Document:

f8k062507ex4viii_redmile.htm

    THIS
      NOTE AND THE SECURITIES ISSUABLE UPON CONVERSION OF THIS NOTE HAVE NOT BEEN
      REGISTERED UNDER THE SECURITIES ACT OF 1933, AS AMENDED (THE “ACT”), OR UNDER
      THE SECURITIES LAWS OF APPLICABLE STATES. THESE SECURITIES ARE SUBJECT TO
      RESTRICTIONS ON TRANSFERABILITY AND RESALE AND MAY NOT BE TRANSFERRED OR RESOLD
      EXCEPT AS PERMITTED UNDER THE ACT AND THE APPLICABLE STATE SECURITIES LAWS
      PURSUANT TO REGISTRATION OR EXEMPTION THEREFROM.

     

    FORM
      OF CONVERTIBLE PROMISSORY NOTE

     

    OF

     

    RED
      MILE ENTERTAINMENT, INC.

     

    
      	 	
              Sausalito,
                CA

            
	
              $•
                US

            	
              Made
                as of June __, 2007

            

    

    

     

    For
      value
      received, RED MILE ENTERTAINMENT, INC., a Delaware corporation, on behalf of
      itself and its successors and assigns (collectively, the
“Company”), with principal offices at 4000 Bridgeway,
      Suite 101, Sausalito, CA 94965, hereby promises to pay to __________________.
      or
      its registered assigns (“Holder”),  $• US
      (the “Principal Amount”) on the Maturity Date, together
      with simple interest on the unpaid principal and interest at a rate equal to
      ten
      percent (10%) per annum, computed on the basis of the actual number of days
      elapsed and a year of 365 days (the “Rate”) from the
      date of this Note until the Maturity Date.  All accrued interest
      hereunder shall be payable in cash by the Company to the Holder on the Maturity
      Date.

     

    Unless
      earlier accelerated or converted pursuant to the terms hereof, the unpaid
      Principal Amount, shall be due and payable immediately on the Maturity
      Date.  Unless earlier accelerated or converted pursuant to the terms
      hereof, any unpaid interest as of the Maturity Date, as applicable, shall become
      immediately due and payable.  Any amounts owed hereunder shall be sent
      by wire transfer in accordance with instructions included in such notice or
      by
      check sent by mail to the address of the registered holder of this Note in
      lawful money of the United States.

     

    Unless
      agreed to by both parties, Company will issue no more than USD $2,400,000 in
      principal amount.

     

    The
      following is a statement of the rights of Holder and the conditions to which
      this Note is subject, and to which Holder hereof, by the acceptance of this
      Note, agrees:

     

    1.  Definitions.  Unless
      otherwise defined herein, the following definitions shall apply for all purposes
      of this Note:

     

    1.1  “Maturity
      Date” means the earlier to occur of a Sale Event or the one year
      anniversary of the date hereof.

     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    1.2  “Next
      Financing” means the contemplated equity financing in which _____
      will act as placement agent for the Company in an approximately $10 million
      equity private placement (or such lesser amount as ________ and the Company
      may
      agree to in writing).

     

    1.3  “Next
      Financing
      Stock” means the capital stock of the
      Company issued in the Next Financing.

     

    1.4  “Note”
      means this Convertible Promissory Note.

     

    1.5  “Person”
      means an individual, a corporation, an association, a joint venture, a
      partnership, a limited liability company, an estate, a trust, an unincorporated
      organization and any other entity or organization, governmental or
      otherwise.

     

    1.6  “Sale
      Event” means a bona fide, negotiated transaction or integrated
      series of transactions pursuant to which either (i) the Company merges or
      consolidates with any other non-affiliated entity or sells, exchanges or
      otherwise disposes of all or substantially all of its assets to a non-affiliated
      third party or (ii) in which in excess of 50% of the Company’s voting power is
      transferred in a private placement to one Person.

     

    2.  Conversion.  Concurrent
      with the consummation of a Next Financing prior to the Maturity Date, the
      outstanding Principal Amount hereunder shall be automatically converted, without
      any action by the Holder, into the Next Financing Stock at price equal to the
      lowest price per share of the Next Financing Stock in such Next
      Financing.  Anything in this Note to the contrary notwithstanding, in
      the event of such a conversion this Note shall not bear any interest and no
      interest shall be due with respect thereto following such conversion.
      Immediately upon conversion of the Note, the holder shall also be offered one
      half of one warrant (“Warrant”), for every share received from the conversion of
      the Note. The Warrant shall be exercisable at $2.75 per share for a period
      2
      years from the Closing Date of such Next Financing.

     

    3.  Termination
      of Rights.  All rights with respect to the Note shall
      terminate on Conversion or on the Maturity Date, whether or not this Note has
      been surrendered.  Notwithstanding the foregoing, Holder agrees to
      surrender this Note to the Company for cancellation as soon as is possible
      following conversion or maturity of this Note.  The Holder shall not
      be entitled to receive the Next Financing Stock and half
      Warrants to be issued upon conversion of this Note until the original of this
      Note (or an executed affidavit of loss, damage or mutilation and agreement
      to
      indemnify the Company therefrom, in form reasonably requested by the Company)
      is
      surrendered (or delivered in the case of such affidavit and agreement) to the
      Company and the agreements referenced in this Section 3 have been executed
      and
      delivered to the Company.

     

    4.  Defaults
      and Remedies.

     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    4.1  Events
      of Default.  Upon
      written notice to the Company by the Holder of its desire to deem any of the
      following events an Event of Default, the following events shall be deemed
      “Events of Default” hereunder:

     

    (a)  the
      Company fails to pay any amounts due under the Note when due;

     

    (b)  the
      Company is or becomes insolvent or is involved in any financial difficulty
      as
      evidenced by:

     

    (i)  an
      assignment, composition or similar device for the benefit of creditors,
      or

     

    (ii)  general
      failure to pay debts when due that results in a material action against the
      Company taken by a third party other than the Holder, or

     

    (iii)  an
      attachment or receivership of assets not dissolved within thirty (30) days,
      or

     

    (iv)  the
      appointment of a custodian, trustee or receiver for a substantial portion of
      the
      Company’s property, or

     

    (v)  the
      filing by the Company or any guarantor of a petition under any chapter of the
      United States Bankruptcy Code or the institution of any other proceeding under
      any law relating to bankruptcy, bankruptcy reorganization, insolvency or relief
      of the Company, or

     

    (vi)  the
      filing against the Company or any guarantor of an involuntary petition under
      any
      chapter of the United States Bankruptcy Code or the institution of any other
      proceeding under any law relating to bankruptcy, bankruptcy reorganization,
      insolvency or relief of the Company where such petition or proceeding is not
      dismissed within thirty (30) days from the date on which it is filed or
      instituted; or

     

    (c)  the
      Company materially breaches, which breach remains uncured for at least five
      (5)
      business days after receipt of notice from the Holder relating thereto, any
      of
      the provisions of this Note.

     

     

    4.2  Rights
      and Remedies on Default

     

    .  Upon
      the occurrence of an Event of Default, the Holder shall have, by way of example
      and not of limitation of the rights and remedies granted to the Holder in law,
      equity or otherwise, the following rights:

     

    (a)  the
      Holder may declare this Note to be immediately due and payable without
      presentment, demand, protest or notice of any kind, all of which are hereby
      expressly waived.

     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    4.3  Waiver

     

    .  No
      course of dealing or delay in accelerating this Note or in taking or failing
      to
      take any other action with respect to any Event of Default shall affect the
      Holder’s right to take such action at a later time.  No waiver as to
      any one Event of Default shall affect the Holder’s rights upon any other Event
      of Default.

     

    4.4  Remedies
      Cumulative

     

    .  The
      Holder may exercise any or all of their rights and remedies upon an Event of
      Default concurrently with or independently of and without regard to the
      provisions of any other document which secures any obligation of the
      Company.

     

    5.  Prepayment.  This
      Note may be prepaid at any time in whole or in part without premium or
      penalty.  While the Note is outstanding and prior to conversion
      thereof, the Company shall not pay any dividends or distributions and shall
      not
      repurchase any shares of stock.

     

    6.  No
      Rights or Liabilities as Stockholder. This Note
      does not by itself entitle the Holder to any voting rights or other rights
      as a
      stockholder of the Company.  No provisions of this Note, and no
      enumeration herein of the rights or privileges of the Holder, shall cause the
      Holder to be a stockholder of the Company for any purpose.

     

    7.  No
      Impairment.  The Company will not
      willfully avoid or seek to avoid the observance or performance of any of the
      terms of this Note, but will at all times in good faith assist in the carrying
      out of all such terms and in the taking of all such action as may be necessary
      or appropriate in order to protect the rights of the Holder under this Note
      against wrongful impairment.  Without limiting the generality of the
      foregoing, the Company will take all such action as may be necessary or
      appropriate in order that the Company may duly and validly issue the Next
      Financing Stock upon a conversion of this Note.

     

    8.  Waivers.  The
      Company and all endorsers of this Note hereby waive notice, presentment,
      protest, notice of dishonor and all other demands in
      connection with the delivery, acceptance, performance and enforcement of this
      Note.

     

    9.  Attorneys’
      Fees.  In the event any party is
      required to engage the services of any attorneys for the purpose of enforcing
      this Note, or any provision thereof, the prevailing party shall be entitled
      to
      recover its reasonable expenses and costs in enforcing this Note, including
      reasonable attorneys’ fees.

     

    10.  Transfer.  This
      Note and any rights hereunder may not be assigned, conveyed or transferred,
      in
      whole or in part, by the Company, on the one hand, or the Holder, on the other
      hand, without the prior written consent of the Holder or the Company,
      respectively.

     

    11.  Governing
      Law.  This Note shall be governed by and
      construed under the internal laws of the State of California, without reference
      to principles of conflict of laws or choice of laws.

     

    12.  Headings.  The
      headings and captions used in this Note are used only for convenience and are
      not to be considered in construing or interpreting this Note.

     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

     

    13.  Notices.
      Unless otherwise provided, any notice required or permitted under
      this
      Note shall be given in writing and shall be deemed effectively given (a) at
      the
      time of personal delivery, if delivery is in person; (b) one (1) business day
      after deposit with an express overnight courier for United States deliveries,
      or
      two (2) business days after such deposit for deliveries outside of the United
      States, with proof of delivery from the courier requested; or (c) three (3)
      business days after deposit in the United States mail by certified mail (return
      receipt requested) for United States deliveries when addressed to the party
      to
      be notified at the address indicated for such party on the signature pages
      hereto or, in the case of the Company, to the address on the first page of
      this
      Note, or at such other address as any party or the Company may designate by
      giving ten (10) days’ advance written notice to all other parties.

     

    14.  Amendments
      and Waivers. This Note may only be amended in
      writing and if the amendment is signed by both the Company and the
      Holder.

     

    15.  Severability.
      If one or more provisions of this Note are held to be unenforceable
      under applicable law, such provision(s) shall be excluded from this Note and
      the
      balance of the Note shall be interpreted as if such provision(s) were so
      excluded and shall be enforceable in accordance with its terms.

     

                  IN
      WITNESS WHEREOF, the Company has caused this Note to be signed in its
      name as of the date first above written.

    

    

    THE  COMPANY:

    

    RED
      MILE
      ENTERTAINMENT, INC.

    

    

    

    By:      ________________________________

               Name:  __________________________

               Title:  ____________________________

    

    

    

    

    AGREED
      AND ACKNOWLEDGED:

    

    THE
      HOLDER:

    

    By:           ________________________________

    Name:  __________________________

    Title:  ____________________________exhibit10-1.htm

    
      

    

    Back
      to Form 8-K

    Exhibit
      10.1

    

    
      
        
          
             

          

        

      

    

    

    OHIO
      DEPARTMENT OF JOB AND FAMILY SERVICES

    

    OHIO
      MEDICAL ASSISTANCE PROVIDER AGREEMENT

    FOR
      MANAGED CARE PLAN

    CFC
      ELIGIBLE POPULATION

    

    This
      provider agreement is entered into
      this first day of July, 2007, at Columbus, Franklin County, Ohio, between the
      State of Ohio, Department of Job and Family Services, (hereinafter referred
      to
      as ODJFS) whose principal offices are located in the City of Columbus, County
      of
      Franklin, State of Ohio, and WellCare of Ohio, Inc, Managed Care Plan
      (hereinafter referred to as MCP), an Ohio for-profit corporation, whose
      principal office is located in the city of Beechwood, County of Cuyahoga, State
      of Ohio.

    

    MCP
      is licensed as a Health Insuring
      Corporation by the State of Ohio, Department of Insurance (hereinafter referred
      to as ODI), pursuant to Chapter 1751. of the Ohio Revised Code and is organized
      and agrees to operate as prescribed by Chapter 5101:3-26 of the Ohio
      Administrative Code (hereinafter referred to as OAC), and other applicable
      portions of the OAC as amended from time to time.

    

    MCP
      is an entity eligible to enter into
      a provider agreement in accordance with 42 CFR 438.6 and is engaged in the
      business of providing prepaid comprehensive health care services as defined
      in
      42 CFR 438.2 through the managed care program for the Covered Families and
      Children (CFC) eligible population described in OAC rule 5101:3-26-02
      (B).

    

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

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

    

    

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

    

    ARTICLE
      I  -  GENERAL

    

    
      	
              A.

            	
              ODJFS
                enters into this Agreement in reliance upon MCP’s representations that it
                has the necessary expertise and experience to perform its obligations
                hereunder, and MCP warrants that it does possess the necessary expertise
                and experience.

            

    

    

    
      	
              B.

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

            

    

    

    
      	
              C.

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

            

    

    

    
      	
              D.

            	
              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.

            

    

    

    
      	
              E.

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

            

    

    

    ARTICLE
      II  -  TIME OF PERFORMANCE

    

    
      	
              A.

            	
              Upon
                approval by the Director of ODJFS this provider agreement shall be
                in
                effect from the date entered through June 30, 2008, unless this provider
                agreement is suspended or terminated pursuant to Article VIII prior
                to the
                termination date, or otherwise amended pursuant to Article
                IX.

            

    

    

    
      	
              B.

            	
              It
                is expressly agreed by the parties that none of the rights, duties
                and
                obligations herein shall
                be binding on either party if award of this Agreement would be contrary
                to
                the terms of Ohio Revised Code (“O.R.C.”) Section 3517.13, O.R.C. Section
                127.16, or O.R.C. Chapter
                102.

            

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

    

    

    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.

            

    

    

    ARTICLE
      IV  -  RELATIONSHIP OF PARTIES

    

    
      	
              A.

            	
              ODJFS
                and MCP agree that, during the term of this Agreement, MCP shall
                be
                engaged by ODJFS solely on an independent contractor basis, and neither
                MCP nor its personnel shall, at any time or for any purpose, be considered
                as agents, servants or employees of ODJFS or the State of Ohio. MCP
                shall therefore be responsible for all MCP’s business expenses, including,
                but not limited to, employee’s wages and salaries, insurance of every type
                and description, and all business and personal taxes, including income
                and
                Social Security taxes and contributions for Workers’ Compensation and
                Unemployment Compensation coverage, if
                any.

            

    

    

    
      	
              B.

            	
              MCP
                agrees to comply with all applicable federal, state and local laws
                in the
                conduct of the work hereunder.

            

    

    

    
      	
              C.

            	
               

            	
              While
                MCP shall be required to
                render services described hereunder for ODJFS duringthe term of
                this Agreement,
                nothing herein shall be construed to imply, by reason ofMCP’s engagement
                hereunder on an
                independent contractor basis, that ODJFS shall have or may exercise
                any right of
                control over MCP with regard to the manner or method of MCP’s performance
                of services
                hereunder. The
                management of the work,
                including the
                exclusive right to control or direct the manner or means by which
                the work
                is performed,
                remains with MCP.  ODJFS retains the right to ensure that MCP's
                work is in
                conformity with the terms and conditions of this
                Agreement.

            

    

    

    
      	
              D.

            	
              Except
                as expressly provided herein, neither party shall have the right
                to bind
                or obligate the other party in any manner without the  other
                party’s prior written consent.

            

    

    

    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
                represents, warrants, and certifies that it and its employees engaged
                in
                the administration or performance of this Agreement are knowledgeable
                of
                and understand the Ohio Ethics and Conflicts of Interest laws and
                Executive Order 2007-01S.  MCP further represents, warrants, and
                certifies that neither MCP nor any of its employees will do any act
                that
                is inconsistent with such laws and Executive Order.  The
                Governor’s Executive Orders may be found by accessing the following
                website:  http://governor.ohio.gov/GovernorsOffice/ExecutiveOrdersDirectives/tabid/105/Default.aspx.

            

    

    

    
      	
              C.

            	
              MCP
                hereby covenants that MCP, its officers, members and employees of
                the MCP,
                shall not, prior to the completion of the work under this Agreement,
                     voluntarily acquire any 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.

            

    

    

    
      	
              D.

            	
              Any
                such person who acquires an incompatible, compromising or conflicting
                personal or business interest, on or after the effective date of
                this
                Agreement, or who involuntarily acquires any such incompatible or
                conflicting personal 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 in its sole discretion 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.

            

    

    

    
      	
              E.

            	
              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.

            

    

    

    
      	
              F.

            	
              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  -  NONDISCRIMINATION OF EMPLOYMENT

    

    
      	
              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, gender,
                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,
                gender,
                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 Part
                74.

            

    

    

    
      	
              B.

            	
              All
                information provided by MCP to ODJFS that is proprietary shall be
                held to
                be strictly confidential
                by ODJFS.  Proprietary information is information which, if made
                public, would put MCP at a disadvantage in the market place and trade
                of
                which MCP is a part [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.  Failure to provide such prior notification is deemed to
                be a waiver of the proprietary nature of the information, and a waiver
                of
                any right of MCP to proceed against ODJFS for violation of this agreement
                or of any proprietary or trade secret laws.  Such failure shall
                also be deemed a waiver of trade secret protection in that the MCP
                will
                have failed to make efforts that are reasonable under the circumstances
                to
                maintain the information’s secrecy. 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 any or all of the information identified by the MCP is proprietary
                or a trade secret.  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 suspended or terminated 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.  MCP agrees to waive any right to, and shall make no
                claim for, additional compensation against ODJFS by reason of such
                suspension or termination.

            

    

    

    
      	
              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
                an
                adjudication hearing under Chapter 119. of the Revised
                Code.

            

    

    

    
      	
              E.

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

            

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

    

    

    ARTICLE
      IX  -  AMENDMENT AND RENEWAL

    

    
      	
              A.

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

            

    

    

    
      	
              B.

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

            

    

    

    
      	
              C.

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

            

    

    

    
      	
              D.

            	
              This
                Agreement supersedes any and all previous agreements, whether written
                or
                oral, between the parties.

            

    

    

    
      	
              E.

            	
              A
                waiver by any party of any breach or default by the other party under
                this
                Agreement shall not constitute a continuing waiver by such party
                of any
                subsequent act in breach of or in default
                hereunder.

            

    

    

    ARTICLE
      X  -  LIMITATION OF LIABILITY

    

    
      	
              A.

            	
              MCP
                agrees to indemnify and to hold ODJFS and the State of Ohio harmless
                and
                immune from any and all claims for injury or damages resulting from
                the
                actions or omissions of MCP or its subcontractors in the fulfillment
                of
                this provider agreement or arising from this Agreement which are
                attributable to the MCP’s own actions or omissions of those of its
                trustees, officers, employees, subcontractors, suppliers, third parties
                utilized by MCP, or joint venturers while acting under this
                Agreement.  Such claims shall include any claims made under the
                Fair Labor Standards Act or under any other federal or state law
                involving
                wages, overtime, or employment matters and any claims involving patents,
                copyrights, and trademarks.  MCP shall bear all costs associated
                with defending ODJFS and the State of Ohio against these
                claims.

            

    

    

    
      	
              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.

            

    

    

    
      	
              D.

            	
              In
                no event shall either party be liable to the other party for indirect,
                consequential, incidental, special or punitive damages, or lost
                profits.

            

    

    

    ARTICLE
      XI - ASSIGNMENT

    

    
      	
              A.

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

            

    

    

    
      	
              B.

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

            

    

    

    ARTICLE
      XII  -  CERTIFICATION MADE BY MCP

    

    
      	
              A.

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

            

    

    

    
      	
              B.

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

            

    

     

    
      	
              C.

            	
              By
                executing this agreement, MCP certifies that neither MCP nor any
                principals of MCP

            

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

    

    

    
      	
               

            	
              (i.e.,
                a director, officer, partner, or person with beneficial ownership
                of more
                than 5% of the MCP’s equity) is presently debarred, suspended, proposed
                for debarment, declared ineligible, or otherwise  excluded from
                participation in transactions by any
                Federal  agency.  The MCP also certifies that it is
                not debarred from consideration for contract awards by the Director
                of the
                Department of Administrative Services, pursuant to either O.R.C.
                Section
                153.02 or O.R.C. Section 125.25.  The MCP also certifies that
                the MCP has no employment, consulting or any other arrangement with
                any
                such debarred or suspended person for the provision of items or services
                or services that are significant and material to the MCP’s contractual
                obligation with ODJFS.  This certification is a material
                representation of fact upon which reliance was placed when this provider
                agreement was entered into. If it is ever determined that MCP knowingly
                executed this certification erroneously, then in addition to any
                other
                remedies, this provider agreement shall be terminated pursuant to
                Article
                VII, and ODJFS must advise the Secretary of the appropriate Federal
                agency
                of the knowingly erroneous
                certification.

            

    

    

    
      	
               D.

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

            

    

    

    
      	
              E.

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

            

    

    

    
      	
              F.

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

            

    

    

    
      	
              G.

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

            

    

    

    
      	
              H.

            	
              By
                executing this agreement, MCP certifies and affirms that, as applicable
                to
                MCP, that no party listed or described in Division (I) or (J) of
                Section
                3517.13 of the Ohio Revised Code who was actually in a listed position
                at
                the time of the contribution, has made as an individual, within the
                two
                previous calendar years, one or more contributions in excess of One
                Thousand and 00/100 ($1,000.00) to the present Governor or to the
                governor’s campaign committees during any time he/she was a candidate for
                office.  This certification is a material representation of fact
                upon which reliance was placed when this provider agreement was entered
                into.  If it is ever determined that MCP's certification of this
                requirement is false or misleading, and not withstanding any criminal
                or
                civil liabilities imposed by law, MCP shall return to ODJFS all monies
                paid to MCP under this provider agreement.  The provisions of
                this section shall survive the expiration or termination
                of this provider agreement.

            

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
          

        

      

    

    

    
      	
               

            	
               

            

    

    

    
      	
              I.

            	
               

            	
              MCP
                agrees to refrain from promising or giving to any ODJFS employee
                anything
                ofvalue that is of such a character as to manifest a substantial
                and
                improper influence uponthe employee with respect to his or her
                duties.  MCP also agrees that it will not solicit an ODJFS
                employee to violate any ODJFS rule or policy relating to the conduct
                of
                contracting parties or to violate sections 102.03, 102.04, 2921.42
                or
                2921.43 of the Ohio Revised
                Code.

            

    

    

    
      	
              J.

            	
               

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

            

    

    

    
      	
              K.

            	
               

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

            

    

     

    
      	
              L.

            	
              MCP,
                its officers, employees, members, any subcontractors, and/or any
                independent contractors (including all field staff) associated with
                this
                agreement agree to comply with all applicable state and federal laws
                regarding a smoke-free and drug-free workplace.  The MCP will
                make a good faith effort to ensure that all MCP officers, employees,
                members, and subcontractors will not purchase, transfer, use or possess
                illegal drugs or alcohol, or abuse prescription drugs in any way
                while
                performing their duties under this
                Agreement.

            

    

    

    
      	
              M.

            	
               

            	
              MCP
                hereby represents and warrants to ODJFS that it has not provided
                any
                materialassistance, as that term is defined in O.R.C. Section 2909.33(C),
                to any organization identified
                by and included on the United States Department of State Terrorist
                Exclusion List
                and that it has truthfully answered “no” to every question on the
                “Declaration Regarding
                Material Assistance/Non-assistance to a Terrorist
                Organization.”  MCP further
                represents and warrants that it has provided or will provide such
                to ODJFS
                priorto execution of this Agreement.  If these representations
                and warranties are found to befalse, this Agreement is void ab
                initio and MCP shall immediately repay to ODJFS any funds
                paid under this Agreement.

            

    

    

    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.  The provisions of this Agreement are
                severable and independent, and if any such provision shall be determined
                to be unenforceable, in whole or in part, the remaining provisions
                and any
                partially enforceable provision shall, to the extent enforceable
                in any
                jurisdiction, nevertheless be binding and
                enforceable.

            

    

    

    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
                Chapter 5101:3-26 and this provider agreement, the provisions of
                OAC
                Chapter 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.

            

    

    

    ARTICLE
      XV – NOTICES

    

    All
      notices, consents, and communications hereunder shall be given in writing,
      shall
      be deemed to be given upon receipt thereof, and shall be sent to the addresses
      first set forth above.

    

    ARTICLE
      XVI – HEADINGS

    

    The
      headings in this Agreement have been inserted for convenient reference only
      and
      shall not be considered in any questions of interpretation or construction
      of
      this Agreement.

    

     

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

    

    

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

    

    

    WELLCARE
      OF OHIO, INC.:

    

    
      	
              BY:   
                /s/   Todd S. Farha   

            	
              DATE: 
                6/12/2007 

            

    

             TODD
      S. FARHA, PRESIDENT & CEO

    

    

    OHIO
      DEPARTMENT OF JOB AND FAMILY SERVICES:

    

    
      	
              BY:   
                /s/  Helen E Jones
                Kelly         

            	
              DATE:  
                6/25/2007   

            

    

             HELEN
      E. JONES-KELLY, DIRECTOR

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      	
              CFC
                PROVIDER AGREEMENT INDEX

              July
                1, 2007

               

            
	
              APPENDIX

            	
              TITLE

            
	
              APPENDIX
                A

            	
              OAC
                RULES 5101:3-26

            
	
              APPENDIX
                B

            	
              SERVICE
                AREA SPECIFICATIONS – CFC ELIGIBLE POPULATION

            
	
              APPENDIX
                C

            	
              MCP
                RESPONSIBILITIES – CFC ELIGIBLE POPULATION

            
	
              APPENDIX
                D

            	
              ODJFS
                RESPONSIBILITIES – CFC ELIGIBLE POPULATION

            
	
              APPENDIX
                E

            	
              RATE
                METHODOLOGY – CFC ELIGIBLE POPULATION

            
	
              APPENDIX
                F

            	
              REGIONAL
                RATES – CFC ELIGIBLE  POPULATION

            
	
              APPENDIX
                G

            	
              COVERAGE
                AND SERVICES – CFC ELIGIBLE POPULATION

            
	
              APPENDIX
                H

            	
              PROVIDER
                PANEL SPECIFICATIONS – CFC ELIGIBLE POPULATION

            
	
              APPENDIX
                I

            	
              PROGRAM
                INTEGRITY– CFC ELIGIBLE POPULATION

            
	
              APPENDIX
                J

            	
              FINANCIAL
                PERFORMANCE – CFC ELIGIBLE POPULATION

            
	
              APPENDIX
                K

            	
              QUALITY
                ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM – CFC ELIGIBLE
                POPULATION

            
	
              APPENDIX
                L

            	
              DATA
                QUALITY – CFC ELIGIBLE POPULATION

            
	
              APPENDIX
                M

            	
              PERFORMANCE
                EVALUATION – CFC ELIGIBLE POPULATION

            
	
              APPENDIX
                N

            	
              COMPLIANCE
                ASSESSMENT SYSTEM – CFC ELIGIBLE POPULATION

            
	
              APPENDIX
                O

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

            
	
              APPENDIX
                P

            	
              MCP
                TERMINATIONS/NONRENEWALS/ AMENDMENTS – CFC ELIGIBLE
                POPULATION

            

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    APPENDIX
      A

    

    OAC
      RULES 5101:3-26

    

    The
      managed care program rules can be accessed electronically through
      the BMHC page of the ODJFS website.

    

    

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    APPENDIX
      B

    

    SERVICE
      AREA SPECIFICATIONS

    CFC
      ELIGIBLE POPULATION

    

    MCP
      : WELLCARE OF OHIO, INC.

    

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

    

    

    

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

    

     

     

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

    

    

    APPENDIX
      C

    

    MCP
      RESPONSIBILITIES

    CFC
      ELIGIBLE POPULATION

    

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

    

     General
      Provisions

    

    
      	
              1.

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

            

    

    

    
      	
              2.

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

            

    

    

    
      	
              3

            	
              The
                MCP must designate the following:

            

    

    

    
      	
              a.

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

            

    

    

    
      	
              b.

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

            

    

    

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

    

    
      	
              4.

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

            

    

    

    
      	
              5.

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

            

    

    

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

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

    

    

    
      	
              7.

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

            

    

    

    
      	
              8.

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

            

    

    

    
      	
              9.

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

            

    

    

    
      	
              10.

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

            

    

    

    
      	
              11.

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

            

    

    

    
      	
              12.

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

            

    

    

    
      	
              13.

            	
               

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

            

    

    

    
      	
              14.

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

            

    

    

    
      	
              15.

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

            

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

    

    

    
      	
               

            	
              planned
                services availability.  If an MCP elects to provide additional
                services, the MCP must ensure to the satisfaction of ODJFS that the
                services are readily available and accessible to members who are
                eligible
                to receive them.

            

    

    

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

    

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

    

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

    

    
      	
              16.

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

            

    

    

    
      	
              17.

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

            

    

    

    
      	
              18.

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

            

    

    

    
      	
              19.

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

            

    

    

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

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

    

    

    

    
      	
               

            	
              a.

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

            

    

    

    
      	
               

            	 	
              b.

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

            

    

    

    
      	
              20.

            	
               

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

                        

                      

                    

                  

                

              

            

    

    

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

    

    
       

      
        	
              	
                 

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

                

              

      

       

    

    
      	
              21.

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

            

    

    

    
      	
              22.

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

            

    

    

    
      	
               

            	
              a.

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

            

    

    

    
      	
               

            	
              b.

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

            

    

    

    
      	
               

            	
              c.

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

            

    

    

    
      	
            	
              d.

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

            

    

    

    
      	
            	
              e.

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

            

    

     

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

    

    

    

    
      	
              23.

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

            	
               

            

    

    

    
      	
               

            	
              a.

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

            

    

    

    
      	
               

            	
              b.

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

            

    

    

    
      	
            	
              i.

            	
              Provides
                written information to all adult members
                concerning:

            

    

    

    
      	
               

            	
              a.

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

            

    

    

    
      	
               

            	
              b.

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

            

    

    

    
      	
               

            	
              c.

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

            

    

    

    
      	
               

            	
              d.

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

            

    

    

    
      	
               

            	
              ii.

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

            

    

    

    
      	
               

            	
              iii.

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

            

    

    

    
      	
               

            	
              iv.

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

            

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

    

    

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

    

    24.           New
      Member Materials

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

    

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

    

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

    

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

    

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

    

    25.           Call
      Center Standards

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

    
      	
               

            	
              ·

            	
              New
                Year’s Day

            

    

    
      	
               

            	
              ·

            	
              Martin
                Luther King’s Birthday

            

    

    
      	
               

            	
              ·

            	
              Memorial
                Day

            

    

    
      	
               

            	
              ·

            	
              Independence
                Day

            

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

    

    

    
      	
               

            	
              ·

            	
              Labor
                Day

            

    

    
      	
               

            	
              ·

            	
              Thanksgiving
                Day

            

    

    
      	
               

            	
              ·

            	
              Christmas
                Day

            

    

    
      	
               

            	
              ·

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

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

            

    

     

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

    

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

    

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

    

    
      	
            	
               

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

              

            

    

    

    26.      Notification
      of Optional MCP Membership

    

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

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
          

        

      

    

     

    
      	
               

            	
              -

            	
              Indians
                who are members of federally-recognized
                tribes.

            

    

    
      	
               

            	
              -

            	
              Children
                under 19 years of age who are:

            

    

    
      	
               

            	
              o

            	
              Eligible
                for Supplemental Security Income under title
                XVI;

            

    

    
      	
               

            	
              o

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

            

    

    
      	
               

            	
              o

            	
              Receiving
                foster care of adoption assistance;

            

    

    
      	
               

            	
              o

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

            

    

    

    27.           HIPAA
      Privacy Compliance Requirements

    

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

    

    
      	
               

            	
              a.

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

            

    

    

    
      	
               

            	
              b.

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

            

    

    

    
      	
            	
              c.

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

            

    

    

    
      	
               

            	
              d.

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

            

    

    

    
      	
            	
              e.

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

            

    

    

    
      	
               

            	
              f.

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

            

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

    

     

    
      	
               

            	
              g.

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

            

    

    

    
      	
               

            	
              h.

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

            

    

    

    
      	
               

            	
              i.

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

            

    

    

    
      	
               

            	
              j.

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

            

    

    

    
      	
              28.

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

            

    

    

    29.           MCP
      Membership acceptance, documentation and reconciliation

    

    
      	
               

            	
              a.

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

            

    

    

    
      	
               

            	
              b.

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

            

    

    

    
      	
               

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

            

    

    

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

    

    

    
      	
            	
              c.

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

            

    

    

    
      	
               

            	
              d.

            	
              Hospital
                Deferment Requests: When an MCP learns of a current
                hospitalized member’s intent to disenroll through the CCR or the 834, the
                disenrolling MCP  must notify ODJFS within five (5) business
                days of receipt of the CCR or 834. When the MCP learns of a new
                member’s  hospitalization that is eligible for deferment prior
                to that member’s discharge, the MCP shall notify the hospital and treating
                providers of the potential that the MCP may not be the
                payer.  The MCP shall work with hospitals, providers and the
                ODJFS to assure that discharge planning assures continuity of care
                and
                accurate payment.  Notwithstanding the MCP’s right to request a
                hospital deferment up to six (6) months following the member’s effective
                date, when the MCP learns of a deferment-eligible hospitalization,
                the MCP
                shall notify the ODJFS and request the deferment within five (5)
                business
                days of learning of the potential deferment.  When the MCP is
                notified by ODJFS of a potential hospital deferment, the MCP must
                respond
                to ODJFS within five (5) business days of the receipt of the deferment
                information from ODJFS.

            

    

    

    
      	
               

            	
              e.

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

            

    

    

    
      	
               

            	
              f.

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

            

    

    

    
      	
            	
              g.

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

            

    

     

    
      
        	
              	
                 

              	
                 

              

      

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

    

    

    
      	
              
                h.

              

            	
              Pending
                Member

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

              

            

    

     

                            i.          Transition
      of Fee-For-Service Members

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

    

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

    

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

    

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

    

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

    

    d.           The
      member is receiving ongoing chemotherapy or radiationtreatment.

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

    

    

    

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

    

    
      	
               

            	
              ii.

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

            

    

     

    
      	
               

            	
              iii.

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

            

    

    

    
      	
               

            	
              a.

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

            

    

    

    
      	
               

            	
              b.

            	
              dental
                services that have not yet been
                received;

            

    

    

    
      	
               

            	
              c.

            	
              vision
                services that have not yet been
                received;

            

    

    

    
      	
               

            	
              d.

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

            

    

    

    
      	
               

            	
              e.

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

            

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

    

    

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

    

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

    

    
      	
               

            	
              iv.

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

            

    

    

    
      	
               

            	
              v.

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

            

    

    

    
      	
               

            	
              a.

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

            

    

    

    
      	
               

            	
              b.

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

            

    

    

    
      	
               

            	
              c.

            	
              For
                panel providers, notification to the provider and member confirming
                the
                MCP’s responsibility to cover the service.  MCPs
                must use the ODJFS-specified model language for the provider and
                member
                notices and maintain documentation of all member and/or provider
                contacts
                relating to such services.

            

    

     

    
      	
               

            	
              30.

            	
              Health
                Information System Requirements

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

            

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

    

     

    a.           Health
      Information System

    

    
      	
               

            	
              i.

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

            

    

    

    
      	
               

            	
              ii.

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

            

    

    

    
      	
               

            	
              iii.

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

            

    

    

    
      	
               

            	
              iv.

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

               

            

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

    

     

    a.           Before
      an MCP may submit production filesODJFS-specified formats; and/or

    
      	
               

            	
              b.

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

            

    

    
      	
               

            	
              c.

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

            

    

    

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

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

    

    

    test
      file
      is acceptable.  Once an MCP’s new or modified  information
      system is operational, that MCP will have up to ninety (90) days to
      submit an acceptable test file and an acceptable production file.

    

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

    

    b.           Electronic
      Data Interchange and Claims Adjudication Requirements

    

    Claims
      Adjudication

    

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

    

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

    

    Electronic
      Data
      Interchange

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

    Health
      care claims;

    Health
      care claim status request and
      response;

    Health
      care payment and remittance
      status;

    Standard
      code sets; and

    National
      Provider Identifier
      (NPI).

    

    Each
      EDI transaction processed by the
      MCP shall be implemented inconformance with the appropriate version of the
      transaction implementationguide, as specified by applicable federal rule or
      regulation.

    

    The
      MCP must have the capacity to
      accept the following transactions from theOhio Department of Job and Family
      services consistent with EDI processing

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
          

        

      

    

    

    specifications
      in the transaction
      implementation guides and in conformance withthe 820 and 834 Transaction
      Companion Guides issued by ODJFS:

    

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

    

    ASC
      X12 834 - Benefit Enrollment and
      Maintenance.

    

    The
      MCP shall comply with the HIPAA
      mandated EDI transaction standards andcode sets no later than the required
      compliance dates as set forth in the federalregulations.

    

    Documentation
      of Compliance with
      Mandated EDI Standards

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

    

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

    

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

    

    i.           Trading
      Partner Agreements

    ii.           Code
      Sets

    iii.           Transactions

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

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

    c.           Referral
      Certification and Authorization (ASC X12N 278)

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

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

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

    g.           Health
      Plan Premium Payments (ASC X12N 820)

    h.           Coordination
      of Benefits

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

    

    

    Trading
      Partner Agreement with
      ODJFS

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

    

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

    

    c.           Encounter
      Data Submission Requirements

    

    General
      Requirements

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

    

    
      	
               

            	
              ·

            	
              Institutional
                Claims - UB92 flat file

            

    

    
      	
               

            	
              ·

            	
              Noninstitutional
                Claims - National standard format

            

    

    
      	
               

            	
              ·

            	
              Prescription
                Drug Claims - NCPDP

            

    

    

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

    

    An
      encounter represents all of the services, including medical supplies and
      medications, provided to a member of the MCP by a particular provider,
      regardless of the payment arrangement between the MCP and the provider. For
      example, if a member had an emergency department visit and was examined by
      a

    physician,
      this would constitute two encounters, one related to the hospital provider
      and
      one related to the physician provider. However, for the purposes of calculating
      a utilization measure, this would be counted as a single emergency department
      visit.  If a member visits their PCP and the PCP examines the member
      and has laboratory procedures done within the office, then this is one encounter
      between the member and their PCP.

    

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

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

    

    

    

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

    

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

    

    Acceptance
      Testing

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

    

    
      	
               

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

            

    

    

    Encounter
      Data File Submission
      Procedures

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

    

    Timing
      of Encounter Data
      Submissions

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

    

     

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

    

     

    d.           Information
      Systems Review

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

    

    The
      following activities, at a minimum, will be carried out during the
      review.  ODJFS or its designee will:

    

    
      	
               

            	
              i.

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

            

    

    

    ii.           Review
      the completed ISCA and accompanying documents;

    

    
      	
               

            	
              iii.

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

            

    

    

    
      	
               

            	
              iv.

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

            

    

    

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

    

    vi.        Examine
      MCP processes for data transfers;

    

    
      	
               

            	
              vii.

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

            

    

    

    
      	
               

            	
              viii.

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

            

    

    

    
      	
               

            	
              ix.

            	
              Assess
                the claims adjudication process and capabilities of the
                MCP.

            

    

    

    As
      noted above, the information system
      review may be performed every twoyears. However, if ODJFS or its designee
      identifies significant informationsystem problems, then ODJFS or its designee
      may conduct, and the MCP must participate in, a review the following year or
      in
      such a timeframe as ODJFS, in their sole discretion, deems appropriate to ensure
      accuracy and efficiency of the MCP health information system.

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

    

     

    If
      an MCP had an assessment performed
      of its information system through aprivate sector accreditation body or other
      independent entity within the two yearspreceding the time when ODJFS or its
      designee will be conducting its review, and has not made significant changes
      to
      its information system since that time, and the information gathered is the
      same
      as or consistent with the ODJFS or its designee’s proposed review, as determined
      by the ODJFS, then the MCP will not required to undergo the IS
      review.  The MCP must provide ODJFS or its designee with a copy of the
      review that was performed so that ODJFS can determine whether or not the MCP
      will be required to participate in the IS review. MCPs who are determined to
      be
      exempt from the IS review must participate in subsequent information system
      reviews, as determined by ODJFS.

    

    31.       Delivery
      Payments

    

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

    

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

    

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

    

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

    

    If
      a
      physician and a hospital encounter is found for the same delivery, only one
      payment will be made. The same is true for multiple births; if multiple delivery
      encounters are submitted, only one payment will be made. The method for
      reimbursing for deliveries

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

    

    

    includes
      the delivery of stillborns where the MCP incurred costs related to the
      delivery.

    

    Rejections

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

    

    Timing
      of Delivery Payments

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

    

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

    

    Updating
      and Deleting Delivery Encounters

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

    

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

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

    

     

    Auditing
      of Delivery Payments

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

    

    
      	
              32.

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

            

    

     

    
      	
              33.

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

            

    

     

    
      	
              34.

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

            

    

    

    
      	
              35.

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

            

    

    

    
      	
              36.

            	
              Franchise
                Fee Assessment Requirements

            

    

     

    
      
        	
                a.

              	
                 

              	
                Each
                  MCP is required to pay a franchise permit fee to ODJFS for each
                  calendar
                  quarter
                  as required by ORC Section 5111.176.  The current fee
                  to be paid is an amount
                  equal to 41⁄2 percent of the managed care premiums, minus  Medicare
                  premiums that the MCP received from any payer in the quarter to
                  which the
                  fee applies.  Any premiums the MCP returned or refunded to
                  members or premium payers during that quarter are excluded from
                  the
                  fee.

              

      

       

    

    
      	
              b.

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

            	
               

            

    

    

    
      	
              c.

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

            	
               

            

    

    

    
      	
              d.

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

            	
               

            	
               

            

    

    

    37.           Information
      Required for MCP Websites

    

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

    

    b.           On-line
      Member Website– MCPs must have a secure internet-based websitewhich is
      regularly updated to include the most current ODJFS approved
      materials.

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

    

    

    The
      website at a minimum must include:
      (1) a list of the counties that are coveredin their service area; (2) the
      ODJFS-approved MCP member handbook, recentnewsletters/announcements, MCP contact
      information including member services hours and closures; (3) the MCP provider
      directory as referenced in section 36(a) of this appendix; (4) the MCP’s current
      preferred drug list (PDL), including an explanation of the list, which drugs
      require prior authorization (PA), and the PA process; (5) the MCP’s current list
      of drugs covered only with PA, the PA process,  and the MCP’s policy
      for covering generic for brand-name  drugs; and
      (6)
      the ability for members to submitquestions/comments/grievances/appeals/etc.
      and
      receive a response (membersmust be given the option of a return e-mail or phone
      call) within one working day of receipt.  MCPs must ensure that all
      member materials designated specifically for CFC and/or ABD consumers (i.e.
      the
      MCP member handbook) are clearly labeled as such.  The MCP’s member
      website cannot be used as the only means to notify members of new and/or revised
      MCP information (e.g., change in holiday closures,
      change in additional benefits, revisions to approved member
      materialsetc.).  ODJFS may require MCPs to include additional
      information on the member website,
      as needed.

    

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

    

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

    

    39.           MCPs
      must not use, or propose to use, any offshore programming or call center
      services

    in
      fulfilling the program
      requirements.

     

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

    

    

    APPENDIX
      D

    

    ODJFS
      RESPONSIBILITIES

    CFC
      ELIGIBLE POPULATION

    

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

    

    General
      Provisions

    

    
      	
              1.

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

            

    

    

    
      	
              2.

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

            

    

    

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

    

    
      	
              4.

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

            

    

    

    
      	
              5.

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

            

    

    

    
      	
              6.

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

            

    

    

    
      	
              7.

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

            

    

    

    
      	
              8.

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

            

    

    

    
      	
              9.

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

            

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

    

    

    
      	
              10.

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

            

    

    

    
      	
              11.

            	
               

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

            

    

     

    
      	
              12.

            	
               

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

            

    

    

    
      	
              13.

            	
               

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

            

    

    

    14.           Consumer
      information

    

    
      	
               

            	
              a.

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

            

    

    

    
      	
               

            	
              b.

            	
              ODJFS
                will notify members or ask MCPs to notify members about
                significant

            

    

    
      	
               

            	
              changes
                affecting contractual requirements, member services or access to
                providers.

            

    

    

    
      	
               

            	
              c.

            	
              If
                an MCP elects not to provide, reimburse, or cover a counseling service
                or
                referral service due to an objection to the service on moral or religious
                grounds, ODJFS will provide coverage and reimbursement for these
                services
                for the MCP’s members.

            

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

    

    

    
      	
               

            	
              ODJFS
                will provide information on what services the MCP will not cover
                and how
                and where the MCP’s members may obtain these services in the applicable
                Consumer Guides.

            

    

    

    15.           Membership
      Selection and Premium Payment

    

    
      	
               

            	
              a.

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

            

    

    

    
      	
               

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

            

    

    

    
      	
               

            	
              b.

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

            

    

    

    
      	
               

            	
              ·

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

            

    

     

    
      	
               

            	
              ·

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

            

    

    
      	
               

            	
              ·

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

            

    

    

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

    

    
      	
               

            	
              c.

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

            

    

     

    
      	
            	
              d.

            	
              Monthly
                member roster (MR): ODJFS verifies managed care plan enrollment on
                a

            

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

    

    

    monthly
      basis via the monthly
      membership roster.  ODJFS or its designated entity provides
      a full member roster (F) and a change roster (C) via HIPAA 834 compliant
transactions.

    

    
      	
               

            	
              e.

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

            

    

    

    
      	
               

            	
              f.

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

            

    

    

    
      	
               

            	
              g.

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

            

    

    

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

    

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

    

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

    

    19.           Communications

    

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

    

     

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
                

          

        

      

    

    

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

    

    c.           MCP
      delegated entities: In that MCPs are ultimately responsible for
      meetingprogram requirements, the BMHC will not discuss MCP issueswith the MCPs’
delegated entities unless the applicable MCP is also participating in the
      discussion.  MCP delegated entities, with the applicable MCP
      participating, should only communicate with the specific CA assigned to that
      MCP.

    

    

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    
APPENDIX
      E

     

    RATE
      METHODOLOGY

    CFC
      ELIGIBLE POPULATION

     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    

    MERCER

    Government
      Human Services Consulting

     

    333
      South
      7th Street, Suite 1600

    Minneapolis,
      MN 55402-2427

    www.mercerHR.com

    October
      20, 2006

     

    Mr.
      Jon
      Barley

    State
      of
      Ohio

    Bureau
      of
      Managed Health Care

    Ohio
      Department of Job and Family Services

    255
      East
      Main Street, 2nd Floor

    Columbus,
      OH 43215-5222

     

    Subject:

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

     

    Dear
      Jon:

     

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

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

     

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

     

    The
      key
      components in the CY 2007 rate-setting process are:

     

    •
Base
      data development,

    •
Managed
      care rate development, and

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

     

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

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    MERCER

    Government
      Human Services Consulting

     

    Page
      2

    October
      20, 2006

    Mr.
      Jon
      Barley

    Ohio
      Department of Job and Family Services

     

    Base
      Data Development

     

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

     

    The
      data
      sources used for CY 2007 rate setting were:

     

    •
Ohio
      historical FFS data,

    •
MCP
      encounter data, and

    •
MCP
      financial cost report data.

     

    Validation
      Process

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

     

    Data
      Sources

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

     

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

     

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

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    MERCER

    Government
      Human Services Consulting

     

    Page
      3

    October
      20, 2006

    Mr.
      Jon
      Barley

    Ohio
      Department of Job and Family Services

     

    Fee-for-Service
      Data

     

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

     

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

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

     

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

     

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

     

    Encounter
      Data

     

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

     

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

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

     

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

     

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

     

    •
Claims
      completion factors,

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

     

    MERCER

    Government
      Human Services Consulting

     

    Page
      4

    October
      20, 2006

    Mr.
      Jon
      Barley

    Ohio
      Department of Job and Family Services

     

    
      	
               

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

            

    

     

    
      	
               

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

            

    

     

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

     

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

     

    Financial
      Cost Reports

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

    
      	
               

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

            

    

    
      	
               

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

            

    

     

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

     

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

    

    
      	
               

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

            

    

    
      	
               

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

            

    

    
      	
               

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

            

    

     

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

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    MERCER

    Government
      Human Services Consulting

     

    Page
      5

    October
      20, 2006

    Mr.
      Jon
      Barley

    Ohio
      Department of Job and Family Services

     

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

     

    Managed
      Care Rate Development

     

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

     

    Blending
      Multiple Years of Data

    As
      the
      programs have matured, we have collected multiple years ofFFS and managed care
      data. In order to utilize all available current information, Mercer combined
      the
      yearly data within each data source using a weighted average methodology similar
      to that used in previous years. Prior to blending these years of data, the
      base
      time period experience was trended to a common time period ofCY 2005. Mercer
      applied greater credibility on the most recent year of data to reflect the
      expectation that the most recent year may be more reflective of future
      experience and to reflect that fewer adjustments are needed to bring the data to
      the effective contract period.

     

    Managed
      Care Assumptions for the FFS Data Source

    In
      developing managed care savings assumptions. Mercer applied generally accepted
      actuarial principles that reflect the impact ofMCP programs on FFS experience.
      Mercer reviewed Ohio's historical FFS experience, CY 2004 and CY 2005 cost
      report data, SFY 2004 and SPY 2005 encounter data, and other state Medicaid
      managed care experience to develop managed care savings assumptions. These
      assumptions have been applied to the FFS data to derive managed care cost
      levels. The assumptions are consistent with an economic and efficiently operated
      Medicaid managed care plan. The managed care savings assumptions vary by region,
      rate cohort and category of service (COS).

     

    Specific
      adjustments were made in this step to reflect the differences between pharmacy
      contracting for the State and contracting obtained by the MCPs. Mercer reviewed
      information

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    MERCER

    Government
      Human Services Consulting

     

    Page
      6

    October
      20, 2006

    Mr.
      Jon
      Barley

    Ohio
      Department of Job and Family Services

     

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

     

    Shadow
      Pricing

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

     

    Prospective
      Policy Changes

    CMS
      also
      requires that the rate-setting methodology incorporates the impact of any
      programmatic changes that have taken place, or are anticipated to take place,
      between the base period (CY 2005) and the contract period (CY
      2007).

     

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

     

    Clinical
      Measures/Incentives

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

     

    Caseload

    Historically,
      the State has experienced significant changes in its Medicaid caseload. These
      shifts in caseload have affected the demographics of the remaining Medicaid
      population. Mercer

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    MERCER

    Government
      Human Services Consulting

     

    Page
      7

    October
      20, 2006

    Mr.
      Jon
      Barley

    Ohio
      Department of Job and Family Services

     

    evaluated
      recent and expected caseload variations to determine if an adjustment was
      necessary to account for demographic changes. Based on the data provided by
      the
      State, Mercer determined no adjustments were necessary for either the
      non-delivery or delivery rate cells.

     

    Selection
      Issues

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

     

    The
      second selection adjustment is voluntary selection, which accounts for the
      fact
      that costs associated with individuals who elect to participate in managed
      care
      are generally lower than the remaining FFS population. Therefore, the voluntary
      selection adjustment adjusts for the risk of only those members selecting
      managed care.

     

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

     

    Non-State
      Plan Services

    According
      to the CMS Final Medicaid Managed Care Rule that was implemented August 13,
      2003, non-state plan services may not be included in the base data for
      rate-setting. The CY 2004 and 2005 cost reports contain information from the
      MCPs that was used to adjust the base data for non-state plan services reported
      in the cost reports and the encounter data. Please refer to Appendix D for
      more
      information concerning this adjustment.

     

    Prospective
      Trend Development

    Trend
      is
      an estimate of the change in the overall cost of providing a specific benefit
      service over a finite period of time. A trend factor is necessary to estimate
      the expenses of providing health care services in some future year, based on
      expenses incurred in prior years. Trend was applied by COS to the blended base
      data costs for CY 2005 to project the data forward to the CY 2007 contract
      period.

     

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

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    MERCER

    Government
      Human Services Consulting

     

    Page
      8

    October
      20, 2006

    Mr.
      Jon
      Barley

    Ohio
      Department of Job and Family Services

     

    (CPI)
      and
      Data Resource Inc. (DRI)), trends in neighboring states, the State FFS trend
      expectations and any Ohio market changes. Moreover, the trend component was
      comprised of both unit cost and utilization components.

     

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

     

    Credibility
      Assignment

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

     

    Cesarean
      Delivery Rate

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

     

    Relational
      Modeling

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

     

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

     

    Administration/Contingencies

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

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

     

    MERCER

    Government
      Human Services Consulting

     

    Page
      9

    October
      20, 2006

    Mr.Jon
      Barley

    Ohio
      Department of Job and Family Services

     

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

     

    Certification
      of Final Rates

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

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

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

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

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

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

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

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

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

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

    •
      Delivery Payment.

     

    A
      summary
      of the rates is included in Appendix E.

     

    Mercer
      certifies the above rates were developed in accordance with generally accepted
      actuarial practices and principles by actuaries meeting the qualification
      standards of the American Academy of Actuaries for the populations and services
      covered under the managed care contract. Rates developed by Mercer are actuarial
      projections of future contingent events. Actual MCP costs will differ from
      these
      projections. Mercer developed these rates on behalf of the State to demonstrate
      compliance with the CMS requirements under 42 CFR 438.6(c) and to demonstrate
      that rates are in accordance with applicable law and regulations.

     

    MCPs
      are
      advised that the use of these rates may not be appropriate for their particular
      circumstance and Mercer disclaims any responsibility for the use of these rates
      by MCPs for any purpose. Mercer recommends any MCP considering contracting
      with
      the State should analyze its own projected medical expense, administrative
      expense, and any other premium needs for comparison to these rates before
      deciding whether to contract with the State. Use of these rates for purposes
      beyond those stated may not be appropriate.

    

     

    MERCER

    Government
      Human Services Consulting

     

    Page
      10

    October
      20, 2006

    Mr.
      Jon
      Barley

    Ohio
      Department of Job and Family Services

     

    Sincerely,

    

    
      	
                /s/  Angela
                WasDyke               
                

            	
                /s/   Wendy
                Radunz         
                

            
	
              Angela
                WasDyke,  MAAA, ASA

            	
              Wendy
                Radunz, MAAA, FSA

            

    

    

     

    

     

    Copy:

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

     

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    MERCER

    Government
      Human Services Consulting

     

    

     

    Appendix
      A - CY 2007 Rate-Setting Methodology

     

    

     

    (GRAPH)

    

     

    

     

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    MERCER

    Government
      Human Services Consulting

     

    Appendix
      B - Regional Delivery System Definition

     

    Regional
      Delivery System Definitions

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

     

    Mandatory
      and Preferred Option Counties

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

     

    
      	
              Mandatory:

            	
              Preferred
                Option:

            
	
              Cuyahoga

            	
              Butler

            
	
              Lucas

            	
              Clark

            
	
              Stark

            	
              Franklin

            
	
              Summit

            	
              Hamilton

            
	
               

            	
              Lorain

            
	 	
              Montgomery

            

    

     

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

     

    Voluntary
      Counties

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

    

    
      	
              Voluntary

            
	
              Clermont

            
	
              Greene

            
	
              Pickaway

            
	
              Warren

            
	
              Wood

            

    

     

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

     

    B-l

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    MERCER

    Government
      Human Services Consulting

    

    

    Medicaid
      Managed Care Program Regions for the CFC Population

    

    

    (MAP)

    

     

    B-2

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    MERCER

    Government
      Human Services Consulting

     

    Appendix
      C - FFS Data Adjustments

     

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

     

    Completion
      Factors

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

    

    
      	
              SFY

            	
              Paid
                Through

            
	
              2004

            	
              03/31/05

            
	
              2005

            	
                 12/31/05

            

    

    

     

    

     

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

     

    Gross
      Adjustment File (GAF)

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

     

    Historical
      Policy Changes

    As
      part
      of the rate-setting process, Mercer must account for policy changes that
      occurred during the base data time period. Changes only reflected in a portion
      of the data must be applied to the remaining data so that all base data reflects
      the policy changes. All policy changes implemented during SFY 2004 and SFY
      2005
      were applied to the FFS data.

     

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

     

    
      
        	
                Policy
                  Changes

              	
                Effective
                  Date

              	
                Category
                  of Service Affected

              	
                Rate
                  Cohorts Affected

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

              	
                1/1/2004

                 

              	
                POP,
                  OB/GYN and Specialists

                 

              	
                Ages
                  19+, including delivery

                 

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

              	
                1/1/2004

              	
                Other

              	
                HF,
                  Age 19-44, M

              
	
                HF,Age19-44,F

              
	
                HF,Age45+,
                  M & F

              
	
                HST,
                  Age 19-64, F

              
	
                Implementation
                  of $3.00 Copay on Prior-Authorized Drugs

              	
                1/1/2004

              	
                Pharmacy

              	
                All

              

      

       

      C-l

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    MERCER

    Government
      Human Services Consulting

     

    Third
      Party Liability Recoveries

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

     

    In
      a "pay
      and chase" scenario, the State pays the claim as though it were the primary
      payer. Subsequent to payment, the State makes recovery from a third party.
      These
      TPL recoveries are not reflected in the FFS MMIS data. Since MCPs are also
      expected to take similar recovery actions, the FFS experience was adjusted
      to
      reflect "pay and chase" recoveries. Mercer made adjustments to both the paid
      claims and utilization for all non-delivery and delivery COS. Since MCPs do
      not
      collect tort recoveries, the data excludes tort collections.

     

    Hospital
      Cost Settlements

    The
      State
      provided Mercer with SFY 2004 and SPY 2005 interim cost settlements for
      Diagnosis Related Group (DRG) and DRG-exempt hospitals. The DRG-exempt hospital
      information included inpatient and outpatient settlements. However, the DRG
      hospitals only include capital settlements, which were incorporated into the
      adjustment. Therefore, an adjustment has been applied to non-delivery and
      delivery inpatient, outpatient, and emergency room (ER) claims to remove these
      additional costs.

     

    Fraud
      and
      Abuse

    The
      State
      does pursue recoveries from fraud and abuse cases. The dollars recovered are
      accounted for outside of the State's MMIS system and are not included in the
      FFS
      data. Since the MCPs are required to pursue fraud and abuse cases, an adjustment
      was applied to the FFS claims and utilization in both the delivery and
      non-delivery data.

     

    Excluded
      Time Periods

    The
      capitation rates paid to the MCPs reflect the risk of serving the eligible
      enrollees from the date of health plan enrollment forward. Therefore, the
      non-delivery FFS data has been adjusted to reflect only the time periods for
      which the MCPs are at risk. Since newborns are automatically eligible for the
      Medicaid program and are enrolled into their mother's MCP at birth, no
      adjustment will be applied to the "Less Than 1" age group.

     

    Adverse
      Selection

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

     

    C-2

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

     

    MERCER

    Government
      Human Services Consulting

     

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

     

    Dual
      Eligibles

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

     

    Catastrophic
      Claims

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

     

    DSH
      Payments

     

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

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

     

    Spend
      Down

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

     

    Graduate
      Medical Education (GME)

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

     

    C-3

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    MERCER

    Government
      Human Services Consulting

     

    Appendix
      C - Encounter Data Adjustments

     

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

     

    Historical
      Policy Changes

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

     

    
      
        	
                Policy
                  Change

              	
                Effective
                  Date

              	
                Category
                  of Service Affected

              	
                Rate
                  Cohorts Affected

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

              	
                1/1/2004

                 

              	
                PCP,
                  OB/GYN and Specialists

                 

              	
                Ages
                  19+, including delivery

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

                 

              	
                1/1/2004

                 

              	
                Other

                 

              	
                H
                  F, Age 19-44, M

              
	
                HF,
                  Age 19-44, F

              
	
                HF,
                  Age 45+, M & F

              
	
                HST,
                  Age 19-64, F

              

      

       

    

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

     

    Data
      Anomaly Corrections

     

    As
      directed by the State, Mercer made adjustments to the encounter data to account
      for

    incomplete
      reporting or other known data issues.

     

    Non-State
      Plan Services

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

     

    Third
      Party Liability Recoveries

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

     

    C-4

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

     

    MERCER

    Government
      Human Services Consulting

     

    Appendix
      C - Cost Report Data Adjustments

     

    IBNR
      Review/Adjustment

    Mercer
      used CY 2005 cost report claims restatement Report IV and lag triangles to
      adjust the MCP IBNR estimates in the CY 2004 and CY 2005 financial
      experience.

     

    Historical
      Policy Changes

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

     

    Data
      Anomaly Corrections

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

     

    Non-State
      Plan Services

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

     

    Third
      Party Liability Recoveries

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

     

    C-5

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    MERCER

    Government
      Human Services Consulting

     

    Appendix
      D - Calendar Year 2007 CFC Rate Development

     

    Credibility
      By Year 

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

     

    FFS
      Historical and Managed Care Historical/Prospective Trend

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

     

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

     

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

     

    Prospective
      Policy Changes

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

     

    Adjustments
      Affecting Unit Cost

    
       

      
        	
                Policy
                  Change

              	
                Effective
                  Date

              	
                Category
                  of Service Affected

              	
                Rate
                  Cohorts Affected

              
	
                Implementation
                  of $2 copay for trade-name preferred drugs for adults (S21)

                 

              	
                1/1/2006

                 

              	
                Pharmacy

                 

              	
                HF,
                  Age 19-44, F

              
	
                HF,
                  Age 19-44, M

              
	
                HF,
                  Age 45+, M & F

              
	
                Implementation
                  of $3 copay for each dental date of service for adults (2:21)

                 

              	
                1/1/2006

                 

              	
                Dental

                 

              	
                HF,Age19
                  -44,F

              
	
                HF,
                  Age 19-44, M

              
	
                HF,
                  Age 45+, M & F

              
	
                Implementation
                  of $2 copay for vision exams and $1 copay for dispensing services
                  for
                  adults (S21)

                 

              	
                1/1/2006

                 

              	
                Other

                 

              	
                HF,
                  Age 19-44, F

              
	
                HF,
                  Age 19-44, M

              
	
                HF,
                  Age 45+, M&F

              
	
                HST,
                  Age 19-64, F

              
	
                Inpatient
                  recalibration and outlier policies

                 

              	
                1/1/2006

                 

              	
                Inpatient

                 

              	
                All

                 

              
	
                Inpatient
                  rate freeze

                 

              	
                1/1/2006

                 

              	
                Inpatient

                 

              	
                All

                 

              

      

       

      D-l

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      MERCER

      Government
        Human Services Consulting

       

      Adjustments
        Affecting Utilization

       

      
        	
                Policy
                  Change

              	
                Effective
                  Date

              	
                Category
                  of Service Affected

              	
                Rate
                  Cohorts Affected

              
	
                Reduction
                  in coverage of dental services for adults (S21)

                 

              	
                1/1/2006

                 

              	
                Dental

                 

              	
                HF,  Age
                  19-44, F

              
	
                HF,  Age
                  19-44, M

              
	
                HF,  Age
                  45+, M & F

              
	
                HST,
                  Age 19-64, F

              

      

       

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

       

      Clinical
        Measures/Incentives

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

       

      D-2

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      MERCER

      Government
        Human Services Consulting

       

      
        	
                Clinical
                  Measure

              	
                Rate
                  Cohort

              	
                Category
                  of Service Affected

              
	
                Prenatal
                  Care - Frequency of Ongoing Prenatal Care

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

              	
                HF/HST,
                  14-18F

                HST,
                  19-64F

                HF,
                  19-44F

                 

              	
                OB/GYN
                  Physician

                 

              
	
                Prenatal
                  Care - Post Partum Visits

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

              	
                HF/HST,
                  14-18 F 

                HST,
                  19-64F

                HF,
                  19-44F

              	
                OB/GYN

                 

              
	
                Preventive
                  Care for Children -WelI-Child Visits

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

              	
                HF/HST,
                  <1 M&F 

                HF/HST,
                  1 M&F 

                HF/HST,
                  2-13 M&F 

                HF/HST,
                  14-18 M 

                HF/HST,
                  14-18F

                 

              	
                Physician

                 

              
	
                Use
                  of Appropriate Medications for People with Asthma

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

              	
                HF/HST,
                  2-13 M&F 

                HF/HST,
                  14-18M 

                HF/HST,
                  14-18F

                HF,
                  19-44M

                HF,
                  19-44F

                HF,
                  45+ M&F

                HST,
                  19-64F

                 

              	
                Pharmacy

              
	
                Annual
                  Dental Visits

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

              	
                HF/HST,
                  2-13 M&F 

                HF/HST,
                  14-18M 

                HF/HST,
                  14-18F

                 

              	
                Dental

                 

              
	
                Lead
                  Screening

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

              	
                HF/HST,
                  1 M&F 

                HF/HST,
                  2-13 M&F

                 

              	
                Physician

                 

              

      

       

      Voluntary
        Selection

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

       

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

       

      D-3

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      MERCER

      Government
        Human Services Consulting

       

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

       

      Credibility
        by Data Source

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

       

      C-Section/Vaginal
        Percent

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

       

      MCP
        Administration/Contingencies

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

       

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

       

      
        	 	
                Admin

              	
                At-Risk

              
	
                Plan
                  Year 1 (months 1-12)

              	
                13%

              	
                0%

              
	
                Plan
                  Year 2 (months 13-24)

              	
                12%

              	
                0%

              
	
                Plan
                  Year 3 (months 25-36)

              	
                12%

              	
                1%

              

      

       

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

       

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

       

      D-4

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      MERCER

      Government
        Human Services Consulting

       

      Appendix
        E - Calendar Year 2007 CFC Regional Rate Summary

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        	
                Appendix
                  E

                Calendar
                  Year 2007 CFC Regional Rate Summary 

              	 
	
                Region

              	
                Rate
                  Cohort

              	 	
                Annualized
                  April 2006 MM/Deliveries

              	 	 	
                %
                  of MM

              	 	 	
                CY
                  2007 Guaranteed Rate

              	 	 	
                CY
                  2007 Rate At Risk

              	 	 	
                CY
                  2007 Rate

              	 
	
                Central

              	
                HF/HST,
                  Age 0, M & F

              	 	 	
                171,818

              	 	 	 	6.00	%	 	$	
                564.92

              	 	 	$	
                5.45

              	 	 	$	
                570.36

              	 
	
                Central

              	
                HF/HST,
                  Age 1, M&F

              	 	 	
                146,106

              	 	 	 	5.10	%	 	$	
                149.56

              	 	 	$	
                1.44

              	 	 	$	
                151.01

              	 
	
                Central

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

              	 	 	
                1,335,641

              	 	 	 	46.60	%	 	$	
                99.74

              	 	 	$	
                0.96

              	 	 	$	
                100.70

              	 
	
                Central

              	
                HF/HST,
                  Age 14-18, M

              	 	 	
                191,907

              	 	 	 	6.70	%	 	$	
                118.11

              	 	 	$	
                1.14

              	 	 	$	
                119.25

              	 
	
                Central

              	
                HF/HST,
                  Age 14-18, F

              	 	 	
                208,187

              	 	 	 	7.30	%	 	$	
                166.07

              	 	 	$	
                1.60

              	 	 	$	
                167.68

              	 
	
                Central

              	
                HF,
                  Age 19-44, M

              	 	 	
                172,314

              	 	 	 	6.00	%	 	$	
                206.93

              	 	 	$	
                2.00

              	 	 	$	
                208.92

              	 
	
                Central

              	
                HF.Age
                  19-44, F

              	 	 	
                531,797

              	 	 	 	18.50	%	 	$	
                299.33

              	 	 	$	
                2.89

              	 	 	$	
                302.21

              	 
	
                 Central

              	
                HF,
                  Age 45+, M&F

              	 	 	
                59,319

              	 	 	 	2.10	%	 	$	
                487.07

              	 	 	$	
                4.70

              	 	 	$	
                491.77

              	 
	
                Central

              	
                HST,
                  Age 19-64, F

              	 	 	
                50,975

              	 	 	 	1.80	%	 	$	
                340.59

              	 	 	$	
                3.28

              	 	 	$	
                343.87

              	 
	
                Central

              	
                Subtotal

              	 	 	
                2,868,064

              	 	 	 	100.00	%	 	$	
                191.93

              	 	 	$	
                1.85

              	 	 	$	
                193.78

              	 
	
                Central

              	
                Delivery
                  Payment

              	 	 	
                9,465

              	 	 	 	0.30	%	 	$	
                4,023.39

              	 	 	$	
                38.79

              	 	 	$	
                4,062.19

              	 
	
                Central

              	
                Total

              	 	 	
                2,868,064

              	 	 	 	100.00	%	 	$	
                205.21

              	 	 	$	
                1.98

              	 	 	$	
                207.19

              	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                East-Central

              	
                HF/HST,
                  Age 0, M & F

              	 	 	
                95,509

              	 	 	 	5.60	%	 	$	
                554.55

              	 	 	$	
                5.35

              	 	 	$	
                559.90

              	 
	
                East-Central

              	
                HF/HST,Age1,M&F

              	 	 	
                78,227

              	 	 	 	4.60	%	 	$	
                145.80

              	 	 	$	
                1.41

              	 	 	$	
                147.21

              	 
	
                East-Central

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

              	 	 	
                786,577

              	 	 	 	46.40	%	 	$	
                98.24

              	 	 	$	
                0.95

              	 	 	$	
                99.19

              	 
	
                East-Central

              	
                HF/HST,
                  Age 14-18, M

              	 	 	
                122,231

              	 	 	 	7.20	%	 	$	
                114.36

              	 	 	$	
                1.10

              	 	 	$	
                115.47

              	 
	
                East-Central

              	
                HF/HST,
                  Age 14-18, F

              	 	 	
                126,757

              	 	 	 	7.50	%	 	$	
                158.66

              	 	 	$	
                1.53

              	 	 	$	
                160.19

              	 
	
                East-Central

              	
                HF,
                  Age 19-44, M

              	 	 	
                98,371

              	 	 	 	5.80	%	 	$	
                200.66

              	 	 	$	
                1.93

              	 	 	$	
                202.59

              	 
	
                East-Central

              	
                HF,
                  Age 19-44, F

              	 	 	
                320,557

              	 	 	 	18.90	%	 	$	
                290.72

              	 	 	$	
                2.80

              	 	 	$	
                293.52

              	 
	
                East-Central

              	
                HF,
                  Age 45+, M&F

              	 	 	
                38,258

              	 	 	 	2.30	%	 	$	
                470.93

              	 	 	$	
                4.54

              	 	 	$	
                475.47

              	 
	
                East-Central

              	
                HST,
                  Age 19-64, F

              	 	 	
                29,264

              	 	 	 	1.70	%	 	$	
                331.03

              	 	 	$	
                3.19

              	 	 	$	
                334.22

              	 
	
                East-Central

              	
                Subtotal

              	 	 	
                1,695,750

              	 	 	 	100.00	%	 	$	
                186.57

              	 	 	$	
                1.80

              	 	 	$	
                188.37

              	 
	
                East-Central

              	
                Delivery
                  Payment

              	 	 	
                5,596

              	 	 	 	0.30	%	 	$	
                4,132.16

              	 	 	$	
                39.84

              	 	 	$	
                4,172.00

              	 
	
                East-Central

              	
                Total

              	 	 	
                1,695,750

              	 	 	 	100.00	%	 	$	
                200.20

              	 	 	$	
                1.93

              	 	 	$	
                202.13

              	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                Northeast

              	
                HF/HST,
                  Age 0, M & F

              	 	 	
                152,915

              	 	 	 	5.20	%	 	$	
                529.07

              	 	 	$	
                5.10

              	 	 	$	
                534.17

              	 
	
                Northeast

              	
                HF/HST,
                  Age 1, M & F

              	 	 	
                133,744

              	 	 	 	4.50	%	 	$	
                140.45

              	 	 	$	
                1.35

              	 	 	$	
                141.80

              	 
	
                Northeast

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

              	 	 	
                1,381,832

              	 	 	 	46.70	%	 	$	
                94.02

              	 	 	$	
                0.91

              	 	 	$	
                94.93

              	 
	
                Northeast

              	
                HF/HST,
                  Age 14-18, M

              	 	 	
                223,275

              	 	 	 	7.50	%	 	$	
                111.31

              	 	 	$	
                1.07

              	 	 	$	
                112.38

              	 
	
                Northeast

              	
                HF/HST,
                  Age 14-18, F

              	 	 	
                236,299

              	 	 	 	8.00	%	 	$	
                153.26

              	 	 	$	
                1.48

              	 	 	$	
                154.74

              	 
	
                Northeast

              	
                HF,
                  Age 19-44 M

              	 	 	
                136,730

              	 	 	 	4.60	%	 	$	
                193.74

              	 	 	$	
                1.87

              	 	 	$	
                195.61

              	 
	
                Northeast

              	
                HF,
                  Age 19-44 F

              	 	 	
                576,329

              	 	 	 	19.50	%	 	$	
                279.38

              	 	 	$	
                2.69

              	 	 	$	
                282.08

              	 
	
                Northeast

              	
                HF,
                  Age 45+, M&F

              	 	 	
                75,738

              	 	 	 	2.60	%	 	$	
                453.99

              	 	 	$	
                4.38

              	 	 	$	
                458.37

              	 
	
                Northeast

              	
                HST,
                  Age 19-64, F

              	 	 	
                41,229

              	 	 	 	1.40	%	 	$	
                318.02

              	 	 	$	
                3.07

              	 	 	$	
                321.09

              	 
	
                Northeast

              	
                Subtotal

              	 	 	
                2,958,090

              	 	 	 	100.00	%	 	$	
                177.71

              	 	 	$	
                1.71

              	 	 	$	
                179.42

              	 
	
                Northeast

              	
                Delivery
                  Payment

              	 	 	
                9,762

              	 	 	 	0.30	%	 	$	
                4,620.33

              	 	 	$	
                44.55

              	 	 	$	
                4,664.87

              	 
	
                Northeast

              	
                Total

              	 	 	
                2,958,090

              	 	 	 	100.00	%	 	$	
                192.96

              	 	 	$	
                1.86

              	 	 	$	
                194.82

              	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                Northwest

              	
                HF/HST,
                  Age 0, M & F

              	 	 	
                95,817

              	 	 	 	6.30	%	 	$	
                559.84

              	 	 	$	
                5.40

              	 	 	$	
                565.23

              	 
	
                Northwest

              	
                HF/HST,
                  Age 1, M&F

              	 	 	
                77,885

              	 	 	 	5.10	%	 	$	
                148.68

              	 	 	$	
                1.43

              	 	 	$	
                150.11

              	 
	
                Northwest

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

              	 	 	
                703,072

              	 	 	 	45.90	%	 	$	
                97.75

              	 	 	$	
                0.94

              	 	 	$	
                98.69

              	 
	
                Northwest

              	
                HF/HST,
                  Age 14-18, M

              	 	 	
                102,361

              	 	 	 	6.70	%	 	$	
                115.24

              	 	 	$	
                1.11

              	 	 	$	
                116.35

              	 
	
                Northwest

              	
                HF/HST,
                  Age 14-18, F

              	 	 	
                111,868

              	 	 	 	7.30	%	 	$	
                162.33

              	 	 	$	
                1.57

              	 	 	$	
                163.89

              	 
	
                Northwest

              	
                HF,
                  Age 19-44, M

              	 	 	
                91,211

              	 	 	 	6.00	%	 	$	
                202.82

              	 	 	$	
                1.96

              	 	 	$	
                204.77

              	 
	
                Northwest

              	
                HF.Age
                  19-44, F

              	 	 	
                289,036

              	 	 	 	18.90	%	 	$	
                299.30

              	 	 	$	
                2.89

              	 	 	$	
                302.18

              	 
	
                Northwest

              	
                HF,
                  Age 45+, M&F

              	 	 	
                29,822

              	 	 	 	1.90	%	 	$	
                483.93

              	 	 	$	
                4.67

              	 	 	$	
                488.60

              	 
	
                Northwest

              	
                HST,
                  Age 19-64, F

              	 	 	
                30,803

              	 	 	 	2	%	 	$	
                338.79

              	 	 	$	
                3.27

              	 	 	$	
                342.06

              	 
	
                Northwest

              	
                Subtotal

              	 	 	
                1,531,875

              	 	 	 	100	%	 	$	
                191.78

              	 	 	$	
                1.85

              	 	 	$	
                193.63

              	 
	
                Northwest

              	
                Delivery
                  Payment

              	 	 	
                5,055

              	 	 	 	0.30	%	 	$	
                4,254.97

              	 	 	$	
                41.03

              	 	 	$	
                4,295.99

              	 
	
                Northwest

              	
                Total

              	 	 	
                1,531,875

              	 	 	 	100.00	%	 	$	
                205.82

              	 	 	$	
                1.98

              	 	 	$	
                207.80

              	 

      

       

    

     

    

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        	
                Appendix
                  E

                Calendar
                  Year 2007 CFC Regional Rate Summary

              
	
                Region

              	
                Rate
                  Cohort

              	 	
                Annualized
                  April 2006 MM/Deliveries

              	 	 	
                %
                  of MM

              	 	 	
                CY
                  2007

                Guaranteed
                  Rate

              	 	 	
                CY
                  2007

                Rate
                  At Risk

              	 	 	
                CY
                  2007

                Rate

              	 
	
                Southeast

              	
                HF/HST,
                  Age 0, M & F

              	 	 	
                54,686

              	 	 	 	4.9	%	 	$	
                523.86

              	 	 	$	
                5.05

              	 	 	$	
                528.91

              	 
	
                Southeast

              	
                HF/HST,
                  Age 1, M & F

              	 	 	
                47,093

              	 	 	 	4.2	%	 	$	
                138.49

              	 	 	$	
                1.34

              	 	 	$	
                139.82

              	 
	
                Southeast

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

              	 	 	
                487,601

              	 	 	 	43.9	%	 	$	
                93.56

              	 	 	$	
                0.90

              	 	 	$	
                94.46

              	 
	
                Southeast

              	
                HF/HST,
                  Age 14-18, M

              	 	 	
                82,844

              	 	 	 	7.5	%	 	$	
                109.68

              	 	 	$	
                1.06

              	 	 	$	
                110.74

              	 
	
                Southeast

              	
                HF/HST,
                  Age 14-18, F

              	 	 	
                84,280

              	 	 	 	7.6	%	 	$	
                153.88

              	 	 	$	
                1.48

              	 	 	$	
                155.37

              	 
	
                Southeast

              	
                HF,
                  Age 19-44, M

              	 	 	
                98,747

              	 	 	 	8.9	%	 	$	
                195.17

              	 	 	$	
                1.88

              	 	 	$	
                197.06

              	 
	
                Southeast

              	
                HF,
                  Age 19-44, F

              	 	 	
                211,664

              	 	 	 	19.0	%	 	$	
                281.12

              	 	 	$	
                2.71

              	 	 	$	
                283.83

              	 
	
                Southeast

              	
                HF,
                  Age 45+, M & F

              	 	 	
                27,930

              	 	 	 	2.5	%	 	$	
                458.74

              	 	 	$	
                4.42

              	 	 	$	
                463.16

              	 
	
                Southeast

              	
                HST,
                  Age 19-64, F

              	 	 	
                16,667

              	 	 	 	1.5	%	 	$	
                320.31

              	 	 	$	
                3.09

              	 	 	$	
                323.40

              	 
	
                Southeast

              	
                Subtotal

              	 	 	
                1,111,511

              	 	 	 	100.0	%	 	$	
                179.73

              	 	 	$	
                1.73

              	 	 	$	
                181.86

              	 
	
                Southeast

              	
                Delivery
                  Payment

              	 	 	
                3,668

              	 	 	 	0.3	%	 	$	
                4,128.68

              	 	 	$	
                39.81

              	 	 	$	
                4,168.49

              	 
	
                Southeast

              	
                Total

              	 	 	
                1,111,511

              	 	 	 	100.0	%	 	$	
                193.36

              	 	 	$	
                1.86

              	 	 	$	
                195.22

              	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                Southwest

              	
                HF/HST,
                  Age 0, M & F

              	 	 	
                121,364

              	 	 	 	6.5	%	 	$	
                570.51

              	 	 	$	
                5.50

              	 	 	$	
                576.01

              	 
	
                Southwest

              	
                HF/HST,
                  Age 1, M & F

              	 	 	
                97,721

              	 	 	 	5.3	%	 	$	
                148.69

              	 	 	$	
                1.43

              	 	 	$	
                150.13

              	 
	
                Southwest

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

              	 	 	
                876,398

              	 	 	 	47.1	%	 	$	
                99.74

              	 	 	$	
                0.96

              	 	 	$	
                100.70

              	 
	
                Southwest

              	
                HF/HST,
                  Age 14-18, M

              	 	 	
                126,346

              	 	 	 	6.8	%	 	$	
                116.29

              	 	 	$	
                1.12

              	 	 	$	
                117.41

              	 
	
                Southwest

              	
                HF/HST,
                  Age 14-18, F

              	 	 	
                140,619

              	 	 	 	7.6	%	 	$	
                163.87

              	 	 	$	
                1.58

              	 	 	$	
                165.45

              	 
	
                Southwest

              	
                HF,
                  Age 19-44, M

              	 	 	
                91,907

              	 	 	 	4.9	%	 	$	
                206.77

              	 	 	$	
                1.99

              	 	 	$	
                208.77

              	 
	
                Southwest

              	
                HF,
                  Age 19-44, F

              	 	 	
                335,867

              	 	 	 	18.0	%	 	$	
                298.60

              	 	 	$	
                2.88

              	 	 	$	
                301.48

              	 
	
                Southwest

              	
                HF,
                  Age 45+, M & F

              	 	 	
                35,032

              	 	 	 	1.9	%	 	$	
                485.99

              	 	 	$	
                4.69

              	 	 	$	
                490.68

              	 
	
                Southwest

              	
                HST,
                  Age 19-64, F

              	 	 	
                35,739

              	 	 	 	1.9	%	 	$	
                340.78

              	 	 	$	
                3.29

              	 	 	$	
                344.06

              	 
	
                Southwest

              	
                Subtotal

              	 	 	
                1,860,993

              	 	 	 	100.0	%	 	$	
                192.06

              	 	 	$	
                1.85

              	 	 	$	
                193.91

              	 
	
                Southwest

              	
                Delivery
                  Payment

              	 	 	
                6,141

              	 	 	 	0.3	%	 	$	
                4,690.50

              	 	 	$	
                45.23

              	 	 	$	
                4,735.73

              	 
	
                Southwest

              	
                Total

              	 	 	
                1,860,993

              	 	 	 	100.0	%	 	$	
                207.53

              	 	 	$	
                2.00

              	 	 	$	
                209.54

              	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                West-Central

              	
                HF/HST,
                  Age 0, M & F

              	 	 	
                81,065

              	 	 	 	6.3	%	 	$	
                580.47

              	 	 	$	
                5.60

              	 	 	$	
                586.06

              	 
	
                West-Central

              	
                HF/HST,
                  Age 1, M & F

              	 	 	
                64,022

              	 	 	 	5.0	%	 	$	
                155.39

              	 	 	$	
                1.50

              	 	 	$	
                156.89

              	 
	
                West-Central

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

              	 	 	
                599,936

              	 	 	 	46.5	%	 	$	
                102.85

              	 	 	$	
                0.99

              	 	 	$	
                103.85

              	 
	
                West-Central

              	
                HF/HST,
                  Age 14-18, M

              	 	 	
                86,948

              	 	 	 	6.7	%	 	$	
                122.06

              	 	 	$	
                1.18

              	 	 	$	
                123.24

              	 
	
                West-Central

              	
                HF/HST,
                  Age 14-18, F

              	 	 	
                95,920

              	 	 	 	7.4	%	 	$	
                169.37

              	 	 	$	
                1.63

              	 	 	$	
                171.01

              	 
	
                West-Central

              	
                HF,
                  Age 19-44, M

              	 	 	
                68,617

              	 	 	 	5.3	%	 	$	
                211.40

              	 	 	$	
                2.04

              	 	 	$	
                213.43

              	 
	
                West-Central

              	
                HF,
                  Age 19-44, F

              	 	 	
                244,883

              	 	 	 	19.0	%	 	$	
                310.07

              	 	 	$	
                2.99

              	 	 	$	
                313.06

              	 
	
                West-Central

              	
                HF,
                  Age 45+, M & F

              	 	 	
                24,806

              	 	 	 	1.9	%	 	$	
                505.52

              	 	 	$	
                4.87

              	 	 	$	
                510.40

              	 
	
                West-Central

              	
                HST,
                  Age 19-64, F

              	 	 	
                23,655

              	 	 	 	1.8	%	 	$	
                352.42

              	 	 	$	
                3.40

              	 	 	$	
                355.82

              	 
	
                West-Central

              	
                Subtotal

              	 	 	
                1,289,853

              	 	 	 	100.0	%	 	$	
                199.16

              	 	 	$	
                1.92

              	 	 	$	
                201.08

              	 
	
                West-Central

              	
                Delivery
                  Payment

              	 	 	
                4,257

              	 	 	 	0.3	%	 	$	
                4,509.84

              	 	 	$	
                43.48

              	 	 	$	
                4,553.32

              	 
	
                West-Central

              	
                Total

              	 	 	
                1,289,853

              	 	 	 	100.0	%	 	$	
                214.04

              	 	 	$	
                2.06

              	 	 	$	
                216.10

              	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	
                All
                  Regions

              	
                HF/HST,
                  Age 0, M & F

              	 	 	
                773,175

              	 	 	 	5.8	%	 	$	
                555.52

              	 	 	$	
                5.36

              	 	 	$	
                560.88

              	 
	
                All
                  Regions

              	
                HF/HST,
                  Age 1, M & F

              	 	 	
                644,798

              	 	 	 	4.8	%	 	$	
                146.75

              	 	 	$	
                1.41

              	 	 	$	
                148.16

              	 
	
                All
                  Regions

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

              	 	 	
                6,171,057

              	 	 	 	46.3	%	 	$	
                97.86

              	 	 	$	
                0.94

              	 	 	$	
                98.80

              	 
	
                All
                  Regions

              	
                HF/HST,
                  Age 14-18, M

              	 	 	
                935,911

              	 	 	 	7.0	%	 	$	
                115.06

              	 	 	$	
                1.11

              	 	 	$	
                116.17

              	 
	
                All
                  Regions

              	
                HF/HST,
                  Age 14-18, F

              	 	 	
                1,003,930

              	 	 	 	7.5	%	 	$	
                160.69

              	 	 	$	
                1.55

              	 	 	$	
                162.24

              	 
	
                All
                  Regions

              	
                HF,
                  Age 19-44, M

              	 	 	
                757,896

              	 	 	 	5.7	%	 	$	
                202.09

              	 	 	$	
                1.95

              	 	 	$	
                204.04

              	 
	
                All
                  Regions

              	
                HF,
                  Age 19-44, F

              	 	 	
                2,510,133

              	 	 	 	18.9	%	 	$	
                293.06

              	 	 	$	
                2.83

              	 	 	$	
                295.89

              	 
	
                All
                  Regions

              	
                HF,
                  Age 45+, M & F

              	 	 	
                290,906

              	 	 	 	2.2	%	 	$	
                474.74

              	 	 	$	
                4.58

              	 	 	$	
                479.32

              	 
	
                All
                  Regions

              	
                HST,
                  Age 19-64, F

              	 	 	
                228,331

              	 	 	 	1.7	%	 	$	
                334.82

              	 	 	$	
                3.23

              	 	 	$	
                338.05

              	 
	
                All
                  Regions

              	
                Subtotal

              	 	 	
                13,316,137

              	 	 	 	100.0	%	 	$	
                187.77

              	 	 	$	
                1.81

              	 	 	$	
                189.58

              	 
	
                All
                  Regions

              	
                Delivery
                  Payment

              	 	 	
                43,943

              	 	 	 	0.3	%	 	$	
                4,345.63

              	 	 	$	
                41.90

              	 	 	$	
                4,387.53

              	 
	
                All
                  Regions

              	
                Total

              	 	 	
                13,316,137

              	 	 	 	100.0	%	 	$	
                202.11

              	 	 	$	
                1.95

              	 	 	$	
                204.06

              	 

      

       

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      	
              APPENDIX
                F

            
	
              REGIONAL
                RATES

            
	 	 	 	 	 	 	 	 	 	 	 	 
	
              1.  PREMIUM
                RATES  WITHOUT THE AT-RISK PAYMENT AMOUNTS FOR 12/01/07 THROUGH
                12/31/07 SHALL BE AS FOLLOWS:

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

            
	 	 	 	 	 	 	 	 	 	 	 	 
	
              MCP:  WellCare
                of Ohio, Inc.

            	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	
              SERVICE

            	
              REGIONAL

            	
              HF/HST

            	
              HF/HST

            	
              HF/HST

            	
              HF/HST

            	
              HF/HST

            	
              HF

            	
              HF

            	
              HF

            	
              HST

            	
              Delivery

            
	
              ENROLLMENT

            	
              STATUS

            	
              Age
                < 1

            	
              Age
                1

            	
              Age
                2-13

            	
              Age
                14-18

            	
              Age
                14-18

            	
              Age
                19-44

            	
              Age
                19-44

            	
              Age
                45

            	
              Age
                19-64

            	
              Payment

            
	
              AREA

            	 	 	 	 	
              Male

            	
              Female

            	
              Male

            	
              Female

            	
              and
                over

            	
              Female

            	 
	
              Northeast

            	
              Mandatory

            	
              $534.17

            	
              $141.80

            	
              $94.93

            	
              $112.38

            	
              $154.74

            	
              $195.61

            	
              $282.08

            	
              $458.37

            	
              $321.09

            	
              $4,664.87

            
	 	 	 	 	 	 	 	 	 	 	 	 
	
              List
                of Eligible Assistance Groups (AGs)

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

            	 
	
                                          -  MA-T   Children
                under 21

            	 	 	 	 
	
                                          -  MA-Y   Transitional
                Medicaid

            	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	
              Healthy
                Start:        -  MA-P  Pregnant
                Women and Children

            	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	
               For
                the SFY 2008 contract period, MCPs will be put at-risk for a portion
                of
                the premiums received for members in counties they served as of
                 January 1, 2006, provided the MCP has participated in the program
                for more than twenty-four months.  

            
	
                       

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

            
	
                      

            	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	
              Page
                1 of 3

            

    

     

     

    
      	
              APPENDIX
                F

            
	
               REGIONAL
                RATES

            
	 	 	 	 	 	 	 	 	 	 	 	 
	
              2.  AT-RISK
                AMOUNTS FOR 12/01/07 THROUGH 12/31/07 SHALL BE AS
                FOLLOWS:

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

            
	 	 	 	 	 	 	 	 	 	 	 	 
	
              MCP:  WellCare
                of Ohio, Inc.

            	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	
              SERVICE

            	
              REGIONAL

            	
              HF/HST

            	
              HF/HST

            	
              HF/HST

            	
              HF/HST

            	
              HF/HST

            	
              HF

            	
              HF

            	
              HF

            	
              HST

            	
              Delivery

            
	
              ENROLLMENT

            	
              STATUS

            	
              Age
                < 1

            	
              Age
                1

            	
              Age
                2-13

            	
              Age
                14-18

            	
              Age
                14-18

            	
              Age
                19-44

            	
              Age
                19-44

            	
              Age
                45

            	
              Age
                19-64

            	
              Payment

            
	
              AREA

            	 	 	 	 	
              Male

            	
              Female

            	
              Male

            	
              Female

            	
              and
                over

            	
              Female

            	 
	
              Northeast

            	
              Mandatory

            	
              $0.00

            	
              $0.00

            	
              $0.00

            	
              $0.00

            	
              $0.00

            	
              $0.00

            	
              $0.00

            	
              $0.00

            	
              $0.00

            	
              $0.00

            
	 	 	 	 	 	 	 	 	 	 	 	 
	
              List
                of Eligible Assistance Groups (AGs)

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

            	 
	
                                          -  MA-T   Children
                under 21

            	 	 	 	 
	
                                          -  MA-Y   Transitional
                Medicaid

            	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	
              Healthy
                Start:        -  MA-P   Pregnant
                Women and Children

            	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	
               For
                the SFY 2008 contract period, MCPs will be put at-risk for a portion
                of
                the premiums received for members in counties they served as of January
                1,
                2006, provided the MCP has participated in the program for more than
                twenty-four months.  

            
	
                        

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

            
	
                       

            	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	
              Page
                2 of 3

            

    

    

    
      	
              APPENDIX
                F

            
	
               REGIONAL
                RATES

            
	 	 	 	 	 	 	 	 	 	 	 	 
	
              3.  PREMIUM
                RATES FOR 12/01/07 THROUGH 12/31/07 SHALL BE AS
                FOLLOWS:

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

            
	 	 	 	 	 	 	 	 	 	 	 	 
	
              MCP:  WellCare
                of Ohio, Inc.

            	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	
              SERVICE

            	
              REGIONAL

            	
              HF/HST

            	
              HF/HST

            	
              HF/HST

            	
              HF/HST

            	
              HF/HST

            	
              HF

            	
              HF

            	
              HF

            	
              HST

            	
              Delivery

            
	
              ENROLLMENT

            	
              STATUS

            	
              Age
                < 1

            	
              Age
                1

            	
              Age
                2-13

            	
              Age
                14-18

            	
              Age
                14-18

            	
              Age
                19-44

            	
              Age
                19-44

            	
              Age
                45

            	
              Age
                19-64

            	
              Payment

            
	
              AREA

            	 	 	 	 	
              Male

            	
              Female

            	
              Male

            	
              Female

            	
              and
                over

            	
              Female

            	 
	
              Northeast

            	
              Mandatory

            	
              $534.17

            	
              $141.80

            	
              $94.93

            	
              $112.38

            	
              $154.74

            	
              $195.61

            	
              $282.08

            	
              $458.37

            	
              $321.09

            	
              $4,664.87

            
	 	 	 	 	 	 	 	 	 	 	 	 
	
              List
                of Eligible Assistance Groups (AGs)

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

            	 
	
                                          -  MA-T   Children
                under 21

            	 	 	 
	
                                          -  MA-Y   Transitional
                Medicaid

            	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	
              Healthy
                Start:        -  MA-P   Pregnant
                Women and Children

            	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	
               For
                the SFY 2008 contract period, MCPs will be put at-risk for a portion
                of
                the premiums received for members in counties they served as of January
                1,
                2006, provided the MCP has participated in the program for more than
                twenty-four months.  

            
	
                       

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

            
	
                       

            	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	
              Page
                3 of 3

            

    

     

     

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

      
        	
                APPENDIX
                  F

              
	
                REGIONAL
                  RATES

              
	 	 	 	 	 	 	 	 	 	 	 	 
	
                1.  PREMIUM
                  RATES  WITHOUT THE AT-RISK PAYMENT AMOUNTS FOR 07/01/07 THROUGH
                  11/30/07 SHALL BE AS FOLLOWS:

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

              
	 	 	 	 	 	 	 	 	 	 	 	 
	
                MCP:  WellCare
                  of Ohio, Inc.

              	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	
                SERVICE

              	
                REGIONAL

              	
                HF/HST

              	
                HF/HST

              	
                HF/HST

              	
                HF/HST

              	
                HF/HST

              	
                HF

              	
                HF

              	
                HF

              	
                HST

              	
                Delivery

              
	
                ENROLLMENT

              	
                STATUS

              	
                Age
                  < 1

              	
                Age
                  1

              	
                Age
                  2-13

              	
                Age
                  14-18

              	
                Age
                  14-18

              	
                Age
                  19-44

              	
                Age
                  19-44

              	
                Age
                  45

              	
                Age
                  19-64

              	
                Payment

              
	
                AREA

              	 	 	 	 	
                Male

              	
                Female

              	
                Male

              	
                Female

              	
                and
                  over

              	
                Female

              	 
	
                Northeast

              	
                Mandatory

              	
                $540.31

              	
                $143.43

              	
                $96.02

              	
                $113.67

              	
                $156.52

              	
                $197.86

              	
                $285.32

              	
                $463.64

              	
                $324.78

              	
                $4,718.49

              
	 	 	 	 	 	 	 	 	 	 	 	 
	
                List
                  of Eligible Assistance Groups (AGs)

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

              	 
	
                                            -  MA-T   Children
                  under 21

              	 	 	 	 
	
                                            -  MA-Y   Transitional
                  Medicaid

              	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	
                Healthy
                  Start:        -  MA-P  Pregnant
                  Women and Children

              	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	
                 For
                  the SFY 2008 contract period, MCPs will be put at-risk for a portion
                  of
                  the premiums received for members in counties they served as
                  of

              	 	 
	
                          January
                  1, 2006, provided the MCP has participated in the program for more
                  than
                  twenty-four months.

              	 	 	 	 
	
                 MCPs
                  will be put at-risk for a portion of the premiums received for
                  members in
                  counties they began serving after January 1, 2006,
                  beginning

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

              	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	
                Page
                  1 of 3

              

      

      

      
        	 	 	 	 	 	 	 	 	 	 	 	 
	
                APPENDIX
                  F

              
	
                 REGIONAL
                  RATES

              
	 	 	 	 	 	 	 	 	 	 	 	 
	
                2.  AT-RISK
                  AMOUNTS FOR 07/01/07 THROUGH 11/30/07 SHALL BE AS
                  FOLLOWS:

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

              
	 	 	 	 	 	 	 	 	 	 	 	 
	
                MCP:  WellCare
                  of Ohio, Inc.

              	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	
                SERVICE

              	
                REGIONAL

              	
                HF/HST

              	
                HF/HST

              	
                HF/HST

              	
                HF/HST

              	
                HF/HST

              	
                HF

              	
                HF

              	
                HF

              	
                HST

              	
                Delivery

              
	
                ENROLLMENT

              	
                STATUS

              	
                Age
                  < 1

              	
                Age
                  1

              	
                Age
                  2-13

              	
                Age
                  14-18

              	
                Age
                  14-18

              	
                Age
                  19-44

              	
                Age
                  19-44

              	
                Age
                  45

              	
                Age
                  19-64

              	
                Payment

              
	
                AREA

              	 	 	 	 	
                Male

              	
                Female

              	
                Male

              	
                Female

              	
                and
                  over

              	
                Female

              	 
	
                Northeast

              	
                Mandatory

              	
                $0.00

              	
                $0.00

              	
                $0.00

              	
                $0.00

              	
                $0.00

              	
                $0.00

              	
                $0.00

              	
                $0.00

              	
                $0.00

              	
                $0.00

              
	 	 	 	 	 	 	 	 	 	 	 	 
	
                List
                  of Eligible Assistance Groups (AGs)

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

              	 
	
                                            -  MA-T   Children
                  under 21

              	 	 	 	 
	
                                            -  MA-Y   Transitional
                  Medicaid

              	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	
                Healthy
                  Start:        -  MA-P   Pregnant
                  Women and Children

              	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	
                 For
                  the SFY 2008 contract period, MCPs will be put at-risk for a portion
                  of
                  the premiums received for members in counties they served as
                  of

              	 	 
	
                          January
                  1, 2006, provided the MCP has participated in the program for more
                  than
                  twenty-four months.

              	 	 	 	 
	
                 MCPs
                  will be put at-risk for a portion of the premiums received for
                  members in
                  counties they began serving after January 1, 2006,
                  beginning

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

              	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	
                Page
                  2 of 3

              

      

      

      
        	 	 	 	 	 	 	 	 	 	 	 	 
	
                APPENDIX
                  F

              
	
                 REGIONAL
                  RATES

              
	 	 	 	 	 	 	 	 	 	 	 	 
	
                3.  PREMIUM
                  RATES FOR 07/01/07 THROUGH 11/30/07 SHALL BE AS
                  FOLLOWS:

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

              
	 	 	 	 	 	 	 	 	 	 	 	 
	
                MCP:  WellCare
                  of Ohio, Inc.

              	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	
                SERVICE

              	
                REGIONAL

              	
                HF/HST

              	
                HF/HST

              	
                HF/HST

              	
                HF/HST

              	
                HF/HST

              	
                HF

              	
                HF

              	
                HF

              	
                HST

              	
                Delivery

              
	
                ENROLLMENT

              	
                STATUS

              	
                Age
                  < 1

              	
                Age
                  1

              	
                Age
                  2-13

              	
                Age
                  14-18

              	
                Age
                  14-18

              	
                Age
                  19-44

              	
                Age
                  19-44

              	
                Age
                  45

              	
                Age
                  19-64

              	
                Payment

              
	
                AREA

              	 	 	 	 	
                Male

              	
                Female

              	
                Male

              	
                Female

              	
                and
                  over

              	
                Female

              	 
	
                Northeast

              	
                Mandatory

              	
                $540.31

              	
                $143.43

              	
                $96.02

              	
                $113.67

              	
                $156.52

              	
                $197.86

              	
                $285.32

              	
                $463.64

              	
                $324.78

              	
                $4,718.49

              
	 	 	 	 	 	 	 	 	 	 	 	 
	
                List
                  of Eligible Assistance Groups (AGs)

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

              	 
	
                                            -  MA-T   Children
                  under 21

              	 	 	 
	
                                            -  MA-Y   Transitional
                  Medicaid

              	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	
                Healthy
                  Start:        -  MA-P   Pregnant
                  Women and Children

              	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	
                 For
                  the SFY 2008 contract period, MCPs will be put at-risk for a portion
                  of
                  the premiums received for members in counties they served as
                  of

              	 	 
	
                         January
                  1, 2006, provided the MCP has participated in the program for more
                  than
                  twenty-four months.

              	 	 	 	 
	
                 MCPs
                  will be put at-risk for a portion of the premiums received for
                  members in
                  counties they began serving after January 1, 2006,
                  beginning

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

              	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	
                Page
                  3 of 3

              

      

       

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      APPENDIX
        G

      

      COVERAGE
        AND SERVICES

      CFC
        ELIGIBLE POPULATION

      

      1.         Basic
        Benefit Package

      

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

      

      
        	
                 

              	
                ·

              	
                Inpatient
                  hospital services

              

      

      

      
        	
                 

              	
                ·

              	
                Outpatient
                  hospital services

              

      

      

      
        	
                 

              	
                ·

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

              

      

      

      
        	
                 

              	
                ·

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

              

      

      

      
        	
                 

              	
                ·

              	
                Laboratory
                  and x-ray services

              

      

      

      
        	
                 

              	
                ·

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

              

      

      

      
        	
                 

              	
                ·

              	
                Family
                  planning services and supplies

              

      

      

      
        	
                 

              	
                ·

              	
                Home
                  health and private duty nursing
                  services

              

      

      

      
        	
                 

              	
                ·

              	
                Podiatry

              

      

      

      
        	
                 

              	
                ·

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

              

      

      

      
        	
                 

              	
                ·

              	
                Physical
                  therapy, occupational therapy, and speech
                  therapy

              

      

      

      
        	
                 

              	
                ·

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

              

      

      

      
        	
                 

              	
                ·

              	
                Prescription
                  drugs

              

      

      

      
        	
                 

              	
                ·

              	
                Ambulance
                  and ambulette services

              

      

      

      
        	
                 

              	
                ·

              	
                Dental
                  services

              

      

       

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        	
              	
                ·

              	
                Durable
                  medical equipment and medical
                  supplies

              

      

      

      
        	
                 

              	
                ·

              	
                Vision
                  care services, including eyeglasses

              

      

      

      
        	
                 

              	
                ·

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

              

      

      

      
        	
                 

              	
                ·

              	
                Hospice
                  care

              

      

      

      
        	
                 

              	
                ·

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

              

      

      

      2.           Exclusions,
        Limitations and Clarifications

      

      a.           Exclusions

      

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

      

      
        	
                 

              	
                ·

              	
                Services
                  or supplies that are not medically
                  necessary

              

      

      

      
        	
                 

              	
                ·

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

              

      

      

      
        	
                 

              	
                ·

              	
                Organ
                  transplants that are not covered by
                  Medicaid

              

      

      

      
        	
                 

              	
                ·

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

              

      

      

      
        	
                 

              	
                ·

              	
                Infertility
                  services for males or females

              

      

      

      
        	
                 

              	
                ·

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

              

      

      

      
        	
                 

              	
                ·

              	
                Reversal
                  of voluntary sterilization
                  procedures

              

      

      

      
        	
                 

              	
                ·

              	
                Plastic
                  or cosmetic surgery that is not medically
                  necessary*

              

      

      

      
        	
                 

              	
                ·

              	
                Immunizations
                  for travel outside of the United
                  States

              

      

      

      
        	
                 

              	
                ·

              	
                Services
                  for the treatment of obesity unless medically
                  necessary*

              

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        	
              	
                ·

              	
                Custodial
                  or supportive care not covered by
                  Medicaid

              

      

      

      
        	
                 

              	
                ·

              	
                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

      

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

      

      Notwithstanding
        the preceding paragraph, MCPs must provide an ODJFS-approved notice to all
        their
        members 90 days in advance of the date that the MCP will impose the co-payment.
        With the exception of member co-payments the MCP has elected to implement
        in
        accordance with OAC rules 5101:3-26-05(D) and  5101:3-26-12, the MCP’s
        payment constitutes payment in full for

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      any
        covered services and their subcontractors must not charge members
        or ODJFS any additional co-payment, cost sharing, down-payment, or similar
        charge, refundable or otherwise.

      

      ii.           Abortion
        and Sterilization

      

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

      

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

      

      iii.           Behavioral
        Health Services

      

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

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

       

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

      

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

      

      Where
        an
        MCP is responsible for providing MH services for their members, the MCP is
        responsible for ensuring access to counseling and psychotherapy,
        physician/psychologist/psychiatrist services, outpatient clinic services,
        general hospital outpatient psychiatric services, pre-hospitalization screening,
        diagnostic assessment (clinical evaluation), crisis intervention, psychiatric
        hospitalization in general hospitals (for all ages), and Medicaid-covered
        prescription drugs and laboratory services.  MCPs are not required to
        cover partial hospitalization, or inpatient psychiatric care in a private
        or
        public free-standing psychiatric hospital. However, MCPs are required to
        cover
        the payment of physician services in a private or public free-standing
        psychiatric hospital when such services are billed independent of the
        hospital.

      

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

      

      Where
        an
        MCP is responsible for providing substance abuse services for their members,
        the
        MCP is responsible for ensuring access to alcohol and other drug (AOD)
        urinalysis screening, assessment, counseling,
        physician/psychologist/psychiatrist AOD treatment services, outpatient clinic
        AOD treatment services, general hospital outpatient AOD treatment services,
        crisis intervention, inpatient detoxification services in a general hospital,
        and Medicaid-covered prescription drugs and laboratory services. MCPs are
        not
        required to cover outpatient detoxification and methadone
        maintenance.

      

      Financial
        Responsibility for Behavioral Health Services:  MCPs are
        responsible for the following:

      

      
        	
                 

              	
                ·

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

              

      

      
        	
                 

              	
                ·

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

              

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        	
                 

              	
                 

              

      

      
        	
                 

              	
                ·

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

              

      

      

      Limitations:

       

      
        	
                 

              	
                ·

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

              

      

      

      
        	
                 

              	
                ·

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

              

      

      
        	
                 

              	
                ·

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

              

      

      
        	
                 

              	
                ·

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

              

      

      

      
        	
                 

              	
                iv.

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

              

      

      

      
        	
                 

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

              

      

      

      
        	
              	
                v. 

              	
                Organ
                  Transplants: MCPs must ensure coverage for
                  organtransplants and related services in accordance with OAC 5101-3-2-07.1
                  (B)(4)&(5).  Coverage for all organ transplant services,
                  exceptkidney transplants, is contingent upon review and recommendation
                  by
                  the “Ohio Solid Organ Transplant Consortium” based on criteria established
                  by Ohio organ transplant surgeons and authorization from the ODJFS
                  prior
                  authorization unit. Reimbursement for bone marrow transplant and
                  hematapoietic

              

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

       

      stem
        cell
        transplant services, as defined in OAC 3701:84-01, iscontingent upon review
        and
        recommendation by the “OhioHematapoietic Stem Cell Transplant Consortium” again
        based oncriteria established by Ohio experts in the field of bone marrow
        transplant.  While MCPs may require prior authorization for these
        transplant services, the approval criteria would be limited to confirming
        the
        consumer is being considered and/or has been recommended for a transplant
        by
        either consortium and authorized by ODJFS.  Additionally, in
        accordance with OAC 5101:3-2-03 (A)(4) all services related to organ donations
        are covered for the donor recipient when the consumer is Medicaid
        eligible.

      

      
        	
                3.

              	
                Care
                  Coordination

              

      

      

                 a.                  Utilization
        Management  (Modification) Programs

      

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

      

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

                   

      
        	
              	
                 

              	
                
                  Prior
                    Authorizations:  MCPs must receive prior approval
                    from  ODJFS
                    on the types of medication that they wish to cover through
                    prior authorizations.  MCPs must establish their prior
                    authorization
                    system so that it does not unnecessarily impede member
                    access to medically-necessary Medicaid-covered services. MCPs
                    must comply with the provisions of 1927(d)(5) of the
                    Social

                

              

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      Security
        Act, 42 USC
        1396r-8(k)(3), and OAC rule 5101:3-26-03.1regarding the timeframes
        for prior authorization of covered outpatientdrugs.

      

      MCPs
        may
        also, with ODJFS prior approval, implement pharmacy utilization modification
        programs designed to address members demonstrating high or inappropriate
        utilization of specific prescription drugs.

      

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

      

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

      

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

      

      
        	
                 

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

              

      

      

      b.           Case
        Management Programs

      

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

      

      
        	
                 

              	
                i.

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

              

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

       

      
        	
                 

              	
                ii.

              	
                Children
                  with Special Health Care Needs
                  (CSHCN):

              

      

      

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

      

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

      -Asthma

      -HIV/AIDS

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

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

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

      

      
        	
                 

              	
                iii.

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

              

      

      

      
        	
                 

              	
                a.

              	
                Identification
                  -

              

      

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

      

      
        	
                 

              	
                b.

              	
                Assessment
                  -

              

      

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

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      oversight
        and monitoring by either a registered nurse or physician.

      

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

      

      
        	
                 

              	
                c.

              	
                Case
                  Management-

              

      

      

      
        	
                 

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

              

      

      

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

      

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

      

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

      

      
        	
                 

              	
                3.  The
                  development of the care treatment plan must be based on the comprehensive
                  health assessment.  The MCP must offer both the member and the
                  member’s PCP/specialist the opportunity to participate in the development
                  of, and any subsequent revisions to, the care treatment
                  plan.  The MCP must have a process for re-evaluating the
                  member’s need for case management and updating the care treatment plan,
                  if
                  necessary, on a semi-annual basis.

              

      

      

      
        	
                 

              	
                4.

              	
                The
                  MCP must have a process to facilitate, maintain,
                  and

              

      

      coordinate
        communication between service providers, the member, and the member’s
        family.  There should be an accountable point of contact (i.e., case
        manager) who can help obtain medically necessary care, assist with
        health-related services and coordinate care needs.

      

      5.      The
        MCP must follow best-practice and/or evidence based clinical guidelines when
        developing a member’s care treatment plan and coordinating the case management
        needs. The MCP must develop and implement mechanisms to educate and
        equip

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      providers
        and case managers with evidence-based clinical guidelines or best practice
        approaches to assist in providing a high level of quality of care to
        members.

      

       6.    The
        MCP must implement mechanisms to notify all    CSHCN 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.

      

      
        	
                 

              	
                7.

              	
                The
                  MCP must provide case management services for all CSHCN, including
                  the
                  ODJFS mandated conditions as specified in Appendix M Case Management
                  Program Performance Measures.  The MCP should also focus on all
                  members, including adults, whose health conditions warrant case
                  management
                  services and should not limit these services only to members with
                  the
                  mandated conditions.

              

      

      

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

      

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

      

      
        	
                 

              	
                iv.

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

              

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      

      

      c.           Care
        Coordination with ODJFS-Designated Providers

      

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

      

      
        	
                 

              	
                i.

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

              

      

      

      
        	
                 

              	
                ii.

              	
                A
                  brief summary document that includes the following
                  information:

              	
                 

              

      

      

      
        	
                 

              	
                ·

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

              

      

      

      
        	
                 

              	
                ·

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

              

      

      

      
        	
                 

              	
                ·

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

              

      

      

      
        	
                 

              	
                ·

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

              

      

      

      
        	
                 

              	
                ·

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

              

      

      

      
        	
                 

              	
                ·

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

              

      

      

      
        	
                 

              	
                ·

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

              

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        	
                 

              	
                 

              

      

      

      d.           Care
        coordination with Non-Contracting Providers

      

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

      

      e.           Integration
        of Member Care

      

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

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

      APPENDIX
        H

      

      PROVIDER
        PANEL SPECIFICATIONS

      CFC
        ELIGIBLE POPULATION

      

      

      
        	
                1.

              	
                GENERAL
                  PROVISIONS

              

      

      

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

      

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

      

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

      

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

      

      2.           PROVIDER
        SUBCONTRACTING

      

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

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
              

          

        

      

      

      Administrative
        Code rule requirements specific to provider subcontracting and therefore
        cannot
be
        modified except to add personalizing information such as the MCP’s
        name.

      

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

      

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

      

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

      

      3.           PROVIDER
        PANEL REQUIREMENTS

      

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

      

      a.           Primary
        Care Physicians (PCPs)

      

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

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

      

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

      

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

      

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

      

      ODJFS
        recognizes that MCPs will need to utilize specialty 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.  These PCPs will, however, need to
        execute a subcontract with the MCP which includes the appropriate Model Medicaid
        Addendum.

      

      The
        PCP
        requirement is based on an MCP having sufficient PCP capacity to
        serve

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

      

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

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

      

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

      

      b.           Non-PCP
        Provider Network

      

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

      

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

      

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

      

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

      

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

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

      

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

      

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

      

      OB/GYNs
        - MCPs must contract with the specified  number of OB/GYNs for each
        county/region, all of whom must maintain a full-time obstetrical practice
        at a
        site(s) located in the specified county/region.  All MCP-contracting
        OB/GYNs must have current hospital delivery privileges at
        a hospital under contract with the MCP in the region.

      

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

      

      Contracting
        CNMs must have hospital delivery privileges at a hospital under contract
        to the
        MCP in the region. The MCP must ensure a member’s access to CNM and CNP services
        if such providers are practicing within the region.

      

      Vision
        Care Providers - MCPs must contract with the specified number of
        ophthalmologists/optometrists for each specified county/region , all of whom
        must maintain a full-time practice at a site(s) located in the specified
        county/region. All ODJFS-approved vision providers must regularly perform
        routine eye exams. (MCPs will be expected to contract with an
        adequate number of ophthalmologists as part of their overall provider panel,
        but
        only ophthalmologists who regularly perform routine eye exams can be used
        to
        meet the vision care provider panel requirement.) If optical dispensing is
        not
        sufficiently available in a region through the MCP’s contracting
        ophthalmologists/optometrists, the MCP must separately contract with an adequate
        number of optical dispensers located in the region.

      

      Dental
        Care Providers - MCPs must contract with the specified number of
        dentists. In order to assure sufficient access to adult MCP
        members, no more than two-thirds of the dentists used to meet
        the provider panel requirement may be pediatric
        dentists.

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

      

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

      

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

      

      
        	
                 

              	
                •

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

              

      

      

      
        	
                 

              	
                •

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

              

      

      

      
        	
                 

              	
                •

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

              

      

      

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

      

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

      pertinent
        information to the member’s PCP and/or MCP.

      

      Behavioral
        Health Providers – MCPs must assure member access to all Medicaid-covered
        behavioral health services for members as specified in Appendix
        G.b.ii.  Although ODJFS is aware that certain outpatient substance
        abuse services may only be available through Medicaid providers certified
        by  the Ohio Department of Drug and Alcohol Addiction
        Services  (ODADAS)  in some areas, MCPs must maintain an
        adequate number of contracted mental health providers in the region to assure
        access for members who are unable to timely access services or
        unwilling to access services through community mental health
        centers.  MCPs are

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

      

      advised
        not to contract with community mental health centers as all services they
        provide to MCP members are to be billed to ODJFS.

      

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

      

      4.           PROVIDER
        PANEL EXCEPTIONS

      

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

      

      
        	
                 

              	
                -

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

              

      

      

      
        	
                 

              	
                -

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

              

      

      

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

      

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

      

      ODJFS
        will aggressively monitor access to all services related to the approval
        of
        a provider panel exception request through a variety of data sources,
        including: consumer satisfaction surveys; member
        appeals/grievances/complaints and state hearing notifications/requests;
        member just-cause for termination requests; clinical quality studies;
encounter
        data volume; provider complaints, and clinical performance
        measures.  ODJFS approval of a provider panel exception request does
        not exempt the MCP from assuring access to the
        services in question.  If ODJFS determines that an MCP has not
        provided sufficient access to these services, the MCP may be subject to
        sanctions.

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

      

      
        	
                5.

              	
                PROVIDER
                  DIRECTORIES

              

      

      

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

      

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

      

      The
        directory must also specify:

      
        
          	
                   

                	
                  •

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

                

        

        
          	
                   

                	
                  •

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

                

        

        
          	
                   

                	
                  •

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

                

        

        
          	
                   

                	
                  •

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

                

        

        
          	
                   

                	
                  •

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

                

        

        
          	
                   

                	
                  •

                	
                  any
                    PCP or specialist practice
                    limitations.

                

        

      

       

      Printed
        Provider Directory

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

      

      On
        a
        quarterly basis, MCPs must create an insert to
        each printed directory that lists those providers deleted
        from the MCP’s provider panel during the previous three
        months.  Although

      this
        insert does not need to be prior approved by ODJFS, copies of the insert
        must be
        submitted to ODJFS two weeks prior to distribution to members.

      

      Internet
        Provider Directory

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

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

      for
        multiple populations, each provider must include a description of which
        population they serve.

      

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

      

      
        	
                6
                  .

              	
                FEDERAL
                  ACCESS STANDARDS

              

      

      

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

      

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

      

      
        	
                 

              	
                •

              	
                The
                  anticipated Medicaid membership.

              

      

      
        	
                 

              	
                •

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

              

      

      
        	
                 

              	
                •

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

              

      

      
        	
                 

              	
                •

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

              

      

      
        	
                 

              	
                •

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

              

      

      

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

      

      In
        order
        to demonstrate adequate provider panel capacity and services, 42 CFR 438.206
        and

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
             

          

        

      

      438.207
        stipulates that the MCP must submit documentation to ODJFS, in a format
        specified by ODJFS, that demonstrates it offers an appropriate range of
        preventive, primary care and specialty

      

      services
        adequate for the anticipated number of members in the service area, while
        maintaining a provider panel that is sufficient in number, mix, and geographic
        distribution to meet the needs of the number of members in the service
        area.

      

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

      

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

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      
        	
                North
                  East Region - Hospitals        

              
	
                Minimum
                  Provider Panel Requirements      

              
	 	
                Total
                  Required Hospitals

              	
                Ashtabula

              	
                Cuyahoga

              	
                Erie

              	
                Geauga

              	
                Huron

              	
                Lake

              	
                Lorain

              	
                Medina

              	
                Additional
                  Required Hospitals: Out-of-Region

              
	
                General
                  Hospital1

              	
                8
                  2

              	
                1

              	
                1
                  2

              	
                1

              	
                1

              	
                1

              	
                1

              	
                1

              	
                1

              	 
	
                Hospital
                  System

              	
                1

              	 	
                1

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

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

              

      

       

       

    

    
      	
               North
                East Region - PCP Capacity

            
	
                  Minimum
                PCP Capacity Requirements       

            
	
              PCPs

            	
              Total
                Required

            	
              Ashtabula

            	
              Cuyahoga

            	
              Erie

            	
              Geauga

            	
              Huron

            	
              Lake

            	
              Lorain

            	
              Medina

            	
              Additional
                Required: In-Region *

            
	
              Capacity
                1

            	
              98,212

            	
              5,256

            	
              66,564

            	
              2,873

            	
              1,111

            	
              2,612

            	
              5,210

            	
              11,431

            	
              3,155

            	
               

            
	
              FTEs

            	
              49.11

            	
              2.63

            	
              33.28

            	
              1.44

            	
              0.56

            	
              1.31

            	
              2.61

            	
              5.72

            	
              1.58

            	 
	
              1  Based
                on an FTE of 2000 members

            	 	 	 	 	 	 	 
	
              *
                Must be located within the region.

            	 	 	 	 	 	 

    

     

    
      	
              North
                East Region - Practitioners      

            
	
              Minimum
                Provider Panel Requirements     

            
	
              Provider
                Types

            	
              Total
                Required Providers1

            	
              Ashtabula

            	
              Cuyahoga

            	
              Erie

            	
              Geauga

            	
              Huron

            	
              Lake

            	
              Lorain

            	
              Medina

            	
              Additional
                Required Providers2

            
	
              Pediatricians4

            	
              90

            	
              1

            	
              66

            	
              2

            	
               

            	 	
              3

            	
              8

            	
              3

            	
              7

            
	
              OB/GYNs

            	
              25

            	
              1

            	
              16

            	
              1

            	 	
              1

            	
              1

            	
              2

            	
              1

            	
              2

            
	
              Vision

            	
              33

            	
              1

            	
              25

            	
              1

            	 	 	
              1

            	
              2

            	
              1

            	
              2

            
	
              General
                Surgeons

            	
              20

            	 	
              12

            	
              1

            	 	
              1

            	
              1

            	
              2

            	
              1

            	
              2

            
	
              Otolaryngologist

            	
              6

            	 	
              2

            	 	 	 	 	
              1

            	 	
              3

            
	
              Allergists

            	
              5

            	 	
              2

            	 	 	 	 	
              1

            	 	
              2

            
	
              Orthopedists

            	
              16

            	 	
              8

            	
              1

            	 	 	
              1

            	
              2

            	
              1

            	
              3

            
	
              Dentists5

            	
              89

            	
              2

            	
              65

            	
              1

            	
              1

            	
              1

            	
              5

            	
              10

            	
              3

            	
              1

            
	
              1
                All required
                providers must be located within the region.

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

            
	
              3
                Preferred
                Providers are the additional provider contracts that must
                be

            
	
                secured
                in order for the MCP to receive bonus points.

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

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

            

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    APPENDIX
      I

    

    PROGRAM
      INTEGRITY

    CFC
      ELIGIBLE POPULATION

    

    MCPs
      must
      comply with all applicable program integrity requirements, including those
      specified in 42 CFR 455 and 42 CFR 438 Subpart
      H.

    

    1.           Fraud
      and Abuse Program:

     

    
      	
            	
               

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

              

            

    

    

    
      	
            	
               

            	
              
                In
                  addition to the requirements in OAC rule 5101:3-26-06, the
                  MCP’s
                  complianceprogram which safeguards against fraud and abuse must,
                  at a
                  minimum, specificallyaddress the
                  following:

              

            

    

    

    
      	
               

            	
              a.

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

            

    

    

    
      	
               

            	
              i.      establish
                and make readily available to all employees, including theMCP’s
                management, the following written policies regarding false
                claimsrecovery:

            

    

    

    
      	
               

            	
              a.

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

            

    

    

    
      	
               

            	
              b.

            	
              the
                MCP’s policies and procedures for detecting and preventing fraud, waste,
                and abuse; and

            

    

    

    
      	
               

            	
              c.

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

            

    

    

    
      	
               

            	
              ii.    include
                in any employee handbook the required written policies regardingfalse
                claims recovery;

            

    

    

    
      	
               

            	
              iii.

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

            	
               

            	
               

            

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

     

    
      	
               

            	
              iv.

            	
              disseminate
                the required written policies to all contractors and agents, who
must
                abide by those written policies.

            	
               

            

    

    

    
      	
               

            	
              b.

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

            

    

    

    
      	
               

            	
              i.

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

            

    

    

    
      	
               

            	
              ii.

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

            

    

    

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

    

    
      	
               

            	
              iii.

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

            

    

    

    
      	
               

            	
              c.

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

            

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

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

    

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

    

    ii.           source
      of complaint;

    

    iii.           type
      of provider;

    

    iv.           nature
      of complaint;

    

    v.           approximate
      range of dollars involved, if applicable;

    

    vi.           results
      of MCP’s investigation and actions taken;

    

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

    

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

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

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

    

    2.           Data
      Certification:

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

    

    
      	
               

            	
              a.

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

            

    

    

    i.           Encounter
      Data [as specified in the Data Quality Appendix (Appendix 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.

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    WellCare

    

    APPENDIX
      J

    

    FINANCIAL
      PERFORMANCE

    CFC
      ELIGIBLE POPULATION

    

    1.           SUBMISSION
      OF FINANCIAL STATEMENTS AND REPORTS

    

    MCPs
      must submit the following
      financial reports to ODJFS:

    

    
      	
               

            	
              a.

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

            

    

    

    
      	
               

            	
              b.

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

            

    

    

    
      	
               

            	
              c.

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

            

    

    

    
      	
               

            	
              d.

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

            

    

    

    
      	
               

            	
              e.

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

            

    

     

    
      	
               

            	
              f.

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

            

    

    

    
      	
            	
              g.

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

            

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      	
            	
              h.

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

            

    

    

    
      	
               

            	
              i.

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

            

    

    

    
      	
               

            	
              j.

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

            

    

    

    
      	
              k.

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

            	
               

            	
               

            

    

    

    

    2.           FINANCIAL
      PERFORMANCE MEASURES AND STANDARDS

    

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

     

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

     

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

    

    
      	
               

            	
              Definition:

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

            

    

    

    
      	
               

            	
              Standard:

            	
              For
                the financial report that covers calendar year 2007, a minimum net
                worth
                per member of $151.00, as determined from the annual Financial Statement
                submitted to ODI and the ODJFS.

            

    

    

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

    

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

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    

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

    

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

    

    b.           Indicator:                                Administrative
      Expense Ratio

    

    
      	
               

            	
              Definition:

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

            

    

    

    
      	
               

            	
              Standard:

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

            

    

    

    c.           Indicator:                                Overall
      Expense Ratio

    

    
      	
            	
              Definition:

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

            

    

    

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

    

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

    

    
      	
               

            	
              Standard:

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

            

    

    

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

    

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

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

     

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

    

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

    

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

     

    d.           Indicator:                                Days
      Cash on Hand

    

    
      	
               

            	
              Definition:

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

            

    

    

    
      	
               

            	
              Standard:

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

            

    

     

    e.           Indicator:                                Ratio
      of Cash to Claims Payable

    

    
      	
               

            	
              Definition:

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

            

    

    

    
      	
               

            	
              Standard:

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

            

    

    

     

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

     

    3.           REINSURANCE
      REQUIREMENTS

     

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

    

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

    

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

    

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

     

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

      	
               

            	
              b.

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

            

      	 	c.  	 the
              number of members covered by the MCP;

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

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

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

      	 	 	 

    

    

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

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

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

     

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

    

    
      	
               

            	
              4.

            	
              PROMPT
                PAY REQUIREMENTS

            

    

    

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

    

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

    

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

    

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

    

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

    

     

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    5.           PHYSICIAN
      INCENTIVE PLAN DISCLOSURE REQUIREMENTS

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

    

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

    

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

    

    
      	
               

            	
              a.

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

            

    

    

    
      	
               

            	
              b.

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

            

    

    

    
      	
               

            	
              c.

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

            

    

    

    
      	
               

            	
              d.

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

            

    

    
       

      6.           NOTIFICATION
        OF REGULATORY ACTION

      

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

    

    

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      APPENDIX
        K

      

      QUALITY
        ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM

      AND

      EXTERNAL
        QUALITY REVIEW

      CFC
        ELIGIBLE POPULATION

      

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

      

      a.  PERFORMANCE
        IMPROVEMENT PROJECTS

      

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

      

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

      

      MCPs
        must
        initiate the following PIPs:

      

      
        	
                 

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

              

      

      

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

      

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

      

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

      

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

      

      b.    UNDER-
        AND
        OVER-UTILIZATION

      

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

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      

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

      

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

      

      c.  SPECIAL
        HEALTH CARE NEEDS

      

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

      

      d.  SUBMISSION
        OF PERFORMANCE MEASUREMENT DATA

      

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

      

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

      

      
        	
                 

              	
                i.

              	
                Well
                  Child Visits in the First 15 Months of
                  Life

              

      

      ii.           Child
        Immunization Status

      iii.           Adolescent
        Immunization Status

      

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

      

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

      

      2.           EXTERNAL
        QUALITY REVIEW

      

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

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

          a.
EQRO
        ADMINISTRATIVE REVIEW 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 include, but not be
        limited to, the following domains as specified by ODJFS:  member
        rights and services, QAPI program, access standards, provider network, grievance
        system, case management, coordination and continuity of care, and utilization
        management.  In accordance with 42 CFR 438.360 and
        438.362, MCPs with accreditation from a national
        accrediting organization approved by the Centers for Medicare and Medicaid
        Services (CMS) may request a non-duplication exemption from certain specified
        components of the administrative review.  Non-duplication exemptions
        may not be requested for SFY 08.

      

      
        	
                 

              	
                b.

              	
                ANNUAL
                  REVIEW OF QAPI AND CASE MANAGEMENT
                  PROGRAM

              

      

      

      
        	
                 

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

              

      

      

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

      

      c.  EXTERNAL
        QUALITY REVIEW PERFORMANCE

      

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

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

       

      APPENDIX
        L

      

      DATA
        QUALITY

      CFC
        ELIGIBLE POPULATION

      

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

      

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

      

      1.
        ENCOUNTER DATA

      

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

      

      1.a.  Encounter
        Data Completeness

      

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

      

      1.a.i.
        Encounter Data Volume

      

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

      

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

      

      

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

                 

        

      

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

      
        	
                Quarterly
                  Report Periods

              	
                Data
                  Source:

                Estimated
                  Encounter  Data File Update

              	
                Quarterly
                  Report

                Estimated
                  Issue Date

              	
                Contract
                  Period

              
	
                Qtr  3
                  &  Qtr 4  2004,  2005, 2006

                Qtr
                  1 2007

              	
                July
                  2007

              	
                August
                  2007

              	
                SFY
                  2008

              
	
                Qtr
                  3 & Qtr 4  2004, 2005, 2006

                Qtr
                  1, Qtr 2 2007

              	
                October  2007

              	
                November  2007

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

              	
                January  2008

              	
                February  2008

              
	
                Qtr
                  1 thru Qtr 4: 2005, 2006, 2007

              	
                April  2008

              	
                May
                  2008

              
	
                Qtr
                  2 thru Qtr 4 2005,

                Qtr
                  1 thru Qtr 4: 2006, 2007

                Qtr
                  1 2008

              	
                July
                  2008

              	
                August
                  2008

              	
                SFY
                  2009

              
	
                Qtr
                  3, Qtr 4: 2005,

                Qtr
                  1 thru Qtr 4: 2006, 2007

                Qtr
                  1, Qtr 2 2008

              	
                October  2008

              	
                November  2008

              
	
                Qtr
                  4: 2005,

                Qtr
                  1 thru Qtr 4: 2006, 2007

                Qtr
                  1 thru Qtr 3: 2008

              	
                January  2009

              	
                February  2009

              
	
                Qtr
                  1 thru Qtr 4: 2006, 2007, 2008

              	
                April  2009

              	
                May  2009

              

      

      Qtr1
        =
        January to
        March                                                        
Qtr2 = April to
        June                                              Qtr3
        = July to SeptemberQtr4 = October to December

      

       

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      

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

      

      Data
        Quality Standard, County-Based Approach:  The standards in Table
        2 apply to the MCP’s county-based results (see County-Based Approach
        below).  The utilization rate for all service

      categories
        listed in Table 2 must be equal to or greater than the standard established
        in
        Table 2 below.

      

      
        	
                Category

              	
                Measure
                  per 1,000/MM

              	
                Standard
                  for Dates of Service

                7/1/2003
                  thru 6/30/2004

              	
                Standard
                  for Dates of Service

                7/1/2004
                  thru 6/30/2006

              	
                Standard
                  for Dates of Service

                on
                  or after 7/1/2006

              	
                Description

              
	
                Inpatient
                  Hospital

              	
                Discharges

              	
                5.4

              	
                5.0

              	
                5.4

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

              
	
                Emergency
                  Department

              	
                Visits

              	
                51.6

              	
                51.4

              	
                50.7

              	
                Includes
                  physician and hospital emergency department encounters

              
	
                Dental

              	
                38.2

              	
                41.7

              	
                50.9

              	
                Non-institutional
                  and hospital dental visits

              
	
                Vision

              	
                11.6

              	
                11.6

              	
                10.6

              	
                Non-institutional
                  and hospital outpatient optometry and ophthalmology
                  visits

              
	
                Primary
                  and Specialist Care

              	
                220.1

              	
                225.7

              	
                233.2

              	
                Physician/practitioner
                  and hospital outpatient visits

              
	
                Ancillary
                  Services

              	
                144.7

              	
                123.0

              	
                133.6

              	
                Ancillary
                  visits

              
	
                Behavioral
                  Health

              	
                Service

              	
                7.6

              	
                8.6

              	
                10.5

              	
                Inpatient
                  and outpatient behavioral encounters

              
	
                Pharmacy

              	
                Prescriptions

              	
                388.5

              	
                457.6

              	
                492.2

              	
                Prescribed
                  drugs

              

      

      

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

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

                 

        

      

      counties
        will remain in the county-based results for MCP AAA until the West Central
        regional measure is implemented.]

      

      Interim
        Regional-Based Approach:

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

      

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

      

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

      

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

      

      
        	
                Category

              	
                Measure
                  per 1,000/MM

              	
                Standard
                  for Dates of Service

                on
                  or after 7/1/2006

              	
                Description

              
	
                Inpatient
                  Hospital

              	
                Discharges

              	
                2.7

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

              
	
                Emergency
                  Department

              	
                Visits

              	
                25.3

              	
                Includes
                  physician and hospital emergency department encounters

              
	
                Dental

              	
                25.5

              	
                Non-institutional
                  and hospital dental visits

              
	
                Vision

              	
                5.3

              	
                Non-institutional
                  and hospital outpatient optometry and ophthalmology
                  visits

              
	
                Primary
                  and Specialist Care

              	
                116.6

              	
                Physician/practitioner
                  and hospital outpatient visits

              
	
                Ancillary
                  Services

              	
                66.8

              	
                Ancillary
                  visits

              
	
                Behavioral
                  Health

              	
                Service

              	
                5.2

              	
                Inpatient
                  and outpatient behavioral encounters

              
	
                Pharmacy

              	
                Prescriptions

              	
                246.1

              	
                Prescribed
                  drugs

              

      

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

            

        

      

      

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

      

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

      

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

      

      1.a.ii.  Encounter
        Data Omissions

      

      Omission
        studies will evaluate the completeness of the encounter data.

      

      Measure:  This
        study will compare the medical records of members during the time of membership
        to the encounters submitted.  Omission rates will be calculated per
        MCP.

      

      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 the  records
        requested for the study.

      

      Data
        Quality Standard:   The data quality standard is a maximum
        omission rate of  15% for studies with report  periods
        ending in CY 2007 and CY 2008.

      

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

      

      1.a.iii.
        Incomplete Outpatient Hospital Data

      

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

      

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

      

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

      

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

      

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

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

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

                 

        

      

       

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

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

      

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

      

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

      

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

      

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

      

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

      

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

      

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

      

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

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

              

        

      

       

      1.a.v.  Rejected
        Encounters

      

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

      

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

      

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

      

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

      

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

      

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

      

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

      

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

      

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

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

                

        

      

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

      

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

      

      Third
        through sixth months with
        membership:   50%

      

      Seventh
        through twelfth month with
        membership:   25%

      

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

      

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

      

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

      

      1.a.vi.                      Acceptance
        Rate

      

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

      

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

      

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

      

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

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

            

        

      

       

      
        	
                Third
                  through sixth month with membership: 

              	
                50
                  encounters per 1,000 MM for NCPDP

              

        	 	65
                encounters per 1,000 MM for NSF

        	 	20
                encounters per 1,000 MM for UB-92

      

       

      
        	
                
                  Sevenththrough
                    twelfth month of membership: 

                

              	
                
                  250 encounters per 1,000 MM for NCPDP

                

              

        	 	350
                encounters per 1,000 MM for NSF

        	 	100
                encounters per 1,000 MM for UB-92

      

       

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

      

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

      

      1.a.vii.  Incomplete
        Birth Weight Data

      

      Measure:
        The percentage of newborn delivery inpatient encounters during the report
        period
        which contained a birth weight.  If a value of  "88" through
        "96" is found on any of the five condition code fields on the UB-92 inpatient
        claim format, then the encounter will be considered to have a birth weight.
        The
        condition code fields are described in Items 24-30 of the "Inpatient Hospital,
        UB-92 Claim Form Instructions."  The measure will be calculated per
        MCP (i.e., to include the MCP’s entire service area for the CFC
        membership.

      

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

      

      Data
        Quality Standard:  The data quality standard is a minimum rate of
        90%.

      

      Penalty
        for noncompliance:   If an MCP
        is  determined to be noncompliant with the standard, ODJFS will impose
        a monetary sanction (see Section 6.) of one percent of the current month’s
        premium payment.  Once the MCP is performing at standard levels and
        violations/deficiencies are resolved to the satisfaction of ODJFS, the money
        will be refunded.

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
          

        

      

       

      1.b.  Encounter
        Data Accuracy

      

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

      

      1.b.i.  Encounter
        Data Accuracy Studies

      

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

      

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

      

      Medical
        records retrieval from the provider and submittal to ODJFS or its designee
        is an
        integral component of the validation process.  ODJFS has optimized the
        sampling to minimize the number of records required.  This methodology
        requires a high record submittal rate.  To aid MCPs in
        achieving

      a
        high
        submittal rate, ODJFS will give at least an 8 week period to retrieve and
        submit
        medical records as a part of the validation process.  A record
        submittal rate will be calculated as a percentage of all records requested
        for
        the study.

      

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

      

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

      

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

      

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

      

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

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

                 

        

      

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

      

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

      

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

      

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

      

      1.b.ii.  Generic
        Provider Number Usage

      

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

      

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

      

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

      

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

      

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

      

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

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

            

        

      

       

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

      

      1.c.
        Timely Submission of Encounter Data

      

      1.c.i.  Timeliness

      

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

      

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

      

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

      

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

      

      
        	
                 

              	
                2.
                  CASE MANAGEMENT DATA

              

      

      

      ODJFS
        designed a case management system (CAMS) in order to monitor MCP compliance
        with
        program requirements specified in Appendix G, Coverage and
        Services.  Each MCP’s case management data submissions will be
        assessed for completeness and accuracy.   The MCP is responsible
        for submitting a  case management file every month.  Failure to
        do so jeopardizes the MCP’s ability to demonstrate
        compliance with CSHCN requirements.   For detailed descriptions
        of the case management measures below, see ODJFS Methods for Case Management
        Data Quality Measures.

      

      2.a.   Case
        Management System Data Accuracy

      

      2.a.i.
        Open Case Management Spans for Disenrolled Members

      

      Measure:  The
        percentage of the MCP’s adult and children case management records in the
        Screening, Assessment, and Case Management System that have open case management
        date spans for members who have disenrolled from the MCP.

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

               

        

      

       

      Report
        Period: For the SFY 2007 contract period, January – March 2007, and April –
June 2007 report periods.  For the SFY 2008 contract
        period,  July – September 2007, October – December 2007, January –
March 2008, and April – June 2008 report periods.  For the SFY 2009
        contract period,  July – September 2008, October – December 2008,
        January – March 2009, and April – June 2009 report periods.

      

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

      

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

      

      For
        any MCP which did not have membership as of
February 1, 2006: Performance will begin to be
        evaluated using region-based results for any active region  in which
        all selected MCPs had at least 10,000 members during each month of the entire
        report period.

      

      Regional-Based
        Approach: MCPs will be evaluated by region, using results for all counties
        included in the region.

      

      Penalty
        for noncompliance:   If an MCP is noncompliant with the
        standard, then the ODJFS will issue a Sanction Advisory informing the MCP
        that a
        monetary sanction will be imposed if the MCP is noncompliant for any future
        report periods.  Upon all subsequent semi-annual measurements
        of

      performance,
        if an MCP is again determined to be noncompliant with the standard, ODJFS
        will
        impose a monetary sanction of one-half of one percent of the current month’s
        premium payment. Once the MCP is performing at standard levels and
        violations/deficiencies are resolved to the satisfaction of ODJFS, the money
        will be refunded.

      

      2.b.  Timely
        Submission of Case Management Files

      

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

      

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

      

      
        	
                 

              	
                3.  EXTERNAL
                  QUALITY REVIEW DATA

              

      

      

      In
        accordance with federal law and regulations, ODJFS  is required to
        conduct an independent quality review of contracting managed care
        plans.  The OAC rule 5101:3-26-07(C) requires MCPs to

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
          

        

      

      submit
        data and information as requested by ODJFS or its designee for the annual
        external quality review.

      

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

      

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

      

      If
        an MCP
        does not complete a study because 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
        percentage of requested records for a study conducted by the External Quality
        Review Organization (EQRO) that are submitted by the managed care
        plan.

      

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

      

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

      

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

      

      4.  MEMBERS’
        PCP DATA

      

      The
        designated PCP is the physician who will manage and coordinate the overall
        care
        for CFC members, including those who have case management needs.  The
        MCP must submit  a Members’ Designated PCP file every
        month.  Specialists may and should be identified as the PCP as
        appropriate for the member’s condition per the specialty types specified for the
        CFC population in ODJFS Member’s PCP Data File and Submission
        Specifications; however, no CFC member may have more than one PCP
        identified for a given month.

      

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

      

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

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

             

        

      

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

      

      4.b.  Designated
        PCP for newly enrolled members

      

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

      

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

      

      Data
        Quality Standard:  SFY 2007 will be informational only. A minimum
        rate of 75% of new members with PCP designation by their effective date of
        enrollment for quarter 1 and quarter 2 of

      SFY
        2008.  A minimum rate of  85% of new members with PCP
        designation by their effective

      

      date
        of
        enrollment for quarter 3 and quarter 4 of SFY 2008.  For SFY 2009, a
        minimum rate of 85% of new members with PCP designation by their effective
        date
        of enrollment.

      

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

      

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

      

      5.
        APPEALS AND GRIEVANCES DATA

      

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

      

      The
        appeal data file and the grievance data file must include all appeal and
        grievance activity, respectively, for the previous month, and must be submitted
        by the ODJFS-specified due date.  These

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

                

        

      

      data
        files must be submitted in the ODJFS-specified format and with the
        ODJFS-specified filename in order to be successfully processed.

      

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

      

      6.  NOTES

      

      
        	
                6.a.

              	
                Penalties,
                  Including Monetary Sanctions, for
                  Noncompliance

              

      

      

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

      

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

      

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

      

      6.b.
        Combined Remedies

      

      If
        ODJFS
        determines that one systemic problem is responsible for multiple deficiencies,
        ODJFS may impose a combined remedy which will address all areas of deficient
        performance.  The total fines assessed in any one month will not
        exceed 15% of the MCP’s monthly premium payment.

      

      6.c.  Membership
        Freezes

      

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

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

            

        

      

      6.d.  Reconsideration

      

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

      

      6.e.  Contract
        Termination, Nonrenewals, or Denials

      

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

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

              

        

      

      APPENDIX
        M

      

      PERFORMANCE
        EVALUATION

      CFC
        ELIGIBLE POPULATION

      

      This
        appendix establishes minimum performance standards for managed care plans
        (MCPs)
        in key program areas.  The intent is to maintain accountability for
        contract requirements.  Standards are subject to change based on the
        revision or update of applicable national standards, methods or
        benchmarks.  Performance will be evaluated in the categories of
        Quality of Care, Access, Consumer Satisfaction, and Administrative
        Capacity.  Each performance measure has an accompanying minimum
        performance standard. MCPs with performance levels below the minimum performance
        standards will be required to take corrective action.  The Ohio
        Medicaid managed care program will transition to a regional-based system
        as
        managed care expands statewide, beginning in SFY 2007.  Evaluation of
        performance will transition to a regional-based approach after completion
        of the
        statewide expansion. Given that statewide expansion was not complete by
        December 31, 2006, ODJFS may adjust performance measure reporting periods
        based
        on the number of months an MCP has had regional membership.  Due to
        differences in data and reporting requirements, transition to the regional-based
        approach will vary by performance measure. Unless otherwise noted, performance
        measures and standards (see Sections 1, 2, 3 and 4) will be applicable for
        all
        counties in which the MCP has membership as of February 1, 2006, until the
        regional-based approach is developed.

      

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

      

      1.  QUALITY
        OF CARE

      

      1.a.i.
        Independent External Quality Review

      

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

      

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

      

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

      

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

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

             

        

      

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

      

      In
        order
        to ensure state compliance with  the provisions of 42 CFR 438.208, the
        Bureau of Managed Health Care established Children with Special Health Care
        Needs (CSHCN) basic program requirements in Appendix G, Coverage and
        Services,  and corresponding minimum performance standards as
        described below. The purpose of these measures is to provide appropriate
        and
        targeted case management services to CSHCN.

      

      1.b.i.Case
        Management of Children

      

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

      

      Report
        Period: For the SFY 2007 contract period, January – March 2007, and April –
June 2007 report periods.  For the SFY 2008 contract
        period,  July – September 2007, October – December 2007, January –
March 2008, and April – June 2008 report periods.  For the SFY 2009
        contract period,  July – September 2008, October – December 2008,
        January – March 2009, and April – June 2009 report periods.

      

      County-Based
        Approach:  MCPs with managed care membership as
        of  February 1, 2006 will be evaluated using their county-based
        statewide result until regional evaluation is implemented for the county’s
        applicable region.  The county-based statewide result will include
        data for all counties in which the MCP had  membership as of February
        1, 2006 that are not included in any regional-based
        result.  Regional-based results will not be used for evaluation until
        all selected MCPs in an active region have at least 10,000 members during
        each
        month of the entire report period.  Upon implementation of
        regional-based evaluation for a particular county’s region, the county will be
        included in the MCP’s regional-based result and will no longer be included in
        the MCP’s county-based statewide result. [Example: The county-based statewide
        result for MCP AAA, which has contracts in the Central and West Central regions,
        will include Franklin, Pickaway, Montgomery, Greene and Clark counties (i.e.,
        counties in which MCP AAA had managed care membership as of February 1,
        2006).  When regional-based evaluation is implemented for the Central
        region, Franklin and Pickaway counties, along with all other counties in
        the
        region, will then be included in the Central region results for MCP AAA;
        Montgomery, Greene, and Clark counties will remain in the county-based statewide
        result for evaluation of MCP AAA until the West Central regional-based approach
        is implemented.]

      

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

      

      County
        and Regional-Based Minimum Performance Standard: For the
        third and fourth quarters of SFY 2007, a case management rate of
        5.0%.  For SFY 2008, a case management rate of 5.0%.  For
        SFY 2009, a case management rate of 6.0%.

       

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

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

      

      1.b.ii.
        Case Management of Children with an ODJFS-Mandated
        Condition

      

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

      

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

      

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

      

      Report
        Periods for Measures 1, 2, and 3: For the SFY 2007 contract period,
        January – March 2007, and April – June 2007 report periods.  For the
        SFY 2008 contract period,  July – September 2007, October – December
        2007, January – March 2008, and April – June 2008 report periods.  For
        the SFY 2009 contract period,  July – September 2008, October –
December 2008, January – March 2009, and April – June 2009 report
        periods.

      

      County-Based
        Approach:  MCPs with managed care membership as
        of  February 1, 2006 will be evaluated using their county-based
        statewide result until regional evaluation is implemented for the county’s
        applicable region.  The county-based statewide result will include
        data for all counties in which the MCP had membership as of February 1,
        2006  that are not included in any regional-based
        result.  Regional-based results will not be used for evaluation until
        all selected MCPs in an active region have at least 10,000 members during
        each
        month of the entire report period.  Upon implementation of
        regional-based evaluation for a particular county’s region, the county will be
        included in the MCP’s regional-based result and will no longer be included in
        the MCP’s county-based statewide result. [Example: The county-based statewide
        result for MCP AAA, which has contracts in the Central and West Central regions,
        will include Franklin, Pickaway, Montgomery, Greene
        and Clark counties (i.e., counties in which MCP AAA had managed care membership
        as of  February  1, 2006).  When regional-based
        evaluation is implemented for the Central region, Franklin and Pickaway
        counties, along with all other counties in the region, will then be included
        in
        the

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

             

        

      

      Central
        region results for MCP AAA; Montgomery, Greene, and Clark counties will remain
        in the county-based statewide result for evaluation of MCP AAA until the
        West
        Central regional-based approach is implemented.]

      

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

      

      County
        and Regional-Based Minimum Performance Standard for Measures 1 and 3:
For the third and fourth quarters of SFY 2007, a case management
        rate of
        70%.  For SFY 2008, a case management rate of 70%.  For SFY
        2009, a case management rate of 80%.

      

      County
        and Regional-Based Minimum Performance Standard for Measure 2:For
        the third and fourth quarters of SFY 2007, a case management rate of
        60%.  For SFY 2008, a case management rate of 60%.  For SFY
        2009, a case management rate of 70%.

      

      Penalty
        for Noncompliance for Measures 1 and 2:  The first time an MCP is
        noncompliant with a standard for this measure, ODJFS will issue a Sanction
        Advisory informing the MCP that any future noncompliance instances with the
        standard for this measure will result in ODJFS imposing a monetary
        sanction.  Upon all subsequent measurements of performance, if an MCP
        is again determined to be noncompliant with the standard, ODJFS will impose
        a
        monetary sanction (see Section 5) of two percent of the current month’s premium
        payment. Monetary sanctions will not be levied for consecutive quarters that
        an
        MCP is determined to be noncompliant.  If an MCP is noncompliant for a
        subsequent quarter, new member selection freezes or a reduction of assignments
        will occur as outlined in Appendix N of the Provider Agreement.  Once
        the MCP is determined to be compliant with the standard and the
        violations/deficiencies are resolved to the satisfaction of
        ODJFS, the penalties will be lifted, if applicable, and monetary
        sanctions will be returned.  Note:  For the first reporting
        period during which regional results are used to evaluate performance, measures
        1, 2, and 3 are reporting-only measures.  For SFY 2008 and SFY 2009,
        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  2005 results (the
        baseline period) and calendar year  2006 results.  The
        methods will be updated and a new baseline will be created during 2007 for
        calendar  year  2006 results.  These results will
        then serve as the baseline to evaluate whether improvement occurred from
        calendar  year 2006 to calendar year 2007. Clinical performance
        measure results will be calculated after a sufficient amount of time has
        passed
        after the end of the report period in order to allow for claims
        runout.  For a comprehensive description of the clinical performance
        measures below, see ODJFS Methods for Clinical Performance Measures
        for the Medicaid CFC Managed Care Program.  Performance standards
        are subject to change based on the revision or update of NCQA methods or
        other
        national standards, methods or benchmarks.

      

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

      

      For
        any MCP which did not have membership as of February 1,
        2006:  Performance will be evaluated using a
        regional-based approach for any active region in which the MCP had
        membership.

      Regional-Based
        Approach: MCPs will be evaluated by region, using results for all counties
        included in the region.  CY 2008 will be the first reporting year that
        MCPs will be held accountable to the performance standards for an active
        region,
        and penalties will be applied for noncompliance.  CY 2007 will be the
        first baseline reporting year for an active region.

      

      ODJFS
        will use a sufficient amount of data needed per performance measure from
        all
        MCPs serving an active region to determine performance standards and targets
        for
        that region.  For example, should a measure call for one calendar year
        of baseline data, first full calendar year data will be used.  CY 2008
        will be the first reporting year for measures that call for one year of baseline
        data. Should a measure call for two calendar years of baseline data, the
        first
        two full calendar years of data will be used.  CY 2009 will be the
        first reporting year for measures that call for two years of baseline
        data.

      

      Report
        Period:  In order to adhere to the statewide expansion timeline,
        reporting periods may be adjusted based on the number of months of managed
        care
        membership.  For the SFY 2007 contract period, performance will be
        evaluated using the January - December 2006 report period.  For the
        SFY 2008 contract period, performance will be evaluated using the January
        -
        December 2007 report period.  For the SFY 2009 contract period,
        performance will be evaluated using the January – December 2008 report
        period.

       

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

            

        

      

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

      

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

      

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

      

      County-Based
        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% (44% for SFY 2009), 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% (44% for SFY 2009), 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.

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

      

      County-Based
        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% (74% for SFY 2009), 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% (74% for SFY 2009), 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.

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
          

        

      

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

      

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

      

      Action
        Required for Noncompliance:  If the standard is not met and the
        results are below 48% (50% for SFY 2009), 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% (50% for SFY 2009), 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.

      

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

      

      County-Based
        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% (42% for SFY 2009), 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% (42% for SFY 2009), 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% (57% for SFY 2009), 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% (57% for SFY 2009), 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% (33% for SFY 2009), 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% (33% for SFY 2009), then ODJFS
        will issue a Quality Improvement Directive which will notify the MCP of
        noncompliance and may outline the steps that the MCP must take to improve
        the
        results.

      

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

      

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

      

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

      

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

      

      Action
        Required for Noncompliance:  If the standard is not met and the
        results are below 83% (84% for SFY 2009), then the MCP is required to complete
        a
        Performance Improvement Project, as described in Appendix K, Quality
        Assessment and Performance Improvement Program, to address the area of
        noncompliance. If the standard is not met and the results are at or above
        83%
        (84% for SFY 2009), 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.

      

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

      

      County-Based
        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% (42% for SFY 2009), 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% (42% for SFY 2009), 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.

      

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

      

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

      

      Action
        Required for Noncompliance (1 year olds): If the standard is not met and
        the results are below 45% then the MCP is required to complete a Performance
        Improvement Project, as described in  Appendix
        K,  Quality Assessment and Performance Improvement Program,
        to address the area of noncompliance. If the standard is not met and the
        results
        are at or above 45%, then ODJFS will issue a Quality Improvement Directive
        which
        will notify the MCP of noncompliance and may outline the steps that the MCP
        must
        take to improve the results.

      

      Action
        Required for Noncompliance (2 year olds): If the standard is not met and
        the results are below  28% then the MCP is required to complete a
        Performance Improvement Project, as described in  Appendix
        K,  Quality Assessment and Performance Improvement Program,
        to address the area of noncompliance.  If the standard is not met and
        the results are at or above 28%, then ODJFS will issue a Quality Improvement
        Directive which will notify the MCP of noncompliance and may outline the
        steps
        that the MCP must take to improve the results.

      

      2.  ACCESS

      

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

      

      2.a.
        PCP Turnover

      

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

      

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

      

      For
        an MCP which had membership as of February 1,
        2006: Prior to the transition to the regional-based approach, MCP
        performance will be evaluated using an MCP’s statewide result for
        the

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

             

        

      

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

      

      For
        any MCP which did not have membership as of February
        1, 2006:  Performance will be evaluated using a regional-based
        approach for any active region in which the MCP had membership.

      

      Regional-Based
        Approach: MCPs will be evaluated by region, using results for all counties
        included in the region. ODJFS will use the first full calendar year of data
        (which may be adjusted based on the number of months of managed care
        membership). from all MCPs serving an active region to determine a minimum
        performance standard for that region.  CY 2008 will be the first
        reporting year that MCPs will be held accountable to the performance standards
        for an active region, and penalties will be applied for
        noncompliance.

      

      Report
        Period:  In order to adhere to the statewide expansion timeline,
        reporting periods may be adjusted based on the number of months of managed
        care
        membership.  For the SFY 2007 contract period, performance will be
        evaluated using the January - December 2006 report period.  For the
        SFY 2008 contract period, performance will be evaluated using the January
        -
        December 2007 report period.  For the SFY 2009 contract period,
        performance will be evaluated using the January - December 2008 report
        period.

      

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

      

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

      

      2.b.
        Children’s Access to Primary Care

      

      This
        measure indicates whether children aged 12 months to 11 years are accessing
        PCPs
        for sick or well-child visits.

      

      Measure:
        The percentage of members age 12 months to 11 years who had a visit with
        an MCP
        PCP-type provider.

      

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

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

             

        

      

      statewide
        result for the counties in which the MCP had membership as of February 1,
        2006
        is CY 2008.

      

      For
        any MCP which did not have membership as of February
        1, 2006:  Performance will be evaluated using a
        regional-based approach for any active region in which the MCP had
        membership.

      

      Regional-Based
        Approach: MCPs will be evaluated by region, using results for all counties
        included in the region. ODJFS will use the first two full calendar years
        of data
        (which may be adjusted based on the number of months of managed care
        membership)  from all MCPs serving an active region to determine a
        minimum performance standard for that region. CY 2009 will be the first
        reporting year that MCPs will be held accountable to the performance standards
        for an active region, and penalties will be applied for
        noncompliance.  Performance measure results for that region will be
        calculated after a sufficient amount of time has passed after the end of
        the
        report period in order to allow for claims runout.

      

      Report
        Period: In order to adhere to the statewide expansion
        timeline, reporting periods may be adjusted based on the number of months
        of
        managed care membership. For the SFY 2007 contract period, performance will
        be evaluated using the January - December 2006 report period. For the SFY
        2008 contract period, performance will be evaluated using the January - December
        2007 report period.  For the SFY 2009 contract period, performance
        will be evaluated using the January - December 2008 report period.

      

      County-Based Minimum
        Performance Standards:

      

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

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

      CY
        2008
        report period – TBD (in May 2007)

      

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

      

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

      

      This
        measure indicates whether adult members are accessing health
        services.

      

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

      

      For
        an MCP which had membership as of February 1,
        2006: Prior to the transition to the regional-based approach, MCP
        performance will be evaluated using an MCP’s statewide result for the counties
        in which the MCP had membership as of February 1, 2006.  The
        minimum performance standard in this Appendix (2.c) will
        be applicable to the MCP’s statewide result for the counties in which the MCP
        had membership as of  February 1, 2006.  The last reporting
        year using  the MCP’s statewide result for the counties in which the
        MCP had membership as of February 1, 2006 for performance evaluation is
        CY2007; the last reporting year using the MCP’s statewide result for
        the

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

            

        

      

      counties
        in which the MCP had membership as of  February 1, 2006 for P4P
        (Appendix O) is CY 2008.

      

      For
        any MCP which did not have membership as of February 1,
        2006:  Performance will be evaluated using a regional-based
        approach for any active region in which the MCP had membership.

      

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

      

      Report
        Period: In order to adhere to the statewide
        expansion timeline, reporting periods may be adjusted based on the number of
        months of managed care membership.  For the SFY 2007 contract period,
        performance will be evaluated using the January - December 2006 report
        period.  For the SFY 2008 contract period, performance will be evaluated
        using the January - December 2007 report period.  For the SFY 2009
        contract period, performance will be evaluated using the January - December
        2008
        report period.

      

      County-Based Minimum
        Performance Standards:

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

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

      CY
        2008
        report period – TBD (in May 2007)

      

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

      

      2.d.
        Members’ Access to Designated PCP

      

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

      

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

      

      Regional-Based
        Approach: MCPs will be evaluated by region, using results for all counties
        included in the region.  ODJFS will use the first full calendar year
        of data (CY2007) as a baseline from all MCPs serving CFC membership to determine
        a minimum performance standard for that region.  CY 2008 will be the
        first reporting year that MCPs will be held accountable to the performance
        standards for an active region and penalties will be applied for
        noncompliance.  Performance measure results for that region will be
        calculated after a sufficient amount of time

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

             

        

      

      has
        passed after the end of the report period in order to allow for claims
        runout.

      

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

      

      Minimum
        Performance Standards: TBD

      

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

      

      3.
        CONSUMER SATISFACTION

      

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

      

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

      

      County-Based
        Approach: Prior to the transition to the regional-based approach, MCP
        performance will be evaluated using an MCP’s statewide result.  For
        performance evaluation, the last year to use the county-based approach will
        be
        SFY 2008, using CY 2008 data.  For P4P  (Appendix
        O),  the last year to use the county-based approach will be SFY
        2009, using CY 2009 data.

      

      Regional-Based
        Approach:  MCPs will be evaluated by region, using results for all
        counties included in the region.  ODJFS will use the first full
        calendar year of regional data (CY 2008 adult and child survey results from
        all
        MCPs serving CFC membership to establish a measure and determine regional
        minimum performance standards.  For performance evaluation, the first
        year to use the regional-based approach will be SFY 2009, using CY 2009
        data.  For P4P  (Appendix O),  the first year to
        use the regional-based approach will be SFY 2010, using CY 2010
        data.

      

      Report
        Period: For the SFY 2007 contract period, performance
        will be evaluated using the results from the most recent  consumer
        satisfaction survey completed prior to the end of the SFY
        2007.   For the SFY 2008 contract period, performance will be
        evaluated using the results from the most recent consumer satisfaction survey
        completed prior to the end of the SFY 2008.  For the SFY 2009 contract
        period, performance will be evaluated using the results from the most
        recent  consumer satisfaction survey completed prior to the end of the
        SFY 2009.

      

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

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

             

        

      

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

      

      4.
        ADMINISTRATIVE CAPACITY

      

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

      

      4.a.
        Compliance Assessment System 

      

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

      

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

      

      Performance
        Standard:  A maximum of 15 points

      

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

      

      4.b. Emergency
        Department Diversion

      

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

      

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

      

      For
        an MCP which had membership as of February 1,
        2006: Prior to the transition to the regional-based approach, MCP
        performance will be evaluated using an MCP’s statewide result for the counties
        in which the MCP had membership as of February1, 2006.  The minimum
        performance standard and the target in this Appendix (4.b) will be
        applicable to the MCP’s statewide result for the counties in which the MCP had
        membership as of  February 1, 2006.  The last reporting
        period using  the MCP’s statewide result for the counties in which the
        MCP had membership as of February 1, 2006 for performance evaluation is
        July-December 2007; the last reporting period using the MCP’s statewide result
        for the counties in which the MCP had membership as of February 1, 2006 for
        P4P
        (Appendix O) is July-December 2006.

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

             

        

      

      For
        any MCP which did not have membership as of February 1,
        2006:  Performance will be evaluated using a regional-based
        approach for any active region in which the MCP had membership.

      

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

      

      Regional-Based
        Measure:  The percentage of members who had TBD or more ED visits
        during the 12 month reporting period.

      

      Report
        Period: In order to adhere to the statewide expansion timeline,
        reporting periods may be adjusted based on the number of months of managed
        care
        membership.  For the SFY 2007 contract period, a baseline level of
        performance will be set using the January - June 2006 report
        period.  Results will be calculated for the reporting period of July -
        December 2006 and compared to the baseline results to determine if the minimum
        performance standard is met.  For the SFY 2008 contract period, a
        baseline level of performance will be set using the January - June 2007 report
        period (which may be adjusted based on the number of months of managed care
        membership).  Results will be calculated for the reporting period of
        July - December 2007 and compared to the baseline results to determine if
        the
        minimum performance standard is met.  SFY 2008 is also the first year
        for regional based reporting, using January – December 2007 as a
        baseline.  For the SFY 2009 contract period, results will be
        calculated for the reporting period January – December 2008 and compared to the
        baseline.

      

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

      

      County-Based
        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

      

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

      

      5.a.
        Report Periods

      

      Unless
        otherwise noted, the most recent report or study finalized prior to the end
        of
        the contract period will be used in determining the MCP’s performance level for
        that contract period.

      

      5.b.
        Monetary Sanctions

      

      Penalties
        for noncompliance with individual standards in this appendix will be imposed
        as
        the results are finalized. Penalties for noncompliance with individual standards
        for each period compliance is determined in this appendix will not exceed
        $250,000.

      

      Refundable
        monetary sanctions will be based on the capitation payment in the month
        of  the cited deficiency and due within 30 days of notification by
        ODJFS to the MCP of the amount.  Any monies collected through the
        imposition of such a sanction would be returned to the MCP (minus any applicable
        collection fees owed to the Attorney General’s Office, if the MCP has been
        delinquent in submitting payment) after they have demonstrated improved
        performance in accordance with this appendix.  If an MCP does not
        comply within two years of the date of notification of noncompliance, then
        the
        monies will not be refunded.

      

      5.c. Combined
        Remedies

      

      If
        ODJFS
        determines that one systemic problem is responsible for multiple deficiencies,
        ODJFS may impose a combined remedy which will address all areas of deficient
        performance.  The total fines assessed in any one month will not
        exceed 15% of the MCP’s monthly capitation.

      

      5.d.
        Enrollment Freezes

      

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

      

      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 

      CFC
        ELIGIBLE POPULATION

      

      

      I.
        General Provisions of the Compliance Assessment System

      

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

      

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

      

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

      

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

      

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

      

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

      

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

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

                    

        

      

      suspend
        any further new member selections.

      

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

      

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

      

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

      

      II.
        Types of Sanctions/Remedial Actions

      

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

      

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

      

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

      

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

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

             

        

      

      

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

      

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

      

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

      

      B.1.
5
        Points -- Failures to meet program requirements, including but not limited
        to, actions which  could impair the member’s ability to obtain correct
information regarding services or which could impair a
        consumer’s or member’s rights, as determined by ODJFS, will result in the
        assessment of 5 points.  Examples include, but are not limited to, the
        following:

      

      
        	
                 

              	
                •

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

              

      

      
        	
                 

              	
                •

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

              

      

      
        	
                 

              	
                •

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

              

      

      
        	
                 

              	
                •

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

              

      

      
        	
                 

              	
                •

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

              

      

      
        	
                 

              	
                •

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

              

      

      
        	
                 

              	
                •

              	
                Use
                  of unapproved marketing or member
                  materials.

              

      

      
        	
                 

              	
                •

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

              

      

      
        	
                 

              	
                •

              	
                Failure
                  to update website provider directories as
                  required.

              

      

      

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

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
          

        

      

      

      
        	
                 

              	
                •

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

              

      

      
        	
                 

              	
                •

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

              

      

      
        	
                 

              	
                •

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

              

      

      
        	
                 

              	
                •

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

              

      

       

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

      

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

      

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

      

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

      

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

      

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

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

              

        

      

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

      

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

                                                       
        
          	 0
                  -15 Points     	Corrective
                  Action Plan (CAP)
	 16-25
                  Points	CAP
                  + $5,000 fine
	26-50
                  Points	CAP
                  + $10,000 fine
	51-70
                  Points	CAP
                  + $20,000 fine
	71-100
                  Points	CAP
                  + $30,000 fine
	100+
                  Points  	Proposed
                  Contract Termination

        

      

                                                       

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

      

      
        	
                 

              	
                -

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

              

      

      

      
        	
                 

              	
                -

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

              

      

      

      
        	
                 

              	
                -

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

              

      

      

      
        	
                 

              	
                -

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

              

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

            

        

      

      

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

      

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

      

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

      

      I.
        Specific Pre-Determined Penalties

      

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

       

      
        	
                 

              	
                ·

              	
                practitioner
                  requirements in Franklin county for the CFC
                  population

              

      

      
        	
                 

              	
                ·

              	
                practitioner
                  requirements in Franklin county for the ABD
                  population

              

      

      
        	
                 

              	
                ·

              	
                hospital
                  requirements in Franklin county for the CFC
                  population

              

      

      
        	
                 

              	
                ·

              	
                PCP
                  capacity requirements in Fairfield county for the CFC
                  population

              

      

      

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

      

      I.2.
        Geographic Information System - Compliance with the Geographic Information
        System (GIS) requirements will be assessed
        semi-annually.  Any

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

             

        

      

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

       

      
        	
                 

              	
                ·

              	
                GIS
                  requirements in Franklin county for the CFC
                  population

              

      

      
        	
                 

              	
                ·

              	
                GIS
                  requirements in Fairfield county for the CFC
                  population

              

      

      
        	
                 

              	
                ·

              	
                GIS
                  requirements in Franklin county for the ABD
                  population

              

      

      

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

      

      
        	
                 

              	
                ·

              	
                Late
                  required submissions

              

      

      
        	
                 

              	
                o

              	
                Annual
                  delegation assessments

              

      

      
        	
                 

              	
                o

              	
                Call
                  center report

              

      

      
        	
                 

              	
                o

              	
                Franchise
                  fee documentation

              

      

      
        	
                 

              	
                o

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

              

      

      
        	
                 

              	
                o

              	
                State
                  hearing notifications

              

      

      
        	
                 

              	
                ·

              	
                Late
                  required data submissions

              

      

      
        	
                 

              	
                o

              	
                Appeals
                  and grievances, case management, or PCP
                  data

              

      

      
        	
                 

              	
                ·

              	
                Late
                  required information requests

              

      

      
        	
                 

              	
                o

              	
                Automatic
                  call distribution reports

              

      

      
        	
                 

              	
                o

              	
                Information/resolution
                  regarding consumer or provider
                  complaint

              

      

      
        	
                 

              	
                o

              	
                Just
                  cause or other coordination care request from
                  ODJFS

              

      

      
        	
                 

              	
                o

              	
                PVS
                  survey forms

              

      

      
        	
                 

              	
                o

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

              

      

      

      If
        an MCP
        determines that they will be unable to meet a program deadline or
        data/documentation submission deadline, the MCP must submit a written request
        to
        its Contract Administrator for an extension of the deadline, as soon as
        possible, but no later than 3 PM EST on the date of the deadline in question.
        Extension requests should only be submitted in situations where unforeseeable
        circumstances have occurred which make it impossible for the MCP to meet
        an

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

             

        

      

      ODJFS-stipulated
        deadline and all such requests will be evaluated upon this
        standard.  Only written approval as may be granted by ODJFS of a
        deadline extension will preclude the assessment of compliance action for
        untimely submissions.

      

      

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

      

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

      

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

      

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

      

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

      
        	
                 

              	
                ·

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

              

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

               

        

      

      
        	
                 

              	
                 

              

      

      
        	
                 

              	
                ·

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

              

      

      
        	
                 

              	
                ·

              	
                Proposed
                  termination or non-renewal of the MCP’s Medicaid provider agreement may
                  occur if the MCP:

              

      

      
        	
                 

              	
                a.

              	
                Fails
                  to pay its franchise permit fee or fails to pay the fee
                  promptly;

              

      

      
        	
                 

              	
                b.

              	
                Fails
                  to pay a penalty imposed under this Appendix or fails to pay the
                  penalty
                  promptly;

              

      

      
        	
                 

              	
                c.

              	
                Fails
                  to cooperate with an audit conducted in accordance with ORC Section
                  5111.176.

              

      

      

      I.7.
        Noncompliance with Clinical Laboratory Improvement Amendments -
Noncompliance with CLIA requirements as specified by ODJFS will result
        in
        the assessment of a nonrefundable $1,000 fine for each violation.

      

      I.8.
        Noncompliance with Abortion and Sterilization Payment - Noncompliance with
        abortion and sterilization requirements as specified by ODJFS will result
        in the
        assessment of a nonrefundable $2,000 fine for each documented
        violation.  Additionally, MCPs must take all appropriate action to
        correct each ODJFS-documented violation.

      

      I.9.
        Refusal to Comply with Program Requirements - If ODJFS has instructed an MCP
        that they must comply with a specific program requirement and the MCP refuses,
        such refusal constitutes documentation that the MCP is no longer operating
        in
        the best interests of the MCP’s members or the state of Ohio and ODJFS will move
        to terminate or nonrenew the MCP’s provider agreement.

      

      III.
        Request for Reconsiderations

      

      MCPs
        may
        request a reconsideration of remedial action taken under the CAS for penalties
        that include points, fines, reductions in assignments and/or selection
        freezes.  Requests for reconsideration must be submitted on the ODJFS
        required form as follows:

      

      A.
        MCPs
        notified of ODJFS’ imposition of remedial  action taken under the CAS
        will have ten (10) working days from the date of receipt of the facsimile
        to request reconsideration, although ODJFS will impose enrollment freezes
        based
        on an access to care concern concurrent with initiating notification to the
        MCP.  Any information that the MCP would like reviewed as part of the
        reconsideration request must be submitted at the

      time
        of
        submission of the reconsideration request, unless ODJFS extends the time
        frame
        in writing.

      

      B.
        All
        requests for reconsideration must be submitted by either facsimile transmission
        or overnight mail to the Chief, Bureau of Managed Health Care, and received
        by
        ODJFS by

      the
        tenth
        business day after receipt of the faxed notification of the imposition of
        the
        remedial action by ODJFS.

      

      C.
        The
        MCP will be responsible for verifying timely receipt of all reconsideration
        requests.  All requests for reconsideration must explain in detail why
        the specified remedial action should not be imposed.  The MCP’s
        justification for reconsideration will be limited to a review of the written
        material submitted by the MCP.  The Bureau Chief will review all
        correspondence and materials related to the violation in question in making
        the
        final reconsideration decision.

      

      D.
        Final
        decisions or requests for additional information will be made by ODJFS within
        ten (10) business days of receipt of the request for
        reconsideration.

      

      E.
        If
        additional information is requested by ODJFS, a final reconsideration decision
        will be made within three (3) business days of the due date for the
        submission.  Should ODJFS require additional time in rendering the
        final reconsideration decision, the MCP will be notified of such in
        writing.

      

      F.
        If a
        reconsideration request is decided, in whole or in part, in favor of the
        MCP,
        both the penalty and the points associated with the incident, will be rescinded
        or reduced, in the sole discretion of ODJFS.  The MCP may still be
        required to submit a CAP if ODJFS, in its sole discretion, believes that
        a CAP
        is still warranted under the circumstances.

      

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        APPENDIX
          O

        

        PAY-FOR
          PERFORMANCE (P4P)

        CFC
          ELIGIBLE POPULATION

        

        This
          Appendix establishes P4P for managed care plans (MCPs) to improve performance
          in
          specific areas important to the Medicaid MCP members.  P4P include the
          at-risk amount included with the monthly premium payments (see Appendix
          F,
Rate Chart), and possible additional monetary rewards up to
          $250,000.

        

        To
          qualify for consideration of any P4P, MCPs must meet minimum performance
          standards established in Appendix M, Performance Evaluation on selected
          measures, and achieve P4P standards established for selected Clinical
          Performance Measures.  For qualifying MCPs, higher performance
          standards for three measures must be reached to be awarded a portion of
          the
          at-risk amount and any additional P4P (see Sections 1 and 2).  An
          excellent and superior standard is set in this Appendix for each of the
          three
          measures.  Qualifying MCPs will be awarded a portion of the at-risk
          amount for each excellent standard met.  If an MCP meets all three
          excellent and superior standards, they may be awarded additional P4P (see
          Section 3).

        

        Prior
          to
          the transition to a regional-based P4P system (SFY 2006 through SFY 2009),
          the
          county-based P4P system (sections 1 and 2 of this Appendix) will apply
          to MCPs
          with membership as of February 1, 2006.  Only
          counties with membership as of February 1, 2006 will be used
          to
          calculate performance levels for the county-based P4P system.

        

        1.
          SFY 2007 P4P

        

        1.a.
          Qualifying Performance Levels

        

        To
          qualify for consideration of the SFY 2007 P4P, an MCP’s performance level
          must:

        

        1)
          Meet
          the minimum performance standards set in Appendix M, Performance
          Evaluation, for the measures listed below; and

        

        2)  Meet
          the P4P standards established for the Emergency Department Diversion and
          Clinical Performance Measures below.

        

        A
          detailed description of the methodologies for each measure can be found
          on the
          BMHC page of the ODJFS website.

        

        Measures
          for which the minimum performance standard for SFY 2007 established in
          Appendix
          M, Performance Evaluation, must be met to qualify for consideration
          of  P4P are as follows:

        

        1.  PCP
          Turnover (Appendix M, Section 2.a.)

        

        Report
          Period: CY
          2006

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        

        2.
          Children’s Access to Primary Care (Appendix M, Section 2.b.)

        

        Report
          Period: CY
          2006

        

        3.  Adults’
          Access to Preventive/Ambulatory Health Services (Appendix M, Section
          2.c.)

        

        Report
          Period: CY
          2006                                                      

        

        4.
          Overall Satisfaction with MCP (Appendix M, Section 3.)

        

        Report
          Period: The most recent consumer satisfaction survey completed prior to
          the
          end of the SFY 2007 contract period.

        

        For
          the
          EDD performance measure, the MCP must meet the  P4P standard for the
          report period of July - December, 2006 to be considered for SFY 2007
          P4P.  The MCP meets the P4P standard if one of two criteria are
          met.  The  P4P standard is a performance level of
          either:

        

        1)
          The
          minimum performance standard established in Appendix M, Section 4.b.;
          or

        

        2)
          The
          Medicaid benchmark of a performance level at or below 1.1%.

        

        For
          each
          clinical performance measure listed below, the MCP must meet the P4P standard
          to
          be considered for SFY 2007 P4P.  The MCP meets the P4P standard if one
          of two criteria are met.  The P4P standard is a performance level of
          either:

        

        1)
          The
          minimum performance standard established in Appendix M, Performance
          Evaluation, for seven of the nine clinical performance measures listed
          below; or

        

        2)
          The
          Medicaid benchmarks for seven of the nine clinical performance measures
          listed
          below.  The Medicaid benchmarks are subject to change based on the
          revision or update of applicable national standards, methods or
          benchmarks.

        
 

        
          
            	
                    Clinical
                      Performance Measure

                  	
                    Medicaid
                      Benchmark

                  
	
                    1.
                      Perinatal Care - Frequency of Ongoing Prenatal Care

                  	
                    42%

                  
	
                    2.
                      Perinatal Care - Initiation of Prenatal Care

                  	
                    71%

                  
	
                    3.
                      Perinatal Care - Postpartum Care

                  	
                    48%

                  
	
                    4.
                      Well-Child Visits – Children who turn 15 months old

                  	
                    34%

                  
	
                    5.
                      Well-Child Visits - 3, 4, 5, or 6, years old

                  	
                    50%

                  
	
                    6.
                      Well-Child Visits - 12 through 21 years old

                  	
                    30%

                  
	
                    7.
                      Use of Appropriate Medications for People with Asthma

                  	
                    83%

                  
	
                    8.
                      Annual Dental Visits

                  	
                    40%

                  
	
                    9.
                      Blood Lead – 1 year olds

                  	
                    45%

                  

          

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

            

          

        

        

        1.b.
          Excellent and Superior Performance Levels

        

        For
          qualifying MCPs as determined by Section 2.a., performance will be evaluated
          on
          the measures below to determine the status of the at-risk amount or any
          additional P4P that may be awarded.  Excellent and Superior standards
          are set for the three measures described below.  The standards are
          subject to change based on the revision or update of applicable national
          standards, methods or benchmarks.

        

        A
          brief
          description of these measures is provided in Appendix M, Performance
          Evaluation.  A detailed description of the methodologies for each
          measure can be found on the BMHC page of the ODJFS website.

        

        1.
          Case
          Management of Children (Appendix M, Section 1.b.ii.)

        

        Report
          Period: April - June
          2007

        Excellent
          Standard:
          5.5%

        Superior
          Standard:
          6.5%

        

        2.
          Use of
          Appropriate Medications for People with Asthma (Appendix M, Section
          1.c.vi.)

        

        Report
          Period: CY
          2006

        Excellent
          Standard:
          86%

        Superior
          Standard:
          88%

        

        3.
          Adults’ Access to Preventive/Ambulatory Health Services (Appendix M, Section
          2.c.)

        

        Report
          Period: CY
          2006

        Excellent
          Standard:
          76%

        Superior
          Standard:
          83%

        

        1.c.
          Determining SFY 2007 P4P

        

        MCPs
          reaching the minimum performance standards described in Section 1.a. herein,
          will be considered for P4P including retention of the at-risk amount and
          any
          additional P4P.  For each Excellent standard established in Section
          1.b. herein,  that an MCP meets, one-third of the at-risk amount may
          be retained.  For MCPs meeting all of the Excellent and Superior
          standards established in Section 1.b. herein, additional P4P may be
          awarded.  For MCPs receiving additional P4P, the amount in the
          P4P fund (see section 2.) will be divided equally, up to the maximum
          additional amount, among all MCPs’ABD and/or CFC programs

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        

        receiving
          additional P4P.  The maximum additional amount to be awarded per plan,
          per program, per contract year is $250,000.  An MCP may receive up to
          $500,000 should both of the MCP’s ABD and CFC programs achieve the Superior
          Performance Levels.

        

        2.
          SFY 2008 P4P

        

        2.a.
          Qualifying Performance Levels

        

        To
          qualify for consideration of the SFY 2008 P4P, an MCP’s performance level must
          meet the minimum performance standards set in Appendix M, Performance
          Evaluation, for the measures listed below.  A detailed
          description of the methodologies for each measure can be found on the BMHC
          page
          of the ODJFS website.

        

        Measures
          for which the minimum performance standard for SFY 2008 established in
          Appendix
          M, Performance Evaluation, must be met to qualify for consideration
          of  P4P are as follows:

        

        1.  PCP
          Turnover (Appendix M, Section 2.a.)

        

        Report
          Period: CY
          2007

        

        2.
          Children’s Access to Primary Care (Appendix M, Section 2.b.)

        

        Report
          Period: CY
          2007

        

        3.  Adults’
          Access to Preventive/Ambulatory Health Services (Appendix M, Section
          2.c.)

        

        Report
          Period: CY
          2007                                                      

        

        4.
          Overall Satisfaction with MCP (Appendix M, Section 3.)

        

        Report
          Period: The most recent consumer satisfaction survey completed prior to
          the
          end of the SFY2008.

        

        For
          each
          clinical performance measure listed below, the MCP must meet the P4P standard
          to
          be considered for SFY 2008 P4P.  The MCP meets the P4P standard if one
          of two criteria are met.  The P4P standard is a performance level of
          either:

        

        1)
          The
          minimum performance standard established in Appendix M, Performance
          Evaluation, for seven of the nine clinical performance measures listed
          below; or

        

        2)
          The
          Medicaid benchmarks for seven of the nine clinical performance measures
          listed
          below.  The Medicaid benchmarks are subject to change based on the
          revision or update of applicable national standards, methods or
          benchmarks.

        

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

         

        
          
            	
                    Clinical
                      Performance Measure

                  	
                    Medicaid
                      Benchmark

                  
	
                    1.
                      Perinatal Care - Frequency of Ongoing Prenatal Care

                  	
                    42%

                  
	
                    2.
                      Perinatal Care - Initiation of Prenatal Care

                  	
                    71%

                  
	
                    3.
                      Perinatal Care - Postpartum Care

                  	
                    48%

                  
	
                    4.
                      Well-Child Visits – Children who turn 15 months old

                  	
                    34%

                  
	
                    5.
                      Well-Child Visits - 3, 4, 5, or 6, years old

                  	
                    50%

                  
	
                    6.
                      Well-Child Visits - 12 through 21 years old

                  	
                    30%

                  
	
                    7.
                      Use of Appropriate Medications for People with Asthma

                  	
                    83%

                  
	
                    8.
                      Annual Dental Visits

                  	
                    40%

                  
	
                    9.
                      Blood Lead – 1 year olds

                  	
                    45%

                  

          

           

        

        2.b.
          Excellent and Superior Performance Levels

        

        For
          qualifying MCPs as determined by Section 2.a., performance will be evaluated
          on
          the measures below to determine the status of the at-risk amount or any
          additional P4P that may be awarded.  Excellent and Superior standards
          are set for the three measures described below.  The standards are
          subject to change based on the revision or update of applicable national
          standards, methods or benchmarks.

        

        A
          brief
          description of these measures is provided in Appendix M, Performance
          Evaluation.  A detailed description of the methodologies for each
          measure can be found on the BMHC page of the ODJFS website.

        

        1.
          Case
          Management of Children (Appendix M, Section 1.b.i.)

        

        Report
          Period: April - June
          2008

        

        Excellent
          Standard:
          5.5%

        

        Superior
          Standard:
          6.5%

        

        2.
          Use of
          Appropriate Medications for People with Asthma (Appendix M, Section
          1.c.v.)

        

        Report
          Period: CY
          2007

        

        Excellent
          Standard:
          86%

        

        Superior
          Standard:
          88%

        

        3.
          Adults’ Access to Preventive/Ambulatory Health Services (Appendix M, Section
          2.c.)

        

        Report
          Period: CY
          2007

        

        Excellent
          Standard:
          76%

         

             Superior
          Standard: 84%

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

         

        2.c.
          Determining SFY 2008 P4P

        

        MCP’s
          reaching the minimum performance standards described in Section 2.a. herein,
          will be considered for P4P including retention of the at-risk amount and
          any
          additional P4P.  For each Excellent standard established in Section
          2.b. herein, that an MCP meets, one-third of the at-risk amount may be
          retained.  For MCPs meeting all of the Excellent and Superior
          standards

        

        

        established
          in Section 2.b. herein, additional P4P may be awarded.  For MCPs
          receiving additional P4P, the amount in the P4P fund (see Section 3.) will
          be
          divided equally, up to the maximum additional amount, among all MCPs’ ABD and/or
          CFC programs receiving additional P4P.  The maximum additional amount
          to be awarded per plan, per program, per contract year is
          $250,000.  An MCP may receive up to $500,000 should both of the MCP’s
          ABD and CFC programs achieve the Superior Performance Levels.

        

        3.
          NOTES

        

        3.a. Initiation
          of the P4P System

        

        For
          MCPs
          in their first twenty-four months of Ohio Medicaid CFC Managed Care Program
          participation, the status of the at-risk amount will not be determined
          because
          compliance with many of the standards cannot be determined in an MCP’s first two
          contract years (see Appendix F., Rate Chart). In addition, MCPs in
          their first two contract years are not eligible for the additional P4P
          amount
          awarded for superior performance.

        

        Starting
          with the twenty-fifth month of participation in the program, a new MCP’s at-risk
          amount will be included in the P4P system. The determination of the status
          of
          this at-risk amount will be after at least three full calendar years of
          membership as many of the performance standards require three full calendar
          years to determine an MCP’s performance level.  Because of this
          requirement, more than 12 months of at-risk dollars may be included in
          an MCP’s
          first at-risk status determination depending on when an MCP starts with
          the
          program relative to the calendar year.

        

        3.b.
          Determination of at-risk amounts and additional P4P
          payments

        

        For
          MCPs
          that have participated in the Ohio Medicaid Managed Care Program long enough
          to
          calculate performance levels for all of the performance measures included
          in the
          P4P system, determination of the status of an MCP’s at-risk amount will occur
          within six months of the end of the contract period.  Determination of
          additional P4P payments will be made at the same time the status of an
          MCP’s
          at-risk amount is determined.

        

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        

        3.c.
          Transition from a county-based to a regional-based P4P
          system.

        

        The
          current county-based P4P system will transition to a regional-based system
          as
          managed care expands statewide.  The regional-approach will be fully
          phased in no later than SFY 2010.  The regional-based P4P system will
          be modeled after the county-based system with adjustments to performance
          standards where appropriate to account for regional differences.

        

        3.c.i.
          County-based P4P system

        

        During
          the transition to a regional-based system (SFY 2006 through SFY 2009),
          MCPs with
          membership as of  February 1, 2006 will continue in the county-based
          P4P system until the

        transition
          is complete.  These MCPs will be put at-risk for a portion of the
          premiums received for members in counties they are serving as of February
          1,
          2006.

        

        3.c.ii.
          Regional-based P4P system

        

        All
          MCPs
          will be included in the regional-based P4P system.  The at-risk amount
          will be determined separately for each region an MCP serves.

        

        The
          status of the at-risk amount for counties not included in the county-based
          P4P
          system will not be determined for the first twenty-four months of regional
          membership.  Starting with the twenty-fifth month of regional
          membership, the MCP’s at-risk amount will be included in the P4P system. The
          determination of the status of this at-risk amount will be after at least
          three
          full calendar years of regional membership as many of the performance standards
          require three full calendar years to determine an MCP’s performance level. Given
          that statewide expansion was not complete by December 31, 2006, ODJFS may
          adjust performance measure reporting periods based on the number of months
          an
          MCP has had regional membership. Because of this requirement, more than
          12
          months of at-risk dollars may be included in an MCP’s first regional at-risk
          status determination depending on when regional membership starts relative
          to
          the calendar year.  Regional premium payments for months prior to July
          2009 for members in counties included in the county-based P4P system for
          the SFY
          2009 P4P determination, will be excluded from the at-risk dollars included
          in
          the first regional P4P determination.

        

        3.d.
          Contract Termination, Nonrenewals, or Denials

        

        Upon
          termination, nonrenewal or denial of an MCP contract, the at-risk amount
          paid to
          the MCP under the current provider agreement will be returned to
          ODJFS  in accordance with Appendix P.,
Terminations/Nonrenewals/Amendments, of the provider
          agreement.

        

        Additionally,
          in accordance with Article XI of the provider agreement, the return of
          the
          at-risk amount paid to the MCP under the current provider agreement will
          be a
          condition necessary for ODJFS’ approval of a provider agreement
          assignment.

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        3.e.
          Report Periods

        

        The
          report period used in determining the MCP’s performance levels varies for each
          measure depending on the frequency of the report and the data
          source.  Unless otherwise noted, the most recent report or study
          finalized prior to the end of the contract period will be used in determining
          the MCP’s overall performance level for that contract period.

         

         

        

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

                   

            

          

          APPENDIX
            P

          

          MCP
            TERMINATIONS/NONRENEWALS/AMENDMENTS

          CFC
            ELIGIBLE POPULATION

          

          Upon
            termination either by the MCP or ODJFS, nonrenewal or denial of an MCP’s
            provider agreement, all previously collected refundable monetary sanctions
            will
            be retained by ODJFS.

          

          MCP-INITIATED
            TERMINATIONS/NONRENEWALS

          

          If
            an MCP
            provides notice of the termination/nonrenewal of their provider agreement
            to
            ODJFS, pursuant to Article VIII of the agreement, the MCP will be required
            to
            submit a refundable monetary assurance.  This monetary assurance will
            be held by ODJFS until such time that the MCP has submitted all outstanding
            monies owed and reports, including, but not limited to, grievance, appeal,
            encounter and cost report data related to time periods
            through the final date of service under the MCP=s
            provider agreement.  The monetary assurance must be in an amount of
            either $50,000 or 5 % of the capitation amount paid by ODJFS in the month
            the
            termination/nonrenewal notice is issued, whichever is greater.

          

          The
            MCP
            must also return to ODJFS the at-risk amount paid to the MCP under the
            current
            provider agreement.  The amount to be returned will be based on actual
            MCP membership for preceding months and estimated MCP membership through
            the end
            date of the contract.  MCP membership for each month between the month
            the termination/nonrenewal is issued and the end date of the provider
            agreement
            will be estimated as the MCP membership for the month the termination/nonrenewal
            is issued. Any over payment will be determined by comparing actual to
            estimated  MCP membership and will be returned to the MCP following
            the end date of the provider agreement.

          

          The
            MCP
            must remit the monetary assurance and the at-risk amount in the specified
            amounts via separate electronic fund transfers (EFT) payable to Treasurer of
            State, State of Ohio (ODJFS).  The MCP should contact their
            Contract Administrator to verify the correct amounts required for the
            monetary
            assurance and the at-risk amount and obtain an invoice number prior to
            submitting the monetary assurance and the at-risk amount.  Information
            from the invoices must be included with each EFT to ensure monies are
            deposited
            in the appropriate ODJFS Fund account.  In addition, the MCP must send
            copies of the EFT bank confirmations and copies of the invoices to their
            Contract Administrator.

          

          If
            the
            monetary assurance and the at-risk amount are not received as specified
            above,
            ODJFS will withhold the MCP’s next month’s capitation payment until such time
            that ODJFS receives documentation that the monetary assurance and the
            at-risk
            amount are received by the Treasurer of State. If within one year of
            the date of
            issuance of the invoice, an MCP does not submit all outstanding monies
            owed and
            required submissions, including, but not limited to, grievance, appeal,
            encounter and cost report data related to time periods through the final
            date of
            service under the MCP’s provider agreement, the monetary assurance will not be
            refunded to the MCP.

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

                    

            

          

          

          ODJFS-INITIATED
            TERMINATIONS

          

          If
            ODJFS
            initiates the proposed termination, nonrenewal or amendment of an MCP=s
            provider agreement  pursuant
            to OAC rule 5101:3-26-10 and the MCP appeals that proposed action, the
            MCP’s
            provider agreement will be extended through the issuance of an adjudication
            order in the MCP’s appeal under R.C. Chapter 119.

          

          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 the proposed
            termination of members is as follows:

          

          
            	
                    ·

                  	
                    All
                      notifications of such a proposed  MCP membership termination
                      will be made by ODJFS via certified or overnight mail to the
                      identified
                      MCP Contact.

                  

          

          

          
            	
                    ·

                  	
                    MCPs
                      notified by ODJFS of such a proposed  MCP membership termination
                      will have three working days from the date of receipt to request
                      reconsideration.

                  

          

          

          
            	
                    ·

                  	
                    All
                      reconsideration requests must be submitted by either facsimile
                      transmission or overnight mail to the Deputy Director, Office
                      of Ohio
                      Health Plans, and received by 3PM on the third working day
                      following
                      receipt of the ODJFS notification of termination. The address
                      and fax
                      number to be used in making these requests will be specified
                      in the ODJFS
                      notification of termination
                      document.

                  

          

          

          
            	
                    ·

                  	
                    The
                      MCP will be responsible for verifying timely receipt of all
                      reconsideration requests.  All requests must explain in detail
                      why the proposed  MCP membership termination is not
                      justified.  The MCP’s justification for reconsideration will be
                      limited to a review of the written material submitted by the
                      MCP.

                  

          

          

          
            	
                    ·

                  	
                    A
                      final decision or request for additional information will be
                      made by the
                      Deputy Director within three working days of receipt of the
                      request for
                      reconsideration.   Should the Deputy Director require
                      additional time in rendering the final reconsideration decision,
                      the MCP
                      will be notified of such in
                      writing.

                  

          

          

          
            	
                    ·

                  	
                    The
                      proposed MCP membership termination will not occur while an
                      appeal is
                      under review and pending the Deputy Director’s decision.  If the
                      Deputy Director denies the appeal, the MCP membership termination
                      will
                      proceed at the first possible effective date.  The date may be
                      retroactive if the ODJFS determines that it would be in the
                      best interest
                      of the
                      members.

Source: [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00125-of-00352.parquet"}, [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00125-of-00352.parquet"}]]