 

  

 -3- 

	 	D.	A substance abuse emergency exists if there is significant risk of serious harm to an enrollee or others, or there is likelihood of return to substance abuse without immediate
treatment. 

  

	 	E.	Emergency dental care is defined as an immediate service needed to relieve the patient from pain, an acute infection, swelling, trismus, fever, or trauma. In all emergency
situations, the HMO must document in the enrollee’s dental records the nature of the emergency. 

  
 Encounter includes the following: 
  

	 	A.	A service or item provided to a patient through the health care system. Examples include but are not limited to: 

  

	 	1.	Office visits 

  

	 	2.	Surgical procedures 

  

	 	3.	Radiology, including professional and/or technical components 

  

	 	4.	Prescribed drugs 

  

	 	5.	Durable medical equipment 

  

	 	6.	Emergency transportation to a hospital 

  

	 	7.	Institutional stays (inpatient hospital, rehabilitation stays) 

  

	 	8.	HealthCheck screens 

  

	 	B.	A service or item not directly provided by the HMO, but for which the HMO is financially responsible. An example would include an emergency service provided by an out-of-network
provider or facility. 

  

	 	C.	A service or item not directly provided by the HMO, and one for which no claim is submitted but for which the HMO may supplement its encounter data set. Such services might include
HealthCheck screens for which no claims have been received and if no claim is received, the HMO’s medical chart. Examples of services or items the HMO may include are: 

  

	 	1.	HealthCheck services 

  

	 	2.	Lead Screening and Testing 

  

	 	3.	Immunizations 

  
 Services or items as used above include those services and items not covered by the Wisconsin Medicaid Program, but which the HMO chooses to provide as
part of its Medicaid managed care product. Examples include educational services, certain over-the-counter drugs, and delivered meals. 
  

 -4- 

 Encounter Record means an electronically formatted list of encounter data elements per encounter
as specified in the Wisconsin Medicaid 2004-2005 HMO Encounter Data User Manual. An encounter record may be prepared from paper claims such as the HCFA 1500, UB-92, or electronic transactions such as ASC XX12N 837. 
  
 Enrollee and Participant means a Medicaid or BadgerCare
recipient who has been certified by the State as eligible to enroll under this Contract, and whose name appears on the HMO Enrollment Reports that the Department transmits to the HMO every month according to an established notification schedule.
Children who are reported to the certifying agency within 100 days of birth shall be enrolled in the HMO their mother is enrolled in from their date of birth if the mother was an enrollee on the date of birth. Children who are reported to the
certifying agency after the 100th day but before their first birthday may be eligible for Medicaid or BadgerCare on
a fee-for-service (FFS) basis. 
  
 Enrollment Area means
the geographic area within which recipients must reside in order to enroll, on a mandatory basis, in the HMO under this Contract. 
  
 Experimental Surgery and Procedures means experimental services that meet the definition of HFS 107.035(1) and (2) Wis. Adm. Code. as determined by
the Department. 
  
 Formally Enrolled with a Continuing Care
Provider (as cited in 42 CFR 441.60(d)) means that a recipient (or recipient’s guardian) agrees to use one continuing care provider as the regular source of a described set of services for a stated period of time. 
  
 Fraud means an intentional deception or misrepresentation made by a
person or entity with the knowledge that the deception could result in some unauthorized benefit to him/herself, itself or some other person or entity. It includes any act that constitutes fraud under applicable federal or state law. 
  
 Grievance means an expression of dissatisfaction about any matter
other than an action. The term is also used to refer to the overall system of grievances and appeals handled by the HMO. Possible grievance subjects include, but are not limited to, the quality of care or services provided, and aspects of
interpersonal relationships such as rudeness of a provider or employee, or failure to respect the enrollee’s rights. 
  
 HHS refers to the Department of Health and Human Services. 
  
 HHS Transaction Standard Regulation means the 45 CFR, Parts 160 and 162. 
  
 HIPAA means the Health Insurance Portability and Accountability Act
of 1996. 
  
 HMO means the health maintenance organization
or its parent corporation with a certificate of authority to do business in Wisconsin, that is obligated under this Contract. 
  

 -5- 

 HMO Encounter Technical Workgroup means a workgroup composed of HMO technical staff, contract
administrators, claims processing, eligibility, and/or other HMO staff, as necessary; Department staff from the Division of Health Care Financing; and staff from the Department’s Medicaid fiscal agent. 
  
 Individually Identifiable Health Information (IIHI) means patient
demographic information, claims data, insurance information, diagnosis information, and any other information the relates to the past, present, or future health condition, provision of health care, payment for health care and that identifies the
individual (or there is reasonable reason to believe could identify the individual). 
  
 Information means any “health information” provided and/or made available by the Department to a Trading Partner, and has the same meaning as the term “health information” as defined by 45
CFR Part 160.103. 
  
 Local Health Department (LHD) means
an agency of local government established according to Chapter 251, Wis. Stats. Local health departments have statutory obligation to perform certain core functions, including assessment, assurance, and policy development to protect and promote the
health of their communities. 
  
 Medicaid means the
Wisconsin Medical Assistance Program operated by the Wisconsin Department of Health and Family Services under Title XIX of the Federal Social Security Act, Ch. 49, Wis. Stats., and related State and Federal rules and regulations. This term is used
consistently in this Contract. Other expressions or words equivalent to Medicaid are “MA,” “Medical Assistance,” and “WMAP.” 
  
 Medical status code means the two digit (alphanumeric) code in the Department’s computer system that defines the type of Medicaid eligibility
a recipient has. The code identifies the basis of eligibility, whether cash assistance is being provided, and other aspects of Medicaid. The medical status code is listed on the HMO enrollment reports. Article V, A of this contract includes a list
of HMO eligible medical status codes. 
  
 Medically Necessary
means a medical service that meets the definition of HFS 101.03(96m) Wis. Adm. Code. 
  
 Newborn means an enrollee less than 100 days old. 
  
 PCP means primary care provider including, but not limited to FQHCs, RHCs, tribal health centers, and physicians, nurse practitioners, nurse midwives, physician assistants and physician clinics with specialties
in general practice, family practice, internal medicine, obstetrics, gynecology, pediatrics. 
  
 Post Stabilization Services means medically necessary non-emergency services furnished to an enrollee after he or she is stabilized following an emergency medical condition. 
  
 Provider means a person who has been certified by the Department to
provide health care services to recipients and to be reimbursed by Medicaid for those services. 
  

 -6- 

 Public Institution means an institution that is the responsibility of a governmental unit or over
which a governmental unit exercises administrative control as defined by federal regulations, including but not limited to prisons and jails. 
  
 Recipient means any individual entitled to benefits under Title XIX and XXI of the Social Security Act, and under the Medicaid State Plan as
defined in Chapter 49, Wis. Stats. 
  
 Service Area means
an area of the State where the HMO has agreed to provide Medicaid services to Medicaid enrollees. The Department monitors enrollment levels of HMOs by the HMO’s service area(s). The HMO indicates whether they will provide dental or chiropractic
services by service area. A service area may be as small as a zip code, may be a county, a number of counties, or the entire State. 
  
 Secretary means the Secretary of HHS and any other officer or employee of the Department of HHS to whom the authority involved has been delegated.

  
 Risk means the possibility of monetary loss or gain by
the HMO resulting from service costs exceeding or being less than payments made to it by the Department. 
  
 State means the State of Wisconsin. 
  
 Subcontract means any written agreement between the HMO and another party to fulfill the requirements of this Contract. However, such term does not
include insurance purchased by the HMO to limit its loss with respect to an individual enrollee, provided the HMO assumes some portion of the underwriting risk for providing health care services to that enrollee. 
  
 Trading Partner shall refer to a provider or HMO that transmits any
health information in electronic form in connection with a transaction covered by 45 CFR Parts 160 and 162, or a business associate authorized to submit health information on the Trading Partner’s behalf. 
  
 Transaction means the exchange of information between two parties to
carry out financial or administrative activities related to health care as defined by 45 CFR Part 160.103. 
  
 Wisconsin Tribal Health Directors Association (WTHDA) means the coalition of all Wisconsin American Indian Tribal Health Departments. 

 
 Terms that are not defined above shall have their primary meaning
identified in HFS 101-108, Wis. Adm. Code. 
  

 -7- 

 ARTICLE II 
  

	II.	DELEGATIONS OF AUTHORITY 

  
 The HMO shall oversee and remain accountable for any functions and responsibilities that it delegates to any subcontractor. For all major or minor
delegation of function or authority: 
  

	 	A.	There shall be a written agreement that specifies the delegated activities and reporting responsibilities of the subcontractor and provides for revocation of the delegation or
imposition of other sanctions if the subcontractor’s performance is inadequate. 

  

	 	B.	Before any delegation, the HMO shall evaluate the prospective subcontractor’s ability to perform the activities to be delegated. 

  

	 	C.	The HMO shall monitor the subcontractor’s performance on an ongoing basis and subject the subcontractor to formal review at least once a year. 

  

	 	D.	If the HMO identifies deficiencies or areas for improvement, the HMO and the subcontractor shall take corrective action. 

  

	 	E.	If the HMO delegates selection of providers to another entity, the HMO retains the right to approve, suspend, or terminate any provider selected by that entity.

  
 ARTICLE III 
  

	III.	FUNCTIONS AND DUTIES OF THE HMO 

  

	 	A.	Statutory Requirement 

  
 In consideration of the functions and duties of the Department contained in this Contract the HMO shall retain at all times during the period of this
Contract a valid Certificate of Authority issued by the State of Wisconsin Office of the Commissioner of Insurance. 
  

	 	B.	Compliance with Applicable Law 

  
 In the provision of services under this contract, the Contractor and its subcontractors shall comply with all applicable federal and state statutes and
rules and regulations, that are in effect when the contract is signed, or that come into effect during the term of the contract. This includes, but is not limited to Title XIX of the Social Security Act and Title 42 of the CFR. 
  

 -8- 

 Changes to Medicaid covered services mandated by federal or state law subsequent to the signing of this
Contract will not affect the contract services for the term of this Contract, unless agreed to by mutual consent, or the change is necessary to continue to receive federal funds or due to action of a court of law. 
  
 The Department may incorporate into the Contract any change in covered
services mandated by federal or state law effective the date the law goes into effect, if it adjusts the capitation rate accordingly. The Department will give the HMO at least 30 days notice before the intended effective date of any such change that
reflects service increases, and the HMO may elect to accept or reject the service increases for the remainder of that contract year. The Department will give the HMO 60 days notice of any such change that reflects service decreases, with a right of
the HMO to dispute the amount of the decrease within that 60 days. The HMO has the right to accept or reject service decreases for the remainder of the Contract year. The date of implementation of the change in coverage will coincide with the
effective date of the increased or decreased funding. This section does not limit the Department’s ability to modify this Contract due to changes in the State Budget. 
  

	 	C.	Organizational Responsibilities and Duties 

  

	 	1.	Ineligible Organizations 

  
 Upon obtaining information or receiving information from the Department or from another verifiable source, the HMO must exclude from participation in the
HMO all organizations that could be included in any of the categories defined in a, 1), a) through e) of this section (references to the Act in this section refer to the Social Security Act). 
  

	 	a.	Entities that could be excluded under Section 1128(b)(8) of the Social Security Act are entities in which a person who is an officer, director, agent or managing employee of the
entity, or a person who has direct or indirect ownership or control interest of 5% or more in the entity has: 

  

	 	1)	Been convicted of the following crimes: 

  

	 	a)	Program related crimes, i.e., any criminal offense related to the delivery of an item or service under Medicare or Medicaid (Section 1128(a)(1) of the Act).

  

	 	b)	Patient abuse, i.e., criminal offense relating to abuse or neglect of patients in connection with the delivery of health care (Section 1128(a)(2) of the Act).

  

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	 	c)	Fraud, i.e., a state or federal crime involving fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct in connection with the delivery of
health care or involving an act or omission in a program operated by or financed in whole or part by federal, state or local government (Section 1128(b)(1) of the Act). 

  

	 	d)	Obstruction of an investigation, i.e., conviction under state or federal law of interference or obstruction of any investigation into any criminal offense described in subsections
a), b), or c) (Section 1128(b)(2) of the Act). 

  

	 	e)	Offenses relating to controlled substances, i.e., conviction of a state or federal crime relating to the manufacture, distribution, prescription or dispensing of a controlled
substance (Section 1128(b)(3) of the Act). 

  

	 	2)	Been excluded, debarred, suspended, otherwise excluded, or is an affiliate (as defined in such Act) of a person described in C, 1, a, above from participating in procurement
activities under the Federal Acquisition Regulation or from participating in non-procurement activities under regulations issued pursuant to Executive Order No. 12549 or under guidelines implementing such order. 

  

	 	3)	Been assessed a civil monetary penalty under Section 1128A of the Act. Civil monetary penalties can be imposed on individual providers, as well as on provider organizations,
agencies, or other entities by the DHHS Office of Inspector General. Section 1128A authorizes their use in case of false or fraudulent submittal of claims for payment, and certain other violations of payment practice standards. (Section
1128(b)(8)(B)(ii) of the Act.) 

  

	 	b.	Entities that have a direct or indirect substantial contractual relationship with an individual or entity listed in subsection 1. A substantial contractual relationship is defined
as any contractual relationship which provides for one or more of the following services: 

  

	 	1)	The administration, management, or provision of medical services. 

  

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	 	2)	The establishment of policies pertaining to the administration, management, or provision of medical services. 

  

	 	3)	The provision of operational support for the administration, management, or provision of medical services. 

  

	 	c.	Entities that employ, contract with, or contract through any individual or entity that is excluded from participation in Medicaid under Section 1128 or 1128A, for the provision
(directly or indirectly) of health care, utilization review, medical social work or administrative services. For the services listed, the HMO must refrain from contracting with any entity that employs, contracts with, or contracts through an entity
that has been excluded from participation in Medicaid by the Secretary of Health and Human Services under the authority of Section 1128 or 1128A of the Act. 

  
 The HMO attests by signing this Contract, that it excludes from participation in the HMO all organizations that could be
included in any of the above categories. 
  

	 	2.	Contract Representative 

  
 The HMO is required to designate a staff person to act as liaison to the Department on all issues that relate to the contract between the Department and
the HMO. The contract representative will be authorized to represent the HMO regarding inquiries pertaining to the Contract, will be available during normal business hours, and will have decision making authority in regard to urgent situations that
arise. The Contract representative will be responsible for follow-up on contract inquiries initiated by the Department. 
  

	 	3.	Attestation 

  
 The HMO’s Chief Executive Officer (CEO), the Chief Financial Officer (CFO) or designee must attest to the best of their knowledge to the
truthfulness, accuracy, and completeness of all data submitted to the Department at the time of submission. This includes encounter data, NICU, AIDS/Vent, Sterilization Reports or any other data regarding claims the HMO paid. HMOs may use the
Department’s attestation form in Addendum VIII, H. 
  

	 	4.	Affirmative Action (AA), Equal Opportunity, Civil Rights Compliance (CRC) and Language Access 

  
 The CRC Plan contains three components: Affirmative Action, Civil Rights/Equal Opportunity, and Language Access. HMOs that
have more than 25 employees or receive more than $25,000 must submit an 

  

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Affirmative Action, Equal Opportunity, Civil Rights and Language Action Plan. HMOs that have less than 25 employees and receive less than $25,000 must submit
a Letter of Assurance and proof that it is exempt from submitting AA information in accordance to s. 16.675, Wis. Stats., and ADM 50, Wis. Adm. Code. HMOs must submit language access information as part of the HMO Certification application.

  

	 	a.	Affirmative Action (AA) Plan 

  

	 	1)	For agreements where the HMO has 25 or more employees and will receive $25,000 or more, the HMO shall complete the AA, Equal Opportunity, CRC and Language Access sections of the
plan that may cover a two or three-year period. HMOs with an annual work force of less than 25 employees or less than $25,000 may be exempt from submitting the AA component of the Plan. 

  
 Exemptions from submitting AA Component requirements will be granted if:

  

	 	a)	The HMO receives a State contract for less than $25,000; 

  

	 	b)	The HMO has fewer than 25 employees regardless of the dollar amount of the contract; 

  

	 	c)	The HMO is a foreign company with a work force of less than 25 employees in the U.S.; 

  

	 	d)	The HMO is a federal government agency or a Wisconsin municipality; and 

  

	 	e)	The HMO has a balanced workforce as defined in Article I. 

  

	 	2)	If the HMO is exempt from submitting an AA component because it has a balanced work force, the HMO must submit its “HMO Work Force Analysis Form, a Request for Exemption from
Submitting an Affirmative Action Component.” 

  

	 	3)	If the HMO is exempt from submitting an AA component for other reasons, the HMO must submit a Request for Exemption from Submitting an Affirmative Action Component.

  

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	 	4)	Exempt HMOs that do not have a balanced work force in specific job groups are required to develop and submit a recruitment strategy to address under-representation of that job
group. 

  

	 	5)	The AA component is written in detail and explains the HMOs AA program. The AA component must be prepared in accordance to the most recently revised AA, Equal Opportunity, CRC and
Language Access plan Instruction Manual for the funding period covering May 1, 2004, to December 31, 2006. 

  

	 	6)	For agreements of $25,000 or more and with 25 employees or more, HMOs shall conduct, keep on file, and update annually, a separate and additional accessibility self-evaluation of
all programs and facilities, including employment practices for compliance with the Americans with Disabilities (ADA) Title I regulations, unless an updated self-evaluation under Section 503 of the Rehabilitation Act of 1973 exists that meets the
ADA requirements. For technical assistance on all the aspects of Civil Rights Compliance, HMOs are encouraged to contact the Department’s AA/CRC Office at (608) 266-9372 (voice), (608) 266-2555 (TDD), or the Department of Health and Family
Services, 1 W. Wilson Street, Room 555, P.O. Box 7850, Madison, Wisconsin 53707-7850. 

  

	 	7)	The HMO must file its AA Plan within 15 days after the award of the contract. The Plan must be submitted to the Department of Health and Family Services, Office of Affirmative
Action and Civil Rights Compliance, Box 7850, Madison, Wisconsin 53707-7850. 

  

	 	b.	Civil Rights Compliance (CRC) Plan 

  

	 	1)	For agreements for the provision of services to enrollees, HMOs must comply with Civil Rights requirements. HMOs with an annual work force of less than 25 employees or receiving
less than $25,000 are not required to submit a CRC Plan, but must, at a minimum, submit a Letter of Assurance that the HMO will comply with all federal and state laws that address nondiscrimination in service delivery. 

  

	 	2)	 The HMO must submit to the Department’s AA/CRC Office proof that it has complied with all of the requirements in the revised AA, Equal Opportunity, CRC and
Language Access Plan Instructions and Manual for 

  

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Profit and Non-Profit Entities for meeting equal opportunity requirements under Title VI and VII of the Civil Rights Act of 1964; Sections 503 and 504 of the
Rehabilitation Act of 1973; Title VI and XVI of the Public Health Service Act; the Age Discrimination in Employment Act of 1967; the Age Discrimination Act of 1975; the Omnibus Reconciliation Act of 1981; the Americans with Disabilities Act of 1990;
and the Wisconsin Fair Employment Act. If a Plan was submitted and approved during the previous year, a plan update must be submitted for this Contract period. 

  

	 	a)	No otherwise qualified person shall be excluded from participation in, be denied the benefits of, or otherwise be subject to discrimination in any manner on the basis of race,
color, national origin, sex, disability or age. This policy covers eligibility for and access to service delivery, and treatment in all programs and activities. All employees of the HMO are expected to support goals and programmatic activities
relating to nondiscrimination in service delivery. 

  

	 	b)	No otherwise qualified person shall be excluded from employment, be denied the benefits of employment or otherwise be subject to discrimination in employment in any manner or term
of employment on the basis of age, race/ ethnicity, color, sex, national origin or ancestry, disability (as defined in Section 504 of the Rehab Act and the ADA) arrest or conviction record, marital status, political affiliation, military
participation, the use of legal products during non-work hours, non-job related genetic and honesty testing. All employees are expected to support goals and programmatic activities relating to non-discrimination in employment.

  

	 	c)	 The HMO must post the Equal Opportunity Policy, the name of the Equal Opportunity Coordinator and the discrimination complaint process in conspicuous places
available to applicants and clients of services, and applicants for employment and employees. The complaint process will be according to Department standards and made available in languages and formats understandable to enrollees, applicants and
employees. The Department will continue to provide appropriate 

  

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translated program brochures and forms for distribution. 

  

	 	d)	The HMO agrees to comply with all of the requirements in the revised Department AA, Equal Opportunity, CRC and Language Access Plan for Profit and Non-Profit Entities and their
subcontractors for this contract period. 

  

	 	e)	These requirements apply to any subcontracts or grants. The HMO has responsibility for ensuring that its subcontractors or sub-grantees also comply with all of the requirements of
the plan. 

  

	 	f)	The Department will monitor the Civil Rights Compliance of the HMO. The Department will conduct reviews to ensure that the HMO is ensuring compliance by its subcontractors or
grantees according to guidelines in the Affirmative Action, Equal Opportunity, Civil Rights and Language Access Compliance Plan. The HMO agrees to comply with Civil Rights monitoring reviews, including the examination of records and relevant files
maintained by the HMO, as well as interviews with staff, clients, and applicants for services, subcontractors, grantees, and referral agencies. The reviews will be conducted according to Department procedures. The Department will also conduct
reviews to address immediate concerns of complainants. 

  

	 	g)	The HMO agrees to cooperate with the Department in developing, implementing and monitoring corrective action plans that result from complaint investigations or monitoring efforts.

  

	 	5.	Non-Discrimination in Employment 

  
 The HMO must comply with all applicable federal and state laws relating to non-discrimination and equal employment opportunity including s. 16.765, Wis.
Stats., Federal Civil Rights Act of 1964, regulations issued pursuant to that Act and the provisions of Federal Executive Order 11246 dated September 26, 1985, and ensure physical and program accessibility of all services to persons with physical
and sensory disabilities pursuant to Section 504 of the Federal Rehabilitation Act of 1973, as amended (29 U.S.C. 794), all requirements imposed by the applicable Department regulations (45 CFR part 84) and all guidelines and interpretations issued

  

 -15- 

 
pursuant thereto, and the provisions of the Age Discrimination and Employment Act of 1967 and Age Discrimination Act of 1975. 
  
 Chapter 16.765, Wis. Stats. requires that in connection with the
performance of work under this Contract, the Contractor agrees not to discriminate against any employee or applicant for employment because of age, race, religion, color, handicap, sex, physical condition, developmental disability as defined in s.
51.01(5), sexual orientation or national origin. This provision shall include, but not be limited to, the following: employment, upgrading, demotion or transfer; recruitment or recruitment advertising; layoff or termination; rates of pay or other
forms of compensation; and selection for training, including apprenticeship. Except with respect to sexual orientation, the Contractor further agrees to take affirmative action to ensure equal employment opportunities. The Contractor agrees to post
in conspicuous places, available for employees and applicants for employment, notices to be provided by the contracting officer setting forth the provisions of the non-discrimination clause. 
  
 With respect to provider participation, reimbursement, or indemnification,
the HMO will not discriminate against any provider who is acting within the scope of the provider’s license or certification under applicable state law, solely on the basis of such license or certification. This shall not be construed to
prohibit an HMO from including providers to the extent necessary to meet the needs of the Medicaid population or from establishing any measure designed to maintain quality and control cost consistent with these responsibilities. 
  

	 	6.	Provision of Services to all HMO Members 

  
 The HMO must provide contract services to Medicaid and BadgerCare enrollees under this contract in the same manner as those services are provided to
other members of the HMO. 
  
 The HMO must ensure that the
services are sufficient in amount, duration, or scope to reasonably be expected to achieve the purpose for which the services are furnished. 
  

	 	7.	Access to Premises 

  
 The HMO must allow duly authorized agents or representatives of the state or federal government access to the HMO’s or HMO subcontractor’s
premises during normal business hours to inspect, audit, monitor or otherwise evaluate the performance of the HMO’s or subcontractor’s contractual activities and shall produce all records requested as part of such review or audit within a
reasonable time, but not more than ten working days. Upon request for such right of access, the HMO or subcontractor must provide staff to assist in the audit or inspection effort, and adequate space on the premises to reasonably accommodate the
state 

  

 -16- 

 
or federal personnel conducting the audit or inspection effort. All inspections or audits must be conducted in a manner as will not unduly interfere with the
performance of HMO’s or subcontractor’s activities. The HMO will have 30 business days to respond to any findings of an audit before the Department finalizes it. All information obtained will be accorded confidential treatment as provided
under applicable laws, rules or regulations. 
  

	 	8.	Liability for the Provision of Care 

  
 Remain liable for provision of care for that period for which capitation payment has been made in cases where medical status code changes occur
subsequent to capitation payment. 
  

	 	9.	Subcontracts 

  
 The HMO must ensure that all subcontracts are in writing, comply with the provisions of Addendum I, include any general requirements of this Contract
that are appropriate to the service or activity identified in Addendum I, and ensure that all subcontracts do not terminate legal liability of the HMO under this Contract. The HMO may subcontract for any function covered by this Contract, subject to
the requirements of this Contract. 
  

	 	10.	Coordination with Community-Based Health Organizations, Local Health Departments, Bureau of Milwaukee Child Welfare, Prenatal Care Coordination Agencies, School-Based Services
Providers and Targeted Case Management Agencies: 

  

	 	a.	Community-Based Health Organizations 

  
 The Department encourages the HMO to contract with community-based health organizations for the provision of care to Medicaid and BadgerCare enrollees in
order to ensure continuity and culturally appropriate care and services. Community-based organizations can provide HealthCheck outreach and screening, immunizations, family-planning services, and other types of services. 
  
 The Department encourages HMOs to work closely with community-based health
organizations as noted in Addendum VI. 
  
 Community-based
health organizations may also provide services, such as WIC services, that HMOs are required by federal law to coordinate with and refer to, as appropriate. 
  

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	 	b.	Local Health Departments 

  
 The Department encourages the HMO to contract with local health departments for the provision of care to Medicaid and BadgerCare enrollees in order to
ensure continuity and culturally appropriate care and services. Local health departments can provide HealthCheck outreach and screening, immunizations, blood lead screening services, and services to targeted populations within the community for the
prevention, investigation, and control of communicable diseases (e.g., tuberculosis, HIV/AIDS, sexually transmitted diseases, hepatitis and others). WIC projects provide nutrition services and supplemental foods, breastfeeding promotion and support;
and immunization screening. Many projects screen for blood lead poisoning during the WIC appointment. Refer to Addendum I, Part A for basic contract requirements. 
  
 As noted in Addendum VI the Department encourages HMOs to work closely with local health departments. Local health
departments have a wide variety of resources that could be coordinated with HMOs to produce more efficient and cost-effective care for HMO enrollees. Examples of such resources are ongoing medical services programs, materials on health education,
prevention, and disease states, expertise on outreaching specific sub-populations, communication networks with varieties of medical providers, advocates, community-based health organizations, and social service agencies, and access to ongoing
studies of health status and disease trends and patterns. 
  

	 	c.	Bureau of Milwaukee Child Welfare 

  
 Milwaukee County HMOs must designate at least one individual to serve as a contact person for the Bureau of Milwaukee Child Welfare (BMCW). If the HMO
chooses to designate more than one contact person, the HMO should identify the service area for which each contact person is responsible. The HMO must provide all Medicaid covered mental health and substance abuse services to individuals identified
as clients of BMCW. Disputes regarding the medical necessity of services identified in the Family Treatment Plan will be adjudicated using the dispute process outlined in Addendum V, except that HMOs must provide court-ordered services in accordance
with Article III, F. Addendum V contains guidelines for how Milwaukee County HMOs and BMCW will work together to provide mental health and substance abuse services. Refer to Article III, F for more information regarding mental health and substance
abuse covered services. 
  

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	 	d.	Prenatal Care Coordination (PNCC) Agencies 

  
 The HMO must sign a Memorandum of Understanding (MOU) with all agencies in the HMO service area that are Medicaid-certified PNCC agencies. The purpose of
the MOU is to ensure coordination of care between the HMO that provides medical services, and the PNCC agency that provides outreach, risk assessment, care planning, care coordination, and follow-up. Refer to Addendum I, Part B, IV, B for the MOU
requirements and a sample PNCC MOU. 
  
 In addition, the HMO
must assign an HMO medical representative to interface with the care coordinator from the PNCC agency. Refer to Article III, E, 12 for more information regarding payment/ non-payment requirements and the HMO representative’s care coordination
responsibilities. 
  

	 	e.	School-Based Services (SBS) Providers 

  
 The HMO must use its best effort to sign a Memorandum of Understanding (MOU) with all SBS providers in the HMO service area to ensure continuity of care
and to avoid duplication of services. Refer to Article III, E, 13 for more information regarding the HMO’s responsibility to coordinate care with SBS providers and Addendum I, Part B, IV, C for the MOU requirements and a sample SBS MOU.

  

	 	f.	Targeted Case Management (TCM) Agencies 

  
 The HMO must interface with the case manager from the TCM agency to identify what Medicaid covered services or social services are to be provided to an
enrollee. Article III, E, 14 and Addendum VII contain more information on how HMOs and TCM agencies should work together to coordinate care. 
  

	 	11.	Clinical Laboratory Improvement Amendments (CLIA) 

  
 The HMO must use only certain laboratories. All laboratory testing sites providing services under this Contract must have a valid CLIA certificate along
with a CLIA identification number, and comply with CLIA regulations as specified by 42 CFR Part 493, “Laboratory Requirements.” Those laboratories with certificates must provide only the types of tests permitted under the terms of their
certification. 
  

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	 	D.	Payment Requirements/Procedures 

  
 The HMO is responsible for the payment of all contract services provided to all Medicaid and BadgerCare recipients listed as ADDs or CONTINUEs on either
the Initial or Final Enrollment Reports (see Article V, B, D and E) generated for the month of coverage. The HMO is also responsible for: 
  

	 	•	The payment for services to all newborns meeting the criteria described in Article VI, F, “Capitation Payments for Newborns.” 

  

	 	•	The provision, or authorizing the provision of, services to all Medicaid enrollees with valid Forward cards indicating HMO enrollment, without regard to disputes about enrollment
status and without regard to any other identification requirements. Any discrepancies between the cards and the enrollment reports must be reported to the Department for resolution. The HMO must continue to provide and authorize provision of all
contract services until the discrepancy is resolved, including recipients who were PENDING on the Initial Report and held a valid Forward card indicating HMO enrollment, but did not appear as a CONTINUE on the Final Report. 

 

	 	1.	Claims Retrieval 

  
 The HMO must maintain a claim retrieval system that can upon request identify date of receipt, action taken on all provider claims (i.e., paid, denied
other), and when action was taken. The HMO must have procedures in place that will show the date a claim was received whether the claim is a paper copy or an electronic submission. In addition, the HMO must maintain a claim retrieval system that can
identify, within the individual claim, the services provided and the diagnoses of the enrollees using nationally accepted coding systems: HCPCS including Level I CPT codes and Level II and Level III HCPCS codes with modifiers, ICD-9-CM diagnosis and
procedure codes, and other national code sets such as place of service, type of service, and EOB codes. Finally, the claim retrieval system must be capable of identifying the provider of services by the appropriate Wisconsin Medicaid provider ID
number assigned to all in-plan providers. Refer to Article III, H, 1, for use of providers certified by the Medicaid program. 
  

	 	2.	Thirty Day Payment Requirement 

  
 The HMO must pay at least 90% of adjudicated clean claims from subcontractors for covered medically necessary services within 30 days of receipt of a
clean claim, 99% within 90 days and 100% within 180 days of receipt, except to the extent subcontractors have agreed to later payment. HMO agrees not to delay payment to a subcontractor pending subcontractor collection of third party liability
unless the HMO has an agreement with the subcontractor to collect third party liability. 
  

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	 	3.	Payment to a Non-HMO Provider for Services Provided to a Disabled Participant Less Than Three or for Services Ordered by the Courts 

  
 The HMO must pay for covered services provided by a non-HMO provider to a
disabled participant less than three years of age, or to any participant pursuant to a court order (for treatment), effective with the receipt of a written request for referral from the non-HMO provider, and extending until the HMO issues a written
denial of referral. This requirement does not apply if the HMO issues a written denial of referral within seven days of receiving the request for referral. 
  

	 	4.	Payment of HMO Referrals to Non-Affiliated Providers 

  
 For HMO approved referrals to non-affiliated providers, the HMO must either establish payment arrangements in advance, or the HMO is liable for payment
only to the extent that Medicaid pays, including Medicare deductibles, or would pay, its FFS providers for services to the AFDC and BadgerCare population. This condition does not apply to cases where there are specific subcontract agreements, MOUs
or other binding agreements entered into before the referral. 
  

	 	5.	Health Professional Shortage Area (HPSA) Payment Provision 

  
 The following provision refers to payments made by the HMO. HMO covered primary care and emergency care services provided to a recipient living in a
Health Professional Shortage Area (HPSA) or by a provider practicing in a HPSA must be paid at an enhanced rate of 20% above the rate the HMO would otherwise pay for those services. Primary care providers are defined in Article I. Specified
HMO-covered obstetric or gynecological services (see the Wisconsin Medicaid Physician Services Handbook) provided to a recipient living in a HPSA or by a provider practicing in a HPSA must be paid at an enhanced rate of 25% above the rate the HMO
would otherwise pay providers in HPSAs for those services. 
  
 However, this does not require the HMO to pay more than the enhanced Medicaid FFS rate or the actual amount billed for these services. The HMO shall ensure that the money for HPSA payments is paid to the physicians and is not used to
supplant funds that previously were used for payment to the physicians. The Department will supply a list of the services affected by this provision, the maximum FFS rates, and HPSAs. The HMO must develop written policies and procedures to ensure
compliance with this provision. These policies must be available for review by the Department, upon request. 
  

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	 	6.	Payment of Physician Services to Pregnant Women and Children Under Age 19 

  
 The HMO must adequately fund physician services provided to pregnant women and children under age 19, so that they are paid
at rates sufficient to ensure that provider participation and services are as available to the Medicaid and BadgerCare population as to the general population in the HMO service area. 
  

	 	7.	Federally Qualified Health Centers (FQHC) and Rural Health Centers (RHC) 

  
 If an HMO contracts with a Medicaid certified FQHC or RHC for the provision of services to its enrollees, the HMO must
negotiate payment rates for that FQHC or RHC on the same basis it negotiates with other clinics and primary providers. An HMO that contracts with an FQHC or RHC must report to the Department within 45 days of the end of each quarter (for example,
January 1 – March 31 is due May 15) the total amount paid to each FQHC or RHC per month and as reported on the 1099 forms prepared by the HMO for each FQHC or RHC. FQHC or RHC payments include direct payments to a medical provider who is
employed by the FQHC or RHC. The report should be for the entire HMO, aggregating all service areas if the HMO has more than one service area. 
  

	 	8.	Immunization Program 

  
 As a condition of certification as a Medicaid and BadgerCare provider, the HMO must share enrollee immunization status with Local Health Departments and
other non-profit HealthCheck providers upon their request without the necessity of enrollee authorization. The Department also requires that Local Health Departments and other non-profit HealthCheck providers share the same information with HMOs
upon request. This provision ensures proper coordination of immunization services and prevents duplication of services. 
  
 The HMO must have a signed user agreement with the Wisconsin Immunization Registry (WIR) or must be able to demonstrate that its major providers have
signed WIR user agreements. 
  

	 	9.	Transplants 

  
 As a general principle, Wisconsin Medicaid does not pay for items that it determines to be experimental in nature. 
  

	 	a.	Medicaid covers cornea transplants and kidney transplants. These services are no longer considered experimental. Therefore, HMOs must also cover these services.

  

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	 	b.	HMOs are not required to cover procedures that are approved only at particular institutions, including bone marrow transplants, liver, heart, heart-lung, lung, pancreas-kidney, and
pancreas transplants. There are no funds in the FFS experience data (and thus in the HMO capitation rates) for these services. 

  
 Enrollees who have had one or more of the transplant surgeries referenced in 9, b, above will be permanently exempted from HMO enrollment. Refer to
Article VIII, C, 14 for the exemption criteria. 
  

	 	10.	Hospitalization at the Time of Enrollment or Disenrollment 

  
 Enrollees, including newborn enrollees, who are hospitalized at the time of disenrollment from the HMO shall remain the financial responsibility of the
HMO. The financial liability of the HMO shall encompass all contract services. The HMO’s financial liability shall continue for the duration of the hospitalization, except where: 
  

	 	a.	Loss of Medicaid and BadgerCare eligibility occurs. 

  

	 	b.	Disenrollment occurs because there is a voluntary disenrollment from the HMO as a result of one of the conditions in Article III, F, in which case HMO liability shall terminate upon
disenrollment being effective. 

  

	 	c.	Disenrollment is due to a medical status change to a code indicating SSI, 503 case, or institutionalized eligibility. Five hundred and three cases are SSI cases that continue
Medicaid eligibility when Social Security cost of living increases cause an SSI recipient to lose SSI eligibility. 

  
 In these three exceptions, the HMO’s liability shall not exceed the period for which it is capitated. 
  
 The HMO will not assume financial responsibility for enrollees who are
hospitalized at the time of enrollment (effective date of coverage) until an appropriate hospital discharge. The Department is responsible for paying on a FFS basis all Medicaid covered services for such hospitalized enrollees during
hospitalization. 
  
 Discharge from one hospital and admission
to another within 24 hours for continued treatment shall not be considered discharge under this section. Discharge is defined here as it is in the UB-92 Manual. 
  

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	 	11.	Enrollees living in a public institution 

  
 The HMO is liable for the cost of providing all medically necessary services to enrollees who are living in a public institution as defined in Article I,
during the month in which they first enter the public institution. Enrollees who remain in a public institution after the last day of the month are no longer eligible for Medical Assistance or BadgerCare and HMOs are not liable for providing care
after the end of the first month. Refer to Article VIII, C, 7 for the disenrollment criteria. 
  
 Enrollees who are living in a public institution and go directly from the public institution to a medical facility, court ordered or voluntarily, are no
longer living in a public institution and remain eligible for Medicaid or BadgerCare. The HMO shall be liable for the provision of medically necessary treatment if treatment is at the HMO’s facilities, or if unable to itself provide for such
treatment. 
  

	 	E.	Covered Medicaid Services 

  
 HMOs are not restricted to providing Wisconsin Medicaid covered services. Sometimes HMOs find that other treatment methods may be more appropriate than
Medicaid covered services, or result in better outcomes. 
  
 None
of the provisions of this Contract that are applicable to Wisconsin Medicaid covered services apply to other services that an HMO may choose to provide, except that abortions, hysterectomies and sterilizations must comply with 42 CFR 441 Subpart E
and 42 CFR 441 Subpart F. 
  
 Whether the service provided is an
alternative or replacement to a Wisconsin Medicaid covered service or is a Wisconsin Medicaid covered service, the HMO or HMO provider is not allowed to bill the enrollee for the service. 
  

	 	1.	Provision of Contract Services 

  
 Promptly provide or arrange for the provision of all services required under s. 49.46(2), Wis. Stats., and HFS 107 Wis. Adm. Code as further clarified in
all Wisconsin Medicaid and BadgerCare Provider Handbooks and Bulletins, and HMO Contract Interpretation Bulletins, and as otherwise specified in this Contract except: 
  

	 	a.	Common Carrier Transportation, except as defined in Article III, E, 7. 

  

	 	b.	Dental, except as defined in Article III, E, 8. 

  

	 	c.	Prenatal Natal Care Coordination (PNCC), except HMOs must sign a Memorandum of Understanding (MOU) as defined in Article III, C, 10, d, and Addendum I, Part B, IV, B.

  

 -24- 

	 	d.	Targeted Case Management (TCM), except HMOs must work with the TCM case manager as defined in Article III, E, 14 and Addendum VII. 

  

	 	e.	School-Based Services (SBS), except HMOs must use its best efforts to sign a Memorandum of Understanding (MOU) as defined in Addendum I, Part B, IV, C. 

  

	 	f.	Milwaukee Childcare Coordination. 

  

	 	g.	Tuberculosis-related Services. 

  

	 	h.	Crisis Intervention Benefit. 

  

	 	2.	Medical Necessity 

  
 The actual provision of any service is subject to the professional judgment of the HMO providers as to the medical necessity of the service, except that
the HMO must provide assessment, evaluation, and treatment services ordered by a court. Decisions to provide or not to provide or authorize medical services shall be based solely on medical necessity and appropriateness as defined in HFS
101.03(96m). Disputes between HMOs and recipients about medical necessity can be appealed through an HMO grievance system, and ultimately to the Department for a binding determination; the Department’s determinations will be based on whether
Medicaid would have covered that service on a FFS basis (except for certain experimental procedures discussed in Article III, D, 9). Alternatively, disputes between HMOs and enrollees about medical necessity can be appealed directly to the
Department. 
  

	 	3.	Required Services Under Wis. Stats., and Wis. Adm. Code 

  
 Services required under s. 49.46(2), Wis. Stats., and HFS 107, Wis. Adm. Code, include (without limitation due to enumeration) private duty nursing
services, nurse-midwife services, and independent nurse practitioner services; physician services, including primary care services, are not only services performed by physicians, but services under the direct, on-premises supervision of a physician
performed by other providers such as physician assistants and nurses of various levels of certification. 
  

	 	4.	Pre-Existing Medical Conditions 

  
 The HMO must assume responsibility for all covered pre-existing medical conditions of each enrollee as of the effective date of coverage under the
Contract. The aforementioned responsibility does not apply in the case of persons hospitalized at the time of initial enrollment, as defined in Article III, D, 10. 
  

 -25- 

	 	5.	Ambulance Services 

  
 HMOs may require submission of a trip ticket with ambulance claims before paying the claim. Claims submitted without a trip ticket need only be paid at
the service charge rate. HMOs must: 
  

	 	a.	Pay a service fee for ambulance response to a call in order to determine whether an emergency exists, regardless of the HMO’s determination to pay for the call.

  

	 	b.	Pay for emergency ambulance services based on established Medicaid criteria for claims payment of these services. 

  

	 	c.	Either pay or deny payment of a clean claim from an ambulance service within 45 days of receipt of the clean claim. 

  

	 	d.	Respond to appeals from ambulance providers within the time frame described in Article III, G. Failure will constitute HMO agreement to pay the appealed claim in full.

  

	 	6.	Chiropractic Services 

  
 The HMO must cover chiropractic services, or in the alternative, enter into a subcontract for chiropractic services with the state as provided in Article
XVI. State law mandates coverage. 
  

	 	7.	Common Carrier Transportation 

  

	 	a.	Enrollees Outside of Milwaukee County 

  
 All HMOs must arrange for transportation for HealthCheck screenings. When authorized by the Department, the HMO may provide non-emergency transportation
by common carrier or private motor vehicle for these visits and be reimbursed by the county. 
  
 HMOs may negotiate arrangements with local county Departments of Health and Social Services for common carrier or private vehicle transportation for HMO services in general and not just for HealthCheck screenings.

  

	 	b.	Enrollees in Milwaukee County 

  
 All Milwaukee County HMOs must provide common carrier transportation to and from Medicaid covered services to their Medicaid and BadgerCare enrollees
that reside in Milwaukee County. 
  

 -26- 

 The HMO is responsible for arranging common carrier transportation and providing monthly costs incurred
to Milwaukee County Department of Human Services (MCDHS). The HMO agrees to submit the monthly costs to the MCDHS within the first 15 days of the following month to: 
  
 Milwaukee County DHS 
 Financial Assistant, Division Administrator 
 1220 W. Vliet Street 
 Milwaukee, WI 53206 
  
 MCDHS is responsible for reimbursing the HMO for mileage and an administration fee. The Department reserves the right to adjust these rates. 

 
 The HMO shall maintain adequate records for each enrollee, including all
pertinent and sufficient information relating to common carrier transportation, and make this information readily available to the Department. The HMO agrees to report suspected abuse by enrollees or providers to the Department. 
  

	 	8.	Dental Services 

  

	 	a.	Dental Services Covered by all HMOs 

  

	 	1)	Emergency Dental Care 

  
 All HMOs must cover emergency dental care. The only exception is the dentist’s or oral surgeon’s direct charges. 
  

	 	2)	Dental Surgeries performed in a Hospital 

  
 All HMOs must pay all charges relating to dental surgeries when a hospital or freestanding ambulatory care setting is medically indicated. These charges
include, but are not limited to physician, anesthesia, pharmacy and facility charges. The only exception is the dentist’s or oral surgeon’s direct charges. 
  

	 	3)	Prescription Drugs Prescribed by a Dental Provider 

  
 All HMOs are liable for the cost of all medically necessary prescription drugs when ordered by a certified Medicaid dental provider. 
  

 -27- 

	 	b.	Dental Services Covered by HMOs Contracted to Provide Dental Care 

  

	 	1)	All Medicaid covered dental services as required under HFS 107.07, provider handbooks, bulletins, and periodic updates. 

  

	 	2)	Diagnostic, preventive, and medically necessary follow-up care to treat a dental disease, illness, injury or disability of enrollees while they are enrolled in an HMO, except as
required in subsection 3) below. 

  

	 	3)	Completion of orthodontic or prosthodontic treatment begun while an enrollee was enrolled in an HMO if the enrollee became ineligible for Medicaid or disenrolled from the HMO, no
matter how long the treatment takes. An HMO will not be required to complete orthodontic or prosthodontic treatment on an enrollee who began treatment as a FFS recipient and who subsequently was enrolled in an HMO. 

  
 [Refer to the chart following this page of the Contract for the specific
details of completion of orthodontic or prosthodontic treatment in these situations.] 
  

	 	c.	Reporting Requirements for HMOs that Cover Dental Services 

  
 HMOs that cover dental services must submit quarterly progress reports to the Department documenting the outcomes or current status of activities
intended to increase utilization. These reports are due 15 days after the end of each calendar quarter. 
  

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 RESPONSIBILITY FOR PAYMENT OF ORTHODONTIC AND PROSTHODONTIC TREATMENT WHEN THERE IS AN

 ENROLLMENT STATUS CHANGE DURING THE COURSE OF TREATMENT 
  

							
	 	  	 Who pays for completion of orthodontic and
 prosthodontic treatment* when there is an enrollment
status change

	 	  	 First HMO

	  	Second HMO

	  	FFS

				
	 Person converts from one status to another:
	  	 	  	N/A	  	X
				
	 1.       FFS to an HMO covering dental.
	  	 	  	 	  	 
				
	 2a.     HMO covering dental to an HMO not covering dental, and person’s residence remains within 50 miles of the
person’s residence when in the first HMO.
	  	X	  	 	  	 
				
	 2b.     HMO covering dental to an HMO not covering dental, and person’s residence changes to greater than 50
miles of the person’s residence when in the first HMO.
	  	 	  	 	  	X
				
	 3a.     HMO covering dental to the same or another HMO covering dental and the person’s residence remains within
50 miles of the residence when in the first HMO.
	  	X	  	 	  	 
				
	 3b.     HMO covering dental to the same or another HMO covering dental and the person’s residence changes to
greater than 50 miles of the residence when in the first HMO.
	  	 	  	 	  	X
				
	 4.       HMO with dental coverage to FFS because:
	  	 	  	 	  	 
				
	 a.       Person moves out of the HMO service area but the person’s residence remains within 50 miles
of the residence when in the HMO.
	  	X	  	 	  	 
				
	 b.       Person moves out of the HMO service area, but the person’s residence changes to greater than
50 miles of the residence when in the HMO.
	  	 	  	N/A	  	X
				
	 c.       Person exempted from HMO enrollment.
	  	 	  	N/A	  	X
				
	 d.       Person’s medical status changes to an ineligible HMO code and the person’s residence
remains within 50 miles of the residence when in that HMO.
	  	X	  	N/A	  	 
				
	 e.       Person’s medical status changes to an ineligible HMO code and the person’s residence
changes to greater than 50 miles of the residence when in that HMO.
	  	 	  	N/A	  	X
				
	 5a.     HMO with dental to ineligible for Medicaid/BC and the person’s residence remains within 50 miles of the
residence when in that HMO.
	  	X	  	N/A	  	 
				
	 5b.     HMO with dental to ineligible for Medicaid/BC and the person’s residence changes to greater than 50
miles of the residence when in that HMO.
	  	 	  	N/A	  	X
				
	 6.       HMO without dental to ineligible for Medicaid/BC.
	  	 	  	N/A	  	X

	*	Orthodontic treatment is only covered by Medicaid and BadgerCare for children under 21 as a result of a HealthCheck referral (HFS 107.07(3)). 

  

 -29- 

	 	9.	Emergency and Post-Stabilization Services  

  

	 	a.	24-Hour Coverage 

  
 The HMO must provide all emergency contract services and post-stabilization services as defined in this Contract 24 hours each day, seven days a week,
either by the HMO’s own facilities or through arrangements approved by the Department with other providers. The HMO must: 
  

	 	1)	Have one toll-free telephone number that enrollees or individuals acting on behalf of an enrollee can call at any time to obtain assistance in determining if emergency services are
needed, to obtain authorization for urgent care and to obtain authorization for transportation. This telephone number must provide access to individuals with authority to authorize treatment as appropriate. Responses to these calls must be provided
within 30 minutes. If the HMO fails to respond timely, the HMO will be liable for the cost of subsequent care related to that illness or injury incident whether the treatment is rendered by in or out-of- plan providers and whether the condition is
emergency, urgent or routine. 

  
 Authorization
here refers to the requirements defined in Addendum II, in the Standard Enrollee Handbook Language, regarding the conditions under which an enrollee must receive permission from the HMO prior to receiving services from a non-HMO affiliated provider
in order for the HMO to reimburse the provider. 
  

	 	2)	Be able to communicate with the caller in the language spoken by the caller or the HMO will be liable for the cost of subsequent care related to that illness or injury incident
whether the treatment is in or out-of-plan and whether the condition is emergency, urgent, or routine. These calls must be logged with the time, date and any pertinent information regarding the persons involved, resolution and follow-up
instructions. 

  

	 	3)	Notify the Department of any changes to this toll-free telephone number for emergency calls within seven working days of the change. 

  

 -30- 

	 	b.	Provision/Payment Requirements 

  
 HMOs must promptly provide or pay for needed contract services for emergency medical conditions and post-stabilization services as defined in Article I,
regardless of whether the provider that furnishes the service has a contract with the entity. Nothing in this requirement mandates HMOs to reimburse for non-authorized post-stabilization services. Payment and liability requirements include but are
not limited to: 
  

	 	1)	Payments for qualifying emergencies (including services at hospitals or urgent care centers within the HMO service area) are to be based on the medical signs and symptoms of the
condition upon initial presentation. The retrospective findings of a medical work-up may legitimately be the basis for determining how much additional care may be authorized, but not for payment for dealing with the initial emergency. Liability for
emergency services continues until the patient is stabilized and can be safely discharged or transferred. 

  

	 	2)	Paying for an appropriate medical screening examination to determine whether or not an emergency medical condition exists. 

  

	 	3)	When emergency services are provided by non-affiliated providers, be liable for payment only to the extent that Medicaid pays, including Medicare deductibles, or would pay, FFS
providers for services to the Medicaid and BadgerCare population. In no case will the HMO be required to pay more than billed charges. This condition does not apply to: (1) Cases where prior payment arrangements were established; and (2) Specific
subcontract agreements. 

  

	 	c.	Memoranda of Understanding (MOU) or Contract with Hospitals/ Urgent Care Centers for the Provision of Emergency Services 

  
 HMOs may have a contract or an MOU with hospitals or urgent care centers
within the HMO’s service area to ensure prompt and appropriate payment for emergency services. The provisions for this type of MOU are defined in Addendum I, Part B, II. Unless a contract or MOU specifies otherwise, HMOs are liable to the
extent that FFS would have been liable for a situation that meets the definition of emergency. The Department reserves the right to resolve disputes between HMOs, hospitals and urgent care centers regarding emergency situations based on the
emergency definition in Article I of this contract. 
  

 -31- 

 For situations where a contract or MOU is not possible, HMOs must identify for hospitals and urgent care
centers procedures that ensure prompt and appropriate payment for emergency services. 
  

	 	10.	Family Planning Services and Confidentiality of Family Planning Information 

  

	 	a.	The HMO must give enrollees the opportunity to have a different primary physician for the provision of family planning services. This physician does not replace the primary care
provider chosen by or assigned to the enrollee. 

  

	 	b.	The enrollee may choose to receive family planning services at any Medicaid certified family planning clinic. Family planning services provided at Medicaid certified family planning
clinics are paid FFS for HMO enrollees except for pharmacy items ordered by the family planning provider. The HMO is liable to provide the prescribed pharmacy items. 

  

	 	c.	All information and medical records relating to family planning shall be kept confidential including those of a minor. 

  

	 	11.	Fertility Drugs 

  
 The HMO must get prior authorization from the Chief Medical Officer in the Division of Health Care Financing before an HMO provider may treat an enrollee
with any of the following drug products: Chorionic Gonadotropin, Clomiphene, Gonadorelin, Menotropins, Urofollitropin and any other new fertility enhancing drugs. 
  

	 	12.	Prenatal Care Coordination (PNCC) Agencies 

  
 The HMO must assign an HMO medical representative to interface with the care coordinator from the PNCC agency. This HMO representative shall work with
the care coordinator to identify what Medicaid covered services, in conjunction with other identified social services, are to be provided to the enrollee. The HMO is not liable for medical services directed outside of their provider network by the
care coordinator unless prior authorized by the HMO. In addition, the HMO is not required to pay for services provided directly by the Prenatal Care Coordinating provider. Such services are paid on a FFS basis. 
  
 The HMO must sign an MOU with all agencies in the HMO service area that are
Medicaid-certified PNCC agencies. Article III, C, 10, d, and Addendum I, Part B, IV, B contain more information regarding this requirement. 
  

 -32- 

	 	13.	School-Based Services (SBS) 

  
 School-Based Services (SBS) are paid FFS by Medicaid when provided by a Medicaid certified SBS provider. However, in situations where an enrollee’s
course of treatment is interrupted due to school breaks, after school hours or during the summer months, the HMO is responsible for providing and paying for all Medicaid covered services. 
  
 To avoid duplication of services and to promote continuity of care the HMO
must use its best efforts to sign a Memorandum of Understanding (MOU) with all SBS providers in the HMO service area who are Medicaid certified. For Medicaid certification purposes, a SBS service provider is a school district under ch. 120, Wis.
Stats., or a cooperative educational service agency (CESA) under ch. 116, Stats. Refer to Addendum I, Part B, IV, C that contains the requirements for an MOU with SBS providers. 
  

	 	14.	Targeted Case Management (TCM) Services 

  
 The HMO must assign an HMO medical representative to interface with the case manager from the TCM agency. This HMO representative will work with the case
manager to identify what Medicaid covered services, in conjunction with other identified social services, are to be provided to the enrollee. The HMO is not required to pay for medical services directed outside of their provider network by the case
manager unless prior authorized by the HMO. The Department will distribute a statewide list of Medicaid-certified TCM agencies to the HMOs and periodically update the list. Addendum VII contains guidelines for how HMOs and TCM agencies should
coordinate care. 
  

	 	F.	Mental Health and Substance Abuse Coverage Requirements/Coordination of Services with Community Agencies 

  
 HMOs must provide Wisconsin Medicaid covered services, but HMOs are not
restricted to providing only those services. HMOs may provide additional or alternative treatments if the other treatment modalities are more appropriate and result in better outcomes than Medicaid covered services. Whether the service provided is a
Medicaid covered service or an alternative or replacement to a Wisconsin Medicaid covered service, the HMO or HMO provider is not allowed to bill the enrollee for the service. 
  

	 	1.	Conditions on Coverage of Mental Health/Substance Abuse Treatment 

  
 On the effective date of this contract, the HMO must, in compliance with s.632.89 Wis. Stats.: 
  

	 	a.	Be certified according to HFS 105.21, 105.22, 105.23, 105.24, and/or 105.255, to provide mental health and/or substance abuse services; or 

  

 -33- 

	 	b.	Have contracted with facilities and/or providers certified according to HFS 105.21, 105.22, 105.23, 105.24, 105.25, and/or 105.255, to provide mental health and/or substance abuse
services. 

  
 The HMO may request variances of
certain certification requirements for mental health providers. The Department will approve the variances to the extent allowed under federal or state law. 
  
 Regardless of whether a. or b., above, is chosen, such treatment facilities and/or providers must provide arrangements for covered transitional treatment
in addition to other outpatient mental health and/or substance abuse services. Such transitional treatment arrangements may include but are not limited to Adult Day Treatment, Child/Adolescent Day Treatment and Substance Abuse Day Treatment.

  
 Department decisions to waive the requirement to cover these
services shall be based solely on whether there is a certified provider that is geographically or culturally accessible to enrollees, and whether the use of psychiatrists, or psychologists alone improves the quality and/or the cost-effectiveness of
care. 
  
 In compliance with said provisions, the HMO must
further guarantee all enrolled Medicaid and BadgerCare enrollees access to all medically necessary outpatient mental health/substance abuse and covered transitional treatment. No limit may be placed on the number of hours of outpatient treatment
that the HMO must provide or reimburse where it has been determined that treatment for mental illness and/or substance abuse or covered transitional treatment is medically necessary. The HMO shall not establish any monetary limit or limit on the
number of days of inpatient hospital treatment where it has been determined that this treatment is medically necessary. 
  

	 	2.	Mental Health/Substance Abuse Assessment Requirements 

  
 The HMO must assure that authorization for mental health/substance abuse treatment for its enrollees is governed by the findings of an assessment
performed promptly by the HMO upon request of a client or referral from a primary care provider or physician in the HMO’s network. Such assessments must be conducted by qualified staff in a certified program, who are experienced in mental
health/substance abuse treatment. All denials of service and the selection of particular modalities of service shall be governed by the findings of this assessment, the effectiveness of the therapy for the condition, and the medical necessity of
treatment. The lack of motivation of an enrollee to participate in treatment shall not be considered a factor in determining medical necessity and may not be used as a rationale for withholding or limiting treatment of a client/enrollee. HMOs will
use Wisconsin Uniform Placement Criteria (WI-UPC), or placement criteria developed by the American Society of Addiction 

  

 -34- 

 
Medicine (ASAM) as mandated for substance abuse care providers in HFS 75. The requirement in no way obligates the HMOs to provide care options included in
the placement criteria, that are not covered services of FFS Medicaid. 
  
 The HMO must involve and engage the enrollee in the process used to select a provider and treatment option. The purpose of the participation is to get a good match between the enrollee’s condition, culture
preference (see Article III, I, 6), medical needs and the provider who must seek to meet these needs. This section does not require HMOs to use providers who are not qualified to treat the individual enrollee or who are not contracted providers.

  

	 	3.	Assurance of Expertise for Child Abuse, Child Neglect and Domestic Violence 

  
 The HMO must consult with human service agencies on appropriate providers in their community. The HMO must arrange for the
provision of examination and treatment services by providers with expertise and experience in dealing with medical and psychiatric aspects of caring for victims and perpetrators of child abuse and neglect and domestic violence. Such expertise shall
include the identification of possible and potential victims of child abuse and neglect and domestic violence, statutory reporting requirements, and local community resources for the prevention and treatment of child abuse and neglect and domestic
violence. 
  
 The HMO must notify all persons employed by or
under contract to the HMO who are required by law to report suspected child abuse and neglect, and ensure they are knowledgeable about the law and about the identification requirements and procedures. Services provided must include and are not
limited to court-ordered physical, psychological and mental or developmental examinations and medical and psychiatric treatment appropriate for victims and perpetrators of child abuse and neglect. 
  
 The HMO must further assure that providers with appropriate expertise and
experience in dealing with perpetrators and victims of domestic abuse and incest are utilized in service provision. 
  

	 	4.	Court-Related Children’s Services 

  
 The HMO is liable for the cost of providing assessments under the Children’s Code, s. 48.295, Wis. Stats., and is responsible for reimbursing for
the provision of medically necessary treatment if unable to itself provide for such treatment ordered by a juvenile court. The medical necessity of court-ordered evaluation and treatment is assumed to be established and the HMO is allowed to provide
the care through its 

  

 -35- 

 
network, if at all possible. The HMO may not withhold or limit services unless or until the court has agreed. 
  

	 	5.	Court-Related Substance Abuse Services 

  
 The HMO is liable for the cost of providing medically necessary substance abuse treatment, as long as the treatment occurs in an HMO-approved facility or
by an HMO-approved provider ordered in the subject’s Driver Safety Plan, pursuant to Chapter 343, Wis. Stats., and HFS 62 of the Wis. Adm. Code. The medical necessity of services specified in this plan is assumed to be established, and the HMO
shall provide those services unless the assessment agency agrees to amend the enrollee’s Driver Safety Plan. This is not meant to require HMO coverage of substance abuse educational programs, or the initial assessment used to develop the Driver
Safety Plan. Necessary HMO referrals or treatment authorizations by providers must be furnished promptly. It is expected that no more than five days will elapse between receipt of a written request by an HMO and the issuance of a referral or
authorization for treatment. Such referral or authorization, once determined to be medically necessary, will be retroactive to the date of the request. After the 5th day, an assumption will exist that an authorization has been made until such time
as the HMO responds in writing. 
  

	 	6.	Crisis Intervention Benefit 

  
 The HMO must assign a medical representative to interface with the designees of crisis intervention agencies certified under HFS 34 Wis. Adm. Code that
provide services within the HMOs service area. The HMO must work with the certified Crisis Intervention Agency to coordinate the transition from crisis intervention care to ongoing Medicaid covered mental health and substance abuse care within the
HMO’s network. The HMO is not responsible for payment for services provided to their enrollees by certified Crisis Intervention Agencies. Those services are to be billed directly to Medicaid FFS. In addition, the HMO is not required to pay for
services directed by the certified Crisis Intervention Agency outside the HMO network, unless the HMO has authorized those services. 
  

	 	7.	Emergency Detention and Court-Related Mental Health Services 

  
 The HMO is liable for the cost of all emergency detention and court-related mental health/substance abuse treatment, including stipulated and involuntary
commitment provided by non-HMO providers to HMO enrollees where the time required to obtain such treatment at the HMO’s facilities, or the facilities of a provider with which the HMO has arrangements, would have risked permanent damage to the
enrollee’s health or safety, or the health or safety of others. The extent of the HMO’s 

  

 -36- 

 
liability for appropriate emergency treatment is the current Medicaid FFS rate for such treatment. 
  

	 	a.	Care provided in the first three business days (72 hours), plus any intervening weekend days and/or holidays, is deemed medically necessary and the HMO is responsible for payment.

  

	 	b.	The HMO is responsible for payment for additional care beyond the time period in paragraph a. above only if notified of the emergency treatment within 72 hours, excluding weekends
and holidays, and if given the opportunity to provide such care. The opportunity for the HMO to provide care to an enrollee admitted to a non-HMO facility is accomplished if the county or treating facility notifies and advises the HMO of the
admission within 72 hours, excluding weekends and/or holidays. The HMO may provide an alternative treatment plan for the county to submit at the probable cause hearing. The HMO must submit the name of an in- plan facility willing to treat the
enrollee if the court rejects the alternative treatment plan and the court orders the enrollee to receive an inpatient evaluation. 

  

	 	c.	If the county attempts to notify the person identified as the primary contact by the HMO to receive authorization for care, and does not succeed in reaching the HMO within 72 hours
of admission excluding weekends and holidays, the HMO is responsible for court-ordered care beyond the initial 72 hours. The county must document the attempts to notify with dates, times, names and numbers attempted to contact, and outcomes. The
care provided to the HMO enrollee by the non-HMO provider is deemed medically necessary, and coverage by the HMO is retroactive to the date of admission. 

  

	 	d.	The HMO is financially liable for the enrollee’s court ordered evaluation and/or treatment when an HMO enrollee is defending him/herself against a mental illness or substance
abuse commitment: 

  

	 	1)	If services are provided in an HMO facility; or 

  

	 	2)	If the HMO approves provision in a non-contracted facility; or 

  

	 	3)	If the HMO was given the opportunity but failed to provide the county with the name of an inpatient facility and, as a result, the enrollee is sent for court ordered evaluation to
an out-of-plan provider; or 

  

 -37- 

	 	4)	If the HMO gives the county the name of an in-plan facility and the facility refuses to accept the enrollee. 

  

	 	e.	The HMO is not liable for the enrollee’s court ordered evaluation and treatment if the HMO provided the name of an inpatient facility and the court ordered the evaluation at on
out-of-plan facility. 

  

	 	8.	Institutionalized Individuals 

  

	 	a.	Institutionalized Children 

  
 If inpatient or institutional services are provided in an HMO facility, or approved by the HMO for provision in a non-contracted facility, the HMO shall
be financially liable for all children enrolled under this Contract for the entire period for which capitation is paid. The HMO remains financially liable for the entire period a capitation is paid even if the child’s medical status code
changes, or the child’s relationship to the original AFDC case changes. 
  

	 	b.	Institutionalized Adults 

  
 The HMO is not liable for expenditures for any service to a person 21 to 64 years of age who is a resident of an institution for mental disease (IMD),
except to the extent that expenditures for a service to an individual on convalescent leave from an IMD are reimbursed by Medicaid FFS. 
  

	 	9.	Transportation Following Emergency Detention 

  
 The HMO shall be liable for the provision of medical transportation to an HMO-affiliated provider when the enrollee is under emergency detention or
commitment and the HMO requires the enrollee to be moved to a participating provider, provided the transfer can be made safely. If a transfer requires a secured environment by local law enforcement officials, i.e., Sheriff Department, Police
Department, etc., the HMO shall not be liable for the cost of the transfer. The HMO is not prohibited from entering into an MOU or agreement with local law enforcement agencies or with county agencies for such transfer. 
  

	 	10.	Mental Health and/or Substance Abuse Exemptions 

  
 The Medicaid or BadgerCare case head shall be given the option of disenrolling the enrollee who meets one or more of the mental health and/or substance
abuse criteria defined in Article VIII, C, 9 of this contract, or applying to have the affected person remain in the Medicaid FFS system. The same privilege applies to HMO enrollees who are 

  

 -38- 

 
thought to meet one or more of the criteria defined in Article VIII at any point during the term of this contract. 
  

	 	11.	Memoranda of Understanding (MOU)/Contract Requirement and Relations with other Human Service Agencies 

  
 The HMO shall develop a working relationship with community agencies
involved in the provision of mental health and/or substance abuse services to enrollees. HMOs must work cooperatively with other community agencies, to treat mental health and/or substance abuse conditions as legitimate health care problems.

  
 The HMO must make a “good faith” attempt to
negotiate either an MOU or a contract with the county(ies) in its service area. A “good faith” attempt is defined as a minimum of one face-to-face meeting between the HMO and the county in an attempt to develop either an MOU or a contract.
If a face-to-face meeting is not possible, the HMO must maintain a written record of their attempt to negotiate either an MOU or a contract with the county(ies). The MOU(s), contract(s) or written documentation of a good faith attempt must be
available during the certification process and when requested by the Department. Failure of the HMO to have an MOU, contract or demonstrate a good faith effort, as specified by the Department, may result in the application by the Department of
remedies specified under Article X of this Contract. MOU requirements are specified in Addendum I, Part B of this contract. 
  

	 	G.	Provider Appeals 

  
 Medicaid and BadgerCare providers must appeal first to the HMO and then to the Department if they disagree with the HMO’s payment or nonpayment of a
claim. 
  

	 	1.	The HMO must inform providers in writing of the HMO’s decision to pay or deny the original claim. 

  

	 	a.	A specific explanation of the payment amount or a specific reason for the nonpayment. 

  

	 	b.	A statement regarding the provider’s rights to appeal to the HMO. 

  

	 	c.	The name of the person and/or function at the HMO to whom provider appeals should be submitted. 

  

	 	d.	An explanation of the process the provider should follow when appealing the HMO’s decision. 

  

	 	1)	Include a separate letter or form clearly marked “appeal.” 

  

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	 	2)	Include the provider’s name, date of service, date of billing, date of payment and/or nonpayment, recipient’s name and Medicaid or BadgerCare ID number.

  

	 	3)	Include the reason(s) the claim merits reconsideration. 

  

	 	4)	Address the letter or form to the person and/or function at the HMO that handles Provider Appeals. 

  

	 	5)	Send the appeal within 60 days of the initial denial or payment notice. 

  

	 	e.	A statement advising the provider of the provider’s right to appeal to the Department if the HMO fails to respond to the appeal within 45 days or if the provider is not
satisfied with the HMO’s response to the request for reconsideration. Appeals to the Department must be submitted in writing within 60 days of the HMO’s final decision or, in the case of no response, within 60 days from the 45 day timeline
allotted the HMO to respond. 

  

	 	2.	The HMO must accept written appeals from providers submitted within 60 days of the HMO’s initial payment and/or nonpayment notice. The HMO must respond in writing within 45
days from the date of receipt of the request for reconsideration. If the HMO fails to respond within 45 days, or if the provider is not satisfied with the HMO’s response, the provider may seek a final determination from the Department.

  

	 	3.	After a provider has appealed to the HMO according to the terms described in subsection 1 above and the provider disputes the determination, the provider may appeal to the
Department for the final determination. Appeals must be submitted to the Department within 60 days of the date of written notification of the HMO’s final decision resulting from a request for reconsideration or, if the HMO fails to respond,
within 60 days from the 45 day timeline allotted the HMO to respond. In exceptional cases, the Department may override the HMO’s time limit for the submission of claims and appeals. The Department will not exercise its authority in this regard
unreasonably. The Department will accept written comments from all parties to the dispute prior to making a final decision. The Department has 45 days from the date of receipt of all written comments to inform the provider and the HMO of the final
decision. If the Department’s decision is in favor of the provider, the HMO will pay provider(s) within 45 days of receipt of the Department’s final determination. The HMO must accept the Department’s determinations regarding appeals
of disputed claims. 

  

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	 	H.	Provider Network and Access Requirements 

  
 The HMO must provide medical care to its Medicaid and BadgerCare enrollees that is as accessible to them, in terms of timeliness, amount, duration, and
scope, as those services are to non-enrolled Medicaid and BadgerCare recipients within the area served by the HMO. 
  

	 	1.	Use of Medicaid Certified Providers 

  
 Except in emergency situations, HMOs must use only providers who have been certified by the Medicaid program for services or items covered by Wisconsin
Medicaid. The Department reserves the right to withhold from the capitation payments the monies related to services provided by non-Medicaid-certified providers, at the Medicaid FFS rate for those services, unless the HMO can demonstrate that it
reasonably believed, based on the information provided by the Department, that the provider was certified by the Medicaid program at the time the HMO reimbursed the provider for service provision. The Wis. Adm. Code, Chapter HFS 105, contains
information regarding provider certification requirements. Every Medicaid HMO must require every physician providing services to enrollees to have a unique physician identifier, as specified in Section 1173(b) of the Social Security Act. 

 

	 	2.	Protocols/Standards to Ensure Access 

  
 The HMO must have written protocols to ensure that enrollees have access to screening, diagnosis and referral, and appropriate treatment for those
conditions and services covered under the Wisconsin Medicaid program. 
  
 The HMO’s protocols must include methods for identification, outreach to and screening/assessment of enrollees with special health care needs. 
  

	 	3.	Written Standards for Accessibility of Care 

  
 The HMO must have written standards for the accessibility of care and services. These standards must be communicated to providers and monitored by the
HMO. The standards must include the following: Waiting times for care at facilities; waiting times for appointments; statement that providers’ hours of operation do not discriminate against Medicaid and BadgerCare enrollees; and whether or not
provider(s) speak member’s language. The HMO must take corrective action if its standards are not met. 
  

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	 	4.	Access to Selected Medicaid Providers and/or Covered Services 

  

	 	a.	Dental Providers 

  
 HMOs that cover dental services must have a dental provider within a 35-mile distance from any enrollee residing in the HMO service area or no further
than the distance for non-enrolled recipients residing in the service area. If there is no Medicaid certified provider within the specified distance, the travel distance shall be no more than for a non-enrolled recipient. The HMO must also consider
whether the dentist accepts new patients, and whether full or part-time coverage is available. 
  

	 	b.	Mental Health or Substance Abuse Providers 

  
 The HMO must have a mental health or substance abuse provider within a 35-mile distance from any enrollee residing in the HMO service area or no further
than the distance for non-enrolled recipients residing in the service area. If there is no Medicaid certified provider within the specified distance, the travel distance shall be no more than for a non-enrolled recipient. The HMO must also consider
whether the providers accept new patients, and whether full or part-time coverage is available. 
  

	 	c.	High Risk Prenatal Care Services 

  
 The HMO must provide medically necessary high risk prenatal care within two weeks of the enrollee’s request for an appointment, or within three
weeks if the request is for a specific HMO provider. 
  

	 	d.	HMO Referrals to Out-of-Network Providers for Services 

  
 HMO must provide adequate and timely coverage of services provided out of network, when the required medical service is not available within the HMO
network. The HMO must coordinate with out-of –network providers with respect to payment and ensure that cost to the enrollee is no greater than it would be if the services were furnished within the network. (42 CFR. §. 438.206(b)(v)(5)).

  

	 	e.	Primary Care Providers 

  
 Primary Care Providers are defined in Article I. HMOs may define other types of providers as primary care providers. If they do so, the HMOs must define
these other types of primary care providers and justify their inclusion as primary care providers during the pre-contract review phase of the HMO Certification process. 
  

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 The HMO must have a Medicaid certified primary care provider within a 20-mile distance from any enrollee
residing in the HMO service area, unless there is no Medicaid certified provider within the specified distance. In that case, the travel distance shall be no more than for a non-enrolled recipient. A service area for an HMO will be specified down to
the zip code. Therefore, all portions of each zip code in the HMO service area must be within 20 miles from a Medicaid certified primary care provider. 
  
 This access standard does not prevent a recipient from choosing an HMO when the recipient resides in a zip code that does not meet the 20-mile distance
standard. However, the recipient will not be automatically assigned to that HMO. If the recipient has been assigned to the HMO or has chosen the HMO and becomes dissatisfied with the access to medical care, the recipient may disenroll from the HMO
because of distance. 
  

	 	f.	Second Medical Opinions 

  
 HMOs must upon enrollee request, provide enrollees the opportunity to have a second opinion from a qualified network provider subject to referral
procedures approved by the Department. If an appropriately qualified provider is not available within the network, the HMO must arrange for a second opinion outside the network at no charge to the enrollee. 
  

	 	g.	Women’s Health Specialists 

  
 In addition to a primary care provider a female enrollee may have a women’s health specialist. The HMO must provide female enrollees with direct
access to a women’s health specialist within the network for covered women’s routine and preventive health care services. 
  

	 	5.	Network Adequacy Requirements 

  
 The HMO must ensure that its delivery network is sufficient to provide adequate access to all services covered under this contract. In establishing the
network, the HMO must consider: 
  

	 	a.	The anticipated Medicaid and BadgerCare enrollment. 

  

	 	b.	The expected utilization of services, considering enrollee characteristics and health care needs. 

  

	 	c.	The number and types of providers (in terms of training experience and specialization) required to furnish the contracted services. 

  

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	 	d.	The number of network providers not accepting new patients. 

  

	 	e.	The geographic location of providers and enrollees, distance, travel time, normal means of transportation used by enrollees and whether provider locations are accessible to
enrollees with disabilities. 

  
 The HMO must
provide documentation and assurance of the above network adequacy criteria as required by the Department for pre-contract certification or upon request of the Department. In addition, the HMO must update the documentation and assurance to the
Department with respect to network adequacy whenever there has been a significant change, as defined by the Department, in the HMO’s operations that would affect adequate capacity and services, including changes in HMO benefits, geographic
service areas, provider network, payments, or enrollment of a new population in the HMO. (42 CFR, §. 438.207(c)(2)(i-ii)). 
  

	 	I.	Responsibilities to Enrollees 

  

	 	1.	Advocate Requirements 

  
 Each HMO must employ a Medicaid/BadgerCare HMO Advocate during the entire contract term. The HMO Advocate must work with both enrollees and providers to
facilitate the provision of Medicaid benefits to enrollees, and the advocate is responsible for making recommendations to management on any changes needed to improve either the care provided or the way care is delivered. The advocate position must
be in an organizational location within the HMO that provides the authority needed to carry out these tasks. The detailed requirements of the HMO Advocate are listed below: 
  

	 	a.	Functions of the Medicaid/BadgerCare HMO Advocate(s) 

  

	 	1)	Investigate and resolve access and cultural sensitivity issues identified by HMO staff, state staff, providers, advocate organizations, and enrollees. 

  

	 	2)	Monitor formal and informal grievances with the grievance personnel for purposes of identification of trends or specific problem areas of access and care delivery. The monitoring
function includes ongoing participation in the HMO grievance committee. 

  

	 	3)	Recommend policy and procedural changes to HMO management including those needed to ensure and/or improve enrollee access to and quality of care. The recommended changes can be for
both internal administrative policies and subcontracted providers. 

  

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	 	4)	Act as the primary contact for enrollee advocacy groups. Work with enrollee advocacy groups on an ongoing basis to identify and correct enrollee access barriers.

  

	 	5)	Act as the primary contact for local community based organizations (local governmental units, non-profit agencies, etc.). Work with the local community based organizations on an
ongoing basis to acquire knowledge and insight regarding the special health care needs of enrollees. 

  

	 	6)	Participate in the Department’s Advocacy Program for Managed Care. Such participation includes working with the Department’s managed care staff person assigned to the HMO
on issues of access to medical care and quality of medical care and working with the Enrollment Specialist and Medicaid Ombudsmen on issues of access to medical care, quality of medical care, and enrollment/disenrollment. 

 

	 	7)	Analyze on an ongoing basis internal HMO system functions, with HMO staff, these functions affect enrollee access to medical care and quality of medical care.

  

	 	8)	Organize and provide ongoing training and educational materials for HMO staff and providers to enhance their understanding of the values and practices of all cultures with which the
HMO interacts. 

  

	 	9)	Provide ongoing input to HMO management on how changes in the HMO provider network will affect enrollee access to medical care and enrollee quality and continuity of care.
Participate in the development and coordination of plans to minimize any potential problems that could be caused by provider network changes. 

  

	 	10)	Review and approve all HMO informing materials to be distributed to enrollees to assess clarity and accuracy. 

  

	 	11)	Assist enrollees and their authorized representatives for the purpose of obtaining their medical records. 

  

	 	12)	The lead advocate position is responsible for overall evaluation of the HMO’s internal advocacy plan and is required to monitor any contracts the HMO may enter into for
external advocacy with culturally diverse associations or agencies. The lead advocate is responsible for training the associations or agencies and ensuring their input into the HMO’s advocacy plan. 

  

 -45- 

	 	b.	Staff Requirements and Authority of the Medicaid/BadgerCare HMO Advocate 

  

	 	1)	At a minimum, one (1) HMO Advocate must be located in the organizational structure so that the Advocate has the authority to perform the functions and duties listed in subsection
section 1, a, 1)-12) above. 

  
 The HMO
Certification Application requires HMOs to state the staffing levels to perform the functions and duties listed in subsection section 1, a, 1)-12) above in terms of number of full and part time staff and total Full Time Equivalents (FTEs) assigned
to these tasks. The Department assumes that an HMO acting as an Administrative Service Organization (ASO) for another HMO will have at least one Advocate or FTE position for each ASO contract as well as maintain their own internal advocate(s). An
HMO may employ less than a FTE advocate position, but must justify to the satisfaction of the Department why less than one (1) FTE position will suffice for the HMO’s enrollee population. The HMO must also regularly evaluate the advocate
position, workplan(s), and job duties and allocate an additional FTE advocate position or positions to meet the duties listed in subsection section 1, a, 1)-12) above if there is significant increase in the HMO’s enrollee population or in the
HMO service area. The Department reserves the right to require an HMO to employ an FTE advocate position if the HMO does not demonstrate the adequacy of a part-time advocate position. 
  
 In order to meet the requirement for the Advocate position statewide, the Department encourages HMOs to contract or have a
formal memorandum of understanding for advocacy and/or translation services with associations or organizations that have culturally diverse populations within the HMO service area. However, the overall or lead responsibility for the advocate
position must be within each HMO. HMOs must monitor the effectiveness of the associations and agencies under contract and may alter the contract(s) with written notification to the Department. 
  

	 	2)	The HMO Advocate is responsible for facilitating and ensuring access to all medically necessary services for each enrollee as stipulated in this Contract. 

 

	 	3)	 The HMO Advocate staffing levels submitted in the HMO Certification Application must be maintained, and solely devoted to the functions and duties listed subsection
1, a, 

  

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1)-12) above throughout the contract term. Changes in the HMO Advocate staffing levels must be approved by the Department 30 days prior to the effective date
of the change. 

  

	 	4)	Prior to contract signing, the HMO Advocate must develop a Medicaid and BadgerCare HMO Advocacy workplan, with the timelines and activities specified, and must maintain and modify
it as necessary, throughout the contract term. 

  

	 	2.	Advance Directives 

  
 The HMO must maintain written policies and procedures related to advance directives. (Written information provided must reflect changes in state law as
soon as possible, but no later than 90 days after the effective date of the change.) An advance directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under Wisconsin law (whether statutory
or recognized by the courts of Wisconsin) and relating to the provision of such care when the individual is incapacitated. The HMO must: 
  

	 	a.	Provide written information at the time of HMO enrollment to all adults receiving medical care through the HMO regarding: 

  

	 	1)	The individual’s rights under Wisconsin law (whether statutory or recognized by the courts of Wisconsin) to make decisions concerning such medical care, including the right to
accept or refuse medical or surgical treatment and the right to formulate advance directives; and 

  

	 	2)	The HMO’s written policies respecting the implementation of such rights. 

  

	 	b.	Document in the individual’s medical record whether or not the individual has executed an advance directive. 

  

	 	c.	Not discriminate in the provision of care or otherwise discriminate against an individual based on whether or not the individual has executed an advance directive. This provision
shall not be construed as requiring the provision of care which conflicts with an advance directive. 

  

	 	d.	Ensure compliance with the requirements of Wisconsin law (whether statutory or recognized by the courts of Wisconsin) respecting advance directives. 

  

 -47- 

	 	e.	Provide education for staff and the community on issues concerning advance directives. 

  
 The above provisions shall not be construed to prohibit the application of any Wisconsin law which allows for an objection
on the basis of conscience for any health care provider or any agent of such provider which as a matter of conscience cannot implement an advance directive. 
  

	 	3.	Choice of Health Care Professional 

  
 The HMO must offer each enrollee covered under this Contract the opportunity to choose a primary health care professional affiliated with the HMO, to the
extent possible and appropriate. If the HMO assigns recipients to primary care providers, then the HMO must notify recipients of the assignment. HMOs must permit Medicaid and BadgerCare enrollees to change primary providers at least twice in any
calendar year, and to change primary providers more often than that for just cause, just cause being defined as lack of access to quality, culturally appropriate, health care. Such just cause will be handled as a formal grievance. If the HMO has
reason to lock in an enrollee to one primary provider and/or pharmacy in cases of difficult case management, the HMO must submit a written request in advance of such lock-in to the Department’s Contract Specialist. Culturally appropriate care
in this section means care by a provider who can relate to the enrollee and who can provide care with sensitivity, understanding, and respect for the enrollee’s culture. 
  

	 	4.	Coordination and Continuation of Care 

  
 Have systems in place to ensure well-managed patient care, including at a minimum: 
  

	 	a.	Management and integration of health care through primary provider/gatekeeper/other means. 

  

	 	b.	Systems to ensure referrals for medically necessary, specialty, secondary and tertiary care. 

  

	 	c.	Systems to ensure provision of care in emergency situations, including an education process to ensure that enrollees know where and how to obtain medically necessary care in
emergency situations. 

  

	 	d.	Systems that clearly specify referral requirements to providers and subcontractors. The HMO must keep copies of referrals (approved and denied) in a central file or the
patient’s medical records. 

  

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	 	e.	Systems to ensure the provision of a clinical determination of the medical necessity and appropriateness of the enrollee to continue with MH/SA providers who are not subcontracted
with the HMO. The determination must be made within ten (10) business days of the enrollee’s request. If the HMO determines that the enrollee does not need to continue with the non-contracted provider, it must ensure an orderly transition of
care. 

  

	 	5.	Conversion Privileges 

  
 The HMO must offer any enrollee covered under this Contract, whose enrollment is subsequently terminated due to loss of Medicaid/BadgerCare eligibility,
the opportunity to convert to a private enrollment contract without underwriting. The time period for conversion following Medicaid/BadgerCare termination notice must comply with Wis. Stats. 632.897 regarding conversion rights. 
  

	 	6.	Cultural Competency 

  
 The HMO must address the special health needs of enrollees who are low income or members of specific population groups needing specific culturally
competent services. The HMO must incorporate in its policies, administration, and service practice such as (1) recognizing members’ beliefs, (2) addressing cultural differences in a competent manner, and (3) fostering in its staff and providers
behaviors that effectively address interpersonal communication styles that respect enrollees’ cultural backgrounds. The HMO must have specific policy statements on these topics and communicate them to subcontractors. 
  
 The HMO must encourage and foster cultural competency among providers. When
appropriate the HMO must permit enrollees to choose providers from among the HMO’s network based on linguistic/cultural needs. The HMO must permit enrollees to change primary providers based on the provider’s ability to provide services in
a culturally competent manner. Enrollees may submit grievances to the HMO and/or the Department regarding to their inability to obtain culturally appropriate care, and the Department may, pursuant to such a grievance, permit an enrollee to disenroll
from that HMO and enroll into another HMO, or into FFS in a county where HMOs do not enroll all eligibles. 
  

	 	7.	Enrollee Handbook, Education and Outreach for Newly Enrolled Recipients 

  

	 	a.	Within one week of initial enrollment notification to the HMO, annually thereafter and whenever the enrollee’s requests, the HMO must mail to each casehead an enrollee handbook
which is at the “sixth grade reading comprehension level” and which at a minimum will include information about: 

  

	 	1)	The phone number that can be used for assistance in obtaining emergency care or for prior authorization for urgent care. 

  

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	 	2)	Information on contract services offered by the HMO. 

  

	 	3)	Location of facilities. 

  

	 	4)	Hours of service. 

  

	 	5)	Informal and formal grievance procedures, including notification of the enrollee’s right to a fair hearing. 

  

	 	6)	Grievance appeal procedures. 

  

	 	7)	HealthCheck. 

  

	 	8)	Family planning policies. 

  

	 	9)	Policies on the use of emergency and urgent care facilities. 

  

	 	10)	Providers and whether the provider is accepting new “enrollees.” 

  

	 	11)	Changing HMOs. 

  

	 	b.	As needed the HMO must provide periodic updates to the handbook and explain changes to the information listed above. Such changes must be approved by the Department prior to
printing. 

  

	 	c.	When HMOs reprint their enrollee handbooks, they must include all of the changes to the standard language as specified in Addendum II, to this Contract. 

  

	 	d.	Enrollee handbooks (or other enrollee information approved by the Department that explains HMO services and how to use the HMO) must be made available in at least: Spanish, Lao,
Russian and Hmong if the HMO has enrollees who are conversant only in those languages. The handbook must tell enrollees how to obtain a copy of the handbook in those languages. The Department will translate the standard handbook language in Addendum
II into the four specified languages. HMOs may use the translated standard handbook language as appropriate to its service area. However, HMOs must have local resources review the final handbook language to ensure that the appropriate dialect(s)
is/are used in the standard translation. HMOs must also arrange for translation into any other dialects appropriate for its enrollees. 

  

 -50- 

	 	e.	HMOs may create enrollee handbook language that is simpler than the standard language of Addendum II, but this language must be approved by the Department. HMOs must also
independently arrange for the translation of any non-standard language. 

  

	 	f.	HMOs must submit their enrollee handbook for review and approval within 60 days of signing the contract for 2004-2005. 

  

	 	g.	Standard language on several subjects, including HealthCheck, family planning, grievance and appeal rights, conversion rights, and emergency and urgent care, must appear in all
handbooks and is included in Addendum II. Any exceptions to the standard must be approved in advance by the Department, and will be approved only for exceptional reasons. If the standard language changes during the course of the contract period, due
to changes in federal or state laws, rules or regulations, HMOs must insert the new language into the enrollee handbooks as of the effective date of any such change. 

  

	 	h.	In addition to the above requirements for the enrollee handbook, HMOs must perform other education and outreach activities for newly enrolled recipients. HMOs must submit to the
Department for prior written approval an education and outreach plan targeted towards newly enrolled recipients. The outreach plan will be examined by the Department during pre-contract review. Newly enrolled recipients are listed as
“ADD-New” on the enrollment reports (Article V, E). The plan must identify at least two educational/outreach activities the HMO will undertake to tell new enrollees how to access services within the HMO network. The plan must include the
frequency (i.e., weekly, monthly, etc.) of the activities, the person within the HMO responsible for the activities, and how the activities will be documented and evaluated for effectiveness. 

  

	 	8.	Health Education and Disease Prevention 

  
 The HMO must inform all enrollees of ways they can maintain their own health and properly use health care services. 
  
 The HMO must have a health education and disease prevention program that is
readily accessible to its enrollees. The program must be offered within the normal course of office visits, as well as by discrete programming. The program must include: 
  

	 	a.	An individual responsible for the coordination and delivery of services. 

  

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	 	b.	Information on how to obtain these services (locations, hours, phones, etc.). 

  

	 	c.	Health-related educational materials in the form of printed, audiovisual, and/or personal communication. 

  
 Health-related educational materials produced by the HMO must be at a sixth grade reading comprehension level and reflect
sensitivity to the diverse cultures served. Also, if the HMO uses material produced by other entities, the HMO must review these materials for grade level comprehension and sensitivity to the diverse cultures served. Finally, the HMO must make all
reasonable efforts to locate and use culturally appropriate health-related material. 
  

	 	d.	Information on recommended check ups and screenings, and prevention and management of disease states that affect the general population. This includes specific information for
persons who have or who are at risk of developing such health problems as hypertension, diabetes, STD, asthma, breast and cervical cancer, osteoporosis and postpartum depression. 

  

	 	e.	Health education and disease prevention programs, including injury control, family planning, teen pregnancy, sexually transmitted disease prevention, prenatal care, nutrition,
childhood immunization, substance abuse prevention, child abuse prevention, parenting skills, stress control, postpartum depression, exercise, smoking cessation, weight gain and healthy birth, postpartum weight loss, and breast-feeding promotion and
support. (Note: any education and prevention programs for family planning and substance abuse would supplement the required family planning and substance abuse health care services covered by Medicaid and BadgerCare. 

  

	 	f.	Promotion of the health education and disease prevention program, including use of languages understood by the population served, and use of facilities accessible to the population
served. 

  

	 	g.	Information on and promotion of other available prevention services offered outside of the HMO, including child nutrition programs, parenting classes, programs offered by local
health departments and other programs. 

  

	 	h.	 Systematic referrals of potentially eligible women, infants, and children to the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and
relevant medical information to the WIC program. Addendum IX contains general information about recipient eligibility requirements for the WIC 

  

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program as well as sample WIC referral forms. More information about the WIC program as well a list of the local WIC agencies can be found on the WIC website
(www.dhfs.state.wi.us/wic). 

  

	 	9.	Interpreter Services 

  
 The HMO must provide interpreter and sign language services free of charge for enrollees as necessary to ensure availability of effective communication
regarding treatment, medical history or health education and/or any other component of this contract. The HMO must: 
  

	 	a.	Provide for 24-hour a day, seven day a week access to interpreter and sign language services in languages spoken by those individuals eligible to receive the services provided by
the HMO or its providers. 

  

	 	b.	Provide an interpreter in time to assist adequately with all necessary care, including urgent and emergency care, when a recipient or provider requests interpreter services in a
specific situation where care is needed. The HMO must clearly document all such actions and results. This documentation must be available to the Department upon request. 

  

	 	c.	Use professional interpreters, as needed, where technical, medical, or treatment information or other matters, where impartiality is critical, are to be discussed or where use of a
family member or friend, as interpreter is otherwise inappropriate. Family members, especially children, should not be used as interpreters in assessments, therapy and other situations where impartiality is critical. 

  

	 	d.	Maintain a current list of “On Call” interpreters who can provide interpreter services. Provision of interpreter services must be in compliance with Title VI of the Civil
Rights Act. 

  

	 	e.	Designate a person responsible for the administration of interpreter/translation services. 

  

	 	f.	Receive Department approval of written policies and procedures for the provision of interpreter services. As part of the certification application, the HMOs must submit the policies
and procedures for interpreters, a list of interpreters the HMO uses, and the language spoken by each interpreter. 

  

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	 	J.	Prohibitions to Billing Enrollees 

  
 The HMO and its providers and subcontractors must not bill a Medicaid or BadgerCare enrollee for medically necessary services covered under this Contract
and provided during the enrollee’s period of HMO enrollment. The HMO and its providers and subcontractors must not bill a Medicaid or BadgerCare enrollee for copayments and/or premiums for medically necessary services covered under this
Contract and provided during the enrollee’s period of HMO enrollment. Any provider who knowingly and willfully bills a Medicaid or BadgerCare enrollee for a Medicaid covered service shall be guilty of a felony and upon conviction shall be
fined, imprisoned, or both, as defined in Section 1128B.(d)(1) [42 U.S.C. 1320a-7b] of the Social Security Act. This provision shall continue to be in effect even if the HMO becomes insolvent. 
  
 However, if an enrollee agrees in advance in writing to pay for a service
not covered by Medicaid or BadgerCare, then the HMO, HMO provider, or HMO subcontractor may bill the enrollee. The standard release form signed by the enrollee at the time of services does not relieve the HMO and its providers and subcontractors
from the prohibition against billing an enrollee in the absence of a knowing assumption of liability for a non-Medicaid or BadgerCare covered service. The form or other type of acknowledgment relevant to an enrollee’s liability must
specifically state the admissions, services, or procedures that are not covered by Medicaid and BadgerCare. 
  

	 	K.	HealthCheck 

  

	 	1.	HMO Responsibilities 

  

	 	a.	Provide HealthCheck services as a continuing care provider as defined in Article I, and according to policies and procedures in the Wisconsin Medicaid HealthCheck Provider Handbook
related to covered services. 

  

	 	b.	Provide HealthCheck screens upon request. For enrollees over one year of age, if an enrollee, parent or guardian of an enrollee requests a HealthCheck screen, the HMO must provide
such a screen within 60 days, if a screen is due according to the periodicity schedule. If the screen is not due within 60 days, then the HMO must schedule the appointment in accordance with the periodicity schedule. For enrollees up to one year of
age, if a parent or guardian of an enrollee requests a HealthCheck screen, the HMO must provide such a screen within 30 days, if a screen is due according to the periodicity schedule. If the screen is not due within 30 days, then the HMO must
schedule the appointment in accordance with the periodicity schedule. 

  

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	 	c.	Provide HealthCheck screens at a rate equal to or greater than 80% of the expected number of screens. The rate of HealthCheck screens will be determined by the calculation in the
HealthCheck Worksheet in Addendum VIII, D. The HMO may complete the worksheet on its own, periodically, as a means to monitor its HealthCheck screening performance. 

  
 HealthCheck data provided by the HMO must agree with its medical record documentation. For the purpose of the HealthCheck
recoupment process, the Department will not include any additional HealthCheck encounter records that are received after January 16, 2006, and 2007 for the year under consideration. (Please note: This date marks the end of the twelve and one half
month period of time from the end of the year under consideration. For example, for dates of service in 2004 the cut-off date will be January 16, 2006). 
  

	 	2.	Department Responsibilities 

  
 The Department will provide quarterly reports to inform the HMO of their progress in meeting the HealthCheck requirements. If the HMO provides fewer
screens in the contract year than 80%, the Department will: 
  

	 	a.	Recoup the funds provided to the HMO for the provision of the remaining screens. The following formula will be used: 

  
 (0.80 x A - B) x (C - D), where 
  

	 	A =	Expected number of screens (line 6 of HealthCheck Worksheet). 

  

	 	B =	Number of screens paid in the contract year as reported in the HMO’s Encounter Data Set as of January 16, 2006, and January 16, 2007. (The end of the twelve and one half month
period following the year under consideration.) 

  

	 	C =	*FFS maximum allowable fee (line 11 of the HealthCheck Worksheet). The FFS maximum allowable fee is the average maximum fee for the year. For example, if the maximum allowable fee
for HealthCheck is $50 from January through June, and $52 from July through December in one calendar year, then the average maximum allowable fee for the year is $51. 

  

	 	D =	HMO discount, if applicable. 

  

	 	b.	Determine the amount of the HMO’s HealthCheck recoupment, by Rate Region, excluding Dane, Eau Claire, Kenosha, Milwaukee and Waukesha counties, which will be determined
separately. Rate Regions are defined in Addendum III. 

  

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	 	c.	Determine the actual number of screens completed, for the recoupment calculation (line 8 of the Worksheet), by using the number of screens reported in the HMO’s Encounter
Database for calendar years 2004 and 2005 by Rate Region, except for Dane, Eau Claire, Kenosha, Milwaukee and Waukesha counties which will be determined separately. The Department will identify and retrieve the HealthCheck screening data from the
Encounter Database. 

  
 When assigning HealthCheck
screens to an age category, the Department will use the member’s age on the first day of the month in which the screening occurred. If a newborn enrollee is screened in the month of their birth, the newborn’s screen will be assigned to the
under one age category. 
  

	 	d.	Determine the number of eligible months and unduplicated enrollees (lines 1 and 2 of the Worksheet) per HMO per year by using the Medicaid Management Information System Recipient
Eligibility File. When calculating member months for each age category, the Department will use the member’s age on the first day of the month except for newborns. Newborns enrolled in an HMO in the month of their birth will be counted as
eligible from their date of birth. 

  
 Inform the
HMO in writing of its preliminary analysis of the HealthCheck data and allow the HMO 30 business days to review and respond to the calculations. If the HMO responds within 30 business days, the Department will review the HMO’s concerns and
notify the HMO of its final decision. If an HMO does not respond within 30 business days, the Department will send a “Notice of Intent to Recover” letter 40 days after the initial letter. 
  

	 	3.	HealthCheck Redesign Project 

  
 The Department is analyzing options for replacing the HMO HealthCheck utilization monitoring and recoupment process with a performance improvement
incentive system. The Department and HMOs will work closely on the HealthCheck redesign project. If the new system requires any changes to this contract, the Department will initiate an amendment to incorporate the changes. 
  

	 	L.	Marketing Plans and Informing Materials 

  
 As used in this section, “marketing materials, other marketing activities, and informing materials” include the production and dissemination of
any informing materials, marketing plans, marketing materials and other marketing activities that refer to Medicaid, Title XIX, BadgerCare, or Title XXI or are intended for Medicaid and BadgerCare recipients. This requirement includes marketing or

  

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informing materials that are produced by providers under contract to the HMO or owned by the HMO in whole or in part. 
  

	 	1.	Approval of Marketing and Informing Materials 

  
 HMOs must submit to the Department for prior written approval all informing materials, marketing plans, and all marketing materials and other marketing
activities that refer to Medicaid Title XIX, BadgerCare, or Title XXI or are intended for Medicaid and BadgerCare recipients. This requirement includes marketing or informing materials that are produced by providers under contract to the HMO or
owned by the HMO in whole or in part. 
  
 Marketing plans and
informing materials must be written at a “sixth grade comprehension level.” The Department will review them in a manner that does not unduly restrict or inhibit the HMO’s informing or marketing plans. When applying this provision to
specific marketing plans, informing materials and/or activities, the entire content and use of the informing/marketing materials or activities will be taken into consideration. The Department will review all materials as follows: 
  

	 	a.	The Department will review and either approve, approve with modifications, or deny all marketing or informing materials within ten business days of receipt of the informing
materials, except that informing, marketing materials and other marketing activities are deemed approved if there is no response from the Department within ten business days. 

  

	 	b.	Time-sensitive marketing or informing materials must be clearly marked time-sensitive by the HMO and will be approved, approved with modifications or denied by the Department within
three business days. The Department reserves the right to determine whether the material is, indeed, time-sensitive. 

  

	 	c.	The Department will not approve any materials it deems confusing, fraudulent, or misleading, or that do not accurately reflect the scope, philosophy, or covered benefits of the
Medicaid and BadgerCare program. 

  

	 	d.	Problems and errors the Department subsequently identifies must be corrected by the HMO when they are identified. The HMO agrees to comply with Ins. 6.07 and 3.27, Wis. Adm. Code,
and practices consistent with the Balanced Budget Amendment of 1997 P.L. 105-33 Sec. 4707(a) [42 U.S.C. 1396v(d)(2)]. 

  

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	 	2.	Prohibited Practices 

  

	 	a.	Practices that are discriminatory. 

  

	 	b.	Practices that seek to influence enrollment in conjunction with the sale of any other insurance product. 

  

	 	c.	Direct and indirect cold calls, either door-to-door or telephonic. 

  

	 	d.	Offer of material or financial gain to potential members as an inducement to enroll. 

  

	 	e.	Activities and material that could mislead, confuse or defraud consumers. 

  

	 	f.	Materials that contain false information. 

  

	 	g	Practices that are reasonably expected to have the effect of denying or discouraging enrollment. 

  

	 	3.	HMOs Agreement to Abide by Marketing/Informing Criteria 

  
 The HMO agrees to engage only in marketing activities and distribute only those informing and marketing materials that are pre-approved in writing. Any
activities must occur in its entire service area and only as indicated in the agreement. HMOs that fail to abide by these marketing requirements may be subject to any and all sanctions available under Article X. In determining any sanctions, the
Department will take into consideration any past unfair marketing practices, the nature of the current problem and the specific implications on the health and wellbeing of the Medicaid enrollees. In the event that an HMO’s affiliated provider
fails to abide by these requirements, the Department will evaluate whether the HMO should have had knowledge of the marketing issue and the HMO’s ability to adequately monitor ongoing future marketing activities of the subcontractor(s).

  

	 	M.	Reproduction/Distribution of Materials 

  
 Reproduce and distribute at HMO expense, according to a reasonable Department timetable, information or documents sent to the HMO from the Department that
contains information the HMO-affiliated providers must have in order to fully implement this Contract. 
  

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	 	N.	HMO ID Cards 

  
 The HMO may issue its own HMO ID cards. The HMO may not deny services to an enrollee solely for failure to present an HMO issued ID card. The Forward ID
card will always determine HMO enrollment, even where an HMO issues HMO ID cards. 
  

	 	O.	Open Enrollment 

  
 Conduct a continuous open enrollment period during which the HMO shall accept recipients eligible for coverage under this Contract in the order in which
they are enrolled. The HMO will not discriminate against individuals eligible to enroll on the basis of race, color, national origin or health status and will not use any policy or practice that has the effect of discriminating on the basis of race,
color, or national origin or health status. 
  

	 	P.	Selective Reporting Requirements 

  

	 	1.	Communicable Disease Reporting 

  
 As required by Wis. Stats. 252.05, 252.15(5)(a)6 and 252.17(7)(9b), Physicians, Physician Assistants, Podiatrists, Nurses, Nurse Midwives, Physical
Therapists, and Dietitians affiliated with a Medicaid HMO shall report the appearance, suspicion or diagnosis of a communicable disease or death resulting from a communicable disease to the Local Health Department for any enrollee treated or visited
by the provider. Reports of human immunodeficiency virus (HIV) infection shall be made directly to the State Epidemiologist. Such reports shall include the name, sex, age, residence, communicable disease, and any other facts required by the Local
Health Department and Wisconsin Division of Public Health. Such reporting shall be made within 24 hours of learning about the communicable disease or death or as specified in Wis. Adm. Code HFS 145.04, Appendix A. Charts and reporting forms on
communicable diseases are available from the Local Health Department. Each laboratory subcontracted or otherwise affiliated with the HMO shall report to the Local Health Department the identification or suspected identification of any communicable
disease listed in Wis. Adm. Rules 145, Appendix A. Reports of HIV infections shall be made directly to the State Epidemiologist. 
  

	 	2.	Fraud and Abuse Investigations 

  
 The HMO agrees to cooperate with the Department on fraud and abuse investigations. In addition, the HMO agrees to report allegations of fraud and abuse
(both provider and enrollee) to the Department within 15 days of the suspected fraud or abuse coming to the attention of the HMO. Failure on the part of HMOs to cooperate or report fraud and/or abuse may result in any applicable sanctions under
Article X. 
  

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	 	3.	Physician Incentive Plans 

  
 A physician incentive plan is any compensation arrangement between the HMO and a physician or physician group that may directly or indirectly have the
effect of reducing or limiting services provided with respect to individuals enrolled with the HMO. 
  
 The HMO shall fully comply with the physician incentive plan requirements specified in 42 CFR s. 417.479(d) through (g) and the requirements relating to
subcontracts set forth in 42 CFR s. 417.479(i), as those provisions may be amended from time to time. 
  
 ARTICLE IV 
  

	IV.	QUALITY ASSESSMENT/PERFORMANCE IMPROVEMENT (QAPI) 

  
 The HMO QAPI program must conform to the requirements of 42 CFR, Part 400, Medicaid Managed Care Requirements, Subpart D, QAPI. The program must also
comply with 42 CFR 434.34 which states that the HMO must have a QAPI system that: 
  

	 	•	Is consistent with the utilization control requirement of 42 CFR 456. 

  

	 	•	Provides for review by appropriate health professionals of the process followed in providing health services. 

  

	 	•	Provides for systematic data collection of performance and patient results. 

  

	 	•	Provides for interpretation of this data to the practitioners. 

  

	 	•	Provides for making needed changes.  

  

	 	A.	QAPI Program 

  
 The HMO must have a comprehensive QAPI program that protects, maintains, and improves the quality of care provided to Wisconsin Medicaid and BadgerCare
program recipients. 
  

	 	1.	The HMO must evaluate the overall effectiveness of its QAPI program annually to determine whether the program has demonstrated improvement, where needed, in the quality of care and
service provided to its Medicaid and BadgerCare population. 

  

	 	2.	 The HMO must have documentation of all aspects of the QAPI program available for Department review upon request. The Department may perform off-site and on-site
QAPI audits to ensure that the HMO is in compliance with contract requirements. The review and audit may 

  

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include: on-site visits; staff and enrollee interviews; medical record reviews; review of all QAPI procedures, reports, committee activities, including
credentialing and recredentialing activities, corrective actions and follow-up plans; peer review process; review of the results of the member satisfaction surveys, and review of staff and provider qualifications. 

  

	 	3.	The HMO must have a written QAPI work plan that is ratified by the board of directors and outlines the scope of activity and the goals, objectives, and time lines for the QAPI
program. New goals and objectives must be set at least annually based on findings from quality improvement activities and studies and results of the HMO on DHCF enrollee satisfaction surveys and MEDDIC-MS performance measures.

  

	 	4.	The HMO governing body is ultimately accountable to the Department for the quality of care provided to HMO enrollees. Oversight responsibilities of the governing body include, at a
minimum; approval of the overall QAPI program and an annual QAPI plan; designating an accountable entity or entities within the organization to provide oversight of QAPI; review of written reports from the designated entity on a periodic basis which
include a description of QAPI activities, progress on objectives, and improvements made; formal review on an annual basis of a written report on the QAPI program; and directing modifications to the QAPI program on an ongoing basis to accommodate
review findings and issues of concern within the HMO. 

  

	 	5.	The QAPI committee must be in an organizational location within the HMO such that it can be responsible for all aspects of the QAPI program. The committee membership must be
interdisciplinary and be made up of both providers and administrative staff of the HMO, including: 

  

	 	•	A variety of health professions (e.g., pharmacy, physical therapy, nursing, etc.). 

  

	 	•	Qualified professionals specializing in mental health or substance abuse and dental care on a consulting basis when an issue related to these areas arises. 

 

	 	•	A variety of medical disciplines (e.g., medicine, surgery, radiology, etc.). 

  

	 	•	OB/GYN and pediatric representation. 

  

	 	•	HMO management or governing body. 

  

	 	6.	 Enrollees of the HMO must be able to contribute input to the QAPI Committee. The HMO must have a system to receive enrollee input on quality improvement, document
the input received, document the HMO’s 

  

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response to the input, including a description of any changes or studies it implemented as the result of the input and document feedback to enrollees in
response to input received. The HMO response must be timely. 

  

	 	7.	The committee must meet on a regular basis, but not less frequently than quarterly. The activities of the QAPI Committee must be documented in the form of minutes and reports. The
QAPI Committee must be accountable to the governing body. Documentation of Committee minutes and activities must be available to the Department upon request. 

  

	 	8.	QAPI activities of HMO providers and subcontractors, if separate from HMO QAPI activities, must be integrated into the overall HMO/QAPI program. Requirements to participate in QAPI
activities, including submission of complete encounter data, are incorporated into all provider and subcontractor contracts and employment agreements. The HMO QAPI program shall provide feedback to the providers/subcontractors regarding the
integration of, operation of, and corrective actions necessary in provider/subcontractor QAPI efforts. Other management activities (Utilization Management, Risk Management, Customer Service, Complaints and Grievances, etc.) must be integrated with
the QAPI program. Physicians and other health care practitioners and institutional providers must actively cooperate and participate in the HMO’s quality activities. 

  
 The HMO remains accountable for all QAPI functions, even if certain functions are delegated to other entities. If the HMO
delegates any activities to contractors, the conditions listed in Article II “Delegations of Authority” must be met. 
  

	 	9.	There is evidence that HMO management representatives and providers participate in the development and implementation of the QAPI plan of the HMO. This provision shall not be
construed to require that HMO management representatives and providers participate in every committee or subcommittee of the QAPI program. 

  

	 	10.	The HMO must designate a senior executive to be responsible for the operation and success of the QAPI program. If this individual is not the HMO Medical Director, the Medical
Director must have substantial involvement in the QAPI program. The designated individual shall be accountable for the QAPI activities of the HMO’s own providers, as well as the HMO’s subcontracted providers. 

  

	 	11.	 The qualifications, staffing level and available resources must be sufficient to meet the goals and objectives of the QAPI program and related QAPI activities. Such
activities include, but are not limited to, monitoring and evaluation of important aspects of care and services, facilitating appropriate use of preventive services, monitoring provider performance, 

  

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provider credentialing, involving members in QAPI initiatives and conducting performance improvement projects. 

  
 Written documentation listing the staffing resources that are directly
under the organizational control of the person who is responsible for QAPI (including total FTEs, percent of time dedicated to QAPI, background and experience, and role) must be available to the Department upon request. 
  

	 	B.	Monitoring and Evaluation 

  

	 	1.	The QAPI program must monitor and evaluate the quality of clinical care on an ongoing basis. Important aspects of care (i.e., acute, chronic conditions, high volume, high-risk
preventive care and services) are studied and prioritized for performance improvement and/or development of practice guidelines. Standardized quality indicators must be used to assess improvement, ensure achievement of minimum performance levels
(Ref: MEDDIC-MS Measures and Technical Specifications), monitor adherence to guidelines, and identify patterns of over utilization and under utilization. The measurement of quality indicators selected by the HMO for areas other than those included
in MEDDIC-MS must be supported by appropriate data collection and analysis methods to improve clinical care and services. 

  

	 	2.	Provider performance must be measured against practice guidelines and standards adopted by the QAPI Committee. Areas identified for improvement must be tracked and corrective
actions taken when warranted. The effectiveness of corrective actions must be monitored until problem resolution occurs. Reevaluation must occur to ensure that the improvement is sustained. 

  

	 	3.	The HMO must use appropriate clinicians to evaluate the data on clinical performance, and multi-disciplinary teams to analyze and address data on systems issues.

  

	 	4.	The HMO must also monitor and evaluate care and services in certain priority clinical and non-clinical areas specified in Article IV, K, 3. 

  

	 	5.	The HMO must make documentation available to the Department upon request regarding quality improvement and assessment studies on plan performance, which relate to the enrolled
population. See reporting requirements in Article IV, K, “Performance Improvement Priority Areas and Projects.” 

  

	 	6.	 The HMO must develop or adopt practice guidelines that are disseminated to providers and to enrollees as appropriate or upon request. The guidelines are based on
valid and reliable medical evidence or consensus of health professionals; consider the needs of the enrollees; developed or 

  

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adopted in consultation with the contracting health professionals, and reviewed and updated periodically (42 CFR, §. 438.236.).

  
 Decisions with respect to utilization
management, enrollee education, coverage of services, and other areas to which the practice guidelines apply are consistent with the guidelines. Variations from the guidelines must be based on the clinical situation. 
  

	 	C.	Health Promotion and Disease Prevention Services 

  

	 	1.	The HMO must identify at-risk populations for preventive services and develop strategies for reaching Medicaid and BadgerCare members included in this population. Local health
departments and community-based health organizations can provide the HMO with special access to vulnerable and low-income population groups, as well as settings that reach at-risk individuals in their communities, schools and homes. Public health
resources can be used to enhance the HMO’s health promotion and preventive care programs. 

  

	 	2.	The HMO must have mechanisms for facilitating appropriate use of preventive services and educating enrollees on health promotion. At a minimum, an effective health promotion and
prevention program includes tracking preventive services, practice guidelines for preventive services, yearly measurement of performance in the delivery of such services, and communication of this information to providers and enrollees.

  

	 	D.	Provider Selection (Credentialing) and Periodic Evaluation (Recredentialing) 

  

	 	1.	The HMO must have written policies and procedures for provider selection and qualifications. For each practitioner, including each member of a contracting group that provides
services to the HMO’s enrollees, initial credentialing must be based on a written application, primary source verification of licensure, disciplinary status, eligibility for payment under Medicaid and certified for Medicaid. The HMO’s
written policies and procedures must identify the circumstances in which site visits are appropriate in the credentialing process. 

  
 The HMO may not employ or contract with providers excluded in Federal Health Care programs under either Section 1128 or Section 1128 A of the Social
Security Act. 
  

	 	2.	The HMO must periodically monitor (no less than every three years) the provider’s documented qualifications to ensure that the provider still meets the HMO’s specific
professional requirements. 

  

	 	3.	 The HMO must also have a mechanism for considering the provider’s performance. The recredentialing method must include updating all the information (except
medical education) utilized in the initial credentialing 

  

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process. Performance evaluation must include information from the QAPI system, reviewing enrollee complaints, and the utilization management system.

  

	 	4.	The selection process must not discriminate against providers such as those serving high-risk populations, or specialize in conditions that require costly treatment. The HMO must
have a process for receiving advice on the selection criteria for credentialing and recredentialing practitioners in the HMO’s network. 

  
 If the HMO declines to include groups of providers in its network, the HMO must give the affected providers written notice of the reason for its
decision. 
  

	 	5.	If the HMO delegates selection of providers to another entity, the organization retains the right to approve, suspend, or terminate any provider selected by that entity.

  

	 	6.	The HMO must have a formal process of peer review of care delivered by providers and active participation of the HMO’s contracted providers in the peer review process. This
process may include internal medical audits, medical evaluation studies, peer review committees, evaluation of outcomes of care, and systems for correcting deficiencies. The HMO must supply documentation of its peer review process upon request.

  

	 	7.	The HMO must have written policies that allow it to suspend or terminate any provider for quality deficiencies. There must also be an appeals process available to the provider that
conforms to the requirements of the HealthCare Quality Improvement Act of 1986 (42 USC §. 11101 etc. Seq.). 

  

	 	8.	The names of individual practitioners and institutional providers who have been terminated from the HMO provider network as a result of quality issues must be immediately forwarded
to the Department and reported to other entities as required by law (42 USC §. 11101 et. Seq.). 

  

	 	9.	Institutional Provider Selection: The HMO must determine and verify at specified intervals that: 

  

	 	a.	Each provider, other than an individual practitioner is licensed to operate in the state, if licensure is required, and in compliance with any other applicable state or federal
requirements; and 

  

	 	b.	The HMO verifies if the provider claims accreditation, or is determined by the HMO to meet standards established by the HMO itself. 

  

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	 	10.	Exceptions to credentialing and recredentialing requirements. 

  
 These standards do not apply to: 
  

	 	a.	Providers who practice only under the direct supervision of a physician or other provider, and 

  

	 	b.	Hospital-based providers such as emergency room physicians, anesthesiologists, and other providers who provide services only incident to hospital services. 

 
 These exceptions do not apply if the provider contracts independently
with the HMO. 
  

	 	E.	Enrollee Feedback on Quality Improvement 

  

	 	1.	The HMO must have a process to maintain a relationship with its enrollees that promotes two way communication and contributes to quality of care and service. The HMO must treat
members with respect and dignity. 

  

	 	2.	Annually, the Department will conduct a satisfaction survey of a representative sample of enrolled Medicaid and BadgerCare recipients. The Department will work with HMOs to develop
the survey instrument and plan. The HMO must have systems in place for acting on survey results and must report to the Department any quality management projects planned in response to survey results. 

  

	 	3.	The HMO is encouraged to find additional ways to involve Medicaid and BadgerCare enrollees in quality improvement initiatives and in soliciting enrollee feedback on the quality of
care and services the HMO provides. Other ways to bring enrollees into the HMO’s efforts to improve the health care delivery system include but are not limited to focus groups, consumer advisory councils, enrollee participation on the governing
board, the QAPI committees or other committees, or task forces related to evaluating services. All efforts to solicit feedback from enrollees must be approved by the Department. 

  

	 	F.	Medical Records 

  

	 	1.	 The HMO must have policies and procedures for participating provider medical records content and documentation that have been communicated to providers and a
process for evaluating its providers’ medical records based on the HMO’s policies. These policies must address patient confidentiality, organization and completeness, tracking, and important aspects of documentation such as accuracy,
legibility, and safeguards against loss, destruction, or unauthorized use. The HMO must also have confidentiality policies and procedures that are applicable to administrative functions that are concerned with confidential patient 

  

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information. Those policies must include information with respect to disclosure of enrollee-identifiable medical record and/or enrollment information and
specifically provide: 

  

	 	a.	That enrollees may review and obtain copies of medical records information that pertains to them. 

  

	 	b.	That policies above must be made available to enrollees upon request. 

  

	 	2.	Patient medical records must be maintained in an organized manner (by the HMO, and/or by the HMO’s subcontractors) that permits effective patient care, reflect all aspects of
patient care and be readily available for patient encounters, administrative purposes, and Department review. 

  

	 	3.	Because HMOs are considered contractors of the state and therefore (only for the limited purpose of obtaining medical records of its enrollees) entitled to obtain medical records
according to Wis. Adm. Code, HFS 104.01(3), the Department requires Medicaid-certified providers to release relevant records to the HMO to assist in compliance with this section. HMOs that have not specifically addressed photocopying expenses in
their provider contracts or other arrangements, are liable for charges for copying records only to the extent that the Department would reimburse on a FFS basis. 

  

	 	4.	The HMO must have written confidentiality policies and procedures in regard to individually-identifiable patient information. Policies and procedures must be communicated to HMO
staff, members, and providers. The transfer of medical records to out-of-plan providers or other agencies not affiliated with the HMO (except for the Department) are contingent upon the receipt by the HMO of written authorization to release such
records signed by the enrollee or, in the case of a minor, by the enrollee’s parent, guardian, or authorized representative. 

  

	 	5.	The HMO must have written quality standards and performance goals for participating provider medical record documentation and be able to demonstrate, upon request of the Department,
that the standards and goals have been communicated to providers. The HMO must actively monitor compliance with established standards and provide documentation of monitoring for compliance with the standards and goals upon request of the Department.

  

	 	6.	Medical records must be readily available for HMO-wide Quality Assessment/Performance Improvement (QAPI) and Utilization Management (UM) activities and provide adequate medical and
other clinical data required for QAPI/UM, and Department use. 

  

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	 	7.	The HMO must have adequate policies in regard to transfer of medical records to ensure continuity of care when enrollees are treated by more than one provider. This may include
transfer to local health departments subject to the receipt of a signed authorization form as specified in subsection 4 above (with the exception of immunization status information described in Article III, D, 8, which does not require enrollee
authorization). 

  

	 	8.	Requests for completion of residual functional capacity evaluation forms and other impairment assessments, such as queries as to the presence of a listed impairment, must be
provided within ten working days of the request (at the discretion of the individual provider and subject to the provider’s medical opinion of its appropriateness) and according to the other requirements listed above. The HMO and its providers
and subcontractor may charge the enrollee, authorized representative, or other third party a reasonable rate for the completion of such forms and other impairment assessments. Such rates may be reviewed by the Department for reasonableness and may
be modified based on this review. 

  

	 	9.	Minimum medical record documentation per chart entry or encounter must conform to the Wis. Adm. Code, Chapter HFS 106.02, (9)(b) Medical record content. 

  

	 	G.	Utilization Management (UM) 

  

	 	1.	The HMO must have documented policies and procedures for all UM activities that involve determining medical necessity, and the approval or denial of medical services. Qualified
medical professionals must be involved in any decision-making that requires clinical judgment. The decision to deny, reduce or authorize a service that is less than requested must be made by a health professional with appropriate clinical expertise
in treating the affected enrollee’s condition(s). Criteria used to determine medical necessity and appropriateness must be communicated to providers. The criteria for determining medical necessity may not be more stringent than HFS 101.03 (96m)
Wis. Adm. Code. 

  

	 	2.	If the HMO delegates any part of the UM program to a third party, the delegation must meet the requirements in Article II Delegations of Authority. 

  

	 	3.	If the HMO utilizes telephone triage, nurse lines or other demand management systems, the HMO must document review and approval of qualification criteria of staff and of clinical
protocols or guidelines used in the system. The system’s performance will be evaluated annually in terms of clinical appropriateness. 

  

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	 	4.	The HMO’s policies must specify time frames for responding to requests for initial and continued service determinations, specify information required for authorization
decisions, provide for consultation with the requesting provider when appropriate, and provide for expedited responses to requests for authorization of urgently needed services. In addition, the HMO must have in effect mechanisms to ensure
consistent application of review criteria for authorization decisions (interrater reliability). 

  

	 	a.	Within the time frames specified, the HMO must give the enrollee and the requesting provider written notice of: 

  

	 	1)	The decision to deny, limit, reduce, delay or terminate a service along with the reasons for the decision. 

  

	 	2)	The enrollee’s right to file a grievance or request a state fair hearing. 

  

	 	b.	Authorization decisions must be made within the following time frames and in all cases as expeditiously as the enrollee’s condition requires: 

  

	 	1)	Within 14 calendar days of the receipt of the request, or 

  

	 	2)	Within three business days if the physician indicates or the HMO determines that following the ordinary time frame could jeopardize the enrollee’s health or ability to regain
maximum function. 

  
 One extension of up to 14
calendar days may be allowed if the enrollee requests it or if the HMO justifies the need for more information. 
  
 On the date that the timeframes expire, HMO gives notice that service authorization decisions are not reached. Untimely service authorizations constitute
a denial and are thus adverse actions. 
  

	 	5.	Criteria for decisions on coverage and medical necessity are clearly documented, are based on reasonable medical evidence, current standards of medical practice, or a consensus of
relevant health care professionals, and are regularly updated. 

  

	 	6.	The HMO oversees and is accountable for any functions and responsibilities that it delegates to any subcontractor. (See Article II Delegations of Authority).

  

	 	7.	 Postpartum discharge policy for mothers and infants must be based on medical necessity determinations. This policy must include all follow-up tests and treatments
consistent with currently accepted medical practice 

  

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and applicable federal law. The policy must allow at least a 48-hour hospital stay for normal spontaneous vaginal delivery, and 96 hours for a cesarean
section delivery, unless a shorter stay is agreed to by both the physician and the enrollee. HMOs may not deny coverage, penalize providers, or give incentives or payments to providers or enrollees. Post hospitalization follow-up care must be based
on the medical needs and circumstances of the mother and infant. The Department may request documentation demonstrating compliance with this requirement. 

  

	 	H.	External Quality Review Contractor 

  

	 	1.	The HMO must assist the Department and the external quality review organization under contract with the Department in identification of provider and enrollee information required to
carry out on-site or off-site medical chart reviews. This includes arranging orientation meetings for physician office staff concerning medical chart review, and encouraging attendance at these meetings by HMO and physician office staff as
necessary. The provider of service may elect to have charts reviewed on-site or off-site. 

  

	 	2.	When the professional review organization under contract with the Department identifies an adverse health situation in which follow-up is needed to determine whether appropriate
care was provided, the HMO must: 

  

	 	a.	Assign a staff person(s) to conduct follow-up with the provider(s) concerning each adverse health situation identified by the Department’s external quality review organization,
including informing the provider(s) of the finding and monitoring the provider’s resolution of the finding; 

  

	 	b.	Inform the HMO’s QAPI Committee of the final finding and involve the QAPI Committee in the development, implementation and monitoring of the corrective action plan; and

  

	 	c.	Submit a corrective action plan or an opinion in writing to the Department within 60 days that addresses the measures that the HMO and the provider intend to take to resolve the
finding. The HMO’s final resolution of all cases must be completed within six months of HMO notification. A case is not considered resolved by the Department until the Department approves the response provided by the HMO and provider.

  

	 	3.	The HMO will facilitate training provided by the Department to its providers. 

  

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	 	I.	Dental Services Quality Improvement (Applies only to HMOs Covering Dental Services) 

  
 The HMO QAPI Committee and QAPI coordinator will review subcontracted dental programs quarterly to ensure that quality
dental care is provided and that the HMO and the contractor comply with the following: 
  

	 	1.	The HMO or HMO affiliated dental provider must advise the enrollee within 30 days of effective enrollment of the name of the dental provider and the address of the dental
provider’s site. The HMO or HMO affiliated dental provider must also inform the enrollee in writing how to contact his/her dentist (or dental office), what dental services are covered, when the coverage is effective, and how to appeal denied
services. 

  

	 	2.	An HMO or HMO affiliated dental provider who assigns all or some Medicaid and BadgerCare HMO enrollees to specific participating dentists must give enrollees at least 30 days after
assignment to choose another dentist. Thereafter, the HMO and/or affiliated provider must permit enrollees to change dentists at least twice in any calendar year and more often than that for just cause. 

  

	 	3.	HMO-affiliated dentists must provide a routine dental appointment to an assigned enrollee within 90 days after the request. Enrollee requests for emergency treatment must be
addressed within 24 hours after the request is received. 

  

	 	4.	Dental providers must maintain adequate records of services provided. Records must fully disclose the nature and extent of each procedure performed and should be maintained in a
manner consistent with standard dental practice. 

  

	 	5.	The HMO affirms by execution of this Contract that the HMO’s peer review systems are consistently applied to all dental subcontractors and providers. 

 

	 	6.	The HMO must document, evaluate, resolve, and follow up on all verbal and written complaints they receive from Medicaid/BadgerCare enrollees related to dental services.

  

	 	J.	Accreditation 

  

	 	1.	The Department encourages the HMO to actively pursue accreditation by the National Committee for Quality Assurance (NCQA), the Joint Commission on Accreditation of Healthcare
Organizations (JCAHO) or other recognized accrediting bodies approved by the Department. 42 CFR §. 438.360 provides that the Department may recognize “a private national accrediting organization that CMS has approved as applying standards
at least as stringent as Medicare under the procedures in §. 422.158.” 

  

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 The Centers for Medicare and Medicaid Services (CMS) has recognized the following accrediting bodies:
The National Committee for Quality Assurance (NCQA), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and the Accreditation Association for Ambulatory Health Care (AAAHC). The Department may recognize other accreditation
bodies as they may qualify for such recognition. 
  

	 	2.	The achievement of full accreditation by an accreditation body approved by the Department and satisfaction of the requirements of the HMO Accreditation Incentive Program as
specified by the Department will result in the HMO qualifying for the Accreditation Incentive. 

  
 Where accreditation standards conflict with the standard set forth in this Contract, the Contract prevails unless the accreditation standard is more
stringent. 
  

	 	K.	Performance Improvement Priority Areas and Projects 

  

	 	1.	The HMO must develop and ensure implementation of program initiatives to address the specific clinical needs that have a higher prevalence in the HMO’s enrolled population
served under this Contract. These priority areas must include clinical and non-clinical Performance Improvement projects. The Department strongly advocates the development of collaborative relationships among HMOs, local health departments,
community based behavioral health treatment agencies (both public and private), and other community health organizations to achieve improved services in priority areas and must report complete encounter data for all services provided. Linkages
between managed care organizations and public health agencies is an essential element for the achievement of the public health objectives, potentially reducing the quantity and intensity of services the HMO needs to provide. The Department and the
HMO are jointly committed to on going collaboration in the area of service and clinical care improvements by the development and sharing of “best practices” and use of encounter data-driven performance measures (MEDDIC-MS).

  
 The HMO must annually monitor and evaluate the
quality of care and services through performance improvement projects for at least two of the priority areas specified by the Department and listed in subsections 3. below, or an HMO may propose to address alternative performance improvement topics
by making a request in writing to the Department. In addition, to two performance improvement projects required under subsection 3 below the HMO may be required to conduct up to two additional performance improvement initiatives and submit reports
as required to achieve performance goals specified in the MEDDIC-MS technical specifications. The final or on-going status report for each project must be submitted by October 1, 2004, and October 1, 2005, or as may be specified in the MEDDIC-MS
technical specifications. The 

  

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performance improvement topic must take into account the prevalence of a condition among, or need for a specific service by, the HMO enrollees served under
this Contract; enrollee demographic characteristics and health risks; and the interest of consumers or purchasers in the aspect of care or services to be addressed. 
  
 The report for each performance improvement project must address each of the following points in order for the Department
to evaluate the reliability and validity of the data and the conclusions described in the study: 
  

	 	a.	Topic 

  

	 	1)	Is the topic important to the enrolled population? 

  

	 	b.	Can it be affected by the actions of the HMO? 

  

	 	1)	Was the process of the topic selection described? 

  

	 	c.	Method 

  

	 	1)	Was the method and procedure used to study the topic clear? 

  

	 	2)	Study question: 

  

	 	•	Was the study question clearly stated and consistent throughout the study? 

  

	 	•	Is the study question specific? 

  

	 	d.	Data Collection 

  

	 	1)	Was the data fully described in detail? 

  

	 	2)	Was the data appropriate to answer the study question? 

  

	 	3)	Was the data collection process fully described? 

  

	 	4)	Was the data collection appropriate to answer the study question? 

  

	 	5)	Were the data collectors appropriate to collect the data? 

  

	 	6)	Was interrater reliability adequate? 

  

	 	7)	Did the loss of data or subjects affect validity? 

  

	 	8)	Was the study time clear? 

  

	 	e.	Intervention (not applicable if the project is to establish a baseline only) 

  

	 	1)	Was the intervention fully described? 

  

	 	2)	Was the intervention practical (can it be widely implemented?) 

  

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	 	3)	Was the implementation of the intervention monitored and reported to ensure that it was done properly? 

  

	 	f.	Results and interpretation 

  

	 	1)	Was the data collected fully reported? 

  

	 	2)	Did the study include comparisons to give meaning to the results? 

  

	 	3)	Is the norm or standard expressed in a specific numerical manner? 

  

	 	4)	Is the goal, norm or standard appropriate to this population and study? 

  

	 	5)	Was the comparison group (if applicable) as close as possible to the population under study and were any differences acknowledged? 

  

	 	6)	If pre-and-post measures were used, was an explanation for the differences between the measures considered? 

  

	 	7)	Was assignment to groups random? 

  

	 	8)	Did the study appropriately use statistical testing? (x2 t-test, regression analysis, etc.)? 

  

	 	9)	Were the conclusions consistent with the results? 

  

	 	10)	Were data tables, figures and graphs consistent with the text? 

  

	 	11)	Did the study consider its limitations? 

  

	 	12)	Did the study conclude or imply causality when the supporting data is only correlational? 

  

	 	13)	Did the study include how to improve the study? 

  

	 	14)	Did the study present recommendations on the results? 

  

	 	15)	Did the report clearly state whether performance improvement goals were met (if an intervention was carried out), and if the goals were not met, was there an analysis of why not and
a plan for future action? 

  

	 	g.	Miscellaneous 

  

	 	1)	Was enrollee confidentiality protected? 

  

	 	2)	Did consumers participate in the study (other than as the subjects)? 

  

	 	3)	Did the study include cost/benefit analysis or some other consideration of financial impact? 

  

	 	4)	Were next steps described in detail? (Dates and timelines) 

  

	 	5)	Were the results and conclusions distributed throughout the HMO? 

  

	 	6)	Did table, figures and graphs convey their information clearly without reference to the report text? 

  

	 	7)	Did the study report include an accurate summary? 

  

	 	8)	Was the study clearly written? 

  

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	 	2.	Performance reporting will utilize standardized indicators appropriate to the performance improvement area or as specified in the MEDDIC-MS technical specifications. Minimum
performance levels must be specified for each performance improvement area, using normative standards derived from regional, national norms, or from norms established by an appropriate practice organization. Goals for improvement for the
“Priority Areas” listed in 3. of this section, may be set by the organization itself. 

  
 The organization must ensure that improvements are sustained through periodic audits of relevant data and maintenance of the interventions that resulted
in the improvement. The HMO agrees to open at least one new performance improvement project during the contract period. In all cases, not less than two performance improvement projects must be reported to the Department in any year and not less than
three different projects must be reported to the Department in 2004-2005. These projects are in addition to any that may be required as the result of sub-goal performance on any MEDDIC-MS Targeted Performance Improvement Measures. However, if the
HMO chooses to initiate or continue a project on a topic that coincides with a required MEDDIC-MS project, the Department will accept the report as fulfilling both requirements during the next contract year. 
  
 The organization must implement a performance improvement project in the
area if a quality improvement opportunity is identified. The HMO must report to the Department on each study, including those areas where the HMO will not pursue a performance improvement project. The Department will accept for fulfillment of the
above requirement Performance Improvement Project Reports arising out of voluntary HMO participation in collaborative quality improvement projects including, but not limited to, the Improving Birth Outcomes Project (IBOP), First Breath smoking
cessation project, Care Analysis Projects (CAP) or other collaborative efforts designated by the Department. In order to be accepted the project report by the HMO must meet all the content criteria described in Performance Improvement Project
Outline in subsection K, I. 
  

	 	3.	Clinical Priority Areas: 1) Prenatal services; 2) Identification of adequate treatment for high-risk pregnancies, including those involving substance abuse; 3) Evaluating the need
for specialty services; 4) Availability of comprehensive, ongoing nutrition education, counseling, and assessments; 5) Family Health Improvement Initiative: Smoking Cessation; 6) Enrollees with special health care needs; 7) Outpatient management of
asthma; 8) The provision of family planning services; 9) early postpartum discharge of mothers and infants; 10) STD screening and treatment; 11) High volume/high risk services selected by the HMO; 12) Prevention and care of acute and chronic
conditions; 13) Coordination and continuity of care; and 14) obesity. 

  

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 Non-Clinical Priority Areas: 1) Grievances, appeals and complaints; 2) Access to and availability of
services; 3) Enrollee satisfaction with HMO customer service; and 4) Satisfaction with services for enrollees with special health care needs or cultural competency of the HMO and its providers. 
  
 In addition, the HMO may be required to conduct performance improvement
projects specific to the HMO and to participate in one annual statewide project that may be specified by the Department. 
  

	 	4.	Performance Measurement and Improvement – MEDDIC-MS Medicaid Encounter Data-Driven Improvement Core Measure Set. 

  
 The Department will evaluate HMO performance using the MEDDIC-MS technical
specifications, based on HMO-supplied encounter data and other data (for selected measures). Evaluation of HMO performance on each measure will be conducted on timetables determined by the Department. The technical specifications for each measure
are established by the Department with HMO and other stakeholder input and are described in “MEDDIC-MS Measures and Technical Specifications,” as revised. 
  
 The Department will inform the HMO of its performance on each measure, whether the HMO’s performance satisfied the
goal requirements set by the Department and whether a performance improvement initiative by the HMO is required. The HMO will have 60 business days to review and respond to the Department’s performance report. When a performance improvement
initiative is required due to sub-goal performance on the measure, the HMO may request recalculation of the performance level based on new or additional data the HMO may supply, or if the HMO can demonstrate material error in the calculation of the
performance level. The Department will provide a tentative schedule of measure calculation dates to the HMO within 90 days of the beginning of each calendar year in the contract period. 
  
 MEDDIC-MS consists of targeted performance improvement measure (TPIMS) and monitoring measures. The specifications for each
TPIM includes denominator and numerator specifications, performance goals and requirements for actions to be taken when sub-goal performance occurs. 
  
 Unless otherwise noted within a specific targeted performance improvement measure, the Department may specify minimum performance levels and require that
the HMOs develop plans to respond to levels below the minimum performance levels. Additions, deletions or modifications to the Targeted Performance Improvement Measures and Monitoring Measures in the MEDDIC-MS Technical Specifications and goals must
be mutually agreed upon by the parties. The Department will give 90 days notice to the HMO of its intent to change any measures, technical specifications or goals. The HMO shall have the opportunity to 

  

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comment on the measure specifications, goals and implementation plan within the 90 day notice period. The Department reserves the right to require the HMO to
report such performance measure data as may be deemed necessary to monitor and improve HMO-specific or program-wide quality performance. 
  
 ARTICLE V 
  

	V.	FUNCTIONS AND DUTIES OF THE DEPARTMENT 

  
 In consideration of the functions and duties of the HMO contained in this Contract, the Department must: 
  

	 	A.	Eligibility Determination 

  
 Identify Medicaid and BadgerCare recipients who are eligible for enrollment in HMOs as a result of eligibility under the following eligibility status:

  

					
	 Med Stat

	  	 Cap Rate*

	  	 Description

	 31
	  	A	  	AFDC-Regular
	 32
	  	A	  	AFDC-Unemployed
	 38,39
	  	A	  	AFDC-Related, No Cash Payment
	 CC, CM, GC, PC
	  	A	  	Healthy Start Children
	 E2
	  	A	  	AFDC-Related, No Cash Payment
	 GE
	  	A	  	Healthy Start Children Ages 15-18
	 N1,N2
	  	A	  	Medicaid Newborn
	 UA
	  	A	  	AFDC-Related, Unemployed
	 WH
	  	A	  	AFDC Employed over 100 Hours a Month
	 X1, X2, X3, X4
	  	A	  	AFDC-Related, No Cash Payment
	 Bl
	  	A	  	BadgerCare – Income equal or greater than 100% of FPL, and less than or equal to 150% of FPL, Kids, No premium.
	 B4
	  	A	  	BadgerCare – Income equal or greater than 100% of FPL, and less than or equal to 150% of FPL, Adults, No premium.
	 B2
	  	A	  	BadgerCare – Income greater than 150% of FPL, and less than 185% of FPL, Kids, Premium.
	 B5
	  	A	  	Income greater than 150% of FPL, and less than 185% of FPL, Adults, Premium.
	 B3
	  	A	  	Income equal or greater than 185% of the FPL, and less than 200% of the FPL, Kids, Premium.
	 B6
	  	A	  	Income equal or greater than 185% of the FPL, and less than 200% of the FPL, Adults, Premium.
	 GP
	  	A	  	Income less than 100% of FPL, Adults Parents of OBRA kids (AFDC), No premium.
	 95
	  	B	  	Pregnant Women in Intact Families
	 A6, A7, A8,
	  	B	  	Pregnant Woman, IRCA Alien
	 E3, E4
	  	B	  	Extension for Pregnant Woman
	 PW, P1
	  	B	  	Healthy Start Pregnant Women

  

	 	*A  =	AFDC/Healthy Start Children/BadgerCare capitation rate. 

  

	 	*B  =	Pregnant Women Healthy Start capitation rate. 

  

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	 	B.	Enrollment 

  
 Promptly notify the HMO of all Medicaid and BadgerCare recipients enrolled in the HMO under this Contract. Notification will be effected through the HMO
Enrollment Reports. All recipients listed as an ADD or CONTINUE on either the Initial or Final HMO Enrollment Report are members of the HMO during the enrollment month. The reports will be generated in the sequence specified under HMO enrollment
reports Article V, E. These reports shall be in both tape and hard copy formats or available through electronic file transfer capability and will include Medical Status Codes. The Department will make all reasonable efforts to enroll pregnancy cases
as soon as possible. 
  

	 	C.	Disenrollment 

  
 Promptly notify the HMO of all Medicaid and BadgerCare recipients no longer eligible to receive services through the HMO under this Contract. Notification
will be effected through the HMO Enrollment Reports which the Department will transmit to the HMO for each month of coverage throughout the term of the Contract. The reports will be generated in the sequence under HMO enrollment reports Article V,
E. Any recipient who was enrolled in the HMO in the previous enrollment month, but does not appear as an ADD or CONTINUE on either the Initial or Final HMO Enrollment Report for the current enrollment month, is disenrolled from the HMO effective the
last day of the previous enrollment month. 
  

	 	D.	Enrollment Errors 

  
 The Department must investigate enrollment errors brought to its attention by the HMO. The Department must correct systems errors and human errors and
ensure that the HMO is not financially responsible for recipients that the Department determines have been enrolled in error. Capitation payments made in error will be recouped. 
  

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	 	E.	HMO Enrollment Reports 

  
 For each month of coverage throughout the term of the Contract, the Department will transmit “HMO Enrollment Reports” to the HMO. These reports
will provide the HMO with ongoing information about its Medicaid and BadgerCare enrollees and disenrollees and will be used as the basis for the monthly capitation claims described in Article VI, payments to the HMO. The HMO Enrollment Reports will
be generated in the following sequence: 
  

	 	1.	The Initial HMO Enrollment Report will list all of the HMO’s enrollees and disenrollees for the enrollment month that are known on the date of report generation. The Initial
HMO Enrollment Report will be available to the HMO on or about the twenty-first of each month. A capitation claim shall be generated for each enrollee listed as an ADD or CONTINUE on this report. Enrollees who appear as PENDING on the Initial Report
and are reinstated into the HMO prior to the end of the month will appear as a CONTINUE on the Final Report and a capitation claim will be generated at that time. 

  

	 	2.	The final HMO Enrollment Report will list all of the HMO’s enrollees for the enrollment month, who were not included in the Initial HMO Enrollment Report. The Final HMO
Enrollment Report will be available to the HMO by the first day of the capitation month. A capitation claim will be generated for every enrollee listed as an ADD or CONTINUE on this report. Enrollees in PENDING status will not be included on the
final report. 

  

	 	3.	The Department will provide HMOs with effective dates for medical status code changes, county changes and other address changes in each enrollment report to the extent that the
county reports these to the Department. 

  
 The
Department agrees to work with the HMOs to develop and implement a new schedule for the final enrollment report. The new schedule will be designed to maximize the HMO’s ability to process the information in the reports by the first of the
month. 
  

	 	F.	Utilization Review and Control 

  
 Waive, to the extent allowed by law, any present Department requirements for prior authorization, second opinions, co-payment, or other Medicaid
restrictions for the provision of contract services provided by the HMO to enrollees, except as may be provided in Article III, F. 
  

	 	G.	HMO Review 

  
 Submit to HMOs for prior approval materials that describe specific HMOs and that will be distributed by the Department or County to recipients.

  

	 	H.	Department Audit Schedule 

  
 HMOs will be notified approximately 30 days prior to regularly scheduled, routine audits being conducted via a letter from the Division of Health Care
Financing. The Department will develop an annual schedule of known audits for the next contract period. 
  

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	 	I.	HMO Review of Study or Audit Results 

  
 Submit to HMOs for a 30 business day review/comment period, Any Medicaid and BadgerCare HMO audits, the annual HMO Comparison Report, HMO Consumer
Satisfaction Reports, or any other Medicaid and BadgerCare HMO studies the Department releases to the public. 
  

	 	J.	Vaccines 

  
 Provide certain vaccines to HMO providers for administration to Medicaid and BadgerCare HMO enrollees according to the policies and procedures in the
Wisconsin Medicaid and BadgerCare Physicians Services Handbook. The Department will reimburse the HMO for the cost of vaccines that are newly approved during the contract year and not yet part of the Vaccine for Children program. The cost of the
vaccine shall be the same as the cost to the Department of buying the new vaccine through the Vaccine for Children program. The HMO retains liability for the cost of administering the vaccines. 
  

	 	K.	Coordination of Benefits 

  
 Maintain a report of recovered money reported by the HMO and its subcontractor.  
  

	 	L.	Wisconsin Medicaid Provider Reports 

  
 Provide a monthly electronic listing of all Wisconsin Medicaid certified providers to include, at a minimum, the name, address, Wisconsin Medicaid
provider ID number, and dates of certification in Wisconsin Medicaid. 
  

	 	M.	Enrollee Health Status and Primary Language Report 

  
 The Department will provide the HMO with an enrollee health status and primary language report of all enrollees who have agreed to participate with the
gathering of this data. The reports will be provided to the HMO on a monthly basis. The purpose of this report is to assist HMOs with continuity of care issues and with the identification of non-English speaking enrollees and to facilitate
appointments for enrollees who have urgent health care needs. 
  

	 	N.	Fraud and Abuse Training 

  
 The Department will provide fraud and abuse detection training to the HMOs annually. 
  

	 	O.	Provision of Data to HMOs 

  
 Provide to each HMO the following data related to the HMO’s members: 
  

	 	1.	Lead testing performed and sent to the State Lab of Hygiene for analysis. 

  

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	 	2.	Immunization information from the Wisconsin Immunization Registry to the extent available. The Department will make every effort to get the Wisconsin Immunization Registry
information to HMOs. 

  

	 	P.	Special Procedures for Retroactive Payment Adjustments for Pregnant BadgerCare Enrollees 

  
 The Department will develop and implement an automated procedure by which payment adjustments will be made for BadgerCare
enrollees who should have been designated as a Healthy Start Pregnant Woman. As long as the woman was enrolled in the HMO at the time of delivery, the adjustment will be made for up to seven months of enrollment before the delivery and two months
following the delivery. 
  
 ARTICLE VI 
  

	VI.	PAYMENT TO THE HMO 

  

	 	A.	Capitation Rates 

  
 In consideration of full compliance by the HMO with contract requirements, the Department agrees to pay the HMO monthly payments based on the capitation
rates specified in Addendum III. The HMO accepts the monthly capitation payment as payment in full except for cost payments from third party payers and payments under the contract for NICU, AIDS and Vent services. The HMO assumes full risk for the
cost of services covered by the capitation payment. The capitation rate does not include any amount for recoupment of losses incurred by the HMO under previous contracts nor does it include services that are not covered under the State Plan.

  
 The Department’s enhanced funding policies include NICU
risk sharing, ventilator dependent and AIDS/HIV enrollees. HMOs cannot submit a request for enhanced funding under more than one of the three funding policies for the same enrollee for the same date(s) of service. 
  

	 	B.	Actuarial Basis 

  
 The capitation rate is calculated on an actuarial basis recognizing the payment limits set forth in 42 CFR 438.6. 
  

	 	C.	Annual Negotiation of Capitation Rates 

  
 The monthly capitation rates set forth in this article are recalculated on an annual basis. The HMO will have 30 calendar days from the date of the
written notification to accept the new capitation rates in writing or to initiate termination or non-renewal of the Contract. The capitation rates are not subject to 

  

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renegotiation once they have been accepted, unless such renegotiation is required by changes in federal or state laws, rules or regulations. 
  

	 	D.	Reinsurance 

  
 The HMO may obtain a risk-sharing arrangement from an insurer other than the Department for coverage of enrollees under this Contract, provided that the
HMO remains substantially at risk for providing services under this Contract. 
  

	 	E.	Payment Schedule 

  
 Payment to the HMO is based on the HMO Enrollment Reports that the Department transmits to the HMO according to the schedule in Article V, E. Payment for
each person listed as an ADD or CONTINUE on the HMO Enrollment Reports shall be made by the Department within 60 days of the date the report is generated. Also, all retroactive capitation payments for newborns will be paid within 60 days of the
child’s first appearance on an enrollment report. (See Article VI, F.) Any claim that is not paid within these time limits will be denied by the Department and the recipient will be disenrolled from the HMO for the capitation month specified on
the claim. Notification of all paid and denied claims will be given through the weekly Remittance Status Report, which is available on both tape and hard copy. 
  

	 	F.	Capitation Payments For Newborns 

  
 The HMO will authorize provision of contract services to the newborn child of an enrolled mother for the first ten days of life. The child’s date of
birth should be counted as day one. In addition, if the child is reported within 100 days of the date of birth, the HMO will provide contract services to the child from its date of birth until the child is disenrolled from the HMO. The HMO will
receive a separate capitation payment for the month of birth and for all other months the HMO is responsible for providing contract services to the child. If the child is not reported within 100 days of the date of birth, the child will not be
retroactively enrolled into the HMO. In this case, the HMO is not responsible for payment of services provided prior to the child’s enrollment and will receive no capitation payments for that time period and may recoup payments from providers
for any services that were authorized in that 100 day time period. The providers who gave services in this 100 day time period may then bill the Department on a FFS basis. More detailed information for providers on billing the Department on a FFS
basis in these situations can be found in the Claims Submission section of the Wisconsin Medicaid and BadgerCare All-Provider handbook. 
  
 HMOs or their providers must complete an HMO Newborn Report (refer to the example and instructions in Addendum VIII, C. for newborns. The HMO will report
all births to the Department’s fiscal agent as soon as possible after the date of birth, but at least monthly. Prompt HMO reporting of newborns will facilitate retroactive enrollment and capitation payments for newborns, since this newborn
reporting will ensure the newborn’s Medicaid or BadgerCare eligibility for the 

  

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first 12 months of life contingent upon the newborn continuously residing with the mother. 
  
 The Department is analyzing the option to exempt from enrollment infants weighing less than 1200 grams. A field has been
added to the Medicaid and BadgerCare Newborn Report (Addendum VIII, C) to identify low birth-weight babies. This box should be checked if the infant weighs less than 1200 grams at birth. The Department will report the results of the analysis and
will work with the HMOs to implement a low birth-weight exemption if the data supports an exemption during this contract period. 
  

	 	G.	Coordination of Benefits (COB) 

  
 The HMO must actively pursue, collect and retain all monies from all available resources for services to enrollees covered under this Contract except
where the amount of reimbursement the HMO can reasonably expect to receive is less than the estimated cost of recovery (this exception does not apply to collections for AIDS and ventilator dependent patients), or except as provided in Article III,
F. COB recoveries will be done by post-payment billing (pay and chase) for certain prenatal care and preventive pediatric services. Post-payment billing will also be done in situations where the third party liability (TPL) is derived from a parent
whose obligation to pay is being enforced by the state Child Support Enforcement Agency and the provider has not received payment within 30 days after the date of service. 
  

	 	1.	Cost effectiveness of recovery is determined by, but not limited to time, effort, and capital outlay required to perform the activity. The HMO upon request of the Department, must
be able to specify the threshold amount or other guidelines used in determining whether to seek reimbursement from a liable third party, or describe the process by which the HMO determines seeking reimbursement would not be cost effective.

  

	 	2.	To ensure compliance, the HMO must maintain records of all COB collections and report them to the Department on a quarterly basis. The COB report must be submitted in the format
specified in Addendum VIII, B HMOs must be able to demonstrate that appropriate collection efforts and appropriate recovery actions were pursued. The Department has the right to review all billing histories and other data related to COB activities
for enrollees. HMOs must seek from all enrollees’ information on other available resources. HMOs must also seek to coordinate benefits before claiming reimbursement from the Department for the AIDS and ventilator dependent enrollees:

  

	 	a.	 Other available resources may include, but are not limited to, all other state or federal medical care programs that are primary to Medicaid, group or individual
health insurance, ERISAs, service benefit plans, the insurance of absent parents who may have 

  

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insurance to pay medical care for spouses or minor enrollees, and subrogation/worker’s compensation collections. 

  

	 	b.	Subrogation collections are any recoverable amounts arising out of the settlement of personal injury, medical malpractice, product liability, or Worker’s Compensation. State
subrogation rights have been extended to HMOs under s. 49.89(9), Act 31, Laws of 1989. After attorneys’ fees and expenses have been paid, the HMO will collect the full amount paid on behalf of the enrollee. 

  

	 	3.	Section 1912(b) of the Social Security Act must be construed in a beneficiary-specific manner. The purpose of the distribution provision is to permit the beneficiary to retain TPL
benefits to which he or she is entitled except to the extent that Medicaid (or the HMO on behalf of Medicaid) is reimbursed for its costs. The HMO is free, within the constraints of state law and this Contract, to make whatever case it can to
recover the costs it incurred on behalf of its enrollee. It can use the Medicaid fee schedule, an estimate of what a capitated physician would charge on a FFS basis, the value of the care provided in the market place, or some other acceptable proxy
as the basis of recovery. However, any excess recovery, over and above the cost of care (however the HMO chooses to define that cost), must be returned to the beneficiary. HMOs may not collect from amounts allotted to the beneficiary in a judgment
or court-approved settlement. The HMO must follow the practices outlined in the Department’s Casualty Recovery Manual. 

  

	 	4.	COB collections are the responsibility of the HMO or its subcontractors. Subcontractors must report COB information to the HMO. HMOs and subcontractors must not pursue collection
from the enrollee, but directly from the third party payer. Access to medical services must not be restricted due to COB collection. 

  

	 	5.	The following requirement applies if the Contractor (or the Contractor’s parent firm and/or any subdivision or subsidiary of either the Contractor’s parent firm or of the
Contractor) is a health care insurer (including, but not limited to, a group health insurer and/or health maintenance organization) licensed by the Wisconsin Office of the Commissioner of Insurance and/or a third-party administrator for a group or
individual health insurer(s), health maintenance organization(s), and/or employer self-insurer health plan(s): 

  

	 	a.	 Throughout the contract term, these insurers and third-party administrators must comply in full with the provision of subsection 49.475 of the Wisconsin Statutes.
Such compliance must include the routine provision of information to the Department in a manner and electronic format prescribed by the Department and based on a monthly schedule established by the Department. The type of 

  

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information provided must be consistent with the Department’s written specifications. 

  

	 	b.	Throughout the contract term, these insurers and third-party administrators must also accept and properly process post payment billings from the Department’s fiscal agent for
health care services and items received by Wisconsin Medicaid enrollees. 

  

	 	6.	If at any time during the contract term any of the insurers or third party administrators fail, in whole or in part, to adhere to the requirements of subsection 5, a or 5, b above,
the Department may take the remedial measures specified in Article XI, B, 2 and Article XI, C, 3, a. 

  

	 	H.	Recoupments 

  
 The Department will not normally recoup HMO per capita payments when the HMO actually provided services. However, if the Medicaid enrollee cannot use HMO
facilities, the Department will recoup HMO capitation payments. Such situations are described more fully below: 
  

	 	1.	The Department will recoup HMO capitation payments for the following situations where an enrollee’s HMO status has changed before the 1st day of a month for which a capitation
payment has been made: 

  

	 	a.	Enrollee moves out of the HMO’s service area 

  

	 	b.	Enrollee enters a public institution 

  

	 	c.	Enrollee dies 

  

	 	2.	The Department will recoup HMO capitation payments for the following situations where the Department initiates a change in an enrollee’s HMO status on a retroactive basis,
reflecting the fact that the HMO was not able to provide services. In these situations, recoupments for multiple month’s capitation payments are more likely: 

  

	 	a.	Correction of a computer or human error, where the person was never really enrolled in the HMO. 

  

	 	b.	Disenrollments of enrollees for reasons of pregnancy and continuity of care, or for reasons specified in Article III, F. 

  

	 	3.	If membership is disputed between two HMOs, the Department will be the final arbitrator of HMO membership and reserve the right to recoup an inappropriate capitation payment.

  

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	 	4.	If an HMO enrollee moves out of the HMO’s service area, the enrollee will be disenrolled from the HMO on the date the enrollee moved as verified by the eligibility worker. If
the eligibility worker is unable to verify the enrollee’s move, the HMO may mail a “certified return receipt requested” letter to the enrollee to verify the move. The enrollee must sign for the letter. A copy of the letter and the
signed return receipt must be sent to the Department or its designee within twenty days of the enrollee’s signature date. If this criteria is met the effective date of the disenrollment is the first of the month in which the certified returned
receipt requested letter was sent. Documentation that fails to meet the twenty-day criteria will result in disenrollment the first day of the month that the HMO supplied information to the Department or its designee. This policy does not apply to
extended service area requests that have been approved by the HMO unless the enrollee moves out of the extended service area or the HMO’s service area. Any capitation payment made for periods of time after disenrollment will be recouped.

  

	 	5.	If a contract is terminated, recoupments will be handled through a payment by the HMO within 30 business days of contract termination. 

  

	 	6.	If an HMO is unable to meet the HealthCheck requirements specified in Article III, K. 

  

	 	I.	Neonatal Intensive Care Unit (NICU) Risk-Sharing Payment(s) 

  
 The HMO may seek reimbursement as specified in Article VI, A. The Department will reimburse each HMO for a portion of the NICU costs incurred by the HMO
per county for those enrollees who meet the criteria defined in subsection 1 below and if the HMO’s average number of NICU days per thousand member years per county exceeds 75 days per thousand member years per county during the contract
period. 
  

	 	1.	Coverage Criteria 

  

	 	a.	NICU days cover any newborn transferred or directly admitted after birth to a Level II, Level III or Level IV SCN/NICD for treatment and/or observation under the care of a
neonatologist or pediatrician. NICU coverage continues until the infant is deemed medically stable to be discharged to a newborn nursery, medical floor or home. Level II, III, and IV facilities provide the following services:

  

	 	1)	Level II facilities provide a full range of services for low birth weight neonates who are not sick, but require frequent feeding, and neonates who require more hours of nursing
than do normal neonates. 

  

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	 	2)	Level III facilities provide a full range of newborn intensive care services for neonatal patients who do not require intensive care but require 6-12 hours of nursing each day.

  

	 	3)	Level IV facilities provide a full range of services for severely ill neonates who require constant nursing and continuous cardiopulmonary and other support.

  

	 	b.	NICU days also cover any newborn infant transferred or directly admitted after birth to a Level II, Level III or Level IV SCN/NICD who requires transfer to another institution for a
severe, compromised physical status, diagnostic testing or surgical intervention that cannot be provided at the hospital of initial admission. NICU coverage continues until the infant is transferred back to the initial hospital and deemed medically
stable to be discharged to a newborn nursery, medical floor or home. 

  

	 	2.	Reimbursement Criteria 

  

	 	a.	The HMO’s NICU reimbursement amount is calculated by contract period and by county. For NICU risk sharing, a “contract period” is defined as one calendar year.

  

	 	b.	The Department will reimburse the HMO for 90% of the HMO’s NICU cost per day, not to exceed a reimbursement of $1,443 per day, for each day that the HMO’s average number
of NICU days per thousand member years exceeds 75 NICU days per thousand member years per county during the contract period. 

  

	 	c.	The HMO’s NICU cost per day includes the HMO’s NICU inpatient payment per day and the HMO’s associated physician payments. Associated physician payments refer to the
total HMO payments made by the HMO to the physician(s) for services provided to the infant during the NICU stay. Associated physician payments are divided by the number of days reported for the NICU stay to determine the HMO’s payment per day
of associated physician payments. 

  
 Amounts paid
must include payments for all physician and hospital services that were provided during the report period regardless of the HMO’s actual payment date. 
  

	 	d.	 The Department makes the NICU reimbursement to the HMO after the end of the contract year, after the HMO has submitted all needed NICU data. The Department will
reimburse the HMO within 60 days of receipt of all necessary data from the HMO. The Department may make a final adjustment to the NICU reimbursement amount one year after the initial payment. This 

  

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adjustment will be based on adjustments to eligible months and, updated information from the HMO such as the number of NICU days, inpatient payments,
associated physician payments and amounts recovered from third parties. 

  

	 	e.	The number of eligible months for the NICU calculation includes Healthy Start Pregnant Women, AFDC and Healthy Start Children (refer to the NICU worksheet in Addendum VIII, E). The
Department will make the final determination regarding the number of eligible months for the NICU calculation by HMO, by county and by year, using the Medicaid Management Information System Recipient Eligibility File. 

  

	 	f.	Costs for care provided to NICU enrollees who are retroactively disenrolled under Article VIII of this Contract are not payable. The HMO must back out the costs of the care provided
during the backdated period from their NICU reports. 

  

	 	3.	Reporting Requirements 

  
 HMOs that choose to submit their report(s) under the NICU enhanced funding policy must follow the reporting requirements listed below: 
  

	 	a.	HMOs may submit an interim and a final report for each contract period if the NICU criteria are met. The HMO does not have to file a report if the NICU criteria are not met:

  

	 	1)	Interim reports must be submitted to the Department on or before May 1 of the following year (i.e., an interim report for the contract period May 1, 2004, through December 31, 2004,
must be submitted on or before May 1, 2005. 

  

	 	2)	Final reports must be submitted on or before May 1 one year after the submission of an interim report (i.e., a final report for the contract period May 1, 2004, through December 31,
2004, must be submitted on or before May 1, 2006). 

  

	 	b.	HMOs must submit all data by county and in the format requested by the Department for calculating the NICU reimbursement on or before May 1 of the following calendar year. The data
and data format requirements are defined in Addendum VIII, E. 

  

	 	c.	HMO’s must submit their NICU report(s) to the Department’s Contract Specialist as specified in Article VII, J. 

  

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	 	4.	Dispute Resolution 

  
 Disputes regarding the Department’s payment or nonpayment of NICU services as well an any adjustments made by the HMO (e.g., adjustments to provider
payments, NICU days or adjustments due to amounts recovered from third parties) must be submitted in the next report period as specified in Article VII, J. 
  

	 	J.	Payment(s) for AIDS/HIV and Ventilator Dependent Enrollees 

  
 The Department will pay 100% of the HMO’s costs of providing Medicaid covered services to HMO enrollees who meet the AIDS, HIV-positive or ventilator
dependent criteria in this section, by county. The HMO may seek reimbursement as specified in Article VI, A. 
  

	 	1.	Reimbursement criteria specific to each policy is defined below 

  

	 	a)	AIDS 

  
 For those enrollees with a confirmed diagnosis of AIDS, as indicated by an ICD-9-CM diagnosis code, the 100% reimbursement is effective on the first day of the month in which they were diagnosed as having AIDS.

  

	 	b)	HIV-positive 

  
 For those enrollees who are HIV-Positive and on antiretroviral drug treatment approved by the Food and Drug Administration, qualify for reimbursement.
The 100% reimbursement is effective on the first day of the month that the first antiretroviral medication was dispensed. If the name of the antiretroviral medication and the date it was started is unclear, the Department will use the HMO’s
pharmacy detail record(s) to determine the effective date of enhanced funding. 
  

	 	c)	Ventilator dependent 

  
 For the purposes of this reimbursement, a ventilator-assisted patient must have died while on total respiratory support or the patient must require
equipment that provides total respiratory support. This equipment may be a volume ventilator, a negative pressure ventilator, a continuous positive airway pressure (CPAP) system, or a Bi (inspiratory and expiratory) PAP. The patient may need a
combination of these systems. Any equipment used only for the treatment of sleep apnea does not qualify as total respiratory support. Total respiratory support must be required for a total of six or more hours per 24 hours. The patient must have
total respiratory support for at least 30 days that need not be continuous. 
  

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 The absolute need for the respiratory support must be supported by appropriate medical documentation.

  
 The period of enhanced funding starts on the first day of
the month that the patient was placed on ventilator support. It ends on the last day of the month that the patient is removed from the ventilator support, or at the end of the hospital stay, whichever is later. 
  
 Dates of enhanced funding are based on the following: 
  

	 	•	Day one is the day that the patient is placed on the ventilator. If the patient is on the ventilator for less than six hours on the first day, the use must continue into the next
day and be more than six total hours. 

  

	 	•	Each day that the patient is on the ventilator for part of any day, as long as it is part of the six total hours per 24 hours, counts as a day for enhanced funding.

  

	 	2.	Adjustments that will be made to the HMO’s final payment include but are not limited to 

  

	 	a.	Reimbursement(s) already paid to the HMO in the form of capitation payments for enrollees who qualify as being AIDS, HIV- positive or ventilator dependent will be deducted from the
HMOs 100% reimbursement. 

  

	 	b.	Costs for care provided to AIDS, HIV-positive or ventilator dependent enrollees who are retroactively disenrolled under Article VIII of this contract are not payable. The HMO must
back out the cost of the care provided during the backdated period from their reports. 

  

	 	3.	Reporting Requirements for AIDS, HIV-Positive and Ventilator Dependent Enrollees 

  

	 	a.	HMOs must submit detail reports on disk and hard copy and in the format specified in Addendum VIII, A of this Contract. 

  

	 	b.	HMOs must submit their reports to the Department’s fiscal agent Contract Monitor on a quarterly basis as specified in Article VII, J, of this Contract.

  

	 	c.	 As required by the Wis. Adm. Code HFS 106.03, payment data or adjustment data must be received by the Department’s fiscal agent within 365 days after the date
of the service. If the HMO cannot meet this requirement, the HMO must provide documentation that substantiates the delay. The Department will make the final 

  

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determination to pay or deny the services. The Department will exercise reasonable discretion in making the determination to waive the 365 day billing
requirement. 

  

	 	4.	Documentation Requirements for AIDS, HIV-Positive and Ventilator Dependent Enrollees 

  
 To qualify enrollees for reimbursement the HMO must submit the documentation that is required for each policy at the same
time as the quarterly reports identified in Article VII, J. HMOs may use the Department’s designated form or develop their own as long as it contains the required information as specified for each policy. 
  

	 	a.	AIDS documentation 

  
 A signed statement from a physician that indicates a confirmed diagnosis of AIDS and the diagnosis date must accompany each new request. 
  

	 	b.	HIV-positive documentation 

  
 A signed statement from the physician that the enrollee is HIV-Positive and on antiretroviral medications, the name of the drug and the date it was
started must accompany each new request. 
  

	 	c.	Ventilator dependent documentation 

  

	 	1)	A signed statement from the physician attesting to the need of the patient. 

  

	 	2)	Copies of progress notes that show the need for continuation of total ventilator support, any change in the type of ventilator support and the removal of the ventilatory support.
Copies of lab reports must be submitted if the progress notes do not include blood gas levels. 

  

	 	5.	Dispute Resolution 

  
 Disputes regarding the Department’s payment or nonpayment of AIDS, HIV-positive or ventilator dependent Medicaid services as well as any adjustments
made by the HMO (e.g., adjustments to provider payments or adjustments due to amounts recovered from third parties) must be submitted in the next report period as specified in Article VII, J. 
  

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 ARTICLE VII 
  

	VII.	COMPUTER/DATA REPORTING SYSTEM, DATA, RECORDS AND REPORTS 

  

	 	A.	Access to and/or Disclosure of Financial Records 

  
 The HMO and any subcontractors must make available to the Department, the Department’s authorized agents, and appropriate representatives of the U.S.
Department of Health and Human Services any financial records of the HMO or subcontractors that relate to the HMO’s capacity to bear the risk of potential financial losses, or to the services performed and amounts paid or payable under this
Contract. The HMO must comply with applicable record keeping requirements specified in HFS 105.02(1)-(7) Wis. Adm. Code, as amended. 
  

	 	B.	Access to and Audit of Contract Records 

  
 Throughout the duration of this Contract, and for a period of five years after termination of this Contract, the HMO must provide duly authorized
representatives of the state or federal government access to all records and material relating to the HMO’s provision of and reimbursement for activities contemplated under the Contract. Such access shall include the right to inspect, audit and
reproduce all such records and material and to verify reports furnished in compliance with the provisions of this Contract. All information so obtained will be accorded confidential treatment as provided under applicable laws, rules or regulations.

  

	 	C.	Abortions, Hysterectomies and Sterilization Reporting Requirements 

  
 The HMO shall comply with the following state and federal reporting and compliance requirements for the services listed below, for the entire HMO,
aggregating all service areas if the HMO has more than one service area: 
  

	 	1.	Abortions must comply with the requirements of Chapter 20.927, Wis. Stats., and with 42 CFR 441 Subpart E—Abortions. 

  

	 	2.	Hysterectomies and sterilizations must comply with 42 CFR 441 Subpart F—Sterilizations. 

  
 Sanctions in the amount of $10,000.00 may be imposed for non-compliance with the above special reporting and compliance
requirements. 
  

	 	3.	HMOs must abide by s. 609.30 Wis. Stats. 

  

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	 	D.	Computer Data Reporting System 

  
 The HMO must maintain a computer/data reporting system that meets the following Department requirements. The HMO is responsible for complying with all the
Department’s reporting requirements and with ensuring the accuracy and completeness of the data as well as the timely submission of data. The data submitted must be supported by records available to the Department or its designee. The
Department reserves the right to conduct on-site inspections and/or audits prior to awarding the Contract. The HMO must have a contact person responsible for the computer/data reporting system and who can answer questions from the Department and
resolve problems identified by the Department regarding the requirements listed below: 
  

	 	1.	The HMO must have a claims processing system that is adequate to meet all claims processing and retrieval requirements specified in this Contract, specifically Article III, D, 1.

  

	 	2.	The HMO must have a computer/data collection, processing, and reporting system sufficient to monitor HMO enrollment/disenrollment (in order to determine on any specific day which
recipients are enrolled or disenrolled from the HMO) and to monitor service utilization for the Utilization Management requirements of Quality Assessment/Performance Improvement (QAPI) that are specified in Article IV, G of this Contract.

  

	 	3.	The HMO must have a computer/data collection, processing, and reporting system sufficient to support the QAPI requirements described in Article IV. The system must be able to
support the variety of QAPI monitoring and evaluation activities, including the monitoring/evaluation of quality of clinical care and service (Article IV, B); periodic evaluation of HMO providers (Article IV, D, 2); member feedback on QAPI (Article
IV, E, 1 and 2); maintenance of and use of medical records in QAPI (Article IV, F, 6 and 9); and monitoring and evaluation of priority areas (Article IV, B). 

  

	 	4.	The HMO must have a computer and data processing system sufficient to accurately produce the data, reports, and encounter data set, in the formats and time lines prescribed by the
Department in this contract, that are included in Article VII, J of this Contract. Newly certified HMOs and HMOs who substantially change the IS system during the contract period are required to submit electronic test encounter data files as
required by the Department in the format specified in the HMO encounter data user manual and timelines specified in Article VII, J of this Contract and as may be further specified by the Department. The electronic test encounter data files are
subject to Department review and approval before production data is accepted by the Department. Production claims or other documented encounter data must be used for the test data files. 

  

 -93- 

	 	5.	The HMO must capture and maintain a claim record of each service or item provided to enrollees, using HCFA 1500, UB-92, NCPDP, HIPAA transaction code sets, or other claim, or claim
formats that are adequate to meet all reporting requirements of this Contact. The computerized database must be a complete and accurate representation of all services the HMO covers for the contract period. The HMO is responsible for monitoring the
integrity of the database, and facilitating its appropriate use for such required reports as encounter data and targeted performance improvement studies. 

  

	 	6.	The HMO must have a computer processing and reporting system that is capable of following or tracing an encounter within its system using a unique encounter record identification
number for each encounter. 

  

	 	7.	The HMO reporting system must have the ability to identify all denied claims/encounters using national HIPAA Claim Adjustment Reason. 

  

	 	8.	The HMO system must be capable of reporting original and reversed claim detail records and encounter records. 

  

	 	9.	The HMO system must be capable of correcting an error to the encounter record within 90 days of notification by the Department. 

  
 The HMO must notify the Department of all significant personnel changes and
system changes that may impact the integrity of the data, including new claims processing software and vendors. 
  

	 	E.	Coordination of Benefits (COB), Encounter Record, Formal Grievances and Birth Cost Reporting Requirements 

  
 The HMO agrees to furnish to the Department and to its authorized agents,
within the Department’s time frame and format, information that the Department requires to administer this Contract, including but not limited to the following: 
  

	 	1.	Coordination of Benefits (COB) 

  
 Summaries of amounts recovered from third parties for services rendered to enrollees under this Contract in the format specified in Addendum VIII, B.

  

	 	2.	Encounter Record for Each Enrollee Service 

  
 An encounter record for each service provided to enrollees covered under this Contract. The encounter data set must include at least those data elements
specified in section F of this Article. 
  

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 The encounter data set must be submitted no less frequently then monthly via electronic media. Refer to
Article I, Definitions, for the definition of an encounter. 
  

	 	3.	Formal Grievances 

  
 Copies of all formal grievances and documentation of actions taken on each grievance, as specified in section Addendum VIII, G. 
  

	 	4.	Birth Cost as specified in Addendum VIII, F  

  

	 	F.	Encounter Data Reporting Requirements 

  
 All HMOs that contract with the Department to provide Medicaid services must submit monthly encounter data files according to the specifications and
submission protocols published in the Wisconsin Medicaid HMO Encounter Data User Manual. 
  

	 	1.	Reporting Requirement 

  
 The rules governing the level of detail when reporting encounters should be those rules established by the following classification schemes: ICD-9-CM (or
ICD-10-CM) diagnosis codes and CPT procedure codes (HCPCS Level I codes), Level II HCPCS codes, Level III HCPCS codes, National Drug Codes (NDC), CDT-2 codes, Hospital revenue codes for inpatient and outpatient hospital services, and hospital
inpatient Diagnostic Related Group (DRG) codes, if DRG codes are used. 
  
 Multiple encounters can occur between a single provider and a single recipient on a day. For example, if a physician provides a limited office visit, administers an immunization, and takes a chest x-ray, and the
provider submits a claim or report specifically identifying all three services, then there are three encounters, and the HMO will report three encounters to the Wisconsin Medicaid Program. 
  

	 	2.	Testing Encounter Data 

  
 New HMOs must test the encounter data set until the Department is satisfied that the HMO is capable of submitting valid, accurate, and timely encounter
data according to the schedule and timetable in Article VII, J. 
  

	 	3.	Primary HMO Contact Person 

  
 Each HMO must specify to the Department the name of the primary contact person assigned responsibility for submitting and correcting HMO encounter and
utilization data, and a secondary contact person in the event the primary contact person is not available. 
  

 -95- 

	 	4.	HMO Encounter Technical Workgroup Requirement 

  
 All HMOs must assign staff to participate in HMO encounter technical workgroup meetings periodically scheduled by the Department. This workgroup’s
purpose is to enhance the HMO and Medicaid data submission protocols and improve the accuracy and completeness of the data. The HMO encounter technical workgroup is also responsible for planning the implementation of the 820 and 834 electronic
transaction formats mandated by the Health Insurance Portability and Accountability Act (HIPAA). 
  

	 	5.	Encounter Data Completeness and Accuracy 

  
 The Department will conduct data validity and completeness audits during the contract period. At least one of these audits will include a review of the
HMO’s encounter data system and system logic. 
  

	 	6.	Analysis of Encounter Data 

  
 The Department retains the right to analyze encounter data and use it for any purpose it deems necessary. However, the Department will make every effort
to ensure that the analysis does not violate the integrity of the reported data submitted by the HMO. 
  

	 	G.	Records Retention 

  
 The HMO must retain, preserve and make available upon request all records relating to the performance of its obligations under the contract, including
paper and electronic claim forms, for a period of not less than five years from the date of termination of this contract. Records involving matters that are the subject of litigation shall be retained for a period of not less than five years
following the termination of litigation. Microfilm copies of the documents contemplated herein may be substituted for the originals with the prior written consent of the Department, if the Department approves the microfilming procedures as reliable
and supported by an effective retrieval system. 
  
 Upon
expiration of the five year retention period and upon request, the subject records must be transferred to the Department’s possession. No records shall be destroyed or otherwise disposed of without the prior written consent of the Department.

  

 -96- 

	 	H.	Reporting of Corporate and Other Changes 

  
 The HMO must report to the Department any change in corporate structure or any other change in information previously reported. The HMO must report the
change as soon as possible, but not later than 30 days after the effective date of the change. Changes in information covered under this section include all of the following: 
  

	 	1.	Any change to the information the HMO previously provided in response to the Department’s questions in the current HMO Certification Application or any previous RFB for
Medicaid and BadgerCare HMO Contracts. This includes any change in information provided by the HMO as a “new HMO,” within the meaning of the HMO Certification Application or RFB. 

  

	 	2.	Any change in information relevant to Article III, C, 1 of this Contract, relating to ineligible organizations. 

  

	 	3.	Any change in information relevant to Addendum I, Part A, III and IIV of this Contract, relating to ownership and business transactions of the HMO. 

  

	 	I.	Provider List Requirement 

  
 All HMOs that contract with the Department to provide Medicaid services must submit provider data once per contract period, based on the HMO files as of
December 31, 2004. 
  
 The data must be provided in a Microsoft
Access database by January 31, 2005. A CD containing the database with instructions for the required fields will be provided by the Department by November 1, 2004. 
  

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	 	J.	Contract Specified Reports and Due Dates 

  
 REPORTS AND DUE DATES 
  

													
							
	 Due
 Date*

	  	 Type of Report

	  	 Reporting Period

	  	 Due to

	  	 Report Format

	  	 Reporting Unit

	  	 Contract Reference

							
	Within 15 days of contract signing	  	Civil Rights Compliance Plan: Affirmative Action Plan and Civil Rights Plan components	  	Contract period	  	DHFS	  	 	  	Affirmative Action/Civil Rights Compliance Office	  	Art. III, C, 4, a and b
							
	Within 30 days of contract signing	  	Disclosure Statements	  	As of present time	  	BMHCP	  	 	  	 	  	Add. I, Part A, III
						
	YEAR 2004	  	 	  	 	  	 	  	 	  	 
							
	Jan 1	  	Encounter Data File (AFDC/HS & BC)	  	Dec. 2003	  	Medicaid Fiscal Agent-MEDS	  	Electronic Media	  	Encounter	  	Art. VII, E and F
							
	Jan 15	  	**Dental Progress Report	  	Oct. – Dec. 2003	  	BMHCP	  	Hardcopy	  	Dental Service Area	  	Art. III, E, 8, c
							
	Jan 31	  	Formal/Informal Grievance Experience Summary report (AFDC/HS & BC)	  	Oct. – Dec. 2003	  	BMHCP	  	Hardcopy	  	Entire HMO	  	 Art. IX;
 Add. VIII, G

							
	Feb 1	  	Encounter Data File (AFDC/HS & BC)	  	Jan. 2004	  	Medicaid Fiscal Agent – MEDS	  	Electronic Media	  	Encounter	  	Art. VII, E and F
							
	Feb 1	  	AIDS/Ventilator Dependent (AFDC/HS & BC)	  	Oct. – Dec. 2003	  	Medicaid Fiscal Agent	  	Hardcopy & Disc	  	HMO Service Area	  	 Art. VI, J;
 Add. VIII, A

							
	Feb 7	  	Abortions/Sterilization/ Hysterectomies (AFDC/HS & BC)	  	Oct. – Dec. 2003	  	Medicaid Fiscal Agent	  	Hardcopy	  	Entire HMO	  	 Art. VII, C;
 Art. X, D, 3

							
	Feb 15	  	Federally Qualified Health Centers & Rural Health Centers (AFDC/HS & BC)	  	Oct. – Dec. 2003	  	BMHCP	  	Hardcopy – no form	  	By FQHC/RHC	  	Art, III, D, 7
							
	Feb 15	  	Coordination of Benefits Report (AFDC/HS & BC)	  	Oct. – Dec. 2003	  	Medicaid Fiscal Agent	  	Hardcopy	  	Entire HMO	  	 Art. VI, G;
 Add VIII, B

							
	Mar l	  	Encounter Data File AFDC/HS and BC)	  	Feb. 2004	  	Medicaid Fiscal Agent-MEDS	  	Electronic Media	  	Encounter	  	Art. VII, E and F
							
	Apr l	  	Encounter Data File (AFDC/HS & BC)	  	March 2004	  	Medicaid Fiscal Agent – MEDS	  	Electronic Media	  	Encounter	  	Art. VII, E and F
							
	Apr 15	  	**Dental Progress Report	  	Jan. – Mar. 2004	  	BMHCP	  	Hardcopy	  	Dental Service Area	  	Art. III, E, 8, c
							
	Apr 30	  	Formal/Informal Grievance Experience Summary report (AFDC/HS & BC)	  	Jan. – Mar. 2004	  	BMHCP	  	Hardcopy	  	Entire HMO	  	 Art. IX;
 Add. VIII, G

							
	May 1	  	Neonatal ICU Patient Care Data	  	Jan. – Dec. 2003	  	BMHCP	  	Hardcopy	  	 HMO By
 County
	  	 Art. VI, I;
 Add VIII, E

							
	May 1	  	Encounter Data File (AFDC/HS & BC)	  	Apr. 2004	  	Medicaid Fiscal Agent-MEDS	  	Electronic Media	  	Encounter	  	Art. VII, E and F

  

 -98- 

													
							
	 Due
Date*

	  	 Type of Report

	  	 Reporting Period

	  	 Due to

	  	 Report Format

	  	 Reporting Unit

	  	 Contract Reference

							
	May 1	  	AIDS/Ventilator Dependent
(AFDC/HS & BC)	  	Jan. – Mar. 2004	  	Medicaid Fiscal Agent	  	Hardcopy & Disc	  	HMO Service Area	  	Art. VI, J; Add.VIII, A
							
	May 7	  	Abortion/Sterilization/
Hysterectomies (AFDC/HS & BC)	  	Jan. – Mar. 2004	  	Medicaid Fiscal Agent	  	Hardcopy	  	Entire HMO	  	Art. VII, C; Art. X, D, 3
							
	May 15	  	Federally Qualified Health Centers & Rural Health Centers (AFDC/HS & BC)	  	Jan. – Mar. 2004	  	BMHCP	  	Hardcopy – no form	  	By FQHC/RHC	  	Art. III, D, 7
							
	May 15	  	Coordination of Benefits Report (AFDC/HS & BC)	  	Jan. – Mar. 2004	  	Medicaid Fiscal Agent	  	Hardcopy	  	Entire HMO	  	Art. VI, G; Add VIII, B
							
	Jun l	  	Encounter File (AFDC/HS & BC)	  	May 2004	  	Medicaid Fiscal Agent-MEDS	  	Electronic Media	  	Encounter	  	Art. VII, E and F
							
	Jul 1	  	Encounter File (AFDC/HS & BC)	  	Jun. 2004	  	Medicaid Fiscal Agent – MEDS	  	Electronic Media	  	Encounter	  	Art. VII, E and F
							
	Jul 15	  	**Dental Progress Report	  	Mar. – Jun. 2004	  	BMHCP	  	Hardcopy	  	Dental Service Area	  	Art. III, E, 8, c
							
	Jul 31	  	Formal/Informal Grievance
Experience Summary report
(AFDC/HS & BC)	  	Apr. – Jun. 2004	  	BMHCP	  	Hardcopy	  	Entire HMO	  	 Art. IX;
 Add. VIII, G

							
	Aug 1	  	AIDS/Ventilator Dependent (AFDC/HS & BC)	  	Apr. – Jun. 2004	  	Medicaid Fiscal Agent	  	Hardcopy & Disc	  	HMO Service Area	  	Art. VI, J; Add. VIII, A
							
	Aug 1	  	Encounter File (AFDC/HS & BC)	  	Jul. 2004	  	Medicaid Fiscal Agent-MEDS	  	Electronic Media	  	Encounter	  	Art. VII, E and F
							
	Aug 7	  	Abortions/Sterilization/
Hysterectomies (AFDC/HS & BC)	  	Apr. – Jun. 2004	  	Medicaid Fiscal Agent	  	Hardcopy	  	Entire HMO	  	 Art. VII, C;
 Art. X, D, 3

							
	Aug 15	  	Federally Qualified Health Centers & Rural Health Centers	  	Apr. – Jun. 2004	  	BMHCP	  	Hardcopy -no
form	  	By FQHC/RHC	  	Art. III, D, 7
							
	Aug 15	  	Coordination of Benefits Report (AFDC/HS & BC)	  	Apr. – Jun. 2004	  	Medicaid Fiscal Agent	  	Hardcopy	  	Entire HMO	  	 Art. VI, G;
 Add VIII, B

							
	Sept 1	  	Encounter File (AFDC/HS & BC)	  	Aug. 2004	  	Medicaid Fiscal Agent-MEDS	  	Electronic Media	  	Encounter	  	Art. VII, E and F
							
	Oct 1	  	Performance Improvement
Projects (AFDC/HS & BC)	  	Jan. – Dec. 2003	  	BMHCP	  	Hardcopy	  	Per Improvement Project	  	Art. IV, K
							
	Oct 1	  	Encounter File (AFDC/HS & BC)	  	Sep. 2004	  	Medicaid Fiscal Agent-MEDS	  	Electronic Media	  	Encounter	  	Art. VII, E and F
							
	Oct 15	  	**Dental Progress Report	  	Jul. – Sep. 2004	  	BMHCP	  	Hardcopy	  	Dental Service Area	  	Art. III, E, 8, c
							
	Oct 31	  	Formal/Informal Grievance
Experience Summary report
(AFDC/HS & BC)	  	Jul. – Sep. 2004	  	BMHCP	  	Hardcopy	  	Entire HMO	  	 Art. IX;
 Add. VIII, G

							
	Nov l	  	AIDS/Ventilator Dependent (AFDC/HS & BC)	  	Jul. – Sep. 2004	  	Medicaid Fiscal Agent	  	Hardcopy & Disc	  	HMO Service Area	  	 Art. VI, J;
 Add. VIII, A

							
	Nov l	  	Encounter File (AFDC/HS & BC)	  	Oct. 2004	  	Medicaid Fiscal Agent-MEDS	  	Electronic Media	  	Encounter	  	Art. VII, E and F

  

 -99- 

													
	 Due
Date*

	  	 Type of Report

	  	 Reporting Period

	  	 Due to

	  	 Report Format

	  	 Reporting Unit

	  	 Contract
Reference

							
	Nov 7	  	Abortions/Sterilization/
Hysterectomies (AFDC/HS & BC)	  	Jul. – Sep. 2004	  	Medicaid Fiscal Agent	  	Hardcopy	  	Entire HMO	  	Art. VII, C; Art. X, D, 3
							
	Nov 15	  	Federally Qualified Health Centers & Rural Health Centers (AFDC/HS & BC)	  	Jul. – Sep. 2004	  	BMHCP	  	Hardcopy - no form	  	By FQHC/RHC	  	Art. III, D, 7
							
	Nov 15	  	Coordination of Benefits Report
(AFDC/HS & BC)	  	Jul. – Sep. 2004	  	Medicaid Fiscal Agent	  	Hardcopy	  	Entire HMO	  	Art. VI, G;
Add VIII, B
							
	Dec 1	  	Encounter File (AFDC/HS & BC)	  	Nov. 2004	  	Medicaid Fiscal Agent-MEDS	  	Electronic Media	  	Encounter	  	Art. VII, E and F
	YEAR 2005	  	 	  	 	  	 	  	 	  	 
							
	Jan l	  	Encounter File (AFDC/HS & BC)	  	Dec. 2004	  	Medicaid Fiscal Agent-MEDS	  	Electronic Media	  	Encounter	  	Art. VII, E and F
							
	Jan 15	  	**Dental Progress Report	  	Oct. – Dec. 2004	  	BMHCP	  	Hardcopy	  	Dental Service Area	  	Art. III, E, 8, c
							
	Jan 31	  	Formal/Informal Grievance Experience Summary report
(AFDC/HS & BC)	  	Oct. – Dec. 2004	  	BMHCP	  	Hardcopy	  	Entire HMO	  	Art. IX;
Add. VIII, G
							
	Jan 31	  	Provider List on Tape	  	Dec. 31, 2004	  	BMHCP	  	Disc	  	HMO Service Area	  	Art. VII, I
							
	Feb 1	  	AIDS/Ventilator Dependent (AFDC/HS & BC)	  	Oct. – Dec. 2004	  	Medicaid Fiscal Agent	  	Hardcopy & Disc	  	HMO Service Area	  	Art. VI, J;
Add. VIII, A
							
	Feb l	  	Encounter File (AFDC/HS & BC)	  	Jan. 2005	  	Medicaid Fiscal Agent-MEDS	  	Electronic Media	  	Encounter	  	Art. VII, E and F
							
	Feb 7	  	Abortions/Sterilization/ Hysterectomies (AFDC/HS & BC)	  	Oct. – Dec. 2004	  	Medicaid Fiscal Agent	  	Hardcopy	  	Entire HMO	  	Art. VII, C;
Art. X, D, 3
							
	Feb 15	  	Federally Qualified Health Centers & Rural Health Centers (AFDC/HS & BC)	  	Oct. – Dec. 2004	  	BMHCP	  	Hardcopy - no form	  	By FQHC/RHC	  	Art. III, D, 7
							
	Feb 15	  	Coordination of Benefits Report (AFDC/HS & BC)	  	Oct. – Dec. 2004	  	Medicaid Fiscal Agent	  	Hardcopy	  	Entire HMO	  	Art. VI, G;
Add VIII, B
							
	Mar l	  	Encounter File (AFDC/HS & BC)	  	Feb. 2005	  	Medicaid Fiscal Agent-MEDS	  	Electronic File	  	Encounter	  	Art. VII, E and F
							
	Apr l	  	Encounter File (AFDC/HS & BC)	  	Mar. 2005	  	Medicaid Fiscal Agent-MEDS	  	Electronic File	  	Encounter	  	Art. VII, E and F
							
	Apr 15	  	**Dental Progress Report	  	Jan. – Mar. 2005	  	BMHCP	  	Hardcopy	  	Dental Service Area	  	Art. III, E, 8, c
							
	Apr 30	  	Formal/Informal Grievance Experience Summary report (AFDC/HS & BC)	  	Jan. – Mar. 2005	  	BMHCP	  	Hardcopy	  	Entire HMO	  	Art. IX;
Add. VIII, G
							
	May 1	  	Neonatal ICU Patient Care Data	  	Jan. – Dec. 2004	  	BMHCP	  	Hardcopy	  	 HMO By
 County
	  	Art. VI, I;
Add. VIII, E
							
	May 1	  	Encounter File (AFDC/HS & BC)	  	Apr. 2005	  	Medicaid Fiscal Agent-MEDS	  	Electronic File	  	Encounter	  	Art. VII, E and F

  

 -100- 

													
	 Due
Date*

	  	 Type of Report

	  	 Reporting Period

	  	 Due to

	  	 Report Format

	  	 Reporting Unit

	  	 Contract Reference

							
	May 1	  	AIDS/Ventilator Dependent
(AFDC/HS & BC)	  	Jan. –Mar. 2005	  	Medicaid Fiscal Agent	  	Hardcopy & Disc	  	HMO Service Area	  	Art. VI, J; Add. VIII, A
							
	May 7	  	Abortions/Sterilization/
Hysterectomies (AFDC/HS & BC)	  	Jan. – Mar. 2005	  	Medicaid Fiscal Agent	  	Hardcopy	  	Entire HMO	  	 Art. VII, C;
 Art. X, D, 3

							
	May 15	  	Federally Qualified Health Centers &
Rural Health Centers (AFDC/HS & BC)	  	Jan. – Mar. 2005	  	BMHCP	  	Hardcopy - no form	  	By FQHC/RHC	  	Art. III, D, 7
							
	May 15	  	Coordination of Benefits Report
(AFDC/HS & BC)	  	Jan. – Mar. 2005	  	Medicaid Fiscal Agent	  	Hardcopy	  	Entire HMO	  	 Art. VI, G;
 Add VIII, B

							
	Jun l	  	Encounter File (AFDC/HS & BC)	  	May 2005	  	Medicaid Fiscal Agent-MEDS	  	Electronic File	  	Encounter	  	Art. VII, E and F
							
	Jul 1	  	Encounter File (AFDC/HS & BC)	  	Jun. 2005	  	Medicaid Fiscal Agent-MEDS	  	Electronic File	  	Encounter	  	Art. VII, E and F
							
	Jul 15	  	**Dental Progress Report	  	Apr. – Jun. 2005	  	BMHCP	  	Hardcopy	  	Dental Service Area	  	Art. III, E, 8, c
							
	Jul 31	  	Formal/Informal Grievance
Experience Summary report
(AFDC/HS & BC)	  	Apr. – Jun. 2005	  	BMHCP	  	Hardcopy	  	Entire HMO	  	Art. IX;
Add. VIII, G
							
	Aug 1	  	AIDS/Ventilator Dependent
(AFDC/HS & BC)	  	Apr. – Jun. 2005	  	Medicaid Fiscal Agent	  	Hardcopy & Disc	  	HMO Service Area	  	Art. VI, J;
Add. VIII, A
							
	Aug 1	  	Encounter File (AFDC/HS & BC)	  	Jul. 2005	  	Medicaid Fiscal Agent-MEDS	  	Electronic File	  	Encounter	  	Art. VII, E and F
							
	Aug 7	  	Abortions/Sterilization/
Hysterectomies (AFDC/HS & BC)	  	Apr. – Jun. 2005	  	Medicaid Fiscal Agent	  	Hardcopy	  	Entire HMO	  	Art. VII, C;
Art. X, D, 3
							
	Aug 15	  	Federally Qualified Health Centers & Rural Health Centers (AFDC/HS & BC)	  	Apr. – Jun. 2005	  	BMHCP	  	Hardcopy -no form	  	By FQHC/RHC	  	Art. III, D, 7
							
	Aug 15	  	Coordination of Benefits Report
(AFDC/HS & BC)	  	Apr. – Jun. 2005	  	Medicaid Fiscal Agent	  	Hardcopy	  	Entire HMO	  	Art. VI, G;
Add VIII, B
							
	Sep l	  	Encounter File (AFDC/HS & BC)	  	Aug. 2005	  	Medicaid Fiscal Agent-MEDS	  	Electronic File	  	Encounter	  	Art. VII, E and F
							
	Oct 1	  	Performance Improvement Projects
(AFDC/HS & BC)	  	Jan. –Dec. 2004	  	BMHCP	  	Hardcopy	  	Per Improvement Project	  	Art. IV, K
							
	Oct 1	  	Encounter File (AFDC/HS & BC)	  	Sep. 2005	  	Medicaid Fiscal Agent-MEDS	  	Electronic File	  	Encounter	  	Art. VII, E and F
							
	Oct 15	  	**Dental Progress Report	  	Jul. – Sep. 2005	  	BMHCP	  	Hardcopy	  	Dental Service Area	  	Art III, E, 8 c
							
	Oct 31	  	Formal/Informal Grievance
Experience Summary report
(AFDC/HS & BC)	  	Jul. – Sep. 2005	  	BMHCP	  	Hardcopy	  	Entire HMO	  	Art. IX;
Add. VIII, G
							
	Nov l	  	AIDS/Ventilator Dependent
(AFDC/HS & BC)	  	Jul. – Sep. 2005	  	Medicaid Fiscal Agent	  	Hardcopy & Disc	  	HMO Service Area	  	Art. VI, J;
Add. VIII, A
							
	Nov l	  	Encounter File (AFDC/HS & BC)	  	Oct. 2005	  	Medicaid Fiscal Agent-MEDS	  	Electronic File	  	Entire HMO	  	Art. VII, E and F

  

 -101- 

													
	 Due
Date*

	  	 Type of Report

	  	 Reporting Period

	  	 Due to

	  	 Report Format

	  	 Reporting Unit

	  	 Contract Reference

							
	Nov 7	  	Abortions/Sterilization/
Hysterectomies (AFDC/HS & BC)	  	Jul. – Sep. 2005	  	Medicaid Fiscal Agent	  	Hardcopy	  	Entire HMO	  	Art. VII, C; Art. X, D, 3
							
	Nov 15	  	Federally Qualified Health Centers & Rural Health Centers (AFDC/HS & BC)	  	Jul. – Sep. 2005	  	BMHCP	  	Hardcopy -no form	  	By FQHC/RHC	  	Art. III, D, 7
							
	Nov 15	  	Coordination of Benefits Report
(AFDC/HS & BC)	  	Jul. – Sep. 2005	  	Medicaid Fiscal Agent	  	Hardcopy	  	Entire HMO	  	 Art. VI, G;
 Add VIII, B

							
	Dec 1	  	Encounter File (AFDC/HS & BC)	  	Nov. 2005	  	Medicaid Fiscal Agent-MEDS	  	Electronic File	  	Encounter	  	Art. VII, E and F

  
 Any reports that are due on a weekend
or holiday are due the following business day. 
  

	**	Only HMOs that are certified to provide dental services are required to submit dental progress reports for the service area in which the HMO is certified to provide dental.

  

							
				
	Report Mailing
Addresses:	  	 Medicaid Fiscal Agent - MEDS
 10 E. Doty Street, Suite
200
Madison, WI 53703
	  	 *BMHCP
 Department of Health and Family Services
Bureau of Managed Health Care Programs
P.O. Box 309
Madison, WI 53701-0309
	  	Medicaid Fiscal Agent Managed
Care Unit P.O. Box 6470 Madison,
WI 53716-0470
				
	 	  	 Department of Health and Family Services
 Affirmative Action/Civil Rights
 Compliance Office P.O. Box 7850 Madison, WI 53707-7850
	  	 	  	 

  

 -102- 

 ARTICLE VIII 
  

	VIII.	 ENROLLMENT AND DISENROLLMENTS 

  

	 	A.	Enrollment 

  
 The HMO must accept as enrolled all persons who appear as enrollees on the HMO Enrollment Reports and newborns as defined in Article I. Enrollment in the
HMO is voluntary by the recipient except where limited by departmental implementation of a State Plan Amendment or a Section 1115(a) waiver. The current State Plan Amendment and 1115(a) waiver require mandatory enrollment into an HMO for those
service areas in which there are two or more HMOs with sufficient slots for the HMO eligible population. The Department reserves the right to assign a Medicaid or BadgerCare recipient to a specific HMO when the recipient fails to choose an HMO
during a required enrollment period. 
  

	 	1.	Section 1115(A) Waiver and State Plan Amendment 

  
 If at any time during the contract period the Department obtains a State Plan Amendment, a waiver or revised waiver authority under the Social Security
Act (as amended), the conditions of enrollment described in this Contract, including but not limited to voluntary enrollment and the right to voluntary disenrollment, will be amended by the terms of said waiver and State Plan Amendment. 

 

	 	2.	Enrollee Lock-In Period 

  
 Under the Department’s State Plan Amendment and waiver authority of Section 1115(a) of the Social Security Act (as amended) enrollees in mandatory
HMO service areas will be locked in to an HMO for twelve months. The first 90 days of the 12-month lock-in period are open enrollment period during which the enrollee may change HMOs without cause. The conditions of disenrollment specified in
Article VIII, C, apply during this lock-in period. 
  

	 	3.	Enrollment Levels 

  
 As specified in Article XVI and Addendum X of this Contract, the HMO must designate its maximum enrollment level for its entire service area. The
Department may take up to 60 days from the date of written notification to implement maximum enrollment level changes. The HMO must accept as enrolled all persons who appear as enrollees on the HMO Enrollment Reports and newborns up to the HMO
specified enrollment level for its service area. The number of enrollees may exceed the maximum enrollment level by 5% on a temporary basis. The Department does not guarantee any minimum enrollment level. The maximum enrollment level for a service
area may be increased or decreased during 

  

 -103- 

 
the course of the contract period based on mutual acceptance of a different maximum enrollment level. 
  

	 	4.	Additional Health-Related Services 

  
 The HMO must not obtain enrollment through the offer of any compensation, reward, or benefit to the enrollee except for additional health-related
services that have been approved by the Department. 
  

	 	B.	Enrollment/Disenrollment Practices 

  
 The HMO must permit the Department to monitor its enrollment and disenrollment practices under this Contract. The HMO will not discriminate in
enrollment/disenrollment activities between individuals on the basis of health status or requirement for health care services, including those who have AIDS or are HIV-Positive. This includes an enrollee with a diminished mental capacity, who is
uncooperative and displays disruptive behavior due to the enrollee’s special needs. 
  
 The Department must ensure that recipients with medical status codes that are not eligible for HMO enrollment are appropriately disenrolled according to Department policy. 
  
 This section does not prevent the HMO from assisting in the disenrollment
process for individuals who the Department determines should be assigned a different medical status code. 
  

	 	C.	Disenrollment/Exemption Requests 

  
 All enrollees shall have the right to disenroll from the HMO pursuant to 42 CFR 434.27(b)(1) unless otherwise limited by a State Plan Amendment or a
Section 1115(a) waiver of federal laws, or pursuant to Article III, F. A voluntary disenrollment shall be effective no later than the first day of the second month following the month in which the enrollee requests termination. The HMO will promptly
forward to the Department or its designee all requests from enrollees for disenrollment. Wisconsin currently has a State Plan Amendment and an 1115(a) waiver which allows the Department to “lock-in” enrollees to an HMO for a period of 12
months in mandatory HMO service areas, except that disenrollment is allowed for good cause as described in subsections 1 through 14 below. The lock-in policy is described more completely in Section A, 2 above. Article III, F allows voluntary
exemptions and disenrollment from HMOs for a variety of reasons. 
  
 Disenrollment/exemption requests will be processed as soon as possible and will generally be effective the first day of the month of the request unless otherwise specified. Disenrollments/exemptions will not normally be backdated further.
The Department will not use its authority regarding backdating unreasonably. If the disenrollment or exemption is approved, the HMO will not be liable for 

  

 -104- 

 
services, as of the effective date of the disenrollment or exemption. If the Department fails to make a disenrollment determination within thirty days of
receipt of all necessary information the disenrollment is considered approved. 
  

	 	1.	AIDS or HIV-Positive Exemption 

  
 Enrollees with a confirmed diagnosis of AIDS, as indicated by an ICD-9-CM diagnosis code, or who are HIV-Positive and on anti retroviral drug treatment
approved by the Federal Food and Drug Administration, are eligible for an exemption. The HMO must not counsel or otherwise influence an enrollee or potential enrollee in such a way as to encourage exemption from enrollment or continued enrollment.

  
 Exemption requests must come from the casehead or the
enrollee and should be directed to the Department’s contracted Enrollment Specialist. Exemptions are processed as soon as possible and are effective on the first day of the month that anti retroviral treatment begins or the date that the
enrollee was diagnosed with AIDS. Exemptions are not backdated more than nine months from the date the request is received. 
  

	 	2.	Developmental Disability or Admission to a Birth to Three Program Exemption 

  
 A child from birth through two years of age (including two year olds), who is severely developmentally disabled or
suspected of a severe developmental delay, or who is admitted to a Birth to Three program is eligible for an exemption. Exemption requests must be made by the casehead of the enrollee or by the County Birth to Three programs, on behalf of an
enrollee. Exemption requests must be directed to the Department’s contracted Enrollment Specialist. 
  

	 	3.	Certified Nurse Midwives or Nurse Practitioners Exemption 

  
 Enrollees may be eligible for an exemption from enrollment if all of the following criteria are met: 
  

	 	a.	The enrollee resides in a service area of a certified nurse midwife or nurse practitioner. 

  

	 	b.	The enrollee chooses to receive her care from a certified nurse midwife or nurse practitioner. 

  

	 	c.	The certified nurse midwife or nurse practitioner is not affiliated with any HMO in the service area either as an independently certified provider or as a non-billing provider.

  
 Exemption requests are made by the casehead or
the enrollee and should be directed to the Department’s contracted Enrollment Specialist. 
  

 -105- 

	 	4.	Commercial HMO Insurance Exemption 

  
 Enrollees who have commercial HMO insurance may be eligible for an exemption or disenrollment from a Medicaid and BadgerCare HMO if the commercial HMO
does not participate in Medicaid. In addition, enrollees who have commercial insurance that limits them to a restricted provider network (e.g., PPOs, PHOs, etc.) may be eligible for an exemption from enrollment in a Medicaid and BadgerCare HMO or
disenrollment. 
  
 Exemption or disenrollment requests are made
by the enrollee and should be directed to the Department’s Enrollment Specialist. The HMO may request assistance from the Department’s contracted Enrollment Specialist in situations where the enrollee has commercial insurance that limits
the enrollee to providers outside the HMO’s network. 
  
 When the Department’s recipient eligibility file indicates commercial HMO coverage limiting an enrollee to providers outside the Medicaid HMO network, and the enrollee seeks services from the Medicaid HMO network providers, the
Medicaid HMO network providers may refuse to provide services to that enrollee and refer him/her to their commercial network, except in the case of an emergency. 
  

	 	5.	Federally Qualified Health Centers Exemption 

  
 Enrollees may be eligible for an exemption from enrollment if the following criteria are met: 
  

	 	a.	The enrollee resides in the service area of an FQHC. 

  

	 	b.	The enrollee chooses to receive their primary care from the FQHC. 

  

	 	c.	The FQHC is not affiliated with any HMO within the service area. 

  
 Exemption requests may be made by the casehead and should be directed to the Department’s Enrollment Specialist. 
  

	 	6.	Just Cause Disenrollment 

  
 The HMO may request and the Department will approve disenrollment for specific cases or persons where there is just cause. Just cause is defined as a
situation where enrollment would be harmful to the interests of the recipient or in which the HMO cannot provide the recipient with appropriate medically necessary contract services for reasons beyond its control. Disruptive behavior resulting from
diminished mental capacity from a special needs enrollee will not qualify as a just cause disenrollment. Disenrollment requests should be directed to the Department’s fiscal agent Contract Monitor. 
  

 -106- 

	 	7.	Inmates of a Public Institution Disenrollment 

  
 HMOs are not liable for providing care to enrollees who are inmates in a public institution for more than a full calendar month as defined in HFS
101.03(85). Disenrollment requests may be made by the HMO and should be directed to the Department’s fiscal agent Contract Monitor. The HMO must provide documentation that shows that the enrollee is incarcerated. The disenrollment will be
effective the first of the month following the incarceration. 
  

	 	8.	Medicare Beneficiaries 

  
 Enrollees who become eligible for Medicare will be disenrolled effective the first of the month of notification to the Medicaid and BadgerCare programs
from the Social Security Administration (SSA). Even if SSA awards Medicare eligibility retroactively, the effective date of HMO disenrollment will be the first of the month of notification. 
  

	 	9.	Mental Health and/or Substance Abuse Exemption 

  
 Requests for exemption from HMO enrollment must be initiated by the casehead or the enrollee who meets one or more of the following: 
  

	 	a.	A child meeting criteria for severe emotional disturbance (SED) who is enrolled or has been accepted in a SED program, such as intensive in-home psychotherapy or child/adolescent
day treatment, during the term of the SED treatment. 

  

	 	b.	A person participating in a methadone treatment program, or who has been determined to need methadone treatment unless the person declines to receive such treatment. Enrollees who
request exemption prior to participation in a methadone treatment program may be exempted for a maximum of two months, and the exemption may be extended if they continue to participate in the program. 

  

	 	c.	A person with a complex physical or psychiatric condition who has extensive non-medical programming needs are best provided or coordinated by the 51.42, 51.437, and/or social/human
services system. 

  
 When the HMO confirms that at
least one of these conditions exists, the HMO must inform the Medicaid or BadgerCare casehead of their options to enroll the affected enrollee in the HMO or to request that the person remain in the Medicaid FFS system. The HMO shall not encourage an
enrollee to request an exemption from enrollment or to continue enrollment. The Department, the local boards, and the county social 

  

 -107- 

 
service departments may notify enrollees or potential enrollees of their options independently where such notification is deemed appropriate. 
  

	 	10.	Native American Disenrollment 

  
 Enrollees who are Native American and members of a federally recognized tribe are eligible for disenrollment. 
  

	 	11.	Ninth Month Pregnancy Exemption 

  
 Enrollees who deliver or are expected to deliver the first month they are assigned to a HMO may be eligible for exemption. In order for exemption to
occur: 
  

	 	a.	The enrollee must have been automatically assigned or reassigned and must not have been in the HMO to which they were assigned or reassigned within the last seven months.; and

  

	 	b.	The enrollee must be seeking care from a provider (physician and/or hospital) not affiliated with the HMO to which they were assigned. 

  
 Exemption requests can be made by the HMO, a provider, or the enrollee.
Providers and HMOs should direct their exemption request to the Department’s fiscal agent Contract Monitor. Enrollees should direct their exemption request to the Department’s Enrollment Specialist. 
  

	 	12.	SSI Exemption and/or Disenrollment 

  
 Families may be eligible for an exemption from enrollment or be disenrolled if: 
  

	 	a.	There are one or more members in the family who are receiving SSI benefits, and 

  

	 	b.	The SSI member receives primary care from a provider who does not accept any Medicaid HMO, and 

  

	 	c.	Other family members receive their primary care from the same provider as the SSI member. 

  
 Exemption and disenrollment requests may be made by the SSI member, parent or guardian and should be directed to the
Department’s Enrollment Specialist. 
  

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	 	13.	Third Trimester Pregnancy Exemption 

  
 Enrollees who are in their third trimester of pregnancy when they are expected to enter an HMO may be eligible for exemption. In order for exemption to
occur: 
  

	 	a.	The enrollee must have been automatically assigned or reassigned to their current HMO; and 

  

	 	b.	The enrollee must be seeking care from a provider (physician and/or hospital) who is either not affiliated with the HMO to which they were assigned or is affiliated but the HMO is
closed to new enrollment. 

  
 Exemption requests
can only be made by the enrollee and/or casehead. Exemption requests must be made before the end of the second month in the HMO or before the birth, whichever occurs first. Exemption requests should be directed to the Enrollment Contractor or the
Department’s contracted Enrollment Specialist. 
  

	 	14.	Transplant Exemption 

  
 Enrollees who have had a transplant that is considered experimental such as a liver, heart, lung, heart-lung, pancreas, pancreas-kidney or bone marrow
transplant are eligible for an exemption: 
  

	 	a.	The person to get the transplant will be permanently exempted from HMO enrollment the first of the month in which surgery is performed. 

  

	 	b.	In the case of autologous bone marrow transplants, the person will be permanently exempted from HMO enrollment the date the bone marrow was extracted. 

  

	 	c.	Enrollees who have had one or more of the transplant surgeries referenced above prior to enrollment in an HMO will be permanently exempted. The effective date will be either the
first of the month not more than six months prior to the date of the request, or the first of the month of the HMO enrollment, whichever is later. Exemption requests may be made by the HMO. 

  

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 ARTICLE IX 
  

	IX.	GRIEVANCE PROCEDURES 

  
 The grievance process refers to the overall system that includes grievances and appeals as defined in Article I. Medicaid and BadgerCare enrollees may
grieve any aspect of service delivery provided or arranged by the HMO to the HMO and to the Department (described in Sections A and B below). The enrollee may appeal an action as defined in Article I to the HMO, the Department and/or to the Division
of Hearings and Appeals (described in Sections C and D below). 
  

	 	A.	Procedures 

  
 The HMO must: 
  

	 	1.	Have written policies and procedures that detail what the grievance system is and how it operates. 

  

	 	2.	Identify a contact person in the HMO to receive grievances and appeals and be responsible for routing/processing. 

  

	 	3.	Operate an informal, oral grievance process that enrollees can use to get problems resolved without going through the formal, written grievance process. 

  

	 	4.	Operate a formal grievance process that enrollees can use to grieve in writing. 

  

	 	5.	Inform enrollees about the existence of the formal and informal grievance processes and how to use the formal and informal grievance process. 

  

	 	6.	Attempt to resolve grievances and appeals informally. 

  

	 	7.	Respond to written grievances (i.e., formal grievances) and appeals in writing within ten business days of receipt, except that in cases of emergency or urgent (expedited grievance)
situations, HMOs must resolve the grievance or appeal within two business days of receiving the complaint or sooner if possible. This represents the first response. More complete procedures are described in Section B, of this Article.

  

	 	8.	Operate a grievance process within the HMO that enrollees can use to grieve or appeal any negative response to the Board of Directors of the HMO. The HMO Board of Directors may
delegate the authority to review grievances and appeals to an HMO grievance appeal committee, but the delegation must be in writing. If a grievance appeal committee is established, the Medicaid HMO Advocate must be a member of the committee.

  

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	 	9.	Grant the enrollee the right to appear in person before the grievance appeal committee to present written and oral information. The enrollee may bring a representative to the
meeting. The HMO must inform the enrollee in writing of the time and place of the meeting at least seven calendar days before the meeting. 

  

	 	10.	Maintain a record keeping “log” of informal grievances and appeals that includes a short, dated summary of each problem, the response, and the resolution. The log must
distinguish Medicaid and BadgerCare from commercial enrollees, if the HMO does not have a separate log for Medicaid and BadgerCare. The HMO must submit quarterly reports to the Department of all informal grievances and appeals. The analysis of the
log will include the number of informal grievances and appeals divided into two categories, program administration and benefit denials. 

  

	 	11.	Maintain a record keeping system for formal grievances and appeals that includes a copy of the original grievance or appeal, the response, and the resolution. The system must
distinguish Medicaid and BadgerCare from commercial enrollees. 

  

	 	12.	At the time of the HMO’s initial grievance denial decision the HMO must notify the enrollee that the grievance denial decision may be appealed to the Department.

  

	 	13.	Ensure that individuals with the authority to require corrective action are involved in the grievance process. 

  

	 	14.	Distribute to its gatekeepers* and IPAs the informational flyer on enrollee grievance and appeal rights (the ombudsman brochure). When a new brochure is available, the HMO must
distribute copies to its gatekeepers and IPAs within three weeks of receipt of the new brochure. 

  

	 	15.	Ensure that its gatekeepers* and IPAs have written procedures for describing how enrollees are informed of denied services. The HMO will make copies of the gatekeepers’ and
IPAs’ grievance procedures available for review upon request by the Department. 

  

	 	16.	Inform enrollees about the availability of interpreter services and provide interpreter services for non-English speaking and hearing impaired enrollees throughout the HMO’s
grievance process. 

  

	*	The word “gatekeeper” in this context refers to any entity that performs a management services contract, a behavioral health science IPA, or a dental IPA, and not to
individual physicians acting as a gatekeeper to primary care services. 

  

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	 	B.	Formal Grievance Process 

  
 The enrollee may choose to use the HMO’s formal grievance process or may appeal to the Department instead of using the HMO’s formal grievance
process. If the enrollee chooses to use the HMO’s process, the HMO must provide an initial response within ten business days and a final response within 30 calendar days of receiving the grievance or appeal. If the HMO is unable to resolve the
grievance or appeal within 30 calendar days, the time period may be extended another 14 calendar days from receipt if the HMO notifies the enrollee in writing that the HMO has not resolved the grievance or appeal, when the resolution may be
expected, and why the additional time is needed. The total timeline for HMOs to finalize a formal grievance or appeal may not exceed 45 calendar days from the date of the receipt. 
  
 Any formal grievance or appeal decision by the HMO may be appealed by the enrollee to the Department. The Department shall
review such appeals and may affirm, modify, or reject any formal decision of the HMO at any time after the enrollee files the formal appeal. The Department will give a final response within 30 days from the date the Department has all information
needed for a decision. Also, an enrollee can submit a formal, written grievance or appeal directly to the Department at any time during the grievance process. Any formal decision made by the Department under this section is subject to enrollee
appeal rights to the extent provided by State and Federal Laws and rules. The Department will receive input from the recipient and the HMO in considering grievances and appeals. 
  
 For an expedited grievance or appeal, the HMO must resolve all issues within two business days of receiving the written
request for an expedited grievance. The HMO must make reasonable effort to provide oral notice, in addition to written notice for the resolution. 
  
 The HMO must ensure that punitive action is not taken against anyone who either requests an expedited resolution or supports an enrollee’s appeal.

  

	 	C.	Denial, Termination, Suspension, or Reduction of Benefit Notifications to Enrollees 

  

	 	1.	When an HMO, its *gatekeepers, or its IPAs discontinues, terminates, suspends, limits, or reduces a service (including services authorized by an HMO the enrollee was previously
enrolled in or services received by the enrollee on a Medicaid FFS basis), the HMO must notify the affected enrollee(s), at least ten days before the date of action, in writing of the following: 

  

	 	a.	The nature of the intended action. 

  

	 	b.	The reasons for the intended action. 

  

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	 	c.	The circumstance under which a benefit will continue during the grievance process. 

  

	 	d.	The fact that if the enrollee continues to receive the disputed service, the enrollee may be liable for the care if the decision is adverse to the enrollee.

  

	 	e.	The fact that the enrollee if appealing the action must do so within 45 days. 

  

	 	f.	The fact that the enrollee has the right to examine the documentation the HMO used to make its determination. 

  

	 	g.	The fact that interpreter services are available free of charge during the grievance process and how the enrollee can access those services. 

  

	 	h.	The fact that the enrollee may bring a representative with him/her to the hearing. 

  

	 	i.	The fact that the enrollee may present “new” information during the grievance process. 

  

	 	j.	The process for requesting an oral or written expedited grievance or appeal. 

  

	 	k.	An explanation of the enrollee’s right to appeal the HMO’s decision to the Department. 

  

	 	l.	The fact that the enrollee, if appealing the HMO action, may file a request for a hearing with the Division of Hearings and Appeals (DHA) and the address of the DHA.

  

	 	m.	The fact that the enrollee can receive help in filing a grievance or appeal by calling either the Enrollment Specialist or the Ombudsman. 

  

	 	n.	The telephone number of both the Enrollment Specialist and the Ombudsman. 

  

	*	The word “gatekeeper” in this context refers to any entity that performs a management services contract, a behavioral health science IPA, or a dental IPA, and not to
individual physicians acting as a gatekeeper to primary care services. 

  

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 This notice requirement does not apply when an HMO, its gatekeeper or its IPA triages an enrollee to a
proper health care provider or when an individual health care provider determines that a service is medically unnecessary. 
  
 The Department must review and approve all notice language prior to its use by the HMO. Department review and approval will occur during the Medicaid
certification process of the HMO and prior to any change of the notice language by the HMO. 
  

	 	2.	If the enrollee files a request for a hearing with the DHA on or before the later of the effective date or within ten days of the HMO mailing the notice of action to reduce, limit,
terminate or suspend benefits, upon notification by the DHA the Department will: 

  

	 	a.	Notify the enrollee they are eligible to continue receiving care but may be liable for care if DHA overturns the decision; and 

  

	 	b.	Put the enrollee on FFS status effective the first of the month in which the enrollee received the termination, reduction, or suspension notice from the HMO; and:

  

	 	1)	If the DHA reverses the HMO’s decision, the Department will recoup from the HMO the amount paid for any benefits provided to the enrollee during the period of the
enrollee’s FFS status while the decision was pending. The enrollee will be reenrolled into the HMO following the resolution of the medical condition, the completion of medical, psychological or dental services or the end of medical necessity of
the service(s) unless the HMO has reversed its original decisions and agrees to reimburse the provider(s) for services provided to the enrollee during the administrative hearing process. 

  

	 	2)	If the DHA upholds the HMO’s decision, the Department may pursue reimbursement from the enrollee for all services provided to the enrollee during the FFS period. The enrollee
will be reenrolled into the HMO no later than the end of the second month following notification from the DHA. 

  
 Under FFS status the benefits must be continued until one of the following occurs: 
  

	 	•	The enrollee withdraws the appeal. 

  

	 	•	A state fair hearing decision adverse to the enrollee is made. 

  

	 	•	The authorization expires or the authorization service is met. 

  

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	 	D.	Denial of New Benefit Notifications to Enrollees 

  

	 	1.	When an HMO or its gatekeeper or IPA denies a new service, the HMO must notify the affected enrollee (s) in writing of the following: 

  

	 	a.	The nature of the intended action. 

  

	 	b.	The reasons for the intended action. 

  

	 	c.	The fact that enrollees who appeal the action must do so within 45 days. 

  

	 	d.	How the enrollee may request an expedited grievance or appeal. 

  

	 	e.	The fact that the enrollee may bring a representative to the hearing. 

  

	 	f.	The fact that the enrollee may present “new” information during the grievance process. 

  

	 	g.	The fact that the enrollee may review the documents used to make the decision. 

  

	 	h.	An explanation of the enrollee’s right to appeal the HMO’s decision to the Department. 

  

	 	i.	The fact that interpreter services are available free of charge during the grievance process and how the enrollee can access those services. 

  

	 	j.	The fact that the enrollee can receive help in filing a grievance or appeal by calling either the Enrollment Specialist or the Ombudsman. 

  

	 	k.	The telephone number of both the Enrollment Specialist and the Ombudsman. 

  

	 	2.	If the enrollee was not receiving the service prior to the denial, the HMO is not required to provide the benefit while the decision is being appealed. 

  
 HMO grievance procedures must be reviewed and approved by the Department
prior to signing the HMO Contract. All changes to HMO grievance procedures require prior review and approval by the Department. 
  

	 	E.	Reporting of Grievances to the Department 

  
 HMOs must forward both the formal and informal grievance reports to the Department within 30 days of the end of a quarter in the format specified in
Addendum VIII, G. Failure on the part of an HMO to submit the quarterly 

  

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grievance reports in the required format within five days of the due date may result in any or all sanctions available under Article X. 
  
 ARTICLE X 
  

	X.	REMEDIES FOR VIOLATION, BREACH, OR NON-PERFORMANCE OF CONTRACT 

  

	 	A.	Suspension of New Enrollment 

  
 Whenever the Department determines that the HMO is out of compliance with this Contract, the Department may suspend the HMO’s right to receive new
enrollment under this Contract. When exercising this option, the Department, must notify the HMO in writing of its intent to suspend new enrollment at least 30 days prior to the beginning of the suspension period. The suspension will take effect if
the non-compliance remains uncorrected at the end of this period. The Department may suspend new enrollment sooner than the time period specified in this paragraph if the Department finds that enrollee health or welfare is jeopardized. The
suspension period may be for any length of time specified by the Department, or may be indefinite. The suspension period may extend up to the expiration of the Contract as provided under Article XVI. 
  
 The Department may also notify enrollees of HMO non-compliance and provide
an opportunity to enroll in another HMO. 
  

	 	B.	Department-Initiated Enrollment Reductions 

  
 The Department may reduce the maximum enrollment level and/or number of current enrollees whenever it determines that the HMO has failed to provide one or
more of the contract services required under Article III or that the HMO has failed to maintain or make available any records or reports required under this Contract that the Department needs to determine whether the HMO is providing contract
services as required under Article III. The HMO will have at least 30 days to correct the non-compliance prior to the Department taking any action set forth in this paragraph. The Department may reduce enrollment sooner than the time period
specified in this paragraph if the Department finds that enrollee health or welfare is jeopardized. 
  

	 	C.	Other Enrollment Reductions 

  
 The Department may also suspend new enrollment or disenroll enrollees in anticipation of the HMO not being able to comply with federal or state law at its
current enrollment level. Such suspension shall not be subject to the 30-day notification requirement. 
  

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	 	D.	Withholding of Capitation Payments and Orders to Provide Services 

  
 Notwithstanding the provisions of Article VI, the Department may withhold portions of capitation payments as liquidated damages or otherwise recover
damages from the HMO on the following grounds: 
  

	 	1.	Whenever the Department determines that the HMO has failed to provide one or more of the medically necessary Medicaid covered contract services required under Article III, the
Department may either order the HMO to provide such service, or withhold a portion of the HMO’s capitation payments for the following month or subsequent months, such portion withheld to be equal to the amount of money the Department must pay
to provide such services. 

  
 If the Department
orders the HMO to provide services under this section and the HMO fails to provide the services within the timeline specified by the Department, the Department may withhold from the HMO’s capitation payments an amount up to 150% of the FFS
amount for such services. 
  
 When it withholds payments under
this section, the Department must submit to the HMO a list of the participants for whom payments are being withheld, the nature of the service(s) denied, and payments the Department must make to provide medically necessary services. 
  
 If the Department acts under this section and subsequently determines that
the services in question were not covered services: 
  

	 	a.	If the Department withheld payments, it will restore to the HMO the full capitation payment; or 

  

	 	b.	If the Department ordered the HMO to provide services under this section, it will pay the HMO the actual documented cost of providing the services. 

  

	 	2.	If the HMO fails to submit required data and/or information to the Department or the Department’s authorized agents, or fails to submit such data or information in the required
form or format, by the deadline specified by the Department, the Department may immediately impose liquidated damages in the amount of $1,500 per day for each day beyond the deadline that the HMO fails to submit the data or fails to submit the data
in the required form or format, such liquidated damages to be deducted from the HMO’s capitation payments. 

  

	 	3.	If the HMO fails to submit state and federal reporting and compliance requirements for abortions, hysterectomies and sterilizations, the Department may impose liquidated damages in
the amount of $10,000 per reporting period. 

  

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	 	4.	The term “erred encounter record” means an encounter record that has failed an edit when a correction is expected by the Department. If the HMO fails to correct an error
to the encounter record within the timeframe specified, the Department may assess liquidated damages of $5 per erred encounter record per month until the error has been corrected. The liquidated damage amount will be deducted from the HMO’s
capitation payment. When applied, these liquidated damages will be calculated and assessed on a monthly basis. 

  
 If upon audit or review, the Department finds that the HMO has removed an erred encounter record without the Department’s approval, the Department
may assess liquidated damages for each day from the date of original error notification until the date of correction. 
  
 The following criteria will be used prior to assessing liquidated damages: 
  

	 	•	The Department will calculate a percentage rate by dividing the number of erred records not corrected within 90 days (numerator), by the total number of records in error
(denominator) and multiply the result by 100. 

  

	 	•	Records failing non-critical edits, as defined in the Wisconsin Medicaid and BadgerCare HMO Encounter Data User Manual, will not be included in the numerator.

  

	 	•	If this rate is 2% or less, liquidated damages will not be assessed. 

  

	 	•	The Department will calculate this rate each month. 

  

	 	5.	Whenever the Department determines that the HMO has failed to perform an administrative function required under this Contract, the Department may withhold a portion of future
capitation payments. For the purposes of this section, “administrative function” is defined as any contract obligation other than the actual provision of contract services. The amount withheld by the Department under this section will be
an amount that the Department determines in the reasonable exercise of its discretion to approximate the cost to the Department to perform the function. The Department may increase these amounts by 50% for each subsequent non-compliance.

  
 Whenever the Department determines that the
HMO has failed to perform the administrative functions defined in Article VI, G, 1 and 2, the Department may withhold a portion of future capitation payments sufficient to directly compensate the Department for the Medicaid and BadgerCare
program’s costs of providing health care services and items to individuals insured by said insurers and/or the insurers/employers represented by said third party administrators. 
  

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	 	6.	In any case under this Contract where the Department has the authority to withhold capitation payments, the Department also has the authority to use all other legal processes for
the recovery of damages. 

  

	 	7.	Notwithstanding the provisions of this subsection, in any case where the Department deducts a portion of capitation payments under subsection 2 above, the following procedures will
be used: 

  

	 	a.	The Department will notify the HMO’s contract administrator no later than the second business day after the Department’s deadline that the HMO has failed to submit the
required data or the required data cannot be processed. 

  

	 	b.	Beginning on the second business day after the Department’s deadline, the HMO will be subject without further notification to liquidated damages per data file or report.

  

	 	c.	If the HMO submits encounter data late but submits it within five business days from the deadline, the Department will rescind liquidated damages if the data can be processed
according to the criteria published in the Wisconsin Medicaid and BadgerCare HMO Encounter Data User Manual. The Department will not edit the data until the process period in the subsequent month. 

  

	 	d.	If the HMO submits any other required data or report but in the required format within five business days from the deadline, the Department will rescind liquidated damages and
immediately process the data or report. 

  

	 	e.	If the HMO repeatedly fails to submit required data or reports, or submits data that cannot be processed, the Department will require the HMO to develop an action plan to comply
with the contract requirements that must meet Department approval. 

  

	 	f.	After the corrective action plan has been implemented, if the HMO continues to submit data beyond the deadline, or continues to submit data that cannot be processed, the Department
will invoke the remedies under Article X, section A (Suspension of New Enrollment), from section B (Department-Initiated Enrollment Reductions), or both, in addition to liquidated damages that may have been imposed for a current violation.

  

	 	g.	 If an HMO notifies the Department that it will discontinue contracting with the Department at the end of a contract period, but reports or data are due for a
contract period, the Department retains the right to withhold up to two months of capitation payments otherwise due the HMO that will not be released to the HMO until all required reports or data are submitted and accepted after 

  

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expiration of the Contract. Upon determination by the Department that the reports and data are accepted, the Department will release the monies withheld.

  

	 	E.	Inappropriate Payment Denials 

  
 HMOs that inappropriately fail to provide or deny payments for services may be subject to suspension of new enrollments, withholding, in full or in part,
of capitation payments, contract termination, or refusal to contract in a future time period, as determined by the Department. The Department will select among these sanctions based upon the nature of the services in question, whether the failure or
denial was an isolated instance or a repeated pattern or practice, and whether the health of an enrollee was injured, threatened or jeopardized by the failure or denial. These sanctions apply not only to cases where the Department has ordered
payment after appeal, but also to cases where no appeal was made (i.e., the Department knows about the documented abuse from other sources). 
  

	 	F.	Sanctions 

  
 Section 1903(m)(5)(B)(ii) of the Social Security Act vests the Secretary of the Department of Health and Human Services with the authority to deny
Medicaid payments to an HMO for enrollees who enroll after the date on which the HMO has been found to have committed one of the violations identified in the federal law. State payment for enrollees of the contracting organization is automatically
denied whenever, and for so long as, federal payment for such enrollees has been denied as a result of the commission of such violations. 
  

	 	G.	Sanctions and Remedial Actions 

  
 The Department may pursue all sanctions and remedial actions with HMOs that are taken with Medicaid FFS providers, including any civil penalties not to
exceed the amounts specified in the Balanced Budget Amendment of 1997 P.L. 105-33 Sec. 4707(a) [42 U.S.C. 1396v(d)(2)]. 
  
 ARTICLE XI 
  

	XI.	TERMINATION AND MODIFICATION OF CONTRACT 

  

	 	A.	Termination by Mutual Consent 

  
 This Contract may be terminated at any time by mutual written agreement of both the HMO and the Department. 
  

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	 	B.	Unilateral Termination 

  
 This Contract between the parties may be terminated by either party as follows: 
  

	 	1.	Either party may terminate this Contract at any time, due to modifications mandated by changes in federal or state laws, rules or regulations that materially affect either
party’s rights or responsibilities under this Contract. At least 90 days prior to the proposed date of termination, the party initiating the termination must notify the other party of its intent to terminate this Contract. Termination by the
Department under these circumstances shall impose an obligation upon the Department to pay the Contractor’s reasonable and necessarily incurred termination expenses. 

  

	 	2.	Either party may be terminate this Contract at any time if it determines that the other party has substantially failed to perform any of its functions or duties under this Contract.
The party exercising this option must notify the other party in writing of this intent to terminate this Contract and give the other party 30 days to correct the identified violation, breach or non-performance of Contract. If such violation, breach
or non-performance of Contract is not satisfactorily addressed within this time period, the exercising party may terminate this Contract. The termination date shall always be the last day of a month. The Contract may be terminated by the Department
sooner than the time period specified in this paragraph if the Department finds that enrollee health or welfare is jeopardized by continued enrollment in the HMO. A “substantial failure to perform” for purposes of this paragraph includes
any violation of any requirement of this Contract that is repeated or ongoing, that goes to the essentials or purpose of the Contract, or that injures, jeopardizes or threatens the health, safety, welfare, rights or other interests of enrollees.

  

	 	3.	 Either party may terminate this Contract if federal or state funding of contractual services rendered by the Contractor become or will become permanently
unavailable. In the event it becomes evident State or Federal funding of claims payments or contractual services rendered by the Contractor will be temporarily suspended or unavailable, the Department shall immediately notify the Contractor, in
writing, identifying the basis for the anticipated unavailability or suspension of funding. Upon such notice, the Department or the Contractor may suspend performance of any or all of the Contractor’s obligations under this Contract if the
suspension or unavailability of funding will preclude reimbursement for performance of those obligations. The Department or Contractor shall attempt to give notice of suspension of performance of any or all of the Contractor’s obligations by 60
calendar days prior to said suspension, if this is possible; otherwise, such notice of suspension should be made as soon as possible. In the event funding temporarily suspended or unavailable is reinstated, the Contractor may remove suspension
hereunder by written notice to the Department, to be made within 30 calendar days from the date the funds are reinstated. In the event the Contractor elects not to reinstate services, 

  

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the Contractor shall give the Department written notice of its reasons for such decision, to be made within 30 calendar days from the date the funds are
reinstated. The Contractor shall make such decision in good faith and will provide to the Department documentation supporting its decision. In the event of termination under this Section, this Contract shall terminate without termination costs to
either party. 

  

	 	C.	Obligations of Contracting Parties Upon Termination 

  
 When termination of the Contract occurs, the following obligations must be met by the parties: 
  

	 	1.	Where this Contract is terminated unilaterally by the Department due to non-performance by the HMO or by mutual consent with termination initiated by the HMO:

  

	 	a.	The Department will be responsible for notifying all enrollees of the date of termination and process by which the enrollees will continue to receive contract services.

  

	 	b.	The HMO will be responsible for all expenses related to said notification 

  

	 	c.	The Department will grant the HMO a hearing before termination by the Department occurs. The Department will notify the enrollees of the hearing and allow them to disenroll from the
HMO without cause. 

  

	 	2.	Where this Contract is terminated on any basis not given in 1 above including non-renewal of the contract for a given contract period: 

  

	 	a.	The Department will be responsible for notifying all enrollees of the date of termination and process by which the enrollees will continue to receive contract services.

  

	 	b.	The Department will be responsible for all expenses relating to said notification. 

  

	 	3.	Where this contract is terminated for any reason the following payment criteria will apply: 

  

	 	a.	Any payments advanced to the HMO for coverage of enrollees for periods after the date of termination will be returned to the Department within the period of time specified by the
Department. 

  

	 	b.	The HMO will supply all information necessary for the reimbursement of any outstanding Medicaid and BadgerCare claims within the period of time specified by the Department.

  

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	 	c.	If a contract is terminated, recoupments will be handled through a payment by the HMO within 90 days of contract termination. 

  

	 	D.	Modification 

  
 This Contract may be modified at any time by written mutual consent of the HMO and the Department or when modifications are mandated by changes in federal
or state laws, rules or regulations. If changes in state or federal laws, rules or regulations require the Department to modify its contract with the HMO, the HMO will receive written notice. 
  
 If the Department exercises its right to renew this Contract, as allowed by
Article XVI, the Department will recalculate the capitation rate for succeeding calendar years. The HMO will have 30 days to accept the new capitation rate in writing or to initiate termination of the Contract. If the Department changes the
reporting requirements during the contract period, the HMO shall have 180 days to comply with such changes or to initiate termination of the Contract. 
  
 ARTICLE XII 
  

	XII.	INTERPRETATION OF CONTRACT LANGUAGE 

  
 When disputes arise, the Department has the right to final interpretation of the contract language. The HMO has the right to appeal to the Department or
invoke the procedures outlined in Chapter 788, Wis. Stats. if it disagrees with the Department’s decision. Until a decision is reached, the HMO will abide by the interpretation of the Department. 
  
 ARTICLE XIII 
  

	XIII.	 CONFIDENTIALITY OF RECORDS AND HIPAA REQUIREMENTS 

  

	 	A.	The parties agree that all information, records, and data collected in connection with this Contract will be protected from unauthorized disclosure as provided in Chapter 19,
Subchapter II, Wis. Stats., HFS 108.01, Wis. Adm. Code, 42 CFR 431 Subpart F and 42 CFR 438 Subpart F. Except as otherwise required by law, rule or regulation, access to such information shall be limited by the HMO and the Department to persons who,
or agencies which, require the information in order to perform their duties related to this Contract, including the U.S. Department of Health and Human Services and such others as may be required by the Department. 

  

	 	B.	The HMO agrees to forward to the Department all media contacts regarding Medicaid and BadgerCare enrollees or the Medicaid and BadgerCare program. 

  

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	 	C.	Regarding the services provided under this Contract, the HMO will comply with all applicable health data and information privacy and security policies, standards and regulations as
may be adopted or promulgated under the Health Insurance Portability and Accountability Act (HIPAA) of 1996 in final form, and as amended or revised from time to time. This includes cooperating with the Department in amending this Contract, or
developing a new agreement, if the Department deems it necessary to meet the Department’s obligations under HIPAA. 

  

	 	D.	Trading Partner requirements under HIPAA. For the purposes of this section Trading Partner means the HMO. 

  

	 	1.	Trading Partner Obligations: 

  

	 	a.	Trading Partner must not change any definition, data condition or use of a data element or segment as proscribed in the HHS Transaction Standard Regulation (45 CFR Part 62.915(a)).

  

	 	b.	Trading Partner must not add any data elements or segments to the maximum data set as proscribed in the HHS Transaction Standard Regulation (45 CFR Part 62.915(b)).

  

	 	c.	Trading Partner must not use any code or data elements that are either marked “not used” in the HHS Transaction Standard’s implementation specifications or are not in
the HHS Transaction Standard’s implementation specifications (45 CFR Part 62.915(c)). 

  

	 	d.	Trading Partner must not change the meaning or intent of any of the HHS Transaction Standard’s implementation specifications (45 CFR Part 162.915(d)). 

 

	 	e.	Trading Partner must submit a new Trading Partner profile form in writing if any of the information provided as part of the Trading Partner profile form is modified.

  

	 	2.	Trading Partner understands that there exists the possibility that the Department or others may request an exception from the uses of a standard in the HHS Transaction Standards. If
this occurs, Trading Partner must participate in such test modification (45 CFR Part 162.904 (a) (4)). 

  

	 	3.	Trading Partners or Trading Partner’s Business Associate have responsibilities to adequately test business rules appropriate to their types and specialties.

  

	 	4.	Trading Partner or their Business Associate agrees to cure Transactions errors or deficiencies identified by the Department. 

  

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	 	5.	Trading Partner or Trading Partner’s Business Associate understands that from time-to-time HHS may modify and set compliance dates for the HHS Transaction Standards. Trading
Partner or Trading Partner’s Business associate must incorporate by reference any such modifications or changes (45 CFR Part 160.140). 

  

	 	6.	The Department and the Trading Partner agree to keep open code sets being processed or used for at least the current billing period or any appeal period, whichever is longer (45 CFR
Part 162.925 (c)(2)). 

  

	 	7.	Privacy 

  

	 	a.	The Trading Partner or the Trading Partner’s Business Associate will comply with all applicable State and Federal privacy statutes and regulations concerning the treatment of
Protected Health Information (PHI). 

  

	 	b.	The Department and the Trading Partner or Trading Partner’s Business Associate will promptly notify the other Party of any unlawful or unauthorized use or disclosure of PHI
that may have an impact on the other Party that comes to the Party’s attention, and will cooperate with the other Party in the event that any litigation arises concerning the unlawful or unauthorized disclosure of use of PHI.

  

	 	c.	The Department retains all rights to seek injunctive relief to prevent or stop the unauthorized use or disclosure of PHI by the Trading Partner, Trading Partner’s Business
Associate, or any agent, contractor or third Party that received PHI from the Trading Partner. 

  

	 	8.	Security 

  

	 	a.	The Department and the Trading Partner or Trading Partner’s Business Associate must maintain reasonable security procedures to prevent unauthorized access to data, data
transmissions, security access codes, envelope, backup files, and source documents. Each party will immediately notify the other Party of any unauthorized attempt to obtain access to or otherwise tamper with data, data transmissions security access
codes, envelope, backup files, source documents other Party’s operating system when the attempt may have an impact on the other Party. 

  

	 	b.	 The Department and the Trading Partner or Trading Partner’s Business associate must develop, implement, and maintain appropriate security measures for its own
Operating System. The Department and the Trading Partner or Trading Partner’s Business Associate must document and keep current its security measures. 

  

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Each Party’s security measure will include, at a minimum, the requirements and implementation features set forth in ‘site specific HIPAA rule’
and all applicable HHS implementation guidelines. 

  
 ARTICLE XIV 
  

	XIV.	 DOCUMENTS CONSTITUTING CONTRACT 

  

	 	A.	Current Documents 

  
 In addition to this base agreement, the contract between the Department and the HMO includes, existing Medicaid provider publications addressed to HMOs,
the terms of the most recent HMO certification application issued by this Department for Medicaid and BadgerCare HMO contracts, any questions and answers released pursuant to said HMO certification application by the Department, and an HMO’s
signed application. The terms of the HMO certification application are also part of this Contract even if the HMO had a Medicaid and BadgerCare HMO Contract in the prior contract period and consequently did not have to answer all the questions in
the HMO certification application. In the event of any conflict in provisions among these documents, the terms of this base agreement will prevail. The provisions in any question and answer document will prevail over the HMO certification
application. And the HMO Certification Application terms shall prevail over any conflict with an HMO’s actual signed application. In addition, the Contract shall incorporate the following Addenda: 
  

	 	I.	Subcontracts and Memoranda of Understanding 

  

	 	II.	Standard Enrollee Handbook Language 

  

	 	III.	Actuarial Basis 

  

	 	IV.	Guidelines for the Coordination of Services between HMOs and the Bureau of Milwaukee Child Welfare 

  

	 	V.	Guidelines for the Coordination of Services between Medicaid HMOs and County Birth to Three Agencies 

  

	 	VI.	Local Health Departments and Community Based Health Organizations a Resource for HMOs 

  

	 	VII.	Guidelines for the Coordination of Services Between HMOs, Targeted Case Management (TCM) Agencies, and Child Welfare Agencies 

  

	 	VIII.	Report Forms and Worksheets 

  

	 	IX.	General Information about the WIC Program and Sample HMO-to-WIC Referral Forms 

  

	 	X.	HMO Specific Service Area and Enrollment Maximum 

  

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	 	B.	Future Documents 

  
 The HMO is required by this Contract to comply with all future Medicaid and BadgerCare provider publications and Contract Interpretation Bulletins issued
pursuant to this Contract. The documents listed in this section constitute the entire Contract between the parties. No other oral or written expression, constitutes any part of this Contract. 
  
 ARTICLE XV 
  

	XV.	MISCELLANEOUS 

  

	 	A.	Indemnification 

  
 The HMO agrees to defend, indemnify and hold the Department harmless with respect to any and all claims, costs, damages and expenses, including reasonable
attorney’s fees, that are related to or arise out of: 
  

	 	1.	Any failure, inability, or refusal of the HMO or any of its subcontractors to provide contract services. 

  

	 	2.	The negligent provision of contract services by the HMO or any of its subcontractors. 

  

	 	3.	Any failure, inability or refusal of the HMO to pay any of its subcontractors for contract services. 

  

	 	B.	Independent Capacity of Contractor 

  
 The Department and the HMO agree that the HMO and any agents or employees of the HMO, in the performance of this Contract, will act in an independent
capacity, and not as officers or employees of Department. 
  

	 	C.	Omissions 

  
 In the event either party hereto discovers any material omission in the provisions of this Contract that is essential to the successful performance of
this Contract, said party may so inform the other party in writing. The parties hereto will thereafter promptly negotiate the issues in good faith in order to make all reasonable adjustments necessary to perform the objectives of this Contract.

  

	 	D.	Choice of Law 

  
 This Contract is be governed by and construed in accordance with the laws of the State of Wisconsin. The HMO shall be required to bring all legal
proceedings against the Department in Wisconsin State courts. 
  

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	 	E.	Waiver 

  
 No delay or failure by either party hereto to exercise any right or power accruing upon noncompliance or default by the other party with respect to any of
the terms of this Contract will impair that right or power or be construed as a waiver thereof. A waiver by either of the parties hereto of a breach of any of the covenants, conditions, or agreements to be performed by the other will not be
construed as a waiver of any succeeding breach thereof or of any other covenant, condition, or agreement contained herein. 
  

	 	F.	Severability 

  
 If any provision of this Contract is declared or found to be illegal, unenforceable, invalid or void, then both parties will be relieved of all
obligations arising under such provision. If such provision does not relate to payments or services to Medicaid and BadgerCare enrollees and if the remainder of this Contract is not affected then each provision not so affected will be enforced to
the fullest extent permitted by law. 
  

	 	G.	Survival 

  
 The terms and conditions contained in this contract that by their sense and context are intended to survive the completion of performance shall so survive
the completion, expiration or termination of the contract. This specifically includes, but is not limited to recoupments and confidentiality provisions. 
  

	 	H.	Force Majeure 

  
 Both parties shall be excused from performance hereunder for any period that they are prevented from meeting the terms of this Contract as a result of a
catastrophic occurrence or natural disaster including but not limited to an act of war, and excluding labor disputes. 
  

	 	I.	Headings 

  
 The article and section headings used herein are for reference and convenience only and do not affect its interpretation. 
  

	 	J.	Assignability 

  
 Except as allowed under subcontracting, the Contract is not assignable by the HMO either in whole or in part, without the prior written consent of the
Department. 
  

	 	K.	Right to Publish 

  
 The HMO must obtain prior written approval from the Department before publishing any material on subjects addressed by this Contract. 
  

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 ARTICLE XVI 
  

	XVI.	 HMO SPECIFIC CONTRACT TERMS 

  

	 	A.	Initial Contract Period 

  
 The respective rights and obligations of the parties as set forth in this Contract shall commence on May 1, 2004, and, unless earlier terminated under
Article XI, shall remain in full force and effect through December 31, 2005. The specific terms for enrollment, rates, risk-sharing, dental coverage, and chiropractic coverage are as specified in section C of this Article. 
  

	 	B.	Renewals 

  
 By mutual written agreement of the parties, there may be one (1) one-year renewal of the term of the Contract. An agreement to renew must be effected at
least thirty (30) calendar days prior to the expiration date of any contract term. The terms and conditions of the Contract shall remain in full force and effect throughout any renewal period, unless modified under the provision of Article XI,
Section D. 
  

	 	C.	Specific Terms of the Contract 

  
 The specific terms of the Medicaid/BadgerCare HMO Contract to which the HMO agrees are set forth in this Contract. The capitation rates to which the HMO
agrees are indicated by the Department in a completed Addendum III, Actuarial Basis of the Medicaid and BadgerCare HMO Contract. Except as stated below, the specific terms in the HMO’s completed application for certification are incorporated
into this Contract, including whether dental services and chiropractic services will be provided by the HMO. Notwithstanding the certification application, the HMO’s service area and maximum enrollment are specified in Addendum X. 

 
 In WITNESS WHEREOF, the State of Wisconsin has executed this agreement:

  

									
	(Name of HMO)	 	 	 	State of Wisconsin
					
	 Official Signature
	 	   /s/ Kathleen R. Crampton
	 	 	 	Official Signature	 	   /s/ Mark S. Moody

					
	 Title
	 	   President and CEO
	 	 	 	 Title
	 	 
					
	 Date
	 	   April 27, 2004
	 	 	 	 	 	 

  
 Note: The following subcontract
with the Department for Chiropractic Services is not effective unless signed below. 
  

 -129- 

 SUBCONTRACT FOR CHIROPRACTIC SERVICES 
  

	A.	THIS AGREEMENT is made and entered into by and between the HMO and the Department of Health and Family Services. 

  
 The parties agree as follows: 
  

	 	1.	The Department agrees to be at risk for and pay claims for chiropractic services covered under this Contract. 

  

	 	2.	The HMO agrees to a deduction from the capitation rate of an amount of money based on the cost of chiropractic services. This deduction is reflected in the Contract that is being
signed on the same date. 

  

	B.	This is the only subcontract for services that the Department is entering into with the HMO. 

  

	C.	The provisions of the Contract regarding subcontracts, in Addendum I, do not apply to this subcontract. 

  

	D.	The term of this subcontract is for the same period as the Contract between HMO and Department for medical services. 

  

									
	Signed:	 	 	 	 
					
	FOR HMO:	 	 /s/ Kathleen R. Crampton
	 	 	 	 FOR
 STATE:
	 	 /s/ Mark S. Moody

					
	TITLE:	 	 President and CEO
	 	 	 	 TITLE:
	 	 
					
	DATE:	 	 April 27, 2004
	 	 	 	 DATE:
	 	 

  

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 ADDENDUM I 
 SUBCONTRACTS AND MEMORANDA OF UNDERSTANDING 
  
 PART A: SUBCONTRACTS 
  
 Part A of this Addendum does not apply
to subcontracts between the Department and the HMO. The Department shall have sole authority to determine the conditions and terms of such subcontracts. 
  

	I.	Subcontracts 

  
 Subcontractor (hereinafter identified as subcontractor) agrees to abide by all applicable provisions of (HMO NAME)’s contract with the Department of
Health and Family Services, hereinafter referred to as the Medicaid and BadgerCare HMO Contract. Subcontractor compliance with the Medicaid and BadgerCare HMO Contract specifically includes but is not limited to the requirements specified in section
A below. 
  

	 	A.	Subcontract Standard Language 

  
 HMOs must ensure that all subcontracts are in writing and include the following standard language when applicable. 
  

	 	1.	Subcontractor uses only Medicaid-certified providers in accordance with Article III, H, 1. of the Medicaid and BadgerCare HMO Contract. 

  

	 	2.	No terms of this subcontract are valid which terminate legal liability of the HMO. 

  

	 	3.	Subcontractor agrees to participate in and contribute required data to HMO Quality Assessment/Performance Improvement programs as required in Article IV. of the Medicaid and
BadgerCare HMO Contract. 

  

	 	4.	Subcontractor agrees to abide by the terms of the Medicaid and BadgerCare HMO Contract (Article III, E, 9.) for the timely provision of emergency and urgent care. Where applicable,
subcontractor agrees to follow those procedures for handling urgent and emergency care cases stipulated in any required hospital/emergency room MOUs signed by the HMO in accordance with Article III, E, 9, c and Addendum I, Part B, II of the Medicaid
and BadgerCare HMO Contract. 

  

	 	5.	Subcontractor agrees to submit HMO encounter data in the format specified by the HMO, so that the HMO can meet the Department specifications required by Article VII of the Medicaid
and BadgerCare HMO Contract. HMOs will evaluate the credibility of data obtained from subcontracted vendors’ external databases to ensure that any patient- reported information has been adequately verified. 

  

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	 	6.	Subcontractor agrees to comply with all non-discrimination requirements in Article III, C, 5. of the Medicaid and BadgerCare HMO Contract. 

  

	 	7.	Subcontractor agrees to comply with all record retention requirements and, where applicable, the special reporting requirements on abortions, sterilizations, hysterectomies, and
HealthCheck requirements. 

  

	 	8.	Subcontractor agrees to provide representatives of the HMO, as well as duly authorized agents or representatives of the Department and the Federal Department of Health and Human
Services, access to its premises and its contracts and/or medical records in accordance with Article III and Article X of the Medicaid and BadgerCare HMO Contract. Subcontractor agrees otherwise to preserve the full confidentiality of medical
records in accordance with Article XIII, A of the Medicaid and BadgerCare HMO Contract. 

  

	 	9.	Subcontractor agrees to the requirements for maintenance and transfer of medical records stipulated in Article IV, F of the Medicaid and BadgerCare HMO Contract.

  

	 	10.	Subcontractor agrees to ensure confidentiality of family planning services in accordance with Article III, E, 10. of the Medicaid and BadgerCare HMO Contract.

  

	 	11.	Subcontractor agrees not to create barriers to access to care by imposing requirements on recipients that are inconsistent with the provision of medically necessary and covered
Medicaid benefits (e.g., COB recovery procedures that delay or prevent care). 

  

	 	12.	Subcontractor agrees to clearly specify referral approval requirements to its providers and in any sub-subcontracts. 

  

	 	13.	Subcontractor agrees not to bill Medicaid and BadgerCare enrollees for medically necessary services covered under the Medicaid and BadgerCare HMO Contract and provided during the
enrollees’ period of HMO enrollment. Subcontractor also agrees not to bill enrollees for any missed appointments while the enrollees are eligible under the Medicaid and BadgerCare Program. This provision will remain in effect even if the HMO
becomes insolvent. However, if an enrollee agrees in writing to pay for a non-Medicaid covered service, then the HMO, HMO provider, or HMO subcontractor can bill. 

  
 The standard release form signed by the enrollee at the time of services does not relieve the HMO and its providers and
subcontractors from the prohibition against billing a Medicaid enrollee in the absence of a knowing assumption of liability for a non-Medicaid covered service. The form or other type of acknowledgment relevant to Medicaid or BadgerCare 

  

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enrollee liability must specifically state the admissions, services, or procedures that are not covered by Medicaid. 
  

	 	14.	Within 15 business days of the HMO’s request subcontractors must forward medical records pursuant to grievances to the HMO. If the subcontractor does not meet the 15-day
requirement, the subcontractor must explain why and indicate when the medical records will be provided. 

  

	 	15	Subcontractor agrees to abide by the terms of Article III, G, regarding appeals to the HMO and to the Department regarding the HMO’s nonpayment for services providers render to
Medicaid or BadgerCare enrollees. 

  

	 	16.	Subcontractor agrees to abide by the HMO marketing/informing requirements. Subcontractor will forward to the HMO for prior approval all flyers, brochures, letters and pamphlets the
subcontractor intends to distribute to its Medicaid and BadgerCare enrollees concerning its HMO affiliation(s), or changes in affiliation, or relating directly to the Medicaid and BadgerCare population. Subcontractor will not distribute any
“marketing” or recipient informing materials without the consent of the HMO and the Department. 

  

	 	B.	Subcontract Submission Requirements 

  

	 	1.	Changes in Established Subcontracts 

  

	 	a.	The HMO must submit changes in previously approved subcontracts to the Department for review and approval before they take effect. This review requirement applies to changes that
affect the amount, duration, scope, location, or quality of services. 

  

	 	1)	Technical changes do not have to be approved. 

  

	 	2)	Changes in rates paid do not have to be approved, with the exception of changes in the amounts paid to HMO management services subcontractors. 

  

	 	b.	This requirement will be considered met if the Department does not respond within 15 business days after receipt of the changes to the approved subcontracts.

  

	 	2.	New Subcontracts 

  
 The HMO must submit new subcontracts to the Department for review and approval before they take effect. This requirement will be considered met if the
Department does not respond within 15 business days after receipt of the new subcontracts. 
  

 -133- 

	 	C.	Review and Approval of Subcontracts 

  
 The Department may approve, approve with modification, or deny subcontracts under this Contract at its sole discretion. The Department may, at its sole
discretion and without the need to demonstrate cause, impose such conditions or limitations on its approval of a subcontract as it deems appropriate. The Department may consider such factors as it deems appropriate to protect the interests of the
state and Medicaid and BadgerCare recipients, including but not limited to the proposed subcontractor’s past performance. The Department will: 
  

	 	1.	Give the HMO (1) 120 days to implement a change that requires the HMO to find a new subcontractor, and (2) 60 days to implement any other change required by the Department.

  

	 	2.	Acknowledge the approval or disapproval of a subcontract within 15 business days after its receipt from the HMO. 

  

	 	3.	Review and approve or disapprove each new subcontract before the contract takes effect. Any disapproval of subcontracts may result in the application by the Department of remedies
pursuant to Article X of this Contract. 

  

	 	4.	Ensure that the HMO has included the standard subcontract language as specified in Addendum I, A (except for specific provisions that are inapplicable in a specific HMO management
subcontract). 

  

	 	D.	Transition Plan 

  
 The HMO may be required to submit transition plans when a primary care provider(s), mental health provider(s), gatekeeper or dental clinic terminates
their contractual relationship with the HMO. The transition plan will address continuity of care issues, enrollee notification and any other information required by the Department to ensure adequate enrollee access. The Department will either
approve, deny, or modify the transition plan within 15 business days of receipt or prior to the effective date of the subcontract change. 
  

	 	E.	Notification Requirements Regarding Subcontract Additions or Terminations 

  

	 	1.	Notify the Department of Additions or Terminations 

  
 The HMO must notify the Department within 10 days of subcontract additions or terminations involving: (i) a clinic or group of physicians, (ii) an
individual physician (iii) an individual mental health provider and/or clinic, (iv) an individual dental provider and/or clinic. 
  

 -134- 

	 	2.	Notify the Department of a Termination or Modification that Involves Reducing Access to Care 

  
 The HMO must notify the Department within seven (7) days of any notice by the HMO to a subcontractor, or any notice to the
HMO from a subcontractor, of a subcontract termination, a pending subcontract termination, or a pending modification in subcontract terms, that could reduce Medicaid and BadgerCare enrollee access to care. 
  
 If the Department determines that a pending subcontract termination or
pending modification in subcontract terms will jeopardize enrollee access to care, then the Department may invoke the remedies pursuant to Article X and Article XI of this Contract. These remedies include contract termination (notice to the HMO and
opportunity to correct are provided for), suspension of new enrollment, and giving enrollees an opportunity to enroll in a different HMO. 
  

	 	3.	Notify the Enrollment Broker of an Addition or Termination 

  
 The HMO must notify the Department’s enrollment broker within 10 days of additions to, and deletions from, the provider network. 
  
 The HMO must submit to the enrollment broker an electronic listing of all
network Medicaid providers, facilities and pharmacies within the first 10 days of each calendar quarter in a mutually agreed upon format approved by the Department. This listing will include, but is not limited to, provider name, provider number,
address, phone number, and specialty as well as indicators designating whether a provider can be selected as a PCP, and whether the PCP is accepting new patients. The listing shall include only Medicaid certified providers who are contracted with
the HMO to provide contract services to Medicaid and BadgerCare enrollees. 
  

	 	4.	Notify Enrollees of Provider Terminations 

  
 Not less than 30 days prior to the effective date of the termination, the HMO must send written notification to enrollees whose PCP, mental health
provider, gatekeeper or dental clinic terminates a contract with the HMO. The Department must approve all notifications before they are sent to enrollees. 
  

	II.	Management Subcontracts 

  
 The Department Will Review HMO Management Subcontracts to Ensure that: 
  

	 	A.	Rates are reasonable. 

  

	 	B.	They clearly describe the services to be provided and the compensation to be paid. 

  

 -135- 

	 	C.	Any potential bonus, profit-sharing, or other compensation, not directly related to the cost of providing goods and services to the HMO, is identified and clearly defined in terms
of potential magnitude and expected magnitude during the Medicaid and BadgerCare HMO Contract period. Any such bonus or profit-sharing must be reasonable compared to the services performed. The HMO must document reasonableness. A maximum dollar
amount for such bonus or profit-sharing shall be specified for the contract period. 

  

	 	D.	The requirements addressed in A through C do not have to relate to non-Medicaid and BadgerCare enrollees if the HMO wishes to have separate arrangements for non-Medicaid enrollees.

  

	III.	Disclosure Statements 

  
 Within 30 days of contract signing, the HMO agrees to submit to the Department full and complete information as to the identity of each person or
corporation with an ownership or controlling interest in the HMO, or any subcontractor in which the HMO has a 5% or more ownership interest. 
  

	 	A.	Ownership 

  

	 	1.	A “person with an ownership or controlling interest” means a person or corporation that: 

  

	 	a.	Owns, directly or indirectly, 5% or more of the HMO’s capital or stock or receives 5% or more of its profits; 

  

	 	b.	Has an interest in any mortgage, deed of trust, note, or other obligation secured in whole or in part by the HMO or by its property or assets, and that interest is equal to or
exceeds 5% of the total property and assets of the HMO; or 

  

	 	c.	Is an officer or director of the HMO (if it is organized as a corporation or is a partner in the HMO (if it is organized as a partnership). 

  

	 	2.	Calculation of 5% Ownership or Control is as follows: 

  
 The percentage of direct ownership or control is the percentage interest in the capital, stock or profits. 
  
 The percentage of indirect ownership or control is calculated by
multiplying the percentages of ownership in each organization. Thus, if a person owns 10% of the stock in a corporation that owns 80% of the stock of the HMO, the person owns 8% of the HMO. 
  

 -136- 

 The percentage of ownership or control through an interest in a mortgage, deed or trust, note or other
obligation is calculated by multiplying the percent of interest that a person owns in that obligation by the percent of the HMO’s assets used to secure the obligation. Thus, if a person owns 10% of a note secured by 60% of the HMO’s
assets, the person owns 6% of the HMO. 
  

	 	B.	Information to be Disclosed 

  
 The following information must be disclosed: 
  

	 	1.	The name and address of each person with an ownership or controlling interest of 5% or more in the HMO or in any subcontractor in which the HMO has direct or indirect ownership of
5% or more; 

  

	 	2.	A statement as to whether any of the persons with ownership or controlling interest is related as spouse, parent, child, or sibling to any other of the persons with ownership or
controlling interest; and 

  

	 	3.	The name of any other organization in which the person also has ownership or controlling interest. This is required to the extent that the HMO can obtain this information by
requesting it in writing. The HMO must keep copies of all of these requests and the responses to them, make them available upon request, and advise the Department when there is no response to a request. 

  

	 	C.	Potential Sources of Disclosure Information 

  
 This information may already have been reported on Form HCFA-1513, “Disclosure of Ownership and Controlling Interest Statement.” Form HCFA-1513
is likely to have been completed in two different cases. First, if an HMO is federally qualified and has a Medicare contract, it is required to file Form HCFA-1513 with CMS within 120 days of the HMO’s fiscal year end. Secondly, if the HMO is
owned by or has subcontracts with Medicaid providers that are reviewed by the state survey agency, these providers may have completed Form HCFA-1513 as part of the survey process. If Form HCFA-1513 has not been completed, the HMO may supply the
ownership and controlling information on a separate report or submit reports filed with the State’s insurance or health regulators as long as these reports provide the necessary information for the prior 12 month period. 
  
 As directed by the CMS Regional Office (RO), the Department must provide
documentation of this disclosure information as part of the prior approval process for contracts. This documentation must be submitted to the Department and the RO prior to each contract period. If an HMO has not supplied the information that must
be disclosed, a contract with the HMO is not considered approved for this period of time and no FFP is available for the period of time preceding the disclosure. 
  

 -137- 

 A managed care entity may not knowingly have as a director, officer, partner, or person with beneficial
ownership of more than 5% of the entity’s a person who is debarred, suspended, or otherwise excluded from participating in procurement or non-procurement activities under the Federal Acquisition Regulation or who has an employment, consulting,
or other agreement for the provision of items and services that are significant and material to the entity’s obligations under its contract with the state. 
  

	IV.	Business Transactions 

  
 All HMOs that are not federally qualified must disclose to the Department information on certain types of transactions they have with a “party in
interest” as defined in the Public Health Service Act. (See Sections 1903(m)(2)(A)(viii) and 1903(m)(4) of the Act.). 
  

	 	A.	Party In Interest as defined in Section 1318(b) of the Public Health Service Act, is: 

  

	 	1.	Any director, officer, partner, or employee responsible for management or administration of an HMO and HIO; any person who is directly or indirectly the beneficial owner of more
than 5% of the equity of the HMO; any person who is the beneficial owner of more than 5% of the HMO; or, in the case of an HMO organized as a nonprofit corporation, an incorporator or member of such corporation under applicable state corporation
law; 

  

	 	2.	Any organization in which a person described in subsection A, 1 above is director, officer or partner; has directly or indirectly a beneficial interest of more than 5% of the equity
of the HMO; or has a mortgage, deed of trust, note, or other interest valuing more than 5% of the assets of the HMO; 

  

	 	3.	Any person directly or indirectly controlling, controlled by, or under common control with an HMO; or 

  

	 	4.	Any spouse, child, or parent of an individual described in subsections 1, 2, or 3 above. 

  

	 	B.	Business Transactions That Must Be Disclosed Include: 

  

	 	1.	Any sale, exchange or lease of any property between the HMO and a party in interest. 

  

	 	2.	Any lending of money or other extension of credit between the HMO and a party in interest. 

  

	 	3.	Any furnishing for consideration of goods, services (including management services) or facilities between the HMO and the party in interest. This does not include salaries paid to
employees for services provided in the normal course of their employment. 

  

 -138- 

	 	C.	Information That Must Be Disclosed In The Transactions Between an HMO and a Party In Interest Includes: 

  

	 	1.	The name of the party in interest for each transaction. 

  

	 	2.	A description of each transaction and the quantity or units involved. 

  

	 	3.	The accrued dollar value of each transaction during the fiscal year. 

  

	 	4.	Justification of the reasonableness of each transaction. 

  
 If the Medicaid and BadgerCare HMO Contract is being renewed or extended, the HMO must disclose information on those business transactions that occurred
during the prior contract period. If the Contract is an initial contract with Medicaid, but the HMO has operated previously in the commercial or Medicare markets, information on business transactions for the entire year preceding the initial
contract period must be disclosed. The business transactions which must be reported are not limited to transactions related to serving Medicaid enrollment. All of these HMO business transactions must be reported. 
  
 PART B: MEMORANDUM OF UNDERSTANDING (MOU) 
  

	I.	MOU Submission Requirements 

  
 The HMO must submit to the Department copies of new MOUs, or changes in existing MOUs for review and approval before they take effect. This requirement
will be considered met if the Department has not responded within 15 business days after receipt of the MOU. 
  
 The HMO shall submit MOUs referred to in this Contract and this Addendum to the Department upon the Department’s request and during the certification
process if required by the Department. 
  

	II.	Emergency Services MOU or Contract 

  
 HMOs may have a contract or an MOU with hospitals or urgent care centers within the HMO’s service area(s) to ensure prompt and appropriate payment
for emergency services. 
  
 The MOU Shall Provide For:

  

	 	1.	The process for determining whether an emergency exists. 

  

	 	2.	The requirements and procedures for contacting the HMO before the provision of urgent or routine care. 

  

 -139- 

	 	3.	Agreements, if any, between the HMO and the provider regarding indemnification, hold harmless, or any other deviation from malpractice or other legal liability which would attach to
the HMO or provider in the absence of such an agreement. 

  

	 	4.	Payments for an appropriate medical screening examination to determine whether or not an emergency medical condition exists. 

  

	 	5.	Assurance of timely and appropriate provision of and payment for emergency services. 

  
 Unless a contract or MOU specifies otherwise, HMOs are liable to the extent that FFS would have been liable for the
emergency situation. The Department reserves the right to resolve disputes between HMOs, hospitals and urgent care centers regarding emergency situations based on FFS criteria. 
  

	III.	County and Other Human Service Agencies MOU or Contract Requirements for Services Ordered by the Courts 

  
 HMOs must make a “good faith” attempt to negotiate either an MOU
or a contract with the county(ies) in their service area. See Article III, F, 11. 
  

	 	A.	MOU Requirement with Boards Created Under §. 51.42, 51.437 or 46.23, Wis. Stats. 

  
 At a minimum the MOU must specify the conditions under which the HMO will either reimburse the Board(s) or another contract
provider, or directly cover medical services, including, but not limited to, examinations ordered by a court, specified by the Board’s designated assessment agency in an enrollee’s driver safety plan as provided under HFS 62. It is the
responsibility of both the HMO and the Board to ensure that courts order the use of the HMO’s providers. If the court orders a non-HMO source to provide the treatment or evaluation, the HMO is liable for the cost up to the full Medicaid rate if
the HMO could not have provided the service through its own provider arrangements. If the service was such that the HMO could reasonably have been expected to provide it through its own provider arrangements, the HMO is not liable. Reasonable
arrangements, in this situation, are certified providers with facilities and services to safely meet the medical and psychiatric needs of the recipient within a prompt and reasonable time frame. The MOU shall further specify reimbursement
arrangements between the HMO and the Board’s provider for assessments performed by the Board’s designated assessment agency under HFS 62, Intoxicated Driver Program rules. The MOU shall also specify other reporting and referral
relationships if required by the Board or the HMO. 
  

 -140- 

	 	B.	MOU Requirement with the Department of Social Services (DSS) Created Under s. 46.21 or 46.22, Wis. Stats., or the Human Service Department Created Under s. 46.23, Wis. Stats.

  
 At a minimum the MOU must specify that the
HMO will reimburse the DSS or its provider if the HMO cannot provide the treatment, or will directly cover medical services including examinations and treatment which are ordered by a court. It is the responsibility of both the HMO and the DSS to
ensure that courts order the use of the HMO’s providers. If the court orders a non-HMO source to provide the treatment or evaluation, the HMO is liable for the cost up to the full Medicaid rate if the HMO could not have provided the service
through its own provider arrangements. If the service was such that the HMO could reasonably have been expected to provide it through its own provider arrangements, the HMO is not liable. The MOU will also specify the reporting and referral
relationships for suspected cases of child abuse or neglect pursuant to s. 48.981, Wis. Stats. The MOU shall also specify a referral agreement for HMO enrollees who are physically disabled and who may be in need of Supportive Home Care or other
programming provided or purchased by the county agency. The MOU may specify that evaluations for substitute care will be provided by a provider acceptable to both parties; the DSS may require in the MOU that the HMO specify expert providers
acceptable to the DSS and the HMO in dealing with court-related children’s services, victims of child abuse and neglect, and domestic abuse. 
  
 HMOs and counties may develop alternative MOU language, if both parties agree. However, all elements defined in 1 and 2 above must be addressed in the
MOU. As an alternative to an MOU, HMOs may enter into contracts with the counties. Any contracts the HMO enters into with the counties must be in compliance with Part A of this Addendum and would supercede any MOU requirements. 
  

	IV.	Required MOUs or Contracts 

  

	 	A.	Milwaukee County Common Carrier Transportation MOU 

  
 Refer to the sample Common Carrier Transportation MOU following this. 
  

 -141- 

 MEMORANDUM OF UNDERSTANDING 
 BETWEEN 
 MILWAUKEE COUNTY MEDICAID AND BADGERCARE HMOS 
 AND 
 MILWAUKEE COUNTY DEPARTMENT OF
HUMAN SERVICES 
  
 All Milwaukee County Medicaid Health Maintenance
Organizations (HMOs) will provide common carrier transportation for their Medicaid and BadgerCare enrollees. Transportation services will be limited to: 
  

	•	Transportation of Medicaid and BadgerCare HMO members only. 

  

	•	Transportation of Medicaid and BadgerCare HMO members to and from Medicaid covered services only. 

  
 The HMO is responsible for arranging for the common carrier transportation and providing monthly costs to the Milwaukee County Department of
Human Services (DHS), of the common carrier transportation provided. Monthly costs will include the information specified in the attachment. The DHS is responsible for reimbursing the HMO for mileage and an administration fee. 
  
 The HMO and DHS agree to facilitate effective communication between agencies, work together
to resolve inter-agency coordination and communication problems, and inform staff from both the HMO and DHS about the policies and procedures for this cooperation, coordination and communication. 
  
 This agreement becomes effective when both the HMO and DHS have signed. 
  

									
	 Milwaukee County Department of
 Human Services
	 	 	 	 Milwaukee County
 Health Maintenance Organization

					
	 Signature
	 	 	 	 	 	 Signature
	 	 
					
	 Title
	 	 	 	 	 	 Title
	 	 
					
	 Date
	 	 	 	 	 	 Date
	 	 

  

 -142- 

 Milwaukee County Medicaid/HMO Common Carrier Transportation 
 Monthly Invoice from HMO to County 
  
 (DATE) 
  
 Milwaukee County DHS 
 Financial Assistance Division Administrator 
 1220 West Vliet Street 
 Milwaukee, WI 53205 
  
 Dear Sir: 
  
 (HMO NAME)’s total transportation costs for the month of (MONTH, YEAR) was
($                         ). This amount includes transportation and administration fees. 
  
 Please remit the above dollar amount to: 
  
 (HMO NAME) 
 (AUTHORIZED INDIVIDUAL) 
 (ADDRESS) 
  
 Thank you. 
  
 Sincerely, 
  
 (NAME/HMO) 
  

 -143- 

	 	B.	Prenatal Care Coordination (PNCC) MOU 

  
 The HMO must sign an MOU with all agencies in the HMO service area that are Medicaid-certified prenatal care coordination agencies. The MOU will be
effective on the effective date of the agency’s PNCC Wisconsin Medicaid certification or when both the HMO and the PNCC agency have signed it, whichever is later. In addition, if the PNCC wants to negotiate additional provisions in the MOU, the
HMO must negotiate in good faith and document those negotiations. Such documentation must be available to the Department for review on request. 
  
 The main purpose of the MOU is to ensure coordination of care between the HMO, that provides medical services, and the Prenatal Care Coordinating Agency
that provides outreach risk assessment, care planning, care coordination, and follow-up. 
  
 Refer to the sample PNCC MOU following this page. 
  

 -144- 

 MODEL MEMORANDUM OF UNDERSTANDING 
 BETWEEN 
 HEALTH MAINTENANCE ORGANIZATION 
 AND 
 PRENATAL CARE COORDINATION
AGENCY 
  
 Prenatal care coordination services are paid FFS by the Wisconsin
Medicaid Program for all recipients, including those enrolled in HMOs. The prenatal care coordination agencies (PNCC) are responsible for services which include outreach, risk assessment, care planning, care coordination and follow-up support to
high-risk pregnant women. The HMOs are responsible for providing and managing medically necessary services. The successful provision of services to individual enrollees requires cooperation, coordination and communication between the HMO and the
PNCC. 
  
 The HMO and the PNCC agree to facilitate effective communication between
agencies, work to resolve inter-agency coordination and communication problems, and inform staff from both the HMO and the PNCC about the policies and procedures for this cooperation, coordination and communication. 
  
 Recognizing that these “clients-in-common” are at high risk for poor birth
outcomes, the HMO and the PNCC agree to cooperate in removing access barriers, coordinating care and providing culturally competent services. 
  
 This agreement becomes effective on the date the PNCC is certified by Wisconsin Medicaid or on the date when both the HMO and the PNCC have signed it, whichever is later.
It may be terminated in writing with two (2) weeks notice by either signer. 
  

									
	HMO	 	 	 	PNCC
					
	 Authorizing Signature
	 	 	 	 	 	 Authorizing Signature
	 	 
					
	 Title
	 	 	 	 	 	 Title
	 	 
					
	 Date
	 	 	 	 	 	 Date
	 	 

  

 -145- 

	 	C.	School-Based Services (SBS) MOU 

  
 The HMO must sign an MOU with all School-Based Services (SBS) providers in the HMO service area who are Medicaid- certified. The MOU will be effective on
the date when both the HMO and the SBS provider have signed it or when the SBS provider is Medicaid-certified, whichever is later. Refer to Article III, C, 10, e and Article III, E, 13 that contain more information regarding SBS providers.

  
 Refer to the sample SBS MOU following this page. 

 

 -146- 

 MODEL MEMORANDUM OF UNDERSTANDING 
 BETWEEN 
 HEALTH MAINTENANCE ORGANIZATION 
 AND 
 SCHOOL DISTRICT
OR CESA MEDICAID-CERTIFIED FOR THE SCHOOL BASED 
 SERVICES BENEFIT 
  
 School-based services are a benefit paid FFS by Wisconsin Medicaid for all school-enrolled
recipients, including those enrolled in HMOs. The School-Based Service (SBS) provider is responsible for services provided in the schools such as occupational/physical/speech therapies, private duty or home care individualized nursing services,
mental health services, testing services, school Individual Education Plan (IEP) services, and Individualized Family Service Program (IFSP) services. The HMOs are responsible for providing and managing medically necessary services outside of school
settings. However, the schools cannot provide services in some situations, such as after school hours, during school vacations, and during the summer. Therefore, avoidance of duplication of services and promotion of continuity of care for Medicaid
and BadgerCare HMO enrollees requires cooperation, coordination and communication between the HMO and the SBS provider. 
  
 The HMO and the SBS provider agree to facilitate effective communication between agencies, work to resolve inter-agency coordination and communication problems, and
inform staff from both the HMO and the SBS provider about the policies and procedures for this cooperation, coordination and communication. Recognizing that these “clients-in-common” could receive duplicate services and could suffer from
problems in continuity of care (e.g., when the school year ends in the middle of a series of treatments), the HMO and the SBS provider agree to cooperate in communicating information about the provision of services and in coordinating care.

  
 This agreement becomes effective on the date when the SBS provider is
certified by Wisconsin Medicaid or when both the HMO and the SBS provider have signed it, whichever is later. It may be terminated in writing with two weeks notice by either signer. The SBS provider is the School District or the CESA. 
  

									
	HMO	 	 	 	SBS Provider
					
	 Authorizing Signature
	 	 	 	 	 	 Authorizing Signature
	 	 
					
	 Title
	 	 	 	 	 	 Title
	 	 
					
	 Date
	 	 	 	 	 	 Date
	 	 

  

 -147- 

 ADDENDUM II 
  
 STANDARD ENROLLEE HANDBOOK LANGUAGE 
  
 INTERPRETER SERVICES 
  

			
	 English –
	 	For help to translate or understand this, please call [1 -800-xxx-xxxx] (TTY).
		
	 Spanish –
	 	Si necesita ayuda para traducir o entender este texto, por favor llame al teléfono [1-800-xxx-xxxx] (TTY).
		
	 Russian –
	 	[GRAPHIC] [1-800-xxx-xxx] (TTY).
		
	 Hmong –
	 	Yog xav tau kev pab txhais cov ntaub ntawv no kom koj totaub, hu rau [1-800-xxx-xxxx] (TTY).
		
	 Laotian –
	 	[GRAPHIC] [1-800-xxx-xxxx] (TTY).

  
 Interpreter services are provided free
of charge to you. 
  
 IMPORTANT [HMO NAME] PHONE NUMBERS 
  

					
	 Customer Service
	  	[1-800-xxx-xxxx]	  	 [Hours/Days Available]

			
	 Emergency Number
	  	[1-800-xxx-xxxx]	  	 Call 24 hours a day, 7 days a week

			
	 TDD/TTY
	  	[1-800-xxx-xxxx]	  	 

  
 WELCOME 
  
 Welcome to [HMO NAME]. As a member of [HMO NAME], you will receive all your health care from
[HMO NAME] doctors, hospitals, and pharmacies. See [HMO NAME] Provider Directory for a list of these providers. You may also call our Customer Service Department at [1-800-xxx-xxxx]. Providers not accepting new patients are marked in the Provider
Directory. 
  
 YOUR FORWARD ID CARD 
  
 Always carry your Forward ID card with you, and show it every time you get care. You may
have problems getting care or prescriptions if you do not have your card with you. Also bring any other health insurance cards you may have. 
  

 -148- 

 PRIMARY CARE PHYSICIAN (PCP) 
  
 It is important to call your primary care physician (PCP) first when you need care. This doctor will manage all your health care. If you
think you need to see another doctor, or a specialist, ask your PCP. Your PCP will help you decide if you need to see another doctor, and give you a referral. Remember, you must get approval from your PCP before you see another doctor. 

 
 You can choose your primary care physician (PCP) from those available (NOTE: For women you
may also see a women’s health specialist (for example a OB/GYN doctor or a nurse midwife) without a referral, in addition to choosing your PCP). There are HMO doctors who are sensitive to the needs of many cultures. To choose a PCP, or to
change to a different PCP, call our Customer Service Department at [1-800-xxx-xxxx]. 
  
 EMERGENCY CARE 
  
 Emergency care is care needed right away. This
may be caused by an injury or a sudden illness. Some examples are: 
  

			
	Choking	  	Severe or unusual bleeding
	Trouble breathing	  	Suspected poisoning
	Serious broken bones	  	Suspected heart attack
	Unconsciousness	  	Suspected stroke
	Severe burns	  	Convulsions
	Severe pain	  	Prolonged or repeated seizures

  
 If you need emergency care, go to a
[HMO NAME] provider for help if you can. BUT, if the emergency is severe, go to the nearest provider (hospital, doctor or clinic). You may want to call 911 or your local police or fire department emergency services if the emergency is severe.

  
 If you must go to a [non-HMO NAME] hospital or provider, call [HMO NAME] at
[1-800-xxx-xxxx] as soon as you can and tell us what happened. This is important so we can help you get follow up care. 
  
 Remember, hospital emergency rooms are for true emergencies only. Call your doctor or our 24-hour emergency number at [1-800-xxx-xxxx] before you go to the emergency
room, unless your emergency is severe. 
  
 URGENT CARE 
  
 Urgent Care is care you need sooner than a routine doctor’s visit. Urgent care is not
emergency care. Do not go to a hospital emergency room for urgent care unless your doctor tells you to go there. Some examples of urgent care are: 
  

			
	Most broken bones	  	Minor cuts
	Sprains	  	Bruises
	Non-severe bleeding	  	Most drug reactions
	Minor burns	  	 

  

 -149- 

 If you need urgent care, call [insert instructions here—call clinic, doctor, 24-hour number, nurse line, etc.] We
will tell you where you can get care. You must get urgent care from [HMO NAME] doctors unless you get our approval to see a [non-HMO NAME] doctor. 
  
 Remember, do not go to a hospital emergency room for urgent care unless you get approval from [HMO NAME] first. 
  
 HOW TO GET MEDICAL CARE WHEN YOU ARE AWAY FROM HOME 
  
 Follow these rules if you need medical care but are too far away from home to go to your
assigned primary care physician (PCP) or clinic. 
  
 For severe emergencies, go to
the nearest hospital, clinic, or doctor. 
  
 For urgent or routine care away from
home, you must get approval from us to go to a different doctor, clinic or hospital. This includes children who are spending time away from home with a parent or relative. Call us at [1-800-xxx-xxxx] for approval to go to a different doctor, clinic,
or hospital. 
  
 PREGNANT WOMEN AND DELIVERIES 
  
 You must go to a [HMO NAME] hospital to have your baby. Talk to your [HMO NAME] doctor to
make sure you understand which hospital you are to go to when it’s time to have your baby. 
  
 Also, talk to your doctor if you plan to travel in your last month of pregnancy. Because we want you to have a healthy birth and a good birthing experience, it may not be a good time for you and your unborn child to
be traveling. We want you to have a healthy birth and your [HMO Name] doctor knows your history and is the best doctor to help you have a healthy birth. Do not go out of area to have your baby unless you have [HMO NAME] approval. 
  
 You may also wish to pick a doctor for your child before you give birth. We will be able to
help you pick a doctor for your unborn child. 
  
 WHEN YOU MAY BE BILLED FOR
SERVICES 
  
 It is very important to follow the rules when you get medical
care so you are not billed for services. You must receive your care from [HMO NAME] providers, hospitals, and pharmacies unless you have our approval. The only exception is for severe emergencies. 
  
 If you travel outside of Wisconsin and need emergency services, health care providers can
treat you and send claims to [HMO NAME]. You will have to pay for any service you get outside Wisconsin if the health care provider refuses to submit claims or refuses to accept [HMO NAME’s] payment as payment in full. 
  
 [HMO NAME] does not cover any service, including emergency services, provided outside of the
United States, Canada and Mexico. 
  

 -150- 

 IF YOU ARE BILLED 
  
 If you receive a bill for services, call our Customer Service Department at [1-800-xxx-xxxx]. You do not have to pay for services that [HMO NAME] is required to provide
you. 
  
 OTHER INSURANCE 
  
 If you have other insurance in addition to [HMO NAME], you must tell your doctor or other
provider. Your health care provider must bill your other insurance before billing [HMO NAME]. If your [HMO NAME] doctor does not accept your other insurance, call the HMO Enrollment Specialist at 1-800-291-2002. The Enrollment Specialist can tell
you how to match your HMO enrollment with your other insurance so you can use both insurance plans. 
  
 SERVICES COVERED BY [HMO NAME] 
  
 [HMO
NAME] provides all medically necessary covered services. Some services may require a doctor’s order or a prior authorization. Covered services include: 
  

	•	Prescription drugs and certain over-the-counter drugs when ordered by a doctor 

  

	•	Services by doctors and nurses, including nurse practitioners and nurse midwives 

  

	•	Inpatient and outpatient hospital services 

  

	•	Laboratory and X-ray services 

  

	•	HealthCheck for members under 21 years of age, including referral for other medically necessary services 

  

	•	Certain podiatrists’ (foot doctors) services 

  

	•	Inpatient care at institutions for mental disease (care for persons 22-64 years of age is not included) 

  

	•	Optometrists’ (eye doctors) or opticians’ services, including eyeglasses 

  

	•	Mental health treatment 

  

	•	Substance abuse (drug and alcohol) services 

  

	•	Family planning services and supplies 

  

	•	The following services when a doctor gives a written order: 

  

	 	•	Prostheses and other corrective support devices 

  

	 	•	Hearing aids and other hearing services 

  

	 	•	Home health care 

  

	 	•	Personal care 

  

 -151- 

	 	•	Independent nursing services 

  

	 	•	Medical supplies and equipment 

  

	 	•	Occupational therapy 

  

	 	•	Physical therapy 

  

	 	•	Speech therapy 

  

	 	•	Respiratory therapy 

  

	 	•	Nursing home services 

  

	 	•	Medical Nutrition Counseling 

  

	 	•	Hospice care 

  

	 	•	Appropriate transportation to obtain medical care by ambulance or specialized medical vehicles 

  

	•	Certain dental services (not all dental services are covered) [Eliminate if HMO does not provide dental] 

  

	•	Certain chiropractic services [Eliminate if HMO does not provide chiropractic] 

  
 MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES 
  

[HMO NAME] provides mental health and substance abuse (drug and alcohol) services to all enrollees. If you need these services, call [PCP, gatekeeper, Customer
Service, as appropriate]. 
  
 FAMILY PLANNING SERVICES 
  
 We provide confidential family planning services to all enrollees. This includes minors. If
you don’t want to talk to your primary care doctor about family planning, call our Customer Service Department at [1-800-xxx-xxx]. We will help you choose a [HMO NAME] family planning doctor who is different from your primary care doctor.

  
 You can also go to any family planning clinic that will accept your Forward ID
card even if the clinic is not part of [HMO NAME]. But we encourage you to receive family planning services from a [HMO NAME] doctor. That way we can better coordinate all your health care. 
  
 DENTAL SERVICES 
  
 [Note to HMO: Use statement 1. if you provide dental services. Use statement 2. if you do not provide dental services. If you provide dental
services in only part of your service area, use both statements and list the appropriate counties with each statement.] 
  

	1.	[HMO NAME] provides all covered dental services. But you must go to a [HMO NAME] dentist. See the Provider Directory or call the Customer Service Department at [1-800-xxx-xxxx] for
the names of our dentists. 

  

	2.	You may get dental services from any dentist who will accept your Forward ID card. Your dental services are provided by the State, not [HMO NAME]. 

  

 -152- 

 Dental Emergency: 
  
 A dental emergency is an immediate dental service needed to treat dental pain, swelling, fever, infection, or injury to the teeth. 
  
 WHAT TO DO IF YOU OR YOUR CHILD HAS A DENTAL EMERGENCY 
  

	1.	If you already have a dentist who is with HMO name: 

  

	 	•	Call the dentist’s office. 

  

	 	•	Identify yourself or your child as having a dental emergency. 

  

	 	•	Tell the dentist’s office what the exact dental problem is. This may be something like a toothache or swollen face. Make sure the office understands that you or your child is
having a “dental emergency.” 

  

	 	•	Call us if you need help with transportation to your dental appointment. 

  

	2.	If you do not currently have a dentist who is with HMO Name 

  

	 	•	Call {HMO specific dental gatekeeper or HMO}. Tell us that you/your child is having a dental emergency. We can help you get dental services. 

  

	 	•	Tell us if you need a ride to the dentist’s office. 

  

	 	•	Alternative language for HMO’s whose dental gatekeeper handles appointment for emergencies. Call [HMO NAME] if you need help with transportation to the dentist’s office.
We can help with transportation. 

  
 For help with a dental
emergency call [xxx-xxx-xxxx]. 
  
 CHIROPRACTIC SERVICES 

 
 [Note to HMO: Use statement 1. if you provide chiropractic services. Use statement 2. if
you do not provide chiropractic services.] 
  

	1.	[HMO NAME] provides covered chiropractic services. But you must go to a [HMO NAME] chiropractor. See the Provider Directory or call the Customer Service Department at
[1-800-xxx-xxxx] for the names of our chiropractors. 

  

	2.	You may get chiropractic services from any chiropractor who will accept your Forward ID card. Your chiropractic services are provided by the State, not [HMO NAME].

  
 HEALTHCHECK 
  
 HealthCheck is a preventive health checkup program for members under the age of 21. The
HealthCheck program covers complete health checkups. These checkups are very important for children’s health. Your child may look and feel well, yet may have a health problem. Your doctor wants to see your children for regular checkups, not
just when they are sick. 
  

 -153- 

 The HealthCheck health program has three purposes: 
  

	1.	To find and treat children’s health problems early, 

  

	2.	To let you know about the special child health services you can receive, and 

  

	3.	To make your children eligible for some health care not otherwise covered. 

  
 The HealthCheck program covers the care for any health problems found during the checkup including medical care, eye care and dental care. 
  
 The HealthCheck checkup includes: 
  

	•	a health history 

  

	•	physical exam 

  

	•	developmental assessment 

  

	•	hearing and vision test 

  

	•	blood and urine lab tests 

  

	•	complete immunizations (shots) 

  
 Children age three and older will be referred to a dentist. You will receive help in choosing and getting to a dentist. 
  
 [HMO NAME] will help arrange for transportation for HealthCheck visits. Call our Customer
Service Department a [1-800-xxx-xxxx]. 
  
 Ask your child’s primary care
doctor (PCP) when your child should have his/her next HealthCheck exam or call our Customer Service Department at [1-800-xxx-xxxx] for more information. 
  
 TRANSPORTATION 
  
 (Note to HMO: Use statement 1. if you arrange transportation for your enrollees. Use statement 2. if you do not arrange transportation for your enrollees. Use statement 3. if you arrange transportation in only part of
your service area.) 
  

	1.	Bus or taxi rides to receive care are arranged by [HMO NAME]. Call our Customer Service Department at [1-800-xxx-xxxx] if you need a ride. 

  

	2.	Bus or taxi rides to receive care are arranged by your county Department of Social or Human Services Call them for information. 

  

	3.	Bus or taxi rides to receive care are arranged by [HMO NAME] if you live in [INSERT COUNTIES]. Call our Customer Service Department at [1-800-xxx-xxxx] if you need a ride. If you
live in a county that is not listed, please call your county Department of Social or Human Services for information about arranging a ride. 

  

 -154- 

 AMBULANCE 
  
 [HMO NAME] covers ambulance service for Emergency Care. We may also cover this service at other times, but you must have approval for all non-emergency ambulance trips.
Call our Customer Service Department at [1-800-xxx-xxxx] for approval. 
  
 SPECIAL MEDICAL VEHICLE (SMV) 
  
 [HMO NAME] covers
transportation by special vehicle for those in wheelchairs. We may also cover this service for others if your doctor asks for it. Call our Customer Service Department at [1-800-xxx-xxxx] if you need this service. 
  
 IF YOU MOVE 
  
 If you are planning to move, contact your county Department of Social or Human Services. If you move to a different county, you must also
contact the Department of Social or Human Services in your new county to update your eligibility. 
  
 If you move out of [HMO NAME’S] service area, call the HMO Enrollment Specialist at 1-800 291-2002. [HMO NAME] will only provide emergency care if you move out of our service area. The Enrollment Specialist will
help you choose an HMO that serves your area. 
  
 HEALTH INSURANCE AFTER YOUR
ELIGIBILITY ENDS 
  
 You have the right to purchase a private health
insurance policy from [HMO NAME] when your eligibility ends. Call our Customer Service Department at [1-800-xxx-xxxx]. If you decide to purchase a policy from us, you have 30 days after the date your eligibility ends to apply. 
  
 SECOND MEDICAL OPINION 
  
 A second medical opinion on recommended surgeries may be appropriate in some cases. Contact your doctor or our Customer Service Department
for information. 
  
 HMO EXEMPTIONS 
  
 An HMO exemption means you are not required to join an HMO to receive your health care
benefits. Most exemptions are granted for only a short period of time so you can complete a course of treatment before you are enrolled in an HMO. If you think you need an exemption from HMO enrollment, call the HMO Enrollment Specialist at
1-800-291-2002 for more information. 
  
 LIVING WILL OR POWER OF ATTORNEY FOR
HEALTH CARE 
  
 You have a right to make decisions about your medical care.
You have a right to accept or refuse medical or surgical treatment. You also have the right to plan and direct the types of health care you may receive in the future if you become unable to express your wishes. You can let your doctor know about
your feelings by completing a living will or power of attorney for health care form. Contact your doctor for more information. 
  

 -155- 

 RIGHT TO MEDICAL RECORDS 
  

You have the right to ask for copies of your medical record from your provider(s). We can help you get copies of these records. Please call [1-800-xxx-xxxx] for help.
Please note: You may have to pay to copy your medical record. You also may correct wrong information in your medical records if your doctor agrees to the correction. 
  
 [HMO NAME’S] MEMBER ADVOCATE 
  
 [HMO NAME] has a Member Advocate to help you get the care you need. The Advocate can answer your questions about getting health care from [HMO NAME]. The Advocate can
also help you solve any problems you may have getting health care from [HMO NAME]. You can reach the Advocate at [1-800-xxx-xxxx]. 
  
 STATE OF WISCONSIN HMO OMBUDSMAN PROGRAM 
  
 The State has Ombudsmen who can help you with any questions or problems you have as an HMO member. The Ombudsman can tell you how to get the care you need from your HMO.
The Ombudsman can also help you solve problems or complaints you may have about the HMO Program or your HMO. Call 1-800-760-0001 and ask to speak to an Ombudsman. 
  
 COMPLAINTS, GRIEVANCES AND APPEALS 
  
 We would like to know if you have a complaint about your care at [HMO NAME]. Please call [HMO NAME’S] Member Advocate at [1-800-xxx-xxxx] if you have a complaint. Or
you can write to us at: 
  
 [HMO name and mailing address]

  
 If you want to talk to someone outside of [HMO NAME] about the problem, call
the HMO Enrollment Specialist at 1-800-291-2002. The Enrollment Specialist may be able to help you solve the problem, or can help you write a formal grievance to [HMO NAME] or to the Wisconsin Managed Care Program. The address to complain to the
Wisconsin Managed Care Program is: 
  
 Wisconsin Managed Care

 Ombudsman 
 P. O. Box 6470

 Madison, WI 53716-0470 
 1-800-760-0001 
  
 If your complaint or grievance needs action right away
because a delay in treatment would greatly increase the risk to your health, please call [HMO NAME] as soon as possible at [1-800-xxx-xxxx]. 
  
 We cannot treat you differently than other members because you file a complaint or grievance. Your health care benefits will not be affected. 
  

 -156- 

 You have the right to appeal to the State of Wisconsin Division of Hearings and Appeals (DHA) for a Fair Hearing if you
believe your benefits are wrongly denied, limited, reduced, delayed or stopped by [HMO NAME]. An appeal must be made no later than 45 days after the date of the action being appealed. If you appeal this action to DHA before the effective date, the
service may continue. You may need to pay for the cost of services if the hearing decision is not in your favor. 
  
 If you want a Fair Hearing, send a written request to: 
  
 Department of Administration 
 Division of
Hearings and Appeals 
 P. O. Box 7875 
 Madison, WI 53707-7875 
  
 The hearing will be held in the county where
you live. You have the right to bring a friend or be represented at the hearing. If you need a special arrangement for a disability, or for English language translation, please call (608) 266-3096 (voice) or (608) 264-9853 (hearing impaired).

  
 We cannot treat you differently than other members because you request a Fair
Hearing. Your health care benefits will not be affected. 
  
 If you need help
writing a request for a Fair Hearing, please call: 
  

			
	Wisconsin Managed Care Ombudsman	  	 1-800-760-0001

	 or
	  	 
	HMO Enrollment Specialist	  	 1-800-291-2002

  
 PHYSICIAN INCENTIVE PLAN

  
 You are entitled to ask if we have special financial arrangements with
our physicians that can affect the use of referrals and other services you might need. To get this information, call our Customer Service Department at [1-800-xxx-xxxx] and request information about our physician payment arrangements. 
  
 PROVIDER CREDENTIALS 
  
 You have the right to information about our providers that includes the provider’s education, Board certification and recertification.
To get this information, call our Customer Service Department at [1-800-xxx-xxxx]. 
  
 MEMBER RIGHTS 
  
 You have the right to ask for an interpreter
and have one provided to you during any Medicaid/ BadgerCare covered service. 
  
 You have the right to receive the information provided in this member handbook in another language or another format. 
  

 -157- 

 You have the right to receive health care services as provided for in Federal and State law. All covered services must be
available and accessible to you. When medically appropriate, services must be available 24 hours a day, 7 days a week. 
  
 You have the right to receive information about treatment options including the right to request a second opinion. 
  
 You have the right to make decisions about your health care. You have the right to be treated
with dignity and respect. 
  
 You have the right to be free from any form of
restraint or seclusion used as a means of force, control, ease or reprisal. 
  
 YOUR CIVIL RIGHTS 
  
 [HMO NAME] provides covered services to all
eligible members regardless of: 
  

	•	Age 

  

	•	Race 

  

	•	Religion 

  

	•	Color 

  

	•	Disability 

  

	•	Sex 

  

	•	Sexual Orientation 

  

	•	National Origin 

  

	•	Marital Status 

  

	•	Arrest or Conviction Record 

  

	•	Military Participation 

  
 All medically necessary covered services are available to all members. All services are provided in the same manner to all members. 
  
 All persons or organizations connected with [HMO Name] who refer or recommend members for services shall do so in the same manner for all
members. 
  
 Translating or interpreting services are available for those members
who need them. This service is free. 
  

 -158- 

 ADDENDUM III 
  
 ACTUARIAL BASIS 
  
 HMO Rate Regions and Established Counties 
  

															
	 Region 1: Duluth/Superior

	  	 Region 2: Wausau/Rhinelander

	 02
	  	Ashland	  	85	  	Red Cliff RNIP	  	21	  	Forest	  	60	  	Taylor
	 04
	  	Bayfield	  	89	  	Bad River	  	34	  	Langlade	  	63	  	Vilas
	 07
	  	Burnett	  	94	  	Lac Courte RNIP	  	35	  	Lincoln	  	86	  	Stockbridge RNIP
	 16
	  	Douglas	  	95	  	St. Croix RNIP	  	37	  	Marathon	  	87	  	Potawatomi RNIP
	 26
	  	Iron	  	 	  	 	  	43	  	Oneida	  	88	  	Lac du Flambeau RNIP
	 57
	  	Sawyer	  	 	  	 	  	50	  	Price	  	91	  	Sokaogon RNIP
	 65
	  	Washburn	  	 	  	 	  	58	  	Shawano	  	 	  	 
	 Region 3: Green Bay

	  	 Region 4: Twin Cities

	 05
	  	Brown	  	38	  	Marinette	  	03	  	Barron	  	47	  	Pierce
	 15
	  	Door	  	42	  	Oconto	  	09	  	Chippewa	  	48	  	Polk
	 19
	  	Florence	  	72	  	Menominee	  	17	  	Dunn	  	54	  	Rusk
	 31
	  	Kewaunee	  	84	  	Menominee RNIP	  	46	  	Pepin	  	55	  	St. Croix
	 36
	  	Manitowoc	  	 	  	 	  	 	  	 	  	 	  	 
	 Region 5: Marshfield/Stevens Point

	  	 Region 6: Appleton/Oshkosh

	 01
	  	Adams	  	39	  	Marquette	  	08	  	Calumet	  	92	  	Oneida RNIP
	 09
	  	Clark	  	49	  	Portage	  	20	  	Fond Du Lac	  	 	  	 
	 24
	  	Green Lake	  	69	  	Waushara	  	43	  	Outagamie	  	 	  	 
	 27
	  	Jackson	  	71	  	Wood	  	68	  	Waupaca	  	 	  	 
	 29
	  	Juneau	  	 	  	 	  	70	  	Winnebago	  	 	  	 
	 Region 7: LaCrosse

	  	 Region 8: Madison/South Central

	 06
	  	Buffalo	  	61	  	Trempealeau	  	11	  	Columbia	  	28	  	Jefferson
	 12
	  	Crawford	  	62	  	Vernon	  	14	  	Dodge	  	33	  	Lafayette
	 32
	  	LaCrosse	  	 	  	 	  	22	  	Grant	  	53	  	Rock
	 41
	  	Monroe	  	 	  	 	  	23	  	Green	  	56	  	Sauk
	 52
	  	Richland	  	 	  	 	  	25	  	Iowa	  	 	  	 
	 Region 9: Southeast Wisconsin

	  	 Established Counties

	 5
	  	Ozaukee	  	 	  	 	  	13	  	Dane	  	 	  	 
	 51
	  	Racine	  	 	  	 	  	18	  	Eau Claire	  	 	  	 
	 59
	  	Sheboygan	  	 	  	 	  	30	  	Kenosha	  	 	  	 
	 64
	  	Walworth	  	 	  	 	  	40	  	Milwaukee	  	 	  	 
	 66
	  	Washington	  	 	  	 	  	67	  	Waukesha	  	 	  	 

  

 -159- 

 Addendum III - Rate Period May-December 2004 
 Duluth/Superior Region 
  

																			
	AFDC/HS Children	 
	1	  	 Eligibility Groups
	  	 	ADFC and Healthy Start Children	 
			
	2	  	 Medical Status Codes
	  	 
 
 	31, 32, 38, 39, CC, CM, E2, GC, GE,
N1, N2, PC, UA, WH, WN, WU, X1,
X2, X3, X4	 
 
 
						
	 	  	 	  	All

	 	 	Dental
No Chiro

	 	 	 Chiro
 No Dental

	 	 	No Dental
& No Chiro

	 
	3	  	 Managed Care Equivalency (MCE)
	  	$	167.50	 	 	$	166.87	 	 	$	162.02	 	 	$	161.39	 
	4	  	 Capitation Rate
	  	$	136.49	 	 	$	135.54	 	 	$	130.53	 	 	$	129.58	 
	5	  	 Age/Gender Factors
	  	 	See Attached Addendum III - A	 
	6	  	 Capitation By Service Category
	  	 	See Attached Addendum III - B	 
	7	  	 Final Capitation Rates by Age/Gender
	  	 	See Attached Addendum III - C	 
	8	  	 Discount
	  	 	18.5	%	 	 	18.8	%	 	 	19.4	%	 	 	19.7	%
	
	Healthy Start Pregnant Women	 
	1	  	 Eligibility Groups
	  	 	Healthy Start Pregnant Women	 
			
	2	  	 Medical Status Codes
	  	 	95, A6, A7, A8, A9, E3, E4, PW, P1	 
						
	 	  	 	  	All

	 	 	Dental
No Chiro

	 	 	 Chiro
 No Dental

	 	 	No Dental
& No Chiro

	 
	3	  	 MCE
	  	$	932.89	 	 	$	931.12	 	 	$	928.39	 	 	$	926.62	 
	4	  	 Cap Rate
	  	$	629.80	 	 	$	628.73	 	 	$	623.47	 	 	$	622.40	 
	5	  	 Discount
	  	 	32.5	%	 	 	32.5	%	 	 	32.8	%	 	 	32.8	%

  

 4/14/04 

 Addendum III - Rate Period May-December 2004 
 Wausau/Rhinelander Region 
  

																			
	AFDC/HS Children	 
	1	  	 Eligibility Groups
	  	 	ADFC and Healthy Start Children	 
			
	2	  	 Medical Status Codes
	  	 
 
 	31, 32, 38, 39, CC, CM, E2, GC, GE,
N1, N2, PC, UA, WH, WN, WU, X1,
X2, X3, X4	 
 
 
						
	 	  	 	  	All

	 	 	Dental
No Chiro

	 	 	Chiro No
Dental

	 	 	No Dental
& No Chiro

	 
	3	  	 Managed Care Equivalency (MCE)
	  	$	141.54	 	 	$	140.92	 	 	$	135.60	 	 	$	134.98	 
	4	  	 Capitation Rate
	  	$	134.93	 	 	$	134.06	 	 	$	129.50	 	 	$	128.63	 
	5	  	 Age/Gender Factors
	  	 	See Attached Addendum III - A	 
	6	  	 Capitation By Service Category
	  	 	See Attached Addendum III - B	 
	7	  	 Final Capitation Rates by Age/Gender
	  	 	See Attached Addendum III - C	 
	8	  	 Discount
	  	 	4.7	%	 	 	4.9	%	 	 	4.5	%	 	 	4.7	%
	
	Healthy Start Pregnant Women	 
	1	  	 Eligibility Groups
	  	 	Healthy Start Pregnant Women	 
			
	2	  	 Medical Status Codes
	  	 	95, A6, A7, A8, A9, E3, E4, PW, P1	 
						
	 	  	 	  	All

	 	 	Dental
No Chiro

	 	 	 Chiro
 No Dental

	 	 	No Dental
& No Chiro

	 
	3	  	 MCE
	  	$	674.34	 	 	$	672.77	 	 	$	672.64	 	 	$	671.07	 
	4	  	 Cap Rate
	  	$	599.03	 	 	$	597.71	 	 	$	595.63	 	 	$	594.31	 
	5	  	 Discount
	  	 	11.2	%	 	 	11.2	%	 	 	11.4	%	 	 	11.4	%

  

 4/14/04 

 Addendum III - Rate Period May-December 2004 
 Green Bay Region 
  

																			
	AFDC/HS Children	 
	1	  	 Eligibility Groups
	  	 	ADFC and Healthy Start Children	 
			
	2	  	 Medical Status Codes
	  	 
 
 	31, 32, 38, 39, CC, CM, E2, GC, GE,
N1, N2, PC, UA, WH, WN, WU, X1,
X2, X3, X4	 
 
 
						
	 	  	 	  	All

	 	 	Dental
No Chiro

	 	 	Chiro No
Dental

	 	 	No Dental
& No Chiro

	 
	3	  	 Managed Care Equivalency (MCE)
	  	$	161.93	 	 	$	161.62	 	 	$	155.65	 	 	$	155.34	 
	4	  	 Capitation Rate
	  	$	128.72	 	 	$	127.96	 	 	$	123.10	 	 	$	122.34	 
	5	  	 Age/Gender Factors
	  	 	See Attached Addendum III - A	 
	6	  	 Capitation By Service Category
	  	 	See Attached Addendum III - B	 
	7	  	 Final Capitation Rates by Age/Gender
	  	 	See Attached Addendum III - C	 
	8	  	 Discount
	  	 	20.5	%	 	 	20.8	%	 	 	20.9	%	 	 	21.2	%
	
	Healthy Start Pregnant Women	 
	1	  	 Eligibility Groups
	  	 	Healthy Start Pregnant Women	 
			
	2	  	 Medical Status Codes
	  	 	95, A6, A7, A8, A9, E3, E4, PW, P1	 
						
	 	  	 	  	All

	 	 	Dental
No Chiro

	 	 	 Chiro
 No Dental

	 	 	No Dental
& No Chiro

	 
	3	  	 MCE
	  	$	753.72	 	 	$	752.75	 	 	$	750.36	 	 	$	749.39	 
	4	  	 Cap Rate
	  	$	591.22	 	 	$	590.60	 	 	$	587.73	 	 	$	587.12	 
	5	  	 Discount
	  	 	21.6	%	 	 	21.5	%	 	 	21.7	%	 	 	21.7	%

  

 4/14/04 

 Addendum III - Rate Period May-December 2004 
 Twin Cities Region 
  

																			
	AFDC/HS Children	 
	 1
	  	 Eligibility Groups
	  	 	ADFC and Healthy Start Children	 
			
	 2
	  	 Medical Status Codes
	  	 
 
 	31, 32, 38, 39, CC, CM, E2, GC, GE,
N1, N2, PC, UA, WH WN, WU, X1, X2,
X3, X4	 
 
 
						
	 	  	 	  	All

	 	 	 Dental
 No Chiro

	 	 	 Chiro
 No Dental

	 	 	 No Dental
 & No Chiro

	 
	 3
	  	 Managed Care Equivalency (MCE)
	  	$	165.20	 	 	$	164.15	 	 	$	159.93	 	 	$	158.88	 
	 4
	  	 Capitation Rate
	  	$	142.17	 	 	$	140.40	 	 	$	134.25	 	 	$	132.48	 
	 5
	  	 Age/Gender Factors
	  	 	See Attached Addendum III - A	 
	 6
	  	 Capitation By Service Category
	  	 	See Attached Addendum III - B	 
	 7
	  	 Final Capitation Rates by Age/Gender
	  	 	See Attached Addendum III - C	 
	 8
	  	 Discount
	  	 	13.9	%	 	 	14.5	%	 	 	16.1	%	 	 	16.6	%
	
	Healthy Start Pregnant Women	 
	 1
	  	 Eligibility Groups
	  	 	Healthy Start Pregnant Women	 
			
	 2
	  	 Medical Status Codes
	  	 	95, A6, A7, A8, A9, E3, E4, PW, P1	 
						
	 	  	 	  	All

	 	 	 Dental
 No Chiro

	 	 	 Chiro
 No Dental

	 	 	 No Dental
 & No Chiro

	 
	 3
	  	 MCE
	  	$	875.27	 	 	$	872.93	 	 	$	871.87	 	 	$	869.53	 
	 4
	  	 Cap Rate
	  	$	599.09	 	 	$	597.44	 	 	$	592.54	 	 	$	590.88	 
	 5
	  	 Discount
	  	 	31.6	%	 	 	31.6	%	 	 	32.0	%	 	 	32.0	%

  

 4/14/04 

 Addendum III - Rate Period May-December 2004 
 Marshfield/Stevens Point Region 
  

																			
	AFDC/HS Children	 
	 1
	  	 Eligibility Groups
	  	 	ADFC and Healthy Start Children	 
			
	 2
	  	 Medical Status Codes
	  	 
 
 	31, 32, 38, 39, CC, CM, E2, GC, GE,
N1, N2, PC, UA, WH WN, WU, X1, X2,
X3, X4	 
 
 
						
	 	  	 	  	All

	 	 	 Dental
 No Chiro

	 	 	 Chiro
 No Dental

	 	 	 No Dental
 & No Chiro

	 
	 3
	  	 Managed Care Equivalency (MCE)
	  	$	140.33	 	 	$	139.51	 	 	$	133.55	 	 	$	132.73	 
	 4
	  	 Capitation Rate
	  	$	133.82	 	 	$	133.01	 	 	$	127.72	 	 	$	126.91	 
	 5
	  	 Age/Gender Factors
	  	 	See Attached Addendum III - A	 
	 6
	  	 Capitation By Service Category
	  	 	See Attached Addendum III - B	 
	 7
	  	 Final Capitation Rates by Age/Gender
	  	 	See Attached Addendum III - C	 
	 8
	  	 Discount
	  	 	4.6	%	 	 	4.7	%	 	 	4.4	%	 	 	4.4	%
	
	Healthy Start Pregnant Women	 
	 1
	  	 Eligibility Groups
	  	 	Healthy Start Pregnant Women	 
			
	 2
	  	 Medical Status Codes
	  	 	95, A6, A7, A8, A9, E3, E4, PW, P1	 
						
	 	  	 	  	All

	 	 	 Dental
 No Chiro

	 	 	 Chiro
 No Dental

	 	 	 No Dental
 & No Chiro

	 
	 3
	  	 MCE
	  	$	717.67	 	 	$	715.93	 	 	$	713.65	 	 	$	711.91	 
	 4
	  	 Cap Rate
	  	$	612.63	 	 	$	611.40	 	 	$	608.82	 	 	$	607.58	 
	 5
	  	 Discount
	  	 	14.6	%	 	 	14.6	%	 	 	14.7	%	 	 	14.7	%

  

 4/14/04 

 Addendum III - Rate Period May-December 2004 
 Appleton/Oshkosh Region 
  

																			
	AFDC/HS Children	 
	 1
	  	 Eligibility Groups
	  	 	ADFC and Healthy Start Children	 
			
	 2
	  	 Medical Status Codes
	  	 
 
 	31, 32, 38, 39, CC, CM, E2, GC, GE,
N1, N2, PC, UA, WH WN, WU, X1, X2,
X3, X4	 
 
 
						
	 	  	 	  	All

	 	 	 Dental
 No Chiro

	 	 	 Chiro
 No Dental

	 	 	 No Dental
 & No Chiro

	 
	 3
	  	 Managed Care Equivalency (MCE)
	  	$	161.03	 	 	$	160.57	 	 	$	154.22	 	 	$	153.76	 
	 4
	  	 Capitation Rate
	  	$	129.74	 	 	$	128.88	 	 	$	123.96	 	 	$	123.10	 
	 5
	  	 Age/Gender Factors
	  	 	See Attached Addendum III - A	 
	 6
	  	 Capitation By Service Category
	  	 	See Attached Addendum III - B	 
	 7
	  	 Final Capitation Rates by Age/Gender
	  	 	See Attached Addendum III - C	 
	 8
	  	 Discount
	  	 	19.4	%	 	 	19.7	%	 	 	19.6	%	 	 	19.9	%
	
	Healthy Start Pregnant Women	 
	 1
	  	 Eligibility Groups
	  	 	Healthy Start Pregnant Women	 
			
	 2
	  	 Medical Status Codes
	  	 	95, A6, A7, A8, A9, E3, E4, PW, P1	 
						
	 	  	 	  	All

	 	 	 Dental
 No Chiro

	 	 	 Chiro
 No Dental

	 	 	 No Dental
 & No Chiro

	 
	 3
	  	 MCE
	  	$	774.53	 	 	$	772.58	 	 	$	769.18	 	 	$	767.23	 
	 4
	  	 Cap Rate
	  	$	590.52	 	 	$	589.85	 	 	$	585.87	 	 	$	585.20	 
	 5
	  	 Discount
	  	 	23.8	%	 	 	23.7	%	 	 	23.8	%	 	 	23.7	%

  

 4/14/04 

 Addendum III - Rate Period May-December 2004 
 La Crosse Region 
  

																					
	AFDC/HS Children	 
	1	  	 	  	 Eligibility Groups
	  	 	ADFC and Healthy Start Children	 
				
	2	  	 	  	 Medical Status Codes
	  	 
 
 	31, 32, 38, 39, CC, CM, E2, GC, GE,
N1, N2, PC, UA, WHWN, WU, X1, X2,
X3, X4	 
 
 
							
	 	  	 	  	 	  	All

	 	 	Dental
No Chiro

	 	 	 Chiro
 No Dental

	 	 	No Dental
& No Chiro

	 
	3	  	 	  	 Managed Care Equivalency (MCE)
	  	$	138.75	 	 	$	137.73	 	 	$	131.62	 	 	$	130.60	 
	4	  	 	  	 Capitation Rate
	  	$	128.54	 	 	$	127.43	 	 	$	122.51	 	 	$	121.40	 
	5	  	 	  	 Age/Gender Factors
	  	 	See Attached Addendum III - A	 
	6	  	 	  	 Capitation By Service Category
	  	 	See Attached Addendum III - B	 
	7	  	 	  	 Final Capitation Rates by Age/Gender
	  	 	See Attached Addendum III - C	 
	8	  	 	  	 Discount 7.4%
	  	 	7.4	%	 	 	7.5	%	 	 	6.9	%	 	 	7.0	%
	
	Healthy Start Pregnant Women	 
	1	  	 	  	 Eligibility Groups
	  	 	Healthy Start Pregnant Women	 
				
	2	  	 	  	 Medical Status Codes
	  	 	95, A6, A7, A8, A9, E3, E4, PW, P1	 
							
	 	  	 	  	 	  	All

	 	 	 Dental
 No Chiro

	 	 	 Chiro
 No Dental

	 	 	No Dental
& No Chiro

	 
	3	  	 	  	 MCE
	  	$	723.50	 	 	$	721.38	 	 	$	719.14	 	 	$	717.02	 
	4	  	 	  	 Cap Rate
	  	$	598.95	 	 	$	597.72	 	 	$	593.87	 	 	$	592.64	 
	5	  	 	  	 Discount
	  	 	17.2	%	 	 	17.1	%	 	 	17.4	%	 	 	17.3	%

  

 4/14/04 

 Addendum III - Rate Period May-December 2004 
 Madison Region 
  

																			
	AFDC/HS Children	 
	1	  	 Eligibility Groups
	  	 	ADFC and Healthy Start Children	 
			
	2	  	 Medical Status Codes
	  	 
 
 	31, 32, 38, 39, CC, CM, E2, GC, GE, N1,
N2, PC, UA, WHWN, WU, X1, X2, X3,
X4	 
 
 
						
	 	  	 	  	All

	 	 	Dental
No Chiro

	 	 	Chiro
No Dental

	 	 	No Dental
& No Chiro

	 
	3	  	 Managed Care Equivalency (MCE)
	  	$	153.40	 	 	$	153.03	 	 	$	146.51	 	 	$	146.14	 
	4	  	 Capitation Rate
	  	$	146.32	 	 	$	145.79	 	 	$	139.68	 	 	$	139.15	 
	5	  	 Age/Gender Factors
	  	 	See Attached Addendum III - A	 
	6	  	 Capitation By Service Category
	  	 	See Attached Addendum III - B	 
	7	  	 Final Capitation Rates by Age/Gender
	  	 	See Attached Addendum III - C	 
	8	  	 Discount
	  	 	4.6	%	 	 	4.7	%	 	 	4.7	%	 	 	4.8	%
	
	Healthy Start Pregnant Women	 
	1	  	 Eligibility Groups
	  	 	Healthy Start Pregnant Women	 
			
	2	  	 Medical Status Codes
	  	 	95, A6, A7, A8, A9, E3, E4, PW, P1	 
						
	 	  	 	  	All

	 	 	Dental
No Chiro

	 	 	Chiro
No Dental

	 	 	No Dental
& No Chiro

	 
	3	  	 MCE
	  	$	819.75	 	 	$	818.66	 	 	$	814.47	 	 	$	813.38	 
	4	  	 Cap Rate
	  	$	618.05	 	 	$	617.43	 	 	$	613.21	 	 	$	612.58	 
	5	  	 Discount
	  	 	24.6	%	 	 	24.6	%	 	 	24.7	%	 	 	24.7	%

  

 4/14/04 

 Addendum III - Rate Period May-December 2004 
 SE Wisconsin Region 
  

																					
	AFDC/HS Children	 
	1	  	 	  	 Eligibility Groups
	  	 	ADFC and Healthy Start Children	 
				
	2	  	 	  	 Medical Status Codes
	  	 
 
 	31, 32, 38, 39, CC, CM, E2, GC, GE, N1,
N2, PC, UA, WHWN, WU, X1, X2, X3,
X4	 
 
 
							
	 	  	 	  	 	  	All

	 	 	Dental
No Chiro

	 	 	 Chiro
 No Dental

	 	 	No Dental
& No Chiro

	 
	3	  	 	  	 Managed Care Equivalency (MCE)
	  	$	147.99	 	 	$	147.59	 	 	$	143.04	 	 	$	142.64	 
	4	  	 	  	 Capitation Rate
	  	$	137.62	 	 	$	137.17	 	 	$	131.96	 	 	$	131.51	 
	5	  	 	  	 Age/Gender Factors
	  	 	See Attached Addendum III - A	 
	6	  	 	  	 Capitation By Service Category
	  	 	See Attached Addendum III - B	 
	7	  	 	  	 Final Capitation Rates by Age/Gender
	  	 	See Attached Addendum III - C	 
	8	  	 	  	 Discount
	  	 	7.0	%	 	 	7.1	%	 	 	7.7	%	 	 	7.8	%
	
	Healthy Start Pregnant Women	 
	1	  	 	  	 Eligibility Groups
	  	 	Healthy Start Pregnant Women	 
				
	2	  	 	  	 Medical Status Codes
	  	 	95, A6, A7, A8, A9, E3, E4, PW, P1	 
							
	 	  	 	  	 	  	All

	 	 	Dental
No Chiro

	 	 	Chiro
No Dental

	 	 	No Dental
& No Chiro

	 
	3	  	 	  	 MCE
	  	$	810.83	 	 	$	809.70	 	 	$	807.93	 	 	$	806.80	 
	4	  	 	  	 Cap Rate
	  	$	603.54	 	 	$	602.97	 	 	$	600.16	 	 	$	599.59	 
	5	  	 	  	 Discount
	  	 	25.6	%	 	 	25.5	%	 	 	25.7	%	 	 	25.7	%

  

 4/14/04 

 Addendum III - Rate Period May-December 2004 
 Milwaukee County 
  

																			
	 	  	AFDC/HS Children	 
	 1
	  	 Eligibility Groups
	  	 	ADFC and Healthy Start Children	 
			
	 2
	  	 Medical Status Codes
	  	 
 
 	31, 32, 38, 39, CC, CM, E2, GC, GE,
N1, N2, PC, UA, WH WN, WU, X1,
X2, X3, X4	 
 
 
						
	 	  	 	  	All

	 	 	Dental
No Chiro

	 	 	Chiro No
Dental

	 	 	No Dental
& No Chiro

	 
	 3
	  	 Managed Care Equivalency (MCE)
	  	$	155.06	 	 	$	154.75	 	 	$	150.95	 	 	$	150.64	 
	 4
	  	 Capitation Rate
	  	$	147.93	 	 	$	147.78	 	 	$	142.56	 	 	$	142.41	 
	 5
	  	 Age/Gender Factors
	  	 	See Attached Addendum III - A	 
	 6
	  	 Capitation By Service Category
	  	 	See Attached Addendum III - B	 
	 7
	  	 Final Capitation Rates by Age/Gender
	  	 	See Attached Addendum III - C	 
	 8
	  	 Discount
	  	 	4.6	%	 	 	4.5	%	 	 	5.6	%	 	 	5.5	%
		
	 	  	Healthy Start Pregnant Women	 
	 1
	  	 Eligibility Groups
	  	 	Healthy Start Pregnant Women	 
			
	 2
	  	 Medical Status Codes
	  	 	95, A6, A7, A8, A9, E3, E4, PW, P1	 
						
	 	  	 	  	All

	 	 	Dental
No Chiro

	 	 	Chiro No
Dental

	 	 	No Dental
& No Chiro

	 
	 3
	  	 MCE
	  	$	940.03	 	 	$	939.23	 	 	$	936.64	 	 	$	935.84	 
	 4
	  	 Cap Rate
	  	$	722.72	 	 	$	722.51	 	 	$	720.77	 	 	$	720.56	 
	 5
	  	 Discount
	  	 	23.1	%	 	 	23.1	%	 	 	23.0	%	 	 	23.0	%

  

 4/14/04 

 Addendum III - Rate Period May-December 2004 
 Dane County 
  

																			
	AFDC/HS Children	 
	 1
	  	 Eligibility Groups
	  	 	ADFC and Healthy Start Children	 
			
	 2
	  	 Medical Status Codes
	  	 
 
 	31, 32, 38, 39, CC, CM, E2, GC, GE,
N1, N2, PC, UA, WH WN, WU, X1,
X2, X3, X4	 
 
 
						
	 	  	 	  	All

	 	 	Dental
No Chiro

	 	 	Chiro No
Dental

	 	 	 No Dental
 & No Chiro

	 
	 3
	  	 Managed Care Equivalency (MCE)
	  	$	137.67	 	 	$	137.41	 	 	$	132.46	 	 	$	132.20	 
	 4
	  	 Capitation Rate
	  	$	131.34	 	 	$	130.75	 	 	$	127.00	 	 	$	126.41	 
	 5
	  	 Age/Gender Factors
	  	 	See Attached Addendum III - A	 
	 6
	  	 Capitation By Service Category
	  	 	See Attached Addendum III - B	 
	 7
	  	 Final Capitation Rates by Age/Gender
	  	 	See Attached Addendum III - C	 
	 8
	  	 Discount
	  	 	4.6	%	 	 	4.8	%	 	 	4.1	%	 	 	4.4	%
	
	Healthy Start Pregnant Women	 
	 1
	  	 Eligibility Groups
	  	 	Healthy Start Pregnant Women	 
			
	 2
	  	 Medical Status Codes
	  	 	95, A6, A7, A8, A9, E3, E4, PW, P1	 
						
	 	  	 	  	All

	 	 	Dental
No Chiro

	 	 	Chiro No
Dental

	 	 	No Dental
& No Chiro

	 
	 3
	  	 MCE
	  	$	809.01	 	 	$	808.15	 	 	$	806.00	 	 	$	805.14	 
	 4
	  	 Cap Rate
	  	$	658.64	 	 	$	658.20	 	 	$	656.04	 	 	$	655.60	 
	 5
	  	 Discount
	  	 	18.6	%	 	 	18.6	%	 	 	18.6	%	 	 	18.6	%

  

 4/14/04 

 Addendum III - Rate Period May-December 2004 
 Eau Claire County 
  

																			
	AFDC/HS Children	 
	 1
	  	 Eligibility Groups
	  	 	ADFC and Healthy Start Children	 
			
	 2
	  	 Medical Status Codes
	  	 
 
 	31, 32, 38, 39, CC, CM, E2, GC, GE,
N1, N2, PC, UA, WH WN, WU, X1,
X2, X3, X4	 
 
 
						
	 	  	 	  	All

	 	 	Dental
No Chiro

	 	 	Chiro No
Dental

	 	 	 No Dental
 & No Chiro

	 
	 3
	  	 Managed Care Equivalency (MCE)
	  	$	160.77	 	 	$	159.07	 	 	$	155.50	 	 	$	153.80	 
	 4
	  	 Capitation Rate
	  	$	132.68	 	 	$	130.56	 	 	$	126.66	 	 	$	124.54	 
	 5
	  	 Age/Gender Factors
	  	 	See Attached Addendum III - A	 
	 6
	  	 Capitation By Service Category
	  	 	See Attached Addendum III - B	 
	 7
	  	 Final Capitation Rates by Age/Gender
	  	 	See Attached Addendum III - C	 
	 8
	  	 Discount
	  	 	17.5	%	 	 	17.9	%	 	 	18.5	%	 	 	19.0	%
	
	Healthy Start Pregnant Women	 
	 1
	  	 Eligibility Groups
	  	 	Healthy Start Pregnant Women	 
			
	 2
	  	 Medical Status Codes
	  	 	95, A6, A7, A8, A9, E3, E4, PW, P1	 
						
	 	  	 	  	All

	 	 	Dental
No Chiro

	 	 	Chiro No
Dental

	 	 	No Dental
& No Chiro

	 
	 3
	  	 MCE
	  	$	820.01	 	 	$	817.16	 	 	$	817.17	 	 	$	814.32	 
	 4
	  	 Cap Rate
	  	$	720.77	 	 	$	718.89	 	 	$	717.70	 	 	$	715.82	 
	 5
	  	 Discount
	  	 	12.1	%	 	 	12.0	%	 	 	12.2	%	 	 	12.1	%

  

 4/14/04 

 Addendum III - Rate Period May-December 2004 
 Kenosha County 
  

																			
	AFDC/HS Children	 
	 1
	  	 Eligibility Groups
	  	 	ADFC and Healthy Start Children	 
			
	 2
	  	 Medical Status Codes
	  	 
 
 	31, 32, 38, 39, CC, CM, E2, GC, GE,
N1, N2, PC, UA, WHWN, WU, X1,
X2, X3, X4	 
 
 
						
	 	  	 	  	All

	 	 	 Dental
 No Chiro

	 	 	Chiro
No Dental

	 	 	 No Dental
 & No Chiro

	 
	 3
	  	 Managed Care Equivalency (MCE)
	  	$	171.29	 	 	$	171.12	 	 	$	165.01	 	 	$	164.84	 
	 4
	  	 Capitation Rate
	  	$	145.43	 	 	$	145.19	 	 	$	138.45	 	 	$	138.21	 
	 5
	  	 Age/Gender Factors
	  	 	See Attached Addendum III-A	 
	 6
	  	 Capitation By Service Category
	  	 	See Attached Addendum III-B	 
	 7
	  	 Final Capitation Rates by Age/Gender
	  	 	See Attached Addendum III-C	 
	 8
	  	 Discount
	  	 	15.1	%	 	 	15.2	%	 	 	16.1	%	 	 	16.2	%
	
	Healthy Start Pregnant Women	 
	 1
	  	 Eligibility Groups
	  	 	Healthy Start Pregnant Women	 
			
	 2
	  	 Medical Status Codes
	  	 	95, A6, A7, A8, A9, E3, E4, PW, P1	 
						
	 	  	 	  	All

	 	 	Dental
No Chiro

	 	 	 Chiro
 No Dental

	 	 	No Dental
& No Chiro

	 
	 3
	  	 MCE
	  	$	810.94	 	 	$	810.62	 	 	$	805.23	 	 	$	804.91	 
	 4
	  	 Cap Rate
	  	$	668.00	 	 	$	667.85	 	 	$	663.17	 	 	$	663.02	 
	 5
	  	 Discount
	  	 	17.6	%	 	 	17.6	%	 	 	17.6	%	 	 	17.6	%

  

 4/14/04 

 Addendum III-Rate Period May-December 2004 
 Waukesha County 
  

																			
	AFDC/HS Children	 
			
	 1
	  	 Eligibility Groups
	  	 	ADFC and Healthy Start Children	 
			
	 2
	  	 Medical Status Codes
	  	 
 
 	31, 32, 38, 39, CC, CM, E2, GC, GE,
N1, N2, PC, UA, WHWN, WU, X1,X2,
X3, X4	 
 
 
						
	 	  	 	  	All

	 	 	Dental
No Chiro

	 	 	 Chiro
 No Dental

	 	 	No Dental
& No Chiro

	 
	 3
	  	 Managed Care Equivalency (MCE)
	  	$	171.57	 	 	$	171.29	 	 	$	166.81	 	 	$	166.53	 
	 4
	  	 Capitation Rate
	  	$	153.50	 	 	$	152.86	 	 	$	147.17	 	 	$	146.53	 
	 5
	  	 Age/Gender Factors
	  	 	See Attached Addendum VII-A	 
	 6
	  	 Capitation By Service Category
	  	 	See Attached Addendum VII-B	 
	 7
	  	 Final Capitation Rates by Age/Gender
	  	 	See Attached Addendum VII-C	 
	 8
	  	 Discount
	  	 	10.5	%	 	 	10.8	%	 	 	11.8	%	 	 	12.0	%
	
	Healthy Start Pregnant Women	 
			
	 1
	  	 Eligibility Groups
	  	 	Healthy Start Pregnant Women	 
			
	 2
	  	 Medical Status Codes
	  	 	95, A6, A7, A8, A9, E3, E4, PW, P1	 
						
	 	  	 	  	All

	 	 	Dental
No Chiro

	 	 	 Chiro
 No Dental

	 	 	No Dental
& No Chiro

	 
	 3
	  	 MCE
	  	$	835.33	 	 	$	834.86	 	 	$	832.21	 	 	$	831.74	 
	 4
	  	 Cap Rate
	  	$	616.11	 	 	$	615.82	 	 	$	612.06	 	 	$	611.77	 
	 5
	  	 Discount
	  	 	26.2	%	 	 	26.2	%	 	 	26.5	%	 	 	26.4	%

  

 4/14/04 

 Addendum III - Rate Period May-December 2004 
 Duluth/Superior Rate Region 
  

																			
	BadgerCare	 
			
	 1
	  	 Eligibility Groups
	  	 	BadgerCare Children and Adults	 
			
	 2
	  	 Medical Status Codes
	  	 	B1,B2, B3, B4, B5,B6, GP	 
						
	 	  	 	  	All Services

	 	 	Dental
No Chiro

	 	 	 Chiro
 No Dental

	 	 	No Dental
& No Chiro

	 
	 3
	  	 MCE
	  	$	180.68	 	 	$	179.76	 	 	$	174.40	 	 	$	173.48	 
	 4
	  	 Capitation Rate
	  	$	147.96	 	 	$	146.94	 	 	$	141.50	 	 	$	140.48	 
	 5
	  	 Discount
	  	 	18.1	%	 	 	18.3	%	 	 	18.9	%	 	 	19.0	%
	 6
	  	 Age/Gender Factors
	  	 	See Attached Addendum III - D	 
	 7
	  	 Capitation by Service Category
	  	 	See Attached Addendum III - E	 
	 8
	  	 Final Capitation Rates by Age/Gender
	  	 	See Attached Addendum III - F	 

  

 4/14/04 

 Addendum III - Rate Period May-December 2004 
 Wausau/Rhinelander Rate Region 
  

																			
	BadgerCare	 
	 1
	  	 Eligibility Groups
	  	 	BadgerCare Children and Adults	 
			
	 2
	  	 Medical Status Codes
	  	 	B1, B2, B3, B4, B5, B6, GP	 
						
	 	  	 	  	All Services

	 	 	Dental
No Chiro

	 	 	 Chiro
 No Dental

	 	 	No Dental
& No Chiro

	 
	 3
	  	 MCE
	  	$	174.54	 	 	$	172.60	 	 	$	170.54	 	 	$	168.60	 
	 4
	  	 Capitation Rate
	  	$	152.33	 	 	$	151.35	 	 	$	146.21	 	 	$	145.23	 
	 5
	  	 Discount
	  	 	12.7	%	 	 	12.3	%	 	 	14.3	%	 	 	13.9	%
	 6
	  	 Age/Gender Factors
	  	 	See Attached Addendum III-D	 
	 7
	  	 Capitation by Service Category
	  	 	See Attached Addendum III-E	 
	 8
	  	 Final Capitation Rates by Age/Gender
	  	 	See Attached Addendum III-F	 

  

 4/14/04 

 Addendum III-Rate Period May-December 2004 
 Green Bay Rate Region 
  

																			
	BadgerCare	 
	 1
	  	 Eligibility Groups
	  	 	BadgerCare Children and Adults	 
			
	 2
	  	 Medical Status Codes
	  	 	B1, B2, B3, B4, B5, B6, GP	 
						
	 	  	 	  	All Services

	 	 	Dental
No Chiro

	 	 	 Chiro
 No Dental

	 	 	No Dental
& No Chiro

	 
	 3
	  	 MCE
	  	$	190.09	 	 	$	188.91	 	 	$	184.40	 	 	$	183.22	 
	 4
	  	 Capitation Rate
	  	$	148.39	 	 	$	147.54	 	 	$	141.92	 	 	$	141.07	 
	 5
	  	 Discount
	  	 	21.9	%	 	 	21.9	%	 	 	23.0	%	 	 	23.0	%
	 6
	  	 Age/Gender Factors
	  	 	See Attached Addendum III-D	 
	 7
	  	 Capitation by Service Category
	  	 	See Attached Addendum III-E	 
	 8
	  	 Final Capitation Rates by Age/Gender
	  	 	See Attached Addendum III-F	 

  

 4/14/04 

 Addendum III-Rate Period May-December 2004 
 Twin Cities Rate Region 
  

																			
	BadgerCare	 
	 1
	  	 Eligibility Groups
	  	 	BadgerCare Children and Adults	 
			
	 2
	  	 Medical Status Codes
	  	 	B1, B2, B3, B4, B5, B6, GP	 
						
	 	  	 	  	All Services

	 	 	Dental
No Chiro

	 	 	 Chiro
 No Dental

	 	 	No Dental
& No Chiro

	 
	 3
	  	 MCE
	  	$	174.88	 	 	$	173.48	 	 	$	171.08	 	 	$	169.68	 
	 4
	  	 Capitation Rate
	  	$	143.21	 	 	$	141.43	 	 	$	135.23	 	 	$	133.45	 
	 5
	  	 Discount
	  	 	18.1	%	 	 	18.5	%	 	 	21.0	%	 	 	21.4	%
	 6
	  	 Age/Gender Factors
	  	 	See Attached Addendum III-D	 
	 7
	  	 Capitation by Service Category
	  	 	See Attached Addendum III-E	 
	 8
	  	 Final Capitation Rates by Age/Gender
	  	 	See Attached Addendum III-F	 

  

 4/14/04 

 Addendum III - Rate Period May-December 2004 
 Marshfield/Stevens Point Rate Region 
  

																			
	BadgerCare	 
	 1
	  	 Eligibility Groups
	  	 	BadgerCare Children and Adults	 
			
	 2
	  	 Medical Status Codes
	  	 	B1, B2, B3, B4, B5, B6, GP	 
						
	 	  	 	  	All Services

	 	 	Dental
No Chiro

	 	 	 Chiro
 No Dental

	 	 	No Dental
& No Chiro

	 
	 3
	  	 MCE
	  	$	170.24	 	 	$	168.93	 	 	$	162.95	 	 	$	161.64	 
	 4
	  	 Capitation Rate
	  	$	146.51	 	 	$	145.61	 	 	$	139.87	 	 	$	138.97	 
	 5
	  	 Discount
	  	 	13.9	%	 	 	13.8	%	 	 	14.2	%	 	 	14.0	%
	 6
	  	 Age/Gender Factors
	  	 	See Attached Addendum III - D	 
	 7
	  	 Capitation by Service Category
	  	 	See Attached Addendum III - E	 
	 8
	  	 Final Capitation Rates by Age/Gender
	  	 	See Attached Addendum III - F	 

  

 4/14/04 

 Addendum III - Rate Period May-December 2004 
 Appleton/Oshkosh Rate Region 
  

																			
	BadgerCare	 
	 1
	  	 Eligibility Groups
	  	 	BadgerCare Children and Adults	 
			
	 2
	  	 Medical Status Codes
	  	 	B1, B2, B3, B4, B5, B6, GP	 
						
	 	  	 	  	All Services

	 	 	 Dental
 No Chiro

	 	 	 Chiro
 No Dental

	 	 	No Dental
& No Chiro

	 
	 3
	  	 MCE
	  	$	165.39	 	 	$	164.74	 	 	$	159.65	 	 	$	159.00	 
	 4
	  	 Capitation Rate
	  	$	136.65	 	 	$	135.74	 	 	$	130.55	 	 	$	129.64	 
	 5
	  	 Discount
	  	 	17.4	%	 	 	17.6	%	 	 	18.2	%	 	 	18.5	%
	 6
	  	 Age/Gender Factors
	  	 	See Attached Addendum III - D	 
	 7
	  	 Capitation by Service Category
	  	 	See Attached Addendum III - E	 
	 8
	  	 Final Capitation Rates by Age/Gender
	  	 	See Attached Addendum III - F	 

  

 4/14/04 

 Addendum III - Rate Period May-December 2004 
 La Crosse Rate Region 
  

																			
	BadgerCare	 
	 1
	  	 Eligibility Groups
	  	 	BadgerCare Children and Adults	 
			
	 2
	  	 Medical Status Codes
	  	 	B1, B2, B3, B4, B5, B6, GP	 
						
	 	  	 	  	All Services

	 	 	Dental
No Chiro

	 	 	 Chiro
 No Dental

	 	 	No Dental
& No Chiro

	 
	 3
	  	 MCE
	  	$	146.74	 	 	$	145.50	 	 	$	140.92	 	 	$	139.68	 
	 4
	  	 Capitation Rate
	  	$	128.08	 	 	$	126.98	 	 	$	122.08	 	 	$	120.98	 
	 5
	  	 Discount
	  	 	12.7	%	 	 	12.7	%	 	 	13.4	%	 	 	13.4	%
	 6
	  	 Age/Gender Factors
	  	 	See Attached Addendum III - D	 
	 7
	  	 Capitation by Service Category
	  	 	See Attached Addendum III - E	 
	 8
	  	 Final Capitation Rates by Age/Gender
	  	 	See Attached Addendum III - F	 

  

 4/14/04 

 Addendum III - Rate Period May-December 2004 
 Madison/South Central WI Rate Region 
  

																			
	BadgerCare	 
	 1
	  	 Eligibility Groups
	  	 	BadgerCare Children and Adults	 
			
	 2
	  	 Medical Status Codes
	  	 	B1, B2, B3, B4, B5, B6, GP	 
						
	 	  	 	  	All Services

	 	 	Dental
No Chiro

	 	 	Chiro
No Dental

	 	 	No Dental
& No Chiro

	 
	 3
	  	 MCE
	  	$	175.16	 	 	$	173.65	 	 	$	168.71	 	 	$	167.20	 
	 4
	  	 Capitation Rate
	  	$	142.93	 	 	$	142.43	 	 	$	136.45	 	 	$	135.95	 
	 5
	  	 Discount
	  	 	18.4	%	 	 	18.0	%	 	 	19.1	%	 	 	18.7	%
	 6
	  	 Age/Gender Factors
	  	 	See Attached Addendum III - D	 
	 7
	  	 Capitation by Service Category
	  	 	See Attached Addendum III - E	 
	 8
	  	 Final Capitation Rates by Age/Gender
	  	 	See Attached Addendum III - F	 

  

 4/14/04 

 Addendum III - Rate Period May-December 2004 
 SE Wisconsin Rate Region 
  

																			
	BadgerCare	 
	 1
	  	 Eligibility Groups
	  	 	BadgerCare Children and Adults	 
			
	 2
	  	 Medical Status Codes
	  	 	B1, B2, B3, B4, B5, B6, GP	 
						
	 	  	 	  	All Services

	 	 	Dental
No Chiro

	 	 	Chiro
No Dental

	 	 	No Dental
& No Chiro

	 
	 3
	  	 MCE
	  	$	187.27	 	 	$	186.68	 	 	$	182.12	 	 	$	181.53	 
	 4
	  	 Capitation Rate
	  	$	146.01	 	 	$	145.54	 	 	$	140.00	 	 	$	139.53	 
	 5
	  	 Discount
	  	 	22.0	%	 	 	22.0	%	 	 	23.1	%	 	 	23.1	%
	 6
	  	 Age/Gender Factors
	  	 	See Attached Addendum III - D	 
	 7
	  	 Capitation by Service Category
	  	 	See Attached Addendum III - E	 
	 8
	  	 Final Capitation Rates by Age/Gender
	  	 	See Attached Addendum III - F	 

  

 4/14/04 

 Addendum III - Rate Period May-December 2004 
 Milwaukee County Rate Region 
  

																			
	BadgerCare	 
	 1
	  	 Eligibility Groups
	  	 	BadgerCare Children and Adults	 
			
	 2
	  	 Medical Status Codes
	  	 	B1, B2, B3, B4, B5, B6, GP	 
						
	 	  	 	  	All Services

	 	 	Dental
No Chiro

	 	 	Chiro
No Dental

	 	 	No Dental
& No Chiro

	 
	 3
	  	 MCE
	  	$	167.20	 	 	$	166.70	 	 	$	163.15	 	 	$	162.65	 
	 4
	  	 Capitation Rate
	  	$	150.79	 	 	$	150.64	 	 	$	145.30	 	 	$	145.15	 
	 5
	  	 Discount
	  	 	9.8	%	 	 	9.6	%	 	 	10.9	%	 	 	10.8	%
	 6
	  	 Age/Gender Factors
	  	 	See Attached Addendum III - D	 
	 7
	  	 Capitation by Service Category
	  	 	See Attached Addendum III - E	 
	 8
	  	 Final Capitation Rates by Age/Gender
	  	 	See Attached Addendum III - F	 

  

 4/14/04 

 Addendum III - Rate Period May-December 2004 
 Dane County Rate Region 
  

																			
	BadgerCare	 
	 1
	  	 Eligibility Groups
	  	 	BadgerCare Children and Adults	 
			
	 2
	  	 Medical Status Codes
	  	 	B1, B2, B3, B4, B5, B6, GP	 
						
	 	  	 	  	All Services

	 	 	Dental
No Chiro

	 	 	Chiro
No Dental

	 	 	No Dental
& No Chiro

	 
	 3
	  	 MCE
	  	$	160.88	 	 	$	160.12	 	 	$	156.48	 	 	$	155.72	 
	 4
	  	 Capitation Rate
	  	$	139.96	 	 	$	139.36	 	 	$	135.36	 	 	$	134.76	 
	 5
	  	 Discount
	  	 	13.0	%	 	 	13.0	%	 	 	13.5	%	 	 	13.5	%
	 6
	  	 Age/Gender Factors
	  	 	See Attached Addendum III - D	 
	 7
	  	 Capitation by Service Category
	  	 	See Attached Addendum III - E	 
	 8
	  	 Final Capitation Rates by Age/Gender
	  	 	See Attached Addendum III - F	 

  

 4/14/04 

 Addendum III - Rate Period May-December 2004 
 Eau Claire County Rate Region 
  

																			
	BadgerCare	 
	 1
	  	 Eligibility Groups
	  	 	BadgerCare Children and Adults	 
			
	 2
	  	 Medical Status Codes
	  	 	B1, B2, B3, B4, B5, B6, GP	 
						
	 	  	 	  	All Services

	 	 	Dental
No Chiro

	 	 	Chiro
No Dental

	 	 	No Dental
& No Chiro

	 
	 3
	  	 MCE
	  	$	171.13	 	 	$	169.79	 	 	$	168.26	 	 	$	166.92	 
	 4
	  	 Capitation Rate
	  	$	145.08	 	 	$	142.78	 	 	$	138.49	 	 	$	136.19	 
	 5
	  	 Discount
	  	 	15.2	%	 	 	15.9	%	 	 	17.7	%	 	 	18.4	%
	 6
	  	 Age/Gender Factors
	  	 	See Attached Addendum III - D	 
	 7
	  	 Capitation by Service Category
	  	 	See Attached Addendum III - E	 
	 8
	  	 Final Capitation Rates by Age/Gender
	  	 	See Attached Addendum III - F	 

  

 4/14/04 

 Addendum III - Rate Period May-December 2004 
 Kenosha County Rate Region 
  

																			
	BadgerCare	 
	 1
	  	 Eligibility Groups
	  	 	BadgerCare Children and Adults	 
			
	 2
	  	 Medical Status Codes
	  	 	B1, B2, B3, B4, B5, B6, GP	 
						
	 	  	 	  	All Services

	 	 	Dental
No Chiro

	 	 	Chiro
No Dental

	 	 	No Dental
& No Chiro

	 
	 3
	  	 MCE
	  	$	214.46	 	 	$	214.04	 	 	$	208.08	 	 	$	207.66	 
	 4
	  	 Capitation Rate
	  	$	151.07	 	 	$	150.82	 	 	$	143.79	 	 	$	143.54	 
	 5
	  	 Discount
	  	 	29.6	%	 	 	29.5	%	 	 	30.9	%	 	 	30.9	%
	 6
	  	 Age/Gender Factors
	  	 	See Attached Addendum III - D	 
	 7
	  	 Capitation by Service Category
	  	 	See Attached Addendum III - E	 
	 8
	  	 Final Capitation Rates by Age/Gender
	  	 	See Attached Addendum III - F	 

  

 4/14/04 

 Addendum III - Rate Period May-December 2004 
 Waukesha County Rate Region 
  

																			
	BadgerCare	 
	1	  	 Eligibility Groups
	  	 	BadgerCare Children and Adults	 
			
	2	  	 Medical Status Codes
	  	 	B1, B2, B3, B4, B5, B6, GP	 
						
	 	  	 	  	All Services

	 	 	Dental
No Chiro

	 	 	Chiro
No Dental

	 	 	No Dental
& No Chiro

	 
	3	  	 MCE
	  	$	207.05	 	 	$	206.67	 	 	$	203.37	 	 	$	202.99	 
	4	  	 Capitation Rate
	  	$	170.12	 	 	$	169.39	 	 	$	163.10	 	 	$	162.37	 
	5	  	 Discount
	  	 	17.8	%	 	 	18.0	%	 	 	19.8	%	 	 	20.0	%
	6	  	 Age/Gender Factors
	  	 	See Attached Addendum III - D	 
	7	  	 Capitation by Service Category
	  	 	See Attached Addendum III - E	 
	8	  	 Final Capitation Rates by Age/Gender
	  	 	See Attached Addendum III - F	 

  

 4/14/04 

 Addendum III - A 
  
 AFDC-Related and Healthy Start Children Age/Gender Factors 
 For Use with 2004 AFDC-Related and Healthy Start Children Base Capitation Rates 
  
 Medical Services (Non-Dental, Non-Chiropractor) 
  

																																	
	 	  	 	  	Region

	 Age Range

	  	Age Code

	  	1

	  	2

	  	3

	  	4

	  	5

	  	6

	  	7

	  	8

	  	9

	  	10

	  	11

	  	12

	  	13

	  	14

	  	Total

	 <1
	  	A	  	2.773	  	2.883	  	2.645	  	2.703	  	2.741	  	2.663	  	2.722	  	2.540	  	2.568	  	2.548	  	2.614	  	2.727	  	2.571	  	2.547	  	2.605
	 01-05
	  	B	  	0.520	  	0.540	  	0.496	  	0.507	  	0.514	  	0.499	  	0.510	  	0.476	  	0.481	  	0.478	  	0.490	  	0.511	  	0.482	  	0.477	  	0.488
	 06-14
	  	C	  	0.413	  	0.429	  	0.394	  	0.402	  	0.408	  	0.396	  	0.405	  	0.378	  	0.382	  	0.379	  	0.389	  	0.406	  	0.382	  	0.379	  	0.388
	 15-20F
	  	E	  	1.579	  	1.642	  	1.506	  	1.539	  	1.561	  	1.516	  	1.550	  	1.446	  	1.463	  	1.451	  	1.489	  	1.553	  	1.464	  	1.450	  	1.483
	 15-20M
	  	D	  	0.537	  	0.559	  	0.513	  	0.524	  	0.531	  	0.516	  	0.528	  	0.492	  	0.498	  	0.494	  	0.507	  	0.529	  	0.498	  	0.494	  	0.505
	 21-34F
	  	G	  	2.352	  	2.445	  	2.243	  	2.293	  	2.325	  	2.258	  	2.309	  	2.154	  	2.178	  	2.161	  	2.217	  	2.313	  	2.180	  	2.160	  	2.210
	 21-34M
	  	F	  	1.163	  	1.209	  	1.109	  	1.134	  	1.150	  	1.117	  	1.142	  	1.065	  	1.077	  	1.069	  	1.096	  	1.144	  	1.078	  	1.068	  	1.093
	 35+F
	  	I	  	2.837	  	2.950	  	2.707	  	2.766	  	2.805	  	2.724	  	2.786	  	2.599	  	2.628	  	2.608	  	2.675	  	2.790	  	2.630	  	2.606	  	2.666
	 35+M
	  	H	  	2.687	  	2.794	  	2.563	  	2.620	  	2.657	  	2.580	  	2.638	  	2.461	  	2.489	  	2.470	  	2.534	  	2.643	  	2.491	  	2.468	  	2.525
	 	  	 	  	
	  	
	  	
	  	
	  	
	  	
	  	
	  	
	  	
	  	
	  	 	  	
	  	
	  	
	  	

	 Composite
	  	 	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000

  
 Dental Services

  

																																	
	 	  	 	  	Region

	 Age Range

	  	Age Code

	  	1

	  	2

	  	3

	  	4

	  	5

	  	6

	  	7

	  	8

	  	9

	  	10

	  	11

	  	12

	  	13

	  	14

	  	Total

	 <1
	  	A	  	0.007	  	0.007	  	0.007	  	0.007	  	0.007	  	0.007	  	0.007	  	0.007	  	0.007	  	0.007	  	0.007	  	0.007	  	0.007	  	0.008	  	0.007
	 01-05
	  	B	  	0.714	  	0.729	  	0.755	  	0.752	  	0.735	  	0.761	  	0.730	  	0.718	  	0.739	  	0.674	  	0.722	  	0.760	  	0.708	  	0.780	  	0.712
	 06-14
	  	C	  	1.322	  	1.349	  	1.398	  	1.392	  	1.361	  	1.409	  	1.351	  	1.330	  	1.369	  	1.248	  	1.337	  	1.406	  	1.311	  	1.445	  	1.308
	 15-20F
	  	E	  	1.303	  	1.330	  	1.377	  	1.372	  	1.341	  	1.388	  	1.332	  	1.311	  	1.349	  	1.230	  	1.317	  	1.386	  	1.292	  	1.424	  	1.285
	 15-20M
	  	D	  	1.362	  	1.391	  	1.440	  	1.435	  	1.402	  	1.452	  	1.393	  	1.371	  	1.411	  	1.286	  	1.378	  	1.449	  	1.351	  	1.489	  	1.349
	 21-34F
	  	G	  	1.281	  	1.308	  	1.355	  	1.349	  	1.319	  	1.365	  	1.310	  	1.289	  	1.327	  	1.210	  	1.296	  	1.363	  	1.271	  	1.400	  	1.257
	 21-34M
	  	F	  	1.349	  	1.377	  	1.427	  	1.421	  	1.389	  	1.438	  	1.379	  	1.358	  	1.398	  	1.274	  	1.365	  	1.436	  	1.339	  	1.475	  	1.341
	 35+F
	  	I	  	1.379	  	1.408	  	1.458	  	1.452	  	1.420	  	1.470	  	1.410	  	1.388	  	1.429	  	1.302	  	1.395	  	1.467	  	1.368	  	1.507	  	1.351
	 35+M
	  	H	  	1.637	  	1.671	  	1.731	  	1.724	  	1.685	  	1.745	  	1.674	  	1.647	  	1.696	  	1.546	  	1.656	  	1.742	  	1.624	  	1.789	  	1.624
	 	  	 	  	
	  	
	  	
	  	
	  	
	  	
	  	
	  	
	  	
	  	
	  	 	  	
	  	
	  	
	  	

	 Composite
	  	 	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000

  
 Chiropractor Services

  

																																	
	 	  	 	  	Region

	 Age Range

	  	Age Code

	  	1

	  	2

	  	3

	  	4

	  	5

	  	6

	  	7

	  	8

	  	9

	  	10

	  	11

	  	12

	  	13

	  	14

	  	Total

	 <1
	  	A	  	0.300	  	0.325	  	0.320	  	0.325	  	0.315	  	0.327	  	0.308	  	0.277	  	0.297	  	0.249	  	0.287	  	0.335	  	0.275	  	0.321	  	0.287
	 01-05
	  	B	  	0.291	  	0.315	  	0.311	  	0.315	  	0.306	  	0.317	  	0.299	  	0.269	  	0.288	  	0.241	  	0.278	  	0.324	  	0.266	  	0.311	  	0.275
	 06-14
	  	C	  	0 802	  	0 869	  	0 857	  	0 869	  	0 843	  	0.875	  	0.824	  	0.742	  	0.794	  	0.665	  	0.767	  	0.895	  	0.734	  	0.858	  	0.745
	 15-20F
	  	E	  	1.928	  	2.090	  	2.061	  	2.089	  	2.028	  	2.104	  	1.983	  	1.784	  	1.909	  	1.599	  	1.845	  	2.151	  	1.766	  	2.063	  	1.778
	 15-20M
	  	D	  	1.687	  	1.829	  	1.803	  	1.829	  	1.775	  	1.841	  	1.735	  	1.561	  	1.671	  	1.400	  	1.614	  	1.883	  	1.545	  	1.806	  	1.574
	 21-34F
	  	G	  	2.905	  	3.150	  	3.105	  	3.148	  	3.056	  	3.170	  	2.988	  	2.688	  	2.877	  	2.410	  	2.780	  	3.242	  	2.661	  	3.109	  	2.635
	 21-34M
	  	F	  	1.612	  	1.748	  	1.723	  	1.747	  	1.695	  	1.759	  	1.658	  	1.492	  	1.596	  	1.337	  	1.542	  	1.799	  	1.476	  	1.725	  	1.512
	 35+F
	  	I	  	4.294	  	4.656	  	4.589	  	4.653	  	4.516	  	4.685	  	4.416	  	3.973	  	4.252	  	3.562	  	4.108	  	4.791	  	3.933	  	4.595	  	3.889
	 35+M
	  	H	  	3.212	  	3.482	  	3.432	  	3.480	  	3.377	  	3.504	  	3.303	  	2.972	  	3.180	  	2.664	  	3.072	  	3.583	  	2.941	  	3.437	  	2.999
	 	  	 	  	
	  	
	  	
	  	
	  	
	  	
	  	
	  	
	  	
	  	
	  	 	  	
	  	
	  	
	  	

	 Composite
	  	 	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000

  

 4/14/04 

 Addendum III - B: 
 AFDC/Healthy Start Children CY 2004 Capitation Rates By Service Category 
  
 2004 Capitation - Medical Only 
  

																																													
	 	  	 	  	1

	  	2

	  	3

	  	4

	  	5

	  	6

	  	7

	  	8

	  	9

	  	40

	  	13

	  	18

	  	30

	  	67

	 Age Range

	  	Age Code

	  	Duluth/Sup

	  	Wausau/Rldr

	  	Green Bay

	  	Twin Cities

	  	Mfld/St Pt

	  	Appleton/ Osh

	  	La Crosse

	  	Madison

	  	SE Wis

	  	Milw Co

	  	Dane Co

	  	Eau Claire Co

	  	Kenosha Co

	  	Wauk Co

	 <1
	  	A	  	$	359.32	  	$	370.85	  	$	323.59	  	$	358.13	  	$	347.88	  	$	327.76	  	$	330.49	  	$	353.40	  	$	337.77	  	$	362.91	  	$	330.48	  	$	339.62	  	$	355.28	  	$	373.16
	 01-05
	  	B	  	$	67.33	  	$	69.49	  	$	60.64	  	$	67.11	  	$	65.19	  	$	61.42	  	$	61.93	  	$	66.23	  	$	63.30	  	$	68.01	  	$	61.93	  	$	63.64	  	$	66.58	  	$	69.93
	 06-14
	  	C	  	$	53.47	  	$	55.18	  	$	48.15	  	$	53.29	  	$	51.76	  	$	48.77	  	$	49.18	  	$	52.58	  	$	50.26	  	$	54.00	  	$	49.17	  	$	50.53	  	$	52.86	  	$	55.52
	 15-20F
	  	E	  	$	204.60	  	$	211.17	  	$	184.26	  	$	203.93	  	$	198.09	  	$	186.63	  	$	188.19	  	$	201.24	  	$	192.34	  	$	206.65	  	$	188.18	  	$	193.39	  	$	202.30	  	$	212.49
	 15-20M
	  	D	  	$	69.64	  	$	71.87	  	$	62.71	  	$	69.41	  	$	67.42	  	$	63.52	  	$	64.05	  	$	68.49	  	$	65.46	  	$	70.34	  	$	64.05	  	$	65.82	  	$	68.86	  	$	72.32
	 21-34F
	  	G	  	$	304.77	  	$	314.54	  	$	274.46	  	$	303.76	  	$	295.06	  	$	277.99	  	$	280.32	  	$	299.75	  	$	286.49	  	$	307.82	  	$	280.31	  	$	288.06	  	$	301.34	  	$	316.51
	 21-34M
	  	F	  	$	150.70	  	$	155.53	  	$	135.71	  	$	150.20	  	$	145.90	  	$	137.46	  	$	138.61	  	$	148.22	  	$	141.66	  	$	152.20	  	$	138.60	  	$	142.44	  	$	149.00	  	$	156.50
	 35+F
	  	I	  	$	367.68	  	$	379.48	  	$	331.12	  	$	366.46	  	$	355.98	  	$	335.38	  	$	338.19	  	$	361.63	  	$	345.63	  	$	371.36	  	$	338.17	  	$	347.53	  	$	363.54	  	$	381.84
	 35+M
	  	H	  	$	348.24	  	$	359.41	  	$	313.61	  	$	347.08	  	$	337.15	  	$	317.65	  	$	320.30	  	$	342.50	  	$	327.36	  	$	351.72	  	$	320.29	  	$	329.15	  	$	344.32	  	$	361.65

  
 2004 Capitation -
Dental Only 
  

																																													
	 	  	 	  	1

	  	2

	  	3

	  	4

	  	5

	  	6

	  	7

	  	8

	  	9

	  	40

	  	13

	  	18

	  	30

	  	67

	 Age Range

	  	Age Code

	  	Duluth/ Sup

	  	Wausau/ Rldr

	  	Green Bay

	  	Twin Cities

	  	Mfld/St Pt

	  	Appleton/ Osh

	  	La Crosse

	  	Madison

	  	SEWis

	  	Milw Co

	  	Dane Co

	  	Eau Claire Co

	  	Kenosha Co

	  	Wauk Co

	 <1
	  	A	  	$	0.04	  	$	0.04	  	$	0.04	  	$	0.06	  	$	0.04	  	$	0.04	  	$	0.04	  	$	0.05	  	$	0.04	  	$	0.04	  	$	0.03	  	$	0.04	  	$	0.05	  	$	0.05
	 01-05
	  	B	  	$	4.25	  	$	3.96	  	$	4.24	  	$	5.95	  	$	4.48	  	$	4.40	  	$	4.40	  	$	4.77	  	$	4.19	  	$	3.62	  	$	3.13	  	$	4.57	  	$	4.94	  	$	4.94
	 06-14
	  	C	  	$	7.88	  	$	7.33	  	$	7.85	  	$	11.03	  	$	8.30	  	$	8.14	  	$	8.15	  	$	8.83	  	$	7.75	  	$	6.70	  	$	5.80	  	$	8.47	  	$	9.15	  	$	9.15
	 15-20F
	  	E	  	$	7.76	  	$	7.22	  	$	7.74	  	$	10.86	  	$	8.18	  	$	8.02	  	$	8.03	  	$	8.70	  	$	7.64	  	$	6.61	  	$	5.72	  	$	8.34	  	$	9.02	  	$	9.01
	 15-20M
	  	D	  	$	8.12	  	$	7.55	  	$	8.09	  	$	11.36	  	$	8.55	  	$	8.39	  	$	8.40	  	$	9.10	  	$	7.99	  	$	6.91	  	$	5.98	  	$	8.73	  	$	9.43	  	$	9.42
	 21-34F
	  	G	  	$	7.64	  	$	7.10	  	$	7.61	  	$	10.69	  	$	8.04	  	$	7.89	  	$	7.90	  	$	8.56	  	$	7.51	  	$	6.50	  	$	5.62	  	$	8.21	  	$	8.87	  	$	8.86
	 21-34M
	  	F	  	$	8.04	  	$	7.48	  	$	8.02	  	$	11.25	  	$	8.47	  	$	8.31	  	$	8.32	  	$	9.02	  	$	7.91	  	$	6.84	  	$	5.92	  	$	8.64	  	$	9.34	  	$	9.34
	 35+F
	  	I	  	$	8.22	  	$	7.64	  	$	8.19	  	$	11.50	  	$	8.66	  	$	8.49	  	$	8.50	  	$	9.21	  	$	8.09	  	$	6.99	  	$	6.05	  	$	8.83	  	$	9.55	  	$	9.54
	 35+M
	  	H	  	$	9.76	  	$	9.08	  	$	9.73	  	$	13.66	  	$	10.28	  	$	10.09	  	$	10.09	  	$	10.94	  	$	9.60	  	$	8.30	  	$	7.19	  	$	10.49	  	$	11.34	  	$	11.33

  
 2004 Capitation -
Chiropractic Only 
  

																																													
	 	  	 	  	1

	  	2

	  	3

	  	4

	  	5

	  	6

	  	7

	  	8

	  	9

	  	40

	  	13

	  	18

	  	30

	  	67

	 Age Range

	  	Age Code

	  	Duluth/ Sup

	  	Wausau/ Rldr

	  	Green Bay

	  	Twin Cities

	  	Mfld/St Pt

	  	Appleton/ Osh

	  	La Crosse

	  	Madison

	  	SE Wis

	  	Milw Co

	  	Dane Co

	  	Eau Claire Co

	  	Kenosha Co

	  	Wauk Co

	 <1
	  	A	  	$	0.28	  	$	0.28	  	$	0.24	  	$	0.58	  	$	0.26	  	$	0.28	  	$	0.34	  	$	0.15	  	$	0.13	  	$	0.04	  	$	0.17	  	$	0.71	  	$	0.07	  	$	0.21
	 01-05
	  	B	  	$	0.28	  	$	0.27	  	$	0.24	  	$	0.56	  	$	0.25	  	$	0.27	  	$	0.33	  	$	0.14	  	$	0.13	  	$	0.04	  	$	0.16	  	$	0.69	  	$	0.06	  	$	0.20
	 06-14
	  	C	  	$	0.76	  	$	0.76	  	$	0.65	  	$	1.54	  	$	0.68	  	$	0.75	  	$	0.92	  	$	0.39	  	$	0.36	  	$	0.10	  	$	0.45	  	$	1.90	  	$	0.18	  	$	0.55
	 15-20F
	  	E	  	$	1.83	  	$	1.82	  	$	1.57	  	$	3.70	  	$	1.64	  	$	1.81	  	$	2.20	  	$	0.95	  	$	0.86	  	$	0.24	  	$	1.09	  	$	4.56	  	$	0.42	  	$	1.32
	 15-20M
	  	D	  	$	1.60	  	$	1.59	  	$	1.37	  	$	3.24	  	$	1.44	  	$	1.58	  	$	1.93	  	$	0.83	  	$	0.75	  	$	0.21	  	$	0.95	  	$	3.99	  	$	0.37	  	$	1.16
	 21-34F
	  	G	  	$	2.76	  	$	2.74	  	$	2.36	  	$	5.57	  	$	2.47	  	$	2.73	  	$	3.32	  	$	1.42	  	$	1.29	  	$	0.36	  	$	1.64	  	$	6.87	  	$	0.64	  	$	1.99
	 21-34M
	  	F	  	$	1.53	  	$	1.52	  	$	1.31	  	$	3.09	  	$	1.37	  	$	1.51	  	$	1.84	  	$	0.79	  	$	0.72	  	$	0.20	  	$	0.91	  	$	3.81	  	$	0.35	  	$	1.10
	 35+F
	  	I	  	$	4.08	  	$	4.05	  	$	3.49	  	$	8.24	  	$	3.66	  	$	4.03	  	$	4.90	  	$	2.11	  	$	1.91	  	$	0.53	  	$	2.42	  	$	10.16	  	$	0.94	  	$	2.94
	 35+M
	  	H	  	$	3.05	  	$	3.03	  	$	2.61	  	$	6.16	  	$	2.74	  	$	3.01	  	$	3.67	  	$	1.57	  	$	1.43	  	$	0.40	  	$	1.81	  	$	7.60	  	$	0.71	  	$	2.20

  

 4/14/04 

 Addendum III - C: 
 May to December 2004 Final AFDC/HS Child Capitation Rates by Age/Gender & Rate Region 
  
 All Services Capitation Rate by Age/Gender and Rate Region 
  

																																													
	 	  	 Rate Region >
 Age Code

	  	1

	  	2

	  	3

	  	4

	  	5

	  	6

	  	7

	  	8

	  	9

	  	40

	  	13

	  	18

	  	30

	  	67

	 Age Range

	  	  	Duluth/
Sup

	  	Wausau/
Rldr

	  	Green
Bay

	  	Twin
Cities

	  	 Mfld/
 St Pt

	  	 Appleton/
 Osh

	  	La
Crosse

	  	Madison

	  	SE Wis

	  	Milw Co

	  	Dane Co

	  	Eau Claire Co

	  	Kenosha
Co

	  	Wauk
Co

	 <1
	  	A	  	$	359.65	  	$	371.17	  	$	323.88	  	$	358.76	  	$	348.18	  	$	328.08	  	$	330.88	  	$	353.60	  	$	337.95	  	$	362.99	  	$	330.68	  	$	340.38	  	$	355.39	  	$	373.42
	 01-05
	  	B	  	$	71.86	  	$	73.72	  	$	65.12	  	$	73.62	  	$	69.92	  	$	66.09	  	$	66.66	  	$	71.14	  	$	67.61	  	$	71.66	  	$	65.23	  	$	68.90	  	$	71.58	  	$	75.07
	 06-14
	  	C	  	$	62.11	  	$	63.26	  	$	56.65	  	$	65.85	  	$	60.75	  	$	57.66	  	$	58.24	  	$	61.81	  	$	58.37	  	$	60.80	  	$	55.43	  	$	60.90	  	$	62.19	  	$	65.22
	 15-20F
	  	E	  	$	214.20	  	$	220.21	  	$	193.57	  	$	218.49	  	$	207.91	  	$	196.46	  	$	198.42	  	$	210.88	  	$	200.83	  	$	213.50	  	$	194.99	  	$	206.29	  	$	211.74	  	$	222.82
	 15-20M
	  	D	  	$	79.36	  	$	81.02	  	$	72.18	  	$	84.01	  	$	77.41	  	$	73.50	  	$	74.38	  	$	78.42	  	$	74.20	  	$	77.45	  	$	70.98	  	$	78.54	  	$	78.66	  	$	82.90
	 21-34F
	  	G	  	$	315.16	  	$	324.39	  	$	284.44	  	$	320.02	  	$	305.58	  	$	288.61	  	$	291.53	  	$	309.73	  	$	295.30	  	$	314.67	  	$	287.57	  	$	303.14	  	$	310.85	  	$	327.36
	 21-34M
	  	F	  	$	160.27	  	$	164.53	  	$	145.04	  	$	164.54	  	$	155.74	  	$	147.28	  	$	148.77	  	$	158.02	  	$	150.29	  	$	159.25	  	$	145.43	  	$	154.89	  	$	158.70	  	$	166.94
	 35+F
	  	I	  	$	379.98	  	$	391.17	  	$	342.80	  	$	368.20	  	$	368.29	  	$	347.91	  	$	351.59	  	$	372.95	  	$	355.63	  	$	378.89	  	$	346.65	  	$	366.52	  	$	374.04	  	$	394.33
	 35+M
	  	H	  	$	361.05	  	$	371.51	  	$	325.95	  	$	366.90	  	$	350.17	  	$	330.75	  	$	334.06	  	$	355.02	  	$	338.39	  	$	360.42	  	$	329.29	  	$	347.23	  	$	356.36	  	$	375.18

  
 Dental_No
Chiropractic Service Capitation Rate by Age/Gender and Rate Region 
  

																																													
	 	  	 Rate Region >
 Age Code

	  	1

	  	2

	  	3

	  	4

	  	5

	  	6

	  	7

	  	8

	  	9

	  	40

	  	13

	  	18

	  	30

	  	67

	 Age Range

	  	  	Duluth/
Sup

	  	Wausau/
Rldr

	  	Green Bay

	  	Twin Cities

	  	Mfld/
St Pt

	  	 Appleton/
 Osh

	  	La Crosse

	  	Madison

	  	SE Wis

	  	Milw Co

	  	Dane Co

	  	Eau Claire Co

	  	Kenosha
Co

	  	Wauk
Co

	 <1
	  	A	  	$	359.36	  	$	370.89	  	$	323.63	  	$	358.19	  	$	347.92	  	$	327.80	  	$	330.54	  	$	353.45	  	$	337.82	  	$	362.95	  	$	330.51	  	$	339.67	  	$	355.32	  	$	373.21
	 01-05
	  	B	  	$	71.59	  	$	73.45	  	$	64.88	  	$	73.06	  	$	69.67	  	$	65.82	  	$	66.33	  	$	70.99	  	$	67.48	  	$	71.63	  	$	65.06	  	$	68.21	  	$	71.52	  	$	74.87
	 06-14
	  	C	  	$	61.34	  	$	62.51	  	$	56.00	  	$	64.31	  	$	60.06	  	$	56.91	  	$	57.32	  	$	61.42	  	$	58.01	  	$	60.70	  	$	54.98	  	$	59.00	  	$	62.02	  	$	64.67
	 15-20F
	  	E	  	$	212.37	  	$	218.39	  	$	192.00	  	$	214.79	  	$	206.27	  	$	194.66	  	$	196.22	  	$	209.94	  	$	199.97	  	$	213.26	  	$	193.90	  	$	201.73	  	$	211.32	  	$	221.50
	 15-20M
	  	D	  	$	77.76	  	$	79.42	  	$	70.81	  	$	80.77	  	$	75.98	  	$	71.91	  	$	72.45	  	$	77.59	  	$	73.45	  	$	77.24	  	$	70.03	  	$	74.55	  	$	78.29	  	$	81.75
	 21-34F
	  	G	  	$	321.40	  	$	321.65	  	$	282.08	  	$	314.44	  	$	303.11	  	$	285.89	  	$	288.22	  	$	308.31	  	$	294.00	  	$	314.31	  	$	285.93	  	$	296.27	  	$	310.21	  	$	325.37
	 21-34M
	  	F	  	$	158.74	  	$	163.01	  	$	143.73	  	$	161.45	  	$	154.37	  	$	145.77	  	$	146.93	  	$	157.23	  	$	149.57	  	$	159.05	  	$	144.52	  	$	151.08	  	$	158.34	  	$	165.84
	 35+F
	  	I	  	$	375.90	  	$	387.12	  	$	339.32	  	$	377.97	  	$	364.63	  	$	343.88	  	$	346.69	  	$	370.84	  	$	353.72	  	$	378.35	  	$	344.22	  	$	356.36	  	$	373.09	  	$	391.39
	 35+M
	  	H	  	$	358.00	  	$	368.49	  	$	323.34	  	$	360.74	  	$	347.43	  	$	327.73	  	$	330.39	  	$	353.44	  	$	336.96	  	$	360.02	  	$	327.47	  	$	339.63	  	$	355.65	  	$	372.98

  
 Chiropractic_No
Dental Service Capitation Rate by Age/Gender and Rate Region 
  

																																													
	 	  	 Rate Region >
 Age Code

	  	1

	  	2

	  	3

	  	4

	  	5

	  	6

	  	7

	  	8

	  	9

	  	40

	  	13

	  	18

	  	30

	  	67

	 Age Range

	  	  	Duluth/
Sup

	  	Wusau/
Rldr

	  	Green
Bay

	  	Twin
Cities

	  	 Mfld/
 St Pt

	  	 Appleton/
 Osh

	  	La
Crosse

	  	Madison

	  	SE Wis

	  	Milw Co

	  	Dane Co

	  	Eau Claire Co

	  	Kenosha
Co

	  	Wauk
Co

	 <1
	  	A	  	$	359.61	  	$	371.13	  	$	323.84	  	$	358.71	  	$	348.14	  	$	328.04	  	$	330.84	  	$	353.55	  	$	337.91	  	$	362.95	  	$	330.65	  	$	340.33	  	$	355.34	  	$	373.37
	 01-05
	  	B	  	$	67.61	  	$	69.77	  	$	60.87	  	$	67.67	  	$	65.44	  	$	61.69	  	$	62.26	  	$	66.37	  	$	63.43	  	$	68.04	  	$	62.09	  	$	64.33	  	$	66.64	  	$	70.13
	 06-14
	  	C	  	$	54.23	  	$	55.94	  	$	48.80	  	$	54.83	  	$	52.45	  	$	49.52	  	$	50.09	  	$	52.98	  	$	50.62	  	$	54.10	  	$	49.63	  	$	52.43	  	$	53.04	  	$	56.07
	 15-20F
	  	E	  	$	206.44	  	$	212.99	  	$	185.83	  	$	207.62	  	$	199.73	  	$	188.44	  	$	190.39	  	$	202.18	  	$	193.19	  	$	206.89	  	$	189.27	  	$	197.95	  	$	202.72	  	$	213.81
	 15-20M
	  	D	  	$	71.24	  	$	73.47	  	$	64.09	  	$	72.65	  	$	68.86	  	$	65.11	  	$	65.98	  	$	69.32	  	$	66.22	  	$	70.55	  	$	65.00	  	$	69.81	  	$	69.23	  	$	73.48
	 21-34F
	  	G	  	$	307.53	  	$	317.28	  	$	276.82	  	$	309.33	  	$	297.54	  	$	280.72	  	$	283.63	  	$	301.17	  	$	287.79	  	$	308.18	  	$	281.95	  	$	294.93	  	$	301.97	  	$	318.50
	 21-34M
	  	F	  	$	152.23	  	$	157.05	  	$	137.61	  	$	153.29	  	$	147.27	  	$	138.97	  	$	140.45	  	$	149.01	  	$	142.38	  	$	152.40	  	$	139.51	  	$	146.25	  	$	149.35	  	$	157.61
	 35+F
	  	I	  	$	371.76	  	$	383.53	  	$	334.61	  	$	374.70	  	$	359.63	  	$	339.41	  	$	343.09	  	$	363.73	  	$	347.55	  	$	371.89	  	$	340.59	  	$	357.68	  	$	364.49	  	$	384.79
	 35+M
	  	H	  	$	351.29	  	$	362.44	  	$	316.22	  	$	353.24	  	$	339.89	  	$	320.66	  	$	323.97	  	$	344.08	  	$	328.79	  	$	352.12	  	$	322.10	  	$	336.74	  	$	345.02	  	$	363.85

  
 No Chiropractic
& No Dental Service Capitation Rate by Age/Gender and Rate Region 
  

																																													
	 	  	 Rate Region >
 Age Code

	  	1

	  	2

	  	3

	  	4

	  	5

	  	6

	  	7

	  	8

	  	9

	  	40

	  	13

	  	18

	  	30

	  	67

	 Age Range

	  	  	Duluth/
Sup

	  	Wausau/
Rldr

	  	Green
Bay

	  	Twin
Cities

	  	 Mfld/
 St Pt

	  	Appleton/Osh

	  	La
Crosse

	  	Madison

	  	SE Wis

	  	Milw Co

	  	Dane Co

	  	Eau
Claire
Co

	  	Kenosha
Co

	  	Wauk
Co

	 <1
	  	A	  	$	359.32	  	$	370.85	  	$	323.59	  	$	358.13	  	$	347.88	  	$	327.76	  	$	330.49	  	$	353.40	  	$	337.77	  	$	362.91	  	$	330.48	  	$	339.62	  	$	355.28	  	$	373.16
	 01-05
	  	B	  	$	67.33	  	$	69.49	  	$	60.64	  	$	67.11	  	$	65.19	  	$	61.42	  	$	61.93	  	$	66.23	  	$	63.30	  	$	68.01	  	$	61.93	  	$	63.64	  	$	66.58	  	$	69.93
	 06-14
	  	C	  	$	53.47	  	$	55.18	  	$	48.15	  	$	53.29	  	$	51.76	  	$	48.77	  	$	49.18	  	$	52.58	  	$	50.26	  	$	54.00	  	$	49.17	  	$	50.53	  	$	52.86	  	$	55.52
	 15-20F
	  	E	  	$	204.60	  	$	211.17	  	$	184.26	  	$	203.93	  	$	198.09	  	$	186.63	  	$	188.19	  	$	201.24	  	$	192.34	  	$	206.65	  	$	188.18	  	$	193.39	  	$	202.30	  	$	212.49
	 15-20M
	  	D	  	$	69.64	  	$	71.87	  	$	62.71	  	$	69.41	  	$	67.42	  	$	63.52	  	$	64.05	  	$	68.49	  	$	65.46	  	$	70.34	  	$	64.05	  	$	65.82	  	$	68.86	  	$	72.32
	 21-34F
	  	G	  	$	304.77	  	$	314.54	  	$	274.46	  	$	303.76	  	$	295.06	  	$	277.99	  	$	280.32	  	$	299.75	  	$	286.49	  	$	307.82	  	$	280.31	  	$	288.06	  	$	301.34	  	$	316.51
	 21-34M
	  	F	  	$	150.70	  	$	155.53	  	$	135.71	  	$	150.20	  	$	145.90	  	$	137.46	  	$	138.61	  	$	148.22	  	$	141.66	  	$	152.20	  	$	138.60	  	$	142.44	  	$	149.00	  	$	156.50
	 35+F
	  	I	  	$	367.68	  	$	379.48	  	$	331.12	  	$	366.46	  	$	355.98	  	$	335.38	  	$	338.19	  	$	361.63	  	$	345.63	  	$	371.36	  	$	338.17	  	$	347.53	  	$	363.54	  	$	381.84
	 35+M
	  	H	  	$	348.24	  	$	359.41	  	$	313.61	  	$	347.08	  	$	337.15	  	$	317.65	  	$	320.30	  	$	342.50	  	$	327.36	  	$	351.72	  	$	320.29	  	$	329.15	  	$	344.32	  	$	361.65

  

 4/14/04 

 Addendum III-D 
 BadgerCare Age/Gender Factors 
 For Use with 2004 BadgerCare Base Rates 
  
 Medical Services (Non-Dental, Non-Chiropractor) 
  

																																	
	 	  	 	  	Region

	 Age Range

	  	Gender

	  	1

	  	2

	  	3

	  	4

	  	5

	  	6

	  	7

	  	8

	  	9

	  	10

	  	11

	  	12

	  	13

	  	14

	  	Total

	 Age 1-14
	  	All	  	0.411	  	0.415	  	0.408	  	0.418	  	0.406	  	0.407	  	0.409	  	0.415	  	0.414	  	0.423	  	0.419	  	0.421	  	0.410	  	0.403	  	0.415
	 Age 15-20
	  	F	  	0.800	  	0.808	  	0.794	  	0.814	  	0.790	  	0.793	  	0.797	  	0.809	  	0.807	  	0.824	  	0.815	  	0.821	  	0.798	  	0.785	  	0.809
	 Age 15-20
	  	M	  	0.535	  	0.540	  	0.531	  	0.544	  	0.528	  	0.531	  	0.533	  	0.541	  	0.540	  	0.551	  	0.525	  	0.549	  	0.534	  	0.525	  	0.541
	 Age 21-34
	  	F	  	1.170	  	1.182	  	1.161	  	1.190	  	1.156	  	1.160	  	1.165	  	1.182	  	1.180	  	1.205	  	1.192	  	1.200	  	1.167	  	1.148	  	1.183
	 Age 21-34
	  	M	  	0.610	  	0.616	  	0.605	  	0.620	  	0.602	  	0.604	  	0.607	  	0.616	  	0.625	  	0.628	  	0.621	  	0.625	  	0.608	  	0.598	  	0.616
	 Age 35-44
	  	F	  	1.559	  	1.574	  	1.547	  	1.584	  	1.539	  	1.545	  	1.552	  	1.574	  	1.572	  	1.606	  	1.588	  	1.598	  	1.555	  	1.529	  	1.576
	 Age 35-44
	  	M	  	1.079	  	1.089	  	1.071	  	1.097	  	1.065	  	1.070	  	1.074	  	1.090	  	1.088	  	1.111	  	1.099	  	1.106	  	1.076	  	1.058	  	1.091
	 Age 45+
	  	F	  	1.906	  	1.924	  	1.891	  	1.937	  	1.822	  	1.889	  	1.897	  	1.925	  	1.922	  	1.963	  	1.941	  	1.954	  	1.901	  	1.869	  	1.926
	 Age 45+
	  	M	  	1.811	  	1.828	  	1.797	  	1.840	  	1.788	  	1.795	  	1.803	  	1.829	  	1.826	  	1.865	  	1.845	  	1.857	  	1.806	  	1.776	  	1.830
	 	  	 	  	
	  	
	  	
	  	
	  	
	  	
	  	
	  	
	  	
	  	
	  	
	  	
	  	
	  	
	  	

	 Composite
	  	 	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000

  
 Dental Services

  

																																	
	 	  	 	  	Region

	 Age Range

	  	Gender

	  	1

	  	2

	  	3

	  	4

	  	5

	  	6

	  	7

	  	8

	  	9

	  	10

	  	11

	  	12

	  	13

	  	14

	  	Total

	 Age 1-14
	  	All	  	1.080	  	1.081	  	1.078	  	1.079	  	1.077	  	1.081	  	1.082	  	1.078	  	1.072	  	1.065	  	1.076	  	1.080	  	1.078	  	1.068	  	1.073
	 Age 15-20
	  	F	  	1.202	  	1.204	  	1.200	  	1.201	  	1.199	  	1.204	  	1.204	  	1.200	  	1.193	  	1.185	  	1.198	  	1.202	  	1.200	  	1.189	  	1.195
	 Age 15-20
	  	M	  	1.004	  	1.005	  	1.002	  	1.003	  	1.002	  	1.005	  	1.006	  	1.002	  	0.997	  	0.990	  	1.000	  	1.004	  	1.003	  	0.993	  	0.998
	 Age 21-34
	  	F	  	0.977	  	0.978	  	0.975	  	0.975	  	0.974	  	0.978	  	0.978	  	0.975	  	0.969	  	0.963	  	0.973	  	0.976	  	0.975	  	0.965	  	0.971
	 Age 21-34
	  	M	  	0.863	  	0.864	  	0.862	  	0.862	  	0.861	  	0.864	  	0.865	  	0.862	  	0.857	  	0.851	  	0.860	  	0.863	  	0.862	  	0.854	  	0.860
	 Age 35-44
	  	F	  	1.000	  	1.001	  	0.998	  	0.998	  	0.997	  	1.001	  	1.001	  	0.998	  	0.992	  	0.986	  	0.996	  	1.000	  	0.998	  	0.988	  	0.994
	 Age 35-44
	  	M	  	0.858	  	0.859	  	0.857	  	0.857	  	0.856	  	0.859	  	0.860	  	0.857	  	0.852	  	0.846	  	0.855	  	0.858	  	0.857	  	0.849	  	0.855
	 Age 45+
	  	F	  	0.959	  	0.960	  	0.957	  	0.958	  	0.956	  	0.960	  	0.961	  	0.957	  	0.952	  	0.946	  	0.955	  	0.959	  	0.957	  	0.948	  	0.954
	 Age 45+
	  	M	  	1.130	  	1.132	  	1.128	  	1.129	  	1.127	  	1.131	  	1.132	  	1.128	  	1.122	  	1.115	  	1.126	  	1.130	  	1.129	  	1.117	  	1.125
	 	  	 	  	
	  	
	  	
	  	
	  	
	  	
	  	
	  	
	  	
	  	
	  	
	  	
	  	
	  	
	  	

	 Total
	  	 	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000

  
 Chiropractor Services

  

																																	
	 	  	 	  	Region

	 Age Range

	  	Gender

	  	1

	  	2

	  	3

	  	4

	  	5

	  	6

	  	7

	  	8

	  	9

	  	10

	  	11

	  	12

	  	13

	  	14

	  	Total

	 Age 1-14
	  	All	  	0.456	  	0.453	  	0.447	  	0.461	  	0.453	  	0.446	  	0.452	  	0.456	  	0.458	  	0.468	  	0.459	  	0.457	  	0.452	  	0.445	  	0.459
	 Age 15-20
	  	F	  	0.964	  	0.959	  	0.944	  	0.975	  	0.968	  	0.943	  	0.956	  	0.963	  	0.967	  	0.988	  	0.971	  	0.967	  	0.955	  	0.940	  	0.968
	 Age 15-20
	  	M	  	0.436	  	0.434	  	0.428	  	0.442	  	0.434	  	0.427	  	0.433	  	0.436	  	0.438	  	0.448	  	0.440	  	0.438	  	0.433	  	0.426	  	0.439
	 Age 21-34
	  	F	  	1.149	  	1.143	  	1.126	  	1.163	  	1.142	  	1.125	  	1.140	  	1.149	  	1.154	  	1.179	  	1.158	  	1.153	  	1.139	  	1.122	  	1.155
	 Age 21-34
	  	M	  	1.006	  	1.001	  	0.986	  	1.019	  	1.000	  	0.985	  	0.998	  	1.006	  	1.010	  	1.032	  	1.014	  	1.010	  	0.998	  	0.982	  	1.008
	 Age 35-44
	  	F	  	1.470	  	1.462	  	1.441	  	1.488	  	1.461	  	1.439	  	1.458	  	1.470	  	1.476	  	1.508	  	1.481	  	1.475	  	1.457	  	1.435	  	1.476
	 Age 35-44
	  	M	  	1.093	  	1.087	  	1.071	  	1.106	  	1.086	  	1.070	  	1.084	  	1.093	  	1.097	  	1.121	  	1.101	  	1.096	  	1.084	  	1.067	  	1.095
	 Age 45+
	  	F	  	2.038	  	2.027	  	1.997	  	2.063	  	2.025	  	1.995	  	2.021	  	2.037	  	2.046	  	2.090	  	2.054	  	2.044	  	2.020	  	1.989	  	2.045
	 Age 45+
	  	M	  	0.813	  	0.809	  	0.797	  	0.823	  	0.808	  	0.796	  	0.807	  	0.813	  	0.817	  	0.834	  	0.820	  	0.816	  	0.806	  	0.794	  	0.816
	 	  	 	  	
	  	
	  	
	  	
	  	
	  	
	  	
	  	
	  	
	  	
	  	
	  	
	  	
	  	
	  	

	 Total
	  	 	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000	  	1.000

  

 4/14/04 

 ADDENDUM III - E - 2004 BadgerCare Capitation Rates - by Service Category 
  
 BadgerCare Rates 
 Medical Capitation Rates by Service Category - Medical Costs 
  

																																													
	 Age Range

	  	Gender

	  	Duluth/
Superior
1

	  	Wausau/
Rhinelander
2

	  	 Green
 Bay
 3

	  	 Twin
Cities
 4

	  	 Marshfield/
 Stevens
Point
 5

	  	 Appleton/
 Oshkosh
6

	  	 La
Crosse
 7

	  	 Madison
 8

	  	 Southeast
 Wisconsin
 9

	  	 Milwaukee
 10

	  	 Dane
 11

	  	 Eau
 Claire
 12

	  	 Kenosha
 13

	  	 Waukesha
 14

	 Age 0
	  	All	  	 	See Addendum III-B - under age 1 rates are the same for BadgerCare as for AFDC/Healthy Start Children
	 Age 1-14
	  	All	  	$	57.72	  	$	60.25	  	$	57.52	  	$	55.73	  	$	56.38	  	$	52.80	  	$	49.49	  	$	56.42	  	$	57.82	  	$	61.43	  	$	56.41	  	$	57.38	  	$	58.83	  	$	65.45
	 Age 15-20
	  	F	  	$	112.45	  	$	117.38	  	$	112.06	  	$	108.58	  	$	109.84	  	$	102.86	  	$	96.42	  	$	109.92	  	$	112.65	  	$	119.67	  	$	109.89	  	$	111.79	  	$	114.60	  	$	127.50
	 Age 15-20
	  	M	  	$	75.19	  	$	78.49	  	$	74.93	  	$	72.60	  	$	73.74	  	$	68.78	  	$	64.74	  	$	73.49	  	$	75.33	  	$	80.02	  	$	73.48	  	$	74.74	  	$	76.63	  	$	85.25
	 Age 21-34
	  	F	  	$	164.41	  	$	171.62	  	$	163.84	  	$	158.75	  	$	160.59	  	$	150.39	  	$	140.97	  	$	160.71	  	$	164.71	  	$	174.97	  	$	160.67	  	$	163.44	  	$	167.56	  	$	186.42
	 Age 21-34
	  	M	  	$	85.64	  	$	89.40	  	$	85.35	  	$	82.70	  	$	83.66	  	$	78.34	  	$	73.44	  	$	83.72	  	$	85.80	  	$	91.15	  	$	83.70	  	$	85.14	  	$	87.29	  	$	97.11
	 Age 35-44
	  	F	  	$	218.98	  	$	228.58	  	$	218.21	  	$	211.44	  	$	213.89	  	$	200.31	  	$	187.76	  	$	214.04	  	$	219.37	  	$	233.04	  	$	213.99	  	$	217.68	  	$	223.17	  	$	248.29
	 Age 35-44
	  	M	  	$	151.57	  	$	158.22	  	$	151.05	  	$	146.35	  	$	148.05	  	$	138.65	  	$	129.96	  	$	148.16	  	$	151.85	  	$	161.31	  	$	148.13	  	$	150.68	  	$	154.48	  	$	171.86
	 Age 45+
	  	F	  	$	267.70	  	$	279.44	  	$	266.77	  	$	258.48	  	$	261.48	  	$	244.88	  	$	229.54	  	$	261.67	  	$	268.19	  	$	284.89	  	$	261.61	  	$	266.12	  	$	272.83	  	$	303.53
	 Age 45+
	  	M	  	$	254.36	  	$	265.51	  	$	253.47	  	$	245.60	  	$	248.45	  	$	232.67	  	$	218.09	  	$	248.63	  	$	254.82	  	$	270.69	  	$	248.57	  	$	252.85	  	$	259.23	  	$	288.40

  
 BadgerCare Rates

 Medical Capitation Rates by Service Category - Dental Costs 
  

																																													
	 Age Range

	  	Gender

	  	 Duluth/
Superior
 1

	  	 Wausau/
Rhinelander
 2

	  	 Green
Bay
 3

	  	 Twin
Cities
 4

	  	 Marshfield/
 Stevens
Point
 5

	  	 Appleton/
 Oshkosh
 6

	  	 La
 Crosse
 7

	  	 Madison
 8

	  	 Southeast
 Wisconsin
 9

	  	 Milwaukee
 10

	  	 Dane
 11

	  	 Eau
Claire
 12

	  	 Kenosha
 13

	  	 Waukesha
 14

	 Age 0
	  	All	  	 	See Addendum III-B - under age 1 rates are the same for BadgerCare as for AFDC/Healthy Start Children
	 Age 1-14
	  	All	  	$	6.98	  	$	6.62	  	$	6.98	  	$	8.61	  	$	7.15	  	$	6.59	  	$	6.49	  	$	6.98	  	$	6.44	  	$	5.85	  	$	4.95	  	$	7.12	  	$	7.85	  	$	7.50
	 Age 15-20
	  	F	  	$	7.77	  	$	7.37	  	$	7.76	  	$	9.58	  	$	7.96	  	$	7.34	  	$	7.23	  	$	7.78	  	$	7.17	  	$	6.51	  	$	5.51	  	$	7.92	  	$	8.74	  	$	8.34
	 Age 15-20
	  	M	  	$	6.49	  	$	6.15	  	$	6.49	  	$	8.00	  	$	6.65	  	$	6.13	  	$	6.04	  	$	6.49	  	$	5.99	  	$	5.44	  	$	4.60	  	$	6.62	  	$	7.30	  	$	6.97
	 Age 21-34
	  	F	  	$	6.31	  	$	5.98	  	$	6.31	  	$	7.78	  	$	6.47	  	$	5.96	  	$	5.87	  	$	6.32	  	$	5.83	  	$	5.29	  	$	4.48	  	$	6.43	  	$	7.10	  	$	6.78
	 Age 21-34
	  	M	  	$	5.58	  	$	5.29	  	$	5.58	  	$	6.88	  	$	5.72	  	$	5.27	  	$	5.19	  	$	5.58	  	$	5.15	  	$	4.67	  	$	3.96	  	$	5.69	  	$	6.28	  	$	5.99
	 Age 35-44
	  	F	  	$	6.46	  	$	6.12	  	$	6.46	  	$	7.97	  	$	6.62	  	$	6.10	  	$	6.01	  	$	6.47	  	$	5.96	  	$	5.41	  	$	4.58	  	$	6.59	  	$	7.27	  	$	6.94
	 Age 35-44
	  	M	  	$	5.54	  	$	5.26	  	$	5.54	  	$	6.84	  	$	5.68	  	$	5.24	  	$	5.16	  	$	5.55	  	$	5.12	  	$	4.65	  	$	3.93	  	$	5.66	  	$	6.24	  	$	5.96
	 Age 45+
	  	F	  	$	6.19	  	$	5.88	  	$	6.19	  	$	7.64	  	$	6.35	  	$	5.86	  	$	5.76	  	$	6.20	  	$	5.72	  	$	5.19	  	$	4.39	  	$	6.32	  	$	6.97	  	$	6.66
	 Age 45+
	  	M	  	$	7.30	  	$	6.93	  	$	7.30	  	$	9.01	  	$	7.49	  	$	6.90	  	$	6.79	  	$	7.31	  	$	6.74	  	$	6.12	  	$	5.18	  	$	7.45	  	$	8.22	  	$	7.84

  
 BadgerCare Rates

 Medical Capitation Rates by Service Category - Chiropractic Costs 
  

																																													
	 Age Range

	  	Gender

	  	 Duluth/
Superior
 1

	  	 Wausau/
Rhinelander
 2

	  	 Green
Bay
 3

	  	 Twin
Cities
 4

	  	 Marshfield/
 Stevens
Point
 5

	  	 Appleton/
 Oshkosh
 6

	  	La
Crosse
7

	  	Madison
8

	  	 Southeast
 Wisconsin
9

	  	Milwaukee
10

	  	 Dane
 11

	  	 Eau
Claire
 12

	  	Kenosha
13

	  	 Waukesha
 14

	 Age 0
	  	All	  	 	See Addendum III-B - under age 1 rates are the same for BadgerCare as for AFDC/Healthy Start Children
	 Age 1-14
	  	All	  	$	0.46	  	$	0.44	  	$	0.38	  	$	0.82	  	$	0.41	  	$	0.41	  	$	0.50	  	$	0.23	  	$	0.22	  	$	0.07	  	$	0.28	  	$	1.05	  	$	0.11	  	$	0.32
	 Age 15-20
	  	F	  	$	0.98	  	$	0.94	  	$	0.80	  	$	1.74	  	$	0.86	  	$	0.86	  	$	1.05	  	$	0.48	  	$	0.45	  	$	0.15	  	$	0.58	  	$	2.22	  	$	0.24	  	$	0.69
	 Age 15-20
	  	M	  	$	0.44	  	$	0.43	  	$	0.36	  	$	0.79	  	$	0.39	  	$	0.39	  	$	0.48	  	$	0.22	  	$	0.21	  	$	0.07	  	$	0.26	  	$	1.01	  	$	0.11	  	$	0.31
	 Age 21-34
	  	F	  	$	1.17	  	$	1.12	  	$	0.96	  	$	2.07	  	$	1.03	  	$	1.02	  	$	1.25	  	$	0.57	  	$	0.54	  	$	0.18	  	$	0.69	  	$	2.65	  	$	0.28	  	$	0.82
	 Age 21-34
	  	M	  	$	1.03	  	$	0.98	  	$	0.84	  	$	1.81	  	$	0.90	  	$	0.90	  	$	1.10	  	$	0.50	  	$	0.47	  	$	0.15	  	$	0.61	  	$	2.32	  	$	0.25	  	$	0.72
	 Age 35-44
	  	F	  	$	1.50	  	$	1.43	  	$	1.22	  	$	2.65	  	$	1.31	  	$	1.31	  	$	1.60	  	$	0.73	  	$	0.69	  	$	0.23	  	$	0.89	  	$	3.39	  	$	0.36	  	$	1.05
	 Age 35-44
	  	M	  	$	1.11	  	$	1.07	  	$	0.91	  	$	1.97	  	$	0.98	  	$	0.97	  	$	1.19	  	$	0.55	  	$	0.52	  	$	0.17	  	$	0.66	  	$	2.52	  	$	0.27	  	$	0.78
	 Age 45+
	  	F	  	$	2.08	  	$	1.99	  	$	1.70	  	$	3.67	  	$	1.82	  	$	1.82	  	$	2.22	  	$	1.02	  	$	0.96	  	$	0.31	  	$	1.23	  	$	4.70	  	$	0.51	  	$	1.45
	 Age 45+
	  	M	  	$	0.83	  	$	0.79	  	$	0.68	  	$	1.47	  	$	0.73	  	$	0.72	  	$	0.89	  	$	0.41	  	$	0.38	  	$	0.13	  	$	0.49	  	$	1.88	  	$	0.20	  	$	0.58

  

 4/14/04 

 Addendum III - F: 
 May to December 2004 Final BadgerCare Capitation Rates by Age/Gender & Rate Region 
  
 BadgerCare - Applies to medical ctatus codes B1, B2, B3, B4, B5, B6, GP - All Services 
  

																																													
	 Age Range

	  	Gender

	  	Duluth/
Superior
1

	  	Wausau/
Rhinelander
2

	  	 Green
Bay
 3

	  	 Twin
Cities
 4

	  	 Marshfield/
 Stevens
Point
 5

	  	 Appleton/
 Oshkosh
6

	  	 La
Crosse
 7

	  	Madison
8

	  	 Southeast
 Wisconsin
9

	  	Milwaukee
10

	  	 Dane
 11

	  	Eau
Claire
12

	  	 Kenosha
 13

	  	Waukesha
14

	 Age 0
	  	All	  	 	See Addendum III-C - rates for BadgerCare under age 1 are the same as rates for AFDC/Healthy Start Children under age 1
	 Age 1-14
	  	All	  	$	65.16	  	$	67.31	  	$	64.87	  	$	65.16	  	$	63.94	  	$	59.80	  	$	56.48	  	$	63.63	  	$	64.48	  	$	67.34	  	$	61.63	  	$	65.55	  	$	66.79	  	$	73.27
	 Age 15-20
	  	F	  	$	121.20	  	$	125.69	  	$	120.63	  	$	119.90	  	$	118.66	  	$	111.06	  	$	104.70	  	$	118.17	  	$	120.28	  	$	126.33	  	$	115.98	  	$	121.93	  	$	123.58	  	$	136.53
	 Age 15-20
	  	M	  	$	82.12	  	$	85.06	  	$	81.78	  	$	81.39	  	$	80.48	  	$	75.30	  	$	70.98	  	$	80.21	  	$	81.52	  	$	85.52	  	$	78.34	  	$	82.37	  	$	84.04	  	$	92.53
	 Age 21-34
	  	F	  	$	171.89	  	$	178.73	  	$	171.10	  	$	168.60	  	$	168.09	  	$	157.38	  	$	148.09	  	$	167.60	  	$	171.08	  	$	180.43	  	$	165.84	  	$	172.53	  	$	174.94	  	$	194.01
	 Age 21-34
	  	M	  	$	92.25	  	$	95.67	  	$	91.76	  	$	91.39	  	$	90.27	  	$	84.51	  	$	79.72	  	$	89.80	  	$	91.43	  	$	95.97	  	$	88.26	  	$	93.15	  	$	93.81	  	$	103.82
	 Age 35-44
	  	F	  	$	226.93	  	$	236.14	  	$	225.89	  	$	222.05	  	$	221.83	  	$	207.72	  	$	195.37	  	$	221.24	  	$	226.03	  	$	238.68	  	$	219.47	  	$	227.66	  	$	230.80	  	$	256.27
	 Age 35-44
	  	M	  	$	158.23	  	$	164.54	  	$	157.50	  	$	155.16	  	$	154.71	  	$	144.87	  	$	136.31	  	$	154.26	  	$	157.48	  	$	166.12	  	$	152.72	  	$	158.86	  	$	160.99	  	$	178.60
	 Age 45+
	  	F	  	$	275.97	  	$	287.30	  	$	274.66	  	$	269.80	  	$	269.66	  	$	252.55	  	$	237.52	  	$	268.89	  	$	274.87	  	$	290.40	  	$	267.24	  	$	277.14	  	$	280.30	  	$	311.64
	 Age 45+
	  	M	  	$	262.49	  	$	273.23	  	$	261.45	  	$	256.07	  	$	256.66	  	$	240.30	  	$	225.77	  	$	256.34	  	$	261.94	  	$	276.94	  	$	254.24	  	$	262.18	  	$	267.65	  	$	296.83
	  
 BadgerCare Rates - Applies to medical
status codes B1, B2, B3, B4, B5, B6, GP
 Dental Services - No Chiropractic
  

	 Age Range

	  	Gender

	  	Duluth/
Superior
1

	  	Wausau/
Rhinelander
2

	  	 Green
Bay
 3

	  	 Twin
Cities
 4

	  	 Marshfield/
 Stevens
Point
 5

	  	 Appleton/
 Oshkosh
6

	  	 La
Crosse
 7

	  	Madison
8

	  	 Southeast
 Wisconsin
9

	  	Milwaukee
10

	  	 Dane
 11

	  	Eau
Claire
12

	  	 Kenosha
 13

	  	Waukesha
14

	 Age 0
	  	All	  	 	See Addendum III-C - rates for BadgerCare under age 1 are the same as rates for AFDC/Healthy Start Children under age 1
	 Age 1-14
	  	All	  	$	64.70	  	$	66.87	  	$	64.49	  	$	64.34	  	$	63.53	  	$	59.39	  	$	55.98	  	$	63.40	  	$	64.27	  	$	67.27	  	$	61.36	  	$	64.50	  	$	66.68	  	$	72.94
	 Age 15-20
	  	F	  	$	120.22	  	$	124.75	  	$	119.82	  	$	118.16	  	$	117.80	  	$	110.20	  	$	103.64	  	$	117.69	  	$	119.82	  	$	126.18	  	$	115.40	  	$	119.71	  	$	123.34	  	$	135.85
	 Age 15-20
	  	M	  	$	81.68	  	$	84.64	  	$	81.41	  	$	80.60	  	$	80.09	  	$	74.91	  	$	70.51	  	$	79.99	  	$	81.31	  	$	85.45	  	$	78.08	  	$	81.36	  	$	83.93	  	$	92.22
	 Age 21-34
	  	F	  	$	170.72	  	$	177.60	  	$	170.15	  	$	166.53	  	$	167.06	  	$	156.36	  	$	146.84	  	$	167.02	  	$	170.53	  	$	180.26	  	$	165.15	  	$	169.88	  	$	174.66	  	$	193.20
	 Age 21-34
	  	M	  	$	91.22	  	$	94.69	  	$	90.92	  	$	89.58	  	$	89.37	  	$	83.62	  	$	78.62	  	$	89.30	  	$	90.95	  	$	95.82	  	$	87.65	  	$	90.83	  	$	93.56	  	$	103.10
	 Age 35-44
	  	F	  	$	225.43	  	$	234.70	  	$	224.67	  	$	219.40	  	$	220.51	  	$	206.41	  	$	193.77	  	$	220.51	  	$	225.34	  	$	238.45	  	$	218.58	  	$	224.27	  	$	230.44	  	$	255.22
	 Age 35-44
	  	M	  	$	157.12	  	$	163.48	  	$	156.59	  	$	153.19	  	$	153.74	  	$	143.89	  	$	135.12	  	$	153.71	  	$	156.97	  	$	165.95	  	$	152.06	  	$	156.33	  	$	160.71	  	$	177.82
	 Age 45+
	  	F	  	$	273.90	  	$	285.32	  	$	272.96	  	$	266.13	  	$	267.83	  	$	250.73	  	$	235.30	  	$	267.87	  	$	273.91	  	$	290.09	  	$	266.01	  	$	272.44	  	$	279.80	  	$	310.19
	 Age 45+
	  	M	  	$	261.66	  	$	272.44	  	$	260.77	  	$	254.61	  	$	255.93	  	$	239.57	  	$	224.89	  	$	255.94	  	$	261.56	  	$	276.81	  	$	253.75	  	$	260.30	  	$	267.44	  	$	296.25
	  
 BadgerCare Rates - Applies to medicals
status codes B1, B2, B3, B4, B5, B6, GP
 Chiropractic Services - No Dental
  

	 Age Range

	  	Gender

	  	Duluth/
Superior
1

	  	Wausau/
Rhinelander
2

	  	 Green
Bay
 3

	  	 Twin
Cities
 4

	  	 Marshfield/
 Stevens
Point
 5

	  	 Appleton/
 Oshkosh
6

	  	 La
Crosse
 7

	  	Madison
8

	  	 Southeast
 Wisconsin
9

	  	Milwaukee
10

	  	 Dane
 11

	  	Eau
Claire
12

	  	 Kenosha
 13

	  	Waukesha
14

	 Age 0
	  	All	  	 	See Addendum III-C - rates for BadgerCare under age 1 are the same as rates for AFDC/Healthy Start Children under age 1
	 Age 1-14
	  	All	  	$	58.19	  	$	60.70	  	$	57.90	  	$	56.55	  	$	56.79	  	$	53.21	  	$	49.99	  	$	56.65	  	$	58.04	  	$	61.50	  	$	56.68	  	$	58.43	  	$	58.94	  	$	65.77
	 Age 15-20
	  	F	  	$	113.43	  	$	118.32	  	$	112.86	  	$	110.31	  	$	110.70	  	$	103.72	  	$	97.47	  	$	110.40	  	$	113.11	  	$	119.82	  	$	110.47	  	$	114.01	  	$	114.84	  	$	128.19
	 Age 15-20
	  	M	  	$	75.63	  	$	78.91	  	$	75.29	  	$	73.39	  	$	73.83	  	$	69.17	  	$	64.95	  	$	73.71	  	$	75.53	  	$	80.09	  	$	73.74	  	$	75.75	  	$	76.74	  	$	85.56
	 Age 21-34
	  	F	  	$	165.58	  	$	172.74	  	$	164.80	  	$	160.82	  	$	161.62	  	$	151.42	  	$	142.22	  	$	161.28	  	$	165.25	  	$	175.15	  	$	161.37	  	$	166.09	  	$	167.85	  	$	187.24
	 Age 21-34
	  	M	  	$	86.67	  	$	90.38	  	$	86.19	  	$	84.51	  	$	84.56	  	$	79.24	  	$	74.53	  	$	84.22	  	$	86.27	  	$	91.30	  	$	84.31	  	$	87.46	  	$	87.53	  	$	97.83
	 Age 35-44
	  	F	  	$	220.47	  	$	230.01	  	$	219.44	  	$	214.08	  	$	215.21	  	$	201.62	  	$	189.36	  	$	214.78	  	$	220.07	  	$	233.27	  	$	214.88	  	$	221.07	  	$	223.53	  	$	249.33
	 Age 35-44
	  	M	  	$	152.69	  	$	159.29	  	$	151.96	  	$	148.32	  	$	149.03	  	$	139.62	  	$	131.16	  	$	148.70	  	$	152.36	  	$	161.48	  	$	148.79	  	$	153.20	  	$	154.75	  	$	172.64
	 Age 45+
	  	F	  	$	269.78	  	$	281.43	  	$	268.47	  	$	262.15	  	$	263.31	  	$	246.69	  	$	231.76	  	$	262.69	  	$	269.15	  	$	285.21	  	$	262.84	  	$	270.82	  	$	273.33	  	$	304.98
	 Age 45+
	  	M	  	$	255.19	  	$	266.30	  	$	254.15	  	$	247.06	  	$	249.18	  	$	233.40	  	$	218.98	  	$	249.03	  	$	255.20	  	$	270.82	  	$	249.06	  	$	254.73	  	$	259.43	  	$	288.98
	  
 BadgerCare Rates - Applies to medical
status codes B1, B2, B3, B4, B5, B6, GP
 No Dental or Chiropractic
  

	 Age Range

	  	Gender

	  	Duluth/
Superior
1

	  	Wausau/
Rhinelander
2

	  	 Green
Bay
 3

	  	 Twin
Cities
 4

	  	 Marshfield/
 Stevens
Point
 5

	  	 Appleton/
 Oshkosh
6

	  	 La
Crosse
 7

	  	Madison
8

	  	 Southeast
 Wisconsin
9

	  	Milwaukee
10

	  	 Dane
 11

	  	Eau
Claire
12

	  	 Kenosha
 13

	  	Waukesha
14

	 Age 0
	  	All	  	 	See Addendum III-C - rates for BadgerCare under age 1 are the same as rates for AFDC/Healthy Start Children under age 1
	 Age 1-14
	  	All	  	$	57.72	  	$	60.25	  	$	57.52	  	$	55.73	  	$	56.38	  	$	52.80	  	$	49.49	  	$	56.42	  	$	57.82	  	$	61.43	  	$	56.41	  	$	57.38	  	$	58.83	  	$	65.45
	 Age 15-20
	  	F	  	$	112.45	  	$	117.38	  	$	112.06	  	$	108.58	  	$	109.84	  	$	102.86	  	$	96.42	  	$	109.92	  	$	112.65	  	$	119.67	  	$	109.89	  	$	111.79	  	$	114.60	  	$	127.50
	 Age 15-20
	  	M	  	$	75.19	  	$	78.49	  	$	74.93	  	$	72.60	  	$	73.44	  	$	68.78	  	$	64.47	  	$	73.49	  	$	75.33	  	$	80.02	  	$	73.48	  	$	74.74	  	$	76.63	  	$	85.25
	 Age 21-34
	  	F	  	$	164.41	  	$	171.62	  	$	163.84	  	$	158.75	  	$	160.59	  	$	150.39	  	$	140.97	  	$	160.71	  	$	164.71	  	$	174.97	  	$	160.67	  	$	163.44	  	$	167.56	  	$	186.42
	 Age 21-34
	  	M	  	$	85.64	  	$	89.40	  	$	85.35	  	$	82.70	  	$	83.66	  	$	78.34	  	$	73.43	  	$	83.72	  	$	85.80	  	$	91.15	  	$	83.70	  	$	85.14	  	$	87.29	  	$	97.11
	 Age 35-44
	  	F	  	$	218.98	  	$	228.58	  	$	218.21	  	$	211.44	  	$	213.89	  	$	200.31	  	$	187.76	  	$	214.04	  	$	219.37	  	$	233.04	  	$	213.99	  	$	217.68	  	$	223.17	  	$	248.29
	 Age 35-44
	  	M	  	$	151.57	  	$	158.22	  	$	151.05	  	$	146.35	  	$	148.05	  	$	138.65	  	$	129.96	  	$	148.16	  	$	151.85	  	$	161.31	  	$	148.13	  	$	150.68	  	$	154.48	  	$	171.86
	 Age 45+
	  	F	  	$	267.70	  	$	279.44	  	$	266.77	  	$	258.48	  	$	261.48	  	$	244.88	  	$	229.54	  	$	261.67	  	$	268.19	  	$	284.89	  	$	261.61	  	$	266.12	  	$	272.83	  	$	303.53
	 Age 45+
	  	M	  	$	254.36	  	$	265.51	  	$	253.47	  	$	245.60	  	$	248.45	  	$	232.67	  	$	218.09	  	$	248.63	  	$	254.82	  	$	270.69	  	$	248.57	  	$	252.85	  	$	259.23	  	$	288.40

  

 Addendum III-G 
  
 Healthy Start Pregnant Women Capitation Rates by Rate Region - Rate Period May to December 2004 
 HSPW Rates can also be found in region-specific information in Addendum III 
  

																																											
	 	  	1

	  	2

	  	3

	  	4

	  	5

	  	6

	  	7

	  	8

	  	9

	  	10

	  	11

	  	12

	  	13

	  	14

	 2004 HSPW RATES

	  	Duluth/
Superior

	  	Wausau/
Rhinelander

	  	Green
Bay

	  	Twin
Cities

	  	 Marshfield/
 Stevens
Point

	  	 Appleton/
 Oshkosh

	  	La
Crosse

	  	Madison

	  	 Southeast
 Wisconsin

	  	Milwaukee

	  	Dane

	  	Eau
Claire

	  	Kenosha

	  	Waukesha

	 All Services
	  	$	629.80	  	$	599.03	  	$	591.22	  	$	599.09	  	$	612.63	  	$	590.52	  	$	598.95	  	$	618.05	  	$	603.54	  	$	722.72	  	$	658.64	  	$	720.77	  	$	668.00	  	$	616.11
	 Dental, No Chiro
	  	$	628.73	  	$	597.71	  	$	590.60	  	$	597.44	  	$	611.40	  	$	589.85	  	$	597.72	  	$	617.43	  	$	602.97	  	$	722.51	  	$	658.20	  	$	718.89	  	$	667.85	  	$	615.82
	 Chiro, No Dental
	  	$	623.47	  	$	595.63	  	$	587.73	  	$	592.54	  	$	608.82	  	$	585.87	  	$	593.87	  	$	613.21	  	$	600.16	  	$	720.77	  	$	656.04	  	$	717.70	  	$	663.17	  	$	612.06
	 No Dental or Chiro
	  	$	622.40	  	$	594.31	  	$	587.12	  	$	590.88	  	$	607.58	  	$	585.20	  	$	592.64	  	$	612.58	  	$	599.59	  	$	720.56	  	$	655.60	  	$	715.82	  	$	663.02	  	$	611.77

  

 ADDENDUM IV 
  
 GUIDELINES FOR THE COORDINATION OF SERVICES BETWEEN HMOS AND THE BUREAU OF MILWAUKEE CHILD WELFARE 
  

	I.	HMO Rights and Responsibilities: 

  

	 	A.	The HMO must designate at least one individual to serve as a contact person for the Bureau of Milwaukee Child Welfare (BMCW). If the HMO chooses to designate more than one contact
person, the HMO should identify the service area for which each contact person is responsible. 

  

	 	B.	The HMO must provide all Medicaid covered mental health and substance abuse services to individuals identified as clients of BMCW. Disputes in the medical necessity of services
identified in the Family Treatment Plan will be adjudicated using the dispute process outlined in this MOU, except that HMOs will provide court ordered services in accordance with Article III, F. 

  

	 	C.	The HMO liaison, or other appropriate staff as designated by the HMO, will participate in case conference with BMCW upon the request of BMCW. The planning session may be done
through telephone contact or other means of communication when attending a formal case conference is not feasible. 

  

	 	D.	The HMO liaison and BMCW will discuss who will be responsible for ensuring that the recipient receives the services authorized and provided through the HMO. The HMO must have a
mechanism in place for notifying BMCW of missed appointments or family crisis situations that could potentially lead to an out-of- home placement by BMCW. The notification will be within three business days of occurrence or sooner if possible.

  

	 	E.	The HMO agrees to participate in dispute resolution using the following process: 

  

	 	1.	The BMCW and the HMO designated personnel will meet or teleconference to discuss the case and attempt to resolve issues of dispute. 

  

	 	2.	If the BMCW designees and the HMO designees (known as the team) are unable to resolve the issues, BMCW and the HMO will schedule a meeting or a teleconference of representatives
with expertise in the area of dispute to look at outstanding issues within two days of the teleconference or sooner if indicated. 

  

	 	3.	If the team is unable to resolve the issues to both parties’ satisfaction, either party may appeal to the Department. It will be the disputing party’s responsibility to
supply the necessary documentation for the Department to adjudicate the dispute. 

  

 -160- 

	 	F.	The HMO will work with BMCW in developing lists of providers and fostering a provider network that has expertise in: 

  

	 	1.	Working with adults and children effectively. 

  

	 	2.	Working with dual diagnosed clients effectively. 

  

	 	3.	Understanding adult functioning problems in the context of parenting, child safety and child well-being. 

  

	 	4.	Recognizing the interrelationship of the problems BMCW families experience and, therefore, the value of close collaboration among the various service providers working with the
family. 

  

	 	G.	The HMO will share with BMCW agency(ies) the procedure and process for prior authorization and out-of-plan referrals. 

  

	II.	Bureau of Milwaukee Child Welfare’s Rights and Responsibilities: 

  

	 	A.	It is the BMCW’s responsibility to initiate contact with the HMO regarding child welfare families and/or individuals in need of service. BMCW will provide (through court order
and/or signed release of information) completed assessment information that supports the request for HMO services. 

  

	 	B.	BMCW will complete and involve the HMO in the development of a comprehensive case plan that identifies the outcomes to be achieved, the services to be provided and the measures to
be used for evaluation. 

  

	 	C.	BMCW will utilize the HMO’s provider network for routine services whenever possible and will attempt to utilize the HMO provider network for emergency services. BMCW will
obtain criteria from the HMO concerning BMCW’s ability to utilize non-participating providers and the mechanism for authorizing non- participating providers. 

  

	 	D.	BMCW will evaluate the progress of the case plan at 90-day intervals, including the effectiveness of services, and will forward those results to the HMO within ten days of
completion. 

  

	 	F.	BMCW will be responsible for informing the HMO of the status of the case, including court-ordered revisions within two business days of the revisions. 

  

	 	G.	BMCW agrees to participate in dispute resolution using the following process: 

  

	 	1.	BMCW and the HMO designated personnel will meet or teleconference to discuss the case and attempt to resolve issues of dispute. 

  

 -161- 

	 	2.	If the BMCW designees and the HMO designees (known as the team) are unable to resolve the issues, the BMCW and the HMO will schedule a meeting of representatives to look at
outstanding issues within two days of the meeting or teleconference or sooner if indicated. 

  

	 	3.	If the team is unable to resolve the issues to both parties’ satisfaction, either party may appeal to the Department. It will be the disputing party’s responsibility to
supply the necessary documentation for the Department to adjudicate the dispute. 

  

 -162- 

 ADDENDUM V 
  

GUIDELINES FOR THE COORDINATION OF SERVICES BETWEEN MEDICAID HMOS AND COUNTY BIRTH TO THREE AGENCIES 
  
 The Birth to 3 program is an entitlement program established by the Federal Individuals with
Disabilities Education Act (IDEA) and is funded by federal, state, and local funds. The goal of the program is to provide Early Intervention (EI) services to children from birth up to the age of three who have developmental disabilities or delays.
The intended outcome of the program is to ensure maximum amelioration of the impact of developmental disabilities or delays on infants and toddlers by early and ongoing provision of rehabilitation services. 
  
 Early Intervention services under Part C of the IDEA are administered in Wisconsin under
Administrative Code HSF 90 by county health and human service department Birth to 3 programs. Birth to 3 agencies arrange for the provision of rehabilitative services (including needed physical therapy, occupational therapy, speech-language
pathology, special instruction, audiology, certain nursing, psychological and other services), service coordination, and related parent education. Regulations require that Birth to 3 services be delivered in a “natural” environment,
frequently the child’s home. Federal rules designate that IDEA, Part C funds are a payer of last resort after all other private and public funds, including Medicaid funds. 
  
 There are HMO enrollees that either are or will be in the Birth to 3 program. To summarize the Birth to 3 program process for ease of HMO
understanding, the Birth to 3 program has four stages. These “stages” are a conceptual tool. 
  

	1.	Stage 1 is the identification of a child as potentially eligible and in need of evaluation of whether the child is developmentally delayed. This can be done simply by a parent who
believes the child is not developing normally, or more formally though a medical evaluation by the HMO provider. The child is then referred to the HMO for evaluation of eligibility and assessment of medically necessary services for the Individual
Family Service Plan (IFSP). If the HMO originated the referral to the Birth to 3 agency, then any evaluations already completed by the HMO can be used as part of the eligibility decision process. 

  

	2.	Stage 2 is the evaluation for eligibility by the Birth to 3 program according to state and federal rules and the assessment of needed medical and developmental services for the
IFSP. 

  

	3.	Stage 3 is the coordinated development of an IFSP that describes the integrated set of services that the child and family should receive. The HMO, the family, the Birth to 3 agency,
and other relevant agencies are involved in the development of the IFSP. 

  

	4.	Stage 4 is the provision of services based on the IFSP. 

  
 The HMO is involved with the Birth to 3 program throughout all of the above stages. The HMO can identify and refer a child to the program based on the physician’s
determination that the child is not developing normally. The HMO will receive referrals from the program. The HMO will be involved in performing evaluation/assessment for eligibility determination and needed IFSP 

  

 -163- 

 
services. The HMO will be involved in family members, program staff, and other agencies. Finally, the HMO will be providing the services in the IFSP that
meet medical necessity per Medicaid guidelines. 
  
 Federal and state regulations
require an evaluation for eligibility, an assessment of needs and the development of an IFSP within 45 days of an EI referral to the Birth to 3 agency. A child eligible for receives services according to the IFSP document. Regulations require that
Medicaid pay for covered IFSP services that meet Medicaid’s definition of medical necessity. Services meeting Medicaid’s coverage requirement are to be paid by Medicaid funds before county, state or federal IDEA funds are used to pay for
the services. Wisconsin Medicaid requires HMOs to seek payment from a recipient’s health insurance first. However, in the Birth to 3 program, parents do not have to allow their Medicaid HMO to bill their health insurance for Birth to 3
services. In this situation, where the enrollee has other insurance but the parents do not allow billing of their health insurance for services, the HMO must work with the Birth to 3 agency on how to bill the agency for services rendered. The
agencies have established an “average insurance liability amount” per month for IFSP therapy services for these situations and will reimburse the HMO this amount. HMOs would be responsible for the cost of services after the county pays the
average insurance liability. The agency will inform the HMOs of those recipients participating in the program for whom the parents/guardians do not allow billing of their health insurance. The agency will inform the HMOs of the alternative billing
procedures for these recipients. 
  
 The following guidelines have been developed
to establish the complementary roles of the HMO and the Birth to 3 agency for clients they have in common and to identify the mutual activities of each party that will promote effective communication and coordination between the two parties. This
language will also be incorporated as an Appendix in the county Birth to 3 provider materials ensuring that both HMOs and county Birth to 3 providers have the same information available to them. All actions are governed by HSF 90, and HMOs are
required to make a reasonable attempt to assure that HSF 90 standards are met (e.g., two day referral). 
  
 HMO Rights and Responsibilities 
  

	A.	The HMO must designate at least one individual to serve as a contact person for county B-3 agencies. If the HMO chooses to designate more than one contact person, the HMO should
identify the counties for which each contact person is responsible. The contact person will work toward achieving a close, cooperative relationship between the HMO and the agency. The contact person will work with the agency to establish a mechanism
to identify and refer eligible recipients for services and for the distribution of appropriate paperwork. 

  

	B.	When the HMO identifies a recipient who may meet the eligibility guidelines for the Wis. Adm. Code, Chapter 90 HFS for Birth to 3 services it will make a referral to the county
agency within two days. A child under the age of 3 can be identified and referred to the agency based on the judgment of the HMO provider that the child is not developing normally. 

  

	C.	 If the parent of a child requests the HMO to conduct an evaluation/assessment, the HMO will determine the need for such evaluation/assessment in accordance with the
Medicaid and Chapter 90 HFS definition of medical necessity. If the evaluation/assessment 

  

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warrants eligibility for Birth to 3 services, a referral should be made to the agency as soon as possible. The HMO evaluation/assessment may be used by the
agency for eligibility determination. If additional information is needed, the HMO and program will coordinate a evaluation of eligibility and an assessment of IFSP services needed. The evaluation and assessment results should be completed within
thirty-five days from the date of the parent request. Results should be sent to the agency with the parent/guardian consent at the time of referral to give the agency sufficient time to complete the IFSP within the forty-five day time limit mandated
by HSF Chapter 90. 

  

	D.	If the county Birth to 3 agency requests a eligibility determination evaluation and assessment of IFSP service needs, the agency will provide a copy of the recipient screening tool
to assist the HMO in determining the need for a full evaluation/assessment. If the HMO agrees with the agency request, the HMO will conduct a complete evaluation/assessment of the recipient’s rehabilitative needs. Federal regulations under
Chapter 90 HFS require the HMO to forward a copy of the findings to the county agency within thirty-five days from the date of the parent/guardian request. This allows the agency sufficient time to complete the IFSP within the forty-five day
deadline required by federal regulations under Chapter 90 HFS. If the HMO determines that no evaluation/assessment is needed, the HMO will document the rationale for this decision. 

  

	E.	If the HMO requires copies of the recipient’s early intervention records held by the county Birth to 3 agency, the HMO may request the records directly from the agency with the
parents’/guardians’ consent: 

  

	 	1.	The HMO case management liaison and the county Birth to 3 case manager must establish feasible administrative procedures for obtaining parents’/guardians’ consent for
release of such records. 

  

	 	2.	If the parents’/guardians’ consent is not obtained, then any further actions on the part of the HMO requiring such records may cease. 

  

	F.	The HMO must determine the need for medical treatment related to Birth to 3 services covered under the HMO Contract based on the results of the evaluation/assessment and the HMO
determination of medical necessity. The HMO will not have final say on the entire IFSP, but only on whether the EI services indicated in the IFSP are the HMO’s responsibility. 

  

	G.	The HMO shall work cooperatively with the Birth to 3 agency so that the provision of medically necessary services identified in the IFSP plan do not suffer interruption due to
delays caused by HMO prior authorization and/or utilization management procedures. 

  

	H.	The HMO Birth to 3 liaison, or other appropriate staff as designated by the HMO, must participate in case planning for the development of the IFSP with the county agency, unless no
services are provided through the HMO: 

  

	 	1.	The case planning may be done through telephone contact or written communication rather than attending a formal case planning meeting. 

  

 -165- 

	 	2.	The HMO is encouraged to recommend the type, frequency, and amount of services that might be on the IFSP. 

  

	 	3.	The HMO must informally discuss differences in opinion regarding the HMO’s determination of medically necessary treatment needs if requested by the recipient or case manager.

  

	 	4.	The HMO case management liaison and the county Birth to 3 manager must discuss the follow-up to be undertaken so that IFSP services authorized by the HMO according to the criteria
of medical necessity are made available and accessible to the recipient, and work with agencies to assist in scheduling recipient appointments. 

  

	 	5.	The HMO’s role in the case planning may be limited to a confirmation of the services the HMO will authorize if the recipient and county Birth to 3 case manager find these
acceptable. 

  

	I.	The parent/guardian of a Birth to 3 recipient may chose to receive Birth to 3 services from the recipient’s HMO or may elect to disenroll the child from the HMO as allowed by
Medicaid. However, HMOs may not restrict in any way the right of the recipient to remain enrolled in the HMO and to receive medically necessary services through the HMO. 

  

	J.	HMOs must arrange for providers with expertise appropriate to treat the infant and toddler population to meet the medically necessary needs of recipients enrolled in the HMO.

  
 County Birth to 3 Agency Rights and Responsibilities

  

	A.	The county Birth to 3 agency is responsible for the initial contact with the HMO to coordinate services to recipient(s) they have in common, and will provide the HMO with the name
and phone number of the county Birth to 3 agency. 

  

	B.	If the HMO refers a recipient to the county Birth to 3 agency, the county agency must conduct an eligibility evaluation/assessment based on their usual procedures and policies in
collaboration with the HMO. 

  

	C.	If the county Birth to 3 agency requires copies of the recipient’s medical records, the agency may request the records directly from the HMO with the consent of the
parent/guardian. 

  

	D.	 The Birth to 3 case manager (service coordinator) may also identify whether the recipient has service or treatment needs over and above what is included in the
child’s IFSP. As a part of this process, the county agency and the recipient may seek additional assessment for treatment of medical conditions not included in the IFSP which the HMO may be expected to assess and treat under the terms of its
contract. In these cases, the HMO will determine if there are specific signs and symptoms indicating the medical necessity for 

  

 -166- 

	 	 
the assessment and treatment. The agency must refer and coordinate evaluation/ assessment with the HMO within two days of identifying a potentially eligible
child. 

  

	E.	The county Birth to 3 agency may not determine the need for specific medical care covered under the HMO contract, nor may the county agency make referrals directly to specific
providers of medical care covered through the HMO. 

  

	F.	The county Birth to 3 agency must complete an IFSP in accordance with the requirements of HSF 90. 

  

	G.	If the county Birth to 3 agency specifically requests the HMO liaison to attend a planning meeting in person, the county agency may coordinate with the HMO for the costs associated
with attending the planning meeting. These are not separately allowable costs for reimbursement through Wisconsin Medicaid. 

  

	H.	The county Birth to 3 agency is responsible for making timely referrals to School Based Services (SBS) providers for recipients participating in Birth to 3 programs, who turn the
age of three and lose eligibility for services and are likely to be eligible for the SBS program. 

  
 Nothing in these guidelines precludes the HMO and the county Birth to 3 agency from entering into a formal contract or memorandum of understanding to address issues not
outlined here. 
  

 -167- 

 ADDENDUM VI 
  
 LOCAL HEALTH DEPARTMENTS AND COMMUNITY-BASED HEALTH ORGANIZATIONS A RESOURCE FOR HMOS 
  
 Local Health Departments (LHDs) throughout the state have an essential role in promoting the
health of citizens of Wisconsin. They have general and specific statutory authority to prevent disease, promote health and protect the health of the citizens. They work in collaboration with community-based organizations, medical care facilities,
and local community agencies to develop and coordinate systems of care so that the public’s health can be protected. Specific statutory authority includes the three public health core functions of assessment, policy development and assurance:

  
 Assessment: means the regular, systematic collection, assembly,
analysis and dissemination of information on the health of the community. This includes incidence and prevalence data, and morbidity, mortality and environmental data in areas that include: communicable disease, chronic disease and environmental
health. 
  
 Policy Development: means the exercise of responsibility to
serve the public’s interest by fostering shared ownership with the community in the development of comprehensive public health plans, programs, services and guidelines. 
  
 Assurance: means to take reasonable and necessary action to assure citizens that services necessary to achieve public health goals
are available. This is done by encouraging the actions of others in the private, public and/or voluntary sectors, and by requiring action through enforcement or by directly providing services. 
  
 Description of Public Health Services: LHDs’ capacities may vary; however, LHDs
are required to provide or ensure five basic public health services. These include: 
  

	1.	Communicable disease surveillance 

  

	2.	Prevention and control 

  

	3.	Health promotion 

  

	4.	Disease prevention 

  

	5.	Human health hazard control 

  

	6.	Generalized public health nursing programs 

  
 Although LHDs serve the population as a whole, they have established traditions of working with population groups at increased risk of illness, disability and premature
death. The following specific services have been delineated with the hope of linking Medicaid Managed Care Plans with LHDs. Linking primary care and public health is an essential strategy to strengthen the health of local communities and thus
benefit the population of the state as a whole. 
  

	•	LHDs have access to population data that may be very useful to managed care organizations in determining their services and quality studies. 

  

 -168- 

	•	LHDs closely collaborate their programs with key community agencies that serve the Medicaid population. These include: Special Supplemental Nutrition Program for Women, Infants, and
Children (WIC), Prenatal Care Coordination, School Health Services, Birth to 3 programs, Family Planning, and Developmental Disabilities. 

  

	•	LHDs promote and provide health education programs on topics that include Domestic Abuse/Violence Prevention, Smoking Cessation, Breast Feeding, Cardiovascular Risk Reduction,
Prenatal/Postpartum Education, Nutrition, and Self-Care Skills. 

  

	•	LHDs provide health-related home/community inspections in areas that include Lead Poisoning, Asbestos, Indoor Air Quality, Home Safety, and Drinking Water Safety.

  

	•	LHDs monitor communicable disease incidence/prevalence, provide information to the public on prevention, and conduct epidemiological investigations of outbreaks/unusual conditions.

  
 Access to Special Populations 
  
 Wisconsin’s LHDs perform many public health services, including the provision of direct
services to Medicaid recipients. Some LHDs provide Medicaid reimbursable services for which HMOs may contract, such as: 
  

	•	HealthCheck screening, outreach and follow-up. 

  

	•	Immunizations. 

  

	•	Blood lead screening. 

  

	•	Extended case management of medical conditions such as asthma, diabetes, hypertension and children with special health care needs. 

  

	•	Home health and personal care services. 

  

	•	LHDs provide important resources such as: 

  

	•	Clinics serving high-risk populations. 

  

	•	Culturally competent staff experienced in dealing with diverse, high risk populations. 

  

	•	Direct access to outreach and follow up with at-risk population groups in home and community settings. 

  

	•	Environmental inspection and case management for children with elevated blood lead levels. 

  

	•	Ability to contact hard-to-reach people to assist HMOs in achieving required rates, such as the HealthCheck screening rate. 

  

	•	Experience in family-centered care. 

  

	•	Linkages with other community based providers and advocacy groups. 

  

	•	Highly skilled staff who emphasize prevention and public health. 

  

 -169- 

 Community Based Health Organizations 
  
 Throughout the state, the health care network includes many nonprofit community based health organizations including private HealthCheck
providers, family planning clinics, and WIC clinics. These organizations may provide some of the same Medicaid reimbursable services as LHDs and are essential to advancing the health of community. They may also have the same access to special
populations as LHDs. 
  
 Collaboration with Public and Community Based Health
Organizations 
  
 HMOs should consider how to utilize the LHDs and community
based health organizations through: 
  

	•	Identifying and utilizing the resources they provide. 

  

	•	Contracting with LHDs and other community health agencies for Medicaid reimbursable services where appropriate. 

  
 The complementary roles of managed care and public health are significant and evolving.
Communities will be healthier and health care costs reduced if health care providers work together. To find out the names of key contacts at LHDs and community based health organizations in your area, contact your LHD. 
  

 -170- 

 ADDENDUM VII 
  
 GUIDELINES FOR THE COORDINATION OF SERVICES BETWEEN HMOS, TARGETED CASE MANAGEMENT (TCM) AGENCIES, AND CHILD WELFARE AGENCIES

  
 (The same language will be incorporated as an Appendix in the case
management provider handbook, ensuring that both HMOs and case management providers have the same language available to them.) 
  
 HMO Rights and Responsibilities 
  

	1.	The HMO must designate at least one individual to serve as a contact person for case management providers. If the HMO chooses to designate more than one contact person, the HMO
should identify the target populations for which each contact person is responsible. 

  

	2.	The HMO may make referrals to case management agencies when they identify an enrollee from an eligible target population who could benefit from case management services.

  

	3.	If the enrollee or case manager requests the HMO to conduct an assessment, the HMO will determine whether there are signs and symptoms indicating the need for an assessment. If the
HMO finds that assessment is needed, the HMO will determine the most appropriate level for an assessment to be conducted (e.g., primary care physician, specialist, etc.). If the HMO determines that no assessment is needed, the HMO will document the
rationale for this decision. 

  

	4.	The HMO must determine the need for medical treatment of those services covered under the HMO Contract based on the results of the assessment and the medical necessity of the
treatment recommended. 

  

	5.	The HMO case management liaison, or other appropriate staff as designated by the HMO, must participate in case planning with the case management agency, unless no services provided
through the HMO are required. 

  

	 	•	The case planning may be done through telephone contact or means of communication other than attending a formal case planning meeting. 

  

	 	•	The HMO must informally discuss differences in opinion regarding the HMO’s determination of treatment needs if requested by the recipient or case manager.

  

	 	•	The HMO case management liaison and the case manager must discuss who will be responsible for ensuring that the enrollee receives the services authorized by and provided through the
HMO. 

  

 -171- 

	 	•	The HMO’s role in the case planning may be limited to a confirmation of the services the HMO will authorize if the enrollee and case manager find these acceptable.

  
 Case Management Agency Rights and Responsibilities

  

	1.	The case management agency is responsible for initiating contact with the HMO to coordinate services to recipient(s) they have in common and providing the HMO with the name and
phone number of the case manager(s). 

  

	2.	If the HMO refers an enrollee to the case management agency, the case management agency must conduct an initial screening based on their usual procedures and policies. The case
management agency must determine whether or not they will provide case management services and notify the HMO of this decision. 

  

	3.	The case management agency must complete a comprehensive assessment of the enrollee’s needs in accordance with the requirements in the Case Management provider handbook. This
includes a review of the enrollee’s physical and dental health needs. 

  

	4.	If the case management agency requires copies of the enrollee’s medical records, the case management agency must obtain the records directly from the service provider, not from
the HMO. 

  

	5.	The case manager must identify whether the enrollee has additional service or treatment needs. As a part of this process, the case manager and the enrollee may seek additional
assessment of conditions which the HMO may be expected to treat under the terms of the HMO Contract, if the HMO determines there are specific signs and symptoms indicating the need for an assessment. 

  

	6.	The case management agency may not determine the need for specific medical care covered under the HMO Contract, nor may the case management agency make referrals directly to
specific providers of medical care covered through the HMO. 

  

	7.	The case manager must complete a comprehensive case plan in accordance with the requirements of the Case Management provider handbook. The plan must include the medical services the
enrollee requires as determined by the HMO. 

  

	8.	If the case management agency specifically requests the HMO liaison to attend a planning meeting in person, the case management agency must reimburse the HMO for the costs
associated with attending the planning meeting. These are allowable costs for case management reimbursement through Wisconsin Medicaid. 

  
 Nothing in these guidelines precludes the HMO and the case management agency from entering into a formal contract or memorandum of understanding to address issues not
outlined here. 
  

 -172- 

 ADDENDUM VIII 
  
 REPORT FORMS AND WORKSHEETS 
  

	A.	AIDS and Ventilator Dependent Quarterly Report Form and Detail Report Format 

  

			
	 AIDS COST SUMMARY
	  	 
		
	 HMO Name:
                                        
                                
	  	 
		
	 Report Period:
                                        
                            
	  	 
		
	 Number of Cases Reported:
                                        
     
	  	 

  

					
	 Category of Service

	 	 Amount Billed

	 	 Amount Paid

	 Inpatient
	 	 	 	 
	 Outpatient
	 	 	 	 
	 Physician
	 	 	 	 
	 Pharmacy
	 	 	 	 
	 All Other
	 	 	 	 
	 Total
	 	 	 	 

  

			
	 VENTILATOR COST SUMMARY
	  	 
		
	 HMO Name:
                                        
                                
	  	 
		
	 Report Period:
                                        
                            
	  	 
		
	 Number of Cases Reported:
                                        
     
	  	 

  

					
	 Category of Service

	 	 Amount Billed

	 	 Amount Paid

	 Inpatient
	 	 	 	 
	 Outpatient
	 	 	 	 
	 Physician
	 	 	 	 
	 Pharmacy
	 	 	 	 
	 All Other
	 	 	 	 
	 Total
	 	 	 	 

  

 -173- 

 AIDS and Ventilator Dependent Detail Report 
  
 The detail report must be provided on disk and paper and must be in the
following layout: 
  

													
	 	  	 Field Name

	  	Type

	  	Width

	  	Dec

	  	Position

	  	 Explanation

	1	  	HMO_ID	  	Num	  	8	  	0	  	1-8	  	Right justified (HMO Service Area Provider Number)
	2	  	MA_ID	  	Num	  	10	  	0	  	9-18	  	Recipient Medicaid ID
	3	  	LNAME	  	Char	  	13	  	 	  	19-31	  	Recipient Last Name - Left justified
	4	  	FNAME	  	Char	  	10	  	 	  	32-41	  	Recipient First Name - Left justified
	5	  	ELIG_CODE	  	Char	  	1	  	 	  	42	  	 A = AIDS;
 N = NICU vent dependent;
 V = Vent dependent, non-NICU

	6	  	DOB	  	Date	  	8	  	 	  	43-50	  	mmddyyyy
	7	  	SEX	  	Char	  	1	  	 	  	51	  	F or M
	8	  	PROV_ID	  	Num	  	8	  	0	  	52-59	  	Medicaid Provider Number
	9	  	PROV LNAME	  	Char	  	13	  	 	  	60-72	  	Medicaid Provider Last Name – Left Justified
	10	  	PROV FNAME	  	Char	  	10	  	 	  	73-82	  	Medicaid Provider First Name – Left Justified
	11	  	FROM_DATE	  	Date	  	8	  	 	  	83-90	  	mmddyyyy
	12	  	TO_DATE	  	Date	  	8	  	 	  	91-98	  	mmddyyyy
	13	  	DIAG_1	  	Char	  	5	  	 	  	99-103	  	Left justified, ICD-9, implied decimal
	14	  	DIAG_2	  	Char	  	5	  	 	  	104-108	  	Left justified, ICD-9, implied decimal
	15	  	QTY	  	Num	  	4	  	0	  	109-112	  	Right justified (do not zero fill)
	16	  	PROC_CODE	  	Char	  	5	  	 	  	113-117	  	Left justified, CPT-4, UB92
	17	  	PROC_DESC	  	Char	  	10	  	 	  	118-127	  	 
	18	  	DRUG_CODE	  	Num	  	11	  	0	  	128-138	  	National Drug Code
	19	  	DRUG DESC	  	Char	  	10	  	 	  	139-148	  	Drug Name – Left Justified
	20	  	AMT_BILL	  	Num	  	9	  	2	  	149-157	  	Include decimal (do not zero fill)
	21	  	AMT-PAID	  	Num	  	9	  	2	  	158-166	  	Include decimal (do not zero fill)
	22	  	ADMIT_DATE	  	Date	  	8	  	 	  	167-174	  	Hospital admission date: mmddyyyy
	23	  	DIS_DATE	  	Date	  	8	  	 	  	175-182	  	Hospital discharge date: mmddyyyy

  

 -174- 

	B.	Coordination of Benefits Quarterly Report Form and Instructions for Completing the Form 

  
 In order to comply with CMS reporting requirements, HMOs must submit a Coordination of Benefits (COB) report regarding their
Medicaid and BadgerCare enrollees. For the purposes of this report, an HMO enrollee is any Medicaid recipient listed as an ADD or CONTINUE on the monthly HMO enrollment report(s) that are generated by the Department’s Medicaid fiscal agent.

  
 Birth costs or delivery costs (e.g., routine delivery and
associated hospital charges) are not to be included in the report. 
  
 The report is to be for the HMOs entire service area, aggregating separate service areas if the HMO has more than one service area. The report must be completed on a calendar quarterly basis and submitted to the Department’s fiscal
agent within 45 days of the end of the quarter being reported, as specified in Article VII, J. 
  

			
	 MAIL TO:
	  	FAX TO:
	 Medicaid Fiscal Agent
	  	Medicaid Fiscal Agent
	 Managed Care Unit
	  	ATTN: Managed Care Unit
	 P.O. Box 6470
 Madison, WI 53716-0470
	  	(608) 224-6318
		
	The COB report form follows this page.	  	 

  

 -175- 

 STATE OF WISCONSIN 
 MEDICAID/BADGERCARE 
 HMO REPORT ON COORDINATION OF BENEFITS 
  

			
		
	 Name of HMO
                                        
                        
	  	Mailing Address
                                        
                                    
		
	 Office Telephone
                                        
                   
	  	___________________________________________________
		
	 Provider Number
                                        
                    
	  	___________________________________________________

  
 Please designate below the quarter
period for which information is given in this report.
                                        
    , 20             through
                                        
    , 20             
  

	A.	Cost Avoidance – Indicate the dollar amount you denied as a result of your knowledge of other insurance that is available for the enrollee. 

 Amount Cost Avoided:
                         
  

	B.	Recoveries (Post-Pay Billing/Pay and Chase) – Indicate below the dollar amounts recovered as a result of: 

  
 Subrogation/Workers’ Compensation:
                                        

 (e.g., collections from auto, homeowners, or malpractice insurance, restitution payments from the Division of Corrections, collections from
Worker’s Compensation). 
  
 Other Recoveries:
                     
 (e.g.,
Third Party Liability (TPL), legal action, estate recoveries or any other recoveries that are not specifically noted above.) 
  
 I HEREBY CERTIFY that to the best of my knowledge and belief, the information contained in this report is a correct and complete statement prepared from the records of
the HMO, except as noted on the report. 
  

			
		
	Signed:	 	 
	 	 	Original Signature of Director or Administrator

			
		
	Title:	 	 

			
		
	Date Signed:	 	 

  

 -176- 

	C.	Medicaid and BadgerCare HMO Newborn Report 

  
 This report should be completed for infants born to mothers who are Medicaid or BadgerCare eligible and enrolled in the HMO at the time of birth of the infant.

  

			
		
	 1.       HMO Name:
	  	In this field enter the name of the HMO reporting.
		
	 HMO Provider Number:
	  	In this field enter the eight digit Medicaid provider number of the HMO reporting.
		
	 Telephone Number:
	  	In this field enter the HMO telephone number the fiscal agent can call with questions about submitted Newborn reports.
		
	 2.       Newborn Name:
	  	In this field enter the name of the newborn infant. If the mother has not given a first and middle name to the baby at the time the report is completed, enter the last name of the newborn as
the mother’s last name; the first name/middle initial can be entered as “baby male” or “baby female.”
		
	 Date of Birth:
	  	In this field enter the date of birth of the newborn infant, in MM/DD/YY format.
		
	 Sex:
	  	In this field check the sex of the newborn infant, Male or.
		
	 Low Birth Weight
 <1200 grams:
	  	In this field check the box if the newborn infant weighs less than 1200 grams.
		
	 Twin:
	  	In this field check no if the newborn infant is not a twin, check yes if the newborn infant is a twin. If the newborn infant is a twin, complete one Newborn Report for each
twin.
		
	 Date of Death:
	  	In this field enter the date of death, if the newborn infant died, in MM/DD/YY format.
		
	 3.       Mother’s Name:
	  	In this field enter the first name, middle initial, and last name of the mother of the newborn infant.
		
	 Address:
	  	In this field enter the address of the mother of the newborn infant – street address, city, state, and zip code.
		
	 Mother’s Medicaid ID
 Number:
	  	In this field enter the ten digit Medicaid or BadgerCare number of the mother of the newborn infant.

  
 The HMO staff person completing the
report should fsign and date the form and send it to the address listed at the bottom of the report. 
  
 The HMO does not have to use the above format. However, whatever format the HMO uses, the HMO must submit all of the information described above to the Department’s fiscal agent. 
  

 -177- 

 MEDICAID AND BADGERCARE HMO NEWBORN REPORT 
  
 Please print, type, or complete in a legible manner 
  

	1.	HMO Name  ___________________________________________________________________________________________ 

  
 HMO Provider
Number  __________________________________________________________________________________ 
  
 Telephone Number  ______________________________________________________________________________________ 
  

	2.	Newborn Name  _________________________________________________________________________________________ 

 (First)                                      
      (M.I.)                                 
           (Last) 
  
 Date of Birth
                                        
             ̈
Male             ̈ Female 
  
  ̈ Low Birth Weight <1200 grams 
  
 Twins:             ̈
No             ̈ Yes (If yes, complete two forms) 
  
 Date of Death if Applicable
                                        

  

	3.	Mother’s Name  ________________________________________________________________________________________ 

 (First)                                      
      (M.I.)                                 
           (Last) 
  
 Address  ______________________________________________________________________________________________ 
 (Street Address)

  
                          
 _______________________________________________________________________________________________ 
 (City)                                      
      (State)                                 
           (Zip Code) 
  

	4.	Mother’s Medicaid or BadgerCare ID Number  _______________________________________________________________ 

  

	5.	I certify this information is accurate to the best of my knowledge. 

  

					
			
	  	  	  	  	  
	Signature	  	 	  	Date

  

			
		
	 Mail To:
	  	FAX To:
		
	 Medicaid Fiscal Agent
	  	Medicaid Fiscal Agent
	 ATTN: Managed Care Unit
	  	ATTN: Managed Care Unit
	 P.O. Box 6470
	  	(608) 224-6318
	 Madison, WI 53716-0470
	  	 

  

 -178- 

	D.	HealthCheck Worksheet 

  
 HEALTHCHECK WORKSHEET 
  
 HMO
NAME:                                       
                      
  

															
	 	 	 	  	 Calculation

	  	Age Groups

	  	Total

	 	 	 	  	  	< 1

	  	1-5

	  	6-14

	  	15-20

	  
	1	 	Number of eligible months for enrollees under age 21	  	Entered (Total is sum of age groups.)	  	 	  	 	  	 	  	 	  	 
	2	 	Number of unduplicated enrollees under age 21	  	Entered	  	 	  	 	  	 	  	 	  	 
	3	 	Ratio of recommended screens per age group member	  	Given	  	5.00	  	1.4	  	0.56	  	0.50	  	 
	4	 	Average period of eligibility (in years)	  	Line 1 ÷ line 2 ÷12 (Total is calculated by formula.)	  	 	  	 	  	 	  	 	  	 
	5	 	Adjusted ratio of recommended screens per age group member	  	Line 3 x line 4	  	 	  	 	  	 	  	 	  	 
	6	 	Expected number of screens (100% of required screens for ages and months of eligibility)	  	Line 2 x line 5 (Total is sum of age groups.)	  	 	  	 	  	 	  	 	  	 
	7	 	Number of screens in goal (80%)	  	Line 6 x 0.80 (Total is calculated by formula.)	  	 	  	 	  	 	  	 	  	 
	8	 	Actual number of screens completed	  	Entered (Total is sum of age groups.)	  	 	  	 	  	 	  	 	  	 
	9	 	Difference between goal and actual	  	Line 8 – line 7 (Positive result means goal is met; negative result means goal is not met.)	  	 	  	 	  	 	  	 	  	 
	10	 	Percent of the HMO discount or premium if applicable except for Milwaukee, Dane, Eau Claire, Kenosha and Waukesha Counties.	  	 	  	 	  	 	  	 	  	 	  	 
	11	 	Amount per screen to be recouped	  	FFS maximum allowable fee *(Refer Article III, K, 2) x line 10	  	 	  	 	  	 	  	 	  	 
	12	 	Total recoupment	  	Line 11 x line 9	  	 	  	 	  	 	  	 	  	 

  

 -179- 

	E.	Neonatal Intensive Care Unit (NICU) Risk-Sharing Report Format and Detail Data Requirements 

  
 HMO reporting of NICU costs must include all of the data elements specified in this section. Risk-sharing for NICU is based
on the criteria defined in Article VI, I of this Contract. As specified in Article VII, J of this Contract NICU reports must be submitted to the Department’s Contract Specialist on or before May 1 of the following year. The HMO does not have to
file a report if the NICU criteria is not met. 
  
 The NICU
report form, detailed data format and worksheet follow this page (report form pg. 118, detailed data reporting format pg. 119, worksheet pg. 120) 
  

 -180- 

 HMO NEONATAL INTENSIVE CARE UNIT (NICU) REPORT FORM 
  
 HMO Name:
                                        
                             
  
 HMO Medicaid (Payee) Number
                                 
  
 Report Period: January 1, 200   through December 31, 200  

  
 Questions regarding this report should be referred to:
____________________________ 
 (please print) 
  
 Phone Number:
                                 
  

	A.	HMO DATA SUMMARY BY COUNTY 

  

	 	1.	Hospital Inpatient Costs Associated with Level II, III, and IV NICU Services as defined in Article VI, I, 1 of this Contract. 

  

							
	 Number
 of Days

	 	 Number of
 Admissions

	 	 Amount
 Billed

	  	 Amount
 Paid

	 	 	 	 	 	  	 

  

	 	2.	Physician Costs Associated with Level II, III, and IV NICU Services 

  

			
	 Amount Billed:

	 	 Amount Paid

	 	 	 

  

 -181- 

	B.	HMO DETAILED NICU DATA FORMAT 

  
 The costs summarized in Section A must be reported by month, by county, and by year (i.e., if an enrollee is in an NICU for two or more months, the NICU
days, physician and hospital costs must be separated by the month in which they occurred). Amounts paid must include payments for all physician and hospital services that were provided during the report period regardless of the HMO’s actual
payment date. 
  

																													
	 Enrollee
Name

	  	Enrollee MA
ID Number

	  	 Admit
 Date
 (mm/dd/yy)

	  	Discharge
Date
(mm/dd/yy)

	  	Total
Number of
NICU
Admissions

	  	Month

	  	NICU Hospital
Data by month
First NICU Day
(mm/dd/yy)

	  	NICU Hospital
Data by month
Last NICU Day
(mm/dd/yy)

	  	Total
Number of
NICU Days
(by month)

	  	NICU
Amount
Billed Hosp
(prorated by
month)

	  	 NICU
Amount
Paid Hosp
(prorated
 by month)

	  	NICU
Amount
Billed
Physician
(by month)

	  	NICU
Amount
Paid
Physician
(by month)

	 Name
	  	xxxxxxxxxx	  	07/01/02	  	07/22/02	  	1	  	Jul	  	07/01/02	  	07/22/02	  	20	  	$	00,000.00	  	$	00,000.00	  	$	0,00.00	  	$	00.00

  
 MAIL REPORTS TO:

 BUREAU OF MANAGED HEALTH CARE PROGRAMS 
 P.O. BOX 309 
 MADISON, WI 53701-0309 
  

	C.	NICU WORKSHEET 

  
 HMOs may complete the worksheet following this page to determine if their NICU days meet the criteria defined in Article VI, I. HMOs do not have to file a
report if the NICU criteria is not met. 
  

 -182- 

 Neonatal Intensive Care Unit Risk-Sharing Worksheet 
  
 Calculation 
  

							
				
	1.	 	HMO enrollee months:	 	 	 	__________________
				
	2.	 	Enrollee years:	 	 (line 1/12)
	 	__________________
				
	3.	 	Threshold (75 days per 1000 enrollee years):	 	 (75 x line 2/1000)
	 	__________________
				
	4.	 	NICU days reported by HMO:	 	 	 	__________________
				
	5.	 	NICU days over threshold to be reimbursed:	 	 (line 4 – line 3)
	 	__________________
				
	6.	 	Inpatient paid:	 	 	 	__________________
				
	7.	 	Physician paid:	 	 	 	__________________
				
	8.	 	Total cost:	 	 (line 6 + line 7)
	 	__________________
				
	9.	 	Average cost per day:	 	 (line 8 /line 4)
	 	__________________
				
	10.	 	90% of cost/day (Not to exceed $1,443):	 	 (0.9 x line 9)
	 	__________________
				
	11.	 	Reimbursement amount (Days x 90% cost):	 	 (line 5 x line 10)
	 	__________________

  

 -183- 

	F.	Court Ordered Birth Cost Requests 

  
 County Child Support Agencies (CSA) obtain court orders requiring fathers to repay birth costs that have been paid by Medicaid FFS as well as Medicaid
Health Maintenance Organizations (HMO). In some counties, judges will not assign birth costs to the father based upon average costs. Upon request of the Medicaid fiscal agent Contract Monitor, the HMO must provide actual charges less any payments
made by a third party payer for the use by the court in setting actual birth and related costs to be paid by the father. Birth cost information must be submitted to the Medicaid fiscal agent Contract Monitor within 14 days from the date the request
was received by the HMO. 
  
 The birth cost report forms
follows this page (Part 1 pg. 120, Part 2 pg. 121) 
  

 -184- 

 MEDICAID AND BADGERCARE HMO BIRTH COST REQUEST 
  
 PART I: Local Child Support Agency Portion 
  
 Part I is to be completed by the Local Child Support Agency. Please type or print, in a
legible manner. 
  

									
			
	1.	  	 HMO Name
	  	 
			
	2.	  	 Newborn’s Name
	  	 
			
	 	  	 	  	                                (First)      
                  (M.I.)                     
           (Last)
		
	 	  	*(If multiple births, please list all names)
					
	 	  	 Date of Birth
	  	 	  	Sex 	  	 
			
	3.	  	 Mother’s Name
	  	 
			
	 	  	 	  	                                (First)      
                  (M.I.)                     
           (Last)
			
	 	  	Medicaid or BadgerCare ID Number 	  	 
			
	 	  	Address	  	 
			
	 	  	 	  	(Street Address)
			
	 	  	 	  	 
			
	 	  	 	  	                    (City)                  
                  (State)                     
               (Zip Code)

  

 -185- 

	4.	I certify this information is accurate to the best of my knowledge: 

  

			
	
	 Name of Local Child Support Agency

	
	Name (Please Print) ___________________________________________________________________________
	
	Signature ___________________________________________________________________________________
	
	Title _______________________________________________________________________________________
	
	Date _______________________________________________________________________________________
		
	 Phone Number: _________________________________________
	  	FAX Number: ______________________

  

			
	          Mail The Form To:	  	FAX The Form To:
	     Medicaid Fiscal Agent
	  	Medicaid Fiscal Agent
	     ATTN: Managed Care Unit
	  	ATTN: Managed Care Unit
	     P.O. BOX 6470
	  	(608) 224-6318
	     MADISON, WI 53716-0470
	  	 

  

 -186- 

 PART II: HMO Portion 
  
 Part II is to be completed by the HMO. Please type or print in a legible manner. 
  

	1.	The actual payment for birthing costs for the mother and her baby. 

  
 Mother’s Name
                                        
                                ID#
                                        

  

			
	 Hospital/Birthing Center Payment (Mother)
	  	$
                            
	 Hospital/Birthing Center Payment (Newborn)
	  	$
                            
	 Physician Payment (Mother)
	  	$
                            
	 Physician Payment (Newborn)
	  	$
                            
	 Amount Paid by Other Insurance
	  	$
                            

  

	2.	Comments: (i.e., retroactively disenrolled from [HMO NAME] effective [DATE], services denied) 

  
 [State Denial Reason]: ____________________________________________ 
  
 _______________________________________________________________ 

 

	3.	I certify this information is accurate to the best of my knowledge. 

  
 Name of HMO
                                        
                                        
                                        
                                        
     
 Name (Please Print)
                                        
                                        
                                        
                                     
 Signature
                                        
                                        
                                        
                                        
              
 Title
                                        
                                        
                                        
                                        
                      
 Date
                                        
                                        
                                        
                                        
                      
  

	4.	Mail or FAX Part I and Part II within 14 days of receipt to: 

  

			
	 Mail The From To:
	  	 FAX The Form To:

		
	 Medicaid Fiscal Agent
	  	 Medicaid Fiscal Agent

	 ATTN: Managed Care Unit
	  	 ATTN: Managed Care Unit

	 P.O. Box 6470
	  	 (608) 224-6318

	 Madison, WI 53716-0470
	  	 

  

 -187- 

	G.	Formal and Informal Grievance Reporting Forms 

  

	 	1.	Formal Grievance Experience Summary Report 

  
 Summarize each Medicaid and BadgerCare grievance reviewed in the past quarter. 
  

	 	a.	Grievances Related to Program Administration 

  

											
	 Member
 Identification
 Number

	 	 Date
 Grievance Filed

	 	 Nature of
 Grievance

	  	Date Resolved

	  	Summary of
Grievance
Resolution

	  	 Administrative
Changes as a Result
of Grievance
 Review

	 	 	 	 	 	  	 	  	 	  	 
	 	 	 	 	 	  	 	  	 	  	 
	 	 	 	 	 	  	 	  	 	  	 
	 	 	 	 	 	  	 	  	 	  	 
	 	 	 	 	 	  	 	  	 	  	 

  

	 	b.	Grievances Related to Benefit Denial/Reduction 

  

											
	 Member
 Identification
 Number

	 	 Date
 Grievance Filed

	 	 Nature of
 Grievance

	  	Date Resolved

	  	Summary of
Grievance
Resolution

	  	Administrative
Changes as a Result
of Grievance
Review

	 	 	 	 	 	  	 	  	 	  	 
	 	 	 	 	 	  	 	  	 	  	 
	 	 	 	 	 	  	 	  	 	  	 
	 	 	 	 	 	  	 	  	 	  	 
	 	 	 	 	 	  	 	  	 	  	 

  

	 	c.	Summary 

  

			
	 SUBTOTAL: Program Administration
	  	_________________
	 SUBTOTAL: Benefit Denial/Reduction
	  	_________________
	 TOTAL NUMBER OF GRIEVANCES:
	  	_________________

  

 -188- 

	 	2.	HMO Reporting Form for Informal Grievances 

  
 ___________________________________________________________________________________________ 
 HMO Name 
  

	 	 ̈	First Quarter 

	 	 ̈	Second Quarter 

	 	 ̈	Third Quarter 

	 	 ̈	Fourth Quarter 

	 	 ̈	Calendar Year 2004 

	 	 ̈	Calendar Year 2005 

  

			
	 TYPE OF INFORMAL GRIEVANCE

	  	 TOTAL NUMBER OF GRIEVANCES

	 1. ACCESS PROBLEMS
	  	 
	 2. BILLING ISSUES
	  	 
	 3. QUALITY OF CARE
	  	 
	 4. DENIAL OF SERVICE
	  	 
	 5. OTHER SPECIFY:
	  	 

  
 General
Definitions 
  

	 	1.	Access problems include any problem identified by the HMO that causes an enrollee to have difficulty getting an appointment, receiving care, or on culturally appropriate care,
including the provision of interpreter services in a timely manner. 

  

	 	2.	Billing issues include the denial of a service or a recipient receiving a bill for a Medicaid covered service that the HMO is responsible for providing or arranging for the
provision of that service. 

  

	 	3.	Quality of care includes long waiting time in the reception area of providers’ offices, rude providers or provider staff, or any other complaint related directly to patient
care. 

  

	 	4.	Denial of service includes any Medicaid covered service that the HMO denied. 

  

	 	5.	Others as identified by each HMO.  

  
 Return the completed forms to: 
  
 Bureau of Managed Health Care Programs 
 ATTN: Grievance Contract Specialist 
 P.O. Box 309 
 Madison, WI 53701-0309 
  

 -189- 

	H.	Attestation Form 

  
 ATTESTATION 
  
 I,
                                        
                , have reviewed the following data: 
 (Name and Title) 
  

	 	 ̈	Encounter Data for (month)                      (year)
200  . 

  

	 	 ̈	Abortion Sterilization and Hysterectomy Report for (quarter)                 for (year)
200  . 

  

	 	 ̈	AIDS/Vent Report for (quarter)
                         for (year) 200  . 

  

	 	 ̈	Other
                                        
(Specify Report) 

  
 I hereby attest and affirm
that the information being submitted is complete, factual and correct to the best of my knowledge. I furthermore attest and affirm that no material facts have been omitted from this form. I understand that payment and satisfaction of this/these
claim(s) will be from federal and state public funds and that I may be prosecuted under applicable federal and state laws for any false claims, statements, or documents, or concealment of a material fact. I furthermore understand that state or
federal authorities may inspect all claims, records or documents pertaining to the provision of these services. 
  

					
			
	  	 	 	 	  
	(Signature)	 	 	 	(Date)
			
	  	 	 	 	  
	(Print Name)	 	 	 	(Print Date)

  

 -190- 

 ADDENDUM IX 
  
 GENERAL INFORMATION ABOUT THE WIC PROGRAM AND SAMPLE HMO-TO-WIC REFERRAL FORMS 
  
 General Information about the WIC Program and its Relationship to Medicaid HMOs 
  
 The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is a
program enacted as an amendment to the Child Nutrition Act of 1996, and is funded by USDA. WIC provides supplemental nutritious foods, nutrition education, and referrals to pregnant and breastfeeding women, infants and children up to age five, who
are determined to be at nutritional risk. Income eligibility is determined by family size and gross income (185% of the poverty level). WIC uses “adjunctive” eligibility which means that any recipient of Medicaid (including Healthy Start
and BadgerCare) is income eligible for WIC. 
  
 The State Division of Public
Health contracts with 69 local agencies to provide WIC benefits. In Wisconsin, most WIC agencies are local health departments, but other community-based organizations are contracted with WIC to provide WIC benefits, including community action
programs. other private non-profit health agencies and one hospital. 
  
 WIC
serves approximately 106,000 women, infants and children each month. Approximately fifty-three thirty-five (53) percent of all Wisconsin births are on WIC. Approximately half of all WIC participants were enrolled in a Medicaid HMO. Seventy-one (71)
percent of all participants have incomes at or below the poverty level; thirty-five (35) percent have less than a high school education. 
  
 Section 1902(a)(11)(C) of the Social Security Act requires coordination between Medicaid HMOs and WIC. This coordination includes the referral of potentially eligible
women, infants, and children to the WIC program and the provision of medical information by providers working within Medicaid managed care plans to the WIC program if requested by WIC agencies. Typical types of medical information requested by WIC
agencies include information on nutrition related metabolic disease, diabetes, low birth weight, failure to thrive, prematurity, infants of alcoholic, mentally retarded, or drug addicted mothers, AIDS, allergy or intolerance that affects nutritional
status, and anemia. 
  
 The WIC referral forms follow this page. Multiple copies
of the forms may be obtained from local WIC agencies. More information about the WIC program and a list of local WIC agencies can be found on the WIC website (www.dhfs.state.wi.us/wic). 
  

 -191- 

			
	DEPARTMENT OF HEALTH AND FAMILY SERVICES	 	STATE OF WISCONSIN
	 Division of Public Health
 DPH 4024B (Rev. 08/03)
	 	 Bureau of Family & Community Health
 WIC Program, Federal Reg. 246

  
 WIC MEDICAL REFERRAL
INFANTS AND CHILDREN (THROUGH 4 YEARS OF AGE) 
 Completion of this form is voluntary. Personally identifiable information is used to determine
WIC services 
 (e.g., certification / enrollment and food package issuance) and may be disclosed to others only as allowed by state and federal laws.

  
 INSTRUCTIONS: To facilitate WIC services (certification and food
package issuance) for your WIC-eligible patient, fill in the blanks and check the boxes, as appropriate, and return this form to the WIC Project indicated at the bottom of the page. 
  

									
	 Patient’s First and Last Name ___________________________
	 	 	 	Birthdate ____________________________________________
			
	 Address ____________________________________________
	 	 	 	 Telephone ___________________________________________

	
	 Parent /Caregiver’s First and Last Name ___________________________________________________________________________

  

					
	ALL INFANTS AND CHILDREN	 	 	 	INFANTS ONLY
			
	   Present weight  _____________________
	 	Hct _______%  and/or  Hgb _______ gm	 	  Birth weight _______________________
	   Length /stature _____________________
	 	Date taken ________________________	 	  Birth length _______________________
	      ̈ recumbent
or  ̈ standing
	 	Blood lead ________________________	 	  Gestational age ____________________
	   Date taken  ________________________
	 	Date taken ________________________	 	  E.D.D. ___________________________
	   Vitamin /Mineral Rx  ________________
	 	 	 	 

  
 INFANTS 
  
 Medical conditions the mother had prenatally 
  

											
	 ̈	  	anemia	  	 ̈ high blood lead	  	 ̈ food allergy or intolerance, specify
	 ̈	  	pregnancy-induced hypertension	  	 ̈ gestational diabetes	  	 	  	______________________________
	 ̈	  	nutrition-related infectious or chronic disease, genetic or central nervous system disorder,
	 	  	or other medical condition, specify __________________________________________________________________________

  
 Current nutrition-related health
problems 
  

									
	 ̈ pyloric stenosis	  	 ̈ GI reflux	  	 ̈ LGA at birth	  	 ̈ currently LGA	  	 ̈ head circumference <5th percentile

  
 ALL INFANTS AND CHILDREN –
Current nutrition-related health problems 
  

					
	 ̈ SGA at birth	  	 ̈ food allergy or intolerance, specify ___________________________________	  	 ̈ failure to thrive
	 ̈ currently SGA	  	 ̈ recent surgery, trauma, or burns, specify _______________________________	  	 
	 ̈ infectious disease in last 6 months, specify:	  	 

  

					
	 ̈ pneumonia	  	 ̈ HIV or AIDS	  	 ̈ tuberculosis
	 ̈ bronchiolitis (# episodes in last 6
mos ______________________)	  	 ̈ meningitis	  	 ̈ parasitic infection

  
  ̈ nutrition-related chronic disease, genetic or central nervous system disorder, or other medical condition ____________________ 
  
 FORMULA PRESCRIBED 
  
 Special formula for infants and children: 
  

							
	 ̈Similac NeoSure Advance	 	 ̈Enfamil AR LIPIL or Enfamil AR	 	 ̈Kindercal	 	 ̈Pediatric EO28
	 ̈Enfamil EnfaCare LIPIL	 	 ̈Neocate	 	 ̈PediaSure	 	 ̈ EleCare
	 ̈Enfamil Nutramigen LIPIL or Enfamil Nutramigen	 	 ̈Similac PM 60/40	 	 ̈PediaSure w/Fiber	 	 ̈ Portagen
	 ̈Alimentum Advance or Alimentum	 	 ̈Enfamil Pregestimil	 	 	 	 

  
 Standard formula for children:

  

					
	 ̈ Similac with Iron	 	 ̈ Isomil Soy with Iron	 	 ̈ Similac Lactose Free with Iron
	 ̈ Similac Advance with Iron	 	 ̈ Isomil Advance Soy with Iron	 	 ̈ Similac Lactose Free Advance with Iron

  
 Intended length of use
________________________________________________________________________________________ 
  
 Additional Diagnoses / Health Concerns / Diet Orders 
  

							
	SIGNATURE – Health Care Provider	  	 	  	Date Signed  	  	 
	
	(Physician, physician assistant, or advanced practice nurse prescriber signature is required for prescription of special formulas and formulas for children.)

  

			
	Medical Office / Clinic	  	 

  

							
	Address  	  	 	  	Telephone  	  	 

  
 LOCAL WIC PROJECT: 

 
 WIC is an Equal Opportunity Provider and Employer 
  

 -192- 

			
	DEPARTMENT OF HEALTH AND FAMILY SERVICES	 	STATE OF WISCONSIN
	 Division of Public Health
 DPH 4024A (Rev. 11/02)
	 	 Bureau of Family & Community Health
 WIC Program, Federal Reg. 246

  
 WIC MEDICAL REFERRAL

 PREGNANT, BREASTFEEDING AND NONBREASTFEEDING POSTPARTUM WOMEN 
 Completion of this form is voluntary. Personally identifiable information is used to determine WIC services 
 (e.g., certification / enrollment and food package issuance) and may be disclosed to others only as allowed by state and federal laws. 
  
 INSTRUCTIONS: To facilitate WIC services (certification and food package issuance) for your WIC-eligible patient, fill in the blanks and check the boxes, as
appropriate, and return this form to the WIC Project indicated at the bottom of the page. 
  

			
	Patient’s First and Last Name ____________________________	 	Birthdate _____________________________________________
	Address _____________________________________________	 	Telephone ____________________________________________

  

							
	ALL WOMEN	 	 	 	PREGNANT	 	POSTPARTUM
	  Present weiqht ___________	 	Hct ___________________%	 	  E.D.D. _________________	 	  Delivery date ____________
	  Present height ___________	 	And/or	 	  Weeks gest. _____________	 	  Prepreg. Weight __________
	  Date taken ______________	 	Hgb __________________gm	 	  Prepreg. weight __________	 	  Weight gained ___________
	  Vitamin/ Mineral Rx ______	 	Date taken _______________	 	 	 	 

  
 ALL WOMEN 
  
 Current nutrition-related health problems 
  
    ̈ food allergy or intolerance, specify ___________________________________________________________________________ 
  
    ̈ recent major surgery, trauma, or burns,
specify _________________________________________________________________ 
  
    ̈ infectious disease in last 6 months: 
  

									
	  ̈ pneumonia
	 	 ̈ tuberculosis	 	 ̈ HIV or AIDS	 	 ̈ meningitis	 	 ̈ parasitic infection

  
    ̈ nutrition-related chronic disease, genetic or central nervous system disorder, or other medical condition, 
       specify: __________________________________________________________________________________________________ 
  
 Obstetrical history in any previous pregnancy (if currently pregnant) or most recent
pregnancy (if currently postpartum) 
  

			
	   ̈ gestational diabetes	  	 ̈ large for gestational age infant
	   ̈ low birth weight or preterm infant	  	 ̈ fetal or neonatal death
	   ̈ infant with nutrition-related birth defect, specify
________________________________________________________________

  
 PREGNANT WOMEN - Current
nutrition-related health problems 
  

			
	   ̈ gestational diabetes	  	 ̈ hyperemesis gravidarum
	   ̈ pregnancy-induced hypertension	  	 ̈ fetal growth restriction

  
 MEDICAL NUTRITIONAL PRESCRIBED

  

																			
	  Ensure:	  	 ̈ Regular	  	 ̈ Fiber	  	 ̈ Glucerna	  	 ̈ Glucerna OS	  	 ̈ High Calcium	  	 ̈ High protein	  	 ̈ Light	  	 ̈ Plus	  	 ̈ Plus HN
	  Boost:	  	 ̈ Regular	  	 ̈ Fiber	  	 ̈ Plus	  	 ̈ High Protein	  	 ̈ Breeze	  	 	  	 	  	 	  	 
	  Sustacal:	  	 ̈ Regular	  	 ̈ Plus	  	 	  	 	  	 	  	 	  	 	  	 	  	 

 Intended length of use
_________________________________________________________________________________________ 
  
 Additional Diagnoses / Health Concerns / Diet Orders 
  

			
	SIGNATURE - Health Care Provider ______________________	  	Date Signed _________________________________________

 (Physician, physician assistant, or advanced practice nurse prescriber signature is required for prescription of a
medical nutritional.) 
  
 Medical Office / Clinic
________________________________________________________________________________________ 

			
	Address_______________________________________________	  	Telephone __________________________________________

  
 LOCAL WIC PROJECT: 

 
 WIC is an Equal Opportunity Provider and Employer 
  
 Pages 190 through 241 have been deleted as the information contained in those
pages can be found on the Bureau of Family and Community Health Services that pertains to the WIC program. 
  

 -193- 

 ADDENDUM X 
  
 HMO SPECIFIC SERVICE AREA AND ENROLLMENT MAXIMUM 
  
 For the rate period of May 1, 2004, through December 31, 2004 (HMO Name) agrees not to reduce its service area that was in effect at the time of contract implementation
on May 1, 2004. (HMO Name) further agrees that its maximum enrollment during the rate period will be (#). (OPTIONAL: The additional enrollment will be limited to             County.)

  

 -194-

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