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exhibit10-2.htm

     
      

    

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    Exhibit
      10.2

     

    

    OHIO
      DEPARTMENT OF JOB AND FAMILY SERVICES

    

    OHIO
      MEDICAL ASSISTANCE PROVIDER AGREEMENT

    FOR
      MANAGED CARE PLAN

    ABD
      ELIGIBLE POPULATION

    

    This
      provider agreement is entered into
      this first day of 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 Aged, Blind or Disabled
      (ABD) eligible population described in OAC rule 5101:3-26-02 (B).

    

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

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

             

        

      

    

    

    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:
                6/12/07

            

    

             TODD
      S. FARHA, PRESIDENT & CEO

    

    

    OHIO
      DEPARTMENT OF JOB AND FAMILY SERVICES:

    

    
      	
              BY:  
                /s/   Helen Jones
                Kelly                 
                

            	
              DATE:
                6/25/07

            

    

             HELEN
      E. JONES-KELLY, DIRECTOR

     

     

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    ABD
      PROVIDER AGREEMENT INDEX

    July
      1, 2007

    

    
      	
              APPENDIX

            	
              TITLE

            
	
              APPENDIX
                A

            	
              OAC
                RULES 5101:3-26

            
	
              APPENDIX
                B

            	
              SERVICE
                AREA SPECIFICATIONS - ABD ELIGIBLE POPULATION

            
	
              APPENDIX
                C

            	
              MCP
                RESPONSIBILITIES – ABD ELIGIBLE POPULATION

            
	
              APPENDIX
                D

            	
              ODJFS
                RESPONSIBILITIES - ABD ELIGIBLE POPULATION

            
	
              APPENDIX
                E

            	
              RATE
                METHODOLOGY - ABD ELIGIBLE POPULATION

            
	
              APPENDIX
                F

            	
              REGIONAL
                RATES - ABD ELIGIBLE POPULATION

            
	
              APPENDIX
                G

            	
              COVERAGE
                AND SERVICES - ABD ELIGIBLE POPULATION

            
	
              APPENDIX
                H

            	
              PROVIDER
                PANEL SPECIFICATIONS - ABD ELIGIBLE POPULATION

            
	
              APPENDIX
                I

            	
              PROGRAM
                INTEGRITY - ABD ELIGIBLE POPULATION

            
	
              APPENDIX
                J

            	
              FINANCIAL
                PERFORMANCE - ABD ELIGIBLE POPULATION

            
	
              APPENDIX
                K

            	
              QUALITY
                ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM AND EXTERNAL QUALITY
                REVIEW
                - ABD ELIGIBLE POPULATION

            
	
              APPENDIX
                L

            	
              DATA
                QUALITY - ABD ELIGIBLE POPULATION

            
	
              APPENDIX
                M

            	
              PERFORMANCE
                EVALUATION - ABD ELIGIBLE POPULATION

            
	
              APPENDIX
                N

            	
              COMPLIANCE
                ASSESSMENT SYSTEM - ABD ELIGIBLE POPULATION

            
	
              APPENDIX
                O

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

            
	
              APPENDIX
                P

            	
              MCP
                TERMINATIONS/NONRENEWALS/AMENDMENTS – ABD ELIGIBLE
                POPULATION

            

    

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    APPENDIX
      A

    

    OAC
      RULES 5101:3-26

    

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

    

    

     

    

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    APPENDIX
      B

    

    SERVICE
      AREA SPECIFICATIONS

    ABD
      ELIGIBLE POPULATION

    

    

    MCP
      : WellCare of Ohio, Inc.

    

    The
      MCP agrees to provide services to Aged, Blind or Disabled
      (ABD) members  residing in the following service
      area(s):

    

    

    Service
      Area: Northeast Region: Ashtabula, Cuyahoga, Erie, Geauga, Huron,
      Lake,Lorain, Medina

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    

    APPENDIX
      C

    

    MCP
      RESPONSIBILITIES

    ABD
      ELIGIBLE POPULATION

    

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

    

     General
      Provisions

    

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

    

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

    

    3.    The
      MCP must designate the following:

    

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

    

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

    

    If
      an MCP
      serves both the CFC and ABD populations, they are not required to designate
      a
      separate provider relations representative or Medicaid Coordinator for each
      population group.

    

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

    

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

    

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

    

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

    

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

    

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

    

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

    

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

    

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

    

    13.   The
      MCP must notify the BMHC of the termination of an  MCP panel provider
      that is designated as the primary care physician for 100 or more of the MCP's
      ABD members.  The MCP must provide notification within one working day
      of the MCP becoming aware of the termination.

    

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

    

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

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

    

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

    

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

     

     c.           MCPs
      must give ODJFS and members ninety (90) days prior notice whendecreasing or
      ceasing any additional benefit(s).  When it is beyond the control
      ofthe 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 ABD eligible individuals in the MCP’s service area have a common
      primary language other than English, the MCP must translate all ODJFS-approved
      marketing materials into the primary language of that group. The MCP must
      monitor changes in the eligible population on an ongoing basis and conduct
      an
      assessment no less often than annually to determine which, if any, primary
      language groups meet the 10% threshold for the eligible individuals in each
      service area.  When the 10% threshold is met, the MCP must report this
      information to ODJFS, in a format as requested by ODJFS, translate their
      marketing materials, and make these marketing materials available to eligible
      individuals. MCPs must submit to ODJFS, upon request, their prevalent non
      English language analysis of eligible individuals and the results of this
      analysis.

    

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

    

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

    

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

    

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

    

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

    

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

    

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

    

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

    

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

    

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

    

    23.           Advance
      Directives – All MCPs must comply with the requirements specified in42 CFR
      422.128.  At a minimum, the MCP must:

    

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

    

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

    

    i. Provides
      written information to all adult members concerning:

    

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

    

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

    

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

    

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

    

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

    

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

    

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

    

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

    

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

    

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

     

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

    

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

    

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

    

    25.           Call
      Center Standards

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

     

     New
      Year’s Day

     Martin
      Luther King’s Birthday

     Memorial
      Day

     Independence
      Day

     Labor
      Day

     Thanksgiving
      Day

     Christmas
      Day

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

    

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

    

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

    

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

    

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

    

    26.       Notification
      of Optional MCP Membership

    

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

    

    -           Indians
      who are members of federally-recognized tribes, except as permitted under 42
      C.F.R 438.50(d)(21).

    

    27.           HIPAA
      Privacy Compliance Requirements

    

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

    

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

    

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

     

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

    

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

    

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

     

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

    

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

    

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

    

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

    

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

    

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

    

    29.           MCP
      Membership acceptance, documentation and reconciliation

     

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

      

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

    

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

    

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

    

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

    

    g.         Pending
      Member   If
      a
      pending member (i.e., an eligible individual subsequent to plan selection or
      assignment, but prior to their membership effective date) contacts the selected
      MCP,  the MCP must provide any membership information requested,
      including but not limited to, assistance in determining whether the current
      medications require prior authorization. The MCP must also ensure that any
      care
      coordination (e.g., 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.

    

    h.         Transition
      of Fee-For-Service Members  Providing
      care coordination, access to preventive and specialized care,
      case     management, member services, and education
      with minimal disruption to members’ established relationships with providers and
      existing care treatment plans is critical for members transitioning from
      Medicaid fee-for-service to managed care.  MCPs must develop and
      implement a transition plan that outlines how the MCP will effectively address
      the unique care coordination issues of members in their first three months
      of
      MCP membership and how the various MCP departments will coordinate and share
      information regarding these new members. The transition plan must include at
      a
      minimum:

    

    i.           An
      effective outreach process to identify each new member’s existing
      and/orpotential health care needs that results in a new member profile that
      includes, but is not limited to identification of:

    

    a.           Health
      care needs, including those services received through state sub-recipient
      agencies [e.g., the Ohio Department of Mental Health (ODMH), the Ohio Department
      of Mental Retardation and Developmental Disabilities (ODMR/DD), the Ohio
      Department of Alcohol and Drug Addiction Services (ODADAS) and the Ohio
      Department of Aging (ODA)];

    

    b.           Existing
      sources of care (i.e., primary physicians, specialists, case manager(s),
      ancillary and other care givers); and

    

    c.           Current
      care therapies for all aspects of health care services, including scheduled
      health care appointments, planned and/or approved surgeries (inpatient or
      outpatient), ancillary or medical therapies, prescribed drugs, home health
      care
      services, private duty nursing (PDN), scheduled lab/radiology tests, necessary
      durable medical equipment, supplies and needed/approved transportation
      arrangements.

    

    ii.           Strategies
      for how each new member will obtain care therapies from appropriate sources
      of
      care as an MCP member. The MCP’s strategies must include at a
      minimum:

    

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

    

    i.           The
      member has appointments within the initial three months of the MCP membership
      with a primary physician or specialty physicians that were scheduled prior
      to
      the effective date of the MCP membership;

    

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

    

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

    

    iv.           The
      member is receiving ongoing chemotherapy or radiation treatment; or

    

    v.           The
      member has been released from the hospital within thirty (30) days prior to
      MCP
      enrollment and is following a treatment plan.

    

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

    

    Allowing
      their new members that are transitioning from Medicaid

     

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

    

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

    

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

    

    ii.           dental
      services that have not yet been received;

    

    iii.           vision
      services that have not yet been received;

    

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

     

    v.    be
      covered at
      the previously-authorized service level until the MCP conducts a medical
      necessity review and renders an authorization decision pursuant to OAC rule
      5101:3-26-03.1.

    

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

    

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

    

        d.           Reimbursing
      out-of-panel providers that agree to provide the transition services at 100%
      of
      the current Medicaid fee-for-serviceprovider rate for the service(s) identified
      in Section 29.h.ii.(a., b.,and c.) of this appendix.

    

        e.           Documenting
      the provision of transition services identified in Section 29.h.ii.(a., b.,
      and
      c.) of this appendix as follows:

    

    i.           For
      non-panel providers, notification to the provider confirming the provider’s
      agreement/disagreement to provide the service and accept 100% of the current
      Medicaid fee-for-service rate as payment.  If the provider agrees, the
      distribution of the MCP’s materials as outlinedin Appendix G.4.e.

    

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

    

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

    

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

    

        f.           Not
      requiring prior-authorization of any prescription drug that does not require
      prior authorization by Medicaid fee-for-service for the initial three months
      of
      a member’s MCP membership.  Additionally, all atypical anti-psychotic
      drugs that do not require prior authorization by Medicaid fee-for-service must
      be exempted from prior authorization requirements for all MCP ABD members
      through December 2007, after which time ODJFS will re-evaluate the continuation
      of this pharmacy utilization  strategy.

    

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

    

    a. Health
      Information System

    

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

    

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

    

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

    

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

    

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

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

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

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

     

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

    

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

    

     b. Electronic
      Data Interchange and Claims Adjudication Requirements

    

     Claims
      Adjudication

    

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

     

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

    

      Electronic
      Data Interchange

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

      Health
      care claims;

      Health
      care claim status request and response;

      Health
      care payment and remittance status;

      Standard
      code sets;
      and

     
National
      Provider Identifier (NPI).

    

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

     

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

    

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

    

      ASC
      X12 834 - Benefit Enrollment and Maintenance.

    

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

    

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

    

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

     

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

    

    i.           Trading
      Partner Agreements

    ii.          Code
      Sets

    iii.         Transactions

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

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

        c. Referral
      Certification and Authorization (ASC X12N 278)

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

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

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

        g. Health
      Plan Premium Payments (ASC X12N 820)

        h. Coordination
      of Benefits 

      

    Trading
      Partner Agreement with ODJFS

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

    

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

    

    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 two
 years. However, if ODJFS or its designee identifies significant
      information  system problems, then ODJFS or its designee may conduct, and
      the MCP mustparticipate in, a review the following year, or in such a timeframe
      as ODJFS, in their sole discretion, deems appropriate to ensure accuracy and
      efficiency of the MCP health information system.

    

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

    

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

    

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

    

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

    

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

    

    35.           Franchise
      Fee Assessment Requirements

     

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

    

        b.           The
      franchise fee is due to ODJFS in the ODJFS-specified format on or before the30th
      day following the end of the calendar quarter to which the fee
      applies.

    

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

    

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

    

    36.           Information
      Required for MCP Websites

    

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

    

    b.           On-line
      Member Website – MCPs must have a secure internet-based website which is
      regularly updated to include the most current ODJFS approved
      materials.  The website at a minimum must include: (1) a list of the
      counties that are covered in their service area; (2) the ODJFS-approved MCP
      member handbook, recent newsletters/announcements, MCP contact information
      including memberservices hours and closures; (3) the MCP provider directory
      as
      referenced in section 36(a) of this appendix; (4) the MCP’s current preferred
      drug list (PDL), including an explanation of the list, which drugs require
      prior
      authorization (PA), and the PA process; (5) the MCP’s current list of drugs
      covered only with PA, the PA process,  and the MCP’s policy for
      covering generic for brand-name  drugs; and (6) the ability for
      members to submit questions/comments/grievances/appeals/etc. and receive a
      response (members must be given the option of a return e-mail or phone
      call).  Responses regarding questions or comments are expected within
      one working day of receipt, whereas responses regarding grievances and appeals
      must be within the timeframes specified in OAC rule
      5101:3-26-08.4.  MCPs must ensure that all member materials designated
      specifically for CFC and/or ABD consumers (i.e. the MCP member handbook) are
      clearly labeled as such.  The MCP’s member website cannot be used as
      the only means to notify members of new and/or revised MCP information (e.g.,
      change in holiday closures, change in additional benefits, revisions to approved
      member materials etc.).  ODJFS may require MCPs to include additional
      information on the member website, as needed.

     

    c.     On-line
      Provider Website – MCPs must have a secure internet-based website for
      contracting providers where they will be able to confirm a consumer’s MCP
      enrollment and through this website (or through e-mail process) allow providers
      to electronically submit and receive responses to prior authorization
      requests.  This website must also include: (1) a list of the counties
      that are covered in their service area; (2) the MCP’s provider manual;(3) MCP
      contact information; (4) a link to the MCP’s on-line provider directory as
      referenced in section 37(a) of this appendix; (5) the MCP’s current PDL list,
      including an explanation of the list, which drugs require PA, and the PA
      process; 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.

    

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

    

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

    in
      fulfilling the program requirements.

    

    39.           PCP
      Feedback – The MCP must have the administrative capacity to offer feedback to
      individual providers on their: 1) adherence to evidence-based practice
      guidelines; and 2) positive and negative care variances from standard clinical
      pathways that may impact outcomes or costs.  In addition, the feedback
      information may be used by the MCP for activities such as physician performance
      improvement projects that include incentive programs or the development of
      quality improvement programs.

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

               

        

      

    

    

    APPENDIX
      D

    

    ODJFS
      RESPONSIBILITIES

    ABD
      ELIGIBLE POPULATION

    

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

    

    General
      Provisions

    

    
      	
              1.

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

            

    

    

    
      	
              2.

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

            

    

    

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

    

    
      	
              4.

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

            

    

    

    
      	
              5.

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

            

    

    

    
      	
              6.

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

            

    

    

    
      	
              7.

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

            

    

    

    
      	
              8.

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

            

    

    

    
      	
              9.

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

            

    

    

    

    
      	
              10.

            	
              On
                a monthly basis, ODJFS will provide MCPs with an electronic Master
                Provider File containing all the Ohio Medicaid fee-for-service providers,
                which includes their Medicaid 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 promote market and program stability, ODJFS
                may limit an MCP’s auto-assignments if they meet any of the following
                enrollment thresholds:

            

    

    

    
      	
              ·  

            	
              40%
                of statewide Aged, Blind, or Disabled (ABD) managed care
                eligibles; and/or

            

    

    
      	
              ·  

            	
              60%
                of the ABD managed care eligibles in any region with two
                MCPs; and/or

            

    

    
      	
              ·  

            	
              40%
                of the ABD managed care eligibles in any region with three
                MCPs.

            

    

    

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

    
      	
               

            	
              c.

            	
              Consumer
                Contact Record (CCR):  ODJFS or their designated
                entity shall forward CCRs to MCPs on no less than a weekly
                basis.  The CCRs are a record of each consumer-initiated MCP
                enrollment, change, or termination, and each
                MCEC

            

    

    

    

    
      	
               

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

            

    

    

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

    

    
      	
               

            	
              e.

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

            

    

    

    
      	
               

            	
              f.

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

            

    

    

    
      	
               

            	
              g.

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

            

    

    

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

    

    17.           ODJFS
      will regularly provide information to MCPs regarding different aspects of
      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) isresponsible for the oversight of
      the
      MCPs’ provider agreements withODJFS. 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 toensure all MCP staff are
      aware
      of, and follow, this communicationprocess.

    

    b.           ODJFS
      contracting entities:  ODJFS-contracting entities should
      never becontacted by the MCPs unless the MCPs have been specificallyinstructed
      by ODJFS 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 ABD ELIGIBLE POPULATION

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    MERCER

    Government
      Human Services Consulting

    333
      South
      7th Street, Suite 1600 

    Minneapolis,
      MN 55402-2427 

    www.mercerHR.com

     

    November
      17, 2006

     

    Mr.
      Jon
      Barley

    Bureau
      of
      Managed Health Care

    Ohio
      Department of Job and Family Services

    255
      East
      Main Street, 2nd Floor

     

    Columbus,
      OH 43215-5222

     

    Subject:

    ABD
      Rate-Setting Methodology & Capitation Rate Certification for the
      2007 Contract Period

     

    Dear
      Jon:

     

    The
      Ohio
      Department of Job and Family Services (State) contracted with Mercer Government
      Human Services Consulting (Mercer) to develop actuarially sound regional
      capitation rates for the Aged, Blind or Disabled (ABD) managed care population.
      During calendar year (CY) 2007, the State will roll out statewide ABD mandatory
      managed care on a regional basis. It is anticipated that managed care will
      be
      implemented in all eight regions by May 2007. The specific contract period
      and
      effective dates vary by region. A summary of the regional rates for each region
      is included in Appendix E. This summary will be updated each time the contract
      period for a new region is determined.

     

    This
      methodology letter outlines the rate-setting process, provides information
      on
      the data adjustments and provides a final rate summary. The key components
      in
      the 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

    November
      17, 2006

    Mr.
      Jon
      Barley

    Bureau
      of
      Managed Health Care

     

    Managed
      Care Eligible Population

     

    The
      following ABD individuals are not eligible to enroll in the managed care
      program.

     

    
      	
              ·  

            	
              Children
                under twenty-one years of age,

            

    

     

    
      	
              ·  

            	
              Individuals
                who are dually eligible under both the Medicaid and Medicare
                programs,

            

    

     

    
      	
              ·  

            	
              Institutionalized
                individuals,

            

    

     

    
      	
              ·  

            	
              Individuals
                eligible for Medicaid by spending down their income or resources
                to a
                level that meets the Medicaid program's financial eligibility
                requirements, or

            

    

     

    
      	
              ·  

            	
              Individuals
                receiving Medicaid services through a Medicaid
                Waiver.

            

    

     

    In
      addition, for managed care eligible individuals who enter a nursing facility,
      managed care plans (MCPs) are responsible for nursing facility payment and
      payment for all covered services until the last day of the second calendar
      month
      following the nursing facility admission.

     

    Base
      Data Development

     

    Data
      Sources

    Since
      ABD
      managed care has not yet been implemented in Ohio, FFS data was the only
      available data source for rate-setting. Mercer used FFS claims and eligibility
      data from State Fiscal Year (SFY) 2003 and from SFY 2004 as the basis for rate
      development. Once mandatory managed care is implemented and the program becomes
      stable. Mercer will incorporate plan-reported managed care data, including
      encounter and cost report data. Other sources of information used, as necessary,
      included State enrollment projections, State financial reports, projected
      managed care penetration rates and other ad hoc sources.

     

    Validation
      Process

    Mercer's
      validation process included reviewing SFY 2003 and SFY 2004 dollars, utilization
      and member months. Mercer also performed additional reasonability checks to
      ensure the base data was accurate and complete.

     

    FFS
      Data

    FFS
      experience from the base time period of SFY 2003 and SFY 2004 was used as a
      direct data source for rate-setting. 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

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    MERCER

    Government
      Human Services Consulting

     

    Page
      3

    November
      17, 2006

    Mr.
      Jon
      Barley

    Bureau
      of
      Managed Health Care

     

    program.
      Mercer excluded claims and eligibility data for the ineligible populations
      outlined on the previous page. The State Medicaid Management Information System
      (MMIS) includes data for FFS paid claims, which may be net or gross of certain
      factors (e.g., gross adjustments or third party liability (TPL)). As a result
      of
      these conditions, it was necessary to make adjustments to the FFS base data
      as
      documented in Appendix C and outlined in Appendix A.

     

    Managed
      Care Rate Development

     

    This
      section explains how Mercer developed the final capitation rates for each of
      the
      eight managed care regions, as defined in Appendix B. After the FFS base data
      was developed and the two years were blended, Mercer applied trend, program
      changes and managed care adjustments to project the program cost into the
      contract year. Next, the MCP administrative component was applied. 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

    Prior
      to
      blending the two years of FFS data, the base time period experience was trended
      to a common time period ofSFY 2004. Mercer applied greater credibility to the
      most recent year of data to reflect the expectation that the most recent year
      may be more reflective of future experience and to reflect that fewer
      adjustments are needed to bring the data to the effective contract
      period.

     

    Managed
      Care Assumptions for the FFS Data Source

    In
      developing managed care savings assumptions. Mercer applied generally accepted
      actuarial principles that reflect the impact of MCP programs on FFS experience.
      Mercer reviewed Ohio's historical FFS experience 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
      and Category of Service (COS). Specific adjustments were made in this step
      to
      reflect the differences between pharmacy contracting for the State and
      contracting obtained by the MCPs. Mercer reviewed information related to
      discount rates, dispensing fees, and rebates to make these adjustments. The
      rates are reflective of MCP contracting for these services. In addition. Mercer
      considered the impact of two pharmacy management restrictions on the MCPs when
      determining pharmacy managed care assumptions. These restrictions include the
      prohibition to prior

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    MERCER

    Government
      Human Services Consulting

     

    Page
      4

    November
      17, 2006

    Mr.
      Jon
      Barley

    Bureau
      of
      Managed Health Care

     

    authorize
      any prescriptions during the first ninety days of managed care implementation
      and the restriction on prior authorization of any atypical antipsychotics (as
      defined by the State).

     

    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 (SPY 2004) and the 2007 contract period.

     

    The
      State
      staff 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. Final programmatic changes approved for
      SFY 2006 and SFY 2007 are reflected in the rates, as appropriate. Please refer
      to Appendix D for more information on these programmatic changes.

     

    Clinical
      Measures/Incentives

    As
      the
      ABD managed care program matures, the State will require MCPs to meet minimum
      performance standards for a defined set of clinical measures. The State expects
      the first full calendar year of the program will be used as a baseline year
      to
      determine performance standards and targets. Since the MCPs will not be at
      risk
      for this period, the rates have not been adjusted to account for improvement
      in
      performance on the clinical measures.

     

    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 evaluated these 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.

     

    Selection
      Issue

    Mercer
      made an adjustment for voluntary selection, which accounts for the fact that
      costs associated with individuals who 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 participating in managed
      care. This adjustment is a reduction to paid claims and utilization. Appendix
      D
      provides more detail around the voluntary selection adjustment.

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    MERCER

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    Page
      5

    November
      17,2006

    Mr.
      Jon
      Barley

    Bureau
      of
      Managed Health Care

     

    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
      FFS
      data does not include costs for non-state plan services. Therefore, no
      adjustment was necessary.

     

    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 costs
      for SFY 2004 to project the data forward to the 2007 contract
      period.

     

    Mercer
      integrated the FFS trend analysis with a broader analysis of other trend
      resources. These resources included health care economic factors (e.g., Consumer
      Price Index (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.

     

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

     

    Administration/Contingencies

    Since
      ABD
      managed care has not yet been implemented, other ABD Medicaid program
      administration/contingencies allowances and the State's expectations were
      factors that were taken into consideration in determining the final
      administration/contingencies percentages. Appendix D provides further detail
      on
      the allowance.

     

    Risk
      Adjustment

    The
      FFS
      data was not categorized by age/sex cohort because the base regional rates
      will
      undergo risk adjustment. Risk adjustment takes into account the demographics
      and
      diagnoses of the population. The risk adjusted rates (RAR) will be implemented
      into the ABD managed care program using a generally accepted risk adjustment
      method to adjust base capitation rates to

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    MERCER

    Government
      Human Services Consulting

     

    Page
      6

    November
      17, 2006

    Mr.
      Jon
      Barley

    Bureau
      of
      Managed Health Care

     

    reflect
      the different health status of the members enrolled in each MCP's program.
      ODJFS
      and its actuarial consultant will develop each MCP's risk score to reflect
      the
      health status of members enrolled in the contractor's program within a
      region.

     

    During
      the initial months of managed care implementation in each region, it is
      anticipated that ODJFS and its actuaries will calculate regional MCP case mix
      scores monthly until the enrollment in the region becomes relatively stable.
      Because enrollment for these months will not be known until after the start
      of
      the month, the initial payment will be made assuming the base capitation rates
      for all MCPs. An adjustment will be made in the subsequent month to reflect
      the
      appropriate risk adjustment reimbursement for the prior month. Once regional
      enrollment has stabilized, it is anticipated that the MCP case mix scores will
      be updated semi-annually. In the event that the ABD implementation is delayed
      or
      a change in methodology is required, the risk assessment schedule may be
      revised.

     

    Certification
      of Final Rates

     

    Base
      capitation rates were developed for the eight managed care regions, and a rate
      summary is provided in Appendix E. Upon receiving final contract period
      information for each region, Mercer will update Appendix E
      accordingly.

     

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

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    MERCER

    Government
      Human Services Consulting

     

    Page
      7

    November
      17,2006

    Mr.
      Jon
      Barley

     

    Bureau
      of
      Managed Health Care

     

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

     

    Sincerely,

     

    

    
      	
                 /s/   Wendy
                Radunz

            	
              /s/  Angela
                WasDyke

            
	
              Wendy
                Radunz, FSA, MAAA

            	
              Angela
                WasDyke, ASA, MAAA

            

    

     

    

     

    

     

    Copy:

    Chuck
      Betley, Mitali Ghatak, Tracy Williams - ODJFS Denise Blank, Katie Olecik-
      Mercer

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    MERCER

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      Human Services Consulting

     

    Appendix
      A - 2007 Contract Period ABD Rate-Setting Methodology

    

    (Graph)

    

    

    A-
      1

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    MERCER

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      Human Services Consulting

     

    Appendix
      B - Region Definition

     

    Please
      refer to the map below, which defines the counties within each of the eight
      managed care regions.

     

    

     

    (Medicaid
      Managed Care Program Regions for the ABD Population Map)

     

    

     

    B-
      1

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    MERCER

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    Appendix
      C - FFS Data Adjustments

     

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

     

    Completion
      Factors

    The
      claims data was adjusted to account for the value of claims incurred but unpaid
      on a COS basis. Mercer used claims for SFY 2003 and SFY 2004 that reflect
      payments through the dates included in the following table.

     

    
      	
              State
                Fiscal Year

            	
              Paid
                Through

            
	
              2003

            	
              03/31/04

            
	
              2004

            	
              12/31/04

            

    

     

    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 the base data reflects
      all of the policy changes. All policy changes implemented during SFY 2003 and
      SFY 2004 were applied to the FFS data.

     

    C-
      1

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    MERCER

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      Human Services Consulting

     

    The
      following table shows the specified policy changes for which Mercer adjusted
      the
      SFY 2003 and SFY 2004 data. Mercer calculated the adjustments based on the
      "History of Policy Changes" document and other information supplied by the
      State.

     

    
      	
              Policy
                Changes

            	
              Effective
                Date

            	
              Category
                of Service Affected

            
	
              Inpatient
                Outlier Payment Methodology - Exceptional cost outlier threshold
                increased
                from $250,000 to $443,463

            	
              8/1/2002

            	
              Inpatient

            
	
              Anesthesia
                Services -Conversion factor decreased to $8.13

            	
              9/1/2002

            	
              Specialists

            
	
              Independently-practicing
                psychologist services eliminated for adults (≥21)

            	
              1/1/2004

            	
              PCP,

              Specialists

            
	
              All
                chiropractic services eliminated for adults (≥21)

            	
              1/1/2004

            	
              Other

            
	
              $3.00
                Copay on Prior-Authorization Drugs

            	
              1/1/2004

            	
              Pharmacy

            

    

     

    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.
      The
      State has indicated the FFS data does not reflect these recoveries. Since MCPs
      are also expected to take similar recovery actions, the FFS experience was
      adjusted for "pay and chase" recoveries. Mercer made adjustments to both the
      paid claims and utilization for all COSs. Since MCPs do not collect tort
      recoveries, the data excludes tort collections.

     

    Hospital
      Cost Settlements

    The
      State
      provided Mercer with SFY 2003 and SFY 2004 interim cost settlements for
      Diagnosis Related Group (DRG) and DRG-exempt hospitals. The DRG-exempt hospital
      information

     

    C-2

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    MERCER

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      Human Services Consulting

     

    included
      inpatient and outpatient settlements. However, the DRG hospitals only include
      capital settlements, which were incorporated into the adjustment. An adjustment
      has been applied to 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. Therefore, Mercer applied adjustments to the FFS claims and utilization
      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 FFS
      data has been adjusted to reflect only the time periods for which the MCPs
      are
      at risk.

     

    Dual
      Eligibles

    Dual
      eligible persons are not enrolled in managed care and are therefore 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.

     

    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
      D - 2007 Contract Period ABD Rate Development

     

    Credibility
      By Year Mercer placed more credibility on the most recent year of FFS
      data.

     

    FFS
      Historical and Prospective Trend

    Historical
      FFS trend assumptions were used to trend SPY 2003 FFS data to the base period
      (SFY 2004). Credibility was then applied to blend together the trended SPY
      2003
      and the SPY 2004 FFS data. Next, prospective FFS trends were applied to the
      base
      period FFS data to trend it to the 2007 contract period.

     

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

     

    Adjustments
      Affectis-sg Unii Cost

     

    
      	
              Policy
                Change

            	
              Effective
                Date

            	
              Category
                of Service Affected

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

            	
              1/1/2006

            	
              Pharmacy

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

            	
              1/1/2006

            	
              Dental

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

            	
              1/1/2006

            	
              Other

            
	
              IP
                Recalibration

            	
              1/1/2006

            	
              Inpatient

            
	
              IP
                Rate Freeze

            	
              1/1/2006

            	
              Inpatient

            

    

     

    D-
      1

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

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    Adjustments
      Affecting Utilization

     

    
      	
              Policy
                Change

            	
              Effective
                Date

            	
              Category
                of Service Affected

            
	
              Reduction
                in coverage of dental services for adults (>21)

            	
              1/1/2006

            	
              Dental

            
	
              Reduction
                in coverage of enteral products

            	
              1/1/2006

            	
              DME/
                Supplies

            

    

     

    Voluntary
      Selection

    The
      FFS
      data reflects the risk of the entire ABD Medicaid program. To solely reflect
      the
      risk of the managed care program, Mercer modified the FFS data based on the
      projected managed care penetration levels for the 2007 contract period. 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).

     

    Administration/Contingencies

    For
      existing managed care plans in Ohio, the MCP administration/contingencies
      allowance will be 12% of premium prior to the franchise fee. After the initial
      two twelve month contract periods for new and existing plans, 1% of the
      pre-franchise fee capitation rate will be put at risk, contingent upon MCPs
      meeting performance requirements. The administration schedule will be as follows
      for managed care plans currently existing in Ohio:

     

    
      	 	
              Admin

            	
              At-Risk

            
	
              Plan
                Year 1 (months 1-12)

            	
              12%

            	
              0%

            
	
              Plan
                Year 2 (months 13-24)

            	
              12%

            	
              0%

            
	
              Plan
                Year 3 (months 25-36)

            	
              12%

            	
              1%

            

    

     

    D-2

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    MERCER

    Government
      Human Services Consulting For managed care plans new to 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 in the chart on the
      previous page, 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-3

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    MERCER

    Government
      Human Services Consulting

     

    Appendix
      E - 2007 Contract Period Summary

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    
      	
              State
                of Ohio

            	
              Final
                & Confidential

            

    

    

    

    Appendix
      E 

    2007
      Contact Period ABD Regional Rate Summary

    

    
      	
              Region

            	
              Contract
                Begin Date

            	
              Contract
                End Date

            	
              Final
                Base Rate

            
	
              Northeast

            	
              January
                1, 2007

            	
              December
                31, 2007

            	
              $1,088.93

            

    

     

    Note:
      As
      the contract periods for the remaining regions are finalized, this exhibit
      will
      be updated to include the corresponding rates.

     

    Mercer
      Government Human Services
      Consulting                                                                                                

     

    E-1

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

      
        	
                Appendix
                  F  

                 

              
	
                PREMIUM
                  RATES WITHOUT THE AT-RISK PAYMENT AMOUNTS FOR 07/01/07 THROUGH
                  11/30/07

              
	
                MCP's
                  premiums will be at-risk starting the 25th month of the ABD Medicaid
                  Managed Care Program participation.

              
	 	 	 
	
                MCP:
                  WellCare of Ohio, Inc.

              	 	 
	 	 	 
	
                Service

              	 	 
	
                Enrollment

              	
                Base

              	
                At-Risk

              
	
                Area

              	
                Rates

              	
                Amounts

              
	
                Northeast
                  Region

              	
                $1,101.45

              	
                $0.00

              
	 	 	 
	
                List
                  of Eligible Assistance Groups (AGs)

              	 
	
                Aged,
                  Blind or Disabled:

              	
                MA-A
                  Aged

              	 
	 	
                MA-B
                  Blind

              	 
	 	
                MA-D
                  Disabled

              	 

      

    

     

    
      	
              Appendix
                F  

               

            
	
              PREMIUM
                RATES WITHOUT THE AT-RISK PAYMENT AMOUNTS FOR 12/01/07 THROUGH
                12/31/07

            
	
              MCP's
                premiums will be at-risk starting the 25th month of the ABD Medicaid
                Managed Care Program participation.

            
	 	 	 
	
              MCP:
                WellCare of Ohio, Inc.

            	 	 
	 	 	 
	
              Service
                

            	 	 
	
              Enrollment
                

            	
              Base

            	
              At-Risk

            
	
              Area

            	
              Rates

            	
              Amounts

            
	
              Northeast
                Region

            	
              $1,088.93

            	
              $0.00

            
	 	 	 
	
              List
                of Eligible Assistance Groups (AGs)

            	 
	
              Aged,
                Blind or Disabled:

            	
              MA-A
                Aged

            	 
	 	
              MA-B
                Blind

            	 
	 	
              MA-D
                Disabled

            	 

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

     

    
       

      
        	
                Appendix
                  F  

                 

              
	
                PREMIUM
                  RATES WITHOUT THE AT-RISK PAYMENT AMOUNTS FOR 7/01/07 THROUGH
                  11/30/07

              
	
                MCP's
                  premiums will be at-risk starting the 25th month of the ABD Medicaid
                  Managed Care Program participation.

              
	 	 	 
	
                MCP:
                  WellCare of Ohio, Inc.

              	 	 
	 	 	 
	
                Service
                  

              	 	 
	
                Enrollment
                  

              	
                Base

              	
                At-Risk

              
	
                Area

              	
                Rates

              	
                Amounts

              
	
                Northeast
                  Region

              	
                $1,106.55

              	
                $0.00

              
	 	 	 
	
                List
                  of Eligible Assistance Groups (AGs)

              	 
	
                Aged,
                  Blind or Disabled:

              	
                MA-A
                  Aged

              	 
	 	
                MA-B
                  Blind

              	 
	 	
                MA-D
                  Disabled

              	 

      

      
         

        
          	
                  Appendix
                    F  

                   

                
	
                  PREMIUM
                    RATES WITHOUT THE AT-RISK PAYMENT AMOUNTS FOR 12/01/07 THROUGH
                    12/31/07

                
	
                  MCP's
                    premiums will be at-risk starting the 25th month of the ABD Medicaid
                    Managed Care Program participation.

                
	 	 	 
	
                  MCP:
                    WellCare of Ohio, Inc.

                	 	 
	 	 	 
	
                  Service
                    

                	 	 
	
                  Enrollment
                    

                	
                  Base

                	
                  At-Risk

                
	
                  Area

                	
                  Rates

                	
                  Amounts

                
	
                  Northeast
                    Region

                	
                  $1,093.97

                	
                  $0.00

                
	 	 	 
	
                  List
                    of Eligible Assistance Groups (AGs)

                	 
	
                  Aged,
                    Blind or Disabled:

                	
                  MA-A
                    Aged

                	 
	 	
                  MA-B
                    Blind

                	 
	 	
                  MA-D
                    Disabled

                	 

        

        

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

      

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

    APPENDIX
      G

    

    COVERAGE
      AND SERVICES

    ABD
      ELIGIBLE POPULATION

    

    1.         Basic
      Benefit Package

    

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

    

    
      	
               

            	
              ·

            	
              Inpatient
                hospital services

            

    

    

    
      	
               

            	
              ·

            	
              Outpatient
                hospital services

            

    

    

    
      	
               

            	
              ·

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

            

    

    

    
      	
               

            	
              ·

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

            

    

    

    
      	
               

            	
              ·

            	
              Laboratory
                and x-ray services

            

    

    

    
      	
               

            	
              ·

            	
              Family
                planning services and supplies

            

    

    

    
      	
               

            	
              ·

            	
              Home
                health and private duty
                nursing services

            

    

    

    
      	
               

            	
              ·

            	
              Podiatry

            

    

    

    
      	
               

            	
              ·

            	
              Physical
                therapy, occupational therapy, and speech
                therapy

            

    

    

    
      	
               

            	
              ·

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

            

    

    

    
      	
               

            	
              ·

            	
              Prescription
                drugs

            

    

    

    
      	
               

            	
              ·

            	
              Ambulance
                and ambulette services

            

    

    

    
      	
               

            	
              ·

            	
              Dental
                services

            

    

    

    
      	
               

            	
              ·

            	
              Durable
                medical equipment and medical
                supplies

            

    

    

    
      	
               

            	
              ·

            	
              Vision
                care services, including eyeglasses 

                         

            

      	 	·  	 Nursing
              facility stays as specified in OAC rule
              5101:3-26-03

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    
      	
               

            	
              ·

            	
              Hospice
                care

            

    

    

    
      	
               

            	
              ·

            	
              Behavioral
                health services (see section G.2.b.iii of this appendix). 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 unwilling to access services through
      community providers.

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    
      	
            	
               

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

            

    

    

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

    

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

    

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

    

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

     

    
      	
               

            	
              ·

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

            

    

    

    
      	
               

            	
              ·

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

            

    

    

    
      	
               

            	
              ·

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

            

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

    Limitations:

     

    
      	
               

            	
              ·

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

               

            

    

    
      	
               

            	
              ·

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

            

    

    

    
      	
               

            	
              ·

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

            

    

    

    
      	
               

            	
              ·

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

            

    

    

    
      	
               

            	
              iv.

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

            

    

    

    
      	
               

            	
              MCPs
                may establish a preferred drug list for members and providers which
                includes a listing of the drugs that they prefer to have prescribed.
                Preferred drugs requiring prior authorization approval must be clearly
                indicated as such.  Pursuant to ORC §5111.72, 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, is contingent upon review
      and
      recommendation by the “Ohio Hematapoietic Stem Cell Transplant Consortium” again
      based on

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    criteria
      established by Ohio experts in the field of bone
      marrowtransplant.  While MCPs may require prior authorization for
      thesetransplant services, the approval criteria would be limited toconfirming
      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.

                 

    
      	
            	
               

            	
              
                MCPs
                  must receive prior approval from ODJFS on the types of medication
                  that they wish to cover through prior authorizations.  MCPsmust
                  establish their prior authorization system so that it does not
                  unnecessarily impede member access to medically-necessary Medicaid-covered
                  services.  As outlined in paragraph 29(i) of Appendix C, MCPs
                  must adhere to specific prior-authorization limitations to assist
                  with the
                  transition of new ABD members from FFS
                  Medicaid. 

              

            

    

    

    MCPs
      must comply with the provisions
      of 1927(d)(5) of the Social

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

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

    

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

    

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

    

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

    

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

    

    
      	
               

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

            

    

    

    b.           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.

              

            

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    

    4.           Case
      Management

    

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

    

    a.           Each
      MCP must inform all members and contracting providers of the MCP’s
      casemanagement services.

    

    b.           The
      MCP’s case management system must include, at a minimum, the
      followingcomponents:

    

    i.      Identification

    The
      MCP
      must have mechanisms in place to identify members potentially eligible for
      case
      management services.  These mechanisms must include an administrative
      data review (e.g. diagnosis, cost threshold, and/or service utilization) and
      may
      also include telephone interviews; provider/self-referrals; or home
      visits.

    

    ii.     Assessment

    The
      MCP
      must arrange for or conduct a comprehensive assessment of the member’s physical
      and/or behavioral health condition(s) to confirm the results of a positive
      identification, and to determine the need for case management
      services.    The goals of the assessment are to identify the
      member’s existing and/or potential health care needs and assess the member’s
      need for case management services.

    

    The
      assessment must be completed by a physician, physician assistant, RN, LPN,
      licensed social worker, or a graduate of a two or four year allied health
      program.  If the assessment is completed by another medical
      professional, there should be oversight and monitoring by either a registered
      nurse or a physician.

    

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

    

    iii.     Case
      Management-

    a.  Risk
      Stratification/Levels of Care

    The
      MCP
      must develop a strategy to assign members to risk stratification levels, based
      on the member’s comprehensive needs assessment.  Once the member’s
      risk level has been determined, the MCP must, at a minimum:

    -develop
      a care treatment plan (as
      described in G.4.iii.b below);

    -implement
      member-level
      interventions;

    -continuously
      monitor the progress of
      the member;

    -identify
      gaps between care recommended and actual care provided,
      and   propose and implement interventions to address the gaps;
      and

    -implement
      a system to monitor the delivery of specific services, including a review of
      service utilization, to re-evaluate the member’s risk level and adjust
      the level of case management services accordingly.

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    b. Care
      Treatment Plan

    The
      MCP
      must assure and coordinate the placement of the member into case-management
–
including identification of the member’s need for services, completion of the
      comprehensive health needs assessment, and development of a care treatment
      plan
      - within ninety (90) days of membership.  The care treatment plan is
      defined by ODJFS as the one developed by the MCP for the member.

    

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

    

    c. Coordination
      of Care and Communication

    The
      MCP
      must arrange or provide for professional case management services that are
      performed collaboratively by a team of professionals appropriate for the
      member’s condition and health care needs.  At a minimum, the MCP’s
      case manager must attempt to coordinate with the member’s case manager from
      other health systems, including behavioral health.  The MCP must have
      a process to facilitate, maintain, and coordinate both care and communication
      with the member, PCP, and other service providers and case
      managers.  The MCP must also have a process to coordinate care for a
      member that is receiving services from state sub-recipient agencies as
      appropriate [e.g., the Ohio Department of Mental Health (ODMH); the Ohio
      Department of Mental Retardation and Developmental Disabilities (ODMR/DD);
      and
      the Ohio Department of Alcohol and Drug Addiction Services
      (ODADAS)].  There should be an accountable point of contact at the MCP
      for each member in case management who can help obtain medically necessary
      care,
      assist with health-related services and coordinate care needs, including
      behavioral health.  The MCP must have a provision to disseminate
      information to the member/caregiver concerning the health condition, types
      of
      services that may be available, and how to access services.

    

     

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    

    iv.        ODJFS
      Targeted Case Management Conditions

        The
      MCP
must, at a minimum, case manage members with the following
      physical and behavioral health conditions:

    
      	
               

            	
              ·

            	
              Congestive
                Heart Failure

            

    

    
      	
               

            	
              ·

            	
              Coronary
                Artery Disease

            

    

    
      	
               

            	
              ·

            	
              Non-Mild
                Hypertension

            

    

    
      	
               

            	
              ·

            	
              Diabetes

            

    

    
      	
               

            	
              ·

            	
              Chronic
                Obstructive Pulmonary Disease

            

    

    
      	
               

            	
              ·

            	
              Asthma

            

    

    
      	
               

            	
              ·

            	
              Severe
                mental illness

            

    

    
      	
               

            	
              ·

            	
              High
                risk or high cost substance abuse
                disorders

            

    

    
      	
               

            	
              ·

            	
              Severe
                cognitive and/or developmental
                limitation

            

    

    

    The
      MCP
      should also focus on all members whose health conditions warrant case management
      services and should not limit these services only to members with these
      conditions (e.g., cystic fibrosis, cerebral palsy and sickle cell
      anemia).

    

    Refer
      to
Appendix M for the performance measures and standards related to case
      management.

    

    v.    Case
      Management Program Staffing

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

    

    vi.   Case
      Management Strategies

    The
      MCP
      must follow best-practice and/or evidence based clinical guidelines when
      devising a member’s care treatment plan and coordinating the case management
      needs.  If an MCP uses a disease management methodology to identify
      and/or stratify members in need of case management services, the methods must
      be
      validated by scientific research and/or nationally accepted in the health care
      industry.

    

    The
      MCP
      must develop and implement mechanisms to educate and equip physicians and case
      managers with evidence-based clinical guidelines or best practice approaches
      to
      assist in providing a high level of quality of care to members.

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    
 

    vii.    Information
      Technology System for Case Management

    The
      MCP’s
      information technology system for its case management program must maximize
      the
      opportunity for communication between the plan, PCP, the member, and other
      service providers and case managers.  The MCP must have an integrated
      database that allows MCP staff that may be contacted by a member in case
      management to have immediate access to, and review of, the most recent
      information with the MCP’s information systems relevant to the
      case.  The integrated database may include the
      following:  administrative data, call center communications, service
      authorizations, care treatment plans, patient assessments, case management
      notes, and PCP notes.  The information technology system must also
      have the capability to share relevant information with the member, the PCP,
      and
      other service providers and case managers.

    

    viii.
      Data Submission

    The
      MCP
      must submit a monthly electronic report to the Case Management System (CAMS)
      for
      all members that are case managed.  In order for a member to be
      submitted as case managed in CAMS, the MCP
      must:  (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.

    

    
      	
               

            	
              c.

            	
              The  MCP
                must have an ODJFS-approved case management program which includes
                the
                items in Section 4(a) and (b) of Appendix G.  Each MCP must
                implement an evaluation process to review, revise and/or update the
                case
                management program.  The MCP must annually submit its case
                management program for review and approval by ODJFS.  Any
                subsequent changes to an approved case management program description
                must
                be submitted to ODJFS in writing for review and approval prior to
                implementation.  Refer to Appendix K for the
                requirements regarding the annual review of the case management
                program.

            

    

    

    d.           Care
      Coordination with ODJFS-Designated Providers

    

    Per
      OAC rule 5101:3-26-03.1(A)(4), MCPs
      are required to 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.  Within the first month of operation, after
      an MCP has obtained a provider agreement, the MCP must provide to the
      ODJFS-designated providers (i.e., ODMH Community Mental Health Centers,
      ODADAS-certified Medicaid providers, FQHCs/RHCs, QFPPs, CNMs, CNPs [if
      applicable], and hospitals) a quick reference information packet which
      includesthe following:

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

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

    

    
      	
               

            	
              ii.

            	
              A
                brief summary document that includes the following
                information:

            	
               

            

    

    

    
      	
               

            	
              ·

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

            

    

    

    
      	
               

            	
              ·

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

            

    

    

    
      	
               

            	
              ·

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

            

    

    

    
      	
               

            	
              ·

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

            

    

    

    
      	
               

            	
              ·

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

            

    

    

    
      	
               

            	
              ·

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

            

    

    

    
      	
               

            	
              ·

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

            

    

    

    e.           Care
      coordination with Non-Contracting Providers

     

    
      	
            	
               

            	
              
                Per
                  OAC rule 5101:3-26-05(A)(9), MCPs authorizing the delivery
                  of
                  servicesfrom a provider who does not have an executed subcontract
                  must
                  ensure thatthey 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
                  ofservices form sent to providers as outlined in paragraph 28.i.c.
                  of
                  Appendix C.

              

            

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    APPENDIX
      H

    

    PROVIDER
      PANEL SPECIFICATIONS

    ABD
      ELIGIBLE POPULATION

    

    
      	
              1.

            	
              GENERAL
                PROVISIONS

            

    

    

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

    

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

    

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

    

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

    

    2.           PROVIDER
      SUBCONTRACTING

    

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

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

          

      

    

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

    

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

    

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

    

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

    

    3.           PROVIDER
      PANEL REQUIREMENTS

    

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

    

    a.           Primary
      Care Physicians (PCPs)

    

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

    

    ODJFS
      reviews the capacity totals for each PCP to determine if they appear
      excessive.

    ODJFS
      reserves the right to request clarification from an MCP for any PCP whose total
      stated

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

        
        

      

    

     

    capacity
      for all MCP networks added together exceeds 2000 Medicaid members (i.e., 1
      FTE).
ODJFS
      may allow up to an additional 750 member capacity for each nurse
practitioner
      or physician’s assistant that is used to provide clinical support for a
      PCP.

    

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

    

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

    

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

    

    b.           Non-PCP
      Provider Network

    

    In
      addition to the PCP capacity requirements, each MCP is also required to maintain
      adequate capacity in the remainder of its provider network within the following
      categories:  hospitals, cardiovascular, dentists, gastroenterology,
      nephrology, neurology, oncology, physical medicine, podiatry, psychiatry,
      urology, vision care providers, obstetricians/gynecologists (OB/GYNs),
      allergists, general surgeons, otolaryngologists, orthopedists, federally
      qualified health centers

    

    (FQHCs)/rural
      health centers (RHCs) and qualified family planning providers (QFPPs). CNMs,
      CNPs, FQHCs/RHCs and QFPPs are federally-required provider types.

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

    

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

    

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

    

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

    

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

    

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

    

    OB/GYNs
      - MCPs must contract with the specified  number of OB/GYNs for each
      county/region, all of whom must maintain a full-time obstetrical practice at
      a
      site(s) located in the specified county/region.  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.

    

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

    

    Other
      Specialty Types (general surgeons, otolaryngologists, orthopedists,
      cardiologists, gastroenterologists, nephrologists, neurologists, oncologists,
      podiatrists, physiatrists, psychiatrists, and urologists ) - MCPs must
      contract with the specified number of all other ODJFS designated specialty
      provider types. In order to be counted toward meeting the provider panel
      requirements, these specialty providers must maintain a full-time practice
      at a
      site(s) located within the specified county/region. Contracting general
      surgeons, orthopedists, otolaryngologists, cardiologists,
      gastroenterologists, nephrologists, neurologists, oncologists,

    podiatrists,
      physiatrists, psychiatrists, and urologists must have  admitting
      privileges at a hospital under contract with the MCP in the region.

    

    4.           PROVIDER
      PANEL EXCEPTIONS

    

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

    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

        
        

      

    

    

    
      	
               

            	
              -

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

            

    

    
      	
               

            	
              -

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

            

      	 	-	the
              MCP presents sufficient assurances to ODJFS that their members will
              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
      population.  For example, an MCP who serves CFC and ABD in the Central
      Region would have two provider directories, one for CFC and one for
      ABD.  Once approved, this directory may be regularly updated with
      provider additions or deletions by the MCP without ODJFS prior-approval,
      however, copies of the revised directory (or inserts) must be submitted to
      ODJFS
      prior to distribution to members.

    

    On
      a
      quarterly basis, MCPs must create an insert to each printed
      directory that lists those providers deleted from the MCP’s
      provider panel during the previous three months.  Although this insert
      does not need to be prior approved by ODJFS, copies of the insert must be
      submitted to ODJFS two weeks prior to distribution to members.

    

    Internet
      Provider Directory

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

    

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

    

    
      	
              6
                .

            	
              FEDERAL
                ACCESS STANDARDS

            

    

    

    MCPs
      must
      demonstrate that they are in compliance with the following federally
      defined

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

        
        

      

    

    provider
      panel access standards as required by 42 CFR 438.206:

    

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

    

    
      	
               

            	
              •

            	
              The
                anticipated Medicaid membership.

            

    

    
      	
               

            	
              •

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

            

    

    
      	
               

            	
              •

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

            

    

    
      	
               

            	
              •

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

            

    

    
      	
               

            	
              •

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

            

    

    

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

    

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

    

    This
      documentation of assurance of adequate capacity and services must be submitted
      to ODJFS no less frequently than at the time the MCP enters into a contract
      with
      ODJFS; at any time there is a significant change (as defined by
      ODJFS)  in the MCP’s operations that would affect

    

    adequate
      capacity and services (including changes in services, benefits, geographic
      service or payments); and at any time there is enrollment of a new population
      in
      the MCP.

    

    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
                Hospital

            	
            	
              1

            	
            	
               

            	
              1

            	
              1

            	
              1

            	
              1

            	
              1

            	 
	
              Hospital
                System1

            	
              1

            	 	
              1

            	 	 	 	 	 	 	
               1

            
	
              1
Hospital
                system
                includes; physician networks and therefore these physicians could
                be
                considered when fulfilling contracts for PCP and non-PCP provider
                panel
                requirements

            

    

     

    
      	
               North
                East Region - PCP Capacity

            
	
                  Minimum
                PCP Capacity Requirements -
                ABD

            
	
              PCPs

            	
              Total
                Required

            	
              Ashtabula

            	
              Cuyahoga

            	
              Erie

            	
              Geauga

            	
              Huron

            	
              Lake

            	
              Lorain

            	
              Medina

            	
              Additional
                Required: In-Region *

            
	
              Capacity
                

            	
              9,981

            	
              585

            	
              7,370

            	
              213

            	
              85

            	
              173

            	
              385

            	
              990

            	
              180

            	
               

            
	
              PCPs1

            	
              31

            	
              4

            	
              16

            	
              2

            	
              1

            	
              1

            	
              2

            	
              4

            	
              1

            	 
	 Number
              of Eligibles	
               25,810

            	
               1462

            	
               18425

            	
               532

            	
               213

            	
               432

            	
               963

            	
               2474

            	
               451

            	 
	
              1  Acceptable
                PCP specialty types include Family/General Practice or Internal
                Medicine

            

    

     

    
      	
              North
                East Region - Practitioners

            
	
              ABD
                Provider Panel Requirements

            
	
              Provider
                Types

            	
              Total
                Required Providers1

            	
              Ashtabula

            	
              Cuyahoga

            	
              Erie

            	
              Geauga

            	
              Huron

            	
              Lake

            	
              Lorain

            	
              Medina

            	
              Additional
                Required Providers2

            
	 Cardiovascular    	
              6

            	
               

            	
               3

            	 	 	 	 	
               1

            	 	
               2

            
	 Dentists	
              28

            	
               1

            	
               20

            	 	 	 	
               2

            	
               3

            	
               1

            	
               1

            
	 Gastroenterology	
              3

            	 	
               2

            	 	 	 	 	 	 	
               1

            
	 General
              Surgeons	
               11

            	
               

            	
               6

            	
               1

            	 	
               1

            	
               1

            	
               1

            	
               1

            	 
	 Nephrology	
              2

            	
               

            	
               1

            	 	 	 	 	 	 	
              1

            
	 Neurology	
              3

            	 	
              2

            	 	 	 	 	 	 	
              1

            
	
              OB/GYN

            	
              12

            	
               

            	
              8

            	
              1

            	
               

            	 	
               

            	
              1

            	
               

            	
              2

            
	 Oncology	
              1

            	 	 	 	 	 	 	 	 	
               1

            
	 Orthopedists	
              7

            	 	
               4

            	 	 	 	
              1

            	 	 	
              2

            
	 Otolaryngologist	
              3

            	 	
               1

            	 	 	 	 	
               1

            	 	
               1

            
	
               Physical
                Med Rehab

            	
              3

            	 	
               2

            	 	 	 	 	 	 	
               1

            
	Podiatry	
              8

            	
               

            	
              4

            	
               

            	 	
               

            	
               

            	
              2

            	
               

            	
              2

            
	
              Psychiatry

            	
              11

            	
               

            	
              5

            	
               

            	 	 	
               

            	
              3

            	
               

            	
              3

            
	Urology	
              4

            	 	
              2

            	
               

            	 	
               

            	
               

            	
               

            	
               

            	
              2

            
	Vision	
              14

            	
               1

            	
              7

            	
               1

            	 	 	
               1

            	
              1

            	 	
              3

            
	
              1
                All required
                providers must be located within the region.

            	
               

            
	
              
                2 
                  Additional required providers may be located anywhere within the
                  region

              

            	 	 	 

    

     

    
    

    
      
        
        

      

      
        
        

        
          

        

      

      
        
        

      

    

     

    

    APPENDIX
      I

    

    PROGRAM
      INTEGRITY

    ABD
      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
                the MCP’s
                management, the following written policies regarding false claims
                recovery:

            

    

    

    
      	
               

            	
              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 regarding false
      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, to the satisfaction of
                ODJFS.

            

    

    

    
      	
               

            	
              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.

    

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

            

        

      

    

    

    

    APPENDIX
      J

    

    FINANCIAL
      PERFORMANCE

    ABD
      ELIGIBLE POPULATION

    

    WellCare

    

    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);

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

                

                    Appendix
              J      
      

                    Page
                    
    

        

      

    

    

    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, 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, 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 of 2.5 or higher calculated from the last annualODI
      financial statement;

    

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

    

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

    

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

    

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

    

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

    

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

    

    5.           PHYSICIAN
      INCENTIVE PLAN DISCLOSURE REQUIREMENTS

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

              

        

      

    

    

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

    

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

    

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

    

    
      	
               

            	
              a.

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

            

    

    

    
      	
               

            	
              b.

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

            

    

    

    
      	
               

            	
              c.

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

            

    

    

    
      	
               

            	
              d.

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

            

    

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

              

        

      

    

    

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

    

    

    6.           NOTIFICATION
      OF REGULATORY ACTION

    

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

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    APPENDIX
      K

    

    QUALITY
      ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM

    AND

    EXTERNAL
      QUALITY REVIEW

    ABD
      ELIGIBLE POPULATION

    

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

    

    a.PERFORMANCE
      IMPROVEMENT
      PROJECTS

    

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

    

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

    

    ODJFS
      will identify the clinical and/or non-clinical study topics for the SFY
      20098 Provider Agreement.  Initiation of the PIPs
      will begin in the second year of participation in the ABD Medicaid managed
      care
      program.

    

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

    

    b.UNDER-
      AND
      OVER-UTILIZATION

    

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

    

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

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

                                        

        

      

    

    

    

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

    

    c.  SPECIAL
      HEALTH
      CARE NEEDS

    

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

    

    d.  SUBMISSION
      OF
      PERFORMANCE MEASUREMENT DATA

    

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

    

    Each
      MCP
      must also submit clinical performance measurement data as required by ODJFS
      that
      uses standard measures as specified by ODJFS.  MCPs will be required
      to submit Health Employer Data Information Set (HEDIS) audited data for measures
      that will be identified by ODJFS for the SFY 2009 Provider
      Agreement.

    

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

    

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

    

    2.           EXTERNAL
      QUALITY REVIEW

    

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

    

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

    

    The
      EQRO
      will conduct administrative compliance assessments for each MCP every three
      (3)
      years.  The review will include, but not be limited to, the following
      domains as specified by ODJFS:  member rights and services, QAPI
      program, access standards, provider network, grievance system, case management,
      coordination and continuity of care, and utilization management.  In
      accordance with 42 CFR 438.360 and 438.362, MCPs with
      accreditation from a national accrediting organization approved by the Centers
      for Medicare and Medicaid Services (CMS) may request a non-duplication exemption
      from certain specified components of the administrative
      review.  Non-duplication exemptions may not be requested for SFY
      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 (refer to Appendix G) program submissions are
      subject to an administrative review by the EQRO.  If the EQRO
      identifies deficiencies during its review, the MCP must develop and implement
      Corrective Action Plan(s) that are prior approved by ODJFS.  Serious
      deficiencies may result in immediate termination or non-renewal of the provider
      agreement.

    

    c.  EXTERNAL
      QUALITY
      REVIEW PERFORMANCE

    

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

     

    

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    APPENDIX
      L

    

    DATA
      QUALITY

    ABD
      ELIGIBLE POPULATION

    

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

    

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

    

    1.
      ENCOUNTER DATA

    

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

    

    1.a.  Encounter
      Data Completeness

    

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

    

    1.a.i.
      Encounter Data Volume

    

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

    

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

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    

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

     

    
      	
              Report
                Period

            	
              Data
                Source:

              Estimated
                Encounter  Data File Update

            	
              Quarterly
                Report

              Estimated
                Issue Date

            	
              Contract
                Period

            
	
              Qtr
                1 2007

            	
              July
                2007

            	
              August
                2007

            	
              SFY  2008

               

            
	
              Qtr
                1, Qtr 2 2007

            	
              October
                2007

            	
              November
                2007

            
	
              Qtr
                1 thru Qtr 3 2007

            	
              January
                2008

            	
              February
                2008

            
	
              Qtr
                1 thru Qtr 4 2007

            	
              April
                 2008

            	
              May 2008

            
	
              Qtr
                1 thru Qtr 4 2007, Qtr 1 2008

            	
              July
                2008

            	
              August
                2008

            	
              SFY
                2009

            
	
              Qtr
                1 thru Qtr 4 2007,

              Qtr
                1, Qtr 2 2008

            	
              October
                2008

            	
              November
                2008

            
	
              Qtr
                1 thru Qtr 4 2007,

              Qtr
                1 thru Qtr 3 2008

            	
              January
                2009

            	
              February
                2009

            
	
              Qtr
                1 thru Qtr 4 2007,

              Qtr
                1 thru Qtr 4 2008

            	
              April
                2009

            	
              May
                2009

            

    

    

    

    Qtr1
      =
      January to
      March                                                           Qtr2
      = April to
      June                                           Qtr3
      = July to SeptemberQtr 4 = October to December

    

    

    Data
      Quality Standard:  The utilization rate for all service
      categories listed in Table 2 must be equal to or greater than the interim
      standards established in Table 2. below (Interim Standards - Encounter Data
      Volume).

    

    Statewide
      Approach:  Prior to establishment of statewide minimum
      performance standards, ODJFS will evaluate MCP performance using the interim
      standards for Encounter data volume. ODJFS will use the first four quarters
      of
      data (i.e., full calendar year quarters) from all MCPs serving ABD program
      membership to determine statewide minimum encounter volume data quality
      standards.

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    

    Table
      2. Interim Standards – Encounter Data Volume

    

    
      	
              Category

            	
              Measure
                per 1,000/MM

            	
              Standard
                for Dates of Service

              on
                or after

              1/1/2007

            	
              Description

            
	
              Inpatient
                Hospital

            	
              Discharges

            	
              2.7

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

            
	
              Emergency
                Department

            	
              Visits

            	
              25.3

            	
              Includes
                physician and hospital emergency department encounters

            
	
              Dental

            	
              25.5

            	
              Non-institutional
                and hospital dental visits

            
	
              Vision

            	
              5.3

            	
              Non-institutional
                and hospital outpatient optometry and ophthalmology
                visits

            
	
              Primary
                and Specialist Care

            	
              116.6

            	
              Physician/practitioner
                and hospital outpatient visits

            
	
              Ancillary
                Services

            	
              66.8

            	
              Ancillary
                visits

            
	
              Behavioral
                Health

            	
              Service

            	
              5.2

            	
              Inpatient
                and outpatient behavioral encounters

            
	
              Pharmacy

            	
              Prescriptions

            	
              246.1

            	
              Prescribed
                drugs

            

    

    

    

    Determination
      of Compliance: Performance is monitored once every quarter for the entire
      report period.  If the standard is not met for every service category
      in all quarters of the report period, then the MCP will be determined to be
      noncompliant for the report period.

    

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

    

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    

    1.a.ii.  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

    

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

     

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    

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

    

    Report
      Period: The report periods for the  SFY 2008 and SFY 2009
      contract periods are listed in  Table 3. below.

    

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

    
      	
              Quarterly
                Report Periods

            	
              Data
                Source:

              Estimated
                Encounter  Data File Update

            	
              Quarterly
                Report

              Estimated
                Issue Date

            	
              Contract
                Period

            
	
              Qtr  3
                &  Qtr 4  2004,  2005, 2006

              Qtr
                1  2007

               

            	
              July
                2007

            	
              August
                2007

            	
              SFY
                2008

            
	
              Qtr
                3 & Qtr 4 2004, 2005, 2006

              Qtr
                1, Qtr 2 2007

            	
              October
                2007

            	
              November
                2007

            
	
              Qtr
                4 2004, 2005, 2006

              Qtr
                1 thru Qtr 3 2007

            	
              January
                2008

            	
              February
                2008

            
	
               

              Qtr
                1 thru Qtr 4: 2005, 2006, 2007

            	
              April
                2008

            	
              May
                2008

            
	
              Qtr
                2 thru Qtr 4 2005,

              Qtr
                1 thru Qtr 4: 2006, 2007

              Qtr
                1 2008

            	
              July
                2008

            	
              August
                2008

            	
              SFY
                2009

            
	
              Qtr
                3, Qtr 4: 2005,

              Qtr
                1 thru Qtr 4: 2006, 2007

              Qtr
                1, Qtr 2 2008

            	
              October
                2008

            	
              November
                2008

            
	
              Qtr
                4: 2005,

              Qtr
                1 thru Qtr 4: 2006, 2007

              Qtr
                1 thru Qtr 3: 2008

            	
              January
                2009

            	
              February
                2009

            
	
               

              Qtr
                1 thru Qtr 4: 2006, 2007, 2008

            	
              April
                2009

            	
              May
                2009

            

    

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

     

     

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    

    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.  Rejected
      Encounters

    

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

    

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

    

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

    

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

    

    Data
      Quality Standard for measure
      1:  Data Quality Standard 1 is a maximum encounter data rejection
      rate of 10% for each file in the ODJFS-specified medium per
      format.  The measure will be calculated per MCP.

    

    

    

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    

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

    

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

    

    Penalty
      for noncompliance with the Data Quality
      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 in the ODJFS-specified medium per format as
      follows:

    

    Third
      through sixth month with
      membership:   50%

    

    Seventh
      through twelfth month with
      membership:     25%

    

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

    

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

    

    Penalty
      for Noncompliance with the Data Quality
      Standard for measure 2:  If the MCP is
      determined to be noncompliant for either standard, ODJFS will impose a monetary
      sanction of one

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    

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

    

    1.a.v.                      Acceptance
      Rate

    

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

    

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

    

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

    

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

    

    Third
      through sixth month with membership:

      50
      encounters per 1,000 MM
      for NCPDP

      65
      encounters per 1,000 MM
      for NSF

      20
      encounters per 1,000 MM
      for UB-92

    

    Seventh
      through twelfth month of membership:

    250
      encounters per 1,000 MM for
      NCPDP

    350
      encounters per 1,000 MM for
      NSF

    100
      encounters per 1,000 MM for
      UB-92

    

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

    

    Penalty
      for Noncompliance:  If the MCP is determined to be noncompliant
      with the standard, ODJFS will impose a monetary sanction of one percent of
      the
      MCP’s current month’s premium payment.  The monetary sanction will be
      applied for each file type  in the ODJFS-specified medium per format
      that is determined to be out of compliance. The monetary sanction will be
      applied only once per file type per compliance determination period and
      will not exceed a total of two percent 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.   Informational
      Encounter Data Completeness Measure

    

    The
      ‘Incomplete Data for Last Menstrual Period’ measure is informational only for
      the ABD population.  Although there is no minimum performance standard
      for this measure, results will be reported and used as one component in
      monitoring the quality of data submitted to ODJFS by the MCPs.

    

    1.b.  Encounter
      Data Accuracy

    

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

    

    1.b.i.  Encounter
      Data Accuracy Study

    

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

    

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

    

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

    

    Data
      Quality Standard for Measure:   TBD for SFY 2008 and SFY
      2009.

    

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

    

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

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    

    1.b.ii.  Generic
      Provider Number Usage

    

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

    

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

    

    Report
      Period:  For the SFY 2008 and SFY 2009 contract period,
      performance will be evaluated using the report periods listed in 1.a.iii.,
      Table
      3.

    

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

    

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

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

    

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

    

    1.c.
      Timely Submission of Encounter Data

    

    1.c.i.  Timeliness

    

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

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    

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

    

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

    

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

    

    
      	
               

            	
              2.
                CASE MANAGEMENT DATA

            

    

    

    ODJFS
      designed a case management system (CAMS) in order to monitor MCP compliance
      with
      program requirements specified in Appendix G, Coverage and
      Services.  Each MCP’s case management data submissions will be
      assessed for completeness and accuracy.   The MCP is responsible
      for submitting a case management file every month.  Failure
      to do so jeopardizes the MCP’s ability to demonstrate
      compliance with case management requirements.   For detailed
      descriptions of the case management measures below, see ODJFS Methods for
      the ABD  and CFC Medicaid Managed Care Programs Data Quality
      Measures.

    

    2.a.   Case
      Management System Data Accuracy

    

    2.a.i.
      Open Case Management Spans for Disenrolled Members

    

    Measure:  The
      percentage of the MCP’s case management records in CAMS for the ABD program that
      have open case management date spans for members who have disenrolled from
      the
      MCP.

    

    Report
      Period: January – March 2007, and April – June 2007 report
      periods. For the SFY 2008 contract period,  July – September
      2007, October – December 2007, January – March 2008, and

    

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

    

    Data
      Quality Standard:  A rate of open case management spans for
      disenrolled members of no more than 1.0%.

    

    Statewide Approach:  MCPs
      will be evaluated using a statewide result specific for the ABD program,
      including all regions in which an MCP has ABD membership.  An MCP will
      not be evaluated until the MCP has at least 3,000 ABD members statewide. As
      the ABD Medicaid managed care program expands statewide and regions become
      active in different months, statewide results will include every region in
      which
      an MCP has membership [Example:  MCP AAA has: 6,000 members in the
      South West region beginning in January 2007; 7,000 members in the West Central
      region

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    

    beginning
      in February 2007; and 8,000 members in the South East region beginning in March
      2007. MCP AAA’s statewide results for the April-June 2007 report period will
      include data for the South West, West Central, and South East
      regions.] 

    

    Penalty
      for noncompliance:   If an MCP is noncompliant with the
      standard, then the ODJFS will issue a Sanction Advisory informing the MCP that
      a
      monetary sanction will be imposed if the MCP is noncompliant for any future
      report periods.  Upon all subsequent semi-annual measurements of
      performance, if an MCP is again determined to be noncompliant with the standard,
      ODJFS will impose a monetary sanction of one-half of one percent of the current
      month’s premium payment. 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 ABD members including those who have case management needs.  The
      MCP must submit  a Members’ Designated PCP file every
      month.  Specialists may and should be identified as the PCP as
      appropriate for the member’s condition per the specialty types specified for the
      ABD population in ODJFS Member’s PCP Data File and Submission
      Specifications; however, no ABD member may have more than one PCP
      identified for a given month. 

    

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

    

    Data
      Quality Submission Requirement:  The MCP must submit a Members’
Designated PCP Data files on a monthly basis according to the specifications
      established in 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:  A minimum rate of  65% of new
      members with PCP designation by their effective date of enrollment for quarter
      3
      and quarter 4 of SFY 2007.  A minimum rate of 75% of new members with
      PCP designation by their effective date of enrollment for quarter 1 and quarter
      2 of SFY 2008.  A minimum rate of  85% of new members with
      PCP designation by their effective date of enrollment for quarter 3 and quarter
      4 of SFY 2008. A minimum rate of  85% of new members with PCP
      designation by their effective date of enrollment for SFY 2009.

    

    Statewide
      Approach:  MCPs will be evaluated using a statewide result,
      including all regions in which an MCP has ABD membership.  An MCP will
      not be evaluated until the MCP has at least 3,000 ABD members
      statewide.

    

    Penalty
      for noncompliance:  If an MCP is noncompliant with the standard,
      ODJFS will impose a monetary sanction of one-half of one percent of the
      current month’s premium payment.  Once the MCP is performing at
      standard levels and violations/deficiencies are resolved to the satisfaction
      of
      ODJFS, the money will be refunded.  As stipulated in OAC rule
      5101:3-26-08.2, each new member must have a designated primary care 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.iv., 1.a.v., and
      1.b.ii  no monetary sanctions described in this appendix will be
      imposed if the MCP is in

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

    

    its
      first
      contract year of Medicaid program participation.  Notwithstanding the
      penalties specified in this Appendix, ODJFS reserves the right to apply the
      most
      appropriate penalty to the area of deficiency identified when an MCP is
      determined to be noncompliant with a standard.  Monetary penalties for
      noncompliance with any individual measure,  as determined in this
      appendix,  shall not exceed $300,000 during each
      evaluation.

    

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

    

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

    

    6.b.
      Combined Remedies

    

    If
      ODJFS
      determines that one systemic problem is responsible for multiple deficiencies,
      ODJFS may impose a combined remedy which will address all areas of deficient
      performance.  The total fines

    assessed
      in any one month will not exceed 15% of the MCP’s monthly premium payment for
      the Ohio Medicaid program.

    

    6.c.  Membership
      Freezes

    

    MCPs
      found to have a pattern of repeated or ongoing noncompliance may be subject
      to a
      membership freeze.

    

    6.d.  Reconsideration

    

    Requests
      for reconsideration of monetary sanctions and enrollment freezes may be
      submitted as provided in Appendix N, Compliance Assessment
      System.

    

    6.e.  Contract
      Termination, Nonrenewals, or Denials

    

    Upon
      termination either by the MCP or ODJFS, nonrenewal, or denial of an MCP provider
      agreement, all previously collected refundable monetary sanctions will be
      retained by ODJFS.

    

    
      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    

      APPENDIX
        M

      

      PERFORMANCE
        EVALUATION

      ABD
        ELIGIBLE POPULATION

      

      This
        appendix establishes minimum performance standards for managed care plans
        (MCPs)
        in key program areas, under the Agreement.  Standards are subject to
        change based on the revision or update of applicable national standards,
        methods, benchmarks, or other factors as deemed
        relevant.  Performance will be evaluated in the categories of Quality
        of Care, Access, Consumer Satisfaction, and Administrative
        Capacity.  Each performance measure has an accompanying minimum
        performance standard. MCPs with performance levels below the minimum performance
        standards will be required to take corrective action. All performance
        measures, as specified in this appendix, will be calculated per MCP and include
        only members in the ABD Medicaid managed care program.

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

      

      1.  QUALITY
        OF CARE

      

      1.a.
        Independent External Quality Review

      

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

      

      Measure:  The
        independent external quality review covers both an administrative review
        and
        focused quality of care studies as outlined in Appendix K.

      

      Report
        Period:  Performance will be evaluated using the reviews conducted
        during SFY 2008.

      

      Action
        Required for Deficiencies:  For all reviews conducted during the
        contract period, if the EQRO cites a deficiency in the administrative review
        or
        quality of care studies, the MCP will be required to complete a Corrective
        Action Plan, Quality Improvement Directive, or Performance Improvement Project
        as outlined in Appendix K of the Agreement.  Serious deficiencies may
        result in immediate termination or non-renewal of the Agreement.

      

      1.b.  Members
        with Special Health Care Needs (MSHCN)

      

      Given
        the
        substantial proportion of members with chronic conditions and co-morbidities
        in
        the ABD population, one of the quality of care initiatives of the ABD Medicaid
        managed care program focuses on case management.  In order to ensure
        state compliance with  the provisions of 42 CFR 438.208, the Bureau of
        Managed Health Care established Members with Special Health Care Needs (MSHCN)
        basic program requirements as set forth in Appendix G, Coverage and
        Services of the

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

             

        

      

      

      Agreement,  and
        corresponding minimum performance standards as described below. The purpose
        of
        these measures is to provide appropriate and targeted case management services
        to MSHCN who have specific diagnoses and/or who require high-cost or extensive
        services.  Given the expedited schedule for implementing the ABD
        Medicaid managed care program, coupled with the challenges facing a new Medicaid
        program in the State of Ohio, the minimum performance standards for the case
        management requirements for MSHCN are phased in throughout SFY 2007 and SFY
        2008.  The minimum standards for these performance measures will be
        fully phased in by no later than SFY 2009.  For detailed methodologies
        of each measure, see ODJFS Methods for the ABD Medicaid Managed Care
        Program’s Case Management Performance Measures.

      

      1.b.i
        Case Management of Members

      

      Measure:
        The average monthly case management rate for members who have at least
        three months of consecutive enrollment in one MCP.

      

      Report
        Period: For the SFY 2007 contract period, April – June 2007 report
        period. For the SFY 2008 contract period,  July – September 2007,
        October – December 2007, January – March 2008, and April – June 2008 report
        periods. For the SFY 2009 contract period,  July – September 2008,
        October – December 2008, January – March 2009, and April – June 2009 report
        periods.

      

      Statewide
        Approach:  MCPs will be evaluated using a statewide result,
        including all regions in which an MCP has membership.  An MCP will not
        be evaluated until the MCP has at least 3,000 members statewide who have
        had at
        least three months of continuous enrollment during each month of the entire
        report period.  As the ABD Medicaid managed care program expands
        statewide and regions become active in different months, statewide results
        will
        include every region in which an MCP has membership [Example:  MCP AAA
        has: 6,000 members in the South West region beginning in January 2007; 7,000
        members in the West Central region beginning in February 2007; and 8,000
        members
        in the South East region beginning in March 2007.  MCP AAA’s statewide
        results for the April-June 2007 report period will include case management
        rates
        for all members who meet minimum continuous enrollment criteria for this
        measure
        in: the South West region for April 2007’s monthly rate calculation; the South
        West and  West Central regions for May 2007’s monthly rate
        calculation; and the South West, West Central, and South East regions for
        June
        2007’s monthly rate calculation.]

      

      Minimum
        Performance Standard: For the fourth quarters of SFY 2007, a case
        management rate of 30%.  For the first and second quarters of SFY
        2008, a case management rate of 30%.  For the third and fourth
        quarters of SFY 2008, a case management rate of 35%.  For the first
        and second quarters of SFY 2009, a case management rate of 40%.  For
        the third and fourth quarters of SFY 2009, a case management rate of
        45%.

      

      Penalty
        for Noncompliance: The first time an MCP is noncompliant with a
        standard for this measure, ODJFS will issue a Sanction Advisory informing
        the
        MCP that any future noncompliance instances with the standard for this measure
        will result in ODJFS imposing a monetary sanction.  Upon all
        subsequent measurements of performance, if an MCP is again determined to
        be

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

             

        

      

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

      

      1.b.ii.
        Case Management of Members with an ODJFS-Mandated
        Condition

      

      Measure
        1:  The percent of members with a positive identification through
        an ODJFS administrative review of data for the ODJFS-mandated case management
        condition of  asthma who have had at least three
        consecutive months of enrollment in one MCP that are case managed.

      

      Measure
        2:  The percent of members with a positive identification through
        an ODJFS administrative review of data for the ODJFS-mandated case management
        condition of  chronic obstructive pulmonary disease who
        have had at least three consecutive months of enrollment in one MCP that
        are
        case managed.

      

      Measure
        3:  The percent of members with a positive identification through
        an ODJFS administrative review of data for the ODJFS-mandated case management
        condition of  congestive heart failure   who
        have had at least three consecutive months of enrollment in one MCP that
        are
        case managed.

      

      Measure
        4:  The percent of members with a positive identification through
        an ODJFS administrative review of data for the ODJFS-mandated case management
        condition of  severe mental illness who have had at least three
        consecutive months of enrollment in one MCP that are case managed.

      

      Measure
        5:  The percent of members with a positive identification through
        an ODJFS administrative review of data for the ODJFS-mandated case management
        condition of  high risk or high cost substance abuse disorders who
        have had at least three consecutive months of enrollment in one MCP that
        are
        case managed.

      

      Measure
        6:  The percent of members with a positive identification through
        an ODJFS administrative review of data for the ODJFS-mandated case management
        condition of  severe cognitive and/or developmental limitation who
        have had at least three consecutive months of enrollment in one MCP that
        are
        case managed.

      

      Measure
        7:  The percent of members with a positive identification through
        an ODJFS administrative review of data for the ODJFS-mandated case management
        condition of  diabetes who have had at least three consecutive months
        of enrollment in one MCP that are case managed.

      

      Measure
        8:  The percent of members with a positive identification through
        an ODJFS administrative review of data for the ODJFS-mandated case management
        condition of  non-mild hypertension who have had at least three
        consecutive months of enrollment in one MCP that are case
        managed.

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

              

        

      

      

      Measure
        9:  The percent of members with a positive identification through
        an ODJFS administrative review of data for the ODJFS-mandated case management
        condition of  coronary arterial disease who have had at least
        three consecutive months of enrollment in one MCP that are case
        managed.

      

      Report
        Periods for Measures 1- 9: For the SFY 2007
        contract period April – June 2007 report periods.  For the SFY 2008
        contract period,  July – September 2007, October – December 2007,
        January – March 2008, and April – June 2008 report periods.  For the
        SFY 2009 contract period,  July – September 2008, October – December
        2008, January – March 2009, and April – June 2009 report
        periods. 

      

      Statewide
        Approach:  MCPs will be evaluated using a statewide
        result, including all regions in which an MCP has membership.  An MCP
        will not be evaluated until the MCP has at least 3,000 members statewide
        who
        have had at least three months of continuous enrollment during each month
        of the
        entire report period.  As the ABD Medicaid managed care programs
        expands statewide and regions become active in different months, statewide
        results will include every region in which an MCP has membership
        [Example:  MCP AAA has: 6,000 members in the South West region
        beginning in January 2007; 7,000 members in the West Central region beginning
        in
        February 2007; and 8,000 members in the South East region beginning in March
        2007.  MCP AAA’s statewide results for the April-June 2007 report
        period will include case management rates for all members in the South West,
        West Central, and South East regions who are identified through the
        administrative data review as having a mandated condition and are continuously
        enrolled for at least three consecutive months in one MCP.]

      

      Minimum
        Performance Standard for Measures 1, 2, 3, 7, 8 and
        9: For the fourth quarter of SFY 2007, a case
        management rate of 60%.  For the first and second quarters of SFY
        2008, a case management rate of 60%.  For the third and fourth
        quarters of SFY 2008, a case management rate of 65%. For the first and
        second quarters of SFY 2009, a case management rate of 75%.  For the
        third and fourth quarters of SFY 2009, a case management rate of
        75%.

      

      Minimum
        Performance Standard for Measures 4-6: For the first and second quarters of
        SFY 2008, a case management rate of 30%.  For the third and fourth
        quarters of SFY 2008, a case management rate of 35%.  For SFY 2009,
        the case management rate is TBD.

      

      Penalty
        for Noncompliance for Measures 1-9: The
        first time an MCP is noncompliant with a standard for this measure, ODJFS
        will
        issue a Sanction Advisory informing the MCP that any future noncompliance
        instances with the standard for this measure will result in ODJFS imposing
        a
        monetary sanction.  Upon all subsequent measurements of performance,
        if an MCP is again determined to be noncompliant with the standard, ODJFS
        will
        impose a monetary sanction (see Section 5) of two percent of the current
        month’s
        premium payment. Monetary sanctions will not be levied for consecutive quarters
        that an MCP is determined to be noncompliant.  If an MCP is
        noncompliant for a subsequent quarter, new member selection freezes or a
        reduction of assignments will occur as outlined in Appendix N of the Provider
        Agreement. Once the MCP is performing at standard levels and the
        violations/deficiencies are resolved to the satisfaction of ODJFS, the
        penalties will be lifted, if applicable, and monetary sanctions will be
        returned.

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

               

        

      

      

      1.c.
        Clinical Performance Measures

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

      

      The
        clinical performance measures described below closely follow the National
        Committee for Quality Assurance’s (NCQA) Health Plan Employer Data and
        Information Set (HEDIS).  NCQA may annually change its method for
        calculating a measure.  These changes can make it difficult to
        evaluate whether improvement occurred from a  prior
        year.  For this reason, ODJFS will use the same methods to calculate
        the baseline results and the results for the period in which the MCP is being
        held accountable.  For example, the same methods are used to
        calculate calendar year  2008 results (the baseline period) and
        calendar year  2009 results.  The methods will be updated
        and a new baseline will be created during  2009 for
        calendar  year 2010  results.  These results will
        then serve as the baseline to evaluate whether improvement occurred from
        calendar  year   2009 to calendar
        year  2010.  Clinical performance measure
        results will be calculated after a sufficient amount of time has passed after
        the end of the report period in order to allow for claims runout.  For
        a comprehensive description of the clinical performance measures below, see
        ODJFS Methods for Clinical Performance Measures, ABD
Medicaid Managed Care Program.  Performance
        standards are subject to change, based on the revision or update of NCQA
        methods
        or other national standards, methods or benchmarks.

      

      MCPs
        will
        be evaluated using a statewide result, including all regions in which an
        MCP has
        membership.  ODJFS will use the first calendar year of an MCP’s ABD
        managed care program membership as the baseline year (i.e.,
        CY2007).  The baseline year will be used to determine performance
        standards and targets; baseline data will come from a combination of FFS
        claims
        data and MCP encounter data.  For those performance measures that
        require two calendar years of baseline data, the additional calendar year
        (i.e.,
        the calendar year prior to the first calendar year of ABD managed care
        program membership, i.e., CY2006) data will come from FFS claims data.

      

      An
        MCP’s
        second calendar year of ABD managed care program membership (i.e., CY2008)
        will be the initial report period of evaluation for performance measures
        that
        require one calendar year of

      baseline
        data (i.e., CY2007), and for performance measures that require two calendar
        years of baseline data (i.e., CY2006 and CY2007).

      

      Report
        Period:  For the SFY 2008 contract period, performance will be
        evaluated using the January - December 2007 report period and may be adjusted
        based on the number of months of ABD managed care membership.  For the
        SFY 2009 contract period, performance will be evaluated using the January
        -
        December 2008 report period.

      

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      1.c.i.  Congestive
        Heart Failure (CHF) – Inpatient Hospital Discharge Rate

      

      Measure:  The
        number of  acute inpatient hospital discharges in the reporting year
        where the principal diagnosis was CHF, per thousand member months, for members
        who had a diagnosis of CHF in the year prior to the reporting year.

      

      Target:  TBD

      

      Minimum
        Performance Standard:  The level of improvement must result in at
        least a TBD% decrease in the difference between the target and the previous
        report period’s results. (For example, if last year’s results were TBD%, then
        the difference between the target and last year’s results is TBD%.  In
        this example, the standard is an improvement in performance of TBD% of this
        difference or TBD%. In this example, results of TBD% or better would be
        compliant with the standard.)

      

      Action
        Required for Noncompliance:  If the standard is not met and the
        results are below TBD%, then the MCP is required to complete a Performance
        Improvement Project, as described in  Appendix
        K,  Quality Assessment and Performance Improvement Program,
        to address the area of noncompliance. If the standard is not met and
        the results are at or above TBD%, then ODJFS will issue a Quality Improvement
        Directive which will notify the MCP of noncompliance and may outline the
        steps
        that the MCP must take to improve the results.

      

      1.c.ii.  Congestive
        Heart Failure (CHF) – Emergency Department (ED) Utilization
        Rate

      

      Measure:  The
        number of emergency department visits in the reporting year where the primary
        diagnosis was CHF, per thousand member months, for members who had a diagnosis
        of CHF in the year prior to the reporting year.

      

      Target:  TBD

      

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

      

      Action
        Required for Noncompliance:  If the standard is not met and the
        results are below TBD%, then the MCP is required to complete a Performance
        Improvement Project, as described in  Appendix
        K,  Quality Assessment and Performance Improvement Program,
        to address the area of noncompliance. If the standard is not met and the
        results are at or above TBD%, then ODJFS will issue
        a
        Quality Improvement Directive which will notify the MCP of noncompliance
        and may
        outline the steps that the MCP must take to improve the results.

      

      1.c.iii.
        Congestive Heart Failure (CHF) – Cardiac Related Hospital
        Readmission

      

      Measure:  The
        rate of cardiac related readmissions during the reporting period for members
        who
        had a diagnosis of CHF in the year prior to the reporting period.  A
        readmission is defined as a cardiac related admission that occurs within
        30 days
        of  a prior cardiac related admission.

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

                

        

      

      

      Target:  TBD.

      

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

      

      Action
        Required for Noncompliance:  If the standard is
        not met and the results are below TBD%, then the MCP is required to complete
        a
        Performance Improvement Project, as described in  Appendix
        K,  Quality Assessment and Performance Improvement Program,
        to address the area of noncompliance. If the standard is not met and the
        results
        are at or above TBD%, then ODJFS will issue a Quality Improvement Directive
        which will notify the MCP of noncompliance and may outline the steps that
        the
        MCP must take to improve the results.

      

      1.c.iv.  Coronary
        Artery Disease (CAD) – Inpatient Hospital Discharge Rate

      

      Measure:  The
        number of  acute inpatient hospital discharges in the reporting year
        where the primary diagnosis was CAD,  per thousand member months, for
        members who had a diagnosis of CAD in the year prior to the reporting
        year.

      

      Target:  TBD

      

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

      

      Action
        Required for Noncompliance:  If the standard is not met and the
        results are below TBD%, then the MCP is required to complete a Performance
        Improvement Project, as described in  Appendix
        K,  Quality Assessment and Performance Improvement Program,
        to address the area of noncompliance. If the standard is not met and the
        results are at or above TBD%, then ODJFS will issue a Quality Improvement
        Directive which will notify the MCP of noncompliance and may outline the
        steps
        that the MCP must take to improve the results.

      

      1.c.v.  Coronary
        Artery Disease (CAD) – Emergency Department (ED) Utilization
        Rate

      

      Measure:  The
        number of  emergency department visits in the reporting year where the
        principal diagnosis was CAD,  per thousand member months, for members
        who had a diagnosis of CAD in the year prior to the reporting year.

      

      Target:  TBD

      

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

      

      Action
        Required for Noncompliance:  If the standard is not met and the
        results are below TBD%, then the MCP is required to complete a Performance
        Improvement Project, as described in  Appendix
        K,  Quality Assessment and Performance Improvement Program,
        to address the area of

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

            

        

      

      

      noncompliance.  If
        the standard is not met and the results are at or above TBD%, then ODJFS
        will
        issue a Quality Improvement Directive which will notify the MCP of noncompliance
        and may outline the steps that the MCP must take to improve the
        results.

      

      1.c.vi.
        Coronary Artery Disease (CAD) – Cardiac Related Hospital
        Readmission

      

      Measure:  The
        rate of cardiac related readmissions in the reporting year for members who
        had a
        diagnosis of CAD in the year prior to the reporting year.  A
        readmission is defined as a cardiac related admission that occurs within
        30 days
        of  a prior cardiac related admission.

      

      Target:  TBD.

      

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

      

      Action
        Required for Noncompliance:  If the standard is
        not met and the results are below TBD%, then the MCP is required to complete
        a
        Performance Improvement Project, as described in  Appendix
        K,  Quality Assessment and Performance Improvement Program,
        to address the area of

      

      noncompliance.
        If the standard is not met and the results are at or above TBD%, then ODJFS
        will
        issue a Quality Improvement Directive which will notify the MCP of noncompliance
        and may outline the steps that the MCP must take to improve the
        results.

      

      1.c.vii.
        Coronary Artery Disease (CAD) – Beta Blocker Treatment after Heart
        Attack

      

      The
        evaluation report period for this measure is CY 2008 only.

      

      Measure:  The
        percentage of members 35 years of age and older as of December 31st of the
        reporting
        year who were hospitalized from January 1 – December 24th of the
        reporting
        year with a diagnosis of acute myocardial infarction (AMI) and who received
        an
        ambulatory prescription for beta blockers within seven days of
        discharge.

      

      Target:  TBD.

      

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

      

      Action
        Required for Noncompliance:  If the standard is
        not met and the results are below TBD%, then the MCP is required to complete
        a
        Performance Improvement Project, as described in  Appendix
        K,  Quality Assessment and Performance Improvement Program,
        to address the area of noncompliance. If the standard is not met and the
        results
        are at or above TBD%, then ODJFS will issue a Quality Improvement Directive
        which will notify the MCP of noncompliance and may outline the steps that
        the
        MCP must take to improve the results.

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

              

        

      

      

      1.c.viii.  Persistence
        of Beta Blocker Treatment after Heart Attack

      

      The
        initial report period of evaluation for this measure is CY 2009.  This
        measure will replace the Coronary
        Artery Disease (CAD) – Beta Blocker Treatment after Heart Attack measure
        (1.c.vii.) in the P4P for SFY 2010.

      

      Measure:  The
        percentage of members 35 years of age and older as of December 31st of the
        reporting
        year who were hospitalized and discharged alive from July 1 of the year prior
        to
        the reporting year to June 30 of the measurement year with a diagnosis of
        acute
        myocardial information  (AMI) and who received persistent beta-blocker
        treatment for six months after discharge.

      

      Target:  TBD.

      

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

      

      Action
        Required for Noncompliance:  If the standard is not met and the
        results are below TBD%, then the MCP is required to complete a Performance
        Improvement Project, as described in  Appendix
        K,  Quality Assessment and Performance Improvement Program,
        to address the area of

      

      noncompliance.
        If the standard is not met and the results are at or above TBD%, then ODJFS
        will
        issue a Quality Improvement Directive which will notify the MCP of noncompliance
        and may outline the steps that the MCP must take to improve the
        results.

      

      
        	
                 

              	
                1.c.ix.
                  Coronary Artery Disease (CAD) – Cholesterol Management for Patients with
                  Cardiovascular Conditions/LDL-C Screening
                  Performed

              

      

      

      Measure:  The
        percentage of members who had a diagnosis of CAD in the year prior to the
        reporting year, who were enrolled for at least 11 months in the reporting
        year,
        and who received a lipid profile during the reporting year.

      

      Target:  TBD.

      

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

      

      Action
        Required for Noncompliance:  If the standard is
        not met and the results are below TBD%, then the MCP is required to complete
        a
        Performance Improvement Project, as described in  Appendix
        K,  Quality Assessment and Performance Improvement Program,
        to address the area of noncompliance. If the standard is not met and the
        results
        are at or above TBD%, then ODJFS will issue a Quality Improvement Directive
        which will notify the MCP of noncompliance and may outline the steps that
        the
        MCP must take to improve the results.

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

             

        

      

      

      1.c.x.  Hypertension  –
        Inpatient Hospital Discharge Rate

      

      Measure:  The
        number of  acute inpatient hospital discharges in the reporting year
        where the primary diagnosis was non-mild hypertension,  per thousand
        member months, for members who had a diagnosis of non-mild hypertension in
        the
        year prior to the reporting year.

      

      Target:  TBD

      

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

      

      Action
        Required for Noncompliance:  If the standard is not met and the
        results are below TBD%, then the MCP is required to complete a Performance
        Improvement Project, as described in  Appendix
        K,  Quality Assessment and Performance Improvement Program,
        to address the area of noncompliance. If the standard is not met and the
        results
        are at or above TBD%, then ODJFS will issue a Quality Improvement Directive
        which will notify the MCP of noncompliance and may outline the steps that
        the
        MCP must take to improve the results.

      

      1.c.xi.  Hypertension
        – Emergency Department (ED) Utilization Rate

      

      Measure:  The
        number of  emergency department visits in the reporting year where the
        principal diagnosis was non-mild hypertension, per thousand member months,
        for members who had a diagnosis of non-mild hypertension  in the year
        prior to the reporting year.

      

      Target:  TBD

      

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

      

      Action
        Required for Noncompliance:  If the standard is not met and the
        results are below TBD%, then the MCP is required to complete a Performance
        Improvement Project, as described in  Appendix
        K,  Quality Assessment and Performance Improvement Program,
        to address the area of noncompliance.  If the standard is not met and the
        results are at or above TBD%, then ODJFS will issue a Quality Improvement
        Directive which will notify the MCP of noncompliance and may outline the
        steps
        that the MCP must take to improve the results.

      

      1.c.xii.  Diabetes  –
        Inpatient Hospital Discharge Rate

      

      Measure:  The
        number of  acute inpatient hospital discharges in the reporting year
        where the principal diagnosis was diabetes,  per thousand member
        months, for members identified as diabetic in the year prior to the reporting
        year.

      

      Target:  TBD

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

              

        

      

      

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

      

      Action
        Required for Noncompliance:  If the standard is not met and the
        results are below TBD%, then the MCP is required to complete a Performance
        Improvement Project, as described in  Appendix
        K,  Quality Assessment and Performance Improvement Program,
        to address the area of noncompliance. If the standard is not met and the
        results are at or above TBD%, then ODJFS will issue a Quality Improvement
        Directive which will notify the MCP of noncompliance and may outline the
        steps
        that the MCP must take to improve the results.

      

      1.c.xiii.  Diabetes
        – Emergency Department (ED) Utilization Rate

      

      Measure:  The
        number of emergency department visits in the reporting year where the
        primary  diagnosis was diabetes, per thousand member months, for
        members identified as diabetic  in the year prior to the reporting
        year.

      

      Target:  TBD

      

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

      

      Action
        Required for Noncompliance:  If the standard is not met and the
        results are below TBD%, then the MCP is required to complete a Performance
        Improvement Project, as described in  Appendix
        K,  Quality Assessment and Performance Improvement Program,
        to address the area of noncompliance. If the standard is not met and the
        results are at or above TBD%, then ODJFS will issue a Quality Improvement
        Directive which will notify the MCP of noncompliance and may outline the
        steps
        that the MCP must take to improve the results.

      

      1.c.xiv.  Diabetes
        – Eye Exam

      

      Measure:   The
        percentage of diabetic members who were enrolled for at least 11 months
        during the reporting year, who received one or more retinal or dilated eye
        exams
        from an ophthalmologist or optometrist during the reporting year.

      

      Target:
        TBD.

      

      Minimum
        Performance Standard: The level of improvement must result in at least a
        TBD%  increase  in the difference between the target and the
        previous year’s results.

      

      Action
        Required for Noncompliance:  If the standard is not met and the
        results are below TBD%, then the MCP is required to complete a Performance
        Improvement Project, as described in  Appendix
        K,  Quality Assessment and Performance Improvement Program,
        to address the area of noncompliance. If the standard is not met and the
        results
        are at or above TBD%, then ODJFS will

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

              

        

      

      

      issue
        a
        Quality Improvement Directive which will notify the MCP of noncompliance
        and may
        outline the steps that the MCP must take to improve the results.

      

      1.c.xv.  Chronic
        Obstructive Pulmonary Disease  (COPD) – Inpatient Hospital Discharge
        Rate

      

      Measure:  The
        number of  acute inpatient hospital discharges in the reporting year
        where the primary diagnosis was COPD,  per thousand member months, for
        members who had a diagnosis of COPD in the year prior to the reporting
        year.

      

      Target:  TBD

      

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

      

      Action
        Required for Noncompliance:  If the standard is not met and the
        results are below TBD%, then the MCP is required to complete a Performance
        Improvement Project, as described in  Appendix
        K,  Quality Assessment and Performance Improvement Program,
        to address the area of

      noncompliance. If
        the standard is not met and the results are at or above TBD%, then ODJFS
        will
        issue a Quality Improvement Directive which will notify the MCP of noncompliance
        and may outline the steps that the MCP must take to improve the
        results.

      

      
        	
                 

              	
                1.c.xvi.  Chronic
                  Obstructive Pulmonary Disease  (COPD) – Emergency Department
                  (ED) Utilization Rate

              

      

      

      Measure:  The
        number of  emergency department visits in the reporting year where the
        principal diagnosis was COPD,  per thousand member months, for members
        who had a diagnosis of COPD  in the year prior to the reporting
        year.

      

      Target:  TBD

      

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

      

      Action
        Required for Noncompliance:  If the standard is not met and the
        results are below TBD%, then the MCP is required to complete a Performance
        Improvement Project, as described in  Appendix
        K,  Quality Assessment and Performance Improvement Program,
        to address the area of noncompliance.  If the standard is not met and
        the results are at or above TBD%, then ODJFS will issue a Quality Improvement
        Directive which will notify the MCP of noncompliance and may outline the
        steps
        that the MCP must take to improve the results.

      

      1.c.xvii.  Asthma
        – Inpatient Hospital Discharge Rate

      

      Measure:  The
        number of  acute inpatient hospital discharges in the reporting year
        where the primary diagnosis was asthma, per thousand member months, for members
        with persistent asthma.

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

              

        

      

      

      Target:  TBD

      

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

      

      Action
        Required for Noncompliance:  If the standard is not met and the
        results are below TBD%, then the MCP is required to complete a Performance
        Improvement Project, as described in  Appendix
        K,  Quality Assessment and Performance Improvement Program,
        to address the area of noncompliance.

      If
        the
        standard is not met and the results are at or above TBD%, then ODJFS will
        issue
        a Quality Improvement Directive which will notify the MCP of noncompliance
        and
        may outline the steps that the MCP must take to improve the
        results.

      

      
        	
                 

              	
                1.c.xviii.  Asthma
                  – Emergency Department (ED) Utilization
                  Rate

              

      

      

      Measure:  The
        number of  emergency department visits in the reporting year where the
        principal diagnosis was asthma,  per thousand member months, for
        members with persistent asthma.

      

      Target:  TBD

      

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

      

      Action
        Required for Noncompliance:  If the standard is not met and the
        results are below TBD%, then the MCP is required to complete a Performance
        Improvement Project, as described in  Appendix
        K,  Quality Assessment and Performance Improvement Program,
        to address the area of noncompliance. If the standard is not met and the
        results are at or above TBD%, then ODJFS will issue a Quality Improvement
        Directive which will notify the MCP of noncompliance and may outline the
        steps
        that the MCP must take to improve the results.

      

      
        	
                 

              	
                1.c.xix.  Asthma
                  – Use of Appropriate Medications for People with
                  Asthma

              

      

      

      Measure:  The
        percentage of members with persistent asthma who received prescribed medications
        acceptable as primary therapy for long-term control of asthma.

      

      Target:  TBD

      

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

      

      Action
        Required for Noncompliance:  If the standard is not met and the
        results are below TBD%, then the MCP is required to complete a Performance
        Improvement Project, as described in  Appendix
        K,  Quality Assessment and Performance Improvement Program,
        to address the area of noncompliance.  If the standard is not met and the
        results are at or above TBD%, then ODJFS will

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

              

        

      

      

      issue
        a
        Quality Improvement Directive which will notify the MCP of noncompliance
        and may
        outline the steps that the MCP must take to improve the results.

      

      1.c.xx.
        Mental Health, Severely Mentally Disabled (SMD) – Inpatient Hospital Discharge
        Rate

      

      Measure:  The
        number of  acute inpatient hospital discharges in the reporting year
        where the primary diagnosis was SMD, per thousand member months, for
        members who had a primary diagnosis of SMD in the year prior to the
        reporting year.

      

      Target:  TBD

      

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

      

      Action
        Required for Noncompliance:  If the standard is not met and the
        results are below TBD%, then the MCP is required to complete a Performance
        Improvement Project, as described in  Appendix
        K,  Quality Assessment and Performance Improvement Program,
        to address the area of noncompliance.  If the standard is not met and the
        results are at or above TBD%, then ODJFS will issue a Quality Improvement
        Directive which will notify the MCP of noncompliance and may outline the
        steps
        that the MCP must take to improve the results.

      

      
        	
                 

              	
                1.c.xxi.  Mental
                  Health, Severely Mentally Disabled (SMD) – Emergency Department
                  Utilization Rate

              

      

      

      Measure:  The
        number of  emergency department visits in the reporting year where the
        primary diagnosis was SMD, per thousand member months, for members who had
        a
        primary diagnosis of SMD in the year prior to the reporting year.

      

      Target:  TBD

      

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

      

      Action
        Required for Noncompliance:  If the standard is not met and the
        results are below TBD%, then the MCP is required to complete a Performance
        Improvement Project, as described in  Appendix
        K,  Quality Assessment and Performance Improvement Program,
        to address the area of noncompliance. If the standard is not met and the
        results are at or above TBD%, then ODJFS will issue a Quality Improvement
        Directive which will notify the MCP of noncompliance and may outline the
        steps
        that the MCP must take to improve the results.

      

      
        	
                 

              	
                1.c.xxii.  Follow-up
                  After Hospitalization for Mental
                  Illness

              

      

      

      Measure:  The
        percentage of discharges for members enrolled from the date of discharge
        through
        30 days after discharge, who were hospitalized for treatment
        of  selected mental health disorders and

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

          
          

        

      

      

      who
        had a
        follow-up visit (i.e., were seen on an outpatient basis or were in intermediate
        treatment with a mental health provider) within:

      1)
        30 Days of discharge,
        and

      2)
        7 Days of discharge.

      

      Target:  TBD.

      

      Minimum
        Performance Standard For Each Measure:  The
        level of improvement must result in at least a TBD%  decrease in the
        difference between the target and the previous year’s results.

      

      Action
        Required for Noncompliance (Follow-up visits within 30 days of
        discharge):  If the standard is not met and the results
        are below TBD%, then the MCP is required to complete a Performance Improvement
        Project, as described in  Appendix K,  Quality
        Assessment and Performance Improvement Program, to address the area of
        noncompliance. If the standard is not met and the

      

      results
        are at or above TBD%, then ODJFS will issue a Quality Improvement Directive
        which will notify the MCP of noncompliance and may outline the steps that
        the
        MCP must take to improve the results.

      

      Action
        Required for Noncompliance (Follow-up visits within 7 days of
        discharge):  If the standard is not met and the results are below
        TBD%, then the MCP is required to complete a Performance Improvement Project,
        as
        described in  Appendix K,  Quality Assessment and
        Performance Improvement Program, to address the area of noncompliance. If
        the standard is not met and the results are at or above TBD%, then ODJFS
        will
        issue a Quality Improvement Directive which will notify the MCP of noncompliance
        and may outline the steps that the MCP must take to improve the results.
        

      

      1.c.xxiii.
        Mental Health, Severely Mentally Disabled (SMD) – SMD Related Hospital
        Readmission

      

      Measure:  The
        number of SMD related readmissions for members who had a diagnosis of SMD
        in the year prior to the reporting year. A readmission is defined
        as a SMD related admission that occurs within 30 days of  a prior SMD
        related admission.

      

      Target:  TBD.

      

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

      

      Action
        Required for Noncompliance:  If the standard is
        not met and the results are below TBD%, then the MCP is required to complete
        a
        Performance Improvement Project, as described in  Appendix
        K,  Quality Assessment and Performance Improvement Program,
        to address the area of noncompliance. If the standard is not met and the
        results
        are at or above TBD%, then ODJFS will

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

               

        

      

      

      issue
        a
        Quality Improvement Directive which will notify the MCP of noncompliance
        and may
        outline the steps that the MCP must take to improve the results.

      

      1.c.xxiv.  Substance
        Abuse – Inpatient Hospital Discharge Rate

      

      Measure:  The
        number of acute inpatient hospital discharges in the reporting year where
        the
        primary diagnosis was alcohol and other drug abuse or dependence (AOD), per
        thousand member months, for members who had, in the year prior to the
        reporting year, a diagnosis of AOD and one of the following: AOD-related
        acute inpatient admission or two AOD related Emergency Department
        visits.

      

      Target:  TBD

      

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

      

      Action
        Required for Noncompliance:  If the standard is not met and the
        results are below TBD%, then the MCP is required to complete a Performance
        Improvement Project, as described in  Appendix
        K,  Quality Assessment and Performance Improvement Program,
        to address the area of noncompliance. If the standard is not met and the
        results are at or above TBD%, then ODJFS will issue a Quality Improvement
        Directive which will notify the MCP of noncompliance and may outline the
        steps
        that the MCP must take to improve the results.

      
         

        1.c.xxv. Substance
          Abuse – Emergency Department Utilization Rate

      Measure:  The
        number of  emergency department visits in the reporting year where the
        principal diagnosis was AOD, per thousand member months, for members who
        had, in
        the year prior to the reporting year, a diagnosis of AOD and one of the
        following: AOD-related acute inpatient admission or two AOD related Emergency
        Department visits .

      

      Target:  TBD

      

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

      

      Action
        Required for Noncompliance:  If the standard is not met and the
        results are below TBD%, then the MCP is required to complete a Performance
        Improvement Project, as described in  Appendix
        K,  Quality Assessment and Performance Improvement Program,
        to address the area of noncompliance. If the standard is not met and the
        results are at or above TBD%, then ODJFS will issue a Quality Improvement
        Directive which will notify the MCP of noncompliance and may outline the
        steps
        that the MCP must take to improve the results.

      

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

             

        

      

      

      1.c.xxvi.
        Substance Abuse – Inpatient Hospital Readmission Rate

      

      Measure:  The
        number of AOD related readmissions in the reporting year for members who
        had, in the year prior to the reporting year, a diagnosis of AOD and one
        of the following: AOD-related acute inpatient admission or two AOD related
        Emergency Department visits. A readmission is defined as an AOD-related
        admission that occurs within 30 days of  a prior AOD-related 
admission.

      

      Target:  TBD.

      

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

      

      Action
        Required for Noncompliance:  If the standard is
        not met and the results are below TBD%, then the MCP is required to complete
        a
        Performance Improvement Project, as described in  Appendix
        K,  Quality Assessment and Performance Improvement Program,
        to address the area of noncompliance. If the standard is not met and the
        results
        are at or above TBD%, then ODJFS will issue a Quality Improvement Directive
        which will notify the MCP of noncompliance and may outline the steps that
        the
        MCP must take to improve the results.

      

      1.c.xxvii.
        Informational Clinical Performance Measures

      

      The
        clinical performance measures listed in Table 1 are informational
        only.  Although there are no performance targets or minimum
        performance standards for these measures, results will be reported and used
        as
        one component  in assessing the quality of care provided by MCPs to
        the ABD managed care population.

      

      Table
        1. Informational Clinical Performance Measures

       

      
        	
                Condition

              	
                Informational
                  Performance Measure

              
	
                CHF

              	
                Discharge
                  rate with age group breakouts

              
	
                CAD

              	
                Discharge
                  rate with age group breakouts

              
	
                Hypertension

              	
                Discharge
                  rate with age group breakouts

              
	
                Diabetes

              	
                Discharge
                  rate with age group breakouts

              
	
                Comprehensive
                  Diabetes Care (CDC)/HbA1c testing

              
	
                CDC/kidney
                  disease monitored

              
	
                CDC/LDL-C
                  screening performed

              
	
                COPD

              	
                Discharge
                  rate with age group breakouts

              
	
                Use
                  of Spirometry Testing in the Assessment and Diagnosis of
                  COPD

              
	
                Asthma

              	
                Discharge
                  rate with age group breakouts

              
	
                Mental
                  Health (SMD)

              	
                Discharge
                  rate with age group breakouts

              
	
                Antidepressant
                  Medication Management

              
	
                Substance
                  Abuse

              	
                Discharge
                  rate with age group breakouts

              
	
                Initiation
                  and Engagement of Alcohol and Other Drug Dependence
                  Treatment

              

      

      

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

              

        

      

      

      2.  ACCESS

      

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

      

      2.a.
        PCP Turnover

      

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

      

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

      

      Statewide
        Approach: MCPs will be evaluated using a statewide result, including all
        regions in which an MCP has membership.  ODJFS will use the first
        calendar year of ABD managed care program membership as the baseline year
        (i.e.,
        CY2007). The baseline year will be used to determine a minimum statewide
        performance standard.  An MCP’s second calendar year of ABD managed
        care program membership (i.e., CY2008) will be the initial report period
        of
        evaluation, and penalties will be applied for noncompliance.

      

      Report
        Period: For the SFY 2008 contract period, a baseline level of performance
        will be established using the CY 2007 report period (and may be adjusted
        based on the number of months of ABD managed care membership).  For
        the SFY 2009 contract period, performance will be evaluated using the CY
        2008
        report period.  The first reporting period in which MCPs will be held
        accountable to the performance standards will be the SFY 2009 contract
        period.

      

      Minimum
        Performance Standard:  A maximum PCP Turnover rate of
        TBD.

      

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

      

      2.b.  Adults’
        Access to Designated PCP

      

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

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

             

        

      

      

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

      

      Statewide
        Approach: MCPs will be evaluated using a statewide result, including all
        regions in which an MCP has membership.  ODJFS will use the first
        calendar year of ABD managed care program membership as the baseline year
        (i.e.,
        CY2007). The baseline year will be used to determine a minimum statewide
        performance standard.  An MCP’s second calendar year of ABD managed
        care program membership (i.e., CY2008) will be the initial report period
        of
        evaluation, and penalties will be applied for noncompliance.

      

      Report
        Period:  For the SFY 2008 contract period, performance will be
        evaluated using the January - December 2007 report period (and may be adjusted
        based on the number of months of ABD managed care membership).  For
        the SFY 2009 contract period, performance will be evaluated using the January
        -
        December 2008 report period.  The first reporting period in which MCPs
        will be held accountable to the performance standards will be the SFY 2009
        contract period.

      

      Minimum
        Performance Standards: TBD

      

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

      

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

      

      This
        measure indicates whether adult members are accessing health
        services.

      

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

      

      Statewide
        Approach: MCPs will be evaluated using a statewide result, including all
        regions in which an MCP has membership.  ODJFS will use the first
        calendar year of ABD managed care program membership as the baseline year
        (i.e.,
        CY2007). The baseline year will be used to determine a minimum statewide
        performance standard.  An MCP’s second calendar year of ABD managed
        care program membership (i.e., CY2008) will be the initial report period
        of
        evaluation, and penalties will be applied for noncompliance.

      

      Report
        Period:  For the SFY 2008 contract period, performance will be
        evaluated using the January - December 2007 report period (and may be adjusted
        based on the number of months of ABD managed care membership).  For
        the SFY 2009 contract period, performance will be evaluated using the January
        -
        December 2008 report period.  The first reporting period in which MCPs
        will be held accountable to the performance standards will be the SFY
        2009 contract period.

      

      Minimum
        Performance Standards: TBD

      

      Penalty
        for Noncompliance:   If an MCP is noncompliant with the Minimum
        Performance

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

            

        

      

      

      Standard,
        then the MCP must develop and implement a corrective action plan.

      

      3.
        CONSUMER SATISFACTION

      

      MCPs
        will
        be evaluated using a statewide result, including all regions in which an
        MCP has
        membership.

      

      In
        accordance with federal requirements and in the interest of assessing enrollee
        satisfaction with MCP performance, ODJFS annually conducts independent consumer
        satisfaction surveys. Results are used to assist in identifying and correcting
        MCP performance overall and in the areas of access, quality of care, and
        member
        services.  Results from the SFY 2008 evaluation will be used to set a
        standard.  For the SFY 2008 contract period, this measure is a
        reporting only measure.  SFY 2009 will be the first contract period in
        which MCPs will be held accountable to the performance standards for this
        measure.

      

      Measure: TBD.
        The results of this measure are reported annually.

      

      Report
        Period: For the SFY 2008 contract period, the measure
        is under review and the report period has not been determined.

      

      Minimum
        Performance Standard: TBD.

      

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

      

      4.
        ADMINISTRATIVE CAPACITY

      

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

      

      4.a.
        Compliance Assessment System

      

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

      

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

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

             

        

      

      

      Performance
        Standard:  A maximum of 15 points

      

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

      

      4.b.
        Emergency Department Diversion

      

      Managed
        care plans must provide access to services in a way that assures access to
        primary and urgent care in the most effective settings and minimizes
        inappropriate utilization of emergency

      

      department
        (ED) services.  MCPs are required to identify high utilizers of ED
        services and implement action plans designed to minimize inappropriate ED
        utilization.

      

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

      

      Statewide
        Approach: MCPs will be evaluated using a statewide result, including all
        regions in which an MCP has membership.  ODJFS will use the first
        calendar year of ABD managed care membership as the baseline year (i.e.,
        CY2007). The baseline year will be used to determine a minimum statewide
        performance standard and a target.  The number of members with an ED
        visit used to calculate the measure for the baseline year will be adjusted
        based
        on the number of months of ABD managed care membership in the baseline
        year.   An MCP’s second calendar year of ABD managed care program
        membership (i.e., CY2008) will be the initial report period

      of
        evaluation, and penalties will be applied for noncompliance.

      

      Report
        Period:  For the SFY 2008 contract period, a baseline level of
        performance will be established using the CY2007 report period (and may be
        adjusted based on the number of months of ABD managed care
        membership).  For the SFY 2009 contract period, results will be
        calculated for the reporting period of CY2008 and compared to the CY2007
        baseline results to determine if the minimum performance standard is
        met.

      

      Target: TBD

      

      Minimum
        Performance Standard: TBD

      

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

      

      5.
        Notes

      

      Given
        that unforeseen circumstances (e.g., revision or update of applicable national
        standards, methods or benchmarks, or issues related to program implementation)
        may impact performance

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

            

        

      

      

      assessment
        as specified in Sections 1 through 4,  ODJFS reserves the right to
        apply the most appropriate penalty to the area of deficiency identified with
        any
        individual measure, notwithstanding the penalties specified in this
        Appendix.

      

      5.a.
        Monetary Sanctions

      

      Penalties
        for noncompliance with individual standards in this appendix will be imposed
        as
        the results are finalized. Penalties for noncompliance with individual standards
        for each period of compliance is determined in this appendix and will not
        exceed
        $250,000.

      

      

      Refundable
        monetary sanctions will be based on the capitation payment for the month
        of  the cited deficiency and will be due within 30 days of
        notification by ODJFS to the MCP of the amount.  Any monies collected
        through the imposition of such a sanction would be returned to the MCP (minus
        any applicable collection fees owed to the Attorney General’s Office, if the MCP
        has been delinquent in submitting payment) after they have demonstrated improved
        performance in accordance with this appendix.  If an MCP does not
        comply within two years of the date of notification of noncompliance, then
        the
        monies will not be refunded.  

      

      5.b.Combined
        Remedies

      

      If
        ODJFS
        determines that one systemic problem is responsible for multiple deficiencies,
        ODJFS may impose a combined remedy which will address all areas of deficient
        performance.  The total fines assessed in any one month will not
        exceed 15% of the MCP’s monthly capitation payment.

      

      5.c.Enrollment
        Freezes

      

      MCPs
        found to have a pattern of repeated or ongoing noncompliance may be subject
        to
        an enrollment freeze.

      

      5.d.
        Reconsideration

      

      Requests
        for reconsideration of monetary sanctions and enrollment freezes may be
        submitted as provided in Appendix N, Compliance Assessment
        System.

      

      5.e.
        Contract Termination, Nonrenewals or Denials

      

      Upon
        termination, nonrenewal or denial of an MCP 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 

      ABD
        ELIGIBLE POPULATION

      

      

      I.
        General Provisions of the Compliance Assessment System

      

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

      

      B.
        The
        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)
	 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)

        ABD
          ELIGIBLE POPULATION

        

        This
          Appendix establishes a Pay-for-performance (P4P) incentive system for managed
          care plans (MCPs) to improve performance in specific areas important to
          the
          Medicaid MCP members.  P4P includes the at-risk amount included with
          the monthly premium payments (see Appendix F, Rate Chart), and possible
          additional monetary rewards up to $250,000.

        

        To
          qualify for consideration of any P4P, MCPs must meet minimum performance
          standards established in Appendix M, Performance Evaluation on selected
          measures, and achieve P4P standards established for selected Clinical
          Performance Measures, as set forth herein below.  For qualifying MCPs,
          higher performance standards for three measures must be reached to be awarded
          a
          portion of the at-risk amount and any additional P4P (see Sections
          1).  An excellent and superior standard is set in this Appendix for
          each of the three measures.  Qualifying MCPs will be awarded a portion
          of the at-risk amount for each excellent standard met.  If an MCP
          meets all three excellent and superior standards, they may be awarded additional
          P4P (see Section 2).

        

        ODJFS
          will use the first calendar year of an MCP’s ABD managed care program membership
          as the baseline year (i.e., CY2007).  The baseline year will be used
          to determine performance standards and targets; baseline data may come
          from a
          combination of FFS claims data and MCP encounter data.  As many of the
          performance measures used in the determination of P4P require two calendar
          years
          of baseline data, the additional calendar year (i.e., the calendar year
          prior to
          the first calendar year of ABD managed care program membership, [i.e.,
          CY2006])
          data will come from FFS claims.

        

        An
          MCP’s
          second calendar year of ABD managed care program membership (i.e., CY2008)
          will
          be the initial report period of evaluation for performance measures that
          require
          one calendar year of baseline data (i.e., CY2007), and for performance
          measures
          that require two calendar years of baseline data (i.e., CY2006 and
          CY2007).  CY2008 will be the initial report period upon which
          compliance with the performance standards will be
          determined.  SFY 2009 will become the first
          year, an MCP’s performance level for P4P can be
          determined.

        

        1.
          SFY 2009 P4P

        

        1.a.
          Qualifying Performance Levels

        

        To
          qualify for consideration of the SFY 2009 P4P, an MCP’s performance level
          must:

        

        1)
          Meet
          the minimum performance standards set in Appendix M, Performance
          Evaluation, for the measures listed below; and

        

        2)  Meet
          the  P4P standards established for the Clinical Performance Measures
          below.

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        

        
          	
                   

                	
                  ·

                	
                  A
                    detailed description of the methodologies for each measure can
                    be found on
                    the BMHC page of the ODJFS website.

                

        

        

        Measures
          for which the minimum performance standard for SFY 2009 established in
          Appendix
          M, Performance Evaluation, must be met to qualify for consideration of
          incentives are as follows:

        

        1.  PCP
          Turnover (Appendix M, Section 2.a.)

        

        Report
          Period: CY
          2008

        

        2.  Adults’
          Access to Preventive/Ambulatory Health Services (Appendix M, Section
          2.c.)

        

        Report
          Period: CY
          2008                                                      

        

        3.
          Consumer Satisfaction measure to be determined (Appendix M, Section
          3.) 

        

        Report
          Period: The most recent consumer satisfaction survey completed prior to
          the
          end of the SFY 2009 contract period.

        

        For
          each
          clinical performance measure listed below, the MCP must meet the
          P4P standard to be considered for SFY 2009 P4P.  The MCP meets
          the P4P standard if one of two criteria is met.  The P4P standard is a
          performance level of either:

        

        1)
          The
          minimum performance standard established in Appendix M, Performance
          Evaluation, for five of eight clinical performance measures listed below;
          or

        

        2)
          The
          Medicaid benchmarks for five of eight clinical performance measures listed
          below.  The Medicaid benchmarks are subject to change based on the
          revision or update of applicable national standards, methods or
          benchmarks.

         

        
          	 	
                  Clinical
                    Performance Measure

                	
                  Medicaid

                  Benchmark

                
	
                  CHF:
                    Inpatient Hospital Discharge Rate

                	
                  TBD

                
	
                  1.CAD:
                    Beta-Blocker Treatment after Heart Attack (AMI -related
                    admission)

                	
                  TBD

                
	
                  2.CAD:
                    Cholesterol Management for Patients with Cardiovascular Conditions/LDL-C
                    screening performed

                	
                  TBD

                
	
                  3.Hypertension:
                    Inpatient Hospital Discharge Rate

                	
                  TBD

                
	
                  4.Diabetes:
                    Comprehensive Diabetes Care (CDC)/Eye exam

                	
                  TBD

                
	
                  5.COPD:
                    Inpatient Hospital Discharge Rate

                	
                  TBD

                
	
                  6.Asthma:
                    Use of Appropriate Medications for People with Asthma

                	
                  TBD

                
	
                  7.Mental
                    Health: Follow-up After Hospitalization for Mental Illness

                	
                  TBD

                

        

        

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        

        1.b.
          Excellent and Superior Performance Levels

        

        For
          qualifying MCPs as determined by Section 1.a.. herein, performance will
          be
          evaluated on the measures below to determine the status of the at-risk
          amount or
          any additional P4P that may be awarded.  Excellent and Superior
          standards are set for the three measures described below.  The
          standards are subject to change based on the revision or update of applicable
          national standards, methods or benchmarks.

        

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

        

        1.
          Case
          Management of Members (Appendix M, Section 1.b.i)

        

        Report
          Period: April
– June 2009

        

        Excellent
          Standard:  TBD

        

        Superior
          Standard:  TBD

        

        2.
          Comprehensive Diabetes Care (CDC)/Eye exam  (Appendix M, Section
          1.c.xiv.)

        

        Report
          Period: CY
          2008

        

        Excellent
          Standard:
          TBD

        

        Superior
          Standard:
          TBD

        

        3.
          Adults’ Access to Preventive/Ambulatory Health Services (Appendix M, Section
          2.c.)

        

        Report
          Period: CY
          2008

        

        Excellent
          Standard:
          TBD

        

        Superior
          Standard:
          TBD

        

        1.c.
          Determining SFY 2009 P4P

        

        MCPs
          reaching the minimum performance standards described in Section 1.a. herein,
          will be considered for P4P including retention of the at-risk amount and
          any
          additional P4P.  For each Excellent standard established in Section
          1.b. herein,  that an MCP meets, one-third of the at-risk amount may
          be retained.  For MCPs meeting all of the Excellent and 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.
          NOTES

        

        2.a. Initiation
          of the P4P System

        

        For
          MCPs
          in their first twenty-four (24) months of Ohio Medicaid ABD Managed Care
          Program
          participation, the status of the at-risk amount will not be determined
          because
          compliance with many of the standards in the ABD program cannot be determined
          in
          an MCP’s first two contract years (see Appendix F., Rate Chart). In
          addition, MCPs in their first two (2) contract years in the ABD program
          are not
          eligible for the additional P4P amount awarded for superior
          performance.

        

        Starting
          with the twenty-fifth (25th) month
          of
          participation in the ABD program, the MCP’s at-risk amount will be included in
          the  P4P system.  The determination of the status of this
          at-risk amount will occur after two (2) calendar years of ABD membership.
          Because of this requirement, the number of months of at-risk dollars to
          be
          included in an MCP’s first at-risk status determination may vary depending on
          when an MCP starts with the ABD program relative to the calendar
          year.

        

        2.b.
          Determination of at-risk amounts and additional P4P
          payments

        

        For
          MCPs
          that have participated in the Ohio Medicaid ABD Managed Care Program long
          enough
          to calculate performance levels for all of the performance measures included
          in
          the P4P system, determination of the status of an MCP’s at-risk amount will
          occur within six (6) months of the end of the contract
          period.  Determination of additional P4P payments will be made at the
          same time the status of an MCP’s at-risk amount is determined.

        

        2.c.
          Statewide P4P system

        

        All
          MCPs
          will be included in a statewide P4P system for the ABD program.  The
          at-risk amount will be determined using a statewide result for all regions
          in
          which an MCP serves ABD membership.

        

        2.d.
          Contract Termination, Nonrenewals, or Denials

        

        Upon
          termination, nonrenewal or denial of an MCP contract, the at-risk amount
          paid to
          the MCP under the current provider agreement will be returned to
          ODJFS  in accordance with Appendix P.,
Terminations/Nonrenewals/Amendments, of the provider
          agreement.

        

        
          
            
            

          

          
            
            

            
              

            

          

          
            
            

          

        

        

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

        

        2.e.
          Report Periods

        

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

         

        

          
            
              
              

            

            
              
              

              
                

              

            

            
              
              

                    

            

          

          APPENDIX
            P

          

          MCP
            TERMINATIONS/NONRENEWALS/AMENDMENTS

          ABD
            ELIGIBLE POPULATION

          

          Upon
            termination either by the MCP or ODJFS, nonrenewal or denial of an MCP’s
            provider agreement, all previously collected refundable monetary sanctions
            will
            be retained by ODJFS.

          

          MCP-INITIATED
            TERMINATIONS/NONRENEWALS

          

          If
            an MCP
            provides notice of the termination/nonrenewal of their provider agreement
            to
            ODJFS, pursuant to Article VIII of the agreement, the MCP will be required
            to
            submit a refundable monetary assurance.  This monetary assurance will
            be held by ODJFS until such time that the MCP has submitted all outstanding
            monies owed and reports, including, but not limited to, grievance, appeal,
            encounter and cost report data related to time periods
            through the final date of service under the MCP=s
            provider agreement.  The monetary assurance must be in an amount of
            either $50,000 or 5 % of the capitation amount paid by ODJFS in the month
            the
            termination/nonrenewal notice is issued, whichever is greater.

          

          The
            MCP
            must also return to ODJFS the at-risk amount paid to the MCP under the
            current
            provider agreement.  The amount to be returned will be based on actual
            MCP membership for preceding months and estimated MCP membership through
            the end
            date of the contract.  MCP membership for each month between the month
            the termination/nonrenewal is issued and the end date of the provider
            agreement
            will be estimated as the MCP membership for the month the termination/nonrenewal
            is issued. Any over payment will be determined by comparing actual to
            estimated  MCP membership and will be returned to the MCP following
            the end date of the provider agreement.

          

          The
            MCP
            must remit the monetary assurance and the at-risk amount in the specified
            amounts via separate electronic fund transfers (EFT) payable to Treasurer of
            State, State of Ohio (ODJFS).  The MCP should contact their
            Contract Administrator to verify the correct amounts required for the
            monetary
            assurance and the at-risk amount and obtain an invoice number prior to
            submitting the monetary assurance and the at-risk amount.  Information
            from the invoices must be included with each EFT to ensure monies are
            deposited
            in the appropriate ODJFS Fund account.  In addition, the MCP must send
            copies of the EFT bank confirmations and copies of the invoices to their
            Contract Administrator.

          

          If
            the
            monetary assurance and the at-risk amount are not received as specified
            above,
            ODJFS will withhold the MCP’s next month’s capitation payment until such time
            that ODJFS receives documentation that the monetary assurance and the
            at-risk
            amount are received by the Treasurer of State. If within one year of
            the date of
            issuance of the invoice, an MCP does not submit all outstanding monies
            owed and
            required submissions, including, but not limited to, grievance, appeal,
            encounter and cost report data related to time periods through the final
            date of
            service under the MCP’s provider agreement, the monetary assurance will not be
            refunded to the MCP.

          

          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 the 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 Eastern Time (ET) on the
                      third working
                      day following receipt of the ODJFS notification of termination.
                      The
                      address and fax number to be used in making these requests
                      will be
                      specified in the ODJFS notification of termination
                      document.

                  

          

          

          
            	
                    ·

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

                  

          

          

          
            	
                    ·

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

                  

          

          

          
            	
                    ·

                  	
                    The
                      proposed MCP membership termination will not occur while an
                      appeal is
                      under review and pending the Deputy Director’s decision.  If the
                      Deputy Director denies the appeal, the MCP membership termination
                      will
                      proceed at the first possible effective date.  The date may be
                      retroactive if the ODJFS determines that it would be in the
                      best interest
                      of the
                      members.exhibit10-3.htm

     
      

    

    Back
      to Form 8-K

    Exhibit
      10.3

     

    Wellcare
      of Florida, Inc.  d/b/a Staywell Health Plan of
      Florida 

    Medicaid
      HMO Contract

     

    AHCA
      CONTRACT NO. FA615

    AMENDMENT
      NO. 1

    

    THIS
      CONTRACT, entered
      into between the STATE OF FLORIDA, AGENCY FOR HEALTH CARE
      ADMINISTRATION, hereinafter referred to as the "Agency" and
WELLCARE OF FLORIDA, INC. D/B/A STAYWELL HEALTH PLAN OF
      FLORIDA, hereinafter referred to as the "Vendor", is hereby amended as
      follows:

    

    
      	
              1.

            	
              Standard
                Contract, Section II, Item A, Contract Amount, the first sentence
                is
                hereby revised to now read as
                follows:

            

    

    

    
      	
               

            	
              To
                pay for contracted services according to the conditions of Attachment
                I in
                an amount not to exceed $1,246,085,621.00 (an increase of $28,056,746.00),
                subject to availability of funds.

            

    

    

    
      	
              2.

            	
              Standard
                Contract, Section III, Item C., Contract Managers, sub-item 2. is
                hereby
                amended to now read as follows:

            

    

    

    
      	
               

            	
              2.

            	
              The
                Vendor’s Contract Manager’s name, address and telephone number for this
                Contract is as follows:

            

    

    

    
      	
               

            	
              Geoffrey
                L. Petrie

            

    

    
      	
               

            	
              HealthEase
                Health Plan of Florida, Inc.

            

    

    
      	
               

            	
              8735
                Henderson Road

            

    

    
      	
               

            	
              Tampa,
                FL  33614-3988

            

    

    
      	
               

            	
              (813)
                865-5038

            

    

    

    
      	
              3.

            	
              Attachment
                I, Section B, Method of Payment, Item 1, General, the first paragraph
                is
                hereby revised to now read as
                follows:

            

    

    

    
      	
               

            	
              Notwithstanding
                the payment amounts which may be computed with the rate tables specified
                in Exhibit III, the sum of total capitation payments under this Contract
                shall not exceed the total Contract amount of $1,246,085,621.00 (an
                increase of $28,056,746.00).

            

    

    

    
      	
              4.

            	
              Attachment
                I, Exhibit I, Maximum Enrollment Levels, is hereby deleted in its
                entirety
                and replaced with Exhibit I-A, Revised Maximum Enrollment Levels,
                attached
                hereto and made a part of the Contract.  All references in the
                Contract to Exhibit I, Maximum Enrollment Levels shall, hereinafter
                refer
                to Exhibit I-A, Revised Maximum Enrollment
                Levels.

            

    

    

    
      	
              5.

            	
              Attachment
                I, Exhibit II, Capitation Rates, is hereby deleted in its entirety
                and
                replaced with Exhibit II-A, Revised Capitation Rates, attached hereto
                and
                made a part of the Contract.  All references in the Contract to
                Exhibit II, Capitation Rates, shall hereinafter refer to Exhibit
                II-A,
                Revised Capitation Rates.

            

    

    

    All
      provisions in the Contract and any attachments thereto in conflict with this
      Amendment shall be and are hereby changed to conform with this
      Amendment.

    

    All
      provisions not in conflict with this Amendment are still in effect and are
      to be
      performed at the level specified in the Contract.

    

    This
      Amendment and all its attachments are hereby made a part of the
      Contract.

    

    This
      Amendment cannot be executed unless all previous amendments to this Contract
      have been fully executed.

     

    
      
        
          
          

        

        
          AHCA
            CONTRACT  No. FA615, Amendment No.1, Page 1 of 2

          
            

          

        

        
          
          

        

      

    

     

    
      Wellcare
        of Florida, Inc.  d/b/a Staywell Health Plan of
        Florida 

      Medicaid
        HMO Contract

    This
      Amendment cannot
      be executed unless all previous amendments to this Contract have been fully
      executed.

     

        IN
      WITNESS
      WHEREOF, the parties hereto have caused this four (4) page amendment
      (which includes all attachments hereto) to be executed by their officials
      thereunto duly authorized.

    

    
      	
              WELLCARE
                OF FLORIDA, INC. D/B/A STAYWELL HEALTH PLAN OF
                FLORIDA

            	
              STATE
                OF FLORIDA, AGENCY FOR HEALTH CARE
                ADMINISTRATION

            
	
              SIGNED
                BY:  /s/  Todd S. Farha    
                

            	
              SIGNED
                BY:  /s/  Andrew C. Agwunobi    
                

            
	
              NAME:
                Todd S. Farha

            	
              NAME:
                Andrew C. Agwunobi, M.D.

            
	
              TITLE:
                President and CEO

            	
              TITLE:
                Secretary

            
	
              DATE:
                5/29/2007

            	
              DATE:
                5/31/2007

            

    

    

    List
      of
      Attachments/Exhibits included as part of this Amendment:

     

    
      
        	
                Specify
                  Type

              	
                Letter/
                  Number                                

              	
                Description                      

              
	
                Exhibit

              	
                I-A

              	
                Revised
                  Maximum Enrollment Levels (1 Page)

              
	
                Exhibit

              	
                II-A

              	
                Revised
                  Capitation Rates (1 Page)

              

      

    

    

    

    REMAINDER
      OF PAGE INTENTIONALLY LEFT BLANK

    
 

    
      
        
          
          

        

        
          AHCA
            CONTRACT  No. FA615, Amendment No.1, Page 2 of 2

          
            

          

        

        
          
          

        

      

       

      EXHIBIT
        I-A 

        REVISED
          MAXIMUM ENROLLMENT LEVELS

      

       

       TABLE
        1

      ENROLLMENT
        LEVELS

       

      
        	
                County

              	
                Maximum
                  Enrollment Level

              
	
                Brevard

              	
                14,000

              
	
                Broward

              	
                25,000

              
	
                Dade

              	
                25,000

              
	
                Hernando

              	
                15,000

              
	
                Hillsborough

              	
                28,000

              
	
                Lee

              	
                15,000

              
	
                Manatee

              	
                12,000

              
	
                Palm
                  Beach

              	
                15,000

              
	
                Pasco

              	
                7,000

              
	
                Pinellas

              	
                15,000

              
	
                Polk

              	
                25,000

              
	
                Orange

              	
                38,000

              
	
                Osceola

              	
                12,000

              
	
                Sarasota

              	
                6,000

              
	
                Seminole

              	
                6,000

              
	
                St.
                  Lucie

              	
                4,500

              
	
                Sumter

              	
                4,500

              

      

      

      

      REMAINDER
        OF PAGE INTENTIONALLY LEFT BLANK

       

      
        
          
            AHCA
              Contract No. FA615, Exhibit I-A, Page 1 of
              1      

          

          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

      EXHIBIT
        II-A

      REVISED
        CAPITATION RATES

      

      

      A.           Table
        2 - General Capitation Rates plus Mental Health Rates:

      

      Area
        3 Counties:

       

      
        	
                County

              	
                Provider
                  Number

              
	
                Sumter

              	
                015016916

              

      

       

       

      Area
        9 Counties:

       

      
        	
                County

              	
                Provider
                  Number

              
	
                St.
                  Lucie

              	
                015016915

              

      

      

      B.           Table
        4 - General Capitation Rates plus Mental Health Rates plus
        Transportation:

      Area
        3 Counties:

       

      
        	
                County

              	
                Provider
                  Number

              
	
                Hernando

              	
                015016901

              

      

      

      Area
        5 Counties:

       

      
        	
                County

              	
                Provider
                  Number

              
	
                Pasco

              	
                015016903

              
	
                Pinellas

              	
                015016904

              

      

      

      Area
        6 Counties:

       

      
        	
                County

              	
                Provider
                  Number

              
	
                Hillsborough

              	
                015016902

              
	
                Manatee

              	
                015016912

              
	
                Polk

              	
                015016905

              

      

      

      Area
        7 Counties:

       

      
        	
                County

              	
                Provider
                  Number

              
	
                Orange

              	
                015016906

              
	
                Seminole

              	
                015016908

              
	
                Osceola

              	
                015016907

              
	
                Brevard

              	
                015016913

              

      

      

      Area
        8 Counties:

       

      
        	
                County

              	
                Provider
                  Number

              
	
                Lee

              	
                015016911

              
	
                Sarasota

              	
                015016914

              

      

      

      Area
        9 Counties:

       

      
        	
                County

              	
                Provider
                  Number

              
	
                Palm
                  Beach

              	
                015016910

              

      

      

      Area
        10 Counties:

       

      
        	
                County

              	
                Provider
                  Number

              
	
                Broward

              	
                015016900

              

      

      

      Area
        11 Counties:

       

      
        	
                County

              	
                Provider
                  Number

              
	
                Miami-Dade

              	
                015016909

              

      

       

       

      AHCA
        Contract No. FA615, Exhibit II-A, Page 1 of
        1

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