Exhibit 10.1
DEPARTMENT
OF JOB AND FAMILY SERVICES
Pursuant
to Article IX.A. the Provider Agreement between the State of Ohio. Department of
Job and Family Services, (hereinafter referred to as "ODJFS") and WELLCARE OF
OHIO, INC. (hereinafter referred to as "MCP") for the Covered Families and
Children (hereinafter referred to as "CFC") population dated July 1, 2008. is
hereby amended as follows:
1. Appendices
C, D, E, F, G, H, J, K, L, M, N, and O have been modified as
attached.
2.
All
other terms of the provider agreement are hereby affirmed.
The amendment contained herein shall be effective January 1,
2009.
|
WELLCARE
OF OHIO, INC.
|
|
|
BY:
/s/ Heath
Schiesser
HEATH
SCHIESSER, CHIEF EXECUTIVE OFFICER AND PRESIDENT
|
DATE:
12-19-08
|
|
OHIO
DEPARTMENT OF JOB AND FAMILY SERVICES:
|
|
|
BY:
/s/ Jan Allen,
Director
JAN ALLEN, DIRECTOR
|
DATE:
12/30/08
|
Covered
Families and Children (CFC) population
MCP
RESPONSIBILITIES
CFC
ELIGIBLE POPULATION
The MCP
must meet on an ongoing basis, all program requirements specified in Chapter
5101:3-26 of the Ohio Administrative Code (OAC) and the Ohio Department of Job
and Family Services (ODJFS) - MCP Provider Agreement. The following are MCP
responsibilities that are not otherwise specifically stated in OAC rule
provisions or elsewhere in the MCP provider agreement, but are required by
ODJFS.
|
1.
|
The
MCP agrees to implement program modifications as soon as reasonably
possible or no later than the required effective date, in response to
changes in applicable state and federal laws and
regulations.
|
|
2.
|
The
MCP must submit a current copy of their Certificate of Authority (COA) to
ODJFS within 30 days of issuance by the Ohio Department of
Insurance.
|
3
The MCP must designate the following:
|
|
a.
|
A
primary contact person (the Medicaid Coordinator) who will dedicate a
majority of their time to the Medicaid product line and coordinate overall
communication between ODJFS and the MCP. ODJFS may also require the MCP to
designate contact staff for specific program areas. The Medicaid
Coordinator will be responsible for ensuring the timeliness, accuracy,
completeness and responsiveness of all MCP submissions to
ODJFS.
|
|
|
b.
|
A
provider relations representative for each service area included in their
ODJFS provider agreement. This provider relations representative can serve
in this capacity for only one service area (as specified in Appendix
H).
|
|
|
As
long as the MCP serves both the CFC and ABD populations, they are not
required to have separate provider relations representatives or Medicaid
coordinators.
|
|
4.
|
All
MCP employees are to direct all day-to-day submissions and communications
to their ODJFS-designated Contract Administrator unless otherwise notified
by ODJFS.
|
|
5.
|
The
MCP must be represented at all meetings and events designated by ODJFS as
requiring mandatory attendance.
|
|
|
|
|
6.
|
The
MCP must have an administrative office located in
Ohio.
|
Covered
Families and Children (CFC) population
|
7.
|
Upon
request by ODJFS, the MCP must submit information on the current status of
their company’s operations not specifically covered under this provider
agreement (for example, other product lines, Medicaid contracts in other
states, NCQA accreditation, etc.) unless otherwise excluded by
law.
|
|
8.
|
The
MCP must have all new employees trained on applicable program
requirements, and represent, warrant and certify to ODJFS that such
training occurs, or has
occurred.
|
|
9.
|
If
an MCP determines that it does not wish to provide, reimburse, or cover a
counseling service or referral service due to an objection to the service
on moral or religious grounds, it must immediately notify ODJFS to
coordinate the implementation of this change. MCPs will be required to
notify their members of this change at least thirty (30) days prior to the
effective date. The MCP’s member handbook and provider directory, as well
as all marketing materials, will need to include information specifying
any such services that the MCP will not
provide.
|
|
10.
|
For
any data and/or documentation that MCPs are required to maintain, ODJFS
may request that MCPs provide analysis of this data and/or documentation
to ODJFS in an aggregate format, such format to be solely determined by
ODJFS.
|
|
11.
|
The
MCP is responsible for determining medical necessity for services and
supplies requested for their members as specified in OAC rule
5101:3-26-03. Notwithstanding such responsibility, ODJFS retains the right
to make the final determination on medical necessity in specific member
situations.
|
|
12.
|
In
addition to the timely submission of medical records at no cost for the
annual external quality review as specified in OAC rule 5101:3-26-07, the
MCP may be required for other purposes to submit medical records at no
cost to ODJFS and/or designee upon
request.
|
|
13.
|
The
MCP must notify the BMHC of the termination of an MCP panel provider that
is designated as the primary care provider for 500 or more of the MCP’s
CFC members. The MCP must provide notification within one working day of
the MCP becoming aware of the
termination.
|
|
14.
|
Upon
request by ODJFS, MCPs may be required to provide written notice to
members of any significant change(s) affecting contractual requirements,
member services or access to
providers.
|
|
15.
|
MCPs
may elect to provide services that are in addition to those covered under
the Ohio Medicaid fee-for-service program. Before MCPs notify potential or
current members of the availability of these services, they must first
notify ODJFS and advise ODJFS of such planned services availability. If an
MCP elects to provide additional services, the MCP must ensure to the
satisfaction of ODJFS that the services are readily available and
accessible to members who are eligible to receive them. Additional
benefits must be made available to members for at least six (6) calendar
months from date approved by
ODJFS.
|
Covered
Families and Children (CFC) population
|
|
a.
|
MCPs
are
required
to
make transportation available to any member requesting transportation when
they
must
travel
(thirty) 30 miles or more from their home to receive a medically-necessary
Medicaid-covered service. If the MCP offers transportation to their
members as an additional benefit and this transportation benefit only
covers a limited number of trips, the required transportation listed above
may not be counted toward this trip
limit.
|
|
|
b.
|
Additional
benefits may not vary by county within a region except out of necessity
for transportation arrangements (e.g., bus versus cab). MCPs approved to
serve consumers in more than one region may vary additional benefits
between regions.
|
|
|
c.
|
MCPs
must give ODJFS and members (ninety) 90 days prior notice when decreasing
or ceasing any additional benefit(s). When it is beyond the control of the
MCP, as demonstrated to ODJFS’ satisfaction, ODJFS must be notified within
(one) 1 working day.
|
|
16.
|
MCPs
must comply with any applicable Federal and State laws that pertain to
member rights and ensure that its staff adheres to such laws when
furnishing services to its members. MCPs shall include a requirement in
its contracts with affiliated providers that such providers also adhere to
applicable Federal and State laws when providing services to
members.
|
|
17.
|
MCPs
must comply with any other applicable Federal and State laws (such as
Title VI of the Civil rights Act of 1964, etc.) and other laws regarding
privacy and confidentiality, as such may be applicable to this
Agreement.
|
|
18.
|
Upon
request, the MCP will provide members and potential members with a copy of
their practice guidelines.
|
|
19.
|
The
MCP is responsible for promoting the delivery of services in a culturally
competent manner, as solely determined by ODJFS, to all members, including
those with limited English proficiency (LEP) and diverse cultural and
ethnic backgrounds.
|
All MCPs must comply with the requirements specified in OAC rules
5101:3-26-03.1, 5101:3-26-05(D), 5101:3-26-05.1(A), 5101:3-26-08 and
5101:3-26-08.2 for providing assistance
to LEP members and eligible individuals. In addition, MCPs must
provide written translations of certain MCP materials in the prevalent
non-English languages of members and
eligible individuals in accordance with the
following:
Covered
Families and Children (CFC) population
|
|
a.
|
When
10% or more of the CFC eligible individuals in the MCP’s service area have
a common primary language other than English, the MCP must translate all
ODJFS-approved marketing materials into the primary language of that
group. The MCP must monitor changes in the eligible population on an
ongoing basis and conduct an assessment no less often than annually to
determine which, if any, primary language groups meet the 10% threshold
for the eligible individuals in each service area. When the 10% threshold
is met, the MCP must report this information to ODJFS, in a format as
requested by ODJFS, translate their marketing materials, and make these
marketing materials available to eligible individuals. MCPs must submit to
ODJFS, upon request, their prevalent non-English language analysis of
eligible individuals and the results of this
analysis.
|
|
|
b.
|
When
10% or more of an MCP's CFC members in the MCP’s service area have a
common primary language other than English, the MCP must translate all
ODJFS-approved member materials into the primary language of that group.
The MCP must monitor their membership and conduct a quarterly assessment
to determine which, if any
,
primary language
groups meet the 10% threshold. When the 10% threshold is met, the MCP must
report this information to ODJFS, in a format as requested by ODJFS,
translate their member materials, and make these materials available to
their members. MCPs must submit to ODJFS, upon request, their prevalent
non-English language member analysis and the results of this
analysis.
|
|
20.
|
The
MCP must utilize a centralized database which records the special
communication needs of all MCP members (i.e., those with limited English
proficiency, limited reading proficiency, visual impairment, and hearing
impairment) and the provision of related services (i.e., MCP materials in
alternate format, oral interpretation, oral translation services, written
translations of MCP materials, and sign language services). This database
must include all MCP member primary language information (PLI) as well as
all other special communication needs information for MCP members, as
indicated above, when identified by any source including but not limited
to ODJFS, ODJFS selection services entity, MCP staff, providers, and
members. This centralized database must be readily available to MCP staff
and be used in coordinating communication and services to members,
including the selection of a PCP who speaks the primary language of an LEP
member, when such a provider is available. MCPs must share specific
communication needs information with their providers [e.g., PCPs, Pharmacy
Benefit Managers (PBMs), and Third Party Administrators (TPAs)], as
applicable. MCPs must submit to ODJFS, upon request, detailed information
regarding the MCP’s members with special communication needs, which could
include individual member names, their specific communication need, and
any provision of special services to members (i.e., those special services
arranged by the MCP as well as those services reported to the MCP which
were arranged by the
provider).
|
Covered
Families and Children (CFC) population
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. Member materials must be
available in written format, but can be provided to the member in
alternative formats (e.g., CD-rom) if specifically requested by the
member, except as specified in OAC rule 5101:3-26-08.4. Marketing and
member materials are defined as
follows:
|
|
|
a.
|
Marketing
materials are those items produced in any medium, by or on behalf of an
MCP, including gifts of nominal value (i.e., items worth no more than
$15.00),which can reasonably be interpreted as intended to market to
eligible individuals.
|
|
|
b.
|
Member
materials are those items developed, by or on behalf of an MCP, to fulfill
MCP program requirements or to communicate to all members or a group of
members. Member health education materials that are produced by a source
other than the MCP and which do not include any reference to the MCP are
not considered to be member
materials.
|
|
|
c.
|
All
MCP marketing and member materials must represent the MCP in an honest and
forthright manner and must not make statements which are inaccurate,
misleading, confusing, or otherwise misrepresentative, or which defraud
eligible individuals or
ODJFS.
|
|
|
d.
|
All
MCP marketing cannot contain any assertion or statement (whether written
or oral) that the MCP is endorsed by CMS, the Federal or State government
or similar entity.
|
|
|
e.
|
MCPs
must establish positive working relationships with the CDJFS offices and
must not aggressively solicit from local Directors, MCP County
Coordinators, or or other staff. Furthermore, MCPs are prohibited from
offering gifts of nominal
value
(i.e. clipboards, pens, coffee mugs, etc.) to CDJFS offices or managed
care enrollment center (MCEC) staff, as these may influence an
individual’s decision to select a particular
MCP.
|
Covered
Families and Children (CFC) population
|
|
f.
|
MCP
marketing representatives and other MCP staff are prohibited from offering
eligible individuals the use of a portable device (laptop computer,
cellular phone, etc.) to assist with the completion of an online
application to select and/or change MCPs, as all enrollment activities
must be completed by the
MCEC.
|
|
23.
|
Advance
Directives
– All MCPs must comply with the requirements specified
in 42 CFR 422.128. At a minimum, the MCP
must:
|
|
|
a.
|
Maintain
written policies and procedures that meet the requirements for advance
directives, as set forth in 42 CFR Subpart I of part
489.
|
|
|
b.
|
Maintain
written policies and procedures concerning advance directives with respect
to all adult individuals receiving medical care by or through the MCP to
ensure that the MCP:
|
i.
Provides written information to all
adult members concerning:
|
|
a.
|
the
member’s rights under state law to make decisions concerning their medical
care, including the right to accept or refuse medical or surgical
treatment and the right to formulate advance directives. (In meeting this
requirement, MCPs must utilize form JFS 08095 entitled
You Have the Right,
or
include the text from JFS 08095 in their ODJFS-approved member
handbook).
|
|
|
b.
|
the
MCP’s policies concerning the implementation of those rights including a
clear and precise statement of any limitation regarding the implementation
of advance directives as a matter of
conscience;
|
|
|
c.
|
any
changes in state law regarding advance directives as soon as possible but
no later than (ninety) 90 days after the proposed effective date of the
change; and
|
|
|
d.
|
the
right to file complaints concerning noncompliance with the advance
directive requirements with the Ohio Department of
Health.
|
Covered
Families and Children (CFC) population
|
|
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.
|
Pursuant
to OAC rule 5101:3-26-08.2 (B)(3), MCPs must provide to each member or
assistance group, as applicable, an MCP identification (ID) card, a new member
letter, a
member handbook, a provider directory, and information on advance
directives.
a. MCPs must use the model language specified by ODJFS for the new member
letter.
b. The ID card and new member letter must be mailed together to the member
via a method that will ensure their receipt prior to the member’s effective date
of coverage.
c.
The member handbook, provider directory and advance directives information may
be mailed to the member separately from the ID card and new member letter. MCPs
will
meet the timely receipt requirement for these materials
if they are mailed to the member within (twenty-four) 24 hours of the MCP
receiving the ODJFS produced monthly
membership roster (MMR). This is provided the materials are mailed via a method
with an expected delivery date of no more than five (5) days. If the member
handbook,
provider directory and advance directives information are mailed separately from
the ID card and new member letter and the MCP is unable to mail the materials
within twenty-
four (24) hours, the member handbook, provider directory and advance directives
information must be mailed via a method that will ensure receipt by no later
than the effective
date of coverage. If the MCP mails the ID card and new member letter with the
other materials (e.g., member handbook, provider directory, and advance
directives), the MCP
must
ensure that
all
materials are mailed via a method that will ensure their receipt
prior
to the member’s
effective date of coverage.
d. MCPs must designate two (2) MCP staff members to receive a copy of
the new member materials on a monthly basis in order to monitor the timely
receipt of these materials.
At least one of the staff members must receive the materials at their home
address.
Covered
Families and Children (CFC) population
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:
•
Martin
Luther King’s Birthday
•
Christmas
Day
•
2
optional closure days: These days can be used independently or in combination
with any of the major holiday closures but cannot both be used within the
same
closure period.
Before
announcing any optional closure dates to members and/or staff, MCPs must receive
ODJFS prior-approval which verifies that the optional closure days
meet the specified criteria.
If a
major holiday falls on a Saturday, the MCP member services line may be closed on
the preceding Friday. If a major holiday falls on a Sunday, the member services
line may be closed on the following Monday. MCP member services closure days
must be specified in the MCP’s member handbook, member newsletter, or other some
general issuance to the MCP’s members at least (thirty) 30 days in advance of
the closure.
The MCP
must also provide access to medical advice and direction through a centralized
twenty-four-hour, seven day (24/7) toll-free call-in system, available
nationwide, pursuant to OAC rule 5101:3-26-03.1(A)(6). The 24/7 call-in system
must be staffed by appropriately trained medical personnel. For the purposes of
meeting this requirement, trained medical professionals are defined as
physicians, physician assistants, licensed practical nurses, and registered
nurses.
MCPs must
meet the current American Accreditation HealthCare Commission/URAC-designed
Health Call Center Standards (HCC) for call center abandonment rate, blockage
rate and average speed of answer. By the 10
th
of each
month, MCPs must self-report their prior month performance in these three areas
for their member services and 24/7 toll-free call-in systems to ODJFS. ODJFS
will inform the MCPs of any changes/updates to these URAC call center
standards.
MCPs are
not permitted to delegate grievance/appeal functions [Ohio Administrative Code
(OAC) rule 5101:3-26-08.4(A)(9)]. Therefore, the member services call center
requirement may not be met through the execution of a Medicaid Delegation
Subcontract Addendum or Medicaid Combined Services Subcontract
Addendum.
Covered
Families and Children (CFC) population
26.
Notification of Optional MCP
Membership
In order to comply with the terms of the ODJFS State Plan Amendment for the
managed care program (i.e., 42 CFR 438.50), MCPs in mandatory membership service
areas must
inform new members that MCP membership is optional for certain
populations. Specifically, MCPs must inform any applicable pending member or
member that the following
CFC populations are not required to select an MCP in order to receive
their Medicaid healthcare benefit and what steps they need to take if they do
not wish to be a member of
an MCP:
- Indians who are members of
federally-recognized tribes.
- Children under 19 years of age who
are:
o
Eligible for Supplemental Security Income under title
XVI;
o
In foster care or other out-of-home placement;
o
Receiving foster care of adoption assistance;
o
Receiving services through the Ohio Department of Health’s Bureau
for Children with Medical Handicaps (BCMH) or any other family-centered,
community-based,
coordinated care system that receives grant funds under section 501(a)(1)(D) of
title V, and is defined by the State in terms of either program participation or
special
health care needs.
27.
HIPAA Privacy
Compliance Requirements
The Health Insurance Portability and Accountability Act (HIPAA) Privacy
Regulations at 45 CFR. § 164.502(e) and § 164.504(e) require ODJFS to have
agreements with MCPs
as a means of obtaining satisfactory assurance
that the MCPs will appropriately safeguard all personal identified health
information. Protected Health Information (PHI) is
information received from or on behalf of ODJFS that meets the definition
of PHI as defined by HIPAA and the regulations promulgated by the United States
Department of
Health and Human Services, specifically 45 CFR 164.501, and any amendments
thereto. MCPs must agree to the following:
|
|
a.
|
MCPs
shall not use or disclose PHI other than is permitted by this agreement or
required by law.
|
|
|
b.
|
MCPs
shall use appropriate safeguards to prevent unauthorized use or disclosure
of PHI.
|
|
|
c.
|
MCPs
shall report to ODJFS any unauthorized use or disclosure of PHI of which
it becomes aware. Any breach by the MCP or its representatives of
protected health information (PHI) standards shall be immediately reported
to the State HIPAA Compliance Officer through the Bureau of Managed Health
Care. MCPs must provide documentation of the breach and complete all
actions ordered by the HIPAA Compliance
Officer.
|
Covered
Families and Children (CFC) population
|
|
d.
|
MCPs
shall ensure that all its agents and subcontractors agree to these same
PHI conditions and restrictions.
|
|
|
|
|
|
|
e.
|
MCPs
shall make PHI available for access as required by
law.
|
|
|
f.
|
MCP
shall make PHI available for amendment, and incorporate amendments as
appropriate as required by
law.
|
|
|
g.
|
MCPs
shall make PHI disclosure information available for accounting as required
by law.
|
|
|
h.
|
MCPs
shall make its internal PHI practices, books and records available to the
Secretary of Health and Human Services (HHS) to determine
compliance.
|
|
|
i.
|
Upon
termination of their agreement with ODJFS, the MCPs, at ODJFS’ option,
shall return to ODJFS, or destroy, all PHI in its possession, and keep no
copies of the information, except as requested by ODJFS or required by
law.
|
|
|
j.
|
ODJFS
will propose termination of the MCP’s provider agreement if ODJFS
determines that the MCP has violated a material breach under this section
of the agreement, unless inconsistent with statutory obligations of ODJFS
or the MCP
.
|
|
28.
|
Electronic
Communications
– MCPs are required to purchase/utilize Transport
Layer Security (TLS) for all e-mail communication between ODJFS and the
MCP. The MCP’s e-mail gateway must be able to support the sending and
receiving of e-mail using Transport Layer Security (TLS) and the MCP’s
gateway must be able to enforce the sending and receiving of email via
TLS.
|
29.
MCP Membership acceptance,
documentation and reconciliation
a.
Selection Services
Contractor
: The MCP shall provide to the MCEC ODJFS
prior-approved
MCP materials and directories for distribution to eligible individuals who
request additional information about the MCP.
b.
Monthly Reconciliation of
Membership and Premiums
: The MCP shall reconcile
member
data as reported on the MCEC produced consumer contact record (CCR)
with the ODJFS-produced monthly member roster (MMR) and report to the ODJFS any
difficulties in
interpreting
or reconciling information received. Membership
reconciliation questions must be identified and reported to the ODJFS prior to
the first of the month to assure that no member is left without coverage. The
MCP shall
reconcile membership with premium payments and delivery payments as reported on
the monthly remittance advice (RA).
Covered
Families and Children (CFC) population
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. Monthly reconciliation data must be submitted in the format
specified by
ODJFS.
|
|
c.
|
Monthly Premiums and
Delivery Payments
: The MCP must be able to receive monthly premiums
and delivery payments in a method specified by ODJFS. (ODJFS monthly
prospective premium and delivery payment issue dates are provided in
advance to the MCPs.) Various retroactive premium payments (e.g.,
newborns), and recovery of premiums paid (e.g., retroactive terminations
of membership for children in custody, deferments, etc.,) may occur via
any ODJFS weekly remittance.
|
|
|
d.
|
Hospital/Inpatient
Facility Deferment
: When an MCP learns of a currently hospitalized
member’s intent to disenroll through the CCR or the 834, the disenrolling
MCP must notify the hospital/inpatient facility and treating providers as
well as the enrolling MCP of the change in enrollment within five (5)
business days of receipt of the CCR or 834
.
The disenrolling MCP
must notify the inpatient facility that it will remain responsible for the
inpatient facility charges through the date of discharge; and must notify
the treating providers that it will remain responsible for provider
charges through the date of
disenrollment.
|
|
|
When
the enrolling MCP learns through the disenrolling MCP, through ODJFS or
other means, that a new member who was previously enrolled with another
MCP was admitted prior to the effective date of enrollment and remains an
inpatient on the effective date of enrollment, the enrolling MCP shall
contact the hospital/inpatient facility within five (5) business days of
learning of the hospitalization. The enrolling MCP shall verify that it is
responsible for all medically necessary Medicaid covered services from the
effective date of MCP membership, including treating provider services
related to the inpatient stay; the enrolling MCP must reiterate that the
admitting/disenrolling MCP remains responsible for the hospital/inpatient
facility charges through the date of discharge. The enrolling MCP shall
work with the hospital/inpatient facility to facilitate discharge planning
and authorize services as
needed.
|
Covered
Families and Children (CFC) population
When an MCP learns that a new member who was previously on Medicaid fee for
service was admitted prior to the effective date of enrollment and remains
an
inpatient
on the effective date of enrollment, the enrolling MCP shall notify the
hospital/ inpatient facility and treating providers that the MCP may not
be the payer.
The MCP shall work with hospital/inpatient facility, treating providers
and the ODJFS to assure that discharge planning assures continuity of care and
accurate
payment. Notwithstanding the MCP’s right to request a hospital deferment up to
six (6) months following the member’s effective date, when the enrolling MCP
learns
of a deferment-eligible hospitalization, the MCP shall notify the ODJFS
and
request the deferment
within five (5) business days of learning of the potential
deferment.
|
|
e.
|
Just Cause
Requests:
The MCP shall follow procedures as specified by ODJFS in
assisting the ODJFS in resolving member requests for member-initiated
requests affecting
membership.
|
|
|
f.
|
Newborn
Notifications:
The MCP is required to submit newborn notifications
to ODJFS in accordance with the ODJFS Newborn Notification File and
Submissions Specifications.
|
|
|
g.
|
Eligible
Individuals:
If an eligible individual contacts the MCP, the MCP
must provide any MCP-specific managed care program information requested.
The MCP must not attempt to assess the eligible individual’s health care
needs. However, if the eligible individual inquires about
continuing/transitioning health care services, MCPs shall provide an
assurance that all MCPs must cover all medically necessary
Medicaid-covered health care services and assist members with
transitioning their health care
services.
|
|
|
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.
|
Covered
Families and Children (CFC) population
i.
Transition of
Fee-For-Service Members
(Does
not apply to regions where members are not required to enroll in an
MCP)
|
|
Providing
care coordination for prescheduled health services and existing care
treatment plans, is critical for members transitioning from Medicaid
fee-for service (FFS) to managed care. Therefore, MCPs
must:
|
i.
Allow their new members that are transitioning from Medicaid
fee-for-service
to receive services from out-of-panel providers if the member or provider
contacts the
MCP to discuss the scheduled health services in advance of the service date and
one of the following applies:
|
|
a.
|
The
member is in her third trimester of pregnancy and has an established
relationship with an obstetrician and/or delivery
hospital;
|
|
|
b.
|
The
member has been scheduled for an inpatient/outpatient surgery and has been
prior-approved and/or precertified pursuant to OAC rule 5101:3-2-40
(surgical procedures would also include follow-up care as
appropriate);
|
|
|
c.
|
The
member has appointments within the initial month of MCP membership with
specialty physicians that were scheduled prior tothe effective date of
membership; or
|
|
|
d.
|
The
member is receiving ongoing chemotherapy or radiation
treatment.
|
|
|
If
contacted by the member, the MCP must contact the provider’s office as
expeditiously as the situation warrants to confirm that the service(s)
meets the above criteria.
|
ii.
Allow their new members that are
transitioning from Medicaid
fee-for-service
to continue receiving home care services (i.e., nursing, aide, and skilled
therapy
services) and private duty nursing (PDN) services if the member or provider
contacts the MCP to discuss the health services in advance of the service date.
These
services must be covered from the date of the member or provider contact at the
current service level, and with the current provider, whether a panel or
out-of-panel
provider, until the MCP conducts a medical necessity review and renders an
authorization decision pursuant to OAC rule 5101:3-26-03.1. As soon as the MCP
becomes aware of the member’s current home care services, the MCP must initiate
contact with the current provider and member as applicable
to ensure
continuity of
care and coordinate a transfer of services to a panel
provider,
if appropriate.
Covered
Families and Children (CFC) population
|
|
iii.
|
Honor
any current fee-for-service prior authorization to allow their new members
that are transitioning from Medicaid fee-for-service to receive services
from the authorized provider, whether a panel or out-of-panel provider,
for the following approved
services:
|
|
|
a.
|
an
organ, bone marrow, or hematapoietic stem cell transplant pursuant to OAC
rule 5101:3-2-07.1 and 2.b.v of Appendix G;
|
|
|
|
|
|
|
b.
|
dental
services that have not yet been received;
|
|
|
|
|
|
|
c.
|
vision
services that have not yet been
received;
|
|
|
d.
|
durable
medical equipment (DME) that has not yet been received. Ongoing
DME services and supplies are to be covered by the MCP as
previously-authorized until the MCP conducts a medical necessity review
and renders an authorization decision pursuant to OAC rule
5101:3-26-03.1.
|
|
|
|
|
|
|
e.
|
private
duty nursing (PDN) services. PDN services must be
covered
at the previously-authorized service level until the MCP conducts a
medical necessity
review
and renders an authorization decision pursuant to OAC rule
5101:3-26-03.1.
|
As soon as the MCP becomes aware of the member’s current fee-for-service
authorization approval, the MCP must initiate contact with the authorized
provider and
member as applicable to ensure continuity of care. The MCP must implement a plan
to meet the member’s immediate and ongoing medical needs and, coordinate the
transfer of services to a panel provider, if appropriate. For organ, bone marrow
or hematapoietic stem cell transplants, MCPs must receive prior approval from
ODJFS
to
transfer services to a panel provider.
When an MCP medical necessity review results in a decision to reduce, suspend,
or terminate services previously authorized by fee-for-service Medicaid, the
MCP
must notify the member of their state hearing rights no less than 15
calendar days prior to the effective date of the MCP’s proposed action, per rule
5101:3-26-08.4 of
the Administrative Code.
iv.
Reimburse out-of-panel providers that agree to provide the transition
services
at 100% of the current Medicaid fee-for-service provider rate for the service(s)
identified in Section 29.i. (i., ii., and iii.) of this
appendix.
Covered
Families and Children (CFC) population
|
|
v.
|
Document
the provision of transition of services identified in Section 29.i. (i.,
ii., and iii.) of this appendix as
follows:
|
|
|
a.
|
For
non-panel providers, notification to the provider confirming the
provider’s agreement/disagreement to provide the service and accept 100%
of the current Medicaid fee-for-service rate as payment. If the provider
agrees, the distribution of the MCP’s materials as outlined in Appendix
G.3.e.
|
|
|
b.
|
Notification
to the member of the non-panel provider’s agreement /disagreement to
provide the service. If the provider disagrees, notification to the member
of the MCP’s availability to assist with locating a provider as
expeditiously as the member’s health condition
warrants.
|
|
|
c.
|
For
panel providers, notification to the provider and member confirming the
MCP’s responsibility to cover the
service.
|
MCPs must use the ODJFS-specified model
language for the provider
and member notices and maintain
documentation of all member and/or
provider contacts
relating
to such s
ervices.
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.
|
Covered
Families and Children (CFC) population
|
|
iv.
|
As
required by 42 CFR 438.242(b)(3), each MCP must make all collected data
available upon request by ODJFS or the Center for Medicare and Medicaid
Services (CMS).
|
|
|
v.
|
Acceptance
testing of any data that is electronically submitted to ODJFS is
required:
|
a. Before an
MCP may submit production files
b.
Whenever
an MCP changes the method or preparer of the electronic media; and/or
c.
When the
ODJFS determines an MCP’s data submissions have an unacceptably high error
rate.
MCPs that change or modify information systems that are involved in producing
any type of electronically submitted files, either internally or by changing
vendors, are required to submit to ODJFS for review and approval a transition
plan including the submission of test files in the ODJFS-specified formats.
Once an acceptable test file is submitted to ODJFS, as
determined solely by ODJFS, the MCP can return to submitting production files.
ODJFS will inform
MCPs
in writing when a test file is acceptable. Once an MCP’s new or modified
information system
is
operational, that
MCP will have up to ninety (90) days
to submit an acceptable test file and an acceptable production
file.
Submission of test files can start before the new or modified information system
is
in
production. ODJFS reserves the right to verify any MCP’s capability
to
report elements in the minimum data set prior to executing the provider
agreement for the next contract period. Penalties for noncompliance with this
requirement are specified in Appendix N, Compliance Assessment System of the
Provider Agreement.
b.
Electronic Data Interchange and Claims
Adjudication Requirements
Claims Adjudication
|
|
The
MCP must have the capacity to electronically accept and adjudicate all
claims to final status (payment or denial). Information on claims
submission procedures
must
be provided to non-contracting providers within thirty (30) days of a
request.
MCPs
must inform providers of its ability to electronically process and
adjudicate
claims
and the process for submission. Such information must be initiated by the
MCP
and not only in response to provider
requests.
|
Covered
Families and Children (CFC) population
|
|
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
N
ational
Provider Identifier (NPI).
Each EDI transaction processed by the MCP shall be implemented in conformance
with the appropriate version of the transaction implementation guide, as
specified
by applicable federal rule or regulation.
The MCP must have the capacity to accept the following transactions from the
Ohio Department of Job and Family services consistent with EDI
processing
specifications in the transaction implementation guides and in conformance
with the 820 and 834 Transaction Companion Guides issued by
ODJFS:
ASC X12 820 - Payroll Deducted and Other Group Premium Payment for Insurance
Products; and
ASC X12 834 - Benefit Enrollment and Maintenance.
The MCP shall comply with the HIPAA mandated EDI transaction standards and code
sets no later than the required compliance dates as set forth in the federal
regulations.
Documentation of Compliance with
Mandated EDI Standards
The capacity of the MCP and/or applicable trading partners and business
associates to electronically conduct claims processing and related transactions
in
compliance with standards and effective dates mandated by HIPAA must be
demonstrated, to the satisfaction of ODJFS, as outlined
below.
Covered
Families and Children (CFC) population
Verification of Compliance with HIPAA
(Health Insurance Portability and Accountability Act of
1995)
MCPs shall comply with the transaction standards and code sets for sending and
receiving applicable transactions as specified in 45 CFR Part 162 – Health
Insurance
Reform: Standards for Electronic Transactions (HIPAA regulations) In addition
the MCP must enter into the appropriate trading partner agreement and
implemented
standard code sets. If the MCP has obtained third-party certification of HIPAA
compliance for any of the items listed below, that certification may be
submitted in lieu
of the MCP’s written verification for the applicable item(s).
i. Trading
Partner Agreements
|
|
a.
|
Health
Care Claims or Equivalent Encounter Information (ASC X12N 837 & NCPDP
5.1)
|
|
|
b.
|
Eligibility
for a Health Plan (ASC X12N 270/271)
|
|
|
c.
|
Referral
Certification and Authorization (ASC X12N 278)
|
|
|
d.
|
Health
Care Claim Status (ASC X12N 276/277)
|
|
|
e.
|
Enrollment
and Disenrollment in a Health Plan (ASC X12N 834)
|
|
|
f.
|
Health
Care Payment and Remittance Advice (ASC X12N 835)
|
|
|
g.
|
Health
Plan Premium Payments (ASC X12N 820)
|
|
|
h.
|
Coordination
of Benefits
|
Trading Partner Agreement with
ODJFS
MCPs must complete and submit an EDI trading
partner agreement in a format specified by the ODJFS. Submission of the copy of
the trading partner agreement prior
to entering into this Agreement may be waived at the discretion of ODJFS; if
submission prior to entering into this Agreement is waived, the trading partner
agreement
must be
submitted at a subsequent date determined by ODJFS.
Noncompliance with the EDI and claims adjudication requirements will result in
the imposition of penalties, as outlined in Appendix N, Compliance Assessment
System, of the Provider Agreement.
c.
Encounter Data Submission
Requirements
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 t
his data
electronically to ODJFS on a monthly basis in the following standard
formats:
Covered
Families and Children (CFC) population
•
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 i
s
one
encounter
between the member and their PCP.
If the PCP sends the member to a lab to have procedures performed, then this is
two encounters; one with the PCP and another with the lab. For pharmacy
encounters,
each
prescription
filled is a separate encounter.
Encounters include services paid for retrospectively through fee-for-service
payment arrangements, and prospectively through capitated arrangements.
Only
encounters with
services
(line items) that are paid by the MCP, fully or in part, and for which no
further payment is anticipated, are acceptable encounter data
submissions, except for
immunization
services. Immunization services submitted to the MCP must be submitted to ODJFS
if these services were paid for by another
entity (e.g., free vaccine program).
All other services that are unpaid or paid in part and for which the MCP
anticipates further payment (e.g., unpaid services rendered during a delivery of
a newborn)
may
not be
submitted
to ODJFS until they are paid. Penalties for noncompliance with this requirement
are specified in Appendix N, Compliance Assessment System
of the Agreement.
Covered
Families and Children (CFC) population
The MCP must have the
capability to report all elements in the Minimum Data Set as set forth in the
ODJFS Encounter Data Specifications and must submit a test file
in
the
ODJFS-specified
medium in the required formats prior to contracting or prior to an information
systems replacement or update.
Acceptance testing of encounter data is
required as specified in Section 29(a)(v) of this Appendix.
Encounter Data File Submission
Procedures
A certification letter must accompany the submission of an encounter data file
in the ODJFS-specified medium. The certification letter must be signed by the
MCP’s
Chief
Executive
Officer (CEO), Chief Financial Officer (CFO), or an individual who has delegated
authority to sign for, and who reports directly to, the MCP’s CEO
or
CFO.
Timing
of Encounter Data Submissions
ODJFS recommends that MCPs submit encounters no more
than thirty-five (35) days after the end of the month in which they were paid.
For example, claims paid in
January are
due March
5. ODJFS recommends that MCPs submit files in the ODJFS-specified medium by the
5th of each month. This will help to ensure that the
encounters are included in
the ODJFS
master file in the same month in which they were submitted.
d.
Information Systems
Review
ODJFS
or its designee may review the information system capabilities of each MCP,
before ODJFS enters into a provider agreement with a new MCP, when
a
participating
MCP
undergoes
a major information system upgrade or change, when there is identification of
significant information system problems, or at ODJFS’
discretion. Each MCP must
participate
in the review. The review will assess the extent to which MCPs are capable of
maintaining a health information system including
producing valid encounter data, p
erformance
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.
|
Covered
Families and Children (CFC) population
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.
|
MCPs will be reimbursed for paid deliveries that are identified in the submitted
encounters using the methodology outlined in the
ODJFS Delivery Payment and
Reporting
Procedures
document. The delivery payment represents the facility
and professional service costs associated with the delivery event and postpartum
care that is rendered in
the hospital immediately following the delivery event; no prenatal or
neonatal experience is included in the delivery payment.
If a delivery occurred, but the MCP did not reimburse providers for any costs
associated with the delivery, then the MCP shall not submit the delivery
encounter to ODJFS and
is not entitled to receive payment for the delivery. Delivery encounters
submitted by MCPs must be received by ODJFS no later than 460 days after the
last date of service.
Delivery encounters which are received by ODJFS after this time will be
denied payment. MCPs will receive notice of the payment denial on the remittance
advice.
To capture deliveries outside of institutions (e.g., hospitals) and deliveries
in hospitals without an accompanying physician encounter, both the institutional
encounters (UB-
92) and the noninstitutional encounters (NSF) are searched for
deliveries.
Covered
Families and Children (CFC) population
If
a physician and a hospital encounter is found for the same delivery, only one
payment will be made. The same is true for multiple births; if multiple delivery
encounters are
submitted, only one payment will be made. The method for reimbursing for
deliveries includes the delivery of stillborns where the MCP incurred costs
related to the delivery.
If
a delivery encounter is not submitted according to ODJFS specifications, it will
be
rejected
and MCPs will receive this information on the exception report (or error
report)
that
accompanies every file in the ODJFS-specified format. Tracking, correcting and
resubmitting
all rejected encounters is the responsibility of the MCP and is required
by
ODJFS.
Timing of Delivery
Payments
MCPs will be paid monthly for deliveries. For example, payment for a delivery
encounter submitted with the required encounter data submission in March, will
be reimbursed in
March. The delivery payment will cover any encounters submitted with the monthly
encounter data submission regardless of the date of the encounter, but will not
cover
encounters that occurred over one year ago.
This payment will be a part of the weekly update (adjustment payment) that is in
place currently. The third weekly update of the month will include the delivery
payment. The
remittance advice is in the same format as the capitation remittance
advice.
Updating and Deleting Delivery
Encounters
The process for updating and deleting delivery encounters is handled
differently from all other encounters. See the
ODJFS Encounter Data Specifications
for detailed
instructions
on updating and deleting delivery encounters.
The process for deleting delivery encounters can be found on page 35 of
the UB-92 technical specifications (record/field 20-7) and page III-47 of the
NSF technical
specifications (record/field CA0-31.0a).
Auditing of Delivery
Payments
A delivery payment audit will be conducted periodically. If medical records do
not substantiate that a delivery occurred related to the payment that was made,
then ODJFS will
recoup the delivery payment from the MCP. Also, if it is determined that
the encounter which triggered the delivery payment was not a paid encounter,
then ODJFS will recoup
the delivery payment.
|
32.
|
If
the MCP will be using the Internet functions that will allow approved
users to access member information (e.g., eligibility verification), the
MCP must ensure that the proper safeguards, firewalls, etc., are in place
to protect member data.
|
Covered
Families and Children (CFC) population
|
33.
|
MCPs
must receive prior written approval from ODJFS before adding any
information to their website that would require ODJFS prior approval in
hard copy form (e.g., provider listings, member handbook
information).
|
|
34.
|
Pursuant
to 42 CFR 438.106(b), the MCP acknowledges that it is prohibited from
holding a member liable for services provided to the member in the event
that the ODJFS fails to make payment to the
MCP.
|
|
35.
|
In
the event of an insolvency of an MCP, the MCP, as directed by ODJFS, must
cover the continued provision of services to members until the end of the
month in which insolvency has occurred, as well as the continued provision
of inpatient services until the date of discharge for a member who is
institutionalized when insolvency
occurs.
|
36.
Franchise Fee Assessment
Requirements
|
a.
|
Each
MCP is required to pay a franchise permit fee to ODJFS for each calendar
quarter as required by ORC Section 5111.176. The current fee to be paid is
an amount equal to 5.5 percent of the managed care premiums, minus
Medicare premiums that the MCP received from any payer in the quarter to
which the fee applies. Any premiums the MCP returned or refunded to
members or premium payers during that quarter are excluded from the
fee.
|
|
b.
|
The
franchise fee is due to ODJFS in the ODJFS-specified format on or before
the 30th day following the end of the calendar quarter to which the fee
applies.
|
|
c.
|
At
the time the fee is submitted, the MCP must also submit to ODJFS a
completed form and any supporting documentation pursuant to ODJFS
specifications.
|
|
d.
|
Penalties
for noncompliance with this requirement are specified in Appendix N,
Compliance Assessment System of the Provider Agreement and in ORC Section
5111.176.
|
37.
Information Required for MCP
Websites
|
a.
|
On-line Provider
Directory
– MCPs must have an internet-based provider directory
available in the same format as their ODJFS-approved provider directory,
that allows members to electronically search for the MCP panel providers
based on name, provider type, geographic proximity, and population (as
specified in Appendix H). MCP provider directories must include all
MCP-contracted providers [except as specified by ODJFS] as well as certain
ODJFS non-contracted
providers.
|
Covered
Families and Children (CFC) population
|
b.
|
On-line Member
Website
- MCPs must have a secure internet-based website which
provides members the ability to submit questions, comments, grievances,
and appeals, and receive a response (members must be given the option of a
return e-mail or phone call). MCP responses to questions or comments must
be made within one working day of receipt. MCP responses to grievances and
appeals must adhere to the timeframes specified in OAC rule
5101:3-26-08.4. The member website must be regularly updated to include
the most current ODJFS-approved materials, although this website must not
be the only means for notifying members of new and/or revised MCP
information (e.g., change in holiday closures, changes in additional
benefits, revisions to approved member
materials).
|
The MCP member website must also include, at a minimum, the following
information which must be accessible to members and the general public without
any log-in
restrictions:
(1) MCP contact information, including the MCP’s toll-free member services phone
number, service hours, and closure dates; (2) a list of counties
covered in the MCP’s service area; (3) the ODJFS-approved MCP member
handbook, recent newsletters and announcements; (4) the MCP’s on-line
provider
directory as referenced in section 36(a) of this appendix; (5) the MCP’s
current preferred drug list (PDL), including an explanation of the list, which
drugs require prior
authorization (PA), and how to initiate a PA; and (6) the MCP’s current list of
drugs covered only with PA, how to initiate a PA, and the MCP’s policy for
covering
name brand drugs. MCPs must ensure that all website member information and
materials are clearly labeled for CFC members and/or ABD members, as
applicable.
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 through which providers can confirm a consumer’s
enrollment and through which providers can submit and receive responses to
prior authorization requests (an e-mail process is an acceptable
substitute if the website includes the MCP’s e-mail address for such
submissions).
|
The MCP provider website must also include, at a minimum, the following
information which must be accessible to providers and the general public without
any log-
in
restrictions:
(1) MCP contact information, including the MCP’s designated contact for provider
issues; (2) a list of counties covered in the MCP’s service area;
(3)
the MCP’s provider manual including the MCP's claims submission process,
as well as a list of services requiring prior authorization, recent newsletters
and
announcements; (4) the MCP’s on-line provider directory as
referenced in section 36(a) of this appendix; (5) the MCP’s current PDL,
including an explanation of the
list, which drugs require PA, and how to initiate a PA; and (6) the MCP’s
current list of drugs covered only with PA, how to initiate a PA, and the MCP’s
policy for
covering name brand drugs. MCPs must ensure that all website information and
materials are clearly labeled for CFC members and/or ABD members, as
applicable.
ODJFS may require MCPs to include additional information on the provider
website as needed.
Covered
Families and Children (CFC) population
|
38.
|
MCPs
must provide members with a printed version of their PDL and PA lists,
upon request.
|
|
39.
|
MCPs
must not use, or propose to use, any offshore programming or call center
services in fulfilling the program
requirements.
|
40.
Coordination of
Benefits
When a claim is denied due to third party liability, the managed care plan must
timely share appropriate and available information regarding the third party to
the provider for
the purposes of coordination of benefits, including, but not limited to
third party liability information received from the Ohio Department of Job and
Family Services.
|
41.
|
MCP
submissions with due dates that fall on a weekend or holiday are due the
next
business
day.
|
Covered
Families and Children (CFC) population
ODJFS
RESPONSIBILITIES
CFC
ELIGIBLE POPULATION
The
following are ODJFS responsibilities or clarifications that are not otherwise
specifically stated in OAC Chapter 5101: 3-26 or elsewhere in the ODJFS-MCP
provider agreement.
|
1.
|
ODJFS
will provide MCPs with an opportunity to review and comment on the
rate-setting time line and proposed rates, and proposed changes to the OAC
program rules or the provider
agreement.
|
|
2.
|
ODJFS
will notify MCPs of managed care program policy and procedural changes
and, whenever possible, offer sufficient time for comment and
implementation.
|
|
3.
|
ODJFS
will provide regular opportunities for MCPs to receive program updates and
discuss program issues with ODJFS
staff.
|
|
4.
|
ODJFS
will provide technical assistance sessions where MCP attendance and
participation is required. ODJFS will also provide optional technical
assistance sessions to MCPs, individually or as a
group.
|
|
5.
|
ODJFS
will provide MCPs with an annual MCP Calendar of Submissions outlining
major submissions and due
dates.
|
|
6.
|
ODJFS
will identify contact staff, including the Contract Administrator,
selected for each MCP.
|
|
7.
|
ODJFS
will recalculate the minimum provider panel specifications if ODJFS
determines that significant changes have occurred in the availability of
specific provider types and the number and composition of the eligible
population.
|
|
8.
|
ODJFS
will recalculate the geographic accessibility standards, using the
geographic information systems (GIS) software, if ODJFS determines that
significant changes have occurred in the availability of specific provider
types and the number and composition of the eligible population and/or the
ODJFS provider panel
specifications.
|
|
9.
|
On
a monthly basis, ODJFS will provide MCPs with an electronic file
containing their MCP’s provider panel as reflected in the ODJFS Provider
Verification System (PVS) database, or other designated
system.
|
Covered
Families and Children (CFC) population
|
10.
|
On
a monthly basis, ODJFS will provide MCPs with an electronic Provider
Master 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. This file also includes National Provider Identifier (NPI)
information where applicable.
|
|
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.
|
|
a.
|
ODJFS
or its delegated entity will provide membership notices, informational
materials, and instructional materials relating to members and eligible
individuals in a manner and format that may be easily understood. At least
annually, ODJFS or designee will provide MCP eligible individuals,
including current MCP members, with a Consumer Guide. The Consumer Guide
will describe the managed care program and include information on the MCP
options in the service area and other information regarding the managed
care program as specified in 42 CFR
438.10.
|
|
b.
|
ODJFS
will notify members or ask MCPs to notify members about significant
changes affecting contractual requirements, member services or access to
providers.
|
|
c.
|
If
an MCP elects not to provide, reimburse, or cover a counseling service or
referral service due to an objection to the service on moral or religious
grounds, ODJFS will
provide
coverage and reimbursement for these services for the MCP’s members.
ODJFS
will provide information on what services the MCP will not cover and how
and
where the MCP’s members may obtain these services in the applicable
Consumer
Guides.
|
Covered
Families and Children (CFC) population
15.
Membership Selection
and Premium Payment
|
a.
|
The
managed care enrollment center (MCEC): The ODJFS-contracted MCEC will
provide unbiased education, selection services, and community outreach for
the Medicaid managed care program. The MCEC shall operate a statewide
toll-free telephone center to assist eligible individuals in selecting an
MCP or choosing a health care delivery
option.
|
The MCEC shall distribute the most current Consumer Guide that includes the
managed care program information as specified in 42 CFR 438.10, as well as
ODJFS
prior-approved MCP materials, such as solicitation brochures and provider
directories, to consumers who request additional materials.
|
b.
|
Auto-Assignment
Limitations
– In order to ensure market and program stability,
ODJFS may limit an MCP’s auto-assignments if they meet any of the
following enrollment
thresholds:
|
|
•
|
55%
of
the
statewide
Covered
Families
and
Children
(CFC)
eligible
population;
and/or
|
|
•
|
70%
of
the
CFC
eligibles
in
any
region
with
two
MCPs;
and/or
|
|
•
|
55%
of
the
CFC
eligibles
in
any
region
with
three
MCPs
|
Once an MCP meets one of these enrollment thresholds, the MCP will only be
permitted to receive the additional new membership (in the region or statewide,
as
applicable) through: (1) consumer-initiated enrollment; and (2) auto-assignments
which are based on previous enrollment in that MCP or based on an historical
provider relationship with a provider who is not on the panel of any other MCP
in that region. In the event that an MCP in a region meets one or more of these
enrollment thresholds, ODJFS, in their sole discretion, may not impose the
auto-assignment limitation and auto-assign members to the MCPs in that region as
ODJFS
deems appropriate.
|
c
.
|
Performance Based
Auto-Assignments
– Consumers who do not voluntarily select an MCP
or are not auto-assigned to an MCP based on previous enrollment in that
MCP or an historical provider relationship with a provider who is not on
the panel of another MCP in that region, will be auto-assigned based on
the MCP performance using the following performance rating
system:
|
Covered
Families and Children (CFC) population
MCPs will be scored based on the following ten measures:
i. MCP
Consumer Call Center (see Appendix C)
– Average Speed of
Answer
ii. MCP
Provider Call Center (measurement and standards will match those set for the MCP
Consumer Call Center outlined in Appendix
C.
– Average Speed of
Answer
– Abandonment
Rate
– Blockage
rate
iii. MCP Prior
Authorization (see OAC 5101:3-26-03.1)
– Average Time to Process
Non-Pharmacy Requests
– Average
Time to Process Pharmacy Requests
iv. Prompt Payment
of Claims (see Appendix J)
– Percentage
of Claims Paid within 30days
– Percentage
of Claims Paid within 90 days
Each MCP will receive a point for meeting the established standard. If an MCP
meets the established standard for each measure, they will receive ten points.
For each region,
the MCP with the highest score will receive the performance-based
auto-assignments for the region. If there is a tie for the highest score, then
each tying MCP will be
considered equal in the auto-assignment process. Scoring will take place
quarterly and applied to the auto-assignment process once the results are
finalized.
On a regional basis, MCPs that have auto-assignment limitations in accordance
with 15(b) do not qualify for performance-based auto-assignments unless (1)
there are two
MCPs in the region, (2) the auto-assignment limited MCP received 10 points
and (3) the other MCP in the regional failed to receive 10 points. In this case,
the MCP with the
auto-assignment limitation shall receive auto-assignments in the amount of
10% of the performance based auto-assignments for every point the other MCP is
below 10 points
(i.e.
if the other MCP has 7 points then the MCP would receive 30% (3 points *
10%)).
If
ODJFS implements a new enrollment freeze on an MCP as outlined in Appendix N,
the MCP will not receive any auto-assignments. Should ODJFS remove the new
enrollment
freeze, the MCP will not be entitled to receive performance based
auto-assignments until the next quarterly review is performed and implemented as
outlined in this section.
Covered
Families and Children (CFC) population
|
d.
|
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.
|
|
e.
|
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.
|
|
f.
|
Monthly Premiums and
Delivery Payments:
ODJFS will remit payment to the MCPs via an
electronic funds transfer (EFT), or at the discretion of ODJFS, by paper
warrant.
|
|
g.
|
Remittance
Advice:
ODJFS will confirm all premium payments and delivery
payments paid to the MCP during the month via a monthly remittance advice
(RA), which is sent to the MCP the week following state cut-off. ODJFS or
its designated entity provides a record of each payment via HIPAA 820
compliant transactions.
|
|
h.
|
MCP Reconciliation
Assistance:
ODJFS will work with an MCP-designated contact(s) to
resolve the MCP’s member and newborn eligibility inquiries, premium and
delivery payment inquiries/discrepancies and to review/approve hospital
deferment requests.
|
16. ODJFS
will make available a website which includes current program
information.
|
17.
|
ODJFS
will regularly provide information to MCPs regarding different aspects of
MCP performance including, but not limited to, information on MCP-specific
and statewide external quality review organization surveys, focused
clinical quality of care studies, consumer satisfaction surveys and
provider profiles.
|
|
18.
|
ODJFS
will periodically review a random sample of online and printed directories
to assess whether MCP information is both accessible and
updated.
|
|
a.
ODJFS/BMHC
:
|
The
Bureau of Managed Health Care (BMHC) is responsible for the oversight of
the MCPs’ provider agreements with ODJFS. Within the BMHC, a specific
Contract Administrator (CA) has been assigned to each MCP. Unless
expressly directed otherwise, MCPs shall first contact their designated CA
for questions/assistance related to Medicaid and/or the MCP’s program
requirements /responsibilities. If their CA is not available and the MCP
needs immediate assistance, MCP staff should request to speak to a
supervisor within the Contract Administration Section. MCPs should take
all necessary and appropriate steps to ensure all MCP staff are aware of,
and follow, this communication
process.
|
Covered
Families and Children (CFC) population
b.
ODJFS
contracting-entities
: ODJFS-contracting entities should never be
contacted
by the MCPs unless the MCPs have been specifically instructed to contact the
ODJFS contracting entity directly.
|
c.
|
MCP delegated
entities
: In that MCPs are ultimately responsible for meeting
program requirements, the BMHC will not discuss MCP issues with the MCPs’
delegated entities unless the applicable MCP is also participating in the
discussion. MCP delegated entities, with the applicable MCP participating,
should only communicate with the specific CA assigned to that
MCP.
|
APPENDIX
F
REGIONAL
RATES
1.
PREMIUM RATES WITHOUT THE AT-RISK PAYMENT AMOUNTS FOR 01/01/09 THROUGH 06/30/09
SHALL BE AS FOLLOWS:
An
at-risk amount of 1% is applied to the MCP rates. The status of the at-risk
amount is determined in accordance with Appendix O, performance
incentives.
MCP:
WellCare of Ohio, Inc.
List
of Eligible Assistance Groups (AGs)
Healthy
Families: - MA-C Categorically eligible due to TANF
cash
- MA-Y Transitional
Medicaid
Healthy
Start: - MA-P Pregnant Women and
Children
For the
SFY 2009 contract period, MCPs will be put at-risk for a portion of the premiums
received for members in regions they served as of
January
1, 2006, provided the MCP has participated in the program for more than
twenty-four months.
MCPs will
be put at-risk for a portion of the premiums received for members in regions
they began serving after January 1, 2006, beginning
with the
MCP's twenty-fifth month of membership in each region. The at-risk amount will
be determined separately for each region an MCP serves. WellCare's regions at
risk: Northeast.
APPENDIX
F
REGIONAL
RATES
2. AT-RISK AMOUNTS FOR 01/01/09 THROUGH 06/30/09 SHALL BE AS FOLLOWS: An at-risk
amount of 1% is applied to the MCP rates. The status of the at-risk amount is
determined in accordance with Appendix O, performance
incentives.
MCP:
WellCare of Ohio, Inc.
List
of Eligible Assistance Groups (AGs)
Healthy
Families: - MA-C Categorically eligible due to TANF
cash
- MA-Y Transitional Medicaid
Healthy
Start: -
MA-P Pregnant Women and Children
For the
SFY 2009 contract period, MCPs will be put at-risk for a portion of the premiums
received for members in regions they served as of
January
1, 2006, provided the MCP has participated in the program for more than
twenty-four months.
MCPs will
be put at-risk for a portion of the premiums received for members in regions
they began serving after January 1, 2006, beginning
with the
MCP's twenty-fifth month of membership in each region. The at-risk amount will
be determined separately for each region an MCP serves. WellCare's regions at
risk: Northeast.
APPENDIX
F
REGIONAL
RATES
3. PREMIUM RATES FOR 01/01/09 THROUGH 06/30/09 SHALL BE AS FOLLOWS: An at-risk
amount of 1% is applied to the MCP rates. The status of the at-risk amount is
determined in accordance with Appendix O, performance
incentives.
MCP:
WellCare of Ohio, Inc.
List
of Eligible Assistance Groups (AGs)
Healthy
Families: - MA-C Categorically eligible due to TANF
cash
- MA-Y Transitional Medicaid
Healthy
Start: -
MA-P Pregnant Women and Children
For the
SFY 2009 contract period, MCPs will be put at-risk for a portion of the premiums
received for members in regions they served as of J
anuary 1,
2006, provided the MCP has participated in the program for more than twenty-four
months.
MCPs will
be put at-risk for a portion of the premiums received for members in regions
they began serving after January 1, 2006, beginning
with the
MCP's twenty-fifth month of membership in each region. The at-risk amount will
be determined separately for each region an MCP serves. WellCare's regions at
risk: Northeast.
Covered
Families and Children (CFC) population
COVERAGE
AND SERVICES
CFC
ELIGIBLE POPULATION
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, and any additional
services as specified in OAC rule 5101:3-26-03. For information on
Medicaid-covered services,
MCPs must refer to the ODJFS website. The following is a general list of
the benefits covered by the Ohio Medicaid fee-for-service
program:
•
Inpatient hospital
services
•
Outpatient hospital
services
•
Rural health clinics (RHCs) and
Federally qualified health centers (FQHCs)
|
•
|
Physician
services whether furnished in the physician’s office, the covered person’s
home, a hospital, or
elsewhere
|
•
Laboratory and x-ray
services
|
•
|
Screening,
diagnosis, and treatment services to children under the age of twenty-one
(21) under the HealthChek (EPSDT)
program
|
•
Family planning
services and supplies
•
Home health and private duty nursing
services
|
•
|
Physical
therapy, occupational therapy, developmental therapy and speech
therapy
|
|
•
|
Nurse-midwife,
certified family nurse practitioner, and certified pediatric nurse
practitioner services
|
•
Ambulance and ambulette
services
Covered
Families and Children (CFC) population
•
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)
2.
Exclusions, Limitations and Clarifications
a
.
Exclusions
MCPs are not required to pay for Ohio Medicaid FFS program (Medicaid)
non-covered services, except as specified in OAC rule 5101:3-26-03. 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
|
|
•
|
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*
•
Services
for the treatment of obesity unless medically necessary*
•
Custodial or supportive care not
covered by Medicaid
•
Sexual or marriage
counseling
•
Acupuncture and biofeedback
services
Covered
Families and Children (CFC) population
•
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.
Covered
Families and Children (CFC) population
Additionally, payment must not be made for associated services such as
anesthesia, laboratory tests, or hospital services if the abortion or
sterilization itself
does not qualify for payment. MCPs are responsible for educating their
providers on the requirements; implementing internal procedures including
systems
edits
to ensure that claims are only paid once the MCP has determined if the
applicable forms are completed and the required criteria are met, as confirmed
by
the appropriate certification/consent forms; and for maintaining
documentation to justify any such claim payments.
iii.
Behavioral Health
Services
Coordination of
Services
:
MCPs must have a process to coordinate benefits
of and referrals to the publicly funded community behavioral health
system.
MCPs
must
ensure that members have access to all medically-necessary behavioral health
services covered by the Ohio Medicaid FFS program and are
responsible
for coordinating those services with other medical and support services. MCPs
must notify members via the member handbook and provider
directory of where and how to access behavioral health
services, including the ability to self-refer to mental health services offered
through ODMH
community
mental
health centers (CMHCs) as well as substance abuse services offered through Ohio
Department of Alcohol and Drug Addiction Services
(ODADAS)-
certified
Medicaid providers. Pursuant to ORC Section 5111.16, alcohol, drug addiction and
mental health services covered by Medicaid are not to
be paid by
the
managed care program when the nonfederal share of the cost of those services is
provided by a board of alcohol, drug addiction, and mental
health
services
or a state agency other than ODJFS. MCPs are also not responsible for providing
mental health services to persons between 22 and 64 years of
age
while
residing in an institution for mental disease (IMD) as defined in Section
1905(i) of the Social Security Act.
MCPs must provide Medicaid-covered behavioral health services for members who
are unable to timely access services or are unwilling to access
services
through community providers.
Mental Health
Services
:
There are a number of Medicaid-covered mental health (MH) services available
through ODMH CMHCs.
Covered
Families and Children (CFC) population
Where an MCP is responsible for providing MH services
for their members, the MCP is responsible for ensuring access to counselingand
psychotherapy,
physician/psychologist/psychiatrist services, outpatient clinic services,
general hospital outpatient psychiatric services, pre-hospitalization
screening,
diagnostic
assessment (clinical evaluation), crisis intervention, psychiatric
hospitalization in general hospitals (for all ages), and
Medicaid-covered
prescription d
rugs and
laboratory services. MCPs are not required to cover partial hospitalization, or
inpatient psychiatric care in a private or public free-
standing p
sychiatric
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. The payment of physician
services in an IMD is also covered by the MCPs, as long as the
member
is 21
years of
age and under or 65 years of age and older.
Substance Abuse
Services
:
There are a number of
Medicaid-covered substance abuse services available through ODADAS-certified
Medicaid providers.
Where
an MCP is responsible for providing substance abuse services for their members,
the MCP is responsible for ensuring access to alcohol and other
drug
(AOD) urinalysis screening, assessment, counseling,
physician/psychologist/psychiatrist AOD treatment services, outpatient clinic
AOD treatment services,
general hospital outpatient AOD treatment
services, crisis intervention, inpatient detoxification services in a general
hospital, and Medicaid-covered
prescription drugs and laboratory services. MCPs are not required to
cover outpatient detoxification, intensive outpatient programs (IOP) or
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.
|
|
•
|
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:
|
Covered
Families and Children (CFC) population
|
•
|
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;
|
|
•
|
MCPs
are
required to cover the payment of physician services in a private or public
freestanding 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, in accordance with OAC rule 5101:3-26-03(A) and
(B).
|
Pursuant to ORC Section 5111.172, MCPs may, subject to ODJFS approval, implement
strategies for the management of drug utilization. (see appendix
G.3.a).
|
v.
|
Organ
Transplants
: MCPs must ensure coverage for organ transplants and
related services in accordance with OAC 5101-3-2-07.1 (B)(4)&(5).
Coverage for all organ transplant services, except kidney transplants, is
contingent upon review and recommendation by the “Ohio Solid Organ
Transplant Consortium” based on criteria established by Ohio organ
transplant surgeons and authorization from the ODJFS prior authorization
unit. Reimbursement for bone marrow transplant and hematapoietic stem cell
transplant services, as defined in OAC 3701:84-01, is contingent upon
review and recommendation by the “Ohio Hematapoietic Stem Cell Transplant
Consortium” again based on criteria established by Ohio experts in the
field of bone marrow transplant. While MCPs may require prior
authorization for these transplant services, the approval criteria would
be limited to confirming the consumer is being considered and/or has been
recommended for a transplant by either consortium and authorized by ODJFS.
Additionally, in accordance with OAC 5101:3-2-03 (A)(4) all services
related to organ donations are covered for the donor recipient when the
consumer is Medicaid
eligible.
|
Covered
Families and Children (CFC) population
3.
Health
Management Programs
In an effort to improve access, quality, and continuity of care for MCP members,
each MCP must:
i. Establish a primary care provider
(PCP) for each member and encourage the member to have an ongoing relationship
with the PCP. For this requirement, a primary care
provider as defined in OAC: 5101: 3-26-01 serves as the ongoing source of
primary and preventive care; assists with coordination of care as appropriate
for the member’s
health care needs; recommends referrals to specialists for the member;
triages the member appropriately; notifies the MCP of a member who may benefit
from care
management services; and participates in development of the Care
Management care treatment plan. The MCP must ensure the primary care provider
agrees to perform the
care coordination responsibilities as outlined in OAC: 5101:
3-26-03.1.
ii. Provide education and outreach to each member to emphasize the
importance of disease prevention and health/wellness promotion. The MCP must
encourage and
enable the member to make informed decisions about accessing and utilizing
health care services appropriately.
iii. Direct and monitor coordination of care efforts for each member for medical
services delivered across the continuum of care. The MCP should incorporate
the
requirements in Sections 3 c, d, and e in its overall strategy for care
coordination.
iv. Develop and implement a strategy to identify members who display risk
factors for developing a disease and/or who over-/under-utilize health care
services, and would
benefit from targeted outreach or education. For this requirement, the MCP
must implement mechanisms to identify such members and should include the
following
information sources: administrative data review (e.g., pharmacy claims,
emergency department claims, or inpatient hospital admissions), provider/self
referrals, telephone
interviews, home visits, referrals resulting from internal MCP operations, and
data as reported by the MCEC during membership selection. Should the MCP
identify
members characterized as having an increased risk for developing a disease
or who inappropriately utilize health care services, the MCP must offer
education and outreach
initiatives (e.g., educational mailing) designed to mitigate the risk factors,
and prevent the member from requiring more progressive interventions, such as
care management
services.
v. Implement Utilization Management Programs as outlined in Section 3.a to
maximize effectiveness of care provided to members.
vi. Each MCP must implement a Care Management Program as outlined in Section 3.b
which coordinates and monitors the care for members with special health care
needs.
The Care Management Program must be designed to ensure the intensity of
interventions provided by the MCP corresponds to the member’s level of
need.
Covered
Families and Children (CFC) population
a.
Utilization Management
Programs
General Provisions
- Pursuant to OAC rule 5101:3-26-03.1(A)(7), MCPs must implement a
utilization management (UM) program to maximize the effectiveness
of the care provided to members and may develop other UM programs, subject
to prior approval by ODJFS. For the purposes of this requirement, the
specific
UM programs which require ODJFS prior-approval are an MCP’s general
pharmacy program, a controlled substances and member management program,
and
any other program designed by the MCP with the purpose of redirecting or
restricting access to a particular service or service
location.
|
i.
|
Pharmacy
Programs - Pursuant to ORC Sec. 5111.172, MCPs may, subject to ODJFS
prior-approval, implement strategies for the management of drug
utilization. Pharmacy utilization management strategies may include
developing preferred drug lists, requiring prior authorization for certain
drugs, placing limitations on the type of provider and locations where
certain medications may be administered, and developing and implementing a
specialized pharmacy program to address the utilization of controlled
substances, as defined in section 3719.01 of the Ohio Revised Code. MCPs
may also implement a retrospective drug utilization review program
designed to promote the appropriate clinical prescribing of covered
drugs.
|
Drug
Prior Authorizations: MCPs must receive prior approval from ODJFS for the
medications that they wish to cover through prior authorization.
MCPs
must establish their prior authorization system so that it does not
unnecessarily impede member access to medically-necessary
Medicaid-covered
services. MCPs must make their approved list of drugs covered only with
prior authorization available to members and providers, as outlined
in
paragraphs 37(b) and (c) of Appendix C.
While MCPs may, with ODJFS approval, require prior
authorization for the coverage of 2
nd
generation antipsychotic drugs, MCPs must allow any
member to continue receiving a specific 2
nd
generation antipsychotic drug if the member is stabilized on that particular
medication. The MCP must
continue to cover that specific antipsychotic for the stabilized member
for as long as that medication continues to be effective for the member.
MCPs
must also collaborate with ODJFS in the retrospective review of 2nd
generation antipsychotic utilization.
MCPs must comply with the provisions of 1927(d)(5) of the Social Security Act,
42 USC 1396r-8(k)(3), and OAC rule 5101:3-26-03.1 regarding the
timeframes for prior authorization of covered outpatient
drugs.
Covered
Families and Children (CFC) population
Controlled Substances and Member Management Programs: MCPs may also, with ODJFS
prior approval, develop and implement Controlled Substances
and Member Management (CSMM) programs designed to address use of
controlled substances. Utilization management strategies may include
prior
authorization as a condition of obtaining a controlled substance, as
defined in section 3719.01 of the Ohio Revised Code. CSMM strategies may
also
include processes for requiring MCP members at high risk for fraud or
abuse involving controlled substances to have their controlled substances
prescribed by a designated provider/providers and filled by a pharmacy, medical
provider, or health care facility designated by the program.
|
ii.
|
Emergency Department
Diversion (EDD)
– MCPs must provide access to services in a way
that assures access to primary, specialist and urgent care in the most
appropriate settings and that minimizes frequent, preventable utilization
of emergency department (ED) services. OAC rule 5101:3-26-03.1(A)(7)(d)
requires MCPs to implement the ODJFS-required emergency department
diversion (EDD) program for frequent
utilizers.
|
Each MCP must establish an ED diversion (EDD) program with the goal of
minimizing frequent ED utilization. The MCP’s EDD program must include
the
monitoring of ED utilization,
identification of frequent ED utilizers, and targeted approaches designed to
reduce avoidable ED utilization. MCP EDD
programs must, at a minimum, address those ED visits which could have
been prevented through improved education, access, quality or care
management approaches.
Although there is often an assumption that frequent ED visits are solely the
result of a preference on the part of the member and education is
therefore
the standard remedy, it is also important to ensure that a member’s frequent ED
utilization is not due to problems such as their PCP’s lack of
accessibility
or
failure to make appropriate specialist referrals. The MCP’s EDD program must
therefore also include the identification of providers who
serve as PCPs for a substantial number of frequent ED utilizers and the
implementation of corrective action with these providers as so
indicated.
This requirement does not replace the MCP’s responsibility to inform and educate
all members regarding the appropriate use of the ED.
Covered
Families and Children (CFC) population
b.
Care Management
Programs
In accordance with 5101:3-26-03.1(A)(8), MCPs must offer and
provide care management services which coordinate and monitor the care of
members with special
health care needs.
i. Each MCP must inform all
members and contracting providers of the MCP’s care management
services.
ii. The
MCP’s care management program must include, at a minimum, the following
components:
|
a.
|
Identification
Strategies
|
|
|
The
MCP must implement mechanisms to identify members potentially eligible for
care management services. These mechanisms must include an administrative
data review of pharmacy claims, emergency department visits, and inpatient
hospital admissions (e.g., diagnosis, cost threshold, and/or service
utilization) and may include provider/self referrals, telephone
interviews, information as reported by MCEC during membership selection,
home visits, or referrals resulting from internal MCP operations (e.g.,
utilization management, 24/7 nurse advice line, member services,
etc.).
|
Each MCP must incorporate identification strategies (i.e., mechanisms and
criteria) as specified in
ODJFS Care Management Program
Requirements
.
|
b.
|
Risk Stratification
Levels
|
|
|
The
MCP must develop a strategy to assign members to low, medium, or high risk
stratification levels based on the results of the identification and/or
assessment processes. This will be a continual process and the risk levels
will be adjusted based on the completion of the health assessment and the
member’s demonstrated progress in meeting the goals of the care treatment
plan. Each MCP must incorporate risk stratification levels as specified in
ODJFS Care Management
Program Requirements.
|
|
|
Once
a member has been identified by the MCP as being potentially eligible for
care management, the MCP must arrange for, or conduct, a health assessment
to determine the member’s need for care management services. The health
assessment completed by the MCP will depend on the member’s initial
assignment to a low-, medium-, or high-risk stratification level. ODJFS
recognizes that the completion of an assessment may result in the
assignment of the member to a different risk stratification level (i.e.,
than the level originally assigned) or that the member may not demonstrate
a need for care management
services.
|
Covered
Families and Children (CFC) population
Page
11
For a member assigned to the low- or medium-risk stratification levels,
the MCP must, at a minimum, complete a health assessment based on a
review
of administrative
claims
data. The health assessment must be able to identify the severity of the
member’s condition/disease state, and must be
reviewed by a qualified health
professional
appropriate for the member’s health condition. If an MCP opts to use a disease
management
methodology/algorithm to assign members to a risk
stratification
level as part of the assessment, there must be clinical input to the development
of the
algorithm.
For
members assigned to a high risk stratification level, the MCP must complete a
health assessment that is comprehensive and evaluates the
member’s medical
condition(s),
including physical, behavioral, social, and psychological
needs. The health assessment must also evaluate if
the
member has co-morbidities, or multiple
complex
health care conditions. 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
care
management services. The health assessment for members assigned to the high risk
stratification level 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 a physician assistant, LPN,
licensed s
ocial
worker, or a graduate of a two- or four-year allied health
program, there should be oversight and monitoring by either a registered
nurse or physician.
The MCP must address the health assessment components as specified in
ODJFS Care Management Program
Requirements.
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
health
assessment, and reflect the member’s health care needs. The care treatment plan
must also include specific provisions for periodic
reviews of the member's
health
care needs. Periodic reviews may include administrative data reviews or
screening questions to alert appropriately
qualified MCP staff to update the health
assessment
and the care treatment plan. The frequency of contact with the member must
correspond to the
member’s risk stratification level, and must include a
provision
for two-way communication or feedback between the member and the
MCP.
Covered
Families and Children (CFC) population
The member and the member's PCP must be actively involved in the
development of, and revisions to, the care treatment plan. The designated PCP
is
the provider, or s
pecialist,
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 c
ompleted
in consultation with the PCP.
The elements of a care treatment plan include:
(a) Goals and actions that
address health care conditions identified in the health
assessment;
(b) Member level
interventions (i.e., referrals and making appointments) that assist members in
obtaining services, providers and programs related
to the
health
care conditions identified in the health assessment;
(c)
Continuous review, revision and contact follow-up,
as needed, with members to insure the care treatment plan is adequately
monitored
including the
following:
|
•
|
Identification
of gaps between recommended care and actual care provided;
and
|
|
•
|
Re-evaluation
of a member's risk level with adjustment to the level of care management
services provided.
|
The
MCP must address care treatment plan components as specified in
ODJFS Care Management Program
Requirements.
e.
Coordination of Care and
Communication
The
MCP must assign an accountable point of contact (i.e., care manager) who can
help obtain medically necessary care, assist with health-related
services and
coordinate
care needs.
Covered
Families and Children (CFC) population
The MCP must arrange or provide for
professional care management services that are performed collaboratively by a
team of professionals appropriate
for the
member’s
condition and health care needs. The MCP’s care manager must attempt to
coordinate with the member’s care manager from other
health systems. The MCP
must have
a process to facilitate, maintain, and coordinate both care and communication
with the member, PCP, and other
service providers and care 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 M
ental
Health (ODMH); the Ohio Department of Mental Retardation and
Developmental Disabilities (ODMR/DD); and the Ohio Department of Alcohol
and Drug
Addiction
Services (ODADAS)]. The MCP must have a
provision to disseminate information to the member/caregiver concerning the
health condition, types of
services
that may be available, and how to
access the services.
f.
Member
Enrollment in the Care Management Program
The MCP must assure and coordinate the placement of the member into the Care
Management Program–including the identification of the member’s need
for
care
management
services, completion of the health assessment, and timely development of the
care treatment plan. This process must occur within the
following
timeframes
for:
a) newly
enrolled members: 90 days from the effective date of enrollment for those
members who are identified as meeting the criteria for care
management; and
b
)
existing members: 90 days from identifying their need for care
management.
For members assigned to
the low or medium risk stratification levels, the MCP may choose to implement an
“opt out” process for members. MCPs that
implement an opt
out
process must provide care management services to the member until the member
declines the initial offer to participate in the program. The
opt out process must be c
learly
defined in all member materials, and the MCP must have a documented process for
honoring any opt out requests. For members
assigned to a low- or medium – l
evel, the
MCP may obtain verbal or written confirmation of the member’s care management
status in the care management
records. For members assigned to the high risk
stratification
levels, the MCP must obtain written or verbal confirmation of the member’s care
management status
in the care management record.
Covered
Families and Children (CFC) population
g.
Provider and Member
Notifications
The MCP must have a process to inform members and their PCPs that they have been
identified as meeting the criteria for care management, including
their
enrollment into
the care
management program. The MCP must develop, at a minimum, the following
notifications for members enrolled in the Care Management
program:
|
1.
|
Member
Enrollment in the Care Management Program: This must include a description
of the opt-out process (if an MCP implements) for members in the low- and
medium- risk stratification levels; contact information for the member’s
care manager; and the care management services available to the
member.
|
|
2.
|
Member
Disenrollment from the Care Management Program: This notice must include
the rationale for disenrolling the member from the care management
program, (e.g., declines participation in the program, meets goals in care
treatment plan, etc.) and information for the member to contact the MCP if
future assistance is needed.
|
The MCP must implement mechanisms to notify all Members with
Special Health Care Needs of their right to directly access a specialist. Such
access
may be assured t
hrough,
for example, a standing referral or an approved number of visits, and documented
in the care treatment plan.
i.
Care Management
Strategies
The MCP must follow best-practice and/or evidence based clinical
guidelines when developing interventions for the risk stratification levels, the
care
treatment plan
and
coordinating the care management needs. The MCP must develop and implement
mechanisms to educate and equip providers and
care managers with evidence-
based
clinical guidelines or best practice approaches to assist in providing a high
level of quality of care to members.
j.
Care Management
Program Staffing
The MCP must identify the staff that will be involved
in the operations of the care management program, including but not imited to:
care manager
supervisors,
care
manager,
and administrative support staff. The MCP must identify the role and functions
of each care management staff member as
well as the educational
requirements,
clinical licensure standards, certification and relevant experience with care
management standards and/or
activities. The MCP must provide care
manager
staff/member ratios based on the member risk stratification and different levels
of care being provided
to members.
Covered
Families and Children (CFC) population
k.
Information Technology
System for the Care Management Program
The MCP’s information technology system for the Care Management Program must
maximize the opportunity for communication between the MCP, the PCP,
the
member,
and other
service providers and care managers. The MCP must have an integrated database
that allows MCP staff who may be contacted by a member
in care
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, health assessments,
care 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 care
managers.
The goal is to integrate information from a variety of sources in an effort to
facilitate care management
needs for the member.
l.
Care Management Data
Submission
The MCP must submit a monthly electronic report to the Care Management System
(CAMS) for all members who are provided care management
services by
the MCP
as outlined in the
ODJFS Case
Management File and Submission Specifications.
In
order for a member to be submitted as care
managed in
CAMS, the
MCP must complete the steps as outlined in Section ii.f: Enrollment in the Care
Management program. ODJFS, or its
designated entity, the external q
uality
review vendor, will validate on an annual basis the accuracy of the information
contained in CAMS with the
member’s care management record.
The CAMS files are due the 15
th
calendar day of each month.
Covered
Families and Children (CFC) population
The MCP must also have an ODJFS-approved care management program which
includes the items in this Section. Each MCP must implement an
evaluation
process
to review, revise and/or update the care management program on an annual basis.
If the evaluation process results in a revision to
identification
strategies,
health assessment(s), and risk stratification strategies, then the MCP must
notify ODJFS in writing of the change, which
may
be subject to review
and
approval by ODJFS.
c.
Care Coordination with
ODJFS-Designated Providers
Per OAC rule 5101:3-26-03.1(A)(4), MCPs are required to share specific
information with certain ODJFS-designated non-contracting providers in order to
ensure that
these providers have been supplied with specific information needed to
coordinate care for the MCP’s members. Once an MCP has obtained a provider
agreement, but
within the first month of operation, the MCP must provide to
the ODJFS-designated providers (i.e., ODMH Community Mental Health Centers,
ODADAS-certified
Medicaid providers, FQHCs/RHCs, QFPPs, CNMs, CNPs [if applicable], and
hospitals) a quick reference information packet which includes the
following:
i. A brief cover letter
explaining the purpose of the mailing; and
|
ii.
|
A
brief summary document that includes the following
information:
|
|
•
|
Claims
submission information including the MCP’s Medicaid provider number for
each region;
|
|
•
|
The
MCP’s prior authorization and referral procedures or the MCP’s website
which includes this
information;
|
|
•
|
A
picture of the MCP’s member identification card (front and
back);
|
|
•
|
Contact
numbers and website location for obtaining information for eligibility
verification, claims processing, referrals/prior authorization, and
information regarding the MCP’s behavioral health
administrator;
|
|
•
|
A
listing of the MCP’s major pharmacy chains and the contact number for the
MCP’s pharmacy benefit administrator
(PBM);
|
Covered
Families and Children (CFC) population
|
•
|
A
listing of the MCP’s laboratories and radiology providers;
and
|
|
•
|
A
listing of the MCP’s contracting behavioral health providers and how to
access services through them (this information is only to be provided to
non-contracting community mental health and substance abuse
providers).
|
d.
Care coordination with
Non-Contracting Providers
Per OAC rule 5101:3-26-05(A)(9), MCPs authorizing the delivery of services from
a provider who does not have an executed subcontract must ensure tha
t
they have a
mutually agreed upon compensation amount for the authorized service and
notify the provider of the applicable provisions of paragraph D of OAC rule
5101:3-26-05.
This notice is provided when an MCP authorizes a non-contracting provider to
furnish services on a one-time or infrequent basis to an MCP member and must
include
required ODJFS-model language and information. This notice must also be
included with the transition of services form sent to providers as outlined in
paragraph 29.h
of Appendix C.
e.
Integration of Member
Care
The MCP must ensure that a discharge plan is in place to meet a member’s health
care needs following discharge from a nursing facility, and integrated into
the
member’s continuum of care. The discharge plan must address the services
to be provided for the member and must be developed prior to the date of
discharge from
the nursing facility. The MCP must ensure follow-up contact occurs with
the member, or authorized representative, within thirty (30) days of the
member’s discharge
from the nursing facility to ensure that the member’s health care needs
are being met.
Covered
Families and Children (CFC) population
PROVIDER
PANEL SPECIFICATIONS
CFC
ELIGIBLE POPULATION
MCPs must
provide or arrange for the delivery of all medically necessary, Medicaid-covered
health services, as well as assure that they meet all applicable provider panel
requirements for their entire designated service area. The ODJFS provider panel
requirements are specified in the charts included with this appendix and must be
met prior to the MCP receiving a provider agreement with ODJFS. The MCP must
remain in compliance with these requirements for the duration of the provider
agreement.
If an MCP
is unable to provide the medically necessary, Medicaid-covered services through
their contracted provider panel, the MCP must ensure access to these services on
an as needed basis. For example, if an MCP meets the pediatrician requirement
but a member is unable to obtain a timely appointment from a pediatrician on the
MCP’s provider panel, the MCP will be required to secure an appointment from a
panel pediatrician or arrange for an out-of-panel referral to a
pediatrician.
MCPs are
required
to make
transportation available to any member requesting transportation when they
must
travel 30 miles or more
from their home to receive a medically-necessary Medicaid-covered service. If
the MCP offers transportation to their members as an additional benefit and this
transportation benefit only covers a limited number of trips, the required
transportation listed above may
not
be counted toward this
trip limit (as specified in Appendix C).
In
developing the provider panel requirements, ODJFS considered, on a
county-by-county basis, the population size and utilization patterns of the
Covered Families and Children (CFC) consumers, as well as the potential
availability of the designated provider types. ODJFS has integrated existing
utilization patterns into the provider network requirements to avoid disruption
of care. Most provider panel requirements are county-specific but in certain
circumstances, ODJFS requires providers to be located anywhere in the region.
Although all provider types listed in this appendix are required provider types,
only those listed on the attached charts must be submitted for ODJFS prior
approval.
2.
PROVIDER
SUBCONTRACTING
Unless
otherwise specified in this appendix or OAC rule 5101:3-26-05, all MCPs are
required to enter into fully-executed subcontracts with their providers. These
subcontracts must include a baseline contractual agreement, as well as the
appropriate ODJFS-approved Model Medicaid Addendum. The Model Medicaid Addendum
incorporates all applicable Ohio Administrative Code rule requirements specific
to provider subcontracting and therefore cannot be modified except to add
personalizing information such as the MCP’s name.
Covered
Families and Children (CFC) population
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 Managed Care Provider Network
(MCPN), maintained by the Managed Care Enrollment Center (MCEC), or other
designated process. The MCPN is a centralized database system that maintains
information on the status of all MCP-submitted providers.
Only
those providers who meet the applicable criteria specified in this document, as
determined by ODJFS, will be approved by ODJFS. MCPs must
credential/recredential providers in accordance with the standards specified by
the National Committee for Quality Assurance (or receive approval from ODJFS to
use an alternate industry standard) and must have completed the credentialing
review before submitting any provider to ODJFS for approval. Regardless of
whether ODJFS has approved a provider, the MCP must ensure that the provider has
met all applicable credentialing criteria before the provider can render
services to the MCP’s members.
MCPs must
notify ODJFS of the addition and deletion of their contracting providers as
specified in OAC rule 5101:3-26-05, and must notify ODJFS within one working day
in instances where the MCP has identified that they are not in compliance with
the provider panel requirements specified in this appendix.
3.
PROVIDER PANEL
REQUIREMENTS
The
provider network criteria that must be met by each MCP are as
follows:
a.
Primary Care Providers
(PCPs)
Primary
Care Provider (PCP) means an individual physician (M.D. or D.O.), certain
physician group practice/clinic (Primary Care Clinics [PCCs]), or an advanced
practice nurse (APN) as defined in ORC 4723.43 or advanced practice nurse group
practice within an acceptable specialty, contracting with an MCP to provide
services as specified in paragraph (B) of OAC rule 5101: 3-26-03.1. The APN
capacity can count up to 10% of the total requirement for the county. Acceptable
specialty types for PCPs include family/general practice, internal medicine,
pediatrics, and obstetrics/gynecology (OB/GYN). Acceptable PCCs include FQHCs,
RHCs and the acceptable group practices/clinics specified by ODJFS. As part of
their subcontract with an MCP, PCPs must stipulate the total Medicaid member
capacity that they can ensure for that individual MCP.
Covered
Families and Children (CFC) population
Each PCP
must have the capacity and agree to serve at least 50 Medicaid members at each
practice site in order to be approved by ODJFS as a PCP. The capacity-by-site
requirement must be met for all ODJFS-approved PCPs.
In
determining whether an MCP has sufficient PCP capacity for a region, ODJFS
considers a provider who can serve as a PCP for 2000 Medicaid MCP members as one
full-time equivalent (FTE).
ODJFS
reviews the capacity totals for each PCP to determine if they appear excessive.
ODJFS reserves the right to request clarification from an MCP for any PCP whose
total stated capacity for all MCP networks added together exceeds 2000 Medicaid
members (i.e., 1 FTE). Where indicated, ODJFS may set a cap on the maximum
amount of capacity that we will recognize for a specific PCP. ODJFS may allow up
to an additional 750 member capacity for each nurse practitioner or physician’s
assistant that is used to provide clinical support for a PCP.
For PCPs
contracting with more than one MCP, the MCP must ensure that the capacity figure
stated by the PCP in their subcontract reflects only the capacity the PCP
intends to provide for that one MCP. ODJFS utilizes each approved PCP’s capacity
figure to determine if an MCP meets the provider panel requirements and this
stated capacity figure does not prohibit a PCP from actually having a caseload
that exceeds the capacity figure indicated in their
subcontract.
ODJFS
recognizes that MCPs will need to utilize specialty providers to serve as PCPs
for some special needs members. Also, in some situations (e.g., continuity of
care) a PCP may only want to serve a very small number of members for an MCP. In
these situations it will not be necessary for the MCP to submit these PCPs to
ODJFS for prior approval. These PCPs will not be included in the ODJFS MCPN
database, or other designated process, and therefore may not appear as PCPs in
the MCP’s provider directory. These PCPs will, however, need to execute a
subcontract with the MCP which includes the appropriate Model Medicaid
Addendum.
The PCP
requirement is based on an MCP having sufficient PCP capacity to serve 40% of
the eligibles in the region if three MCPs are serving the region and 55% of the
eligibles in the region if two MCPs are serving the region. At a minimum, each
MCP must meet both the PCP FTE requirement for that region, and a ratio of one
PCP FTE for each 2,000 of their Medicaid members in that region. MCPs must also
satisfy a PCP geographic accessibility standard. ODJFS will match the PCP
practice sites and the stated PCP capacity with the geographic location of the
eligible population in that region (on a county-specific basis) and perform
analysis using Geographic Information Systems (GIS) software. The analysis will
be used to determine if at least 40% of the eligible population is located
within 10 miles of PCP with available capacity in urban counties and 40% of the
eligible population within 30 miles of a PCP with available capacity in rural
counties. [Rural areas are defined pursuant to 42 CFR
412.62(f)(1)(iii).]
Covered
Families and Children (CFC) population
In
addition to the PCP FTE capacity requirement, MCPs must also contract with the
specified
number
of pediatric
PCPs for each region. These pediatric PCPs will have their stated capacity
counted toward the PCP FTE requirement.
A
pediatric PCP must maintain a general pediatric practice (e.g., a pediatric
neurologist would not meet this definition unless this physician also operated a
practice as a general pediatrician) at a site(s) located within the
county/region and be listed as a pediatrician with the Ohio State Medical Board.
In addition, half of the required number of pediatric PCPs must also be
certified by the American Board of Pediatrics. The provider panel requirements
for pediatricians are included in the practitioner charts in this
appendix.
b.
Non-PCP Provider
Network
In
addition to the PCP capacity requirements, each MCP is also required to maintain
adequate capacity in the remainder of its provider network within the following
categories: hospitals, dentists, pharmacies, vision care providers,
obstetricians/gynecologists (OB/GYNs), allergists, general surgeons,
otolaryngologists, orthopedists, certified nurse midwives (CNMs), certified
nurse practitioners (CNPs), federally qualified health centers (FQHCs)/rural
health centers (RHCs) and qualified family planning providers (QFPPs). CNMs,
CNPs, FQHCs/RHCs and QFPPs are federally-required provider
types.
All
Medicaid-contracting MCPs must provide all medically-necessary Medicaid-covered
services to their members and therefore their
complete
provider
network will include many other additional specialists and provider types. MCPs
must ensure that all non-PCP network providers follow community standards in the
scheduling of routine appointments (i.e., the amount of time members must wait
from the time of their request to the first available time when the visit can
occur).
Although
there are currently no FTE capacity requirements of the non-PCP required
provider types, MCPs are required to ensure that adequate access is available to
members for all required provider types. Additionally, for certain non-PCP
required provider types, MCPs must ensure that these providers maintain a
full-time practice at a site(s) located in the specified county/region (i.e.,
the ODJFS-specified county within the region or anywhere within the region if no
particular county is specified). A full-time practice is defined as one where
the provider is available to patients at their practice site(s) in the specified
county/region for at least 25 hours a week. ODJFS will monitor access to
services through a variety of data sources, including: consumer satisfaction
surveys; member appeals/grievances/complaints and state hearing
notifications/requests; clinical quality studies; encounter data volume;
provider complaints, and clinical performance measures.
Hospitals -
MCPs must
contract with the number and type of hospitals specified by ODJFS for each
county/region. In developing these hospital requirements, ODJFS considered, on a
county-by-county basis, the population size and utilization patterns of the
Covered Families and
Children
(CFC) consumers and integrated the existing utilization patterns into the
hospital network requirements to avoid disruption of care. For this reason,
ODJFS may require that MCPs contract with out-of-state hospitals (i.e. Kentucky,
West Virginia, etc.).
Covered
Families and Children (CFC) population
For each
Ohio hospital, ODJFS utilizes the hospital’s most current Annual Hospital
Registration and Planning Report, as filed with the Ohio Department of Health,
in verifying types of services that hospital provides. Although ODJFS has the
authority, under certain situations, to obligate a non-contracting hospital to
provide non-emergency hospital services to an MCP’s members, MCPs must still
contract with the specified number and type of hospitals unless ODJFS approves a
provider panel exception (see Section 4 of this appendix – Provider Panel
Exceptions).
If an
MCP-contracted hospital elects not to provide specific Medicaid-covered hospital
services because of an objection on moral or religious grounds, the MCP must
ensure that these hospital services are available to its members through another
MCP-contracted
hospital
in the
specified county/region.
OB/GYNs
- MCPs must contract
with the specified number of OB/GYNs for each county/region, all of whom must
maintain a full-time obstetrical practice at a site(s) located in the specified
county/region. Only MCP-contracting OB/GYNs with current hospital privileges at
a hospital under contract with the MCP in the region can be submitted to the
MCPN, or other system, count towards MCP minimum panel requirements, and be
listed in the MCPs’ provider directory.
Certified Nurse Midwives (CNMs) and
Certified Nurse Practitioners (CNPs)
- MCPs must ensure access to CNM and
CNP services in the region if such provider types are present within the region.
The MCP may contract directly with the CNM or CNP providers, or with a physician
or other provider entity who is able to obligate the participation of a CNM or
CNP. If an MCP does not contract for CNM or CNP services and such providers are
present within the region, the MCP will be required to allow members to receive
CNM or CNP services outside of the MCP’s provider network.
Only CNMs
with hospital delivery privileges at a hospital under contract with the MCP in
the region can be submitted to the MCPN, or other system, count towards MCP
minimum panel requirements, and be listed in the MCPs’ provider directory.The
MCP must ensure a member’s access to CNM and CNP services if such providers are
practicing within the region.
Vision Care Providers -
MCPs
must contract with the specified number of ophthalmologists/optometrists for
each specified county/region , all of whom must maintain a full-time practice at
a site(s) located in the specified county/region. All ODJFS-approved vision
providers must regularly perform routine eye exams.
(
MCPs will be expected to
contract with an adequate number of ophthalmologists as part of their overall
provider panel, but only ophthalmologists who regularly perform routine eye
exams can be used to meet the vision care provider panel requirement.) If
optical dispensing is not sufficiently available in a region through
the MCP’s
contracting ophthalmologists/optometrists, the MCP must separately contract with
an
adequate
number of optical dispensers located in the
region.
Covered
Families and Children (CFC) population
Dental Care Providers
- MCPs
must contract with the specified number of dentists. In order to assure
sufficient access to adult MCP members, no more than two-thirds of the dentists
used to meet the provider panel requirement may be pediatric
dentists.
Federally Qualified Health
Centers/Rural Health Clinics (FQHCs/RHCs)
- MCPs are required to ensure
member access to any federally qualified health center or rural health clinic
(FQHCs/RHCs), regardless of contracting status. Contracting FQHC/RHC providers
must be submitted for ODJFS approval via the MCPN process, or other designated
process. Even if no FQHC/RHC is available within the region, MCPs must have
mechanisms in place to ensure coverage for FQHC/RHC services in the event that a
member accesses these services outside of the region.
In order
to ensure that any FQHC/RHC has the ability to submit a claim to ODJFS for the
state’s supplemental payment, MCPs must offer FQHCs/RHCs reimbursement pursuant
to the following:
|
•
|
MCPs
must provide expedited reimbursement on a service-specific basis in an
amount no less than the payment made to other providers for the same or
similar service.
|
|
•
|
If
the MCP has no comparable service-specific rate structure, the MCP must
use the regular Medicaid fee-for-service payment schedule for non-FQHC/RHC
providers.
|
|
•
|
MCPs
must make all efforts to pay FQHCs/RHCs as quickly as possible and not
just attempt to pay these claims within the prompt pay time
frames.
|
MCPs are
required to educate their staff and providers on the need to assure member
access to FQHC/RHC services.
Qualified Family Planning Providers
(QFPPs) -
All MCP members must be permitted to self-refer to family
planning services provided by a QFPP. A QFPP is defined as any public or
not-for-profit health care provider that complies with Title X
guidelines/standards, and receives
either
Title X funding or family planning funding from the Ohio Department of Health.
MCPs must reimburse all medically-necessary Medicaid-covered family planning
services provided to eligible members by a QFPP provider (including on-site
pharmacy and diagnostic services) on a patient self-referral basis, regardless
of the provider’s status as a panel or non-panel provider.
MCPs will
be required to work with QFPPs in the region to develop mutually-agreeable HIPAA
compliant policies and procedures to preserve patient/provider confidentiality,
and convey pertinent information to the member’s PCP and/or
MCP.
Covered
Families and Children (CFC) population
Behavioral Health Providers –
MCPs must assure member access to all Medicaid-covered behavioral health
services for members as specified in Appendix G.b.ii. Although ODJFS is aware
that certain outpatient substance abuse services may only be available through
Medicaid providers certified by the Ohio Department of Drug and Alcohol
Addiction Services (ODADAS) in some areas, MCPs must maintain an adequate number
of contracted mental health providers in the region to assure access for members
who are unable to timely access services or unwilling to access services through
community mental health centers. MCPs are advised not to contract with community
mental health centers as all services they provide to MCP members are to be
billed to ODJFS.
Other Specialty Types
(
pediatricians, general surgeons,
otolaryngologists, allergists, and orthopedists)
- MCPs must contract
with the specified number of all other ODJFS designated specialty provider
types. In order to be counted toward meeting the provider panel requirements,
these specialty providers must maintain a full-time practice at a site(s)
located within the specified county/region. Only contracting general surgeons,
orthopedists, and otolaryngologists with admitting privileges at a hospital
under contract with the MCP in the region can be submitted to the MCPN, or other
system, count towards MCP minimum panel requirements, and be listed in the MCPs’
provider directory.
4.
PROVIDER PANEL
EXCEPTIONS
ODJFS may
specify provider panel criteria for a service area that deviates from that
specified in this appendix if:
|
-
|
the
MCP presents sufficient documentation to ODJFS to verify that they have
been unable to meet or maintain certain provider panel requirements in a
particular service area despite all reasonable efforts on their part to
secure such a contract(s),
and
|
|
-
|
if
notified by ODJFS, the provider(s) in question fails to provide a
reasonable argument why they would not contract with the MCP,
and
|
|
-
|
the
MCP presents sufficient assurances to ODJFS that their members will have
adequate access to the services in
question.
|
If an MCP
is unable to contract with or maintain a sufficient number of providers to meet
the ODJFS-specified provider panel criteria, the MCP may request an exception to
these criteria by submitting a provider panel exception request as specified by
ODJFS. ODJFS will review the exception request and determine whether the MCP has
sufficiently demonstrated that all reasonable efforts were made to obtain
contracts with providers of the type in question and that they will be able to
provide access to the services in question.
Covered
Families and Children (CFC) population
A
provider panel exception request (PPE) may be approved for a period of not more
than one year. Approvals shall have an effective date of the 1st day of the
month in which the PPE is approved by ODJFS. ODJFS will not accept or review a
request to extend the effective date of a PPE that is submitted earlier than 15
calendar days prior to the date of expiration. Once the MCP has resolved the
deficiency, the PPE is no longer valid. If the MCP becomes deficient in the same
area a new PPE request will need to be submitted prior to the next compliance
review.
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.
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 MCPN, or other designated
process.
MCP
provider directories must utilize a format specified by ODJFS. Directories may
be region-specific or include multiple regions, however, the providers within
the directory must be divided by region, county, and provider type, in that
order.
The
directory must also specify:
• provider
address(es) and phone number(s);
• an
explanation of how to access providers (e.g. referral required vs.
self-referral);
•
an indication of which providers are available to
members on a self-referral basis
|
•
|
foreign-language
speaking PCPs and specialists and the specific foreign language(s)
spoken;
|
|
•
|
how
members may obtain directory information in alternate formats that takes
into consideration the special needs of eligible individuals including but
not limited to, visually-limited, LEP, and LRP eligible individuals;
and
|
•
any PCP or specialist practice limitations.
Printed Provider
Directory
Prior to
receiving a provider agreement, all MCPs must develop a printed provider
directory that shall be prior-approved by ODJFS for each covered population. For
example, an MCP who serves CFC and ABD in the Central Region would have two
provider directories, one for CFC and one for ABD. Once approved, this directory
may be regularly updated with provider additions or deletions by the MCP without
ODJFS prior-approval, however, copies of the revised directory (or inserts) must
be submitted to ODJFS prior to distribution to members.
Covered
Families and Children (CFC) population
On a
quarterly basis, MCPs
must
create an insert to each printed directory that lists those providers
deleted
from the MCP’s
provider panel during the previous three months. Although this insert does not
need to be prior approved by ODJFS, copies of the insert must be submitted to
ODJFS two weeks prior to distribution to members.
Internet Provider
Directory
MCPs are
required to have an internet-based provider directory available in the same
format as their ODJFS-approved printed directory. This internet directory must
allow members to electronically search for MCP panel providers based on name,
provider type, and geographic proximity, and population (e.g. CFC and/or ABD).
If an MCP has one internet-based directory for multiple populations, each
provider must include a description of which population they
serve.
The
internet directory may be updated at any time to include providers who are
not
one of the ODJFS-required
provider types listed on the charts included with this appendix. ODJFS-required
providers
must
be added
to the internet directory within one week of the MCP’s notification of
ODJFS-approval of the provider via the Provider Verification process. Providers
being deleted from the MCP’s panel must deleted from the internet directory
within one week of notification from the provider to the MCP. Providers being
deleted from the MCP’s panel must be posted to the internet directory within one
week of notification from the provider to the MCP of the deletion. These deleted
providers must be included in the inserts to the MCP’s provider directory
referenced above.
6
.
FEDERAL ACCESS
STANDARDS
MCPs must
demonstrate that they are in compliance with the following federally defined
provider panel access standards as required by 42 CFR
438.206:
In
establishing and maintaining their provider panel, MCPs must consider the
following:
• The
anticipated Medicaid membership.
|
•
|
The
expected utilization of services, taking into consideration the
characteristics and health care needs of specific Medicaid populations
represented in the MCP.
|
|
•
|
The
number and types (in terms of training, experience, and specialization) of
panel providers required to deliver the contracted Medicaid
services.
|
|
•
|
The
geographic location of panel providers and Medicaid members, considering
distance, travel time, the means of transportation ordinarily used by
Medicaid members, and whether the location provides physical access for
Medicaid members with
disabilities.
|
•
M
CPs 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.
North East Region - PCP
Capacity
|
|
Minimum
PCP Capacity Requirements
|
|
|
|
|
Ashtabula
|
Cuyahoga
|
Erie
|
Geauga
|
Huron
|
Lake
|
Lorain
|
Medina
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
¹ Based
on an FTE of 2000 members
|
|
* Must be
located within the region.
North
East Central Region - PCP Capacity
|
|
Minimum
P
CP
Capacity Requirements
|
|
|
|
Columbiana
|
Mahoning
|
Trumbull
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
¹ Based on an
FTE of 2000 members
|
|
* Must be
located within the region.
East
Central Region - PCP Capacity
|
|
|
Minimum
PCP Capacity Requirements
|
|
|
|
|
Ashland
|
Carroll
|
Holmes
|
Portage
|
Richland
|
Stark
|
Summit
|
Tuscarawas
|
Wayne
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
¹ Based on an
FTE of 2000 members
|
|
* Must be
located within the region.
Central Region - PCP
Capacity
|
¹ Based on an
FTE of 2000 members
|
|
* Must be
located within the region.
South East Region - PCP
Capacity
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Additional
Required
:
In-Region
*
|
|
|
|
¹ Based on an
FTE of 2000 members
|
|
* Must be
located within the region.
South West Region - PCP
Capacity
|
|
Minimum
PCP Capacity Requirements
|
|
|
|
|
Adams
|
Brown
|
Butler
|
Clermont
|
Clinton
|
Hamilton
|
Highland
|
Warren
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
¹ Based on an
FTE of 2000 members
|
|
* Must be
located within the region.
West
Central Region - PCP Capacity
|
|
Minimum
PCP Capacity Requirements
|
|
|
|
|
Champaign
|
Clark
|
Darke
|
Greene
|
Miami
|
Montgomery
|
Preble
|
Shelby
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
¹ Based on an
FTE of 2000 members
|
|
* Must be
located within the region.
North West Region - PCP
Capacity
|
|
|
|
|
|
|
|
|
Total
Required
|
68,540
|
34.27
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Additional
Required
:
In-Region
*
|
|
|
|
¹ Based on an
FTE of 2000 members
|
|
* Must be
located within the region.
FINANCIAL
PERFORMANCE
CFC
ELIGIBLE POPULATION
1.
SUBMISSION OF FINANCIAL STATEMENTS AND
REPORTS
MCPs must submit the following financial reports to ODJFS:
|
a.
|
The
National Association of Insurance Commissioners (NAIC) quarterly and
annual Health Statements (hereafter referred to as the “Financial
Statements”), as outlined in Ohio Administrative Code (OAC) rule
5101:3-26-09(B). The Financial Statements must include all required Health
Statement filings, schedules and exhibits as stated in the NAIC Annual
Health Statement Instructions including, but not limited to, the following
sections: Assets, Liabilities, Capital and Surplus Account, Cash Flow,
Analysis of Operations by Lines of Business, Five-Year Historical Data,
and the Exhibit of Premiums, Enrollment and Utilization. The Financial
Statements must be submitted to BMHC even if the Ohio Department of
Insurance (ODI) does not require the MCP to submit these statements to
ODI. A signed hard copy and an electronic copy of the reports in the
NAIC-approved format must both be provided to
ODJFS;
|
|
b.
|
Hard
copies of annual financial statements for those entities who have an
ownership interest totaling five percent or more in the MCP or an indirect
interest of five percent or more, or a combination of direct and indirect
interest equal to five percent or more in the
MCP;
|
|
c.
|
Annual
audited Financial Statements prepared by a licensed independent external
auditor as submitted to the ODI, as outlined in OAC rule
5101:3-26-09(B);
|
|
d.
|
Medicaid
Managed Care Plan Annual Ohio Department of Job and Family Services
(ODJFS) Cost Report and the auditor’s certification of the cost report, as
outlined in OAC rule
5101:3-26-09(B);
|
|
e.
|
Medicaid
MCP Annual Restated Cost Report for the prior calendar year. The restated
cost report shall be audited upon BMHC
request;
|
|
f.
|
Annual
physician incentive plan disclosure statements and disclosure of and
changes to the MCP’s physician incentive plans, as outlined in OAC rule
5101:3-26-09(B);
|
g. Reinsurance
agreements, as outlined in OAC rule 5101:3-26-09(C);
Covered
Families and Children (CFC) population
Page
2
|
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 2009, a minimum net
worth per member of $363.00, as determined from the annual Financial
Statement
submitted to ODI and the
ODJFS.
|
The Net Worth Per Member (NWPM) standard is the Medicaid Managed
Care Capitation amount paid to the MCP during the preceding calendar year,
including
delivery payments, but excluding the at-risk amount,
expressed as a per-member per-month figure, multiplied by the applicable
proportion below:
Covered
Families and Children (CFC) population
0.75 if the MCP had a total membership of 100,000 or more during that calendar
year
0.90 if the MCP had a total membership of less than 100,000 for that calendar
year
If the MCP did not receive Medicaid Managed Care Capitation payments during the
preceding calendar year, then the NWPM standard for the MCP is the
average
Medicaid Managed Care capitation amount paid to Medicaid-contracting MCPs
during the preceding calendar year, including delivery payments, but excluding
the at-
risk amount, multiplied by the applicable proportion above.
b.
Indicator:
Administrative Expense
Ratio
|
Definition:
|
Administrative
Expense Ratio = Administrative Expenses minus Franchise Fees divided by
Total Revenue minus Franchise
Fees.
|
|
Standard:
|
Administrative
Expense Ratio not to exceed 15%, as determined from the annual Financial
Statement submitted to ODI and
ODJFS.
|
c.
Indicator:
Overall Expense
Ratio
|
Definition:
|
Overall
Expense Ratio = The sum of the Administrative Expense Ratio and the
Medical Expense Ratio.
|
Administrative Expense Ratio = Administrative Expenses minus Franchise Fees
divided by Total Revenue minus Franchise Fees.
Medical Expense Ratio = Medical Expenses divided by Total Revenue minus
Franchise Fees.
Previous Section